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Re: [IPk] Pump or New Insulin

Dear all,

Thank you very much to all who have written about using a lantus-based
regime. I've been on it for several days and things have gone reasonably
well. I have, however, had problems on the following occasions:
* whenever I've done a blood test at around 2.00am it has been between 4.0
and 4.5, yet my pre-breakfast result has been 6.9-8.5;
* I chaired a (rather contentious!) meeting on Monday morning - my blood
sugar immediately before was 7.6 and immediately after was 15.5;
* I gave a presentation at a meeting yesterday - my blood sugar immediately
before was 6.9 and afterwards 18.6;
* I went to the gym on Monday after work - my blood sugar before was 7.1;
during the gym session it fell to 4.2 and afterwards it was 3.1 (I assume
the hypo symptoms were hidden by the effects of the exercise). I had a
banana and some lucozade and went home instead of having a swim.

Regarding the meeting and the presentation, have any of you been in these
situations often enough to be able to confidently give yourself an accurate
bolus on a pump? I'm sure that some of you will have worked out how to deal
with a session at the gym - is it quite easy? (Of course, as many of you
have said, my situation demonstrates the weakness of glargine as it is a
one-off injection.)

Can you experts let me know the best way to work out if I need different
levels of basal insulin during the day? Is it simply a case of fasting and
missing out a different meal over 3 as-normal-as-possible days? If so,
should I test before the normal time of the meal and 2 hours after, or what?

Thanking you all in anticipation,


----- Original Message -----
From: "Melissa Ford" <email @ redacted>
To: <email @ redacted>
Sent: Friday, April 25, 2003 8:59 AM
Subject: Re: [IPk] Pump or New Insulin

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> 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
> 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,
> 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
> set of quite compelling reasons other than basal rate flexibility for
> pumping (truly chaotic lifestyle--like unavoidably working three nights
> 2 days per week--or incapability to do frequent injections, or tolerance
> 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
> basic difference between a pump and Lantus clear, or does the above not
> sense?
> 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
> 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
> 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
> me, I would need a total of 8 injections per day. I would need injections
> 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
> 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,
> 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
> a.m.-->high bg before lunch' or 'high bg at 2 p.m. (from too little
> 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
> should reveal quite quickly what times of day you need more or less
> Almost 7 years ago my isophane + regular regimen showed enough of a
> that we knew I would benefit from a pump, but we didn't know where to
> with choosing basal rates (ah, the fun of trying and erring). When I got
> 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
> 'brittle diabetic'? Given our 'funny' requirements, I should think that
> pumpers *would* be 'brittle' on MDI.
> Good luck,
> Melissa
> IDDM 10 years; MiniMed pumper 6+ years
> Co-ordinator, Oxford University Student Union Diabetes Network
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