Do we need to try a different insulin?

[SophiaW]

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?

 

[janabelle]

Hi, you're right to doubt your daughter's your ex-consultant. Repeated swings are not a good thing, and will make your daughter feel pretty lousy too. I was told exactly the same thing by my consultant a few years ago, when my BGs were up and down like a yo-yo and I was suffering other symptoms. She told me it was ok to go as high as 15-18 as long as it came down quick, but I'd been type-1 too long to swallow it, and believe she was fobbing me off as she was reluctant to take me off Lantus.
It turned out that Lantus did not suit me, it caused a host of problems, which I've since discovered are being increasingly reported, and lousy diabetes control.
You should expect your daughter's diabetes team to listen to you and work with you, after all you are the one dealing with her diabetes everyday and will have the most knowledge of her daily control.
I don't know about Apidra, but there are plenty of other insulins available including animal insulins. Here' a link to page on this website listing all available insulins. http://www.diabetes.co.uk/insulin-in-the-uk.html
I had a problem with Actrapid many years ago,that I would take it before a meal, but invariably end up hypo 2 hours after and hours after that! I'm on Porcine Neutral now, which is quite similar in action to Actapid, according to the profile charts, but works completely differently has a much more gentle action- my BG rarely goes above 9 after a meal, and no hypos 2 hours later.
We're all different and the current "one size fits all" prescribing of analogue insulin for everyone, is not, in my view, beneficial to us type-1s.
Your daughter's very lucky to have such a caring mum looking out for her.
Jus

 

[Dollyrocker]

I wonder if you need to look at ratios, for example I use 1unit to 10g for breakfast 1u to 15g for lunch but 1unit to 20g for my evening meal as otherwise I go massively hypo.

Are you using the same ratios all day?

Also, bear in mind the foods she is eating, Novo lasts for up to 4 hours so slow release carbs are a lot more east to cover than fast carbs like white bread and pasta

 

[Jen&Khaleb]

Khaleb is also on Levermir/Novorapid and just lately his levels have been doing some weird things. I too am thinking it could be the insulin but I also feel Khaleb is having a growth spurt so am going to wait it out and see what happens. Sometimes I think the Novorapid is beating the food it is working so quickly and then at night the Levemir seems to go on idle for a few hours between 3am and 7am. I've tried increasing the Levemir by half a unit and all I got was hypo's and still didn't help the early morning.

My only consolation is that Khaleb has been well for several weeks.

I always think that if I ask to change insulin I'll have to go on that whole re-learning diabetes experience and the grass might not be greener ....

For comparison's sake I can say that if I've given the Novorapid .5 hour before his meal and his blood sugar is between 6-8mmol he will not peak very high with his meal even at the 1 hour mark. Khaleb's meal would consist of some high GI and some low GI food eg. meat and veg with some fruit and custard. I certainly wouldn't have any levels above 15mmol and more likely still under 10mmol.

You can only give something else ago - hopefully with the support of your clinic - to see if there is a better match for your daughter.

 

[SophiaW]

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.

 

[leggott]

Hi. We have the same problem with our son, although only in the morning. We find that we have to give him a snack mid morning to avoid him dropping too low before lunch. if we adjust the ratio and give less insulin we too find he is too high at the 2 hour mark. We have his levemir at the right amount, although it would seem that at this time of day he needs far less back ground insulin. This problem will only be resolved for him by pumping. The snack works for us as he quite likes having a piece of fruit mid morning, but I understand how it could be missed; leading to a hypo. leggott

 

[jopar]

I was going to suggest pulling her injection time back, until you mentioned that pulling it back to 30 minutes before injecting would be inpractical, this will also rule out animal insulin as this has to be injected a min 30 minutes before eating...

By what you are saying, changing the ratio might solve the problems of the high, but will cause even more problems later with the tail end..

Apridra does have a lot more hit to it, and burns out a lot quicker, this might enable you to increase the ratio's and not cause the problem of the tail end, as it's a lot shorter...

A pump could be useful, but if the problem lies with a large spike, you would still have a problem with the tail end, it could be over come by turning the basal rate on the pump, but the user needs to be the main one in control..

It might be that a change to Aprida and using it in a pump would be more the answer

I would disguss these two options with the consultant

 

[janabelle]

Hi again Sophia,
Re- animal insulin. I can honestly say there is no problem with injecting animal insulin shortly before a meal, half an hour is not always required, as previous poster suggests. It works more gently and as a result goes in-line better with the carbohydrate eaten resulting in less of a BG raise.
Having been on synthetic Human short acting (actrapid) & rapid-acting analoguues, (both Novorapid & Humalog) in the past,my experience is that porcine insulin works more naturally, which isn't surprising as a pig insulin is very similar to natural human insulin.

I was never told about animal insulin when I was diagnosed in '88 or anytime afterward, I just considered it was not as effective as "modern" insulins. Everyone is different, and personally I wish I had been given the opportunity to try it rather than being told my diabetes would always be brittle when I was in my mid-twenties. I'd become resigned to the rollercoaster. Only been on it now for 2 1/2 yrs, but it works for me and no more rollercoaster thank heavens but ****-ups do happen!
If only type-1 diabetes was an exact science
Whatever you decide to do,whether it be a pump or otherwise, I sincerely hope things get sorted for your daughter, and best of luck.
Jus x
PS Carrots, Peas, and sweetcorn contain quite a bit of carbohydrate, though slow-acting, they can still raise BG. x

 

[SophiaW]

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.

 

[josie38]

hi sophiaw,

i have just been changed to apidra from humalog. i use it with a pump. i have found it quite good. it works quicker than my previous one so you have to be careful you dont hypo 2 hours after yaking it.

maybe getting a pump is the solution.

josie.