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[IPm] Re: Humalog Sensitivity -- Problem, Solutions
Please do not interpret my reply as a "poo-poo" of your observations. I
think that they are probably correct, but I think that the explanation that
you were given is highly unlikely. Instead, I offered a mechanism by which
I believe that they can plausibly be explained.
I am not surprised that the "tail" effect proved undesireable. Lispro
insulin has been a tremendous boon. It finally made pumps really useful.
unfortunately, it is far from an ideal pump insulin, just as you point out.
From the data that I have seen and from my own pre-launch experience, I
think that aspart (Novolog) may be superior in pumps, although I am not yet
ready to endorse it as the universal pump insulin.
> > Dear Michael:
> > The explanations that you have been given are very improbable.
> > Although I am not privy to all of the physico-chemical data
> > regarding lispro insulin, insulin loss can occur by one of three
> > mechanisms.
> Hi Dr. Shank.
> I don't have any personal knowledge or understanding of the
> mechanisms involved in the chemical interactions that I reported, I'm
> just the bearer of the news.
> > I invite your pharmacist contact, Sofia A. Iqbal, R.Ph., to respond
> > to my analysis.
> This is not the person who provided the information, she is the Novo
> representative co-ordinating the Compassionate Need program.
> If you'd like to pursue further discussion, contact
> > Bill Van Antwerp <email @ redacted>
> > I am perfectly happy to be quoted, in fact if any doctors want to
> > talk, give them my phone number, 818 576 4913.
> Bill is the scientist doing the investigation into the Humalog / site
> life problem. Bill has been investigating this for some time and as I
> understand it is co-ordinating his work with people at Lilly.
> I'm sure you have a better grasp than I of what is going on with
> insulin in the tubing and at the infusion site. However, just
> because conventional wisdom dictates that my hypothesis doesn't make
> sense, it should not be discounted because there are are large number
> of people for whom mixing insulin demonstratively extends the life of
> the infusion site. I must admit it does not seem reasonable to me on
> the surface, but having carefully tested that mixing H/V works I can
> at least say personally that the results are very compelling. I did
> not relate this in my original post because I don't feel that it is
> relevant nor does it add to the "science" behind why it works but I
> will relate my experience to you in the hope that it will raise some
> questions in your mind.
> My daughter (now 18) has been diabetic since age 11 and began pump
> therapy with a few months of diagnosis using steel needles and
> Velosulin. She quickly developed a regimen of changing her infusion
> sites twice a week on every 3rd and 4th day. This routine fit nicely
> into her schedule and there was no discernable change in bg's on the
> 3rd or 4th day for a particular infusion set. When Humalog came on
> the market, she stopped using Velosulin and switched to the new
> insulin analog. Immediately she began seeing bg's rise unpredictably,
> usually on the second day after an infusion set change. Putting in a
> new set would immediately fix the problem. At the time, it was not as
> simple as that since we had no idea what was causing the problem and
> investigated all imaginable scenarios. I am an engineer by profession
> so I like tidy answers. After a month of "fooling" with Humalog, I
> switched her back to Velosulin and her bg's immediately stabilized
> with site life returning to >> 3-4 days. Around that time I received
> an email report from a man in Davis Calif. that he had tried mixing
> insulins and found that it helped with site life problems. This
> didn't make a lot of sense to me but my daughter much preferred the
> rapid action of the Humalog and wanted to continue using it if
> possible. We continued using only Velosulin for a 4 week period while
> I kept a record of my daughter's bg's and site longevity. We then
> switched to a mixture of 5 parts Humalog and 1 part Velosulin and I
> again observed her bg's and site life. These remained substantially
> identical to the case with Velosulin only but much better than her
> previous experience with Humalog. We later experimented with lower
> mix ratios, but the "tail" on the longer acting insulin was
> undesirable and there was no apparent improvement in bg stability or
> site life.
> I realize that a data point of one is not good science, but it is
> what I have to offer for direct evidence. I don't have any
> explanation for the results other than what I've related to you.
> However, I have related this information to others who have
> experienced similar problems with Humalog and site life. There are
> over 3400 members of the Insulin Pumpers support forum. Of these,
> over 1200 have voluntarily submitted information about various
> aspects of their diabetes management including details about their
> insulin usage. 6% report using an H/V or H/regular mix in their
> pumps. I have not contacted all of them, but of those with whom I
> have corresponded, universally they relate a similar story to the one
> I shared with you about my daughter. This scenario has been poo-pooed
> by many until the numbers became so large that an investigator (Bill
> Van-Antwerp at Minimed) became interested enough to check it out.
> I have no axe to grind in this, I just want to help out others who
> are having difficulty with similar problems. I will be collecting
> data on the results of those switching to Novolog from an H/V mix to
> see if Novolog can replace the H/V mix for those experiencing
> difficulty with H alone. Hopefully within a few months, there will
> be some useful statistics.
> Michael Robinton
> Executive Director
> Insulin Pumpers
> 4600 El Camino Real - Suite 206
> Los Altos, CA 94022
> Tel: 650 947-3350
> Fax: 650 947-3356
> email @ redacted
> Insulin-Pumpers website http://www.insulin-pumpers.org/
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