Hi all, I have had T1D for 18 years and have always been doing Multiple Daily Injections. Last year I moved to the US and started using pump and CGM. After 1 year, I feel that I really miss the convenience of using injection pens and that I don’t have something hooked to me 24/7.
Now after using CGM for a year, I know the way the food I usually eats take longer to digest and therefore BG often go into the system over 4-6 hour period, I think I need a type of insulin that function like an extension on a pump. I was thinking if anyone on MDI here are using NPH? How do you use that? Do you use it only for certain type of food that digest longer?
I wouldn’t touch those older insulins at all. My brother’s been doing the T1 Tango for 46 years and I remember the older insulins were a pain, often requiring him to eat at a specific time rather than when he wanted to.
NPH is awfully long-lasting for your 4-6 hour window. It lasts 12 to 18 hours. I would look at Humulin R or Novolin R.
I would try using a dual wave bolus on your pump. That’s a function that allows you to take a certain amount of insulin now and take the remainder of the bolus over time. I use it to compensate for my higher carb meals.
For me, carb-rich meals have a tendency to make me spike in the first 30-60 minutes. Once I go high, my BG becomes hard to move down. I usually add more Novolog to my bolus and keep about 25% back to be released over the next 30-60 minutes after the initial bolus.
There’s no reason you couldn’t adjust it for different types of foods.
Generally, very few T1s use NPH in the U.S. anymore. Those who have experience using it would be long-time diabetics (35 years or more).
NPH is too long a duration for food. It would be tough to plan and deal with. (I do like NPH as a basal for nighttime if you have higher basal needs at night.)
You could go with one of the R insulins. That would take some testing and adjustment and figuring out. You would probably want to use both a rapid insulin (NovoLog, Humalog, Apidra, Fiasp) and an R insulin.
Another way would be to do multiple injections of a rapid insulin for your meal. An app to remind you or something would probably help - as long as you don’t mind taking several injections.
Thank you so much! That’s good to know. Do you know what’s the action profile of Humulin R and Novolin R? I can search it online but just like to know whether it corroborates with what is in real life when used by patients. Thank you!!
Nice. I think the R insulin are exactly what I need in addition to the Novolog/Humalog I am already using.
I may even be able to just use those 2 without a need for basal since my basal rate is so low (0.1-0.15u/hr). Will try them out and adjust accordingly. Thank you for the suggestion!
NPH (I’ve never used it) also has a reputation for being uneven in its action, with a distinct peak, and sometimes erratic and unpredictable—one behavior today and a different one tomorrow. As I say, this is just what people tell me.
For about 26 years (1990…2006) I did MDI with NPH as the basal. I split it evenly 4 ways and took the shots 6 hours apart. I mixed with regular for bolus.
I was really happy with that. 2x a day NPH was just horrible but 4x a day was pretty good.
I have since switched to Lantus (2x a day) for basal plus 3x a day Humalog for bolus. I think this is slightly superior to the MDI I did with NPH+Regular. But just like you longing for the old days instead of the pump, sometimes I have issues with the new regime - especially when the Humalog comes charging out of the gate with a giant hypo right at lunchtime.
If you are having hypos right after meals, that’s because your Humalog is coming on too fast. You might ask your pump team to teach you the other extended bolus patterns, like the dual wave pattern.
If you really don’t like the pump, you might express to your doc/pump team your desire for a different method of control, and suggest your previous MDI. If your doc doesn’t support MDI (I know there are local endos around me that would require me to be on their brand of pump) you can always go looking for a new doc.
Gary Scheiner did a review of afrezza but then decided to continue using it for corrections but my understanding is he is now using it more and more at meal time. Being one of the original pump users I don’t think he has given up his pump yet but as Keith Campbell said others have. You can find Gary’s review here
" Review: Afrezza Rapid Acting Insulin | Integrated Diabetes Services
Seems like the chief drag on wider adoption of Afrezza is the respiratory aspect. Okay, there are market things too, but this was the aspect my endo dug in her heels about. I’m very prone to bronchitis ever since a case of pneumonia many years ago. A lot of people have no problem with it that way, but a significant number do and there’s some question about long term effects (as with anything new). For my part I don’t give a damn about the inhale-able aspect but the way it acts and clears so quickly is game changing. If they came up with an injectable form as well that would solve a lot of problems. But I suspect that absorption through the respiratory system is a big part of why it has the profile it does.
It was in trails an unusually long time and has been on the market closing in on 3 years now, I’ve yet to hear any concerns from the people who use it frequently. It clears the lungs as fast as it works. There is no residue, no change in lung function, exactly what Al said.
DrBB - as Gary Scheiner said in his review the lung concerns have turned out to be “mostly” FUD. In reality pretty much all FUD. The first compassionate use was approved in 2008 so there is a pretty good track record. The interesting thing is some people are actually reporting better lung function after their first year lung test than after the baseline test primarily due to better control/health.
The biggest issue has been big pharma doesn’t want afrezza in the market. As Keith Campbell said “there might be a therapeutic advantage to using Afrezza as the initial treatment early in T2D” especially if you believe the hundreds of studies over the past 40 years saying early insulin use in T2s can stop and in some cases reverse T2 complications. Right now Big Pharma has a T2 market approaching $40B.
Dr Bruce Bode said last month at a Medscape education session that after diet and exercise afrezza should be first line use for T2s. This would be a huge issue for existing T2 med sales as 70+% of current T2s are not hitting an A1c of 7.0 and 90% are not hitting 6.0 which should be the target with CGMs and time in range emerging as the new standard. Big Pharma does not want this market disrupted. Dr. Bode was asked about lung issues and he also said it was all FUD. Its hard to argue with 9 years of patient use.
Here is a short video on the lung absorption which is actually safer IMO than site injection especially when considering most “insulins” used today are not human insulin but rather analogs. But like everything else afrezza is not for everyone and if you have existing lung issues you are probably not a good candidate. - YouTube
Not trying to get into a wrangle about it but it was on my mind b/c I was just talking to a T1 on another site: her son is also T1; they both tried it, he loves it and is still using it, she loved it but developed a persistent cough that took a couple of weeks to clear up after she had to stop using it. :shrug: Some people are sensitive that way. I suspect I may be too b/c of the bronchitis thing. I’m also a semi-pro singer so I’m leery of ingesting anything that way (FUD factor for me). I’d still be interested in trying it, could probably persuade my endo if I pushed about it, but it hasn’t felt like a big priority.
I have now heard from at least three people that Afrezza worked like gangbusters at first but then became less effective after a few months. This may be one of those unexpected issues that only crops up after a product has been out there for a long enough time and taken up by enough people to show a pattern. (Let’s hope not.) Or, it may follow the usual diabetes pattern: true for some people, not for others, and not a one-size-fits-all remedy. Wouldn’t be the first time, by a long way.
David - great discussion point. I have heard this a few times. What is important for people to understand is the human body has spent thousands of years fine tuning itself to remove glucose from the blood with the human insulin molecule. Unlike all T2 meds and all the analog insulins which are not natural to the body afrezza is nothing more than the exact same insulin molecule which is release by a healthy pancreas. So when people report afrezza is not working or not working as well as it had there is usually more to understand because if human insulin is not working something else is going on.
There are usually two main issues which are typically the root cause. The first is their diet has changed and they have started eating things which they could not before. In one case the PWD said afrezza wasn’t working anymore only to find out she added chocolate cake, brownies and ice cream to her diet. Cutting back a bit and a little more afrezza solved that issue. The second thing is some people have cut back on the exercise because their numbers were so great. Adding the exercise back also solves that problem. Of course adding more afrezza would do it too but the exercise is the way to go.
The third issue not seen too much is people put afrezza in the freezer and then leave it in there and then try and use it without it returning to room temperature. afrezza will tend to clump at low temperature and not all the insulin will get out of the inhaler resulting in a lower dose. Again easily solved.
If your people are seeing an unexplained insulin resistance that would be interesting to further investigate if these people are keeping near non-diabetic BG control.
Those are all valid points, but they don’t really resolve the uncertainty. At least two of the people who have commented to me fit none of your scenarios (not sure about the other one). The argument that Afrezza is more like the natural human product is really beside the point; the modern pharmacopeia is replete with compounds that are nothing remotely like any natural body substance but are stunningly effective all the same. Everyone has to decide these things for themselves; personally I am a hardcore empiricist. Where something comes from is an interesting academic point, but whether it’s effective is the only thing I care about at the end of the day—the only thing. (Did I remember to say “only”? Good.) Show me empirical results; I’m not interested in the academic niceties. My meter doesn’t respond to them.
Other drugs have exhibited the same behavior being discussed (working for a while and then, not so much), including both diabetic and non-diabetic meds. The reasons are many and varied. Again: there is no one-size-fits-all. Repeat as needed.
No I haven’t. The reasons, in no particular order, are (1) cost; zero insurance coverage, (2) my GP won’t prescribe it and I don’t have an endo, and (3) what I’m using works beautifully. It ain’t broke, so . . . you know the rest.
Nor does any of that mean that I don’t fully support other people in getting the most out of it if it works great—for them. More power to ya.
@Timbeak48 my daughter was dxd in 2009 & started on NPH, Levemir & Novolog. Ped endos still prescribe it for some newly dxd kids. A morning dose is used to cover lunch, so there’s no need for injections at school. It worked well for us.
The big problem with NPH is having to eat to the clock, but since the day is regulated and predictable at the elementary school level that makes a pretty good use case. Still plenty of ways to get out of kilter with NPH, but that seems like a reasonable trade-off.
