Taking Control and Starting Insulin

So… are you telling me your endo is refusing to put you on insulin and you are taking matters into your own hands? Firstly, I would be endo shoppping. Secondly, the insulin you can get over the counter is NPH, an insulin that has been deemed by many “Not Particularly Helpful.” I think you are making the right decision but this can be dangerous without medical attention. Manny recently posted about “Type 1 Universary.” Gary Scheiner, at integratediabetes.com works with diabetics many ways. You can pay him for one or two individual sessions, or buy a three, six or year block with unlimited access. You can fax in numbers daily and talk to someone as often as you need. We used him when my niece started pump training, her CDE who was Type 1 and trained by Gary left the practice. A nurse who only handled Type 2s was temporarily put in charge. We were in a real bind; endo appointments were only once in three months; we would fax in the numbers weekly and told “everything is fine; no change” when numbers were in the 200s most of the time. Gary was a lifesaver. I would advise you to get professional advice, if not from Gary, from some other source. Insulin is a dangerous drug. Don’t think Type 2s have the same risk for hypos as Type 1s (not sure if alpha cells are secreting glucagon normally in Type 2s) but of course there must be some risk because insulin resistance can cause high dosing. I really hope you don’t have to do this alone, without any help.

Ding, Ding, Ding. Yes, I am a bonehead.

Yes, I am looking for a new endo. As a new patient, I expect I will get a first appointment in 3-6 months. I've spent nearly three years asking my doctors for insulin and they have repeatedly refused, mostly out of what I consider concern over their own liability. I've concluded that the only way that any doctor will prescribe insulin for me is if I let my blood sugar get out of control, and I'm not going to do that to myself. I am not doing this in an uninformed manner and I do have a network for assistance should I need it. I own half a dozen books on insulin therapy and have read quite a bit more. I've been on injectables for more than two years. I maintain close ties to my local Inova Diabetes Center, I know the director and several of the RNs and CDEs quite well. I have discussed this move over the last two years with them. Should I need assistance, I am sure they are just a short call or email away.

In the end, this move is what I consider a three month venture out on my own. I am taking my doctors out of the decision loop and I am taking responsibility for the decision and all the liability associated with it. I understand the poor profile and variability in NPH, but it is available to me and I have a right to it. At the end of the three month period, I will see my doctors and review my progress. But we will be in a different situation on insulin, my doctors will no longer have to worry about whether they are liable for the decision. And don't worry, I don't intend to do this alone and will ask for help should I need it.

And I do thank you, all your comments are appropriate, and I would say much the same to someone else jumping up and declaring that they are going initiate insulin therapy on their own.

It is not surprising that you would have an increase in c-peptide with medication. Some medications like the sulfonylureas directly stimulate the pancreas to increase insulin production. I had been on what is called a triple therapy with maximum doses of metformin, actos and byetta/victoza. I suspect that those medications increased my insulin production. Without knowing the units on the c-peptide test and the reference range, you really can’t compare.

I say go for it, I have been on Insulin for a couple of months now and my a1c has already dropped 3 full percentage points and have never been happier. Everything else can be worked around once you get the bg’s under control

I had the same experience with my endo, she wanted to add glyburide after doubling my metformin doses and I told her, I would rather have Insulin instead. good thing she didn’t give me any hassles. they are your support team and if they don’t support you then kick em to the curb I say, find someone who will work with you, its not like it is clearly asking for the impossible to try insulin, it might work but then again it might not who’s to know until you try.

You are brave… I agree you should be able to try insulin if you feel it will aid you in control. A regular MD can prescribe insulin. If you can locate an MD or a Nurse Practitioner that will prescribe Lantus or Levimir and you have access to CDEs already, you would be a lot better off than with NPH and Regular. Not sure if you just need the basal insulin alone or would only use insulin to correct highs. And then Humalog, Novolog or Apidra for meals and corrections if needed. I think it is outrageous that you have been forced to take matters into your own hands. And I don’t see why you should be forced into using the older insulins.

That’s a good point, Jan. I get my insulin prescribed by my Primary Doctor.

Yeah, I was assuming thats what made your c-peptide go up…but without those medicines your c-peptide seems low so I would think insulin would be the best choice for you. But hey I’m only a year into this whole thing and about a week into the whole educating myself on insulin so what do I know???lol Hope it’s workin for ya! Maybe you can even have a Christmas dessert and bolus for it, if so eat some for me too haha

I also use a PCP and he did the paperwork for my Dexcom & my pump. A friend of mine was in the same boat as BSC and her endo turned her down for insulin but her PCP agreed with her.

bsc- You are definitely NOT a bonehead. If any one is it is your endo. I am T-1, and when I was dx’ed 12 years ago, I was put on NPH and R. I mixed them in the AM and at dinner time. If I was high during the day I took more R. I managed fine, did have some lows, but not many more than I have now. I am now on Lantus and Humalog. While on the NPH and R I was able to keep my A1c in the low 6%. I give you a lot of credit for taking things into your own hands. You do have the DOC which was not available to me or anyone at that time. Best of luck !!!

Most doctors have no problem writing a prescription for refills, but that is very different than asking for a prescription that initiates insulin therapy. As I mentioned earlier, doctors are conservative by nature and risk adverse. They believe that they won’t get sued for allowing a patient to develop complications over the years with elevated blood sugars, but they might get sued because a patient had a hypo after they prescribed insulin even though the patient had perfectly good control with a HbA1c of 6.5%.

Thanks for your vote of confidence. I do appreciate your support.

When BG levels are abnormally high, insulin production goes down due to glucotoxicity -- that means that too much glucose actually poisons the cells rather than making them secrete more.

That's why classic Type 1's who present in DKA (which means they're producing little to no insulin) have a honeymoon period -- when their BGs are brought down, the remaining beta cells recover and start to produce insulin again. However, for them, the autoimmune attack is relentless, and the honeymoon comes to an end.

With Type 2's, however, the beta cells that recover are not attacked, so they can have better c-peptides for a long time. That doesn't mean that the beta cells are not still dying off, but it's a lot slower than in Type 1, and for different reasons.

LiL MaMa, you just gotta go with the flow, and let it happen as it happens. I admire your passion for learning! :-)

I don’t think I can add much to this remarkable discussion. I’m sure that once you are on insulin and have done the experimenting that is necessary for reasonably good control, your new endo will prescribe the insulins in current use. I want to recommend Levemir, which will probably work for you twice a day, although actually, I need it three times. Your experimenting with the NPH will give you a good clue about the appropriate time and doses for the Levemir, or Lantus if that’s what you prefer. I applaud you for going forward, basically on your own, esp. since you have listed some medical backup if you should need it. Good luck, and Merry Christmas and Happy New Year, too.

Type 2's can and do have hypos. Too much insulin is too much insulin, no matter what type you are. However, Type 2's DO have functioning alpha cells, and so are not so much at risk of severe hypos, although it CAN happen. A friend of mine, relatively newly diagnosed, went face-down into his dinner plate one night.

If you accidentally inject into a blood vessel, it can lead to severe hypoglycemia for anyone. When I was new to insulin, I injected for breakfast, felt low as I was eating my first bites, tested, and found a 57. I was already eating (and not low-carbing at the time), so I just kept on eating, and it came up. The only explanation that makes sense to me is that I injected into a blood vessel.

Now BSC, please don’t tell me that you did not copies of your labs to know what the reference ranges are – I hope you just mean as far as comparing your labs with someone like Lil MaMa. I am going to smack you if you tell me that you don’t have your labs!

I guess you know me pretty well. I keep copies of all my labs. But my c-peptide tests were actually done by different labs and have different reference ranges. And I just don’t remember. Having diabetics compare c-peptides makes as much sense as a bunch of men sitting around a campfire drunk, pulling up their shirts in a competition to see who has the biggest scar.

I would have been surprised if you had said that you did not have them!

Amen. Once you are on insulin their asses are covered, Post by Jan is too pessimistic. NPH is not ideal but 4 to 6 injections per day and it is manageable and it is cheap. R I have not used but might be as good as the novo. It is a different risk for a type 2 our alpha cells may still work so you will not go to zero. I injected much too much at lunch so it went to 70 for sure I did not feel well but no big deal I ate a small piece of bread.

Looking back about 28 years …I must give my then GP credit for listening to me , when in a time frame of 6 plus weeks after diagnosis , weekly blood work done at the Lab ( after my work shift was over…4. 30 pm ?? ) and BG’s not coming down with meds ( I recall the number 260 ) I told him , that I needed to start using insulin …I was hospitalized for the training for 5 days within one week .