Doctor suggestion on Lantus insulin

[Chandradev819]

Before few month i had gone to hospital to my complete body checkup. Then Sr MD physician doctor suggested me, you can stop the Mixtard insulin (i.e Fast acting) and Increase the dose of Lantus insulin. So you have to take only one time insulin
in whole days.

But i donot find any logic in his suggestion, Lantus is long acting insulin which will last upto 20 to 24 hrs.

But After having dinner, our bg will increase more as compare to other time, so there will be demand of fast acting insulin which could brign the bg level in the normal rang. So i ignored the suggestion of doctor and I take Mixtard and Lantus both insulin.

Am i right or wrong in this decision ?

 

[catapillar]

Are you taking mixtard and lantus? Do you not have access to a bolus insulin, just a fast acting insulin?

Mixtard has both long acting and fast acting insulin. So the fast acting might cover your meal, but the long acting will continue to drop blood sugar for 6+ hours.

If you're taking both lantus and mixtard you are doubling up on your basal insulin.

You are at risk of hypos taking your insulin like this and you should get a bolus insulin.

 

[azure]

It's unusual to take Mixtard and Lantus too @Chandradev819

Have you considered swapping to a basal/bolus regime?

 

[novorapidboi26]

An increasing blood sugar not connected to a meal digestion doesn't mean fast acting is required..........it would be handy for corrections of course...

as others have said Lantus and mixtard seems to be a strange combination.....wrong possibly...

 

[azure]

I've just noticed that you said Mixtard was fast acting @Chandradev819 Thats only partly true - it's both fast acting insulin and slow acting insulin mixed together, hence its name.

I used a mixed insulin when first diagnosed (only that as it contains both types of insulin needed) and then swapped to basal/bolus.

 

[azure]

If your Mixtard isn't working properly that would suggest a change of dose or a change of mix (that is, a different percentage of fast and slow).

 

[noblehead]

Am i right or wrong in this decision ?

You need to contact your diabetes clinic and mention what @catapillar has explained to you, I'm thinking there may have been a misunderstanding somewhere along the way.

 

[SimonCrox]

I totally agree with above; if T1DM, lantus plus mixtard (no longer available in UK) is an odd regime, but lantus on own does not seem a step forward. Trying to attain reasonable control on Lantus alone in T1DM will mean either you are high after meals or on a bigger dose that you go low before breakfast or at 3.00 am.

If you are happy on your odd Lantus / Mixtard regime, I would not rock the boat, but I would check that control is OK.

So, I hesitate to be judgemental, and sometimes one does not know all the facts, but sticking to what works and finding out what is going on and what plans are sounds eminently sensible.

Stupid question coming up now; it really is mixtard cos not available here in UK, and being withdrawn elsewhere in world? Your diabetes is type 1? Sorry.

best wishes

 

[TheBigNewt]

I'm guessing the OP's native language is not English based on their post. Also, at least in the US, a prescription is required to get Lantus and Novolog (Novorapid in the UK), but one can get the older generic insulins like NPH and maybe what you call Mixtard (NPH/regular) without a prescription. Which makes no sense to me, but that's the way it is.

 

[Daibell]

Hi. I agree with the other posters that the normal regime for T1 is Basal/Bolus. Lantus is a very popular Basal in the UK and you need a Bolus. In the UK that would typically be NovoRapid (aka Novolog); there are some others. There is no real advantage in having any other regime although the insulin brands might vary. A lot depends on where you live but having a mixed insulin even with Lantus as aT1 is not the most flexible approach.

 

[Chandradev819]

Are you taking mixtard and lantus? Do you not have access to a bolus insulin, just a fast acting insulin?

Mixtard has both long acting and fast acting insulin. So the fast acting might cover your meal, but the long acting will continue to drop blood sugar for 6+ hours.

If you're taking both lantus and mixtard you are doubling up on your basal insulin.

You are at risk of hypos taking your insulin like this and you should get a bolus insulin.

Hi @catapillar, I am from India. Here we get all type of insulin. But when i was hospitalize in hospital, They were giving me 75 unit of Human insulin in 3 slots, Then my bg level come to normal range after 10 days. After that they make the combination of Lantus and Mixtard insulin combination. At that time i was taking 20 unit Mixtard in morning and 20 unit before lunch and 20 unit lantus at bed time

I was always checking my bg level and i was getting hypo then i started to decrease the dose. Now I am taking 2 unit before dinner and 2 unit at bed time. Now i donot get hypo symptoms any time. Only @4 or 5 pm evening i feel low bg level. At that time, i will eat fruit.

But in that hospital, for maximum people they were giving this combination of insulin. Really in this forum i donot have seen any person are taking this combination of insulin. Now i am confusion what to do ?.

 

[Chandradev819]

You need to contact your diabetes clinic and mention what @catapillar has explained to you, I'm thinking there may have been a misunderstanding somewhere along the way.

I used to go to hospital in every 4 months. They were telling to stop mixtard and keep continue lantus, but only with lantus i canot manage by bg level as per as expected level.

 

[TheBigNewt]

As others have said Mixtard is a combination of NPH (medium long acting, twice daily) and Regular (short acting, not as short as Novorapid or Humulog though). To add another longer acting insulin (Lantus) to the NPH/regular is unusual. Now you have 3 different acting insulins on board vitually 24 hours/day. I'd bring it up with a doctor and see if they understand what combination you are now taking. Most Type 1 diabetics take a true long acting insulin (Lantus is the prototype there are newer ones now) and a short acting with each meal (Novorapid, Humulog, Humulin).

 

[Chandradev819]

Hi. I agree with the other posters that the normal regime for T1 is Basal/Bolus. Lantus is a very popular Basal in the UK and you need a Bolus. In the UK that would typically be NovoRapid (aka Novolog); there are some others. There is no real advantage in having any other regime although the insulin brands might vary. A lot depends on where you live but having a mixed insulin even with Lantus as aT1 is not the most flexible approach.

In India also we get all type of insulin, but doctor has to give the prescription for that insulin.

 

[azure]

I used to go to hospital in every 4 months. They were telling to stop mixtard and keep continue lantus, but only with lantus i canot manage by bg level as per as expected level.

Some Type 2s only take a long acting insulin. It sounds like you're not being treated like most Type 1s would be.

If all insulins are available, you could stop the Mixtard and try Lantus plus a fast acting insulin like Humalog, etc.

If you feel your local hospital isn't as familiar with Type 1 as you'd like, could you swap hospitals or doctors?

I personally wouldn't take only Lantus as you'll go high whenever you eat.

 

[Chandradev819]

Thanks all for your suggestion, I will discuss with my doctor and change the insulin therapy.

 

[SimonCrox]

I feel that the main question to address at moment is type of diabetes.

If you started with 75 units insulin per day, unless you weigh 150 KG, you were insulin resistant then; mild insulin resistance happens in T1DM after diabetic keto-acidosis, but significant insulin resistance is the hallmark of type 2 diabetes. Type 2 diabetes can present as DKA (ketosis prone T2DM). And T2DM much more common than T1DM in Indo-Asian folk; so one must not miss the rare cases of T1DM that do occur.

If you are now on 2 units mixtard before dinner and 2 units lantus before bed, that is a very small dose; either you are in the honeymoon period (lasts up to about 1 year from diagnosis) of T1DM, or you have T2DM and your diet / exercise etc is working well.

If you have T1DM, then treatment is limited to insulin regimes alone; if you have T2DM, then there are many options, some of which would help with weight and not cause hypos.

So, IMHO, the first step is to ask your doctors what type of diabetes you have, and to consider urinary c-peptide to creatinine ratio to determine if your beta cells are making insulin themselves. I suspect that they think you have T2DM on small doses of insulin, which is why they have suggested stopping the Mixtard.

But, as you say, first thing is to chat with your doctors and see what they think

Best wishes

 

[Chandradev819]

Hi @SimonCrox ,
Thanks for sending your suggestion. I am type 1 person. When i was diagnosed i went for all the test, My pancreas produce
very less insulin, I hope i am in honeymoon phase, and i go to morning walk and aerobic exercise and i walk 2 to 3 km while going to office. So i hope i able to manage my bg level with less insulin.

I had feel some time it will go low and high due to wrong insulin therapy. So i will discuss with them.

You told "T2DM much more common than T1DM in Indo-Asian folk;" Yes i had also observed same thing, is there some reason behind this ?

 

[SimonCrox]

Why do Indo-Asian folk get more diabetes? A good question.

It is clear from data, that Indo-Asian folk get T2DM when less obese and younger than Europid folk.

See http://onlinelibrary.wiley.com/doi/10.1111/dom.12915/full

It has been suggested that the increased prevalence is due to lifestyle, sugary diet, lack of exercise, and obesity. But the above shows that they get diabetes more easily and the westernisation of lifestyle just makes it worse.

I have always been struck by the sugar content of Indian sweets, pure sugar! But I doubt that poorer folk could afford these; some studies eg in Nederlands have shown that a high sugar diet increases risk of diabetes, even with same BMI.

One study looked at middle aged folk in rural India, and on testing (cos 30 – 50% T2DM undiagnosed) 3% had diabetes despite being skinny and working on the fields – this is a high rate of diabetes.

Cannot find the paper, but the following summarises:-

http://journals.sagepub.com/doi/abs/10.1177/14746514070070010301

Some proposed the “Thrifty Genotype” theory which is in populations at risk of starvation, skinny folk do not survive, and the fatter ones survive episodes of starvation to breed and maintain their genes; this tendency to be energy efficient and fat is believed to make one more susceptible to diabetes (I have always felt this is a bit of an unsupported leap). Also, in Europe, we also had starvation; after the Black Death, there were not the folk to work the fields so there was no food, and people were not unduly upset to get press ganged into the Navy, cos they got “a square meal per day” (hence the origin of the English phrase).

https://en.wikipedia.org/wiki/Thrifty_gene_hypothesis

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2723682/

Others (Barker and Hales) were also not convinced and developed the thrifty phenotype hypothesis which is that if one is starved in utero as a foetus before being born, then one adapts to this, and this programming makes one more prone to diabetes, and cardiovascular disease.

Folk seem to favour this idea, and the data is clear; if one is born underweight and then gets overweight, one has a greatly increased risk of heart attack, stroke etc. But again, with modern life, maternal under nutrition will hopefully be less common; we have had Indo-Asian families in UK for decades, but their “children” – adults and parents themselves now, still have a very high prevalence of diabetes. So I am not totally convinced this is the answer – I think the phenomenon exists cos of good data, but am not sure it explains fully why so much diabetes in Indo-Asian people.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3390698/

https://en.wikipedia.org/wiki/Thrifty_phenotype



We know that relatives of Indo-Asian diabetic folk who do not have diabetes themselves, have insulin resistance (the start of T2DM), at a much greater rate than white Europeans. So something is happening to cause this, whether it be genetic or environmental.

At the end of the day, I suspect that it is a lot of bad luck giving the Indo-Asian population genes that confer high risk of T2DM, plus the thrifty phenotype and then they just cannot cope with a western lifestyle. The “Bad Luck Theory” has never been proposed before. The Finns have a lot of T1DM, cos of the bad luck to be a small population with an above average number of genes for T1DM (known as “The Founder Effect”).

Perhaps, you could ask your diabetes doctors and see what they think? Would be interested to know.

Best wishes

 

[SimonCrox]

Would be worth knowing for how long you have had the diabetes and to confirm that you are just on two units twice per day of insulin.
Also, what tests were done to show no insulin production?
In Ketosis Prone T2DM, when the blood glucose levels are high, the pancreatic beta cells go to sleep and do not make insulin, and then after a while of good glucose control, the beta cells wake up and produce insulin. So might be worth repeating the tests.
Best wishes