Starting the discussion ---- insulin

I feel so fortunate to have the education and support from you all here. So once again, I am looking for some education and support.

I am going to start the conversation with my doc about insulin at my next visit in a month. I am a type II and take met, amaryl, and januvia. We are new to each other, so haven’t had but maybe two visits…I want the discussion to start with me, not come as a surprise from her.

So help me out, please, what questions do I need to know the answers to? What should I ask her?
My last A1C was 6.8, so she is going to be surprised that I am asking this question, I’m sure.

Did you have an education session/practice session when you started taking insuling on how to do it, where, when, etc? Also, needles or pens? What are the ups and downs of both?

Thanks in advance…I’m sure you’ll be very informative.

You’re going to have a more productive conversation with the doctor if she’s an endocrinologist. If she’s not, don’t be surprised if she dismisses your questions about insulin.

  1. Tell you doctor you want to know if insulin will help you and ask her opinion. (BTW, exactly why ARE you interested in insulin?)
  2. Ask the doctor if if she thinks you can control your BG without insulin.
  3. Ask your doctor if using insulin will mean you will stop taking amaryl, met and/or januvia.
  4. Ask your doctor if you should be tested for LADA. (latent autoimmune disease in adults)

If you do start insulin you should get training in how to inject, when to inject, and how to calculate the dosage for your short acting insulin. You should learn about basal insulin, insulin:carbohydrate ratios and carb counting. Don’t let your doctor just throw you into the pool. In this regard you should ask if your doctor as a certified diabetes educator (CDE) on staff and, if not, can refer you to one. Pens are more convenient than needles as the insulin is self contained and therefore more portable. The needles tend to be smaller as well.

Terry, thanks so much for your input. It will be helpful and very much used.

One thought, and this is for anyone, but you brought the subject up and I feel the need to address the subject for everyone’s thoughts and education. NOT all of us have access to an endo. There are places in the US (and I am sure outside of the US) where endos and other specialists just aren’t available for a visit. Our closest endo is 200 - 300 miles away. That is not a day visit for a 20 minutes appointment, that is a two day over night much money trip for 20 minutes. So as much as many of us want to be able to have access to those specialists, we don’t. We have to rely on the docs that we do have available, work in tandem with them on the knowledge that we can gather on our own, and with them That is why CDE’s here in the area I live in are so very, very important. Sometimes, and in my case I can say most times, she is more knowledgeable about diabetes care and what is a new update than the docs, they can’t know it all as we all know. So please, folks consider that problem when thinking that we all have access to medical care, we can only get what we can get. And that is why honest sites like this are so very important to us all.

Terry, and whomever else…this is a tough subject for me and I will admit on of my many soapbox areas. So if anyone is offended I am sorry, if anyone feels I have spoke unknowingly, so be it. I apologize…but I live with this knowledge knowing that there is more out there,and yet not being able to access it for many reasons. Amen.

Since you will be visiting with your doctor for the first time, it is important that you communicate your background, situation and goals before you get to the whole insulin thing. You have struggled with this, I know, I’ve watched your posts. You need to discuss this with your new doctor and help them understand. What I have heard you say repeatedly and I agree, you want better blood sugar control. Tell your doctor that you want to explore using insulin to help you get that control. But be prepared to have your doctor want to explore all the other approches, why can’t you fix your diet, why can’t you lose weight, can’t we just juggle your medications. Just be prepared.

As to learning to use insulin, a CDE is perfect to help with that. But you can also take steps on your own to learn about this. I may have suggested it before, but the books “Using Insulin” by John Walsh and “Think like a Pancreas” by Gary Scheiner are both good resources. In terms of what regime to use and how to go about injecting, most T2s are moved to a basal insulin such as Lantus or Levemir which come in a convenient pen and can be taken with one or two injections a day. You get pen needles for the pens. The basal insulin will help to get your fast number down to a good range, but using just a basal insulin is not optimal and eventually it is best to move to a multiple daily injections (MDI).

And as a final note, I might actually suggest that you closely involve your CDE in this discussion. Get her to provide some input to the new doctor, may even have them talk. Your CDE should be able to provide you with an instruction you need.

Thanks BSC, you have given me some great ideas. I have contacted the hospital here, and requested the names and numbers of the CDE’s in Aberdeen, unfortunately, there are few. At my former clinic there were three, at the new clinic there is none, but they are part of the hospital, so there is someone or someone(s). If not them, I will call and beg my old CDE to help me out, she is a good woman, and I think will be there.

I am puzzled though, I don’t know whether this is clinic policy, doc policy or medicaid policy…but the doc asked through her nurse, how many times I test? I do three to four times a day, because I have had a problem this summer with stress being the formiable enemy…the doc said, that’s too much (huh?, I didn’t think you could test too much, at least not 3 -4 times being too much) So she said once in the AM was fine…now I know that I am only going to be getting enough strips and lancets for once a day…glad I have a goodly supply of them and will question that decision when I see her. I can tell that this is going to be a little harder than I expected, but, I’m in control for now.

Emmy, just to bring you up to speed, this is a “new” doc for me. She has 14 years experience in dealing with diabetics, and is a type I herself. But that doesn’t always mean she is an expert.I am in the same position you are in, please see post to Terry, there are two big clinics in town, and our docs belong to one or the other. We have one internist who is, inho, a quack, I’d go to my vet first. Otherwise, she was the best choice I had, as far as a PCP, who took my medicaid and who will take me on…and I interviewed many if not all of them. I have to find a CDE first, as my former CDE is no longer seeing patients…completely left the profession due to the stress it put on her family, sick parents, and other personal issues. She was also my CNP…which meant she knew me well, I’d seen her for almost 22 years…so it was a tough haul this summer finding the doc I did find. I am up to finding another if this one doesn’t work out, and have already spoke to him about taking me on, but he has to clear a space, and is in the same clinic…so it’s rather messy. At any rate, as I said I am in charge of my diabetes care, and I intend to talk to her about the number of tests I do, and the insulin…I don’t think we will go that route right away, but I do want to be able to open the door myself to the discussion rather than have her make it…because then there may be NO discussion…and that’s not how I do business. As I haven’t seen her for a month, and won’t see her until the second of November, I want to be armed with the best knowledge I can, and the ability to make sure we have an understanding about all my medical care. She is not “just” my diabetes doc, but my whole person doc, too. All of this makes me really want my old situation back again, even at it’s worst, it was never this complicated.

I might be wrong on this, but I believe Medicaid follows Medicare guidelines. Medicare will only pay for 1 test strip a day for T2s unless your doctor will say that it is medically necessary – I am not sure what requirements make it necessary (other than we all know that you should be testing more than once a day!). The requirements for people on insulin are 3 tests a day and doctors have to state that it is medically necessary to get more than that.

As far as the endo vs. PCP discussion, I am T1 on insulin and now on a pump. I see a PCP not an endo. I also live where there are not many endos available (at least there are some here) but they are not any good. I travel several hours to see decent doctors and have other health problems that I need help with. For me, it is not worth the trip to see and endo when I am managing my BS well on my own.

I do have a T2 friend that also wanted to start taking insulin. Her endo actually shot her down so she asked her PCP. Her PCP gave her the script for it.

I’m going to take a different tack here. How about getting together data to convince your doctor you can be classified as a T1. Once classified, the rules are different.
What data do you have? Are you spiking with meals? What is your fasting glucose? Show 3 out of 5 days these types of BG events. Show what carbs grams you’re taking and the spike.
Talk with the diabetes educators at the hospital about what they provide in education. They may or not be certified.

Okay, maybe I didn’t make this clear and people don’t know my situation, me bad! I have been a diabetic for 11 years now, I’m not new to this game. What I am new to is this doc. I have seen her once…after a long summer of looking for a doc and hoping that there would be one out there. I live in an area of the US where docs are about 1 to 600 people…(not exact but pretty darn close) I had an excellent CDE/CNP for a medical provider for 22 years, she left the clinic that she worked at, that I went to, and is no longer practicing. I don’t NEED to go to insulin, but am “exploring” my options, with the insulin. The CDE’s that I have contacted are all certified by their association nationally, checked that out on line at their website. But there are few here, just like few docs. I know what to do, again, just exploring so that I can get things under BETTER control…and when the time comes, because this doc and I are beginning our relationship, I want to be on the educated side, not just looking at her like a deer in the headlights, stunned that she would suggest such a thing.

As far as data, I have three years of daily BG’s three times a day at least, I have A1C’s for the last 11 years, I have food diaries that although sketchy are good for at least the months I have done them, and I have recommendations from the past of what I have done with CDE’s and my former provider. Do I spike with meals, not usually, daily my BG’s are around 120- 130; night time they can plummet, when I don’t eat a snack. I have documented what snacks or foods will cause me to plunge and what will cause me to soar. In the AM, if I have taken a middle of the night snack for a low, it will be higher, maybe 160…normally I run about 127 - 147…

Leo2, you have been helpful for someone who doesn’t know what they are doing…but I do have a little knowledge of the situation, I do apologize if this sounds trite or condescending to you, I’m sorry. I guess I have to learn to give my total history here, not assume that people know what I am, who I am, and my situation. Again, me bad.

thanks, and have a great weekend. It’s hunting season here, great times…NOT!

THANK YOU KELLY, hope at the middle of the tunnel. I guess I have to remember that when people have access to medical providers, they don’t always understand what being in the sticks, and then having bad care is like. If they would think about it, as we do here, we live in a town of about 21,000 people…we are 200- 300 miles from anything of great social value, theatre, movies, music, shopping, We are not going to get the cream of the crop from medical school. We might get the bottom of the middle third or the bottom third of those docs…so you do have to be careful. They are good enough to come here, and when they do they don’t’ stay.

That aside, I have talked to Medicaid, and they will indeed give me more strips to test, if I can get her to write a script for more…and I will. I am not comfortable with testing only once, especially since I tend to have days/weeks where things go awre that are unexplainable as of yet. Unfortunately, in this country you have to learn to play the system, if you can’t afford to pay…and that’s a bad situation to be put in.

THANKS Emmy, its good to hear that someone understands the doc shortage, that’s why we have more CNP’s than docs, and even more PA’s than docs. That’s what we have and you learn to live with it, or spend the money on driving hundreds of miles. I have recommended this site and other information to my cnp in the past, don’t know how this doc takes to that sort of thing, but I’m going to continue to do it, just because that’s what I do…it proves I am a self starter and more assertive than passive about my treatment.

I moved away from here when I got out of school and ended up moving back here to be close to my family when I started having alot of problems because neuropathy. I hate it here! Who ever said small town life is the good life obviously did not have health problems. I almost lost my leg because of the stupid doctors here and had I not been in a position to travel thanks to my family, I would not have my leg today. Believe me, I feel your pain!

If Medicaid will pay for the strips, there is no reason your doctor should not write the script for them. I don’t care what type anyone is, the more someone tests, the better control they can have. There are so many things besides food that impact your BS, how can you know what is going on unless you test. Everyone talks about more preventive care, but still don’t want to cough up test strips for people to prevent ending up with complications. I hope you convince your doctor to give them to you.