Such a thing as too much MDI?


#21

Hello Scott Eric,
Going to assume Scott is your last name, yes???

The question was about MDI, not pumps.

Unless you have syringes that will provide quarter, half, tenth units, its got very real dangers because we are the ones micro managing doing those calculations. All it takes is we get it wrong. Absorption, exertion, overly aggressive calculations, bad timing, bad luck, forgetting XYZ, deliberately not caring… there are any number of ways to make mistakes.

With MDI, stacking even well intentioned is dangerous.


#22

Sprocket1
First time I remember hearing the term was in the late 70’s. early 80’s. Stacking simply means there is more than one dose onboard at the same time. Could be 2 doses, could potentially be a lot more.


#23

Do you thing scar tissue is INEVITABLE?

Regardless of the method shot/pump will it occur to some degree given enough time…


#24

You can call me Scott. I strongly disagree with what you are saying and I think it is dangerous to spread this kind of information, because newly-diagnosed people will get the idea that unless they have a pump they are stuck taking 1 injection at a time and living rigid, inflexible lifestyles when that isn’t the case. Yes pumps can deliver smaller units, but you don’t need special syringes. A half-unit dosing pen will do most of the time if you need to inject less than 1 unit. There is no reason why a person on a pump can bolus as many times as they want for the food they are eating, but a person on MDI can’t do that with a syringe or pen.


#25

Pump users are taught to bolus as needed because in theory a unit of insulin should cover a given amount of carbs. While I know digestion, absorption, and a million other variables will mean it doesn’t exactly work like this, Sprocket is correct that it isn’t “stacking” per se to take an insulin dose to cover a certain amount of carbs, and then take another dose to cover an additional amount of carbs. If I were to eat a 15g piece of toast and my carb ratio is 1:15 for example, I would take 1 unit of insulin. If I then decided I want to eat another piece, I’d take another unit and eat it. There is no danger because theoretically each unit should be enough to cover the digestion of 15g of carbs. It’s no different than taking 2 units in 1 dose and then eating 2 pieces of toast. It’s also no different whether you take 2 separate boluses on a pump or 2 injections of 1 unit from a pen.


#26

This idea of “stacking” insulin as being dangerous does not hold true for all of us. Steven Ponder’s Sugar Surfing dynamic insulin management is filled with stacking insulin doses. This is an advanced technique and requires a certain mindset and good monitoring habits.

When I first heard about stacking was from certified diabetes educators warning about dosing an additional correction and failing to consider the insulin on board from the first correction.

I think we are starting to appreciate that insulin dosing for diabetes is a dynamic game. Adam Brown recently expanded his 22 factors that affect blood glucose to a list of 47! I think there are probably more than that. All these factors lead us to making insulin dosing decisions based as much on art as science.

The concept of stacking is based, I think, on the idea that we can mathematically quantify dosing insulin. This precise following of formulas implies that the perfect dose can be calculated if we just consider a few different factors. I see this as an idealization of glucose metabolism in the person with diabetes. I also think that this is a good first understanding about how insulin works. In real life, there is just more variation than simple formulas can manage.

Diabetes is a dynamic disease. Insulin dosing based on trends and momentum can be a very effective regimen, even though this system will “stack” insulin. These are advanced techniques and do require paying attention and applying learned experience.

The biggest problem I have with adherence to a strict anti-stacking mindset is that any insulin correction dose needs to run its complete duration of insulin action time before another correction may be made. My insulin endures for six hours. My control would be poor if I followed the prohibition of stacking. Insulin dosing is evolving and many of us no longer comply with the stacking prohibition.

There is no right or wrong here, just an updating of insulin dosing ideas.


#27

Well said, and Ponder uses MDI most of the time to manage dynamically!


#28

And even beyond that, you can get diluent free from Lilly, and fill your own pens to do micro-dosing with a pen.

Alex O’Meara wrote about it on ASweetLife:
https://asweetlife.org/the-unmet-need-for-diluted-insulin/

For anyone who wants to do this, I can send you a link that explains in great detail how to do it. It’s pretty easy. All you need is a non-disposable pen, insulin, and diluent. And I can also send you a link that gives info on how to get the diluent from Lilly.


#29

Awesome, I love a good MDI hack. This might sound weird but there’s almost something geeky cool about figuring how out to do things on MDI that most people only think pumps can do. It’s sort of like knowing MS-DOS commands back in the day.


#30

Scott

My words are no “danger”. Permit me to try again…

I am not familiar with any pens/syringes in common use FOR HUMANS which have less than a full single unit of insulin per dose. Have they finally been developed/redeveloped? Smaller doses, smaller potential problems in theory at least.

Curious whether you believe that lypo in inevitable, regardless of the delivery tool?


#31

Hello Terry4

Stacking as an advanced technique I gladly concede. Dynamic game, good way to put it.

How about “developing” new dosing ideas instead…


#32

The NovoPen Echo doses in half units and is exactly the same as the NovoPen 5. It has been on the market for a while now and works with all Novo Nordisk insulins sold in penfill cartridges. For Humalog there is the HumaPen Luxura HD and I think they make a disposable version as well (KwikPen Jr maybe?). Plus there are more advanced pens now that can dose as small as 0.1 units, such as the Pendiq and InPen (I think?) which is coming soon. I only have experience with the NovoPen Echo but it is very accurate and I have no problems just dosing 0.5 u when I need it. I’m not worried about lypo as long as I rotate. Pen needles are small these days and as I initially said, it’s the repeated infusion of insulin into 1 spot from pumping that is more likely to cause this.


#33

Excellent news, had not come across them!

Re: skin toughening no matter how much we try and rotate, I believe it will happen, its identical to lancets, just much bigger surface area. Diabetic Kung-Fu as I see it -wg-.


#34

In addition to the medical issues of excessive MDI, there are also the psycho-social issues connected with it. It is quite possible that the time and effort invested in MDI may exceed the benefits in terms of increased life expectancy and lower complication rate that may be produced by it. Complications are in part conditioned by genetic influences and continuing autoimmunity which no amount of MDI can address, so depending on how much of the complications in your care is caused by factors MDI cannot control, your investment may be partially depleted.

Because diabetes is incurable, the temptation to impose limitlessly cruel and oppressive controls on the patient has always been great. Just as now many patients die from side-effects of chemotherapy and the resultant cachexia rather than from cancer itself, so too in diabetes the intensive therapy required not only kills or permanently maims people occasionally through severe hypoglycemia, but it also diminishes quality of life by the time and effort involved. Drs. Allen and Elliott prior to the insulin era were severely criticized for starving their patients to death to try to achieve the best possible glucose levels even though a limited rather than a starvation diet seemed to produce better results. Why did Allen and Elliott do what they did then? I suspect it is part of an unconscious medical sadism that arises when it is confronted with incurable illness, and patients should guard themselves against this.


#35

Seriously, I don’t know what planet you’re living on. You are the master of your own body. The only person forcing you to limit your quality of life by maintaining an A1C in the 4s, even though you think it’s futile, is you.


#36

Sorry, I meant Elliott P. Joslin when I wrote ‘Elliott’ above. I guess I just associate the name ‘Elliott’ with ‘idiot.’

When I make a comment I’m not necessarily talking about myself or what I do, but about general social and medical phenomena. Patients typically obey what their doctors tell them to do, and when doctors prescribe abusive medical regimens, patients become self-abusers. It is estimated, for example, that 46% of the patients treated by the Allen and Joslin method may have died from starvation as a result of it. When Dr. von Noorden visited Allen’s starvation clinic and saw the diabetic walking skeletons, he refused to continue the tour because he was so horrified of the methods being used. In contrast, he had found an oatmeal diet which seemed to help his own diabetic patients and which was certainly less cruel. But why, we have to wonder, were Allen and Joslin so eager to use such a cruel treatment when it was producing such obviously bad results?

Today, around 4% to 6% of diabetics today die of hypoglycemia, the rates of which have tripled since the recommendation of strict control since the DCCT. In addition, strict control often destroys quality of life and severely impacts the patient’s lifestyle, yet this is very little noticed in the medical literature on diabetes. A fully rational medicine would more carefully calibrate the costs of strict control against the benefits, rather than just insist constantly and uncritically on the benefits. I have had around 10,000 hypoglycemic episodes that required treatment in my life, 1000 which needed the assistance of another person to enable me to recover from them, 20 which resulted in a call to emergency services and hospitalization, and 5 which caused broken bones. Perhaps I would have been better off being blind and on dialysis a decade ago after having let my blood sugar run constantly high so I could have lived in peace and security.

Every diabetic has two diseases: a metabolic condition which prevents normal metabolism and an iatrogenic disease which causes a disposition to dangerous hypoglycemia episodes. Unfortunately, you can’t treat one disease without worsening the other, but perhaps the medical profession should come to recognize that they face two diseases, not one, and it might actually be much better to for the patient to be blind and on dialysis a decade earlier in exchange for avoiding hypoglycemia completely.


#37

i feel like this conversation was supposed to be addressing the scarring issue not if stacking or getting multiple injections is possible or not. im continuing reading the comments and i just keep seeing comments on other issues not the initial scarring questions.


#38

Hi Ala,

I don’t mean to sound stupid but what does MDI stand for? I am “old” and don’t understand all the new abbreviations. I use Fiasp and a basal insulin also, much like you, so what are the actual words for MDI? Does the M stand for “multiple”? the I for “injections”? The D for “diabetic”?

Sorry I am so clueless.

Post Script I just found the answer on this forum. Multiple Daily Injections. Is this correct?


#39

Multiple Daily Injections.

Opposed to the old-timers (like me), that started out on single injection of Lente insulin per day, in 1960s.
My version of MDI was NPH plus Regular, not the newer 12–24 hour insulin, plus very fast meal time analog insulins, more commonly referred to as MDI.


#40

Thanks. One would think I should know what MDI stands for since I do multiple daily injections but I am just not familiar with abbreviations. My nieces laugh at me because they need to “translate” for me.

When people write IDK or BTW or LOL, I have to ask what they mean.

I finally know these 3 abbreviations. I don’t know. By the way. Laugh out loud. Well, maybe I know them or I could be wrong. :slight_smile: