Questions

Type 2
1

ok so maybe im posting in the wrong forum but I am lil frustrated and thought maybe yalls could provide a lil perspective on things.

I have been dealing with diabeties for over 2 years now (i dont claim to be a vet on this subject). I have been thru multiple insulin medication changes (started at 500mg 2x day of metformin moved up to 1000 a day then put on novolog and lantus). My a1c was a 9.1 last time it was done. My sugar is uncontrolled (my last fbs was 437 and normally ranges from 200-300 believe it or not.)

Recently my PCP referred me to the endo and they knocked my insulin to lantus in the morning and evening and a set number of units for novolog. My PCP had me on a sliding scale. Is there a reason for this. I just dont see the point in a set dosage with novolog without a sliding scale.

Also my PCP believes i should be a canidate for an insulin pump. but here are my fears about that. I live on a limited income (i have medicare and medicade) and I allready have issues getting my insulin with prior authorizations. I do worry about supply cost.

anyway i should stop this post before it turns into a rant. Feedback welcomed

thanks

2

Actually, neither a set dose nor a sliding scale are the best way to dose your novolog. The best is to use and Insulin: Carb ratio; that way you can dose for the food you are actually eating.. If you are high before your meal you can add in a correction using your ISF (Insulin Sensitivity Factor). You obviously aren't on the right dose of Lantus if you are waking up that high and you need to slowly increase it. You don't say how much Lantus you are taking but you need to go up one or two units at a time and then see how it is changing your numbers for a couple days.If you wake up too high in the meanwhile you need to do a correction, or else you will just get higher all day. To find out your ISF (how much one unit of insulin lowers your blood sugar) start conservatively - say 1 unit for a drop of 20 points. If you are still high after a couple hours, try 1 unit for a drop of 18 points. If you are too low, then go up to say one unit for 22 points. Fiddle with it until you get back down where you want to be by say 2-3 hours later.

You should get the book Using Insulin by John Walsh which will explain all these things, and help get your numbers into line. I would work on carb counting and I:C ratios and ISF long before you even consider a pump. A pump doesn't solve problems without getting those skills in line.

3

Get and read “Using Insulin”. Sliding scale, and set novolog doses are huge red flags. You need to do basal testing, and bring down your fasting numbers, though based on personal experience and a lot of reading, do it slowly in stages. Aim for 180 fasting to start perhaps. After a month or so, go for 140, then down to 120, and in six months, you should be able to hit around 100 regularly. I’d also ask about switching to levemir maybe, and splitting the dose. Pumping is great tool to help control diabetes but you should get stabilized first in my opinion. I’m not a doc of course, etc. Also, a cgm can offer wonderful insight and help with bg control. Asking here is a wonderful first step, prepare to learn more!

4

Ok, then try increasing the Lantus to 27 units and see how that works for a couple days. Again, the "18 Novolog per meal" is pretty meaningless. Would you take the same dose for a salad or a plate of pasta? To figure out your I:C ratio: If you currently eat, let's say for a round number, 72 carbs, then your 18 units is 1:4 or 1 unit for every 4 carbs. If you are always high after your meals you might try 1:3. Another thing you might want to do is make some changes in how you eat. My example of 72 carbs is way too many carbs, and if you eat things like rice, cereal, pasta. potatoes you may not be able to accurately bolus. Try limiting your carbs a bit and then work on figuring your I:C ratio

5

Definitely some good advice above.

Regarding a pump - yes, pumps do come at a cost. However, I believe Medtronic offers some assistance programs if your endo completes the certificate of medical necessity (basically, the form that says they are recommending you get a pump). If you're interested in a pump, you can call Medtronic/Minimed directly to find out if they have any assistance that they can offer you. Make sure to tell them that you are on Medicare & Medicaid.

Medicare does have more stringent insulin pump requirements (compared to private insurance companies). I do not know what Medicare's requirements are for T2 diabetics.

In addition to the cost of the pump, you also have to factor in the cost of the pump supplies (reservoirs, infusion sets, tegaderm, etc). This can all really add up.

I agree that the first thing you need to do is get off the sliding scale regimen. That is not used anymore. Learn about dosing based on the amount of carbs you eat. Doing that will set you up for using a pump in the future if that happens.

6

I have Medicare & Medicade myself and they will cover the MM pumps. It would be great for u it has helped me alot. U have to turn in a log for 30 days every 6 months that covers a month and shows how manytimes u test a day and what ur bs's run. ur dr must order that u need it too.

7

Second all Zoe's advice.

I've been D 25yrs. pumping almost 3 years, now I think.. The past year without $ or insurance. I've found some tricks to make supplies go further, but it took some figuring out.

I'd suggest diet is the most effective and easiest thing to change. Then, proper insulin dosages, based on IC ratio. Then, moderate, consistent exercise.

Once you do these, the the pump can make life easier.

Good luck. Be patient. You can do it.

8

Being an uninsured freelancer, I called Medtronic at CDE's suggestion and asked about the assistance program. To qualify, you can't be working at all, but not unemployed for more than a certain time 6mos or a year, I believe. Also, you need proof of income and a letter of dismissal from your previous employer. Basically, the point of this program is not to help anyone out, rather to appear charitable, IMO.

9

I'm just going to advise u on the Medicare & Medicare info here. U will also have to do an A1C done by ur dr every 3 months to get ur supplies for the pump

10

Animas too has low income help. You can get money off the original purpose if you have a co-pay (mine was 20% which they waived) and you can also get money off your monthly supplies (I got an extra 30% off my 20% share)

11

Does Subway list the carb counts on their sandwiches? I can't even imagine how much insulin I would need for all that bread!

12

I don't eat much fast food but when I do Subway is often the choice. However I don't touch the bread at all, it would turn the meal into a blood sugar disaster for me.

13

Oh ok but the pump ppl (I think) will also want it

14

Also, are you sure that you are not LADA?

15

Your insulin doses are pretty typical of Type 2. But I would focus on figuring out your I:C and ISF and basal and getting things into range.

16

You should definately learn to count carbs, and start dosing for what you eat. Sliding scales and set doses are outdated. Set doses can work if you eat exactly the same thing for every meal, and the dose is the right dose for that meal, but that gets pretty inconvenient, not to mention unbalanced from a nutritional standpoint.

You should also consider cutting your carbs back, fast food is notoriously highi in carbs, salt, and grease, all bad things for diabetics.

If you want a plan you can follow, try the South Beach Diet, maintenance level. Start making your own lunches and brown bag it. Its your health, its up to you to make this work. Take the time to make lunch the night before. Eating out is destroying your health, and hurting your wallet too. If you're on a limited income, I don't know how you can afford to eat out anyway.

Also, if you make changes in your insulin, make only one change at a time, and make it a small one. Wait at least 4 or 5 days before making any other changes, because it can take a few days for those changes to have their full effect on your body.

And last, but certainly not least, test more often. Try testing before each meal, and at 1 and 2 hours post meal (start timing from the beginning of your meal). Keep a log of what you eat and how much, and these numbers, then you can start to figure out which foods trigger high numbers and which ones help keep your numbers in line.

Check with your endo before making changes in your insulin regime, and talk to him about carb counting. Obviously what you're doing now isn't working for you and the doctor should be able to help you make these changes safely. If he's not willing to help, try to find a better doctor, who is more uptodate on treatment.

Good luck, and don't give up!

17

You've gotten great advice. In addition to appropriate insulin doses based on what you're eating, timing is also very important. The usual guideline of 15 minutes before meals isn't always helpful for everyone. Some meals digest more quickly or slowly than others. Those high in carbs digest fast. Those high in protein & fat digest slowly & you may not see rise for 3-4 hours. Though medical people rarely, if ever, tell us, protein does effect BG. The only way to head off the spike is testing for a while using both one & two hour readings.

The best way to learn your I:C ratio is by keeping meals consistent to learn how food effects you & when. Lowering carbs will result in lower insulin doses. Lower insulin doses result in better control. Pass on the starchy foods. Eat protein, eggs, cheese, nuts, & non-starchy vegetables. Portion control is important. Just because something is lower carb doesn't mean you can eat it in large quantity. The good thing about avoiding carby foods is that soon you stop craving them. I'm a former carb junkie & promise they hold no appeal any more. The other positive thing about forgoing high carb items is that you won't be hungry. Protein & fat stay with us a lot longer. It's carbs that make us hungry & craving more because they digest quickly.

18

Second Gerri's advice. Timing was a very big problem for me when eating a lot of carbs. I found that none of the insulin I tried peaked as quickly or consistently as expected. Also, couldn't predict quite when the food would hit me. Got the best results bolusing about an hour before eating, but rarely pulled this off. Protein didn't seem to affect my BG much.

On the LC diet, I bolus Apidra right before eating. Food and insulin both peak about 1 - 2 hours, and not as hard, so cover eachother pretty well. Protein does affect me a lot more, now. I bolus for it 50%/g vs carb. If I eat a lot of it (eg. 1/2 roast chicken), it hits me fairly hard, about 3-4 hours and later. Also, if you choose to go this route, you will be very hungry the first few days, while your body is adjusting.

19

Personally, I don't think the insulin pump is the way to go for you. I think your doctor is just trying to prescribe the latest "big thing", hoping it will help. But if you're not achieving even moderate control on injections, the pump will only let you achieve the same, but for $6000 or so more.

Another commenter asked if you're sure you aren't LADA. That's a very good question, and misdiagnosing LADA as T2 is unfortunately very common. I would ask your PCP or Endo for a C-Peptide test to see if your body's making any insulin at all. If he says no, find another doctor.

You say your PCP thinks you should be a candidate for a pump, but what about the endo? Once you see an endo, every other doctor that tries to care for diabetes becomes irrelevent. Listen to the specialized expert.