Novorapid - Could switching to Apidra or Humalog offer some benefit?

[Maxy]

Hey everyone,

After a long time waiting I've finally been able to begin pump therapy, I've experienced a great increase in control despite it being early days and "starting again". Before my main problems were:

• A very erratic and unpredictable basal rate that would still result in night-time hypos, which meant I had to cut out basal over-night altogether.
• My body digesting carbohydrates/proteins/fat extremely quickly (insulin not beginning to make a dent sometimes up to 2–3 hours after a meal) resulting in huge spikes unless I did my insulin a long time before the meal.
• Having to suddenly stop a highly active life-style/exercise routine due to hypos and other problems (despite carb-counting religiously, injecting temp basal/bolus to accomodate varying levels of activity).
• Not being able to eat certain types of carbohydrate without experiencing nasty spikes- in my case this has been bread, potato and pasta in that order. I've noticed rice sits with me a bit better regardless of white/brown. Low GI as expected sits with me better.

To get the idea/ to see some figures showing my general control please view this thread.

Since beginning pump therapy, my basal has been incredibly stable and predictable most of the time but I still have a long way to go before having a fine tuned regime. This as a result has alleviated the other problems in some ways- the main one for me being able to go to sleep without fearing hypo and/or waking up with ridiculously high readings.

______________

Thanks for reading this far! Today my diary is as follows:

I've had some extreme problems today again with my bolus not working at the time when I've eaten proper carbohydrate based meals. I wouldn't usually as much carbohydrate due to the fear of this.

This morning I was up at 6:45am, with a reading of 7.3mmol/L and had breakfast at 7:30, so:

06:49: 7.3 mmol/L

07:14: 6.4 mmol/L - 2 x slices of bread with cream cheese & slice of smoked salmon *yummy* (23g of carb per slice= 46g)

Felt extremely ill on the way to work, my Libre measured 15.0 mmol/L

At work did a blood test:

09:29: 13.3 mmol/L - Bolused for a cup of coffee 15g carbs

10:18: 11.1 mmol/L

Now went for lunch, had sausage and mash with onions and instant gravy- I predicted based on the portion size using carbs & cals app to be 65g of carbs approx- which offered a sizeable bolus.

12:36: 8.5 mmol/L - Approx 65g carbs, bolus just before meal

At around 14:27 I scanned libre and it read 21.4 mmol/L , I was shocked and thought it could just be a misreading - but did proper blood test and it was roughly correct:

14:31: 18.2 mmol/L - Gave a correction (with guidance from bolus wizard)

15:53: 15.3 mmol/L - Gave an additional correction with guidance of bolus wizard.

I double checked for ketones when I returned home from work, as usual I registered 0.1 ket mmol/L- I'm quite fortunate up to now *touch wood* to not be too susceptible to developing ketones very quickly- but i'm being extra vigilant now I'm pumping and take usual protocol - drinking water, retesting etc.
I suspect my doggy is lying on Libre on my bed.. once the lazy boy moves I'll download results for the whole day to show where I've gone since then.

Today was slightly different to others, I started in a very good place so thought I'd for once not stick with low carb/low GI and eat 'normal' quantities of carbs. Despite bolusing properly for both meals a similar pattern has emerged which is leading me to ask some questions in the interest of finding answers.

_________

After all that, my question is this- might I have any luck switching from Novorapid, to Humalog or Apidra?

I was considering this quite a while ago, but was told that it wouldn't be a good idea to make a change as I was attempted to get pump therapy approval- and if it suddenly worked better it could potentially affect my chances of success.

Would hugely appreciate hearing anyones experience on the following:

1. Have you experienced this chronic meal-spiking despite having an approved basal rate?
2. Had experience using Novorapid, Humalog and Apidra or experienced differences using different types?
3. Found that the type of insulin works better or worse when being pumped opposed to SQ injection?

I feel that injecting 30 minutes before eating just doesn't suit my lifestyle. I get great success following a low-carb diet but I would really like to be able to eat meals with substantial carb contents, especially when I begin exercising again. After reading through threads on here as well as other forums with anecdotal experience- I feel that Apidra might be well worth a try but would really value anyone's personal experience with any of this.

Thanks for reading and good-night all.

 

[tim2000s]

I think the key is in your decision today to move off a low carb regime. It normally takes a couple of days for the body to get used to going back on to carbs, and you see what appears to be insulin resistance. I've been there and it is wholly frustrating. Your body will take a few days to settle down, as what is effectively happening is that with the sudden increase in carbs, it tries to flood insulin and there is associated glucagon causing you the issues. Changing insulin won't help this. There are a number of studies in non-Diabetics showing the sudden insulin increase compared to a normal reaction.

Now went for lunch, had sausage and mash with onions and instant gravy- I predicted based on the portion size using carbs & cals app to be 65g of carbs approx- which offered a sizeable bolus.

12:36: 8.5 mmol/L - Approx 65g carbs, bolus just before meal

At around 14:27 I scanned libre and it read 21.4 mmol/L , I was shocked and thought it could just be a misreading - but did proper blood test and it was roughly correct:

Don't forget that this isn't only a high GI and high GL meal, it also has all the accelerants you might not want in it. Protein, Carbs and Fat together in this sort of combination have also sorts of weird and wonderful effects. I also wonder whether your estimate of carb content was correct - your blood results would suggest otherwise.

However you look at it, eating mashed potato is more or less the equivalent of eating sugar as it gets digested and into the blood incredibly quickly. Apidra, Humalog and Novorapid all have a peak action at around 1.5-2 hours, and the anecdotal feedback on Apidra from Libre users is that it is no faster in taking action than Novorapid. As a result, your bolus just before the meal won't stop the spike. You need to bolus ahead of time, but having the Libre has already told you that.

The other thing to consider is use of the super bolus with high carb meals. This rolls the next two or three hours of basal into your bolus and you set a low tbr for that period.

I think your biggest issue is that you want the impossible. Exogenous insulin that works instantly. Sorry, that just doesn't happen, The only thing that comes near is Afrezza, and that's not yet available in the UK. If you want your spikes smoothing you have to consider when to bolus. Otherwise you will continue to get them.

 

[Maxy]

I think the key is in your decision today to move off a low carb regime. It normally takes a couple of days for the body to get used to going back on to carbs, and you see what appears to be insulin resistance. I've been there and it is wholly frustrating. Your body will take a few days to settle down, as what is effectively happening is that with the sudden increase in carbs, it tries to flood insulin and there is associated glucagon causing you the issues. Changing insulin won't help this. There are a number of studies in non-Diabetics showing the sudden insulin increase compared to a normal reaction.


Don't forget that this isn't only a high GI and high GL meal, it also has all the accelerants you might not want in it. Protein, Carbs and Fat together in this sort of combination have also sorts of weird and wonderful effects. I also wonder whether your estimate of carb content was correct - your blood results would suggest otherwise.

However you look at it, eating mashed potato is more or less the equivalent of eating sugar as it gets digested and into the blood incredibly quickly. Apidra, Humalog and Novorapid all have a peak action at around 1.5-2 hours, and the anecdotal feedback on Apidra from Libre users is that it is no faster in taking action than Novorapid. As a result, your bolus just before the meal won't stop the spike. You need to bolus ahead of time, but having the Libre has already told you that.

The other thing to consider is use of the super bolus with high carb meals. This rolls the next two or three hours of basal into your bolus and you set a low tbr for that period.

I think your biggest issue is that you want the impossible. Exogenous insulin that works instantly. Sorry, that just doesn't happen, The only thing that comes near is Afrezza, and that's not yet available in the UK. If you want your spikes smoothing you have to consider when to bolus. Otherwise you will continue to get them.

Think the sugar and frustration was clouding my mind and judgement yesterday- all of the above rationalises a lot of my concerns. Thanks for your reply.

• "Don't forget that this isn't only a high GI and high GL meal, it also has all the accelerants you might not want in it. Protein, Carbs and Fat together in this sort of combination have also sorts of weird and wonderful effects. "
  
  - All great points for consideration.
  
  
• "I also wonder whether your estimate of carb content was correct - your blood results would suggest otherwise."
  
  - Equally, although on many other occasions- especially in the evening I'm able to eat a meal like this no question- which would lead me to believe ratios/basal rate early morn till noon could be part of the problem.
  
  
• "However you look at it, eating mashed potato is more or less the equivalent of eating sugar as it gets digested and into the blood incredibly quickly."
  
  - I think I knew this but subconsiously didn't want to accept this at the time.. I'm a sucker for sausage and mash.
  
  
• "The other thing to consider is use of the super bolus with high carb meals. This rolls the next two or three hours of basal into your bolus and you set a low tbr for that period."
  
  - Find this idea very interesting, would like to learn more- would you have some advice on where to start with this?
  
  
• "I think your biggest issue is that you want the impossible. Exogenous insulin that works instantly. Sorry, that just doesn't happen, The only thing that comes near is Afrezza, and that's not yet available in the UK. If you want your spikes smoothing you have to consider when to bolus. Otherwise you will continue to get them."
  
  - Final reality check, thanks again. As I should have already learnt by now there's never a simple nor convenient way to do anything with T1. Saying that I never believed DSNs words suggesting that you can eat ANYTHING on the pump as long as you bolus pre-meal.. this skips the part about the long list of foods you actually can't necessarily eat at all (not that I'd eat most of them anyway) and having to inject in prep a long time before.
  I'm seriously struggling with this- at work I have the obvious limitations of not being able to weigh food I buy at cafeteria- and the food that is conveniently labelled with carb values (often sandwiches) send me flying up. I find myself a lot of the time just not eating to avoid the hassle of getting ill so I can keep up with my work schedule which makes things even worse.

It feels there are so many oddities and factors coming into play that I can't keep up with what's going on.

The same thing has happened today with a pretty similar patterns- got into work after basal had taken me down to an okay place last night, was too scared to have breakfast- had a coffee with milk.. bolused for 15 grams of carbs (which from my memory is conventionally enough to cover 245ml of milk) and BAM. Shot up through the roof and didn't even show signs of coming down until lunch. (12:30) I'll post Libre logs from past two days below:

In other news the sensor has been quite dodgy- off by 3mmol/L at times, close to blood at others and I've got this nasty bruise:

When I first put it on around 8 days ago blood literally shot straight out the end of it all over my bed, first 48 hours or so were hopelessly inaccurate- following days after were intermittently okay. Scans have been close to real blood readings, especially considering over past two days rising and falling has been so steep that interstitial fluid is going to appear very behind blood.

This leads me to think (and worry) that these spikes aren't signs of the body fighting infection due to sensor? Not sure if that's a realistic consideration. Something has suddenly changed this week than what was happening doing the same thing last week.
(Just to add, no sign of itching or anything which makes me think an infections is probably unlikely, but I've been a bit sniffly- I would have expected this to raise blood sugars full stop, not just at bolus).

 

[Maxy]

And also,

I think the key is in your decision today to move off a low carb regime. It normally takes a couple of days for the body to get used to going back on to carbs, and you see what appears to be insulin resistance. I've been there and it is wholly frustrating. Your body will take a few days to settle down, as what is effectively happening is that with the sudden increase in carbs, it tries to flood insulin and there is associated glucagon causing you the issues. Changing insulin won't help this. There are a number of studies in non-Diabetics showing the sudden insulin increase compared to a normal reaction.

Just to make my eatings habits more clear- I consume up to 100 grams of carbohydrate a day at the moment, I don't really have days where I eat little/no carbs, I just tend to eat much lower- eat roasted root vegetables with meat and vegetables for example.
The above sounds very familiar to me though.. Not being able to exercise as I usually would makes this even harder as I don't have as much desire to eat as many carbohydrates either.
How would you suggest I eat at the moment as a general rule of thumb? (Say 'x' number of carbs per meal, 'x' many times a day) I ask this in the interest in avoiding this continuous shift. Cheers Tim

 

[Maxy]

Although I'm certain it's not impossible, plus I'm willing to work and practise discipline to try anything that works to my benefit- I cannot honestly picture myself knowing exactly how much I'm going to eat in a single sitting; that's before even knowing exactly what I'm going to eat.. and more importantly when I'm going to eat it.

To top it all off having to bolus 30–90 minutes prior to the said unknown meal makes it seem even less likely I can make it happen with my work-life. I've certainly noticed the pump has made things a bit more convenient to an extent- but I really hope your suspicions above are indeed the case otherwise I can't see things getting better anytime soon.

Things just seem to be going from okay to absolutely crazy at the tip of a hat- perhaps I'm just forgetting that diabetes is just like this a lot of the time.

 

[tim2000s]

Have you corrected in those libre logs or is that just the up and down from your normal bolus? If it is the latter, you need to bolus significantly earlier than you are doing. Maybe even 45-60 minutes earlier. You seem to be incredibly sensitive to carbs and not so much to insulin. They also look like very fast carbs.

This is mine today. Ignore the Reds - my sensor is reading 2mmol lower than it should. While I'm a bit up and down, I bolus 30-40 mins before food and it limits my ups. I've eaten about the same amount of carbs as you today.

 

[Maxy]

Have you corrected in those libre logs or is that just the up and down from your normal bolus? If it is the latter, you need to bolus significantly earlier than you are doing. Maybe even 45-60 minutes earlier. You seem to be incredibly sensitive to carbs and not so much to insulin. They also look like very fast carbs.

This is mine today. Ignore the Reds - my sensor is reading 2mmol lower than it should. While I'm a bit up and down, I bolus 30-40 mins before food and it limits my ups. I've eaten about the same amount of carbs as you today.

Just thinking back to it- I'm not even eating more carbs than I was before really, i've been eating meals with significant quantity every day- would only a few hours of not eating carbs be enough to send my body into this state? Last night I had roast dinner with roast potatoes, vegetables, home made gravy (no carbs) chicken with skin- high fat content, see late evening above 02 Nov Monday. Surely if anything the protein and fat would decrease the rate of carb absorption in the gut? (albeit it high GI) Instead it immediately spiked as it had done throughout the day.

I'm honestly not sure I can actually bolus that amount of time earlier.

I've had some days that look like yours above recently since I've begun pumping, then I keep getting days like this; sporadically.

 

[tim2000s]

On your other point about what you could eat - try having a breakfast that doesn't involve carbs. Bacon and eggs for example, and see what happens there with regard to levels? I've a suspicion about other things going on, but I'll pm you about them, and a no carb meal would confirm it.

The other question is are you sure your basal incorrect as that can also affect bolus behaviour?

 

[Maxy]

On your other point about what you could eat - try having a breakfast that doesn't involve carbs. Bacon and eggs for example, and see what happens there with regard to levels? I've a suspicion about other things going on, but I'll pm you about them, and a no carb meal would confirm it.

The other question is are you sure your basal incorrect as that can also affect bolus behaviour?

Sorry to correct yet again Tim, (trying not to sound like I'm changing my story or anything!) but this is my breakfast of choice and will eat it every day when I can. Most days I have a carb free breakfast like this (exactly like this, bacon and eggs)- even this raises my levels in a similar respect. When I say I low carb, I probably refer to some meals having low/no carb content to some being full (e.g. bacon and egg for breakfast) , meat and potatoes for dinner).
The morning where I had toast and smoked salmon was an exception as I tend to not eat carbohydrates for breakfast (probably developed this habit through avoiding morning spikes).

I'm laughed at when I tell them that protein and fat raises blood sugar levels so significantly- told I must be doing something else wrong.

In answer to your question about basal, some days my rate seems to bringing me down to a perfect 7-9 with flatline stability, other days it just hovers around 12–14 (doing the same things/same activity on both days). Before pumping I did two separate basal tests for each time block- I was told my basal was fine on two occasions (but still experienced the bolusing problems).

I've been trying to begin my night-time basal recently but I've not qualified with a stable enough starting point/been able to fast.

 

[Maxy]

Just wanted to update everyone on how this went.

I found switching to Apidra very beneficial- as forum members mentioned above, there more than likely wasn't much in speed of action on an individual basis- but I strongly believe that just switching analogue was effective. Fewer spikes, flatter levels overall. Even after switching temporarily back to Insulin aspart (Novorapid) whilst I waited for GP to sign off new prescription; there was a noticeable responsiveness to the medication- body seems to metabolise carbohydrates more as it should.

Have currently misplaced my Libre so I'm currently unable to show my data at the moment. However throughout this time my basal rates remained the same. I wonder why this worked in the way it did- perhaps the insulin gets lazy/the body develops a resistance to the individual analogue?

Thanks for the above replies, take it easy everyone.