So I started insulin

I finally started insulin on Tuesday! I cant use the word happy (I’m sure no one is happy about having to take insulin everyday) but I am overwhelmingly relieved :slight_smile: The Dr started me on a 4, 4, 4 and 8 combination of Apidra and Lantus. So far my numbers have been excellent (I think). Morning numbers have been 4.2 and 4.6 (for the last few months I’ve been between 10-12). Post meal numbers have also been excellent, averaging about 6 at 2 hours (I’ve been between 10-16 for the last few months). The Diabetes educator told me to try and eat about 30g carbs per meal. For me this is new as I’ve been on 5-10g carbs for so long. Do you think 30 is a reasonable number per meal?

The Dr also told me I can stop taking the Diamicron and Metformin :slight_smile: as they are both doing nothing for me at this point. He said some Type 1s do take Metformin but with my body type (150lbs and 6’-1" and very active) it probably wont help.

Just a few questions about the insulin. I’m going camping this weekend so do the pens need to be kept in a cooler? I was told the unopened ones do but what about the pen I’m currently using? Also, how often should I be changing the needle?

Thanks for listening, Paul…

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Congratulations on getting started on insulin. It sounds like you’re on a “set” dosage of insulin - 30g of carbs is reasonable if your dosage of insulin is keeping you at numbers you’re happy with. Hopefully in the future, after this first step of settling in, your doctor will help you figure out insulin-to-carb ratios so you can have more flexibility with your meals and insulin dosing.

As to the pens, yes, keep any unopened ones cool - and remember to pack a spare just in case something happens to the one you’re currently using. I wouldn’t stick it directly into a standard ice chest, down in the ice, though, as that can be too cold. If you look on the box of pens it has temperatures that you want to keep your insulin at. Normally you don’t need to do anything to keep your opened pen cool, but when camping outdoors that’s a different subject entirely. A lot of people use a Frio cooling case, but it’s probably too late to get your hands on now. A normal soft-sided lunchbox with one of those small gel-pack icepacks wrapped in a towel (to keep it from ending up right against your insulin) should be good enough if you’re going camping somewhere where the temperature is going to be considerably warmer than about 80-85F.

Technically you’re supposed to remove the pen needle after each injection and throw it away, then put a new needle on before each injection. A lot of us don’t though, and either remove it and place it in some sort of small container to reuse, or just leave it on the pen and put the small plastic cap back on before putting the pen’s cap back on over that. Leaving the needle on like that can, reportedly, lead to air bubbles in the insulin which may be more important for T1s using small doses of insulin than to a T2 using larger doses.

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There’s nothing mysteriously difficult about I:C’s and it’s beyond me why anyone is ever placed on set doses these days… Way to tie someone down to eating lots of carbs at set times! :-1:t3:

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I’m sure this is a relief to you. I think getting a proper diagnosis can really be a struggle and in the end what really matters is getting proper treatment. And finally I think you are on track. I wonder, has your doctor decided you are type 1?

I think many of us have struggled finding a proper number of carbs that we can tolerate. Finally having insulin you can adjust to different intakes of carbs without risking spikes in blood sugar. I would encourage you to experiment. If you eat 30g of carbs per meal, that is 90g/day, still pretty low carb. If can do carb counting and dose your insulin to be on target 2 hours after a meal that would be fine.

I keep my pens in something called a Frio. And it works fine in all kinds of hot weather as long as it isn’t like 100% humidity. Pens do need to be kept reasonably cool although at room temperature. Apidra says keep below 77 degF (25 degC) and Lantus says to keep 86 degF (30 degC). And neither of them should be exposed to sunlight. It really depends on whether. It is in the 90s here, too hot. It would be best to either keep them in a cooler or possibly wrap them in damp paper towels.

I replace the needle on my basal on every use but will sometimes keep the needle on my rapid so I can inject rapid several times during the day. I probably use 2-4 needle tips a day. It is ok to change them every time.

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Actually, I got my Frio at CVS, and I believe the Walmart where I live has them, too. Might be worth checking out!

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Thanks, I’ll have a look and see if I can find one at the Walmart here…

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Thanks Brian,

I had a sandwich for the first time in a long time and was a little high at 2 hours (9.6) so how would I adjust for this? Do I just increase the dose from 4 to 5 or 6? Does everyone have an I:C ratio? I’m not sure I’ve been tested for this or is this something I can do?

Thanks, Paul

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Some doctors do sliding scale - basically giving you a set amount of insulin to use, and a set amount of carbs to eat, plus use a little more or less depending on where your BG is before you eat, if I understand sliding scale correctly, but it’s considered somewhat archaic.

Dosing based on an I:C ratio as part of a basal/bolus regimen involves quite a bit of testing, and a bit of trial-and-error. As you are a T1 new to insulin, with no experience with it, I would definitely not recommend simply increasing your dose from 4 to 5 or 6 without speaking to your Diabetes Educator first. If your CDE is up to date, they may simply have you on the set dosage for now to get an idea as to how your body responds to insulin before fine-tuning things.

Some T1s are VERY sensitive to insulin, and going from 4U up to 6U could easily mean the difference between being high and a dangerous low. A good diabetes educator can help you figure out your Insulin Sensitivity (how much 1U of insulin will lower your blood sugar) as well as your Insulin to Carb ratio. Doing so does require that they have some data to work with, though. Do you have a follow up in a few weeks rather than 3-4 months? Are you logging your meal carb counts and BG#s? If, after a few weeks of eating ~30g of carbohydrates and taking 4u of insulin, your doctor/CDE sees that you are consistently high after meals, they can use that information to figure out a more accurate I:C.

There is a very basic explanation of the basis for an I:C ratio here and here. In the latter, Apidra would fall under the 500 rule with Humalog and Novolog as it is a very rapid acting insulin - perhaps even slightly faster than either of those, in some people’s experience.

Another thing to keep in mind is that insulin keeps working in the body for anywhere from 4-6 hours. So while you may increase the dose to handle the 2 hour spike you could end up sending yourself low in doing so. An alternative to this is to try taking your insulin a little sooner before eating to give it a chance to get going before you eat. Many times with these newer, faster-acting insulins we are told we can take them right before our first bite of food (which is usually the best policy at a restaurant!!!), but many of us have found that giving them anywhere from 10-30 minutes of lead time has helped our post-prandial numbers when we have full control over when, where, and what we’re going to eat.

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Congratulations on gaining access to the most powerful tool available, which insulin is. As you intimated, no one clamors to join the diabetes club, but once in . . . it makes sense to attack it with the best weapon in the arsenal. Insulin is an absolute, total game-changer—as you’re already experiencing.

Lots of good advice in the previous replies. Frios are terrific if you have one, but the main thing, however you achieve it, is to keep the insulin within its safe temperature range. Freezing or getting too hot will render it useless, which can get expensive. :wink:

Knowing your I:C ratios and ISFs (Insulin sensitivity factors) will give you a lot more flexibility in dosing, but there’s time to learn that. “Diabetes is a marathon, not a sprint.” You’re in this for the long haul, so there’s no need to learn it all at once (even if you could, which you can’t; at some point the brain won’t take in any more and needs a cooling period). Learn a bit at a time. It will all come into focus more quickly than you may think.

Determining your I:C ratio is indeed something you can do. It’s simply a matter of controlled testing. Start when your BG is stable, eat a known amount of carbohydrate, wait until your BG reaches its peak, take a known amount of insulin and test every few minutes to see how much that amount of insulin drops your BG. Then it’s simple arithmetic to figure out how many carbs one unit of insulin will cover.

But, of course, it’s not quite that simple; nothing in diabetes ever is. For many (most?) people, I:C ratios are different at different times of day. So multiple tests are needed, not only to make sure you’re not relying on one single data point that could be an outlier, but also to determine what your circadian pattern is. But all of that can wait. You don’t need to do it right now. Get familiar with insulin in general terms first. There’s time.

One other thing you need to know about your own individual response to insulin: how long it takes to begin working. That’s a simple thing to test, too. The ideal we aim for is to mimic as closely as possible how a normal body responds to food. Pre-injecting allows you to time it so that the insulin begins working just as BG starts to climb. To do that you need to know how long a shot takes to begin working, which varies from individual to individual and from one type of insulin to another.

For example, Humulin R takes about 40 minutes to begin working for me, and Apidra takes about 15. So injecting that many minutes before sitting down to eat matches the insulin’s action with the food about as well as possible. That’s the ideal; not always achievable in practice. As someone else pointed out, in a restaurant it’s usually safer to bolus when the food arrives since the delay is essentially unpredictable and unknowable.

Sounds complicated, and in a sense it is. But trust us, it will become second nature, just like driving a car. Anyway, welcome to the Determined Survivors’ Club. :smiley:

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I have to admit, I am notoriously loose with my carb counting and dosing calculations. Part of that has to do with my diet being low carb and thus my mealtime responses are often much more complex than just carb counts. And overtime I have fine-tuned my dosing so that I dose for a meal based on having eaten it many times before. This is particularly true for lunch and dinner. I know how many units to take because I have run many experiments.

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Same here. Once you’ve been at this long enough to have a good baseline of experience, you can streamline many of these processes. But it takes a while to reach that point, there’s no magic shortcut.

And it is more complex, of course. Low carb/high protein meals required different insulins than high carb/low protein ones, and so on and so forth.

30 grams of carbs is reasonable if you’re doing the lower carb thing. (I don’t, so I aim for 60g per meal). Sometimes I eat a little more, so my dosing is based on the carb count. More carbs= more insulin.

Keeping insulin cool is only for unused insulin. You’re going to want to have your insulin un-chilled. Cold Lantus burns (more precisely stings) when you inject it. The insulin, once taken out of the fridge, is “good” for about a month. With the amount you’re using now, pens make a lot of sense compared to a vial.

You’ve been given some very helpful advice here and I won’t repeat. Just be aware, as to the preferred quantity of carb per/day or per/meal, there exists a spectrum of preference in the diabetes community. I only eat about 50 grams of carbs/day, so eating 30 at one meal is a lot for me. There is no text-book definition of what, exactly, low carb eating is.

Before and for much of my diabetes career I consumed about 50% of my calories as carbs. In a 2000 calorie diet, that means about 250 grams of carbs/day. Given that standard, 100 grams/day can be seen as “low carb.” There are many adherents to the Dr. Bernstein low carb method. It only prescribes 30 grams of carbs per day. From my 50 gram/day perspective, 30 grams/day is what I would call “low carb.”

As you can see, the definition of “low carb” varies quite a bit, depending on your point of view. The important thing you need to understand at this early point in your diabetes is that carbohydrates are the primary driver of post-meal blood glucose levels. Limiting carbs will tend to make your blood sugar easier to control, with less variability. Almost every person with diabetes has their own threshold of carbs that, when exceeded, makes good control very trying, if not impossible. For you, it may be 200 grams/day or even 100 grams/day. This level is for you to discover. Just be aware that it exists!

I think some doctors want to observe how interested a patient will be in active management before they cut them loose with instructions to adjust their own doses. I remember when I first started insulin (day 1). The doctor explaining to me that he was sending me to a CDE to determine if I was going to be interested and capable enough to count carbs and adjust doses right away or if I would start with fixed doses and a sliding scale…

I like the analogy “it’s like asking a long haul trucker when they should shift gears…” They might be able to sort of explain it, but ultimately they just know… The same applies with how I dose insulin

It becomes tacit knowledge over time…

This, too, is highly variable. I keep all my insulin refrigerated all the time, and it doesn’t sting. Like nearly everything else concerning diabetes, this depends on the insulin, the individual physiology, and for all I know, on the phase of the moon and the position of sagittarius in relation to capricorn.

Yeah, but you’re the Chuck Norris of insulin injectors.

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THANK you. You have no idea how much I needed a good laugh today. :laughing:

The vast majority of parents of Type 1 children to whom I’ve spoken were instructed to use an I:C of around 1:30 right from the start after initial diagnosis. I had no idea that many adults are instructed to eat a certain number of carbs per meal and use a set dose of insulin until I came to this Forum. After giving it some more thought, I suppose children are instructed to use I:C’s from the get-go for several reasons including: 1. Kids don’t necessarily eat on schedule; when a child is hungry, they are ravenous right NOW and if you value your life, you’d better feed them soon. 2. Kids eyes are bigger than their stomachs and they are often dead certain that they can eat at least that plate full-o-food, when in reality about 1/2 to 3/4 of the way through their meal they will begin complaining that if you make them eat one more bite, they will have no other choice than to projectile vomit on everyone seated at the dining room table (which goes a long way towards explaining why some parents bolus for less than what they think their child will eat, then bolus more insulin if their child eats more), and 3. Kids, perhaps more so than adults, feel a huge loss of control over their lives after a Type 1 diagnosis, and trying to impose a relatively strict eating regimen is the absolute last thing they need at this point in their innocent little lives, etc. I guess because we’ve used I:C’s since diagnosis, doing so just doesn’t seem like a big deal that one needs to be “motivated enough” to do.

I’m certain you’ve encountered a number of patients though that are either unmotivated or incapable of making decisions on their own. I imagine it can be difficult to determine in a 20 minute doctors appointment if your patient is one of them when starting them on insulin… And the stakes are fairly high if the Doctor makes the wrong assumption about their patients willingness or ability to get it right with insulin… So I do understand why they often start out with very conservative and simple protocols until the patient shows they are both capable of and interested in self management…

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