New Levemir Insulin User - Many Questions

Type 2
1

Hi All. Just joined Tudiabetes a few days ago.

Brief history: I was diagnosed with T2 15 years ago. I've taken Metformin much of the time since (Doc would let me discontinue it when I was maintaining 5s and 6s). Most of that time I was able to keep my A1C at 5, 6, or 7. When I would stray higher my Doctor would suggest adding one of the additional oral medications. I'd read all the potential side effects and elect not to take them. I'd buckle down and get them back in range.

For the last three years that has become increasingly more difficult to do. At my Doctors appt last week, we spoke about my BG Levels, and she once again wanted to add another oral medication. I told her my concerns and asked if she thought Insulin would be a better choice. If I wasn't scared to do it, she agreed.

So we have started with Levemir. 10 units before bed. That didn't do anything but swap my high and lows. My out of bed numbers were always the highest and before meal numbers throughout the day would always be lower. The first week on Levemir, my morning numbers were lower, and it would go up during the day. I read a lot of Discussion on this site about Levemir and the general opinion was that it didn't last 24 hours and 2x a day was better. Started that yesterday so we'll see where that lands. On Friday she also had me increase to 15 units a day.

There are 2 Diabetic Specialist in the area, and was told that the waiting list to get a first appointment was about 6 months, so I'm sorta on my own with learning in-depth about this new phase of my treatment. Which I'm fine with, I'm feeling empowered right now.

Can anyone suggest a good book about maintaining your BG with insulin?

I've seen the term "sliding scale" in many discussions? What does that mean and what is the alternative? Seems other members don't like it. IDK does it even apply to me, just being on Basil Insulin. (Thank you - Although I knew there was short, med, and long acting, I didn't know what was meant when members referred to Basil vs Bolus. I do know).

Is it common to be just on a long acting? Doc and I didn't discuss future plans, she is probably just waiting to see where the long acting gets me. Just guessing, I didn't really know what questions to ask at that appt.

Neuropathy: Doc looks at me like I'm crazy when I tell her this. But I can use it as a measure of how well I'm controlling my BG. When I'm out of control for a while the numbness spreads to all my toes, and when I stay in control a while all feeling returns to normal with the exception of a small area on the medial side of each big toe. Does anyone else experience this?

I'm sure I'll have more question as I learn more.

Thanks for listening,
Rob

2

Although you were told the waiting list is 6 months, if you ask to be put on a waiting list for canceled appointment you can often get in much quicked. In general you can do well as a T2 on a low carb diet with a basal insulin, but you may need to to add a rapid insulin for meals. And usually you start with a conservative dose (like you have) and then make adjustments. Waiting 6 months for adjustments is not reasonable.

3

Thanks for the advise all.

Brian, I’m working with my regular doctor on adjustments. Every few days I’ll text her my numbers and she’ll advise on adjustments. So that will get me started.

4

Very true, especially with a basal insulin. Changes take time to settle in and stabilize -- at least 4 days, sometimes longer. Otherwise you're aiming at a target that's moving so fast that it's almost impossible to make valid decisions; you're always working off of incomplete or even obsolete data.

5

Hi Robbo, and welcome. I've been reading all the replies here and they are chock full of excellent advice. I'll add $0.02 of my own.

In addition to the Walsh and Scheiner books, you should also read Berntein's:

Richard K. Bernstein, Dr. Bernstein's Diabetes Solution, 4th ed. (New York: Little, Brown and Company, 2011)

Bernstein is a true pioneer in the management of diabetes. Just as an example, he invented the basal/bolus approach that is now pretty much standard practice. But importantly, he is himself a Type 1 diabetic so he has more skin in the game than the great majority of doctors. His book is the bible for me and many others. Regardless of how much of his advice you do or don't choose to follow, his book will give you a more thorough, grounded understanding of practical day-to-day management than even many doctors possess.

Reiterating what someone else said here, the "sliding scale" is bad news. Don't have anything to do with it. (After reading Bernstein you'll really appreciate what a bad idea it is). The sliding scale basically says, "if your blood sugar reading is x, then take y units of insulin before eating," regardless of whether you're planning to eat a stalk of celery or half a chocolate cake. Absurd.

You also ask, "Is it common to be just on a long acting?" Not necessarily. "Common" is a word you have to use with great caution when talking about diabetes. One thing you'll discover -- if you haven't already -- is that everyone's physiology is distinct and individual, and what works for one person may be of no use to another. We even have an acronym for it -- YDMV (Your Diabetes May Vary). Among insulin users, a combination of basal and bolus insulin is probably the most common pattern, but there are wide individual variations.

Take me for example. I am T2 and don't use any basal insulin but only bolus for meals. When fasting, I don't need insulin -- my numbers stay very close to normal. But I can't handle food at all -- when I eat, my BG skyrockets. So I need to cover meals with a fast acting (bolus) insulin. That's just me, however; everyone is different.

[Reading Bernstein will also explain a pattern like mine -- just to whet your curiosity! :) ]

Finally, let me say that you have exactly the right attitude. Your determination to understand and control this yourself is fundamentally the most powerful weapon you have.

6

Makes sense. Thanks.

7

YDMV, I like that. I can see that in all the different discussions I've found. I hope to get over to Barnes and Noble this weekend to get some reading material. Thanks.

8

When starting out, I don't think it is bad to work with your doctor to make initial adjustments every few days. Your doctor likely started you on a dose which was too small to actually have an effect (the so called physiological dose). They will likely increase it by steps every few days looking for effect and then slow down adjustments. As others have noted, basal insulins like Levemir have a long and stacking effect. You won't truly know how they work for some days. When I adjust my basal, I average my readings over a week or more and then make small adjustments. I'll only know if it helps after a week or so. Often the day by day variations are so large, it can be almost impossible to see if things make a difference.

9

I want to applaud you for taking such a proactive approach to you D treatment. Most of us T2's (Brian,BSC excluded)are pulled kicking and screaming across that threshold.

Starting with a low dose and working your way up is a good approach. My doctor started me a 10 units Levemir and told me to increase dose by 2 every third day until my BS was under control. For me Levemir never did achieve my goal and short acting insulin was added to my treatment plan.

Every diabetic is different and that's especially true for T2's. A lot of T2's do perfectly well on long acting insulin only. I have no numbers to back this up but would guess that that's the most common insulin regime for T2's. Somebody correct me if I'm wrong.

You doctor is taking a good aproach. The most important part of this process is testing so that you will know what the insulin is doing for you.

As suggested by others reading Dr Bernstiens book is a good idea.

Gary

10

lol @ Kicking and Screaming. I'm a Nursing student, and over the summer we had to do "Med Cards" for the 40 most seen medications. So that exercise changed how I felt about Insulin. Took the fear away. It just seems like the best choice to help get me where I needed to be.

Ive been testing morning, before all meals, and before bed.

11

That's exactly the right attitude to have toward insulin. There are certain things that people just get weird about, and needles are one of those. (But as a nursing student, you know that.) If insulin were a pill you could swallow, I suspect there would be much less resistance to using it. Silly, but there it is.

The other big factor is that many diabetics -- and many HCPs, I am sorry to say -- view insulin use as a last resort, or an admission of failure. Now that's really ridiculous. It's just a tool. When a job needs doing, you use the right tool for the job. If you had a nail to drive, would you say "I've tried and tried to insert this nail by hand and it just isn't working. I may as well admit failure and get a hammer"?

On second thought, here's a much better analogy. If you had a broken leg, would you view the need for a cast as an "admission of failure?" Of course not -- you'd want it right now and you'd be grateful that it existed and was available. But many people don't look at insulin that way. As I said, silly.

Personally, I'm just grateful to be living now, when we have such excellent treatments available, and not 80 or 90 years ago -- not to mention a state of the art that advances nearly every day.

12

As a last resort, that's exactly how I viewed using Insulin. The doctor I had when first diagnosed years ago planted that seed of fear. Insulin was the threat he used if I didn't get my glucose level down.
I was OK about the needle, but do have to admit, that first injection... I held over my skin a few minutes before getting the courage to push it in. Then I did it so slowly, it did hurt a little. Now it's right in and I rarely feel it.

13

You've probably figured this out already, but the key to a painless injection is to do it quickly. Bernstein's explanation is about as good a description as you'll find anywhere (chapter 16).

Another afterthought, about that "last resort" mentality . . . I think a lot of it stems from having one's focus on the tool rather than where it belongs -- on the goal. The goal is normal blood sugar; you use whatever method or technique is successful in getting you there. Obsessing about the method or technique is, IMHOP, thinking about the problem exactly backwards.

14

Way to many doctors try to instill fear of insulin as something to be avoided so that they can make us fearful and use it the whip us into compliance (hate that word) with the drug cocktails they like to use.

That's a great disservice to T2's because sometimes insulin is the best treatment but it's avoided at all cost because of the fear factor. I would much prefer that they talk of the good points of insulin so that when the time comes the transition is easier.

I'm going to borrow a line from Acidrock "You rock dude" It looks like your on the right track.

Gary

15

Right on, Gary. Bull's-eye.

16

I agree. Im happy with my decision.

17

My 2 cents.
When you read something be carefull to take what applies you and discard the rest. You are type 2, using metformin I suppose and now basal insulin. It's a different situation than a type 1 diabetic with no metformin and basal+bolus.
You have still your pancreas that can kick in and hopefully in a good timing.
You have metformin and its curve-of-action: I read here on tudiabetes of people with up-down BG excursions due to metformin+insulin which found themself better using only insulin in a basal+bolus way.
I don't know "the answer" but be carefull not to stack on too many pharma, they can play together well as well as not.
Good to see you empowered.Bye

18

Thanks. Actually once I get the Levemir dose close, my doctor wants me to half the Metformin, and taper it off so I’m just taking the Levemir. I’m getting close so I’ll probably be doing that next week after I base with her.

19

Garidan offers good advice. Taking metformin+insulin was never a problem for me but I did discontinue it because I felt it was redundant.

I like the KISS principle (Keep It Simple Stupid) if the metformin is not necessary then why complicate things. If the metformin is needed I would not hesitate to use it but would keep a close eye on things. The impression I get of you is that you already got that part under control.

Gary

20

I continue to take a maximum dose of metformin with my MDI regime. I've not noticed any excursion problems, but then I've not really had much gastric distress over the long-term. What metformin does for a T2 is to improve your insulin sensitivity thereby reducing your insulin needs and presumably the postprandial variations. If you are not insulin resistant, then metformin will not necessarily help (but what T2 is not insulin resistant?). Metformin has specifically been approved by the FDA for use concurrently with sulfonylurea or insulin. Note that the FDA didn't approve it for use with other medications although metformin is widely prescribed off-label in conjunction with other medications. I consider metformin + insulin to be very safe and appropriate for me as a T2.