When you start insulin

Do you start slow with one dose a day? Do you typically start mealtime insulin at the same time? Though my recent A1c was excellent at 5.6 the doctor stopped the sulfa I was taking saying that it was no longer working, and told me I was at the max with the other drugs and there was nowhere else to go but the insulin route.

A year ago my A1c went way back up so I started yet another med. That has proved very successful I am just looking toward the future.

My guess is that you would start based on when your BGs are highest. If just after meals, then fast acting insulin or Afrezza may be a good choice. If morning fasting is high, then maybe a basal like Lantus or tresiba. Also depends on whether you would also reduce or stop taking other meds, and to what degree your pancreas is providing insulin. Have you had recent c-peptide test?

Different insulins require different schedules. Over 10 years I’ve been on 2-6 shots a day and now use a pump. So will depend on the choices your Doc makes with you so be sure to ask questions and do discuss your lifestyle to get the best plan going for you. A1C is of 5.6 is pretty dang good in IMHO! I predict you will do well on any regime your Doc prescribes.

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It is definitely highest in the morning. The addition of Pioglitizone this year has brought even those numbers way down though it will still be up to 135. The Sulfa worked well in the day for a year but didn’t bring the morning numbers down. I take Met of course and Onglyza too.

It was my experience and the experience of two of my brothers to be started first on slow acting basal insulin. In my case it was only later that bolus insulin was added and even later when I started on a pump.

Al Mann was one of the great minds in diabetes which included inventing the insulin pump. If you can get insurance coverage I would follow his advise.

Al starts talking diabetes at 8:30m but it gets interesting at 11:00m and then the statement at 15:00M “interesting this (afrezza) lowers insulin resistance… this (afrezza) is even likely to slow and even stop the progression of Type 2 diabetes” www.youtube.com/watch?v=SvZxYmYPXYQ

The one thing all T2s lose is first phase insulin release. This results in huge post meal sugar spikes. While the standard protocol used today is to start on long acting insulin like Lantus, this is the wrong approach since it is not addressing the issue which is controlling the meal time sugar spike. If you can stop the spike you can control your numbers and there is a chance you will see improved beta cell function.

I had consistent morning highs (often 150-180) while on MDI. Different dosing schedules were tried but none solved the problems and bed time doses would tend to send my BG too low while sleeping. These problems went away immediately after starting on a pump. The steady basal dose from the pump made all the difference for me. So as you start insulin just keep in mind that there are many choices on type, dose and schedule so keep working on it with your Doc until you find your best solution.

Also want to add that my Doc started me initially on both long and fast acting insulin. FYI Lantus for basal and Humalog for meal time boluses. Took me off Metformin at the insulin start but added then added it back in about 6 months later. IDK the rationale behind the Metformin stop. I didn’t ask as many questions then as I do now.

My guess is that is the combo I would start on. Lantus and Humalog. Both covered by the insurance I have.

My numbers are a bit higher with out the Glipizide but the doctor said to stop that. Even so if the next A1c is higher like 6 or 7 not sure if that warrants insulin.

why would a reading this low 5.6 A1C need any insulin? this does not make sense.

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It went up to 8.2 earlier this year a change in meds is what brought it back down.

Before meds were first prescribed in 2015 the A1c was closer to nine. The doctor says I am pretty much at the max now when it comes to the medication so another rise like that and the next step is insulin.

What do you all suggest if your morning fasting level is okay, but rises significantly after you get up, even higher after you get into the kitchen, and shoots up even more after having a few bites of breakfast? And then it stays up way too high until I exercise it down, but it doesn’t go completely down to normal before the next meal (which is always just snack-size).
I kept A1cs in the 6s for the first 11 years, in the 7s the last 11 years (with metformin and glucotrol), and now after staying home (but still eating carefully and exercising) A1c has risen into the 8s – with the likely reason that I’m not getting out and about with running the usual errands, inadvertently decreasing my overall activity level. Wondering if I can make up for that with adding some extra exercise, or if I should be discussing starting insulin with my doc at tomorrow’s follow-up appointment…

Talk to your doctor about taking a fast-acting insulin only. No basal. I test and then based on results take 6-8 units of Humalog before I get up as have the same problem starting with a hot shower that drives my BG quite high and then even skipping breakfast does not want to come down. My insulin takes 26 minutes to kick in so by taking 1/2 hour before I get up, keeps my BG’s flat-lined until about 10:30 AM when it starts to rise again so I take an additional 2 units at 10 AM so I can keep flat-lined until lunchtime. That is what works best for me. At lunch, I pre-bolus for lunch 15 minutes before I eat as it takes 15 minutes for the food to hit my BG’s and at the 26 min mark that way I continue to flatline until 2:30 PM so at 2:00 PM I take an additional 4 units to keep me flatlined throughout the afternoon. For me, it is quite easy to always pretty much time perfectly and fine-tune as I am on a Dexcom CGM and fast acting insulin only. Before the CGM I was able to keep my A1C’s in the low 6-6.3% range using this method but after CGM staying in the low 5’s for A1C is not difficult using MDI (Multiple Daily Injections). I am not on a pump.

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I think insulin and the others you mentioned would be great to discuss with endo. Letting endo know you are ok with insulin is good to mention, since some want to avoid till last resort. Dr may want to order tests first to help decide.

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Extra exercise will most likely make you hungry resulting in you eating a little more and BG will go up. When I need to tame BG or Weight eatind fat to suppress appetite is the only eating I will do and cut exercise rather than add more.

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Thanks, MM1; I will do that. At 77, I’m thinking that a pre-filled insulin pen would be the easiest/less stressful way for me to go, but I don’t know how much my doc (a family primary care physician) knows about insulin options for type2s (although he’s been very good and well-informed, so far). And I know nothing about injecting insulin. How did you learn what you needed to do, in the beginning?

Good to know. Thanks!

Thanks, CJ114! I like that idea of fast-acting insulin, since my main problem is with Dawn Phenomenon and breakfast. I feel like I already eat very little (have been cutting back over the years), so food is not really my focus as much as metabolizing it and exercising my numbers down.
Do you use an insulin pen? Pre-filled? Covered by Medicare?
(Sorry for all the Q’s; I know nothing about any of this.)

Humalog is available in pre-filled pens. Will take 20 minutes at most to review with someone how and where best to inject. The small needle you will mostly not feel or at worst case be equivalent to a mosquito bite for pain. There is a lot of pomp and ceremony at first where they want you to alcohol wipe the spot, use a new needle every time etc. After a while you will most likely just find that you can drive and inject at the same time, even through your clothes, although that dulls the needles faster. Needle reuse, I get at least 50 injections from same needle before it gets bent or plugged.

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Good to know. Thanks, again, CJ!