Bloody pen!

[Becka]

Did my morning injection (right thigh) and when the pen came out there was a rich looking dollop of blood behind it. But then I noticed this:



A search for advice reveals that it is impossible to draw in blood as pens do not aspirate, but also that if the remains clear it is safe to use. But since taking that photo the blood drop seems to have disappeared, and it looks perfectly normal that you would have never known it was there. Anyone have any different advice. Part of me think throw it anyway to be safe, and part of me already hates the amount of plastic waste of throwing out empty ones.

At least I feel fine. After the recent thread about how glargine works, that injecting into a blood vessel prevents the formation of crystal to allow slow release, I have been waiting anxiously with a carton of juice just in case.

 

[rebrascora]

Personally that tiny drop of blood would not concern me in the slightest and I would be quite surprised if it didn't disperse. I wouldn't consider ditching a pen just because a drop of blood somehow managed to find it's way up the needle and into the cartridge.... but then I don't worry about best before dates on foods etc. I use my own judgement. Everyone is different, so go with what you feel comfortable doing, but I don't think it can be a health hazard.

 

[Becka]

I think it is just concern about anything interfering with the release action which makes me hesitant. I must have hit a vessel for it to get in there, but that does not seem to have caused any dangerous effects so I will keep using it and see how it goes.

Thanks.

 

[helli]

If the plastic waste is a concern, do you use reusable pens?
They are more robust than the single use ones, the cartridges take up much less space in your fridge and there is fat less plastic to throw away when you finish a cartridge so much better on the environment.
Reusable pens are definitely available for NovoRapid (I used them all the time until I migrated to a pump) and I believe they are available for Levemir.

 

[Ljc]

Tbh if I spotted anything wrong with my insulin I would not use that pen/cartridge in case of contamination

 

[trophywench]

What happens very occasionally accidentally when injecting insulin, is actually going straight through a teeny tiny thread vein in the skin and out the other side into the interstitial layer where you deliver the insulin, rather than actually 'injecting into a vein'.

Yep - re usable pens for both Novo and Lev - same manufacturer, same pens which come in different colours - I used red for Novo and blue for Lev. The ones that are still stashed away in a bedroom drawer since 2011 are metal; previous ones were plastic.

 

[Becka]

Would it not need to be in the vein to draw blood though? If any gets caught on the needle going in the release of insulin would push it away, so I assumed drawing any in would occur after releasing the button when the pressure changes. Although I suppose the pressure changes when releasing too, so maybe I have that back to front?

Anyway, my prescription is for disposable pens. I have an appointment with the nurse next week to review how things are going, but unfortunately it is still going to be by telephone rather than in person which makes it a lot more difficult for me. I already want to raise concerns about weight gain, which seems to be a common issue with glargine specifically; the limited flexibility of a 24 hour insulin which is only barely helped by me splitting it into twice daily doses; and just wanting to know what they think the situation is with my diabetes anyway, and so why this particular treatment (as I have discussed on the forum plenty of times before).

Being ignored so many times before and it having taken so much effort to have reached this point, I do not feel comfortable making a fuss yet. And I am pretty sure they still class it as type 2, which I think means they only prescribe disposable pens (you can get Abasaglar in cartridges too). But as my HbA1c will almost certainly have gone down to an acceptable level, what will likely happen is the nurse will say everything looks good, and that will be that.

 

[helli]

Anyway, my prescription is for disposable pens. I have an appointment with the nurse next week to review how things are going

I know others have had their prescriptions changed to reusable pens.
Your appointment with your nurse is the ideal time to make the request. I see no reason why your type of diabetes should make any difference to whether you are more environmentally friendly or not.

If you are able to get your prescription changed, don't forget to request spare pens as they do fail.

The time with the nurse is YOUR time so you should not be made to feel too uncomfortable to ask questions or make a request. Your nurse is not doing a good job if you are unable to talk to her.

Hope your appointment goes well ... or not too bad.

 

[Becka]

I do not know how widespread it is, but I have definitely read that for some C.C.G.s it is not their normal prescribing practice for type 2. I guess there must be an attitude that type 2s bring it on themselves? Just like how someone with type 1 can qualify for C.G.M. but a person with type 2 on the same regimen with the same hypo awareness and risk would not. But while I do not know what the local policies are, my experience with their diabetes service has given me little confidence in them.

 

[Lucyr]

I do not know how widespread it is, but I have definitely read that for some C.C.G.s it is not their normal prescribing practice for type 2. I guess there must be an attitude that type 2s bring it on themselves? Just like how someone with type 1 can qualify for C.G.M. but a person with type 2 on the same regimen with the same hypo awareness and risk would not. But while I do not know what the local policies are, my experience with their diabetes service has given me little confidence in them.

I’m type 2 and use a reuseable half unit pen for my rapid acting insulin and have done for about 10 years. I use disposables for my lantus out of personal preference. I didn’t think there’s much difference in price and the reusable pens have a much nicer look and feel more solid, plus I like the accuracy of half u it’s. Some pens have a memory too for other insulin brands which sounds handy.

 

[Becka]

I will see what they say if I am able to get that far down my list of topics, but I am not optimistic that they will be one of the better C.C.G.s.

 

[Lucyr]

I will see what they say if I am able to get that far down my list of topics, but I am not optimistic that they will be one of the better C.C.G.s.

Reusable pens aren’t specified as something T2s can’t have so should be fine hopefully 🙂

 

[Becka]

Finished the bloodied pen okay, and so now it is waiting to fill the land for centuries to come. Yay! On a complete tangent, it was the last of the French pens (these days most things from my local pharmacy are parallel distributed E.U. stock) so now I am back on a German one. It surely has to be just a coincidence, but the action is so much smoother with the German pens that after two boxes of French ones I forgot how much easier they are to use.

Anyway, I have been making my notes for tomorrow's telephone appointment with the nurse and it has left me with a "I cannot do this" feeling. It might be easier just to ask if I can send a letter with everything in it, as that is far easier for me. Partly as it is just overwhelming, but I am not sure how to properly put how inflexible it feels into words rather than just pointing to a load of numbers.

So below are my notes, if anyone has any advice or comments on whether they seem reasonable?

Although if they seem long, they are only meant to be notes rather than it all needing saying. So just for referring to as required and to not forget anything. Had it been in person I would have printed it out to take too. Yet despite that, I feel like it is not enough as it is dry and does not include how any of it makes me feel, which is not particularly good. (Though one line on it is mainly to remind myself, if it should come up, to explain about how angry I still am with them and my lack of trust.)

WEIGHT GAIN

Weight never not changed much despite diabetes since before diagnosis (HbA1c 11.2% (99))​

Including taking gliclazide (as low as 5.0% (31)) and after it stopped working (9.3% (78) with Sitagliptin added)​

Did increase when taking steroids due to PsA which was not lost​

Has noticeably increased since starting insulin despite days without eating and otherwise mainly one proper meal a day​

INFLEXIBILITY

Because insulin lasts 24 hours I find I have to work around it​

Cannot react as a situation today was not known about when taken previous evening​

Too low readings, no appetite, other situation makes me feel compelled to eat more to counteract insulin​

And reducing insulin because of how I felt at the time may be different tomorrow / later​

Too high readings or a little higher having reduced dose make me feel I cannot eat​

​

To stay within D.V.L.A. requirements concerned about taking full dose before riding my bike​

First few times reduced evening dose (34u to 10u and 17u) but woke as 6.9 and 7.8​

However when waking as 4.5 (17u) skipped completely time after and woke as 12.1​

​

Decided to split dose to 10pm and 10am so will always have full dose when waking but can adjust morning dose if riding​

Only ridden twice since but helped both times, waking as 5.8 and 6.9​

Took full dose, though eating during day to keep levels up created evening fasting readings (at eat 4h) of 9.2 and 6.8​

Reducing or skipping morning dose obviously leads to higher evening readings​

So still leaves me hesitant whether to to not eat or inject​

​

Third to half of morning readings still over target of under 6, but increasingly hesitant at increasing dose as average is close to 6​

Last increase to 38u (as 18+20u) on May 11th after run of 6.1, 4.6, 8.4, 10.6, 6.7.​

DO NOT UNDERSTAND DIAGNOSIS / PURPOSE

DIAGNOSIS​

​

Had trouble accessing G.P. help when sheilding so sought advice from Diabetes U.K. site about Gliclaizde stopping working​

LADA type diabetes was suggested, and to ask G.P. for C-Peptide test when shielding ends​

Understanding was C-Peptide result showed I only produced fasting insulin levels despite 12h fasting glucose level of 11.1​

HbA1c a same time was 9.3% (78) with two medications​

Impression was this suggested LADA type so referred to diabetes service​

Where C-peptide result was ignored, told to resume Gliclazide, prescribed Dapagliflozin when refused​

Leaves me unclear of situation with my diabetes​

PURPOSE​

​

My understanding is that my levels rise after eating then drop slowly​

This was shown by testing (fell to normal levels when not eating, otherwise in double digits) and consistent with C-peptide result​

But prescribed a 24 hour insulin even though my understanding is I produce enough insulin for between meals​

Normally eat in evening, not much during day, but with an afternoon meal instead the evening fasting (at least 4h) still reads 8–12​

PLASTIC WASTE

Pens not recyclable​

Uncomfortable with throwing away every week, which is already in addition to needles and lancets (mostly avoiding landfill)​

I am expecting my HbA1c to be somewhere around 6.8% / 51, and so being told everything is good and just to carry on. In which case, if there is nothing the nurse wants to discuss, I will probably just ask if I can send my concerns in a letter.

 

[Lucyr]

It looks like you have good points prepared to raise, I’d probably consider starting with what you want to change though. Is it that you would like to start a mealtime insulin? I’d probably go straight in with “I’d like to discuss starting a meal time insulin, changing to reusable pens, and xyz” at the start of the appointment, then they know what you want to discuss within the time available, and start with the highest priority.

 

[CivicFreak]

Did my morning injection (right thigh) and when the pen came out there was a rich looking dollop of blood behind it. But then I noticed this:

View attachment 17055

A search for advice reveals that it is impossible to draw in blood as pens do not aspirate, but also that if the remains clear it is safe to use. But since taking that photo the blood drop seems to have disappeared, and it looks perfectly normal that you would have never known it was there. Anyone have any different advice. Part of me think throw it anyway to be safe, and part of me already hates the amount of plastic waste of throwing out empty ones.

At least I feel fine. After the recent thread about how glargine works, that injecting into a blood vessel prevents the formation of crystal to allow slow release, I have been waiting anxiously with a carton of juice just in case.

This happened to me once with my Tresiba. It was a bit of a shock to see at first. As with you, the blood dispersed and if I hadn't spotted the blood drop initially I would never have known it was even there. I was concerned about the contamination of the insulin, so I asked around a few forums, and people I knew that had also experienced a similar thing. The consensus I got was that it wouldn't cause you any harm, so contamination wouldn't be an issue, but as there was now an extra amount of fluid in the pen this would affect the dosing. As such - and especially with me being fairly new to insulin, I decided to throw the pen away and start with a fresh one. I would suspect the impact on the dosing would be extremely minimal though.

This has so far only happened once, but does seem like a bit of a freak occurrence. I wasn't sure if my technique had anything to do with it though, as I used to press the button, wait a few seconds, then let go of the button before I withdrew the pen. I now keep the button pressed down until I have removed the pen entirely from my body. Not sure if this makes a difference or not tbh.

 

[Becka]

It looks like you have good points prepared to raise, I’d probably consider starting with what you want to change though. Is it that you would like to start a mealtime insulin? I’d probably go straight in with “I’d like to discuss starting a meal time insulin, changing to reusable pens, and xyz” at the start of the appointment, then they know what you want to discuss within the time available, and start with the highest priority.

Thank you. The problem is I do not know what I want to happen! There may be a good reason for what they are doing, but it is not being able to understand it and why that makes me feel distressed about it all.

Following the blood tests I thought it all made sense, but the way they are treating it makes me think I must have got that wrong. So it might be that for my situation there is no better flexibility and I just need to learn to live with it.

The call should be before 1:30pm, so I am just sitting here anxiously waiting.

 

[Becka]

This has so far only happened once, but does seem like a bit of a freak occurrence. I wasn't sure if my technique had anything to do with it though, as I used to press the button, wait a few seconds, then let go of the button before I withdrew the pen. I now keep the button pressed down until I have removed the pen entirely from my body. Not sure if this makes a difference or not tbh.

I have been holding it down but then releasing and waiting a second before withdrawing. As this was the first time, and it left a pool of blood on my skin before seeing the pen, I do not think that was a problem per se. More just being unfortunate and catching a blood vessel.

It has made me more observant that it does seem to be when releasing the button when priming that draws air in. Maybe though only the first time when the needle is still empty, so it sucks that air back in, whereas if it had insulin inside it that would get pulled back instead?

The instructions do not say to prime with a different number of units the first time using a pen, but I go through two or three goes at 2u before anything comes out. Maybe it should be a greater number to ensure insulin in the needle before letting it draw back? What do other people do?

 

[Gyles77]

I always fearful about talking injection. But I love to take medicine if needed.

 

[Becka]

I am prescribed nine tablets, from which I have to take sixteen every day, plus a painkiller and two gels to use as required. I assume the diabetes ones will eventually stop being effective, as with the Gliclazide, but the others I guess are for the rest of my life. And one of those requires fortnightly blood tests.

So my relationship with taking medicine is not one of love! Having to inject insulin was not a problem though after all those blood tests. I actually wish I could be taught to collect my own bloods as it would make things so much easier. And to be honest, I think I prefer the higher glucose levels if nothing can stop the insulin's weight gain with neither of which being particularly good long term.

 

[Becka]

So I have spoken to the nurse, and it sort-of went the exact opposite of what I expected.

My HbA1c is down to 6.5% / 48 mmol/mol, I have only put on 1Kg since I was weighed in December, and despite all that the nurse agreed I am on the wrong regimen!

I was so confused by those numbers, and in having to explain about splitting my dose, meant I brought up all my main talking points. Although I never got to the issue of plastic waste as it would be redundant if my prescription is changing anyway.

Although afterwards I realized I made a mistake with my HbA1c expectation. I forgot that though it covered two months of taking insulin, it started when titrating from 10u rather than my usual dose. I have not been that low since 2017! After that things started creeping up, which in hindsight is presumably when my pancreatic output started going down.

But the weight is very confusing. I feel so much bigger yet it has only gone up 2lbs, so maybe that says something about my perception? My clothes do still fit, but I would swear they no longer do so as well as they used to. Will need time to process this.

Anyway, the nurse felt I should be on either a twice-a-day insulin or multi-dose regimen, although she could not help clarify what my diabetes actually is. But I now have an in-person appointment next month where there will be a consultant who can review things. So hopefully I can get confirmation then, as well as find out what my new prescription will be.

After all the problems I have had trying to get help over the last sixteen months, the only times things have seemed positive is when the diabetic nurses have been making the decisions.