How is insulin started?

[MEValentijn]

Background Info:
I'm not type I, but had an extreme adverse reaction to metformin, lactic acidosis. 1.8mg daily Victoza injection worked well for about a year, then levels started rising with no changes in my diet. Gliclazide was added at 30mg then 60mg per day, but had a very sporadic effect at first, working too well on some days but not at all on others, and now has no effect for the past several weeks. I went back to 30mg gliclazide one day due to running out and not being able to get the prescription refilled, and that made no difference in my blood sugar levels.

Unable to get in to see anyone to deal with this for another month, since my GP doesn't want to deal with it and there's a long wait to get referred to the specialist), I upped the gliclazide dose to the recommended official maximum of 120mg and it didn't help at all. I stopped taking it entirely 2 days ago, and it's had no impact on my blood sugar readings. Some symptoms (sporadic headache, bouts of vertigo, tremors) seem to have resolved since I stopped taking gliclazide - but these are also symptoms of my other chronic illness, so I don't know if their cessation is related to the cessation of gliclazide.

I've been using FreeStyle Libre constant monitoring for a couple months, and my average blood sugar keeps rising. It was about 10.5 (190) average for the entire day a month ago, and now it's up to 11.1 for the past week. Basically it just keeps creeping up, and it's now at the point where I'm basically hyperglycemic all day. My fasting is usually 11-14 (200-250), then goes down after a few hours of not eating any carbs. It goes up a lot after dinner typically to 14-19 (250-350. Aside from a couple hours during midday, every 10 carbs = an extra point of glucose, and it takes several hours to drop again.

Since metformin isn't an option, gliclazide isn't doing anything, and Victoza isn't helping enough, it seems like insulin is unavoidable at this point.

Question:
Are Type 2's usually started on long-acting or short-acting insulin first, when insulin is required? What's a common starting dose, and how is it calculated? I looked at a couple sites which try to explain it, but my brain couldn't process it at all :-(

Related Info:
My diabetes is secondary to a mitochondrial disease. Exercising makes me extremely ill and raises my blood sugar, presumably due to whatever it is that shuts down the rest of my body when exercising. I CANNOT EAT LOW CARB. Please do not suggest that I eat low carb: I'm sick of having it shoved down my throat here, and extremely cranky currently due to the chronic hyperglycemia, and I don't want to be forced to verbally eviscerate anyone Due to the same mitochondrial disease, cutting off a source of energy really messes me up, and leaves me completely nonfunctional.

I do limit my carbs, aiming for 100 per day. Less is nice, but hard for me to prepare because I can only sit and stand for a total of about 1 hour per day currently. Under 60-70 carbs makes me sicker. So basically I'm already eating less that half of the official recommended carbs.

A chart of my blood sugar over the past 2 weeks:

 

[Antje77]

I started insulin when still thinking I was T2. I started on basal only. I think the recommended amount to start with was 8 or 10 units, but my GP practice nurse and I decided to be more careful so I started on 4 units with the advice to up a little every 3 days until numbers got better.

Now we don't have the same HCP and aren't even in the same country so it may be completely different to how you'll be advised

After a month my fasting numbers had gotten a lot better but I still was very unhappy about the rises after foods, even with only a little carbs, so I started short acting as well.

Good luck, hope you'll find a way to juggle your different conditions and feel better!

 

[WuTwo]

Not T2 but wanted to come and say how very difficult all this sounds for you. I was started on mixed insulin when I began, and then after a couple of years I went basal-and-bolus, which I have to say is much easier to deal with.

I hope you get your clinic appointment sooner than a month! Good luck.

 

[Chook]

I am not on insulin any more but when I was I started on 10 units of Lantus both morning and evening which rapidly went up to 30 units twice a day then they added in Novorapid before every meal. My insulin resistance was (and remains) very bad so my insulin requirements carried on growing. I was still taking metformin and sitaglyptin while on insulin.

 

[MEValentijn]

Thank you for the info. I spoke to my GP on Friday on the phone (I can't sit up long enough for a visit), and she seemed pretty clueless about constant hyperglycemia being a somewhat urgent problem, especially combined with my other illness.

Her first suggestion was to get me tested for infections, treat the infections, and get my blood sugar down by removing the theorotical infection. Which would take weeks at a minimum, while I was really sick and getting sicker by the day. So I explained that when glucose is elevated due to an infection, insulin is still necessary to reduce it.

She wanted to try raising the dose of my Victoza, but I was already at the normal maximum (1.8mg) , and I'm pretty sure only a specialist can raise it higher. A specialist had to fill out a special form to authorize the use of it for me in the first place. And with my blood sugar 10-14 for most of the day, increasing the dose by 33-66% probably would not have had much impact.

So she agreed to try insulin, but was afraid that long-acting would make me hypoglycemic. The first insulin she prescribed doesn't exist anymore. The 2nd one she tried isn't very common here so didn't arrive at the pharmacy until this morning. I'm not a patient patient, so I may or may not have made alternative arrangements for the weekend, since I was at the point where I was going to end up in the emergency room, and I'm too ****** sick to get to the emergency room (A&E), much less sit around and wait and put up with whatever BS happens in hospitals.

I got the prescription this morning for Insuman Rapid SoloStar, with the instructions (translated directly): "1 x PER DAY 2 UNITS for subcutaneous injection if blood sugar is between 12 and 15." And no, that's not a typo. Even on the phone she was saying "maybe 4 units in the morning". For a fasting blood sugar that is 13 on average, and stays 10-14 all day when I was taking the maximum normal dose of both Victoza and Gliclazide Fortunately it came in a pack of 5 pens with 300 units each, and 40-50 units per day seems to work pretty well for me. So it's plenty to last me until I see the specialist in 3 weeks.

So typically I'm injecting 6-8 units when I wake up (sometimes going back to sleep) and then with breakfast and lunch, 10-14 with dinner, and another 8-10 at bed time to clean up whatever I missed from dinner. It's a little annoying because I'm using bolus injections to compensate for basal glucose levels, so there's a lot of up and down. I do wait until the prior injection wears off before injecting again, and I've been very cautious in dosing so far, which means I've mostly been in the 8-11 mmol/L range so far with insulin.

Even with that modest improvement, I've noticed huge improvements in my cognitive function, fatigue, and headaches, which I expected. What I was not expecting is that I've been able to be upright a lot longer while using insulin without depriving my brain of oxygen. So the 6-month exacerbation of my orthostatic intolerance (OI) may have been largely due to constant hyperglycemia. I started on the gliclazide shortly after the OI episode started, due to my blood sugar getting out of control starting several months prior.

Apparently OI from hyperglycemia is extremely common in diabetics, and can even be induced acutely in non-diabetics. Now it feels incredibly stupid that me and my doctors let it stay so high for so long. My previous GP even refused to adjust my diabetes medication further until I agreed to start exercising, which would make me extremely ill due to my other chronic disease (I fired her on the spot).

Oh well. The situation is under control for the time, and improved far more than I expected, despite the gross negligence of the Dutch medical system. I'm looking forward to seeing my old specialist again (she sent me back to my GP a couple years ago after we got my blood sugar under control at the time), and I'm not letting her discharge me again, I don't care how well things are going My diabetes is simply too complicated for untrained GPs to handle it.