Emergency supplies and basic insulin strategies

Type 1 and LADA
1

@Michael_Birch’s post about price gouging led to the mention of inexpensive relion insulin, of which I have many bottles of R, N, and 70/30. His post also prompted me to realize that I really have no idea how to use them…

I’d really be clueless if all of a sudden I had to manage with just novolin 70/30.

Anyone want to talk about how, in a SHTF situation, perhaps with no more access to additional test strips or modern insulins, how would you attempt to manage a crude emergency regimen with R, NPH, and/ or 70/30?

I’m hoping some people weigh in who actually managed with these products before widespread home bg testing… Because their knowledge gained in doing so is completely lost on my diabetes generation

2

I wouldn’t touch 70/30. I’ve never used it, but I have used R and NPH and 70/30 would be even less flexible. The only way I’d use it is if there was nothing else left and it were that or death, but I think it would be nearly impossible to get any type of control with it.

I used R for the first eight or so years of diabetes before it was replaced with Humalog, and used NPH for the first 15 years of diabetes before switching to Lantus. So, I was on a non-MDI, NPH-based regimen for the the majority of my 24 years of diabetes (even though it doesn’t seem like it!). I was diagnosed when home blood glucose testing was available, although my prescription was only for 100 strips a month, which is much less than today’s half dozen or dozen tests a day and CGMs.

R and NPH used to be given as two shots a day, a mixture of R and NPH in the morning and R and NPH again before dinner. The R would cover breakfast, the NPH peak would cover lunch, the R again would cover dinner, and the NPH would peak in the middle of the night, which meant that you had to eat a bedtime snack consisting of carbohydrates and protein to prevent a low. With R and NPH, you also had to eat morning and afternoon snacks because of the long tails. Also, R had to be bolused half an hour to an hour ahead of eating. And with all of these insulins you had to eat exactly on time—being even half an hour late would result in really low blood sugar because of the peaks and tails. NPH is not really a basal insulin, it’s just regular insulin that has a substance added that greatly slows down its absorption, so it has a large peak. Also, when mixing R and NPH in the same syringe the R had to be measured in first and then the NPH, otherwise you’d get some of that slowing-down substance in the R insulin and it would affect its action (or at least that was my understanding).

But, if I were using R and NPH today, off the top of my head I think I would use R to cover three meals, make sure I always had food available for snacks in between, and then take NPH before bed to cover overnight and the dawn phenomenon. R has a tail of six to eight hours, so it would easily last between meals, and NPH has a tail of about 12 hours, so it would last overnight, probably with a snack before bed to prevent lows. I think trying to use NPH during the day would just result in a lot of lows—and NPH lows are nasty—I haven’t had anything close to those hours-long, semi-conscious, requiring-assistance lows since being on MDI or a pump. It would also remove trying to guess at which insulin you had to adjust up or down for highs or lows.

I think that any of this would be very hard to do without any form of glucose monitoring at all. Even before people had access to glucose meters, they still measured their urine glucose and ketones. If I were using this type of regimen, assuming no access to test strips, I’d definitely want some urine ketone and glucose strips so I could at least get an idea of those levels.

3

Thanks Jen… Were there any books from back in the day when you were learning with R and NPH that helped you get s grasp on them?

I’m not actually probably going to read it right now, just wondering if there’s a good 30+ year old reference on diabetes management with R and NPH before home by testing was prevalent— I’d probably just keep it with my stash

4

Jen’s memory is better than mine. R + NPH was the first regimen I used. I started, in fact, with just shooting NPH once a day at night, then I added a morning shot. I used BG Chemstrips to measure my blood glucose. I didn’t use a meter but just compared the color of the two pads on the strip to a spectrum published on the side of the container.

I added Regular to that routine first with just the breakfast and dinner shots but eventually added a lunch dose of R. This was early on and I was honeymooning so my control was pretty good. I do remember having to eat my lunch on time every day or get hit with a bad low.

Like Jen mentioned, the optimal prebolus time was in the 30-60 minute range. You could get distracted between taking a dose and eating and end up in the ER. I fell asleep in an easy chair one time and woke up to a drug-like psychedelic scene.

When I first started on a pump in 1987 I used Regular insulin. The rapid acting analogs didn’t come out until 1996. The Regular actually worked pretty well in the pump but we used a Regular brand with buffering agents to counteract interaction with the plastic tubing and consequent occlusions. I remember the name Velosulin.

I wouldn’t want to use these old insulin formulations unless I had a CGM or plenty of fingerstick strips. They were a lot riskier than current insulin formulations. I know people got by for decades using these with just urine testing. I don’t know how they endured that.

I never used 70/30 insulin.

As far as a written reference to use to learn to dose, I would take a look at the package inserts and pay attention to the onset, peak and duration times for each formulation. There is a lot of info on the package insert that could help you.

That’s a situation that I would never want to face. It would be a rude awakening for me.

5

Yeah it’s certainly not something I’d ever do by choice… It’s an emergency preparedness measure only… I mean it’d have to be like a War of the Worlds situation when there’s no other options… Still would like to have the confidence that I know enough of the basics to get by…

6

One important point is that you’d probably have to give up on any notion of good control if you were trying to do this without any glucose monitoring. If someone monitored closely they could maybe tailor their diet and exercise to match the insulin, but it would be hard. It’s the opposite today, tailoring your insulin to your food and exercise, but for many years it was the opposite.

I remember when I was a pre-teen a girl did an experiment where she tested her blood sugar and her sister’s blood sugar after eating. Her sister’s was normal, but hers was in the 20s mmol/L every time. (This is why we were told not to test after eating, being that high back then after eating was just considered unavoidable.) Maybe it would work better with a low-carbohydrate diet, but I’ve never tried it so don’t know how the peak and timing would work out.

I’m actually in the process of purging (going through all my old files and scanning/shredding), and I have a whole file full of old diabetes stuff. I think that I might have a page in there about adjusting R and NPH insulin. The only book I have is a kid’s book, and I’m not sure how much regimen-specific information it has (and I doubt it’s still in print). I was diagnosed at age 9, so I didn’t really do much reading about diabetes until I was in my 20s and became interested in Lantus.

7

So @Jen, @Terry4— what do you think would be the best bang for the buck in terms of a stockpile of emergency insulin? R only? A mix of R and NPH (in what ratios). Or 70/30?

When 70/30 is used, what type of protocol is generally followed? I’m sure it’s not ideal, but judging by how many times my own local small town pharmacy has tried to mistakenly give me novolog 70/30 instead of novolog, I have to assume that a lot of people out there are still on 70/30 regimens…

Keep in mind I’m not talking about an effective management plan here-- I’m talking about best bang for the buck in terms of surviving in an absolute emergency…

8

The 70/30 is a mixture of 70% NPH and 30% rapid insulin (or maybe it’s the other way around). I think the only way to use it is using the two shots per day I described above, eating three meals and three snacks, since it would have to be taken with food (due to the rapid insulin) and there would be NPH peaks that would necessitate meals and snacks.

The problem with this type of insulin is that it’s impossible to adjust. If you’re high at dinner, usually with that type of regimen you’d increase your morning NPH (if I remember correctly). But with 70/30, if you increase your morning NPH, you’re also increasing your morning rapid insulin, which means you’ll end up going low in the morning or at lunch unless you eat more. Similarly if you were low at bedtime and decreased your dinner rapid insulin, you’d also be decreasing your dinner NPH insulin which would then lead to morning highs.

Maybe there would be a way to use 70/30 with four shots a day like I described myself doing if I were to go back on those types of insulin, but again, you’d be getting NPH during the day (so not sure how all those peaks would affect things) and you’d be getting a dose of rapid insulin at night (so you’d need a big snack). I think the only way to use 70/30 would be to either spend half the day high or spend half the day low. If it were truly the only option, though, it would be better than the alternative.

Another thing I thought of is the advice to treat lows with 15 grams of carbohydrates every 15 minutes and then follow up with a snack of a carbohydrate and protein if not eating a meal or snack right away came from the NPH days. Although it’s overkill today because we can fine-tune our insulin to meet our exact needs, it worked well back in those days. So, if you’re going to stockpile these insulins, I’d also stockpile lots of glucose tablets, crackers, and peanut butter…

It really was a different world compared to today’s flexibility, which is partly why I’m so surprised it was barely more than 10 years ago for me! I do recall that there were some, maybe @acidrock23, who were using R and NPH in a sort of MDI regimen that was perhaps more flexible, though. I also agree with @Terry4, I’d study these insulins and really get to know their peaks and durations (and, for NPH, its variability), because that’s what dictates everything I’m describing like having to have meals and snacks on time.

9

How much insulin would this possible emergency require? Insulin does have a shelf life but I know it doesn’t go bad the day after it’s shelf life expires. It lasts longer with refrigeration. If your emergency plan does not include a way to keep the insulin cool, then a long term emergency, like more than six months would threaten the insulin’s longevity.

If I were doing this exercise, I would try to stock as much of the good stuff, the analogs, as possible. Many of us develop an “emergency” stockpile measured in months with judicious insulin use and ordering with a safety factor in mind. Are you trying to stock up for a few years?

If I had to choose only between R, NPH, and 70/30, I would only stock R and NPH. My first thought was that a 50/50 split of NPH to R would make sense. With NPH’s longer duration with a significant peak, it could probably take care of most of a mid-day meal. Maybe 60/40 would make sense, that is 60% NPH and 40% R.

10

When I was on R/NPH (shudder! 20 years–gack) they used to tell us it was ok to mix them into a single shot, so that’s what I used to do. I’m a long way from being able to remember what my combination was, but you could at least adjust things in a kind of gross way. This 70/30 stuff sounds like it would further limit what meager control parameters you do have with R/NPH, so yeah, I’d stay far far away. R/NPH is hard enough without crippling yourself further.

As for test strips, if you’re really rationing I’d guess you could get by with testing twice a day on R/NPH, maybe even once, based on my experience as a really sucky (in denial, burned out) diabetic who would go for days without testing back when I was on it.

11

Yep, you could mix them (it’s Lantus you can’t mix, I think). I just remember having to do the R first so as to not contaminate that vial with NPH’s cloudy slowing-down substance.

12

I live in a place where there is a real possibility of a significant earthquake, so I stockpile at least 2 months’ supplies, which I figure is plenty to get through the main post-emergency craziness. I’m doing MDI and I think my short and long insulins should be fine too depending on season and assuming I’m keeping them as cool as I can with an evaporative pouch if there’s no electricity. I feel very fortunate to have been diagnosed after the days of NPH and R!

13

I had forgotten that bit. I totally don’t remember what my proportions were or how I determined them. Sheer guesswork most likely. My way of using it was different from most of what I hear from other old-timers on TUD. From early on I was told that the R was going to peak at midday and the N at dinner time, and that’s how it seemed to work for me, but maybe that was just an illusion born of the long tail both of them have. I do know I had to eat to the clock. As I fondly call it, the “Eat Now Or Die!” regimen–that legendary NPH crash was no joke. But I also have a small amount of endogenous insulin production, so that probably helped. At any rate, I just took a single combined shot per day for 20 years. Helps explain why the initial reaction of the first real endo I got to see after finally getting a decent health plan was “You’re not doing too badly considering what you’re doing doesn’t make any goddamn sense.” That was the guy who switched me to Lantus/Novolog MDI, which was life-changing.

14

I don’t have an exact fantasy in mind, I just like to be prepared.

Regarding refrigeration, I live in Alaska and would have no trouble keeping insulin cool in coolers full of naturally occurring snow and ice about 7 months / year… In the summer I have a shallow well on my property, my guess, though I’d like to investigate further, is that he water in it never exceeds 50 F which I could easily trickle through a cooler to keep it at that temp…So I feel pretty good about my ability to keep insulin from spoiling.

I also have no doubt I have the abilities to provide food for myself and family even if there was a total breakdown of the supply chain and infrastructure… Maybe not a balanced diet but certainly fish, meat, eggs, and to a lesser extent vegetables and milk…

15

I also live in an earthquake zone where they warn about a massive megathrust earthquake happening at some point, maybe next year and maybe in a hundred years. So, I’m also working up to having several months of supplies at home, plus an emergency backpack if I had to evacuate my building, and I have about a week’s worth of insulin in my bag at all times in case I were on public transit when an earthquake hit and had to make my way home or to some other location.

16

man R and Nph… I don’t know how I survived those days. I remember going into a couple overnight comas back in those days.

As far as stockpiling goes, I have accumulated about 4-6 months worth of reserve insulin. You can probably do this in a relatively short amount of time by asking the doctor to adjust your doses higher. Another option coming soon is the generic/bio similars of lantus coming to market in a few months… I’m assuming those bio similar a will be really cheap. Then you can just use the R for your short acting… Just have to remember to do it an hour before you eat! :slightly_smiling:

17

Way ahead of you;). I probably have 6 months of the good stuff on hand or more at all times then I’m trying to keep 2+ years of last resort stay alive last resort gear…

The more I think about it it seems that with the stockpile I have the limitation of test strips being readily available might pose the greatest challenge in the intermediate term in an emergency

18

[quote]The more I think about it it seems that with the stockpile I have the
limitation of test strips being readily available might pose the
greatest challenge in the intermediate term in an emergency.[/quote]

If you are planning for the possibility of civilization being down for two or more years, I’d pick up some Ketostix and Diastix. I think if unopened they have an expiration date of four or five years, and they’re super cheap ($10 for 50), though the ketone sticks have to be tossed six months after opening according to the bottle. But, I have some glucose sticks that expired in 2013 that I found while cleaning out my old earthquake kit this past summer. The bottle has been opened for several months, and I just tried one now since my blood sugar is 13.4 mmol/L, and it changed to a colour mid-way up the chart, which seems to be reasonable since I’m high but not alarmingly high. Since we’re talking last-ditch here, your goals presumably would be to not die of hypoglycemia and not die of ketoacidosis. The glucose and ketone urine strips would at least warn you of the latter. For the former you’d just have to rely on how you felt, and stock up on lots of glucose tablets, crackers, and peanut butter.

19

Or just a few 10lb sacks of sugar… To keep it simple

20

Depending on the circumstances of the emergency food would possibly be in short supply so you may not use so much insulin.