October 2006 NEWSLETTER
MORE ‘HUMAN’ INSULINS TO GO - BUT DOES MODERN MEAN
BEST?
In August, Novo Nordisk announced yet
further discontinuations of their ‘human’ insulin range, this time they
estimate that this will affect 16,000 people. In a letter to IDDT, Novo Nordisk
send their apologies for the inconvenience that it may cause people, so I pass
this on to you.
Inconvenience!
‘Inconvenience’ is used with every
discontinuation the company makes but what a word to use! It’s inconvenient if
I run out of milk, it’s inconvenient if the postman’s late delivering, it’s
inconvenient if my computer crashes. But 'inconvenience'
grossly underestimates what is involved for the people who are affected –
looking at that remaining choices; once chosen, more blood glucose testing
during the changeover period; learning about the peaks and duration of action
of new insulin and how it affects you as an individual; perhaps a change in
regime from two injections to four injections a day, especially with the
removal of pre-mixed insulins.
Only someone without diabetes could
describe changing insulin as an 'inconvenience' but as a marketing word to
health professionals for Novo Nordisk's policy, it’s a good word! Health
professionals will be inconvenienced by having to change the insulins of 16,000
people. For people who are happy and managing their diabetes satisfactorily,
any change of their insulin type is unnecessary
- a bad marketing word, not used in relation to insulin discontinuations! It
may be necessary for Novo Nordisk to maximise their profits by insulin
discontinuations but for people with diabetes, such changes are unnecessary and
an unwelcome disruption in their lives.
Change
for commercial reasons, not clinical reasons
Yet again we are witnessing a treatment
change that is being made for commercial reasons and not for clinical reasons.
Yet again 16000 people are having their insulin changed not because they and
their doctors have decided that it is best treatment for them but because a
pharmaceutical company has decided it is in the best interests for their
shareholders. It is a policy that further reduces patient, doctor and
prescribing nurse choice and from this perspective, it is a policy that is
indefensible. From a wider perspective and equally indefensible, it means that
the pharmaceutical industry is dictating treatments - not patient need, not
evidence of benefit and not doctors' experience and knowledge.
Belief
is not the evidence we need
But Novo Nordisk’s defence appears to be
that the ‘human’ insulins are being discontinued in favour of ‘modern’ insulin preparations that the
company 'believes' are best for
patients. Dear me – this really does insult our intelligence! Since when has
‘modern’ automatically meant better? The ‘modern’ drug for arthritis was Vioxx
and how many unnecessary heart attacks and deaths did that cause? Simply
calling a drug ‘modern’ does not mean it is the best treatment or even that it
is safe – evidence of superiority and both short and long-term safety is
what we need.
Novo
Nordisk says that it ‘believes’ that
insulin analogues are best for patients but belief
is not good enough – we need evidence
of what is best for patients! At one time it was believed that the world was
flat but the evidence proved otherwise and it is unacceptable in the 21st
century the word ‘belief’ is applied to medicines and treatment choices!
Treatment must be based on evidence of benefit, not beliefs or assumptions of
benefit. To health professionals Novo Nordisk's explanation for these latest
discontinuations on their website is that 'current treatment trends supported
by clinical evidence indicate that analogue insulin is now a preferred option
to human insulins'. But all this actually says is that analogues are prescribed
more frequently but not that the evidence is that they are better than the
alternatives. Indeed, even the reference the company quotes only concludes that
overall control was similar in people with Type 1 and Type 2 diabetes when
comparing pre-mixed analogue with premixed 'human' insulins. Note - not better,
just similar. [Diabetic Med, 2002, 19, 393-399]
Further
reduction of patient choice
While we cannot doubt Novo Nordisk’s belief
in their latest products, it is difficult to accept that they also truly
believe that reducing choice is best for patients! But it appears that they do
as it has been made clear to IDDT that they intend that their range of insulins
will be analogues only. This means eventually all 'human' insulins will be
discontinued. While this is their choice and their right, it is a policy that
ignores patient need, patient choice and even patient safety. What happens to
people who have adverse reactions to insulin analogues?
The easy and short-term answer for patients
is to use 'human' insulin made by other companies but in the longer term, it
really is not that simple. There are only 3 major suppliers of insulin in the
world and all three seem to function as if joined at the hip – all going in the
same direction, the analogue route. In the
Will
the marketing techniques work again?
Twenty years ago marketing techniques
managed to sell 'human' insulins to the medical profession without any evidence
of benefit, just assumptions, and 84% of the diabetic community were
transferred to it for no clinical reason. And here we go again, this time the
'human' insulins that we were told were so wonderful 20 years ago, are being
discontinued for 'modern' insulins, the analogues!
Have lessons been learnt? It appears not.
Will the marketing techniques work again? Will Novo Nordisk's belief that their modern insulins are best for patients, be sufficient to sell
analogues to the medical and nursing professionals who prescribe them? Being
realistic, the answer is, yes probably. This time will diabetes organisations
put people with diabetes first and fight for them to keep choices available, to
have insulins to suit all their differing needs and to have insulins which have
evidence of long-term safety? Will they
stand up to defend the health and wellbeing of people who require insulin both
now and in the future? IDDT will. IDDT has always believed that people should
have the insulin that suits them best and to achieve this, 'human', analogues
and animal insulins must remain available and we cannot allow the power and
influence of the pharmaceutical industry to dictate our treatment.
Doing nothing is not an option and IDDT
welcomes the support of anyone who wishes to add weight to our call for insulin
treatment to be prescribed by health professionals in conjunction with patients
and not dictated by industry.
SO
WHICH INSULINS ARE GOING THIS TIME AND WHEN?
Novo
Nordisk has stated that the following 'human' insulins are to be discontinued
and will not be available after December 2007 [and they could run out before]:
·
Mixtard 10 3ml
penfill cartridges
·
Mixtard 20 3ml
penfill cartridges
·
Mixtard 40 3ml
penfill cartridges
·
Mixtard 50 3ml
penfill cartridges
·
Velosulin 10ml vial
There
is no direct equivalent to these insulins and Novo Nordisk advise that the
following are the closest available insulin options:
Novo Nordisk
alternative products
·
MovoMix
30 Flexpen - analogue
·
NovoMix
30 Penfill - analogue
·
Mixtard
30 Penfill - 'human'
Non Novo Nordisk alternative products
·
Humulin
M3 [Lilly] - 'human'
·
Humalog
Mix 25 [Lilly] - analogue
·
Insuman
Comb 15, 25 or 50 [Sanofi-Aventis] - 'human'
·
Hypurin
Porcine 30/70 Mix [Wockhardt] - animal
But some are not
that close an alternative, so which one do you choose?
Your
health professional will have a support package from Novo Nordisk which
includes estimated numbers of people in each area affected by this
discontinuation, a standard letter to be sent to these patients and all the
above information. Health professionals should also have a copy of MIMs that
clearly shows the actions of all insulins - the peaks and duration of action
and these can be compared with the insulins that are being discontinued. It
shows the following:
·
Humalog
Mix 25 and NovoMix 30 both have a peak of action that starts much sooner and
lasts for a significantly shorter time.
·
The
peak of action of Humulin 3 starts much sooner and lasts longer.
·
The
peaks of action of all the Insuman Comb insulins are much shorter than the
Mixtard insulins being discontinued.
·
Mixtard
30 [human] and Hypurin Porcine 30/70 have the nearest and very similar action
profiles both in term of duration and peak of action.
So if the latest
discontinuations affect you, then your health professional should give you all
this information to provide you with an informed choice of insulins so discuss
your options with your health professional and decide on the best insulins for
you.
AVAILABILITY OF DIABETES PRODUCTS
Finding
products to help you manage your diabetes can seem like a search for a needle
in a haystack! Medical Shop is a Mail
Order service - you can buy products to help manage your diabetes as well as
travel products and other health products.
Products
include lancing devices, First Aid kits, small sharps bins, skin care products,
pill containers cases and cool wallets for carrying diabetes supplies and more…
A
Free copy of their catalogue is available or orders can be placed by telephone,
by mail order, or online:
Freephone 0800 731
6959, Medical Shop, Freepost OF1727,
"MY CLINIC
IS REFUSING TO ALLOW ME TO TRY ANIMAL INSULIN". What does NICE say?
This is something we hear all too often on
the IDDT phone line! Don't misunderstand, we want to hear from you but it is
the statement itself that we wish we didn't hear. As we know, there are no good
reasons for refusing animal insulin but there are wider implications. Firstly,
the clinic is not following the National Institute for Health and Clinical
Excellence [NICE] guidance on patient education [implementation Jan 2006] which
entitles you to an informed choice of insulin. Secondly and perhaps more
importantly, there are no NICE guidelines that recommend any particular type of
insulin for people with Type 1 or Type 2 diabetes which of course means that
there are no NICE guidelines that say animal insulin should not be used!
NICE
guidelines for Type 1 diabetes state:
Prescribe the type of insulin that allow
people optimum well-being.
·
Use
multiple insulin injection regimens in adults who prefer them in an integrated
package with education, food, skills training and appropriate self-monitoring.
·
Advise
twice daily insulin regimens [often bi-phasic pre-mixes: analogues in those
prone hypoglycaemia at night] for those who want them, who find adherence to
lunchtime insulin injections difficult, those with learning difficulties who
may require assistance.
NICE
guidelines for Type 2 diabetes state:
Insulin maybe used to help control your
blood glucose level if other medicines have not brought your HbA1c down to your
target. Your doctor will talk to you about the different types of insulin that
are available and when they should be taken so that you can agree on the one
that will suit you best.
Are
there guidelines that say that animal insulins should not be used? NO!
In
fact, NICE guidelines do not make any specific recommendations about the type
of insulin to be used. Indeed, NICE clearly emphasises that the needs and
wishes of the patient with the use of phrases such as 'in adults who prefer them', 'for
those who want them' and 'so that you
can agree on the one that will suit you best'.
Nowhere
does NICE state that animal insulin should not be used. The only insulins to
which that NICE says NO are long-acting insulin analogues in people with Type 2
diabetes, except under special circumstances.
What
can we conclude?
·
The
key recommendation is that the insulin used should be the ones that will allow
patients the optimum 'well-being'. The dictionary definition of well-being is
"a contented state". So for whatever reason, if you are more
'content' using animal insulin, then you will be using the insulin that
provides you with optimum well-being!
·
NICE
guidelines do not make any specific recommendations about the type of insulin
to be used.
·
NICE
emphasise the importance of the needs and wishes of patients.
So it
does seem that if your clinic is refusing to prescribe animal insulin, then the
clinic is NOT following NICE Guidelines and you can use this to argue your
case.
HAND LUGGAGE -
UPDATE AUGUST 2006
As a result of recent events hand luggage on aircraft is
restricted to a bag the size of a lap top and the rules for medications have
been tightened. At the time of writing the position is as follows.
The
advice for the
·
Carry a letter from your
GP explaining that insulin, syringes, pens and needles are essential for the
journey and must not be separated from you.
·
Speak to the supervisor
at the check-in desk and explain the situation and also explain to the cabin
crew that your diabetes supplies must stay with you on the journey.
·
All diabetes equipment should
be placed in a plastic bag.
·
Up to 50mls of insulin is
allowed on board a plane.
Warning!
The Dept of Transport is advising that if more insulin is
required, then it should be packed in the suitcase that goes in the hold.
However, as readers will know, we have always been told that insulin should NOT
go in the hold because of the risk of it freezing. Freezing insulin makes it
inactive and it would then have little or no effect on blood sugars. This issue
was highlighted by someone with diabetes in the Birmingham Mail [17.8.06] and
the Dept of Transport said that this matter had not been raised with them but
they would now be seeking advice. In the meantime, the airline gave special
dispensation for all her insulin to be onboard the aircraft.
Additional
advice from the American Transport Security Administration [TSA] and issued by
the American Diabetes Association is well worth following:
·
Insulin
and insulin loaded dispensing products should be clearly identified and
labelled. In other words keep your insulin in the packet with your name and
details on it, even if the vial/cartridge is in-use.
·
Glucagon
emergency kit should be clearly identified and labelled.
And for pump
wearers
Although
insulin pump manufacturers indicate that pumps can safely go through airport
security systems, pump wearers may request a visual inspection rather than
walking through the metal detector or being hand-wanded. Note that this may
subject you to closer scrutiny or a "pat-down."
·
Advise
the screener that the insulin pump cannot be removed because it is connected to
a catheter inserted under your skin.
·
Insulin
pumps and supplies must be accompanied by insulin with a label clearly
identifying the medication.
Note: Any medication
and/or associated supplies that cannot be cleared visually must be submitted
for x-ray screening. If you refuse, you will not be permitted to carry your
medications and related supplies into the sterile area.
IDDT
GOES TO
Thanks
to your help and that of your MPs, Parliamentary Questions were asked up to the
summer recess of Parliament all relating to the need for an insulin strategy
that ensures that choice of insulins remains available with special reference
to animal insulins. These have been answered by Minister of Health, Andy Burnham
MP.
Update:
Second supplier - following the
meeting at the Dept of Health in May, it is now in the public domain that
Wockhardt is looking to pass its technology for manufacturing animal insulins
to another company and they have expanded their production facilities. So it
seems that the contingency plans that we have been requesting are likely to be
put into place so in the event of production/supply problems at their
Patients having a
fully informed choice of all insulins – we know that this does not really happen
and so a Parliamentary Question asked what plans the Minister has to ensure
that diabetes patients receive a fully informed choice of all available
insulins and their risks and benefits, despite the absence of NICE guidelines.
The
Minister's answer is significant in particular: ‘from January 2006, NICE has required all primary care trusts to
implement NICE guidance on patient education by providing all people with
diabetes with high quality, structured education which should include
information on insulin use.’
Referring all
insulins to NICE
- IDDT believes that all insulins should be referred to the National Institute
for Clinical Excellence [NICE] for guidance on their clinical effectiveness and
their cost effectiveness with a view to developing standard guidance regarding
their comparative safety, efficacy and cost effectiveness. However, the
Minister has continually refused to do this and a further Question asked on
what grounds the Minister made this refusal. His answer is significant as it
once more publicly emphasises that synthetic human insulins have no advantages
over animal insulins and that patients have the right to be involved in
decisions about their insulin options.
‘NICE‘s
clinical guidance on the management of both type 1 and type 2 diabetes conclude
that the majority of studies indicate that both human and animal insulins are
equally effective and report no significant differences in hypoglycaemic
episodes and glycaemic control between insulin of human and animal structures.
I
understand that the choice of insulin is influenced by other factors such as
delivery systems and cultural preferences, and so the decision to use one or
other of the insulin types rests entirely with the physician in consultation
with the patient.’
All Party
Parliamentary Group for Diabetes [APPG] - while the above answer is significant,
without NICE involvement there is still no guidance or assessment of the
various insulins, so we have to pursue this. Thanks to the help and support of
Philip Dunne MP, IDDT was invited to make a presentation to the APPG to present
the case for NICE guidance on all insulins. Following the presentation and
various questions, the APPG agreed to support our request and follow this up
with the Minister. IDDT prepared a paper for NICE and we are waiting for news
on this.
Carcinogenic
potential of insulin analogues - a Parliamentary Question asked what
action the Dept of Health has taken following the European Agency for the Evaluation
of Medicinal Products [EMEA] recommendations regarding further investigation of
the carcinogenic potential of insulin analogues. The answer was unsatisfactory
- the Medicines and Healthcare products Regulatory Agency [MHRA] continually
monitor the safety of human analogue insulin and the MHRA have not requested
pre-clinical studies specifically on this issue. This answer fails to recognise
it is further pre-clinical research that is needed as recognised by the
European Agency [EMEA]. MHRA standard monitoring of adverse reactions will not
pick up possible tumours at this stage because they take years to develop.
So what's in the
pipeline?
During
the summer we have been assessing our strategy, especially in view of Novo
Nordisk's intention of reducing insulin choices even further with the eventual
aim of only analogue insulins being available. As this decision affects people
with diabetes globally, we are meeting with colleagues from other countries to
discuss a joint strategy to protect the health and interests of people with
insulin-requiring diabetes.
We
are still hoping for an Adjournment debate in the House of Commons and thank
David Amess MP for his support with this. Following the Earl Howe's meeting
with the Minister on our behalf, he received a written response and we shall be
discussing with him further steps that we can take.
We
are planning an Early Day Motion [EDM]. EDMs are a little strange because they
ask MPs to sign to show their support for a motion but there is no obligation
on the part of government to act on this. Nevertheless, EDMs with lots of MPs'
signatures are an indication of strength of feeling, so we will be asking for
your help with this in the coming months. No longer is this an issue that just
affects people who need animal insulin but all those who want choice of
insulins to remain available.
FOR READERS IN
On
August 25th Australian Health Minister, Tony Abbott announced that
following a recommendation by the Pharmaceutical Benefits Advisory Committee
[PBAC], long-acting insulins, Lantus and Levemir will be subsidised from
October 1st for treatment of Type 1 and Type 2 at a cost of
$145million [over £58million] during the next 3 years. Reports describe the
negotiations to achieve this as 'protracted and difficult'.
About
210,000 Australians will qualify for these insulins and the government expects
about 110,000 to use them in the first year with a rise to 160,000 by 2009. The
subsidised cost to patients is expected to be $9.40 for concession card holders
and $59 for non-concessional patients for a years supply.
WELL
WORTH A READ………….
TESTING TREATMENTS
Better Research for Better Healthcare
Imogen Evans, Hazel Thornton and
Iain Chalmers
In
out Newsletters we frequently talk about looking at evidence to support treatment
decisions, such as a change of insulin and how often have I said that GM
'human' insulin was introduced as first line treatment on assumptions of
benefit and not on evidence of benefit? 'Testing
Treatments' is a book well worth reading and makes what could be a
complicated subject easy to read and easy to understand for patients as well as
for doctors and health professionals. As Nick Ross says in the foreword, 'Once you have read this book you will never
feel quite the same about your doctor's advice again'.
The
book demonstrates the uncertainties about the effects of treatment - how two
doctors can give opposing advice for the same condition and highlights the need
for rigorous testing of treatments in order to ensure that we, the patients,
receive treatments and interventions based on available evidence.
While
the book points out that many medical practitioners are sincere and skilful,
they are not always aware of what makes good scientific evidence and their
treatment recommendations may be based on what they were taught at medical
school, what other doctors do or what has worked in their experience. The book
points out that this can be very misleading and ultimately harmful.
Nevertheless the book does not disparage doctors or modern medicine but aims to
encourage better research, more informed decision-making and therefore
healthcare.
It is well worth
obtaining a copy: Testing Treatments, Better Research for Better Healthcare is
published by the British Library, ISBN 0 712 3 4909
Very different books but useful to
dip into………….
Diabetes
for Dummies
Dr Sarah Jarvis and
Alan L Rubin, MD
Like
all the Dummie books, this is a book for beginners, those who are new to
diabetes who will come across many questions as they learn to live with their
condition. It is useful to have around to dip into when these questions arise.
Published
by Wiley, ISBN 0-7645-7036-6
The
GL Diet for Dummies
Nigel Denby and Sue
Baic
GL
stands for Glycaemic Load and again this book is one to dip into, it helps to
provide a better understanding of what many of us have come to know as the
glycaemic index of foods. It is not specifically for people with diabetes but
provides useful information and recipes.
Published
by Wiley, ISBN 0-470-02753-3
AND WELL WORTH A WATCH…………
Philip
Johnston of The Small Video Company has produced a range of DVDs about various
aspects of diabetes. The DVDs were produced with the help and advice of doctors
and so are reliable educational sources of information that can be watched and
re-watched as the need arises.
The DVDs are as
follows:
·
Childhood Diabetes
60mins
- for the family or carer of a child with Type 1 diabetes. Produced with Dr
Kenneth Robertson, Dr Louise Bath and Dr John Schulga.
·
Teenage Diabetes
60mins
- for teenagers with diabetes covering topics like blood glucose monitoring,
hypos, drinking, smoking, exercise. Produced with Dr Mike Small and Dr Kenneth
Robertson.
·
Pregnancy and
Diabetes 42mins -
a teaching aid for women with Type 1 diabetes who are planning to have a baby
or are in early pregnancy. Produced with Dr Donald Pearson , Dr Judith Steel
and Dr Mike Small.
·
From Pills to
insulin 42mins-
a positive outlook for people with Type 2 who have to go through the
progression from pills to insulin. Produced with Dr Chris Kelly and Dr Andrew
Gallagher.
·
Type 2 Diabetes -
The No Nonsense Guide 73mins - for people with Type 2 diabetes,
especially those who are newly diagnosed in primary care, their family and
carers. It also has a 43minute bonus feature containing 6 mini features ranging
from 'Foot care' to 'Holidays'. Produced
with Dr Ann Gold, Dr John Knight and Dr Andrew Collier.
The DVDs normally
cost £10.00 each including delivery for orders in the
[Further discounts are available to health
professionals for the use in diabetes clinics, if they mention that they heard
about the DVDs through IDDT's Newsletter]
RESEARCH
NEWS
'Human' insulin molecule produced in
safflower
A
Canadian company has achieved 1% insulin accumulation in safflower which is a
commercially viable level. It means that they can produce over one kilogram of
insulin per acre of safflower production - enough to supply 2,500 people for a
year. The company, SemBioSys Genetics, believe that they could supply the
world's total projected insulin demand in 2010 with less than 16,000 acres of
crop production. They plan to scale up production for sufficient insulin to
start clinical trials.
Marijuana Compound
May Help Stop Diabetic Retinopathy
Researchers
are studying a compound found in marijuana, cannabidiol, because there are
indications that it may protect the eye from growing new leaky blood vessels -
one of the main problems with diabetic retinopathy. They are looking at the
role of cannabinoid receptors in the body and trying to modulate them so they
can defend the eye against diabetic retinopathy by intervening early in the
process of the development of retinopathy. [American Journal of Pathology,
January 2006]
Insulin itself may be the trigger
for Type 1 diabetes –
research from two teams suggests that insulin itself may be the trigger that
actually causes Type 1 diabetes. One team cloned immune cells from people with
Type 1 diabetes and healthy people and discovered that the cells from the
people with diabetes reacted to insulin but those from the healthy people
didn’t. The second team genetically engineered mice so they lacked normal
insulin but still had a form of insulin hormone that is not recognised by
immune cells. None of the mice with the modified insulin developed diabetes.
The researchers say that if these results can be confirmed, it could be that
insulin is the driving force behind Type 1 diabetes and the next step would
then be to test the hormone to see if it can be manipulated to prevent the
condition.
We now have
diabetes Type 1.5!
This
is a new term used to describe a group of people who have diabetes but do not
seem to fit into either Type 1 or Type 2 diabetes. In this group of people
there does not seem to any evidence of autoimmunity as there is in Type 1
diabetes when the body’s own immune system kills off the insulin producing
cells. Equally, there does not seem to be any evidence of insulin resistance as
seen in Type 2 diabetes. Usually this group have good control by using
medications that increase insulin secretion but do not respond to those that
improve insulin resistance such as metformin or the glitazones [Actos and
Avandia]. After some years they may require insulin injections.
TIGHTER TARGETS - CAN WE DO
IT? YES WE CAN!
By Dr Katherine
Morrison
So
we are being set tighter targets for diabetes [IDDT Newsletter July 2006]. This
is not likely to be achievable by people with diabetes who stick to the advice
given to them in hospital clinics across the land. In a recent article in the
BMJ [ref1], only 37% of pregnant women had an HbA1c of less than 7% at 13 weeks
of pregnancy.
Pregnant
women run very high risks for themselves and their babies if they have high
blood sugars, Extensive pre-natal and peri-natal counselling and dietary advice
is given to this group, yet this most highly motivated group is not getting
anything like normal blood sugars.
Many
people who read this Newsletter know that they can achieve very good blood
sugar results and a major reason for this is that they never abandoned their
low or restricted carbohydrate diets in favour of the more popular high carbohydrate,
low fat diet.
If
50% of NHS dieticians are not happy about their own knowledge of carb-counting,
how do they expect patients to do it? Certainly in my own area carb-counting is
simply not on the agenda whatsoever, even for people who are insulin dependent.
In her article I was struck to see Jenny's simply suggestion that an egg-sized
portion of mashed potato amounted to 10g of carbohydrate. This is the sort of
eyeball technique tip which I suspect is almost second nature to more
experienced people who have had diabetes for many years. It concerns me that
this expertise could be lost if we do not record these sorts of tips for
posterity.
The
NHS is not going to educate the newly diagnosed on carb-counting for the
foreseeable future, but can you realistically match insulin to carbohydrate
intake when you haven't got a good idea how much carbohydrate is in the food
you intend to eat? I have struggled with various techniques to estimate carbs.
From
my previous article you may know that my son Steven is a teenager with Type 1
diabetes. I found that initially keeping 100g of carbohydrate or less a day
gave him excellent blood sugars with an HbA1c of around 5.0%. Now he has come
out of the honeymoon phase and is also undergoing a growth spurt he is needing
extra carbohydrate and insulin to keep up. We also cannot fully compensate for
the dawn phenomenon [highs in the morning]. Currently his HbA1c, some 3 months
after starting a 100-200g carb diet, is 6.0% but this has been at the expense
of blood sugar swings. We reach target blood sugars about 60% of the time but
he has hypos [below4] about 10% of the time and high blood sugars [over 8] 30%
of the time. These figures include post-prandial [after meal] peaks and delayed
sugar rises which can often be due to protein or higher fat content with higher
carb meals.
In
order to attempt to get some control over this I have come up with some tips of
my own which I am happy to share. I also hope there will be more contributions
from readers.
Insulin Tips
Tip 1: Steven takes
Levemir [long-acting analogue] as a basal insulin but during the summer we
found that he had to have less in the morning than at night because of
inexplicable afternoon hypos.
[Jenny's comment after 30 years: maybe the hypos aren't that inexplicable - hot
weather causes hypos and may be extra exercise.]
Tip 2: We found that
Tip 3: We find that
Actrapid is an excellent insulin to cover high-protein and high-fat meals. At
the current time the only availability in cartridge form is Wockhardt's pork or
bovine Neutral insulin but it is a pity that this is not available in half-unit
pens. [I have stockpiled a large supply of Actrapid and will simply have to
keep an eye on its potency]. Actrapid is also very helpful given in the
mornings not only to cover a high protein breakfast, but also to deal with the
dawn phenomenon and insulin resistance which is definitely more active in the
morning for most people with diabetes.
Tip 4: To cover meals
with high protein content, 2 units of Actrapid per deck of cards size of meat
works well to reduce delayed blood sugar rises.
Tip 5: NovoRapid
[analogue] works quickly and is good for correction doses if blood sugars are
high and also for higher carb meals, such as when at a restaurant.
Tip 6: After school we
have added exercise as an alternative to insulin injections for correction of
high sugars. We've got a rowing machine and it is very surprising how little
you have to do to bring sugars down abruptly with this, much more rapidly than
with insulin - a cycle ride is also effective.
Tip 7: Because Steven's
bedtime snack is at
Tip 8: In order to
prevent any spiking of blood sugars at all after meals, Dr Richard Bernstein
has worked out that 12g of slow-acting carbohydrate is the most that can be
consumed with each meal but this can be too restrictive for many people. From
experimentation I have found that carbohydrate:insulin ratios seem to work out
reasonably steadily up to 30g of carb but after 30g blood sugars after meals
tend to be much higher than expected and I found that we need to add an extra
0.5 units for every 10g of carbs up to 80g. After 60g results are getting a bit
unpredictable and really after 80g results become so increasingly unpredictable
that I don't recommend going over that
in one meal. This is of course, perfectly adequate for even the fussiest of
eaters. I call this tip "weighting" the insulin.
Tip 9: Steven has a
survival pack which he takes to school with him everyday containing: his
insulin pens, mobile phone, money, carb-count list, pastilles to cover
exercise, glucose for hypos, spare needles and his glucose monitor, Freestyle
to school because its smaller.
Tip 10: Because I am
worried about night-time hypos , which indeed he has never had, we go easy on
the insulin and give him only 2/3 of the estimated dose prior to bed time.
Because I am not adequately covering the insulin we stick to 35g or less at
bedtime, with most of the time any bedtime snacks being considerably less than
this. I try to get a good amount of fat and protein into him at this time too
as this slows down the absorption rate of the carbohydrate making it last
longer.
Tip 11: Whenever possible
we wait for the insulin to act before eating, 15minutes for NovoRapid and 45
minutes for Actrapid. These times can be extended to drop the blood sugars if
blood sugars are unusually high. The combination of "waiting" and
"weighting" seems to work well. Use the right insulin for the meal. Wait
for the insulin to work. Wait for the blood sugar to drop. Weight
the insulin according to the carb content of the meal.
If you have any
tips that you would like to share, especially those from the good old days, then
call Jenny at IDDT on 01604 622837 or write to her at IDDT, PO Box 294, Northampton NN1 4XS.
Ref 1 Peri-natal mortality and congenita;
anomalies in babies of women with Type 1 or Type 2 diabetes in
Test your knowledge and learn some carbohydrate values…
1. A normal blood sugar before meals is: