[Eddy]

Anybody diluting N, R, or rapid? I'd like just a little more granularity on my dosing... and I'm certain that plenty of children actually _need_ their insulin diluted...

I wonder why some diluents claim to be for rapid only. I mix rapid with regular R and N on a regular basis...

Thoughts?

TIA!

[morrisma]

Eddy,
Never heard of diluting insulin but I suppose with kids it might be needed. With my pump's ability to supply small increments, it just never occurred to me. What sort of granularity are you looking for?
Mike

[Eddy]

Originally Posted by morrisma

Never heard of diluting insulin but I suppose with kids it might be needed. With my pump's ability to supply small increments, it just never occurred to me. What sort of granularity are you looking for?

I'd like reliable 0.15U doses. Even if a pump were affordable (no insurance), I'd rather stick with MDI.

Background:

The hospital told me 1U:20mg/dL when I was DXed. Perhaps small errors were hidden by Lantus fluctuation. I also had an infection at the time, which could have made things honkerwonky. Or maybe the hospital numbers were correct at the time.

However, I've recently determined that I'm approximately 1U:35mg/dL... it just happens slooowly when I'm hyperglycemic, making the effect appear smaller. This makes sense, considering that 1U of CHO raises me about 35mg/dL; the apparent inconsistency between insulin:CHO, insulin:BG, and CHO:BG had annoyed me for some time.

The methods behind my madness:

When I eat imprecise portions, normal "0.{thatlooksaboutright}U" granularity is good enough. When I eat precise portions, or would like to correct from (e.g.) 115 to 95 before bed, I'd like the ability to measure reliably 5mg/dL coverage.

My TDD is low enough that I virtually never use a complete vial of rapid, R, or N. I end up discarding after 8-10 weeks of use, when effectiveness gets dicey and my BG gets screwy. However, I draw from the well 2-6 times per day, depending on insulin type and how the day goes; I imagine that frequent punctures reduce the vials' useful lives. Perhaps I could mix a month's worth in each mixing vial, then stretch the "master" vials out longer... particularly for N, for which my need is small and inconsistent -- but non-negligible.

Feel free to tell me that I'm nuts. I'll not argue that... but I still would like to try diluting.

[morrisma]

Well Eddy,
If you want to do this, I see 2 items to solve right away:
1) where will you store the diluted insulin?
2) what will you dilute it with?
Sterilization being key to both of those, can you get sterile saline or water to dilute and which is better? If saline, what concentration of saline is right? You could pre-draw syringes but air & mixing might be problems. Maybe insulin producers offer an already diluted version.
Rather than dilution, maybe you could find small dose syringes that would make .05 unit gradations possible. I'm guessing that might be easiest.
Mike

[shiftzor]

Well my stance would be that diabetes has enough variables without trying to add more variables (i.e.% of mix); imprecision in carb counting can be solved by judgement and experience. Yes I would love to have something smaller than a half unit just to do corrections once in a while .

[BlueSky]

Eddy, I have a few comments and questions ...

Originally Posted by Eddy

.... 1U of CHO raises me about 35mg/dL; ...

What is 1U of CHO?

Originally Posted by Eddy

... I'd like the ability to measure reliably 5mg/dL coverage. ...

The only way to get such fine control is with a pump. But I question whether this kind of micro-management is such a good idea. I have been down that road and it nearly drove me crazy .

Originally Posted by Eddy

... I virtually never use a complete vial of rapid, R, or N. I end up discarding after 8-10 weeks of use, when effectiveness gets dicey and my BG gets screwy. ...

You could cut down on the waste by getting your insulin in 3 ml cartridges.

Originally Posted by Eddy

... particularly for N, for which my need is small and inconsistent -- ...

I am curious. Why would you want to use NPH to bolus, as you say in your signature? It is a long acting insulin.

As far as diluting is concerned, sure you could do that. But your insulin sensitivity doesn't seem to warrant it. You are going to have to do this for a vary long time, so IMO you need to keep it all as simple as possible. The suggestion to find smaller needles sounds like a sensible one to me.

[Eddy]

Originally Posted by morrisma

1) where will you store the diluted insulin?
2) what will you dilute it with?

In a sterile dilution vial; with diluent.

ASHP Website : Resolved Shortages
Diluting Insulin Primer
New insulins in the management of diabetes.(CONTINUING EDUCATION: An ongoing CE program of The University of Florida College of Pharmacy and DRUG TOPICS) Industry & Business Article - Research, News, Information, Contacts, Divisions, Subsidiaries, Bu

It's not just the sterile water... pH balance, preservatives, and other goodies are part of the solution.

Supposedly, rapid diluent is not to be used with human. However, considering that I already mix rapid, human R, and human N, I'm tempted to try it. I just wondered if anybody had any experience.

Originally Posted by morrisma

Sterilization being key to both of those, can you get sterile saline or water to dilute and which is better? If saline, what concentration of saline is right?

Normal saline:

Insulin Drug Information, Professional

and search for "0.9% sodium chloride".

Originally Posted by morrisma

Maybe insulin producers offer an already diluted version.

I'd love that. I've heard that some countries get U-40... but have heard nothing but "no" re American availability.

Originally Posted by morrisma

Rather than dilution, maybe you could find small dose syringes that would make .05 unit gradations possible. I'm guessing that might be easiest.

That would be nice. Every pharmacy I've asked has said that 30U is the smallest syringe available.

[Eddy]

Originally Posted by BlueSky

What is 1U of CHO?

15g (sorry; I thought that was considered "standard")

Originally Posted by BlueSky

The only way to get such fine control is with a pump. But I question whether this kind of micro-management is such a good idea. I have been down that road and it nearly drove me crazy .

I get my best sleep in the low 90s and high 80s... so I really like to nail my nighttime numbers. And more [accurate] information is better information. And I might decide that it's not worth the effort.

Originally Posted by BlueSky

You could cut down on the waste by getting your insulin in 3 ml cartridges.

Pen only, right? I like creating a mix to match what I eat.

Originally Posted by BlueSky

I am curious. Why would you want to use NPH to bolus, as you say in your signature? It is a long acting insulin.

In the small doses that I use, it finishes in about 5.5 hours. Certain foods, such as whole-grain rice spaghetti with marinara, match up near perfectly with 1:1:3 rapid:R:N mix.

Once in a while, I'll eat a huge lunch. Not often, but I've done the 200g CHO lunch now and then. Unless I substitute a couple units of N for R, I'll go hypo around two hours post-prandial.

When I used Lantus (I'm nearly 100% switched to Levemir now), I shot Lantus at dinnertime. I added 1U NPH to my breakfast bolus, and 2U NPH to my lunchtime, to cover the Lantus fade. I decided it wasn't worth an extra needle to split the Lantus dose.

Now I'm trying shorter-acting, and supposedly/seemingly more-consistent, Levemir. To exercise, I need to cut my basal dose; I go hypo _very_ quickly. There's a good chance I'll use some NPH for a supplemental basal to make up for reduced Levemir when I'm not exercising.

e.g.:

0900 : 8U Levemir instead of normal 15.5U
0900 : 1U R + 4U N to hold me until mid-day
1300 : aerobic exercise
2100 : 15.5U Levemir

(I've not gotten that far, so I have no idea what actual numbers will be.)

Originally Posted by BlueSky

As far as diluting is concerned, sure you could do that. But your insulin sensitivity doesn't seem to warrant it.

I might change my mind after trying it. But... as much as I respect your experience and opinions, I'm still not dissuaded from wanting to try.

Originally Posted by BlueSky

You are going to have to do this for a vary long time, so IMO you need to keep it all as simple as possible.

Any time I feel "cloud-headed", I check. Unless I've not eaten enough, I'm inevitably above 110. (Sometimes I'll feel fine at higher numbers.) I _really_ like to stay below 110-120 if at all possible. This limits my range, and means that sometimes I want a small correction.

So far, the rapid/R/N mix has proved more desirable than multiple shots or "close enough with one insulin for bolus" control. Would monthly preparation of diluted rapid/R/N really add that much hassle or complexity? I tend to think it would not.

Originally Posted by BlueSky

The suggestion to find smaller needles sounds like a sensible one to me.

That might be worth a shot, so to speak. If anyone has any leads... I've found naught less than 30U.

[Eddy]

Originally Posted by shiftzor

Well my stance would be that diabetes has enough variables without trying to add more variables (i.e.% of mix);

Actually, that argument _supports_ diluting. Did I bolus 5.0 U? Maybe 4.8? Perhaps closer to 5.4? How much dead space did that needle have? Were there teeny air bubbles that added up to 0.1 U? Whoops, I just leaked a little; how much of my 3U dose did I lose?

Fractional-unit errors become proportionately smaller when shooting more units. Hence, dilution to increase the number of units.

Originally Posted by shiftzor

imprecision in carb counting can be solved by judgement and experience.

Inaccuracy, yes. Imprecision, no. (Or, if someone can eyeball the difference between 88g and 93g, please share your secrets!)

Again... when I eat an _imprecise_ meal, U-100 is "good enough". When I eat a _precise_ meal, I'd like insulin precision to match.

I'd like to know when to chalk up a 15mg/dL error to food, to bolus, or to something else.

Originally Posted by shiftzor

Yes I would love to have something smaller than a half unit just to do corrections once in a while .

That too.

[lilituc]

As far as I've heard, only Humalog can be diluted, and it's "not recommended" although I've heard people had success with it. Frankly all that was the reason I went to pumping.

[BlueSky]

Originally Posted by Eddy

.... I get my best sleep in the low 90s and high 80s... so I really like to nail my nighttime numbers. And more [accurate] information is better information. ....

It is interesting that you feel unwell at relatively low numbers. When my blood sugar gets up to 180 my bladder fills up, and that is the only way I know that I am high.

Originally Posted by Eddy

.... So far, the rapid/R/N mix has proved more desirable than multiple shots or "close enough with one insulin for bolus" control. Would monthly preparation of diluted rapid/R/N really add that much hassle or complexity? ....

If it is an option for you, getting a pump would sort all this out for you. You will quickly get used to it, and it provides all the tools you need for tight control.

You can use cartridges with syringes too. I used to do this before pens that deliver half units became available (the Novopen Demi). It makes carrying the insulin around a lot more convenient as you can slip a cartidge and a syringe into most BG meter cases.

As far as the CHO standard goes, the 15 gram exchange system is actually a very old standard. It was the norm when I was diagnosed 30 years ago, and I am surprised that it is still used. The exchange system was superceded by carb counting (in grams) after Humalog (the first rapid acting insulin) became available in the early 90's. It was part of the transition from "conventional therapy" (two injections a day) to "intensive therapy" (separate basal and bolus dosing).

[Eddy]

Originally Posted by BlueSky

It is interesting that you feel unwell at relatively low numbers. When my blood sugar gets up to 180 my bladder fills up, and that is the only way I know that I am high.

Wow. I [usually] start feeling _really_ rotten around 140-150. By the time I hit 180, I want to gouge someone's eyes out. I'm told there's a reason I was nicknamed "Edwardosaurus" prior to my DX.

Also interesting is that I've remained conscious below 20 mg/dL. Note, however, that I prefer to stay well away from such numbers... and keep telling myself I'll shoot glucagon if I drop below the 30-35 range again.

Originally Posted by BlueSky

If it is an option for you, getting a pump would sort all this out for you. You will quickly get used to it, and it provides all the tools you need for tight control.

Not an option. Even if it were, I'm still not convinced...

Originally Posted by BlueSky

You can use cartridges with syringes too. I used to do this before pens that deliver half units became available (the Novopen Demi). It makes carrying the insulin around a lot more convenient as you can slip a cartidge and a syringe into most BG meter cases.

This intrigues me. I'll have to check out cartridge pricing. Thanks!!! (Now, if I could just find some smaller syringes with better granularity... that would address both granularity and waste.)

Originally Posted by BlueSky

As far as the CHO standard goes, the 15 gram exchange system is actually a very old standard. It was the norm when I was diagnosed 30 years ago, and I am surprised that it is still used. The exchange system was superceded by carb counting (in grams) after Humalog (the first rapid acting insulin) became available in the early 90's. It was part of the transition from "conventional therapy" (two injections a day) to "intensive therapy" (separate basal and bolus dosing).

Hunh. I was DXed a bit less than a year ago, and that's what I was told... and the 15:1 works for me... so... I just assumed.

[RobiJo]

You can dilute it. It would be done by the pharmacist, who would dilute it with a saline mixture and then repackage it (it would not still be in the humalog vial) The child I know that did it was very sensitive to the insulin and needed very small amounts. He is an adult now and no longer uses diluted insulin.

[RobiJo]

Originally Posted by Eddy

Not an option. Even if it were, I'm still not convinced...



Hunh. I was DXed a bit less than a year ago, and that's what I was told... and the 15:1 works for me... so... I just assumed.

As much as you are micromanaging you would be a prime candidate for a pump. If your insurance situation changes---get one. You are taking sooo many shots a day, mixing insulins, adjusting doses etc. A pump could take care of all of that and more.

15g does equal 1 carb choice to many. Some consider 1 carb choice 12g or 8g or whatever they cover with 1 unit of insulin. It is all a matter of wording and how their doctor worded it to them.

[Funnygrl]

You can't dilute NPH because of the protamine suspension. Diluting it would dilute the suspension too, and cause it not to have the same action profile. You can dilute Lantus either, because of the acidity of it. Humalog is the only insulin that can officially be diluted, with a special dilutent.

But why you would bother is beyond me. You're not especially insulin sensitive. You don't need lower doses than typical MDI can provide.

I'll admit, your insulin plan makes no sense to me.

If you really want the level of micromanagement you're going for, a pump is your only option. But there's no evidence that this level of micromanagement is helpful.

Further, there's really no reason to shoot glucagon just because you're a certain level if you can eat.

Also, why does your Lantus dose vary (sig)?