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muttduck

Updates & Insulin Questions...

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muttduck

About 3 months ago, life looked good. Victoza was doing its job beautifully, my A1C was pretty, and I was maintaining a fairly level BG through the day.

 

Then the 1st of June hit.

Hubby was bit by our dog (whom we bottle raised 6 years ago), dog was put to sleep... Two weeks later, hubby was in a car accident, totaled the car adding in the stress of his accident, the resulting insurance headaches, and then the search for a new vehicle...

 

It looked like the stress load triggered the final blow to the few insulin producing cells left. BGs soaredp, didn't matter if I was starving myself of carbs or not.

 

So in July, I called the doc, and went in to figure out what we could do.

 

Results: No more Victoza. Hello Lantus.

 

Went 1 month on Lantus, and it's got the fasting levels into a nice range of 100-150... much better than the 170-220. But the 2hpps are still way out of whack.

 

Saw the doc earlier this week, (blood panel run, but results not back), and he said we're going to add a fast acting insulin. He wanted me to see the dietician first, to ensure I have a grasp on carb counting... but she's booked for another month. So... I'm going back tomorrow to start the fast acting insulin, since I have seen the dietician once in the past, and already have a fairly good idea about carb counting and serving sizes.

 

 

Questions...

Anything I should know, or should watch for, after starting the fast acting stuff?

 

I'm not a fan of this whole sticking a needle in my gut once a day, let alone adding another needle at every meal. My S-I-L and niece (both type 1) are on pumps and like it a lot better than having to inject all the time.

Is a pump something to consider instead? Or do I need to try the needles for a while until I know how it all works, and then consider a pump later? Any downsides to pumps that would make you completely avoid them?

 

Any advice, opinions, rants, raves, etc... that might help a newbie to (fast acting) insulin?

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Subby

It must take some adjustment to have this come on in that kind of time frame. Good one you for obviously taking it in your stride.

 

You have a grasp of carb counting, but I'm curious how are you going to actually dose your insulin? Do you have an I:C ratio suggestion from your doctor?

 

The main issue is to nut out and seek best bolusing practise for yourself, asap. That means honing in on better and more effective boluses through method, timing, and dose, while avoiding issues like hypos or spikes you don't want. As well as an I:C ratio for food, using a correction factor to correct highs, is the other very useful element to using short acting.

 

As for the pump, you can (and people, and countries) come at it from very different directions. Some examples:

 

Theory 1: people should thoroughly familiarise themselves first with MDI, only when an old pro, move on to pumping.

Theory 2: Pumps should only be for those who show they are motivated enough to control well on mdi first.

Theory 3: Pumps should be for those who find they have difficulty with controlling with injections.

etc etc...

If there is one that I think does pretty much automatically apply, it would be this:

You need to be happy and willing to monitor closely, take a number of tests a day ad infinitum, 4-6 would be a common target for pumping. It also requires a different kind of motivation, to work with settings and possible issues, that can get more pervasive and involved than injections.

 

My personal take is that if you want to pump, and can access the pump, sounds like a great idea. When you move to a pump from injections, there is often a heap of changes in how you deliver basal and bolus, and a belief out there that you should get it all sorted out forst with injections is a little nonsensical to me. If pump is gettable, I personally don't think there is any need for injections beyond using them to know what the "deal is" with them. To that aim, you may like to try MDI at least for a few weeks/months so that when you pump, you know what the other option is personally, rather than wondering about it. But that's just a suggestion from me.

 

I suggest you follow your instinct, and look in to the practicalities of getting a pump now or down the line, if you want one.

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muttduck

The other day, he mentioned an initial ratio of "1 unit : 30g of carbs" to start. But I'm sure we'll discuss that more tomorrow...

 

I can say that 30g of carbs at breakfast today resulted in a 104 fasting to a 203 2hpp.

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aiah23
The other day, he mentioned an initial ratio of "1 unit : 30g of carbs" to start. But I'm sure we'll discuss that more tomorrow...

 

I can say that 30g of carbs at breakfast today resulted in a 104 fasting to a 203 2hpp.

 

You may notice that you have a different I:C ratio for breakfast (many of us on insulin have to take more insulin for breakfast than we would for the same amount of carbs at lunch or dinner). For breakfast, you may want to change your I:C (for a conservative start, you'll probably have to change it again) of 1:20 and keep it for 2 or 3 days to see how you're 2 hr pps are (make sure you eat the same thing for breakfast on each of those days to eliminate additional variables). If you're still reading high, you'll maybe want to change it to 1:15, etc...it's a bit of trial and error to arrive at the right I:C for each meal but it is doable.

 

Concerning the pump (having done both) I'd recommend trying MDI at least for a couple of months. This gives you a better idea of how to set your own basal and bolus needs so that it's one less overwhelming thing should you switch to a pump. The transition is tough but totally doable. Another thing to keep in mind, should your pump fail or you experience problems, you may have to revert back to MDI so being familiar with that first is a very good idea.

 

Fawn

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Subby
The other day, he mentioned an initial ratio of "1 unit : 30g of carbs" to start. But I'm sure we'll discuss that more tomorrow...

 

I can say that 30g of carbs at breakfast today resulted in a 104 fasting to a 203 2hpp.

 

Since insulin has a different efficacy unit for unit between people, you can't actually deduce a great deal about it until you start using it, and your doc's guess/deduction is likely to be a reasonable starting point. From there you can adjust for yourself with trial and (hopefully not too much) error. I would highly recommend getting either Using Insulin by John Walsh, or alternatively if you think a pump is indeed on the cards (and for a lot of discussion on about thinking about pumping, ie helping you to make up your mind), Pumping Insulin by John Walsh. These books will help you to take control of how to use I:Cs, correction factors, and many more relevant issues regarding insulin use, quite encyclopedic.

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Jan B

Pumping Insulin by John Walsh is a very good book, if you are interested in learning in detail about pumping. However, right now, I would simply use the ratio given (many people start w/1:15 for their insulin to carb ratio, but try what your doctor said). A common place to start for corrections is 1 unit for every 50 points above your bg goal (but not right if the 1:30 actually works). Not many people end up where they first start though.

 

The best way to learn how much fast-acting you use is to know exactly how many carbs you are consuming . . . no guessing! I believe (only me) it would also be ideal to keep the carb count fairly low while you are learning until you have a good idea of what your ratio is. And then you need to test frequently. Be ready for if/when you go low with some glucose tablets or orange juice for example. Always keep fast acting glucose on/with you.

 

I have pumped, and done MDI. The pump has a lot of cool features, but I still think it's for more experienced bolus users. It's a lot more involved and can be an excellent tool, but it does have its drawbacks. It can be like magic, or a total PITA . . . depending on how you experience things. Many people can't imagine life without it.

 

After you have successfully figured out your carb to insulin ratio . . . don't think it's set in stone! It may very well change over time and with seasons!

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Subby
I have pumped, and done MDI. The pump has a lot of cool features, but I still think it's for more experienced bolus users. It's a lot more involved and can be an excellent tool, but it does have its drawbacks. It can be like magic, or a total PITA . . . depending on how you experience things. Many people can't imagine life without it.

 

I largely agree with this. But for me MDI was very troublesome no matter how pro I got, due to specific physical issues. Pumping provided clear control improvement through basal control and improved absorption, that immediately improved my daily health and life, compared to a long time on shots. I do agree that at least some experience with MDI is a very good idea, for being able to revert to shots as Fawn mentioned, and so you know thoroughly what MDI entails ... but in regards to my body, pumping is a significantly better tech, period, and MDI was very troublesome in and of itself for specific issues (which I could never work out, until getting more pro with the pump). I know I'm probably in a minority with how "individual" my needs are, but I don't know who else might be as well or what other issues might operate in a similar way.

 

Certainly if MDI is proving to be very troublesome despite some time and motivation, and there can be a variety of reasons why that is beyond issues of competence, I'd really urge considering at least a trial of the pump to see if it simply works better for you, in terms of effort to result ratio.

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Rekarb

There is so much that goes into bolusing. Just take your time. What you're actually doing is building up a knowledge set that will allow you to know what to do for most situations. I started low and would test for results. After a few months I could pretty much tell how much I needed for most circumstances. I still sometimes wind up on the high side with new things but eventually I get it right.

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muttduck

Thank you all for the great advice so far... I'm trying to sponge as much of it as I can.

This has been one crazy roller coaster since January, that's for sure!

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muttduck

I meant to update everyone on the Dr visit the other day...

 

Yes, he added Novalog, but it's only for bringing down already high sugars from the prior meal. He still wants to wait until I see the dietician (sp?) before using the insulin to counterbalance what I will be eating. Got the dietician's office to move my appt up from 9/28 to 9/10, so maybe I can get these sugars under control soon.

 

He also added a statin to lower my LDL. It's not much higher than his "goal" (I'm 121, the goal is 100), but because it's not really coming down on its own, and because 'diabetics are more at risk to heart disease', he went ahead and put me on it. No biggie, as long as the side effects don't hit me hard, just another pill in my box.

 

 

More frustrating was the conversation about a pump in the future.

 

He said he generally doesn't prescribe pumps to type 2's. He usually reserves them for type 1s that refuse to take their medications. But, since I am good about taking my medications, and trying to manage my levels, he doesn't think I'm a good candidate for a pump.

 

Soo... that leads to being frustrated with my doctor in general. I have antibodies present - I'm 33, 5' 4", 142 lbs - insulin dependent in less than 7 months of initial diagnosis - can someone tell me how is that a type 2?

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Subby

Strange comment from your doc about pumps being for unmotivated patients. It's pretty common knowledge that patients generally need to be more motivated, not less, to pump. I wonder if he was pulling your leg a bit. I would also wonder if he doesn't do the pump much. The T2 comment was not encouraging either. It sounds like you are not, or not particularly, insulin dependent at this stage, as far as the way the term is usually used, and I assume this is why the T2 comment (even though T2s can get fully insulin dependent). But you need someone who will stay responsive to your situation and your needs. Sounds to me like you just found a brick wall or two with this doc. Maybe time to start looking around. In the meantime learning how to bolus and easing into that really is a good course of action for at least a month or two, if that's enough for you to get on with at the moment.

 

If you are dependent on insurance, it might be worth finding out what requirements they might have to help provide a pump, eg, certain c-peptide result.

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aggie168
Soo... that leads to being frustrated with my doctor in general. I have antibodies present - I'm 33, 5' 4", 142 lbs - insulin dependent in less than 7 months of initial diagnosis - can someone tell me how is that a type 2?

 

Hello MuttDuck,

 

I am going to assume you meant GAD-65 antibody test. Then in my book, you are definitely a T1.5. Also, do you already have a c-peptide test? That tells you how much insulin producing beta cell is still functioning. For myself, I have no antibody and c-peptide test runs low. I basically burnout my pancreas in the last 10 years and become insulin dependent.

 

Yes, I did basel (Levemir) insulin for a short period and then went straight on the pump. It is a lot of learning but is all worth it. I went from a1c of 8.x to 6.0 in less than one year and dropped half a dozen of oral medication.

 

Yes, it does take a little while to get use to having two item attached to your body at all time. A CGM sensor and an infusion set. However, I am use to it now and there is no going back. :)

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sarahspins
I suggest you follow your instinct, and look in to the practicalities of getting a pump now or down the line, if you want one.

 

I agree.. if you know you want a pump, I wouldn't necessarily wait. You can learn plenty about how insulin works while pumping, and if for some reason your pump fails, it's not that hard to switch back to MDI... your ratios for corrections and carbs would remain similar, the only tricky part is figuring out how to replace your basal (either with shots every few hours, or with a long-acting insulin like Lantus).

 

With positive antibodies and the fact that you are already using insulin, it shouldn't be a problem to get a pump approved by insurance.

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