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Re: [IPk] my response to the DAFNE trial published in the BMJ

To me the question of whether or not a long-acting insulin can match
your regular daily insulin requirements misses the single greatest
advantage of the pump, at least for me. 
I hate long-acting insulin with a vengeance - I still remember (4 years
ago now, and only one year of MDI since diagnosis) the horrors of the
ongoing hypos - sense of being dragged into the depths when I least
expected it by the silent claws of the long-acting insulin.
I can't be the only person whose insulin requirements are so sensitive
to exercise, stress etc - and the exercise does not have to be
something you think of as major exercise - indeed my major form of
exercise is walking - I do sometimes go on hikes for several hours, in
which case I certainly have to adjust the pump rate down, but all sorts
of things are exercise and reduce my insulin requirement temporarily:
for example if I just have to rush around picking up shopping from
different shops, then carry a supermarket load up the 3 flights of
stairs to our flat, respond to sudden 'urgent' requests from husband or
kids to go somewhere or do something, or rush around at work. I work in
a large hospital - and some days mostly sit at my desk, other days, due
to unpredictable factors may run to the medical school library at the
other end of the building, up 7 flights of stairs (the lifts are so
slow to come - I have no patience) for a meeting with colleagues in
another department, or a friend suddenly turns up from out of town and
we go for a walk together - i.e. not planned deliberate exercise at
times I could foresee - yet a series of such activities in quick
succession could easily send me badly hypo in the old days of MDI. A
life with no spontaneity seems to me cruelly restrictive, and a life
with none of what for me is normal exercise, obtained in the course of
my daily activities, would also not be physically healthy.
One day when I was still on MDI, my endocrinologist asked me why I
didn't seem able to eat at predictable times - he understood about
lunch at work, but said "What about breakfast, at least you should
always be able to eat breakfast at the same time?" I then told him the
story of that particular morning when one of our teenage daughters had
overslept and needed driving quickly in order to get to school in time
for an important test - he then laughed and said that his similarly
aged son had done something comparable the same day, and he too had not
eaten his breakfast as intended (and as a non-diabetic not thought
twice about that) - since then he has clearly realized that I too have
a life, and never once expected me to have a rigid routine.
> Date: Sun, 13 Oct 2002 23:10:58 +0100
> From: Pat Reynolds <email @ redacted>
> Subject: Re: [IPk] my response to the DAFNE trial published in the
> In message <001f01c272f8$d8bcc160$email @ redacted>, Diana Maynard
> <email @ redacted> writes
> >Hi Pat
> >You completely missed my first point.
> >Having a stable basal insulin (as MDI would give me if I had Lantus)
> isn't
> >enough - I need to be able to set my basal insulin to give me
> differing
> >rates at different times. That's pretty much impossible with MDI
> unless
> >you're very lucky and can time the peaks and troughs appropriately.
> I still don't get it. If you need different basal rates at different
> times, and there is a long-acting insulin which gives you those
> different rates, then you don't need a pump to give you those
> different
> rates.
> Say you needed to have 1 unit p/h from 5am to 10am, and then 0.7 ph
> until 5m, and then 0.5 p/h until 5am.   It might be that Monotard (or
> some other insulin) would give you that pattern.  Then the pump wuuld
> have no advantage. But if you can't find a long-acting which matches
> the
> pattern, then you need the pump.  Having 'different rates at
> different
> times' isn't a problem which pumps solve.  Having 'different rates at
> different times which cannot be matched by any long-acting insulin'
> is
> the problem - but you seem to be ruling that out as your problem.
> One extra advantage to the pump: basal patterns need to be delivered
> with some regularity. On the pattern I gave as an example, the 1/unit
> h
> rate needs to start at around 5am on virtually every day = i.e. not
> starting the 1/unit at 5am on some days, but on others starting it at
> 2ma, sending you hypo, and on other days, not starting it until 8am,
> making you high.

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