Making Insulin Work

As you all probably experience in your own lives, it often seems like things come in waves. And this past week the wave I have been experiencing has been full of worried emails from people who report that they or a loved one have recently started insulin but that it isn't working.

In every case, the insulin is a slow acting insulin, Lantus or Levemir, and there's a good reason why the insulin isn't working. It is because the dose being used is far too low to have an impact on an insulin resistant Type 2.

When doctors intially start a person with Type 2 diabetes on a slow acting insulin they start out with a very low dose, usually 10 units. This is prudent. One in ten "Type 2s" is not really a Type 2. Most of these misdiagnosed "type 2s" turn out to be people in the early stages of LADA, Latent Autoimmune Diabetes of Adults, which is a a slow onset form of autoimmune diabetes. People with LADA usually have normal or near normal insulin sensitivity and for them an injection of ten units is a LOT of insulin.

One or two percent of people diagnosed as Type 2 turn out to be people like me who have other oddball genetic forms of diabetes that also make them very sensitive to insulin. So starting everyone out at a low dose of insulin makes sense since this way the misdiagnosed people who turn out to have normal insulin sensitivity will avoid hypos caused by too much insulin.

But once it is clear that a person really is a Type 2--since they see no response at all to a dose of 10 units of insulin, the doctor is supposed to raise the dose until it gets to the level where it will drop the fasting blood sugars. But many doctors do not explain this to their patients and quite a few raise the dose so slowly that it does seem to the poor patient that insulin won't solve their problems.

For example, I have heard from obese Type 2s people whose doctors started them at 10 units and have instructed them to increase that dose by 2 units every three days. That means that after a month of "using insulin" they will be using 30 units.

But as many of you have learned in your own exploration of insulin, the dose that works for most obese Type 2s is closer to 100 units than 30. In fact, the only Type 2 I know who uses a dose of basal insulin anywhere near 30 units weighs about 125 lbs and eats a strict low carb diet. All the rest, including several people who eat carb restricted diets, are using anywhere from 80 to 110 units.

No wonder these people are frustrated! They've overcome significant fear to take that step into using insulin but when they have done it, nothing has happened.
And what is really sad, is that I know that for everyone out there that contacts me, there are thousands who "use insulin" for a month, conclude it isn't working, and stop--which means that they continue to live with fasting blood sugars in the high 200s or worse. If these people don't have health insurance and are paying $85 a vial for the insulin that "doesn't work" you can well understand why they give up.

If we had a system where doctors followed up on their patients, this wouldn't be so big of a a problem, but in today's environment of overworked family doctors, most are too busy to follow up with patients and it takes a lot of hard work on the part of the patient to reach anyone at the doctor's practice who can help adjust their insulin dose to where it actually does something to lower their blood sugar. If a patient is not capable of harassing the doctor until they get some help they may be out of luck.

So it's crucial that if you or a loved one has diabetes you understand how insulin should be used so that you can make those phone calls to the doctor that it will take to get help setting insulin dosages to where they really work.

With that in mind, here is a very brief summary of how insulin works.

1. Long Acting Insulins Lower Fasting Blood Sugar. They Cannot Cover Carbohydrates in Meals. Lantus, Levemir, and to some extent NPH are slow acting insulins. They are used to lower your fasting blood sugar level. They are also called "basal insulins". After they are injected they release insulin molecules into your blood stream very slowly over a course of anywhere from 8 hours (for NPH) to 24 hours.

Long acting insulins are started at a low dose and then the dose is increased every few days until the fasting blood sugar has reached a target. This target should be a normal blood sugar, but doctors who don't have the time or resources to educate patients often settle for a dangerously high fasting blood sugar level--often around 170 mg/dl (9 mmol/L) because patients maintained at that level run zero risk of having a dangerous hypo. Unfortunately, they also run zero risk of avoiding complications.

The daily dose of a long acting insulin that will give a normal fasting blood sugar varies from person to person. For a person with Type 2 diabetes, it may be anywhere from 30 to 120 units. To learn what dose works for you you will have to slowly raise your dose--pausing a few days to let the insulin reach its potential, and test your blood sugar first thing in the morning and before meals to track how well the slow acting insulin is working. Your blood sugar will often be higher first thing in the morning than before meals. The before meals number is the one you should be the most concerned about.

If you need more than 110 units of insulin you should demand to see an endocrinologist because there are tricks that specialists know that can help you lower that dose.

Because the absorption of long acting insulins is so slow, you cannot use them to get normal blood sugars after meals. Blood sugar rises very fast after a meal, and if you inject enough long acting insulin to cover the mealtime rise you are very likely to experience a low blood sugars--possibly dangerously low blood sugars-- hours later when there isn't glucose from a meal in your body.

Many doctors prescribe doses of long acting insulin that are a bit too high and then counsel their patients to eat steadily through the day to avoid hypos. This, not surprisingly, leads to weight gain, and may be one reason why many doctors believe that injecting insulin causes weight gain.

If you are using too much long acting insulin, the time you are most likely to feel it is at 3-4 AM when many of us are prone to hypo. Signs you are hypoing are waking up suddenly at 3 or 4 AM from a sound sleep, nightmares, sweating, and experiencing fast heart beat. By the time you test after waking up this way may already have had a release of hormones that pushed your fasting blood sugar back up. If you keep experiencing the symptoms of 3 AM hypo talk to your doctor about cutting back on your long acting insulin to see if that improves matters.

2. Fast Acting Insulins are intended to cover the carbohydrates that come in with a meal. They must be matched to the amount of carbohydrate you eat to work properly.

Fast acting insulins include Humalog, Novolog, Novorapid, Apidra and the slightly slower Humulin or Novolin R insulins. These start working as soon as you inject them. Each one has a slightly different speed with which it kicks in and that speed varies from person to person. If you have trouble matching a fast acting insulin to your meals, ask your doctor if you can try another version. There really is a difference.

To use these insulins correctly you have to learn, by trial and error, how many grams of carbohydrates one unit will "cover". For many Type 2s that number is somewhere around 5 grams, but exactly how much depends on your body size and your degree of insulin resistance. You can only tell how well your insulin is controlling your meals by testing your blood sugar 2 or 3 hours after a meal and noting how much insulin you used, how much carbohydrate you ate, and what the resulting blood sugar was.

To make mast acting insulin cover the carbohydrates in your meals you need to know exactly how much carbohydrate is in the portion of food you eat. This involves study and careful weighing of portions until you get the hang of it. If you aren't willing to do the study and learn the carbohydrate content of your food, you run a very real risk of using too much insulin and causing a hypo. If you are willing to do the work, you can get excellent blood sugar control.

Because there is work involved in using fast acting insulin correctly, many doctors are reluctant to prescribe these fast acting insulins to people with Type 2 and when they do prescribe them, they prescribe them at set doses low enough to guarantee that you won't lower your post-meal blood sugar anywhere near normal. This prevents hypos (attacks of low blood sugar) but promotes complications.

The sign that your doctor is not up-to-date on how to use insulin is if you are told to inject a set amount of fast acting insulin based on your blood sugar before a meal. This is called "sliding scale" dosing and it is considered by endocrinologists to be out of date and ineffective. Sadly, it is also still widely in use because so many doctors got their training in how to use insulin while they were in training decades ago.

There are many of us in the online diabetes community who have figured out how to use fast acting insulin. So if you are considering using insulin or having trouble with it after it has been prescribed, it is worth visiting one of the online diabetes support communities and participating in discussions on the topic.

People with Type 1 diabetes get much better training in how to use insulin, so they can be extremely helpful in explaining how it works, though the doses they use will be very different from those that Type 2s need. The point of any support group discussion should be to learn the theory behind using insulin. Do not ask for or accept dosage recommendations. Suggesting doses is the job of your doctor or a trained diabetes educator. If they aren't doing that job, you need to find a competent doctor or educator who will do it.

You can also learn a lot from books that explain insulin usage. Several books that are often recommended in online support groups are, Think Like a Pancreas by Gary Scheiner, Using Insulin by John Walsh, and Dr. Bernstein's Diabetes Solution by Dr. Richard K. Bernstein. These books all take different approaches but if you read them all you'll get some idea of how to start thinking about using insulin. Your public library should have copies. If not, ask that they purchase them.

If your doctor is not helpful and books don't give you the information you need to tailor your insulin doses so that they give you normal healthy blood sugars, you will have to demand to see an endocrinologist.

3. Premixed insulins combine fast acting and slow acting insulin and therefore guarantee mediocre control. Insulins that have 70/30 in their names are a mixture of 70% slow acting insulin with 30% fast acting. They are most likely to be prescribed by doctors who don't have the resources to teach patients the correct way to use insulins.

By mixing the two kinds of insulin in one injection you make it impossible to match the fast acting part of the insulin to the carbs in your meals as well as making it impossible to match the slow acting part of the insulin to your fasting blood sugar. These insulins may give patients slightly better blood sugars than a regimen of only slow acting insulin--which is the only insulin they are compared to in studies. But that is only because slow acting insulin alone cannot give most people anything near a normal, healthy blood sugar.

Because for most people these 70/30 insulins they make it very hard to lower blood sugar anywhere near normal they are likely to produce the much too high blood sugars that lead to complications.

4. Brand Name Insulins are expensive. If you do not have insurance you will probably not be able to afford the newer brand name insulins which run about $85 for a vial that contains 1000 units or $185 for five pens that contain a total of 1500 units.

Fortunately, you can still get excellent control using the older insulins that are based on R insulin. These are NPH (for slow acting) and Humulin or Novolin R (fast acting) insulin. You will need to use two or three shots of NPH a day to cover your fasting blood sugars as NPH only lasts about 8 hours. R insulin needs to be injected 45 minutes to an hour before eating and it will last 3-5 hours.

However, once you get the hang of how to use these older, cheaper insulins you can get safe blood sugars with them. They are much cheaper at Wal-Mart than anywhere else, so if you are strapped for cash, that is where to buy your insulins.

5. Pens are more convenient than vials but much more expensive. Insulin comes in vials containing 1000 units and pens that contain 300 units each and are sold in packs of 5. If you buy vials you will also need a prescription for syringes with which to inject the insulin. If you buy pens, you will need a prescription for pen needles.

The pen is easier to use, but it is really not necessary if you are only doing one shot a day of long acting insulin. If you are using fast acting insulin in public places, a pen is much less confrontational than a syringe and many people prefer it for that reason. If cost is an issue, the vials are a much better deal.