Bad insulin

For the first time in my 16+ years of diabetes I have experienced insulin going bad. In my previous post, I talked about unusually high BG-levels of last weekend that appeared only to be lowered when using my insulin pen for correction boluses. I ended up concluding that it must be due to lacking effect of the insulin sitting in my pump, as nothing was wrong with the tubing or the sites that I pulled out on Sunday and again on Monday.

When I got back from work Monday evening, I changed infusion set - though I had just done that the day before, and the site turned out to be okay - and switched to a fresh vial of insulin. That helped! The last few days, BG has been more manageable, although the heat still does a lot to mess with my levels. Although it is against all I have ever been instructed to do, I have refrigerated the newly opened vial of insulin (I have always been told NEVER to refrigerate opened vials or pens of insulin). I figured that while having this warm summer weather this may be needed if I am not to through out half-used vials again.

F..... roller coaster!

The past weekend has truly been frustrating diabetes-wise. I don't know if it the immense summer heat that Denmark along with the rest of Europe are experiencing at the moment, the reactions of my body being out of wack or whatever. Anyway my BG levels sure has taken roller coaster rides all weekend.

Saturday morning I started out on the low side (2.3 (41)) which made me re-check about an hour and a half after breakfast. At this time I was up to 11 (200), and because I had reasons to believe that I would shoot even higher, I took an additional bolus of 2 U by pen (I don't know why I didn't use the pump for that). At lunch time I was in range at 4.5 (81) and I used the pump wizard to calculate lunch bolus. The pump suggested 4.7 U for my 1.5 slice of rye bread, 1 glass of milk and a small banana (estimated carb count: 69 g). Bearing in mind that I had just finished 8.5 km bike ride for grocery shopping, I figured this dosing reasonable. However, a couple of hours later, I could hardly wake up from a book-reading-induced power nap on the sofa when the phone rang, so I figured I better check the BG. I usually suspect a low, when I have trouble waking up from sleep, and as I was also hungry, I was rather surprised to see a 15.4 (277) result on my meter. I corrected for this, again using my insulin pen rather than the pump, and once again I was back in range at dinner: 4.6 (83). We had dinner at one of Jimmi's colleagues - home-smoked trout with homemade white bread as starter, grilled trout with potatoes and mixed salad as the main course, and homemade ice cream for dessert. Very delicious! The main course and the dessert was about 1.5 h apart, so I thought I might do a quick check to assess the amount of insulin needed for the dessert: 15.6 (281). WTF?!!! At that time, I started to suspect that either the insulin in the pump had gone bad (it was due for a change and fill-up the next day), the site was not working properly or other pump-related issues were causing these crazy sugars. Thus, I corrected with my pen once again - and of course I was low later that night :-/ I checked before going to bed and was 3.5 (63), so I had an apple and went to sleep.

At 9 o'clock the next morning I was 2.3 (41), and because it had now been 12.5 h since my correction with pen, I thought that maybe I was wrong, maybe there wasn't anything wrong with the insulin in the pump, maybe I had just misjudged the amount of insulin needed for the first two courses last night. So I bolused with the pump, and didn't check again until lunch: At 12.30 PM I was 18.6 (335)!! This reading closed the deal for me, and besides taking a correction and lunch bolus with my insulin pen, I also changed the site and reservoir, hoping that this would help. There didn't seem to be anything wrong with the site, or anything blocking the tube, though. The rest of the afternoon and before dinner BGs were fine, 3.9-5.9 (70-106). I had planned to go for a bike ride in the afternoon, but I postponed that due to a thunder storm. After dinner the weather was dry, but still warm and because of all the rain it was rather humid. I went for a good ride on my mountain bike, 27 km, but I ran into a nasty hypoglycemia attack on the way, and I am actually surprised that I managed to get home safely. I do have glucose tabs along with me when I ride, but I just never got around to eat any yesterday, so when I arrived at our home Jimmi was out with the trash and even at distance he could see that I was in need of something sweet and rushed to get something to put in my mouth. I didn't test at the time so I don't know how low I was, but the way I experienced it a good guess would be around 2 (36). Anyway, I started feeling a bit better and hit the shower before hitting the couch to enjoy the strawberry and ice cream (sugar free ice cream) treat that Jimmi and I had agree upon at dinner. I bolused a bit conservative for this, 1.4 U for approximately 50 g of carbs, due to my bike ride which will usually affect my BG both during the night and the next morning. Before going to bed at 10 PM I tested 7.2 (130) which seemed perfect about an hour and a half after strawberries and ice cream.

In the middle of the night (I don't know what time it was, because I did not look at the clock - this is intentionally because otherwise I will have even more difficulties getting back to sleep when my mind calculates how few hours are left before I am to get up!) I woke up, having to go to the bathroom. I usually don't have to get up at night, so this, along with the line of unexplainable highs of the weekend and a dry mouth, made me suspicious. Sure enough: 21.4 (385) - the record of this insane weekend! Again, this made be doubt my pump, and a correction of 5 U was taken by pen. That made me wake up at perfect 5.8 (104), determined that today I will evaluate the function of the insulin in the pump by closely monitoring my BGs after boluses taken by the pump. For breakfast (6.45 AM) I bolused with the pump, and once I got to work at 8 AM I tested again: 3.9 (70). That is a bit too low to work with so I had a small snack of 10 grams of carb, because if the breakfast bolus was working as it is supposed to do then its tale along with the effect of yesterday's and this morning's bike rides will lower my BG even more throughout the morning.

At 9.45 AM I was up to 9.7 (175). Hmm, not quit what I would expect if the morning bolus was working. I usually eat 0.5 slices of rye bread mid morning, so I bolused for this and the slightly high BG by the pump, 1.9 U, and postponed my snack for 45 minutes while getting a sample ready for LC-MS/MS. Out of curiosity, and to get a feeling of the effect of the insulin delivered by the pump, I tested again at 10.30 and got a reading of 9.6 (173). This is certainly not impressive, so I think that I am back to using my flex-pen the rest of the day, and then I will try another vial of insulin when I get home. If that does not solve the problem, I am getting back to Lantus, Actrapid and NovoRapid by injections!

Changes

This morning I had an appointment with my diabetes nurse, Alice. As I mentioned in my previous post, I had several issues to discuss with her. Fortunately, she had time for it. Actually my appointment lasted almost 75 min! We agreed on a few changes to be tested and some habits of mine that I should try to change. The latter is going to be the hardest task as these habits are actually a question about remembering to make some changes that I haven't been used to give much thought to. An example is the use of temporary basals on the pump. This is a function that I have only used occationally, but certainly could turn out to be an advantage on some of my longer bike rides. I haven't been use to pay attention to insulin delivery just prior to a bike ride, because when on injections, I would usually just reduce the last meal bolus before a ride. This I still tend to do, but especially on days when I am low around dinner time and want to take a ride after dinner, a temporary reduction in the basals is likely to prevent hypos during or just after the trip. I will have to work on remembering this.

Alice also suggested that I should pay more attention to, and make use of, temporary basals on soccer game days and the following nights. In the light of that last serious hypo on the night following the last game of the spring season, this may be a good idea. Because I have been using additional Lantus shots on the game days, I have a pattern of much lower basals coded within my pump for these, but I may need to run a temporary lowering of those even so.

As we discussed the issues around soccer games, we also discussed the possibility of wearing the pump during the game. I haven't been very fund of the thought of this, but because of the BG-difficulties I have been having during games, I think it may be worth at least to try it. I got a neoprene case for the pump during sport. It is designed to be worn in a belt, but it should be fairly easy accustoming it for using a clip or something like that in stead. The best place to place the pump during a game seems to be under my arm, so maybe I can just slip it into my sports bra without any clip or other things to hold. I will try it out and see what will work the best.

To eliminate the BG drop that I tend to see in the late afternoon/around dinner, we decided to start with a reduction in my basal during these hours. If this doesn't work we will take a look at the insulin-carb ratio. Alice pointed out that most people, especially doctors - and mine is no exception - refuses to believe that 0.05 U changes can make any differences, but her experience with pumping tells her they certainly do. She encouraged be to make such a reduction in all the basals, if not now then when I had gotten the around-dinner-hypos under control. She had also seen my last A1C and didn't fail to comment upon that ;-) (remember, she would like to increase it to 6.0 %).

Fairly good BGs

The last couple of weeks have been fairly good BG-wise. The majority of my readings have been in target, and the outliers haven't been that far out. I have only had a few low lows (below 2.9 (52)), but I still have a fair amount of readings in the 3.0-4.0 (54-72) interval that I would like loose. I can just accept such readings if they are fasting, first-thing-in-the-morning readings, but they usually aren't. Rather, they seem to cluster in the hours around dinner.

My last HbA1C (3 weeks ago) was 5.7 %, and I would actually have been happy with that if it wasn't because I know that it covers the severe rollercoaster rides that my BG has taken in the 3 months that I have been trying to adjust to pumping. The aim for even testing pump therapy was actually to even out the swings and reducing the number of lows to eventually increase my A1C to 6.0 %. In these months I have had more readings above 15.0 (270) and certainly many more below 2.0 (36) than I can ever remember having in such a short period of time when on injections, at least when using Lantus. I have had two episodes of severe hypoglycemia where I lost track of my actions and needed help from others. Of course I had times of erratic control when on injections, especially the last couple of years that I used Insulatard (NPH) as the basal insulin, but compared to the 2.5 years using Lantus before trying out the pump, I sort of feel that the change to the pump has been a change to the worse. Or at least a change with MANY issues to be solved before being the advantage it was meant to.

I have an appointment with Alice, my diabetes nurse, on wednesday and before that I am trying to write down all the pros and cons of the pump that I can think of. So far the cons lead (12 to 7), although I have a feeling that in the end it will be rather close. I think that I will constantly find new advantages and disadvantages as long as I use the pump, so for now I am just trying to get an overview. In the meantime I hope that Alice will have the time to go through my readings with me. I think that I see a few pattern here and there, and I would like her evaluation of these as well as any suggestions on how to avoid them.

I have a feeling that either I will have to change the settings of my insulin-carb ratio in the afternoon and possibly early evening, or I will have to enter less carbs than I am actually going to eat in order to avoid all the readings below 4.0 that I tend to see at this time of day. It is a bit difficult to figure out though, because I can have a reading of, say, 6.2 (112) mid afternoon at the time where I usually have a snack to keep hunger away until dinner. If I then test 1-2 h after the snack, before I head home from work, I may be at 7.8 (140), which would actually suggest that the carb and insulin calculations are ok, but another 1-2 h later, before dinner, I am likely to be below 4.0 (70). I do have a 9 km bike ride home between the last two reading, and this of course is also likely involved in this drop, but I don't really know how to get about it. I have heard that reducing the basal rates doesn't really have an effect untill an hour later, but I haven't played with that yet. In general I haven't been good at remembering and using the possibility of reduced basal rates when I bike (I also like to go for longer bike rides just for the exercise and fun of it). Maybe it is because I haven't been use to having to speculate too much about adjusting insulin for biking when I was on injections. I would usually only reduce my dinner bolus in the summer because I usually go for my bike rides after dinner. Only rarely have I had to also reduce the basal dose during summer, and when it was needed, only 1 u was cut off. So in order to get as much benefit of the pump as it enables you to, I guess I have to change my way of thinking from the conventional MDI-linked way of action to the CSII one.

Grrr.....!!!

Yesterday, on my way home from work, I suddenly had a flad rear tyre on my bike. At the time I was about 4.5 km from home, travelling at 30 km/h. Fortunately, I didn't crash when my rear wheel suddenly started to "jump around" unabling me to control the bike properly.

Now, a flat tyre can happen, and I probably wouldn't have been so surprised and a bit angry if it wasn't because I, back in November after my first puncture on this new bike, got a special tyre with 1-year guarantee against punctures mounted. I use my bike a lot, and a couple of years ago, when I went to my preveous bike shop for different repairs on my old bike, I asked for the best tyres he could think of to avoid the annoyance of standing with a flad tyred bike. He recommented these special ones, telling me that he had had costumers using the same tyres for several years without any punctures. I couldn't really believe that to be true as the tyres I had on the bike at that time were kevlar tyres that were also supposed to be puncture-free - something they were clearly not. However, I followed his advise, and actually rode on those tyres for almost 2 years without any punctures whatsoever. At the end, the tyres were so worn down the wearing face was almost completely gone. Now I believed in the quality of those tyres!

So, when I bought my present bike last fall, I asked for these tyres again. I was told that the ones mounted on the bike was just as good, but of course I could come in if I had a flad tyre, and have them changed. I had that flad tyre within the first month! Thus, at the first check-up of the bike I asked to get a new hose and one of these special tyres for the rear wheel - I figured I could go a bit longer on the front wheel without having that one changed. Now, yesterday it was my rear wheel that had the puncture so I immediately called the bike shop, telling them that I would have to repair the hose and hand them the bike the next day to have this issue fixed. When I got home and started looking for the injury in the hose, I realized that the bike shop had reused the old hose, because it had the patch on it from my initial repair back in November! It turned out that this old injury was actually the cause of this new puncture, because the initially small hole that was readily covered by a patch had somehow expanded to a 2 cm cut in the hose! I could see that when lifting the old patch. It was difficult to patch up because I didn't have a patch big enough to cover the cut, so i had to put a new patch on top of the old one, and the new patch really wasn't big enough for this either, so I didn't trust this repair to retain its position. Sure enough! This morning I had to stop 7 times on my way to work to inflate the tyre. Grrr.....!!!!

When I handed the bike into the bike shop, he fortunately took care of it in half an hour, but I still had to pay the labour cost of him putting in a new hose. He inspected the tyre, and just as I didn't find any holes in that yesterday, he didn't either, so hopefully it will last untill I have the 1-year check-up on the bike next November. At that time I think the tyre will be so worn down that it will not be safe not to replace it.