June 14, 2007

R Insulin - Cheap, Effective, and Unknown

If you are injecting meal-time insulin, you're probably using one of the analog insulins: Humalog or Novolog. Your doctor probably told you these are the newest, fastest insulins, and that is true. What he probably didn't tell you because few doctors know this, is that regular human insulin (R insulin) can be a better choice for many type 2s.

The reason your doctor doesn't know this has a lot to do with price. A 10 ml vial of the Regular Human insulin Novo Nordisk sells as Novolin costs about $20 at Wal-Mart. A vial of Novolog, Novo Nordisk's analog insulin, costs somewhere around $94. With that kind of price differential--the analog being almost five times the cost of the Regular--which of its two meal-time insulins do you think Novo-Nordisk is promoting to doctors?

But if you think that Novolog is almost five times as expensive as Novolin because it is five times better, you're making a big mistake.

The main difference between the two insulins is the speed with which they act. R insulin takes about an hour to start working and has an observable effect for 5 hours, where the Novolog starts acting within 15 minutes and is pretty much done at 3 hours.

But while this means that you can inject the faster Novolog when you begin to eat rather than having to plan ahead, speed is not always a good thing when you are talking about insulin. That is because if the fast insulin gets to your blood stream faster than your food, you have the risk of going low. And if your food takes longer to digest than you expect, the fast insulin can be all done long before your food is and you'll go high. This is why a food like Pizza, which has a lot of carb but digests slowly because of its fat content, can end up producing very ugly blood sugars when you use a fast insulin--a dip at hour hour followed by a nasty rise at hour 3 or 4.

R insulin, in contrast, dribbles in more slowly over a longer period of time. This means that if your food's speed of digestion is unpredictable, there's coverage for a longer window of time. Not only that, but because the insulin dribbles in more slowly than the analogs, if you are going low, you have more warning and can correct more easily. If you end up not eating as much as you expected, you don't experience a sudden WHOMP of insulin hitting a blood stream devoid of carb and you have time to hit the Smarties or glucose tabs or whatever it is you use to correct.

This slower speed can be particularly important to you Type 2s who are striving for very tight control. This is because, unlike the Type 1s who cover meals with insulin, you may still have some residual beta cell function, which means that when you use a meal time insulin your own phase 2 may occasionally kick in and mop up some carbs--especially after you've used insulin for a while and given those overwhelmed beta cells a little "beta cell rest." This can produce unexpected lows, and may be one reason why doctors rarely suggest meal time insulin for a Type 2 until their blood sugars are terrible and much harder to control with insulin or anything else.

Making R work safely, for a Type 2, requires that you keep your carb intake modest. While I don't officially low carb while using insulin, my daily intake is only around 100 to 120 grams--25 to 40 per meal. That's because my basic ground rule is not to take so much insulin that if something went seriously wrong, I'd face a life-threatening hypo.

By "going wrong" I mean that after injecting and having a few bites of your food, you start to throw up and can't keep anything down. Or after you inject there's a sudden emergency that has you rushing to your car to rescue a family member. Or even, after injecting you get so caught up in what you are working on that you completely lose track of time and forget to eat. These kinds of things happen rarely, but they do happen--especially the forgetting to eat part, so I stick with a dose of insulin that if it does produce a low, produces a low my own body's counterregulatory system can compensate for perhaps with the help of some glucose. Type 2s who are not low carbing, unlike Type 1s, usually have a robust counterregulatory system that will dump carbs from stored glycogen into the blood stream if you get down to the low 60s or worse.

With this in mind, and since I subscribe to Dr. Bernstein's dictum that "small inputs make for small errors" and have resisted the impulse to increase my insulin dose to try to cover any more carbs than 40 grams, which for me takes about 4 units to cover it. This means Pad Thai with its 100 grams of carb per serving is still permanently off the menu. But 40 grams is enough to let me have a nice slice of artisanal bread, half a potato, or a scoop of ice cream. I can have Chinese food (avoiding the stuff encased in fried dough) and a very small serving of rice. For me moving to 40 grams compared to the 12 grams I ate when low carbing, opens up a huge world of food choices and makes food much less problematic, while keeping the insulin to 4 units or less has, so far, kept me from ever seeing truly dangerous lows when something goes wrong.

I always check my blood sugar 3 hours after using the R to make sure I'm not going to go low, and if I'm in the low 80s or 70s by then, I'll have a couple grams more carb--and I mean a few--maybe 5 or so.

Another reason I like R insulin is that though it is pretty much done working at 5 hours, it has a very small residual effect that lasts up to 8 hours. For me, this means that if I use it for my meals, I don't have to use a basal insulin, because there seems to be enough insulin left in my system to keep me low through the first part of the night, but it's gone by that 4 AM period which is when I was waking up in a cold sweat when I was taking Lantus because of the early morning hypo.

There's one last benefit that I've observed with R insulin. I don't know if this would be true for other people, but it certainly is for me. Unlike the analogs, R insulin does not make me hungry.

I suspect it is because it is slower in action and my body interprets swift changes in blood sugar (or perhaps in insulin levels) as hunger. Whatever it is, when I was using Novolog, I observed that though I was getting very good blood sugars after eating, especially in restaurant situations, I was always hungry 2-3 hours later. With R insulin, I never get the munchies. In fact, I've noticed that I have no desire to snack at night, which is unusual for me.

Another thing with R insulin, which I find useful, is that I can delay its action a bit by injecting into the top of my leg, rather than the belly fat. My current regimen is to inject 3 units into my belly when I wake up, when I'm most insulin resistant, and into the top of the leg for the other two meals. I eat 25 grams of carb for breakfast, an hour after injection (it takes that long until I can face food, anyway, so waiting isn't a problem). I inject 3 or 4 units into my leg 5 hours after the morning shot, and 3 units 5 hours after that. Lunch and dinner are generally 30-40 grams of carb but with this schedule, I'm finding I can pretty much eat my meals when I want to without seeing bad highs. With the R slowed down a bit more with the leg injections, this is the closest I've gotten to the way I was eating while taking Ultralente, the discontinued insulin, which worked so well for me.

I've been waking up in the 80s-low 90s doing this, and staying between 80 and 120 after meals except when I've eaten something ridiculous. Even then the worst reading I've seen has been 143 and that was after eating something ridiculous. I'm not feeling my blood sugar go up and down, which makes me feel lousy. I'm remembering why it is that I like R so much.

The only other drug I take right now is 1500 mg of Metformin ER in mid morning, mostly because it keeps me from gaining weight. If I stopped taking it, I'd have to use another 1 to 2 units of insulin per meal to cover that 30-40 grams, but I'd be more prone to gain weight, especially now that I'm off my estrogen replacement for good.

Stopping the estrogen has boosted my insulin requirement a bit. I have been using 4 units where I would have been using 2.5 units in the past and 3 units where I would have used 2. But while quitting estrogen has made me more insulin resistant, my insulin resistance still does not begin to rise to the level of a typical Type 2.

Once off the estrogen, my almost 59 year old body seems to have decided it wants more fat--which is what bodies do when they are trying desperately to store what estrogen they can, since estrogen is stored in fat. The Metformin helps, but the chances are that I'm going to have accept some weight gain. It's better than cancer, and after all the years I have been taking estrogen, cancer risk was starting to become an issue. I've been lucky enough to be able to be a "hot babe" into my late 50s. Time to count my blessings and move on! Especially since, according to the research Kolata's book cites, a bit more weight at my age appears to correlate with better health and longevity.

Note: Weirdly enough, R insulin is available in most states without a prescription. If you need needles, you will probably need a prescription for those, but if you are already using syringes and wish to try R, all you have to do is walk up to the pharmacist at Wal-Mart, say, "Can I please have a vial of Novolin R," and pay your $20.

I find this very odd, but that's how it is. The plus side to it is that you can replace a vial without going through a major song and dance if something happens to it.

26 comments:

Scott said...

Thank you for calling attention to the fact that human insulin is for many people, type 1 and type 2, a better choice. For one thing, its less of a foreign substance in the human body, and while it can be slower, I found regular was not too much slower than Novolog, and only about 15 minutes slower than Apidra, I only found Humalog to be notably faster. I would also remind everyone that some of the others that now seem to be shunned, like N are the only mid-range insulins left on the market, and not everyone needs 18-24 hours of coverage. This has more to do with profits than it does improved control for many people, but its worth it for many people to revisit these varieties!

Jenny said...

Scott,

You make a very good point. We know a lot more about the long term health consequences of regular human insulin than we do about the analogs, which are insulin molecules with various amino acids substituted.

I, personally, found Novolog faster than Humalog, which I could NOT make work for me. I would go too high, then too low. It never worked. Novolog worked very well, but the hunger bothered me and I did start to gain weight when I used it exclusively for a few weeks.

There are two major problems with N. One is that it absorbs very unpredictably, and for many people this translates into unexpected hypos.

The other is that it contains protamine. This can cause dangerous allergic reactions in some people. I have not met anyone who was happy with N, but that doesn't mean they aren't there.

But the idea that everyone needs a basal insulin is certainly NOT true for many Type 2s, and I have found that restoring post-meal blood sugars at meal times with R gives me normal blood sugars for 24 hours.

Bethany said...

Hi Jenny - thanks for sharing this and for your comment on my Pizza Hubris post. Shortly after I started using Humalog , I asked my PA about trying R, but she said she didn't recommend R and cited a variety of reasons like more variability in blood sugar control and timing, and even said that "no one use it any more" (gee, wonder why!), but I still would like to give it a try at some point after I've regained my motivation to experiment. Next time I see her I will press her for a prescription or sample.

Jenny said...

Bethany,

You do NOT need a prescription to buy R insulin in most states. Weird, but true. So if you have needles, you can stop by Wal-mart, fork over your $20 and give it a try.

They don't give out free samples of R. The general rule with samples is that any drug they give out samples for is extremely expensive, probably new, and the subject of an aggressive campaign to get you hooked on it.

DietKing2 said...

Jenny,
This is the blog I've been looking for! What great information and insight you've given! I'm sending this right over to my type 2 diabetic papa right now!
Keep up this great work!
Adam

DietKing2 said...

Come on, Jenny! I'm hooked! How about another post! Let's talk about how gross Stevia is or something! LOL
Sincerely,
Adam

Bob said...

Interesting about R insulin. Now my question is whether it would be possible to use it with an insulin pump? My card ratio with Humalog is 3 carbs to 1 unit of Humalog. Would this present problems? With the current cost of insulin as I use 4 bottles a month. . my Medicare insurance does not provide me with complete enough coverage for a year's worth. What do you think?

Jenny said...

Bob,

I do not know anything about pumps, so you'd have to speak to someone from your pump company. A bit of Boogling turns up the info that it is possible to use R in a pump, but it sounds like it might clog more than the analogs. There apparently used to be a "buffered" version of R that was used in pumps, but I don't think there is any more.

It's still worth a phone call to customer service.

whit1282 said...

Hi Jenny,
I've been a type 1.5 diabetic for 12 yrs now my 3 month average is 7.4 not bad. I take 4 shots a day: fast acting H and N.

It is interesting that R can be had without a prescription. I'm going to get a vial from
Walmart.

I've recently lost my good insurance so I will have to buy everything myself. Thanks, Whit1282

CookinsForMe said...

Thank you for this entry. I used to take Lantus and Novolog but recently had to find another solution due to finances. My previous experience with regular insulin wasn't very good but this entry gave me the courage to try it again. The results have been fantastic and at a fraction of the cost of the others. I also inject in both the belly and thigh, something I learned from you. Again, thank you and I hope others will read this entry and consider the option of using regular insulin. You can bet I'll refer others to your blog.

Anonymous said...

I take R & N mixed AM & PM, 30-40 N & 3-5 units of R and around 5-10 units of R before lunch. I test 3 times a day. I have went low a few times but i take advantage of this by eating my favorite candy (Cherry Slices) lol.

Zolar1 said...

I use both Humulin R and Humalog at the same time.

For example: In the mornings I take 5 units each. Humalog in the abdomen, and Humulin R in a non muscular region like near the hip, outer or inner thigh, or top of the buttocks.

My spikes are nearly non existent.

I do have a problem every now and then if I exercise too much afterward. I went as low as 48 today.

I like and use both kinds of insulin.
Humalog for it's speed dealing with fast carbs and the Humulin R for the medium to slow carbs, like fiber.
I can get complete and total control without any insulin whatsoever, but that severely restricts my lifestyle, and my food choices. With any kind of insulin, I have more flexibility, more freedom in my lifestyle and schedule.
I NEVER take more than 5 units of Humalog within a 4 hour period, just to be safe. I heard that Walmart has the Rely-on brand of human insulin. I wonder how cheap it is and what kind it is made of.
I would like to know what area(s) of the body has/have the SLOWEST absorption rate for insulin.

If I knew that info, I could basal with Humalin R or similar for a basal dose.
I do take about 1 unit of Humulin R in the leg or buttocks right before bedtime. Sometimes I inject just above the pelvic bone about 2 inches. The 'fatty pouch' area if you know what I mean. Anyone know the best way to use NPH or the 75/25 NPH or the 50/50 NPH?
About needles - many places will sell needles without a prescription as long as you buy the insulin at the same time.
Just ask for a bottle of insulin, and a box of 100 - 31 gauge 1/2cc insulin syringes, and for good measure, a box of 100 alcohol swabs, which you should be using anyway. If you have insulin with you and a glucose meter, that will make things a LOT easier.
Note: Humulog needles are available over the counter for the pens.

djh/texas said...

i was on nph/regular for a few years and then on 70/30 with lots of hypos and peaks. i started eating low carb and was having terrible hypos even on very small doses. so i stopped insulin for a while and had great readings for a few months still on very low carb. however i could tell i needed insulin - i had lost a lot of weight and couldn't gain even though i increased my protein intake which led to high BGs - and my BGs kept creeping up til they were almost always in the 200's. so i bought humulin R insulin (yes from wal-mart) and also the NPH. however i started using the R - at first 2 units with each meal including lunch (found out quickly i need ZERO for lunch lol) and now i'm doing 1 unit for breakfast and 1 with dinner and then i also take 1 unit right before i go to sleep.
well i never needed to use the NPH. the regular is working perfect!!!
i am totally amazed!!!
thanks for this site!
i have always injected in the abdomen and am going to try the upper thigh. do you pinch up the fat (like i have any left lol) and do it the same as the abdomen?

Jenny said...

Some of us don't have a problem finding fat on our thighs, alas. But yes that is what you'd do. I like that spot because it isn't as likely to bruise. But the absorption speed might be a bit different, so be cautious.

Zolar1 said...

I noticed that injecting over a large muscle that you use a lot of like on the front of the thigh causes the insulin to be absorbed more quickly.

Inner thigh seems to be about the same as the abdomen. Upper buttocks too.

I wonder if the calf area is different?

Have been too sick for the past week to try anything new as I can barely eat anything.

I did use the NPH. I started with 1 then 2 then 3 then 4 then back to 3 then back to 2 before settling on 2 units in the AM.

It kept my fasting blood sugars in the low to mid 70's most of the time.

Any thoughts on beta cell rest?
Will it help regenerate damaged (but not dead) beta cells?? Sort of a 'recharge' of your insulin stores?

On this Thanksgiving, I plan on using 3 kinds of insulin. NPH in the AM, Regular insulin right before eating, and at 2 hour post, Humulin if needed.

I missed out on ALL the goodies last year because I had no meds.

This year will be different.

I am armed with knowledge and tools (insulin). Now, I should be able to have my mashed potatoes and eat them too - LOL.

And there's that yummie pumpkin pie...

I figure the NPH will help boost control, along with the Regular insulin to help for the long digestion period afterward. The Humalog is just in case I spike too highly.

I really don't want to drink 1/2 gallon of water then walk briskly on a treadmill for 2 hours to burn off the spike.

Personally, I want to try Lantus. Just one unit a day in the AM (maybe 2), just to help keep a1c's a bit lower.

NPH has peaks, Lantus doesn't. I usually don't have a problem with fasting BG. I just want it a tad lower.

I want to be in the 4% club. Right now, I am in the low 5% club.

The sooner and longer I can stay in the 4% club, the less chances of a heart attack I will have.

Note: I can go hypo without any insulin or meds. Strange huh?
My pancreas must be doing something...

Caleb's Blog said...

Jenny, I'm wondering if you still consider the info in this post to be current.

My problem, apparently, is insulin resistance. I am already injecting 45 units of Lantus and haven't seen a normal BS reading yet -- and I fear I'll have to go all the way up to 60 (I don't have insurance). Part of my problem is that I can't give up the carbs, and I'm eating about 150 carbs a day. However, if you can eat 125, I don't see why I can't eat a similar amount.

Don't tell me that I need bolus -- I know that. However, I'm not willing to take more than 2 injections a day (they often hurt). My plan with Lantus is to get my FBS to 100, at which time my spikes should drop to about 160, and that will be acceptable. But as I said, I seem to need more and more insulin to accomplish that.

How do I find out if insulin R is available without a prescription in RI or MA? Just call a pharmacy?

Jenny said...

Caleb,

Yes, this post is still current. You can definitely buy R insulin without a prescription in MA. I don't know about RI. Walmart has the cheapest price. It's been a while since I bought it but it was about $20 when I last did.

However R insulin isn't a replacment for Lantus, it is for mealtime coverage. The only R-based longer acting insulin available now is NPH, also available without a prescription. But NPH lasts a much shorter time than Lantus and has a peak of action that can cause hypos.

Read Dr. Bernstein's "Diabetes Solution" book to get a better understanding of these insulins and how they work before you use them, and if you use NPH be very cautious as your blood sugar comes down.

Most people who are insulin resistant need up to 100 units of Lantus, BTW.

Zolar1 said...

go to isletsofhope.com

It has a list by State of what you can buy without a prescription (diabetes-wise).

Most states do not prevent you from buying insulin, but many do have controls over the purchase of syringes.

Jenny said...

I figured if the poster was using Lantus he already had a prescription for needles--or a doctor who would write one.

Caleb Murdock said...

I thought I would let you know that I got an A1c of 6.2 on 9/30/11 after taking R insulin for 4-5 months. Actually, I lost control of my diet for the two months prior to the test, and I was averaging more than 200 carbs each day. If the test had been taken about 2 months earlier, I think my A1c might have been as low as 5.8. I'm now trying to get better control of my diet, and I'm aiming to be under 6 when I see the doctor next.

Thank you again for turning me on to R insulin. It really works. On a shot of 30 units, I can eat about 75 carbs, and my blood sugar will return to normal after 5-6 hours. If I eat a low-carb breakfast and then take a shot before lunch and dinner, I can eat two small meals on each shot, for a total of 5 small meals a day. The problem is that I often go over 75 carbs and end up eating 100. When that happens, my BS doesn't get back down as low as I would like.

My real problem, then, is that I have trouble controlling my diet -- but then, that's been true all my life. If I can actually get my carbs down to 150, I think I could get my A1c to 5.5 or lower. I supposed I could eat 200-225 carbs a day and inject 80 units a day, but that just seems cockeyed (and I would gain weight on that).

Anyway, my point is that R insulin really works. I have come to see it as an "unsung hero" that more diabetics should try. Are you still using it, or did you switch to something else?

Jenny said...

Caleb,

You might find it easier to control your eating if you cut your carbs down under 100 for a week. It would be tough the first few days, but you'd be eliminating the huge spikes those 75 gram meals are producing (even with insulin cleaning them up.) The spikes are what cause the physiological hunger that can make it very hard not to eat.

I'm not currently using any insulin, as there is an oral drug that was very helpful for the oddball form of diabetes I have. My guess is that the several years during which I used insulin helped get me to a state where it could help. I may very well go back on it at some time, though.

Brandon said...

It looks like the major manufacturers have removed their pen support for their insulin R products. Lilly says Humulin is now only available in vials (1), and Norvo-Nordisk discontinued Novolin R prefilled pens and pen cartridges (2).

1. I called Eli Lilly's customer support today and inquired.
2. http://www.cornerstones4care.com/DiabetesMedicines/OtherPens.aspx

Jenny said...

Brandon,

R hasn't been available in pens for many years.

john leonard said...

I am a type 2 diabetic, 53 yrs old. I have been using nomolin R to control mealtime carbs. I usually eat no more than one time per day , which is at evening meal. I just have no appatite during day time. I will not eat more than 75 to 100 grams of carb. I was requiring 50 units of insulin. I do achieve a blood sugar of 120 or sometimes 100 two to three hours after meal. I recently was, with advice of doc, put on novolin N to help control my fasting blood sugars.And kept on novolin R for meals. I was always high in morning 160 to 190. And my pre meal sugar reading was usually 160. Doc advised me to eat more during day time and take R insulin to control sugar. I just did not have appatite to eat during day and informed doc that I just can not bring myself to eat until evening meal. So he was left with advising me to use novolin N. I asked doc about using novolin R to control my fasting blood sugar. He said he did not advise it without eating. I am willing to keep a check on my blood sugar reading by testing every few hours. I do have a warning signal that my body sends when I feel a hypo coming on. Because when I first began R insulin I , in the process of finding correct dosage, learned when too much was too much by experiencing hypo's. I am aware that some of these were false hypo,s because some happened at a glucocometer reading of 80. I would have extreme hunger. And sometimes go into a feeding frenzy. However , with the correct dosage of novolin R and eating carbs , in a meal, that had a normal digestion time, I contol the hypo's of insulin to meal ratio. .. Now I have a new problem. I am experiencing some very real hypo's (50 and one was 40) now that I am on novolin N. I have discussed this with doc and began to follow his advice about eating during daytime. Even though I eat often I have still had some hypo's. And of course, I need less R insulin with meals. doc and I have used lower dosages of novolin N and I have experienced unpredictable results. I am coming to the conclusion that novolin N is very unpredictable. I have read much on the different injection sites and how the release time of insulin can be slower and faster at different injection sites. My big question Is; Does anyone agree that I would be better off using novolin R to control my fasting blood sugar? And would I get more reliable control than I will ever achieve with Novolin N to control fasting blood sugar?

And by the way, anyone wondering the new updated prices of novolin R,N, and 70/30. It is about $25. to 26. now. And still available without RX.

Jenny said...

Novolin N is notoriously unpredictable. There is nothing you can do about it except use a different insulin. There used to be better long-acting cheap insulins but they were taken off the market in the mid-2000s.

If you can afford it, it would be worth switching to Levemir which is a very steady long-acting insulin. Talk to your doctor about it. You can use R for meals and Levemir for long-acting coverage. Lantus is another long acting insulin, but Levemir causes less weight gain (which probably means less hunger.)

Perry said...

I'd like to throw in a couple comments. Eating one meal a day, although not recommended by nutritionists, is a good way to keep your weight under control. I've heard of a lot of people losing weight that way. (I've never tried it because I couldn't stand to go without food for so long.) If you are slender, increasing the number of meals per day may cause you to gain weight.

If one meal a day is how you like to eat, you could try the "Carbohydrate Addict's Diet" in which you have one large meal a day and then eat two other small meals that have no carbohydrates at all. I don't know how that would affect your blood sugar, though. Eating a small protein meal might stimulate a release of natural insulin, but I'm not sure. On the other hand, eating small protein meals could stimulate your hunger for carbs.

Jenny's advice to take Levemir is probably the best advice. Personally, I've found that covering all my meals with R insulin causes me to have relatively low fasting levels (around 120). I make one-half to one-third of my shots 70/30, which gives them a longer "tail" (period of effectiveness). Caleb