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Re: [IPk] Pump or New Insulin

Hi Graham,

The territory that's been covered quite frequently on this listserv since 
glargine (Lantus) was first released is the fact that Lantus does NOT mimic 
the basal rates of a pump. One of the biggest points of pumping is that it 
allows for several basal rates across a 24-hour day.

My basal rates are:
12 a.m.-5 a.m. 1.1
5 a.m.-9.30 a.m. 1.2
9.30 a.m.-7 p.m. 1.3
7 p.m.-12 a.m. 1.4
for a total of 30.2 units of basal insulin, delivered in 4 profiles, across 
24 hours.

Lantus is intended to provide ONE basal profile across 24 hours.

If someone would do well with one basal profile on a pump, he or she would 
likely get on fine with Lantus. Any pumper on one basal rate probably has a 
set of quite compelling reasons other than basal rate flexibility for 
pumping (truly chaotic lifestyle--like unavoidably working three nights and 
2 days per week--or incapability to do frequent injections, or tolerance for 
only one kind of insulin are some reasons I've heard).

Still, I have yet to meet a pumper who has only one basal rate. Is the most 
basic difference between a pump and Lantus clear, or does the above not make 

Additional differences between a pump and Lantus: I can suspend my insulin 
when I need to allow my bg to rise so I will have enough glucose to burn 
when I exercise. If I were to have insulin working in the background when I 
didn't need it while exercising, I would have a massive hypo. That pattern 
became clear whenever I tried to exercise properly before I got a pump.

All of us have our own quirks. Body chemistry differs: just as the same 
perfume can smell different on two different women, two individuals of the 
same height, weight, and gender can have totally different insulin 
requirements. Diabetes is an art, not a science, and any DSN or doctor who 
tries to tell you otherwise ought to...well, go away. We rely on science, 
but we must use it creatively. There is no 'one-size-fits-all' panacea for 
type 1.

If I were to be put on a dose of Lantus that would keep me from going hypo 
between midnight and 5 a.m., that amount would most likely give me 
increasing bgs throughout the day. I would have to inject Humalog not only 
for meals, but for several correction doses that might wind up being too big 
and sending me into big hypos. Or I would need to be on a third insulin.

A few months ago I worked out that in order to 'mimic' what a pump does for 
me, I would need a total of 8 injections per day. I would need injections at 
ungodly hours like 4 every morning, which would disturb sleep (sleep 
deprivation bad!) and increase the likelihood that I would make a stupid 
mistake and take the wrong amount, or just sleep through my injection and 
ruin the next several hours. I am not coherent when woken from deep sleep at 
4 a.m., trust me (once put shampoo on my toothbrush and had it to my lips 
before I sniffed and realised what I'd done!).

Last thing: insulin requirements change throughout life. If what you're on 
now is not controlling your blood sugars properly, a total 'refit' of your 
regimen is the first place to start. If what works for a couple of days 
doesn't work for the next week, but then works again for one or two days, or 
something like that, I'd say to examine the external variables in each day 
that the plan did or didn't work: keep a food and activity diary and look 
for the connections between things, like: 'hypo at 10 a.m.-->snack at 10:10 
a.m.-->high bg before lunch' or 'high bg at 2 p.m. (from too little insulin 
at lunch)-->correction dose of 2 u. Humalog at 2.05 p.m.-->taking a brisk 
30-min. walk at 2.30 p.m.-->hypo at 3.30 p.m. (aha! The insulin + activity 
made the Humalog peak when your bg was already falling because of the 
walk...double whammy).

One potentially GOOD thing about trying Lantus is that fasting whilst on it 
should reveal quite quickly what times of day you need more or less insulin! 
Almost 7 years ago my isophane + regular regimen showed enough of a pattern 
that we knew I would benefit from a pump, but we didn't know where to start 
with choosing basal rates (ah, the fun of trying and erring). When I got my 
pump, I had one basal rate for the first week so that we could observe the 
patterns and make adjustments.

VERY LAST thought: might a politically incorrect observer describe you as a 
'brittle diabetic'? Given our 'funny' requirements, I should think that most 
pumpers *would* be 'brittle' on MDI.

Good luck,

IDDM 10 years; MiniMed pumper 6+ years
Co-ordinator, Oxford University Student Union Diabetes Network

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