Why are some people on full basal and others are not?

[Dixon1995]

Hi all just a quick question. For years my grandad was on 1 injection of glargine, 40-50 units to last him 24 hours until the next day, he suffered a lot with he's type 1 diabetes and recently passed away...

It was taking it's toll on he's body but he died of somehing else...I can't help think, those months leading up to hes death, the steroids he was on caused he's blood sugar to be high, like 16, he would go in hospital and they would lower it for him, but he couldn't take corrections if it went high at home, yet I have Novo-rapid and wanted to give him some and was told I am not allowed, but he kept deterioting and the high blood sugars did not help.

He's last months of life where constant high sugars and I think

Is there a true reason for not giving it? Was it he's age?

 

[kitedoc]

Hi @Dixon1995, I can make some guesses based on my general experience but cannot provide a definitive, professional type answer. So, the following is conjecture and not meant to criticise any group, just state it as I saw and experienced it.
In past years (I was diagnosed in 1966) the management of diabetes by doctors was less stringent than that of today.
There were no blood glucose monitors. Insulins back then had irregular absorption compared to today's offerings; and pumps, pens, HBA1C testing did not exist.
Typical regimes I was prescribed or were prescribed to others I spoke with whilst waiting in the hospital diabetic clinics, were once per day long acting insulin, maybe there would be a dose of soluble insulin (which was not ideal for dealing with meals anyway). Sometimes this extended to twice daily long and short-acting insulin.
Also there was the concern about hypos so one default position was to just prescribe long-acting insulin as a least harm measure whilst ignoring the long term problems of diabetic complications.
One sad eventuality, too, was that such patients later might have developed blindness and the work schedules of district nurses may have only allowed them time to give a once daily dose of insulin.
There could also have been some patients who refused to change to a better insulin regime or only to do so in respect to the continuation of a long acting regime alone. Whether this refusal is due to stubbornness, loyalty to the original doctor or whatever who can tell? Refusal or inability to adapt to finger-prick testing or the negative attitude of a an old doctor towards new-fangled gadgets may have also been factors in perpetuating inadequate insulin regimes for patients, and again the concern for hypos in the elderly might have influenced the decisions about insulin prescription at some point.
Mind you, there are so many insulin options these days, (and available since the 80s in some cases) including pre-mix insulin which in theory at least might have offered better BSL control than a once daily long-acting insulin.
I am sorry for what happened to your grandfather when there are some who have lived for 70 + years on insulin.

 

[Dixon1995]

Hi @Dixon1995, I can make some guesses based on my general experience but cannot provide a definitive, professional type answer. So, the following is conjecture and not meant to criticise any group, just state it as I saw and experienced it.
In past years (I was diagnosed in 1966) the management of diabetes by doctors was less stringent than that of today.
There were no blood glucose monitors. Insulins back then had irregular absorption compared to today's offerings; and pumps, pens, HBA1C testing did not exist.
Typical regimes I was prescribed or were prescribed to others I spoke with whilst waiting in the hospital diabetic clinics, were once per day long acting insulin, maybe there would be a dose of soluble insulin (which was not ideal for dealing with meals anyway). Sometimes this extended to twice daily long and short-acting insulin.
Also there was the concern about hypos so one default position was to just prescribe long-acting insulin as a least harm measure whilst ignoring the long term problems of diabetic complications.
One sad eventuality, too, was that such patients later might have developed blindness and the work schedules of district nurses may have only allowed them time to give a once daily dose of insulin.
There could also have been some patients who refused to change to a better insulin regime or only to do so in respect to the continuation of a long acting regime alone. Whether this refusal is due to stubbornness, loyalty to the original doctor or whatever who can tell? Refusal or inability to adapt to finger-prick testing or the negative attitude of a an old doctor towards new-fangled gadgets may have also been factors in perpetuating inadequate insulin regimes for patients, and again the concern for hypos in the elderly might have influenced the decisions about insulin prescription at some point.
Mind you, there are so many insulin options these days, (and available since the 80s in some cases) including pre-mix insulin which in theory at least might have offered better BSL control than a once daily long-acting insulin.
I am sorry for what happened to your grandfather when there are some who have lived for 70 + years on insulin.

Yeah that all makes sense, and re-reading my original post makes it seem as though I was being, perhaps, one sided, as I don't know the full ins and outs of grandads treatment, but I do know he was refused any insulin that worked quicker than the Glargine, which in my opinion was a shame, because he was only diagnosed type 1 in 1993 at age 41. It's just annoying know that I basically had the medicine to take he's blood sugars down a touch, maybe through 1 or 2 units quick acting, but was given no explanation as to why I couldn't, and neither was he when he asked.. but througg your explanation I can see possible reasons why that might be, especially the NHS being stretched being one of them as they might not have had time to teach him new methods of treatment.. but I dunno, I guess I look at it narrow mindedly sometimes

 

[ickihun]

Hi all just a quick question. For years my grandad was on 1 injection of glargine, 40-50 units to last him 24 hours until the next day, he suffered a lot with he's type 1 diabetes and recently passed away...

It was taking it's toll on he's body but he died of somehing else...I can't help think, those months leading up to hes death, the steroids he was on caused he's blood sugar to be high, like 16, he would go in hospital and they would lower it for him, but he couldn't take corrections if it went high at home, yet I have Novo-rapid and wanted to give him some and was told I am not allowed, but he kept deterioting and the high blood sugars did not help.

He's last months of life where constant high sugars and I think

Is there a true reason for not giving it? Was it he's age?

Not sure if because of his age. More his capability. If he cannot manage novarapid doses he would have died earlier and from diabetes. Right?
They may have risk assessed his capabilities to manage novarapid or similiar before deciding his management plan and its constant reassessment.

However I did see in our own forum diabetes news a thread regarding news of requests to give more individual diabetic care per person in the elderly. I hope this happens too as not all 65yr old are the same. I fear me getting that age and Neglect of my management due to assuming all 65yr olds are the same. Not all type2s are, neither type1s.

 

[KK123]

Yeah that all makes sense, and re-reading my original post makes it seem as though I was being, perhaps, one sided, as I don't know the full ins and outs of grandads treatment, but I do know he was refused any insulin that worked quicker than the Glargine, which in my opinion was a shame, because he was only diagnosed type 1 in 1993 at age 41. It's just annoying know that I basically had the medicine to take he's blood sugars down a touch, maybe through 1 or 2 units quick acting, but was given no explanation as to why I couldn't, and neither was he when he asked.. but througg your explanation I can see possible reasons why that might be, especially the NHS being stretched being one of them as they might not have had time to teach him new methods of treatment.. but I dunno, I guess I look at it narrow mindedly sometimes

So your Granddad was 66? I thought at first you were talking about someone of 90 and was thinking that maybe that was the reason they weren't too concerned about his high levels. I cannot answer your question but I wonder if as you say, it was to do with a whole combination of drugs he was on and that they thought highs of 16 was the lesser of two evils? Would you mind telling us what he died of and what his general health was like because at 66 he was a 'young' man. You sound like a very concerned grandchild and I am sure he was grateful for that. x

 

[kitedoc]

Hi @Dixon1995, In 1993 multiple insulin injections, basal bolus regimes we all the rage. I am amazed that he would have been refused anything other than long-acting insulin at age 41. There is something fishy here - unless he was totally unable to manage short-acting insulin, was prone to hypos or had hypo unawareness. There should be medical notes to justify such an unusual insulin regime, as opposed to use of usual guidelines and the variety of insulins that were available then.
It is possible, i suppose, that during the honeymoon period he was prescribed a long-acting insulin regime - as others I have spoken with describe but that is really only the first 12 months or so (usually).

 

[Dixon1995]

Not sure if because of his age. More his capability. If he cannot manage novarapid doses he would have died earlier and from diabetes. Right?
They may have risk assessed his capabilities to manage novarapid or similiar before deciding his management lan and its constant reassessment.

However I did see in our own forum diabetes news a thread regarding news of requests to give more individual diabetic care per person in the elderly. I hoe this happens too as not all 65yr old are the same. I fear me getting that age and Neglect of my management due to assuming all 65yr olds are the same. Not all type2s are, neither type1s.

I would say he was capable of using a faster acting insulin. I don't know the reason he was refused, but I know he had asked years earliar, as early as being 55 years old, to go on something more manageable, even NovoMix etc. I guess that did not come to fruition.

Im not knocking any health authority here either, I just wanted some suggestions really that I haven't already thought of, and these are great, it just seemed like a waste to me for him to come from Hospital, to be having to go back into hospital when he's sugars where too high, but not start him on something more manageable.

This is the thing, 8 years prior to he's death he did ask to go on Novo Rapid because I was on it, and he was amazed how my sugars stayed at the low end, he was a smoker however, had Angina, and had a heart attack previously I believe, which was probably related to him smoking but also he's high blood sugars.. he also had low blood sugars if he didnt eat as much I think he found that most difficult.

In the end he died from another heart attack whilst battling a brain tumor and lung cancer, but he's quality of life was ruined by Diabetes, I know he probably still would have died anyway, but 8 years prior, or even 22 years prior, he could have been given an opportunity to try something else, he said he was never given that choice, and be that because he's health, or the reasons above, at least now I know why, and that it is good that I didn't try lower he's sugars for him...

 

[tim2000s]

In 1993 multiple insulin injections, basal bolus regimes we all the rage. I am amazed that he would have been refused anything other than long-acting insulin at age 41.

I can imagine what happened. In 1991, the way T1D was treated in the UK was that you were started on 2x Daily Dose, before being moved onto MDI in most cases.

If you were using 2x Daily, it was two doses of NPH, usually in the form of what is now known as Insulatard. You then had to eat regularly and consistently to the insulin, which of course had a peaky profile. Most of us were moved on to MDI using this as background and Actrapid as mealtime.

If he was under the care of a GP, it's very possible that the GP believed that he was T2 (late onset and he was on 2x NPH) so he only needed background insulin, so moved over to Glargine because, well, that's what is recommended as the first step for insulin with T2. He should probably have been put on 2x Novomix 30/70 rather than Glargine.

Using only Glargine would really make life difficult as you'd have to take a massive dose and then eat to lift your glucose levels, which would be incredibly tough. I imagine that his Hba1C values probably fell in the larger numbers?

Whilst I know it doesn't help you or your grandfather, it does appear that he has been very poorly managed within the NHS area that you are in, and I think you'd be within your rights to make a number of complaints about his treatment.

 

[Dixon1995]

I can imagine what happened. In 1991, the way T1D was treated in the UK was that you were started on 2x Daily Dose, before being moved onto MDI in most cases.

If you were using 2x Daily, it was two doses of NPH, usually in the form of what is now known as Insulatard. You then had to eat regularly and consistently to the insulin, which of course had a peaky profile. Most of us were moved on to MDI using this as background and Actrapid as mealtime.

If he was under the care of a GP, it's very possible that the GP believed that he was T2 (late onset and he was on 2x NPH) so he only needed background insulin, so moved over to Glargine because, well, that's what is recommended as the first step for insulin with T2. He should probably have been put on 2x Novomix 30/70 rather than Glargine.

Using only Glargine would really make life difficult as you'd have to take a massive dose and then eat to lift your glucose levels, which would be incredibly tough. I imagine that his Hba1C values probably fell in the larger numbers?

Whilst I know it doesn't help you or your grandfather, it does appear that he has been very poorly managed within the NHS area that you are in, and I think you'd be within your rights to make a number of complaints about his treatment.

Life was very difficult for him with diabetes but he never ever complained to us, just got on with it. Thankyou for your advice

 

[Daibell]

Hi. Sounds like he was not given the correct insulin regime for his condition by the GP or whoever. Needs some investigation and explanation.

 

[ickihun]

I would say he was capable of using a faster acting insulin. I don't know the reason he was refused, but I know he had asked years earliar, as early as being 55 years old, to go on something more manageable, even NovoMix etc. I guess that did not come to fruition.

Im not knocking any health authority here either, I just wanted some suggestions really that I haven't already thought of, and these are great, it just seemed like a waste to me for him to come from Hospital, to be having to go back into hospital when he's sugars where too high, but not start him on something more manageable.

This is the thing, 8 years prior to he's death he did ask to go on Novo Rapid because I was on it, and he was amazed how my sugars stayed at the low end, he was a smoker however, had Angina, and had a heart attack previously I believe, which was probably related to him smoking but also he's high blood sugars.. he also had low blood sugars if he didnt eat as much I think he found that most difficult.

In the end he died from another heart attack whilst battling a brain tumor and lung cancer, but he's quality of life was ruined by Diabetes, I know he probably still would have died anyway, but 8 years prior, or even 22 years prior, he could have been given an opportunity to try something else, he said he was never given that choice, and be that because he's health, or the reasons above, at least now I know why, and that it is good that I didn't try lower he's sugars for him...

I definitely understand why you're questioning his treatment of diabetes in his past. I do the same for me, as many others do.
Seeing as your grandad was a type1 I'm led to believe more of a risk of diabetes complications or hypos. When did his cancer treatment start? As if at a time where his diabetic treatment was working I can see why they allowed the stability of his insulin. Could he have indicated similiar whilst worrying about his cancer?
I know I had a period on mixed insulins and easier for me as I took before food and just tested, no corrections. I was asked to go on separates at time of possible heart failure investigations so I asked for it to be postponed for a few weeks. Which they did.
If your grandad was unhappy with his treatment I can definitely see why you are too. Or was he just going with the flow so less stress. I'm sure his breathing must have been very very affected. When I'm having asthma problems I'm exhausted. He definitely must have been.
It just may not have never been the right time for him to be changed?