Do we need to try a different insulin?

This has been troubling me for some time and I want to ask other T1's what their thoughts are. Last year my daughter was switched onto a basal bolus regime using Levemir and Novorapid. After quite a lot of testing and fasting I feel confident that I have her basal dose correct. Most of the time her readings when she's not eating keep level. We have problems in the early hours of the morning but that's a different topic. Apart from the early mornings her readings stay level when fasting.

The Novorapid is what's troubling me. I carb count and inject for a meal. At 2 hours post meal her readings have gone quite high. Sometimes as high as 15 to 18 mmol/l. At 2.5 hours her readings can still be high, still around 12 to 15 mmol/l. Only from 2.5 hours onwards does she see a reasonable reduction in levels and by 3 hours she's returned to around 7 to 8 mmol/l. From 3 to 4 hours post meal her readings continue to drop, more slowly now, to around anywhere between 4.5 and 6.5 mmol/l. I have tried increasing the amount of insulin she has with a meal so that her readings come to an acceptable level within 2 to 2.5 hours. But the trouble we have then is that her levels continue to drop until the 4 hour mark resulting in a hypo. It's like the insulin takes too long to act and then goes on working for too long.

Last year when I first identified this problem our previous consultant (we've recently moved to a different consultant) said that perhaps we'll just have to accept that her readings take longer to drop and we left her at the ratio she is on now. It works well in that her reading comes back to a good level after 4 hours and stays there. But I'm concerned that it's taking too long to come down and that she's going too high before the insulin works effectively. I'm not confident that the consultant's opinion was correct.

I have read about Apidra insulin which appears to have a quicker action and a shorter lasting effect than Novorapid. What are your thoughts about our situation? Should I ask to try out Apidra? Is a reading in the mid to high teens 2 hours after a meal acceptable? Is it ever acceptable to go that high?

Thanks everyone for the replies. I'm going to discuss this with our new consultant when I see him next and see what his opinion is.

We have tried adjusting the insulin carb ratios, a year ago when we first started this, but what we're on now seemed to work the best to avoid hypos at the 3 to 4 hour mark. But it doesn't work so well, in my opinion, in the first 2 hours.

We do have varying carb ratios depending on the time of day. It's currently 1:8 for breakfast, 1:13 for lunch and 1:12 for evening meal.

I know injecting about half an hour before the meal might solve this problem. But it's not practical to do so. We could increase her insulin and then make her have a snack at the 2 hour mark but again it's not really practical and then we run the risk of her forgetting the snack and ending up in a hypo.

Jess doesn't eat bread very often as she doesn't like it. Breakfast is typically one of the following weetabix, porridge, fruit (melon) and yoghurt, eggs mushrooms bacon and milk or a very small glass of fruit juice. Lunch is typically a combination of the following fruit, vegetable sticks, quavers, yoghurt, cereal bar (kellogs special K) or crackers/oat biscuits and cheese, a very small Kinder chocolate bar (6.6g carbs) and sugar free squash. On a Friday I usually include a treat of some sort like a small muffin or kitkat. Evening meals are typically a very small piece of meat (she doesn't like meat and often won't eat any of it) or fish which she does like a lot, lots of veg like carrots, peas, broccoli, green beans, baby sweetcorns - all very low in carbs, and then a small serving of carbohydrates like rice, couscous, potatoes or pasta. She often has a pudding that is a yoghurt, fruit or a small helping (75g) of vanilla icecream. Inbetween meal snacks, when she has them as she doesn't snack a lot, is fruit, popcorn, cheese, peanuts, sugar free jelly, quavers, small biscuit (usually reserved for the days she will be doing sport and needs an extra boost).

Jen, I know what you mean about the feeling of having to relearn the whole thing all over again. We've been through too many insulins to try and find something that works for us and the thought of trying yet another one is something I dread. But, we're hoping to get onto a pump sometime soon and if that is going to happen then it might be the opportunity to look at finding a more suitable insulin if this one turns out not to be the right one for us.

Thanks once again to everyone for your reply. It is reassuring to know that I have a network of people who can help me brainstorm when things aren't working as well as I'd like.

Jopar, you have it exactly right, that is exactly the problem we're facing. Our new consultant has recommended a pump for Jess and we're hoping to get the ball rolling with that quite soon. This is why I'm thinking if we're going to make changes to the type of insulin this would be a good time to do it as we'll be starting over once again.

I'll also mention animal insulin together with Apidra and see what he thinks. But if it indeed means injecting up to half an hour before the meal then it won't work for us.

Leggott, Jess seems to be similar to your son. Her most difficult spike is in the mornings, lunch time and evening meal time isn't so bad - still not ideal but not as high figures as the morning spikes. She already is on a high dose of insulin for the mornings. I think this problem is being compounded in the morning because she experiences something like dawn phenomenon where she sees a rise in readings from around 4am. If we increase her Levemir at night then we see hypos around 2am.

We've tried so many variations of Levemir doses that I feel exhausted by it. My most recent solution was to get up every morning at 4am to do a small Novorapid injection which did help tremendously but after a few months of doing this I was exhausted, tearful and not really coping all that well anymore. This is when I asked our GP to refer us for a second opinion, best thing we ever did. The new consultant immediately recommended a pump, he says it's the best way to get around the problem successfully.

Jus, yes I wish diabetes was an exact science. I wish everyone was the same and one solution would fit all. It would makes things a whole lot easier to manage. I should have worded my reference to the veg differently, I meant they're low in quick acting carbs.