Going Old School! Using MDI for Diabetes Management
Month to month our team at Integrated Diabetes Services puts out the effort to do a Food Challenge. We try to pick foods that are, well, a challenge for so many people with diabetes.
In the past, we have navigated our way through ice cream, pizza, popcorn, candy, cereal, Chinese food, sushi, hot chocolate bombs, coffee (caffeine), alcohol, and numerous other foods that appear to pop up on the list of questions we get from those we work with or from the many questions that get posted in all the social media avenues.
As we discussed our challenge for the month of January, we couldn’t find a food to settle on. However, since we all are using the most current technology for insulin delivery and glucose management someone suggested we all try to go back to using MDI. We could use insulin pens or syringes with vials, but we all agreed that giving up CGM and going back to only finger sticks would not fly with MDI (my son would say “You made a rhyme Mom!”)!
We all settled on a week/weekend to give it a try. We all use different long-acting insulin – some with Tresiba, some Levemir and some Lantus.
HERE’S WHAT HAPPENED:
I had been a long-term Lantus user. After switching to this years ago from my L-Lente basal insulin (cloudy intermediate insulin I took AM and PM), I keep a vial of it handy in my fridge. Any person on an insulin pump should keep a vial or a pen of basal insulin as a backup in case of pump failure.
I had originally decided on a Saturday evening when I would be set for a pump site change anyway. However, as only the universe can predict my pod died on Friday evening so there it was, a chance to just switch to my MDI plan. Thankfully it failed in the evening when I had usually used my Lantus insulin in the past (ummm…like 20 years ago). Have I had to use my Lantus in between, of course, but it has only been the few times that my PDM for my Omnipod died and my pod died at the same time. Thankfully, it has been very rare and so it had been A LONG time since I used Lantus.
I am glad I have the information about how to make a switch. Using about 10% more basal with an injected basal insulin compared to my pump, I adjusted my Lantus dose up and took my basal at 8PM at night. I used to take it at 10pm along with a snack with good protein source otherwise like clockwork I was low by 3am. The night I started MDI happened to be a busy evening with exercise after dinner that was not planned – soccer with kids in the basement after dinner resulted in a bit lower BG due to IOB from dinner. With no pump to adjust, I treated the lower value and then added a bit more to avoid a low overnight without the use of my algorithm as well as the added end of night movement which I know to make me more sensitive. By bedtime, I was sitting in the upper 160 range and while I’d usually not go to bed with this value, it was stable and a good opportunity to do my basal test on this MDI dose.
Fortunately, while I didn’t love waking up at 158mg/dl I did stay very stable, literally flat, all night long. Lovely – at least the basal is a good set dose and I know now how to navigate a night snack and the evening dose of basal insulin.
Ha – bring in the variables. My day on Saturday happened to start out well with a great 6.5 mile run after I added a small correction with rapid insulin and my coffee for the higher valuer. I knew I had no help from a pump and no way to adjust the basal down, so I ate breakfast about 30 min prior to the run and didn’t bolus. About 30g of carb with very little IOB when I started running had me nice and stable in the 120-130 range while I ran. I also was very stable into the early afternoon when things really got busy.
House stuff and time with my boys is a lot of my Saturday. It snowed Friday night into Saturday and with 8” of snow on my driveway and patio off I went to shovel after my run. Applesauce loaded in prior, and things sat pretty good as we headed to the snow hills in our neighborhood for sledding. 90 minutes outside, in the cold and trudging around in the snow will hit hard at some point…. WHEN was the question in my mind. Dinner on Saturday night is always homemade pizza (almond flour or cauliflower crust) with a movie.
Bolusing and strategy with injections, I adjusted and navigated well for dinner and into the bedtime.
Thinking about the day prior to taking my basal insulin Saturday night as well as knowing Sunday was also going to be a busier day, I adjusted my basal dose down by 1.5 units. Expecting my higher fat dinner (and snack with lower carb Ice cream) to keep things a little better from the activity as well as the lower basal dose I didn’t adjust for the higher fat. The snack may have helped a bit had I not added a minimal bolus for it, but honestly this is where a pump with an algorithm is so beneficial. Over the course of the night, I ate at least 30g carb and still woke up with a BG in the 60s.
Sunday transitioned into showing me the basal dose with the lower amount was better with a busy day. While it didn’t help the overnight, it did require me to adjust my bolus timing for meals differently than I was used to with a pump. The activity in my day on Sunday (more shoveling in the morning and a swim and a walk in the afternoon) with a lower basal proved I didn’t need as much carb to counter the effect as I thought it would and still needed some rapid insulin with some prebolus time. Swimming after a small lunch without a bolus actually proved the worst without a bolus but came down without correction in the afternoon. Finally got it right by the evening dinner on Sunday.
I coasted into the 9p time Sunday evening with lots of thoughts of what I learned and thankful for all the technology that has been developed in the past 10-15 years. I happily switched back to my pump Sunday night and uninterrupted sleep was so wonderful!!
MY takeaway pearls for using MDI:
- It provided me with a review of what I need to do when it is all up to me making decisions and calculations.
- Real calculation and adjustment for all the variables is less precise, but means I also paid more attention to what I was doing.
- No technology was kind of nice. Outside of using my CGM I had less to think about, less connected to my body and I felt a bit free even with less precision.
- I had to use what I know in a different way. When you get used to your normal routine it can be easy to miss when something changes, or you put off acknowledging the change. Going back to MDI made me use the tools I know, but in a different way and it helped in that short 3 days of MDI as I went back to my pump.
- I made use of the tools I had such as CGM and event markers to keep track of my IOB and see the impact of my decisions. With technology we learn to step back a bit with all the smart things we can tell our pumps to do. When you are back in the driver’s seat completely, using what you know about the 80-90% of your normal day can help to navigate and plan for what is coming even if you don’t have an algorithm or smart features helping you.
- Lower carb made it easier to navigate the lack of precision.
- Basal dose needs adjustment based on activity level of that day and the day ahead.
- Bolus dose timing was different without the benefit of smart features on my pump. Less basal meant meals even prior to active time still required some insulin but may have needed some carb later to avoid a drop after the activity was done.
It was an excellent experience to use what I know in a different way and have something more solid to fall back to if/when my technology fails. I have a more solid plan to work with in the future now that I took the time to make notes and pay attention. I’m thankful for the ability to use the smart technology that is available today and that with MDI this time I was able to have a CGM to help fill in the gaps I’m sure were there when I was using MDI so many years ago with only finger sticks to go by.
We all participated in this challenge of sorts and if you feel you’d like some assistance navigating all your notes while using injections, give us a call – we love data and more than that we love helping people learn to navigate life with whatever way you choose to use insulin.
This is great, as is the overview of three team members’ experiences in the email. We just tried one day of basal after my son’s T slim infusion sets failed four times over 24 hours (eeee). Ended up going for 1/3 TDD basal as NPH at night, which … did nothing other than keep him from going above 400. We now have Levemir on hand after finally getting a plan from his endo; we had been asking for how to match variable basal needs (from 0.5u/hr overnight to 1.2u/hr daytime… you can’t really match that curve with a flat stick like Tresiba).
Also affirming to know that my constant going low overnight on Tresiba (previously Lantus) is not some complete zebra fluke :-) I am not alone!
Thanks for all you do!