The Late Great Gold Standard For MDI And Its Unheralded Demise

[david4503]

Before pumps, there was a way to maximize flexibility in limiting highs and lows with the added benefit of minimizing fuss and bother in day-to-day, hour-to-hour management. As far as I know, it’s no longer being recommended or even talked about, especially in the case of newer Type 1 diabetics.

Why that is is a whole other discussion but the regimen involves three insulins: regular, rapid-acting and intermediate-acting (for example, Humulin R, Humalog and Humulin N). In my case, I started out after diagnosis with only intermediate, then added Regular, and finally added fasr-acting when it was introduced. It’s five shots a day (including one mixed) with additional shots of Humalog if needed.

This MDI regimen has many advantages over standard MDI regimens and pumping. However, many doctors don’t know about it and/or don’t have the.training or expertise necessary to recommend it to patients. (There’s also a learning curve for patients going from one or two to three different insulins.) That’s a shame because all these insulins are still available. I’ve used this regimen for 25 years and have no plans to change it — at least until a reliable, implantable artificial pancreas comes along.

Anyway, this may all be a moot point but I thought I’d share it.

 

[jonathan183]

Thanks for sharing - it sounds like it may be quite complicated to work ... with potential to inject the wrong insulin. I'm on MDI but only rapid and long acting ... only mixed them up once so far and was fortunate and injected the rapid rather than long acting.
How many times have you injected the wrong insulin by mistake in the last 25 years ?

 

[Antje77]

I don't think using three different insulins was ever a common approach or standard, although I use 3 insulins myself, none of them resembling R, N or Humalog.

From your other posts I take it you're from the US. Most of our members are from the UK and Europe.

Around here, N is usually referred to as NPH, and I think the most common brand of it is Insulatard (by NovoNordisk), not the Humulin N by Lilly. It's mostly prescribed to T2's, and while you're proof it can work well, it's not an easy insulin to use as a basal because of it's short action time and sharpish peak action.

The R, I know mainly from low carbing T1's who use it to bolus for protein in the absence of carbs, and of course from US diabetics who have to buy their insulin at Walmart because their insurance won't pay for what they need.
I'm not even sure that Humulin or Novolin R are available in Europe.
Humalog (Lilly) is used here but I think it's sister NovoRapid (NovoNordisk) is slightly more common.

For myself, none of those insulins would be useful, even on low carbs I need a very quick acting insulin for meals (Fiasp or Lyumjev) so I won't have to prebolus by up to an hour.
For my basal, I'm very happy with the stable Tresiba, allowing me to inject at any time in a 10 hour window or so. Not possible with NPH.
On top of that I use Levemir as a shorter acting basal on an as needed basis, depending on activity and time of month. I guess NPH would work for this purpose as well.

 

[Yaya10_10]

Thanks for sharing - it sounds like it may be quite complicated to work ... with potential to inject the wrong insulin. I'm on MDI but only rapid and long acting ... only mixed them up once so far and was fortunate and injected the rapid rather than long acting.
How many times have you injected the wrong insulin by mistake in the last 25 years ?

I have had the long acting twice by mistake
It was an aeful experience

 

[david4503]

Thanks for sharing - it sounds like it may be quite complicated to work ... with potential to inject the wrong insulin. I'm on MDI but only rapid and long acting ... only mixed them up once so far and was fortunate and injected the rapid rather than long acting.
How many times have you injected the wrong insulin by mistake in the last 25 years ?

Twice, maybe three times as I recall. Only one time was memorable because that involved a much higher than normal dose of Humalog. I was fighting that low for hours but managed without needing glucagon. It is actually hard to mix these insulins up since they’re color-coded and clearly labeled.

The regimen is less complicated than it may appear and, of course, it gets simpler as you get used to it. However, as Antje mentioned, Regular and NPH both have peaks and valleys which can be a challenge if you’re used to insulins with a steady release. I had the advantage of experience with how they worked, so those peaks and valleys turn out to be a good thing. All three complement each other well. When I had to drop the Regular during one hospital stay, there was a big hole. More Humalog was required to fill the gaps and fight the highs (Lantus might have worked better than NPH for basal but it still would have required more Humalog to replace the Regular and Humalog is tricky stuff).

In the U.S. there was maybe a ten year period when this regimen was the official or maybe unofficial gold standard. At some point, pumps started getting all the attention and publicity. I see the appeal there but the downside is fairly obvious to me also.

 

[EllieM]

I have had the long acting twice by mistake
It was an aeful experience

I've done the short acting instead of long acting twice by mistake too. It was also an awful experience. (Though maybe easier to cope with, once you realise you've done it, as you just need lots of carbs before your bg plummets you into unconsciousness).