What the heck was NPH for, anyway?

Originally posted this on the Acronyms thread where a discussion of Sliding Scale was starting up and touched on the old regimens, but I didn’t want to clutter up that important thread with stuff not immediately relevant. Anyway here’s the question:

Looking back on it now I realize that I don’t really understand what the rationale was for NPH. At the time I was told it was to cover meals later in the day, R for morning, N for afternoon. But it was like setting a time bomb that was going to go off several hours hence. N was really the worst part about that whole regimen, which I called ENOD (Eat Now Or Die). NPH was the “die” part. So what was the justification for it? Why not just take an R dose closer to the time you were actually going to eat? Was it supposed to be a kinda-sorta basal insulin? Total fail at that if so. You’d end up having to take an extra shot, as opposed to mixing them into the single one in the morning (as most of us did), but if it was just to skip an injection it was a lousy trade-off, weighed against how much scary trouble it could get you into. Back then I just did what I was told pretty much, so it never occurred to me to ask. Now I really wonder. Theories? Facts? Anyone care to weigh in? Kind of an old-timer question, I realize…

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I think NPH and other treatment tactics suffered from helpfulness (and profit) motivations of non-diabetics. It sounded like a great idea from people who didn’t have to live with it. It’s amazing that we who used it put up with it for as long as we did!

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I liked the NPH. It was my excuse to leave class every day to eat a snack. It’s amazing how it can take 30 minutes or more to eat a packet of handi-snacks! LOL

I was my grandfather’s best friend as a kid, because I always wore one of those fanny packs full of snacks. He followed me with puppy dog eyes!

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NPH was created in 1946, and used primarily because they didn’t have disposable syringes or needles.

As well, at least part of it was covering off basal needs (but it definitely wasn’t a basal insulin).

When I first started (1965), it was simply not an option to carry a sterilized glass syringe around with you and do MDI as required.

The first 8-10 years of my diabetes were hell thanks to NPH. :cold_sweat::cold_sweat:

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My grandmother, whom I remember being diabetic throughout the '50s, got one shot a day and it was NPH. She lived through hell on wheels with roller coasters every day. And, yes, there was also the issue of glass syringes. I think she died of a heart attack in 1960 because she got fed up with it all.

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When I was first diagnosed, I took one shot a day of Lente insulin. I was eventually switched to NPH but I think I always took two shots a day of it. In retrospect many of us say that NPH stands for Not Particularly Helpful. Actually NPH does have some uses these days. Some people take it before bedtime to help combat dawn phenomenon. Some others have found that if you take it 3 times per day, you can get rid of some of the extreme peaks and valleys. I certainly remember the lows between 3-4:00PM every day and sometimes I miss “having to snack.” I also remember sweaty lows at 3:00am and eating bowls of Frosted Flakes st my kitchen table. With my pump, I rarely can eat anything without a bolus. I probably haven’t had Frosted Flakes in 15-20 years.

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Yes they tried to get me to use my morning NPH dose for lunch etc. at diagnosis… total fail! I think the docs thought “this way there’s only two shots a day” but control is very tough this way. I was taking upwards of 80 units a day and bg’s were crazy.

About… 5 years after diagnosis ? … I found an early Dr B book and read about MDI. I used 4x a day NPH as a basal, R as bolus, and got very good control! And my TD dropped to 35-40 units a day and has been stable ever since.

4x a day NPH was my basal for 30 years. Lantus 2x a day and now Tresiba x1 a day are improvements for basal. And humalog kicks in faster than R.

I really hated NPH because it meant I had to eat 4 hours after I took it. And my life was never so regimented that I could make it work.
I would crash all the time and end up eating sugar and then needing more insulin for meals.
I had my first decent regimen when I switched to regular and ultra Lente which I split in 2 doses. Then I went to humalog and ultralente.

They discontinued ultralente so I decided to start pumping.

Each step was a much better existence for me.
Now I’m on a tandem pump with control algorithm and it’s really been the best thing.

I feel like I dodged a bullet with NPH, it really nearly killed me several times.

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How about a doctor who knew about the more modern insulins, but insisted that I start out with NPH? I also hated NPH because I definitely did not know how to handle it. It seemed like I was always low or high, never in the middle. Finally something told me that I needed to at least have a consult with an Endocrinologist which I did. He did proper testing and then ‘consulted’ with the GP I was seeing. Finally the GP switched me to Ultra Lente which was better, but I like the pump I have now a whole lot more.

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I started lente only also, in 1965, then NPH + Reg in mid-80s. I was in school, and this meant all injections were done at home.

But only urine testing available (or popular) back then, and later we were supposed to follow an exchange diet that tried to keep meal choices somewhat “equal” each day. I only changed dosing after doctor visit and review of 3-6 months of urine logs.

In late 80s insulin pumps introduced the idea of carb counting and adjusting meal dosing based on food eaten.
And as BG testing got more common, using carb counts and corrections based on BG were taught. This was based on reduction of complications observed in the DCCT trials.
Seems obvious now, but early on, it wasn’t common knowledge that high BG caused complications. I had heard many say whatever attacked pancreas was also damaging other organs.

THEN I found the internet and learned more than what doctors had been telling me. I learned how to use the Medtronic sof-sensor work better (ISIG factor), and other things the medical folks don’t tell you.

Later I attended TCOYD conferences and continued to expand my experimentation to find what works best for me.

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I think it was intended to make diabetes easier to live with. Not having to carry around medical paraphernalia while at work or school (remember the looks we could get from people thinking we were drug addicts in those days). My school nurse didn’t have to administer insulin everyday and she wasn’t even at my school all the time anyway so if I required a shot before lunch someone else would have had to do it.

NPH was definitely ENOD though as I can attest to passing out a lot from not getting that snack in time but with a CGM or frequent fingersticks NPH can be helpful especially for people who have a hard time giving themselves shots whether from being too young, physical hindrances or fear.

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You make a good case for it, and I agree. We had disposable syringes by 1983, when I was dx’d, but even with those it wasn’t necessarily convenient to carry around the stuff for doing injections in the wild.

I guess I’m focusing on the fact that it wasn’t even a question, which is maybe equal parts medicos going with the prevailing regimen without question and patients—me, anyway—doing the same. “Why am I using this stuff when it’s causing me all these problems? Could we try just using R?” Never would have occurred to me or my Docs. The huge change that swept in with true basal insulin and carb-counting wasn’t just about better A1Cs; it ushered in a fundamental shift in philosophy from organizing your whole life to conform to your treatmen to organizing your treatment to conform to your life. Now that philosophy is so pervasive that it’s hard to even notice that it’s a thing, but “before” it just didn’t exist for the predominant T1 population. For me, the dam started to crack when I finally met another T1 (pre-Internet that was also a rare thing) who was on the new regimen and told me about it. At that point I did start pressing my (non-specialist) Drs about it but it was about ten years of LNCAYDF (Let’s Not Change Anything You’re Doing Fine) before I finally got out from under the referral-resistant HMO I was in and got a referral to Joslin.

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When I was diagnosed in ‘84, the way it was explained to me was that taking two shots a day (before breakfast and before dinner) of R and NPH resulted in peaks of insulin activity that corresponded with prescribed meal and snack times while also ensuring that there was always some insulin on-board. Similar to this graph:

image

Prior to this time, one shot per day was standard, so I wonder if, initially, two shots per day was new enough that the thought of 3, 4, or more shots per day sounded excessive to many. During the DCCT, 4 shots per day was considered very intensive (and experimental) therapy. And, as already stated, the standard thinking was that diabetics needed to adjust their lives to their treatment rather than the other way around. As in, ‘Isn’t it enough that we can keep you alive? You should just be grateful for that.’

As a kid, I hated the regimented schedule, but was thankful that I only had to take two shots a day. I was terrified of needles, so two shots a day felt plenty sufficient. Eventually I got over that, but then, I felt like taking more than two shots a day would make me focus on being different from other kids more than twice a day. A few years after diagnosis, when my doctor suggested 3 or 4 shots a day, I pushed back with the argument that I didn’t want diabetes to interfere more in my life than it already did. It took a few more years of maturity to realize that more shots per day gave me more freedom, not less.

But, yes, those NPH lows were really awful. And the theory shown in the graph above never really seemed to work the way it was supposed to. Thank God we have so many other options now!

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Why did so many people take NPH back then? Why didn’t they just use pumps? Or a better basal insulin like Levemir, Lantus, or Tresiba?

Why did they use insulin derived from cow or pig pancreases, instead of recombinant DNA insulin?

And why did they use glass syringes? Why not use disposable syringes, or pens?

And why the hell did we test our pee?

Um… cuz that’s all we had.

What the heck was NPH for, anyway? Well, it helped me stay alive and in good health back then.

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They still sell NPH so it has some users, as well as 70/30 NPH+Regular premix. I wonder what a typical regimen is for 70/30 premix is - twice a day?

Lente and Ultralente, which I understand are like NPH but with even more zinc/protamine slow-down, have been unavailable since at least the mid-2000’s now. I might think I coulda used them as a basal in the 80’s and 90’s instead of 4x NPH but never tried so no experience with them.

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Interesting—no one ever explained it to me like that back in the day. I wasn’t aware of the concept of “basal insulin” until Lantus finally came into my life. @MM1’s reference to the DCCT (Diabetes Control and Complications Trial) reminded me not only of the fact that up to that point the link between tight control and better results was still somewhat controversial, but also how late it was in coming: the DCCT was published in 1993, ten years after my own dx. I actually remember that event. I was covered through the MIT clinic at the time and my PCP though not an endocrinologist was the designated diabetes “specialist” and was a real militant about tight control. I remember how he crowed about the DCCT when it came out. But the basal-bolus regimen as such was still not a thing, so the use of NPH was never explained to me in those terms if that was how they were conceiving of it. It was all about covering meals as far as I knew.

When I finally did hear about basal-bolus was not until 2000, and not even from a doctor but from a guy I met at a dinner party. (I think he was the first other T1 I had ever met—no DOC back then! Really says something about the importance of us learning more from each other than from the medical establishment as such.) By then I was covered under the Harvard HMO, but still only got YDFLNCA when I asked about changing, and a big NO when I asked about getting a referral to an Endo. I didn’t start on it until 2003, when we finally got private insurance from a non-.edu employer that actually covered specialist referrals without argument. I’ll never forget my first meeting with a genuine endo at Joslin, whose exact words after examining my (self compiled) data, regimen, and A1C results were “Well, you’re not doing so bad considering that what you’re doing makes no goddamned sense.” He then went on to explain to me about basal insulin, why your body needs it, and signed me up for training on the whole carb-counting regimen.

So that was the perspective on the R/NPH regimen from the world’s leading diabetes clinic as of 2003, about 3 years after Lantus and Novolog were introduced.

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I find your comments especially interesting since my diagnosis date, January 1984, occurred within a year of yours. My progression from starting on once/day injection of NPH evolved more quickly than yours did. I went from once per day NPH in the morning to twice per day, adding a bedtime NPH.

I also used Regular (pork-derived) for meals. That meant I was technically on a basal/bolus regimen though I don’t remember that that term was ever mentioned. I don’t remember counting carbs at that time and I likely was injecting a fixed amount of Regular and eating to cover the insulin.

I moved from Idaho to San Francisco in early 1986 and saw my first endo who was in the UCSF orbit at the time. He suggested going on a pump but I resisted until mid-1987. When I did start on the pump, I began counting carbs and that was the start of the basal/bolus treatment for me.

I think my divergence from your treatment regimen was due to my private insurance status and my moving to the enlightened medical culture of the SF Bay Area. I think your HMO-constrained status delayed your escape from the NPH regimen that I left in 1987, even though you were living at ground zero of the diabetes treatment culture.

This brings up an important point even at this late date. Medical knowledge and awareness spreads at a snail’s pace from this patient’s point of view. Doctors are naturally skeptical of new developments and that is not inherently bad – to a point.

Dr. Bernstein was banging the basal/bolus drum for many years (late 1970’s, I believe) and the established medical culture resisted, belittled, and even mocked him. The DCCT in the '90’s finally proved that the basal/bolus regimen was the real deal and yet it took another 10 years for the mainstream practitioners to manage their skepticism and appreciate the good sense that it made.

It’s satisfying to me that Dr. Bernstein has lived long enough to see his prescient view of treating diabetes become the medical mainstream thinking. It would be even more statisying in the ADA’s, Joslin’s, and UCSF’s of the world would acknowledge that Bernstein was right all along and that they should have seen it sooner.

The glacial speed of mainstream medical thinking evolution is something that we diabetics need to factor into our view of current treatment practices. We only have one life and waiting for the mainstream medical culture to catch up is a luxury that many of us cannot afford.

As patients, our thinking and perception should not be easily dismissed by any medical practitioner. Our skin-in-the-game authority and deep experience gives us a rightful place at the table alongside our medical providers as well as the academic and scientific researchers. I definitely hold any doctor’s dismissal of the patient point of view as a negative and a mark against all of their advice.

So what sort of basal did he start you on in 2003? I think Lantus was just barely out of clinical trials and approved right around then? Or a pump?

I transitioned from “exchange system” to “carb counting” in very early 1980’s. But you’re right, none of my docs in the 80’s had any clue about basal (as opposed to meal coverage). I didn’t know about that until I found one of Dr. B’s books in… 1987? … in local library.

It was Lantus and it was life-changing. Teh Google Machine sez it was launched in 2000, so my dinner party acquaintance must have been an early adopter as I remember it was several years between then and starting on it myself.

They started me on R + N in the a.m. (beef or pork derived), which I did mixed as soon as I learned it was ok to do that, plus another injection for dinner time. I totally don’t remember if that was R + N or just R. Pretty sure just R as I don’t recall having N overnight and all the associated problems you might run into. @Laddie’s comment that some people still find N useful to help combat dawn phenomenon actually makes sense to me. I started struggling with DP a lot after going on Lantus/Novolog, though I don’t know that that’s a causal relationship. I started trying to fight it by giving myself a small novolog injection, which was probably pretty stupid. My endo thought so and that’s why she started pushing me to try a pump. That would have been about 2013.