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.