Alicia: UnLeashed! July 2018 monthly article
The right tools for the job: We can get more refined results by using more than 2 insulins.
One question we get a lot is whether someone should change from multiple daily injections (MDI) to pump therapy to improve their blood sugar management. My answer on this subject is almost always “no”.
The fact of the matter is that studies have shown that simply using an insulin pump is not going to improve your blood sugar variability, time in range, or A1C. My “no” comes with a “however”. Insulin pumps do allow us some increased freedom in how we manage our diabetes. We can temp basal, we can extend boluses, we can generally bob and weave with the ups and downs of food and life a little more dynamically with a pump than we can with injections. That said, I have patients achieving phenomenal levels of blood sugar management without pumps, without restrictive dieting, and without giving up active lifestyles. This is achieved because they are using the right tools!
When most of us start on MDI therapy our doctors hand us two insulins, a fast acting (Bolus) insulin and a long acting (Basal) insulin. And we are sent forth into the world and told to craft our lives. So we start tweaking with our basal pliers, and swinging away with a bolus hammer. Through no small amount of blood, sweat, tears, smashed thumbs, burns and blisters, most of us manage to fashion something livable. We aren’t too high too often, we aren’t dangerously low too often, and we manage to keep ourselves warm enough and dry enough to remain livable. We are living in the diabetes management equivalent of a shack. But if the wind blows too hard we’re in trouble, and we don’t go into that one corner over there because it leaks, and be careful not to get too carried away having fun because the whole thing might fall down. Some of us have even found ourselves standing in the rubble not sure where we went wrong.
With just two tools not even the best craftsman can build a really nice home. Electrical work, plumbing, trim, painting, they all take different tools. You can get REALLY skilled using a tool (check out those guys who carve with chainsaws!). But, you’re not going to get too far doing plumbing with a hammer.
We need the right tool for the job.
Here are some situations that MDI users can really struggle with, and some insulin tools that help get the job done!
Temp basal changes for less than 24 hours
From illness or hormones to high fat foods, there are lots of times we need more basal support than our standard dose allows. But with long acting insulins like glargine and degludec we have to see the need coming a day or more in advance! Then we have to chose between taking the added basal we need, and going low when we don’t need it, or not taking what we need and probably going low from throwing big boluses around all day trying not to go high. This is trying to fix a problem that needs a small pair of pliers, with a hammer! We either don’t do the job, or we smash our thumbs trying. One really good tool here is NPH insulin. Yeah that old school cloudy stuff! NPH insulin has a duration of action of 10-18 hours with a moderate peak at 4-10 hours. This makes it a good way to get a little more basal to combat hormones, illness, or even high fat meals. These situations don’t always give us warning that they are coming, and by the time they happen and we notice, they may not last the full 24 hours that our long acting insulin demands.
Fast acting insulins work for about 4 hours, but some meals take more than 4 hours to digest and impact blood sugars. This time of year we also have meals that take more than an hour (or even two hours) to eat, at parties and gatherings. For patients with gastroparesis , chronic constipation, or other digestive concerns this can be extra difficult as meal timing of insulin is already a good deal slower. The first tool we have to deal with these situations is splitting the bolus. We can take some of the insulin now, and some later. This spreads out the insulin action time to more closely match the foods. However there are issues that can arise here as well. First is the problem of forgetting the second bolus. Trying to improve your glycemic control only to wind up doing more “harm than good” is extremely frustrating. Secondly there is the inconvenience of having to bolus a second time. For some people this might mean interrupting an activity, social function or work to administer a second bolus dose. Again the hammer just isn’t the right tool for the job. So here we have Regular insulin. Regular insulin takes about an hour to act, avoiding an early post meal drop that we often see in these situations. It then takes 2 hours to peak and acts over about 6 hours. This makes it a good option either on its own, or along with fast acting insulins like novolog, humalog, apidra and fiasp for additional coverage over time.
The final weapon in the tool box that many people are not familiar with is inhaled insulin.
The inhaled insulin Afrezza is the fastest acting tool we have. This stuff is like a power drill. It’s great for times when we want insulin to get in, do the job and get out! Active in less than 10 minutes, peaking in about 15 minutes and clears our systems in about 2 hours. This makes it a great tool for people who need a bloods sugar correction, but don’t want to have active insulin lingering around (Before physical activity for example) For those who find it difficult to remember to bolus before a meal, or who fear doing so inhaled insulin is a fantastic tool. The fast action helps reduce post prandial spikes without lingering active insulin to increase hypo-risk. (You can read a full review of Afrezza insulin here) .
People often ask what I would do to manage my diabetes if I was not on a pump and I know that I would have a CGM, Long acting insulin, Rapid acting insulin, NPH and Afrezza in my tool box. I wouldn’t use them all everyday, but I’d make sure I had the tools and knew how to use them. I’m not content to live in a shack worried about the wind, I’d rather live in a home of comfort and security.
We really enjoy working with our patients to help them find and use the best tools for them! set up an appointment to discuss with our education team what tools are available, and how they can best fit the needs of your life and diabetes management goals!