Injecting in more than 1 site and impact on absorption rate

[rebrascora]

,@rebrascora isn't that particular to Fiasp?

Apologies Patti. Only just seen this comment.
I believe that insulin resistance does increase with higher BG levels regardless of the insulin you are using. I certainly find that Fiasp turns into a bit of a wimp when faced with a tall opponent (high BG 🙄 ) but it is so long since I used NR and of course my body has changed since then (honeymoon period has ended I think) that I can't remember/don't know if NR would act similarly poorly but perhaps not so extremely as Fiasp to high BG levels.

It was the 7u I thought of too - I think there’s a suggestion that for larger single doses it’s possible for the absorption to be less reliable, and that some units may ‘go missing’.

I had half a thought it might be John ‘Using Insulin’ Walsh who said something similar, but I might be completely wrong!

Is that 7 bolus units or just 7 units of any insulin? .... Just thinking I may need to grow another buttock to accommodate a third injection for my basal
I know you guys on pumps don't inject basal but all your insulin goes into the one site and I imagine you occasionally bolus more than 7 units and clearly no option to change sites unless you get a pen out and supplement.....
Obviously there are also people with insulin resistance who inject much larger doses and it would not be practical for them to split it into that many injections, so just wondering if there is any real use in that information. I know Berstein's approach is low carb so it would be another good "reason" to follow his "teaching".
It was my own reasoning which caused me to split my large basal dose in two, but just interesting to know that someone other than Bernstein also sees this as a "real" potential issue and if there has been any studies on it or if it is mostly anecdotal. I would guess that the more insulin you inject into what is, essentially, a mildly pressurized system (the human body), then there is the potential for some to be squeezed or leak back out as the needle is removed, especially if there is a bit of bleeding and of course, the dose is larger. It just seems logical but with so many things affecting BG levels I imagine it would be pretty difficult to assess it's impact, with no 2 injections having the exact same outcome, even when the dose is the same. Maybe ignorance is bliss sometimes!

 

[PattiEvans]

I believe that insulin resistance does increase with higher BG levels regardless of the insulin you are using. I certainly find that Fiasp turns into a bit of a wimp when faced with a tall opponent (high BG 🙄 ) but it is so long since I used NR and of course my body has changed since then (honeymoon period has ended I think) that I can't remember/don't know if NR would act similarly poorly but perhaps not so extremely as Fiasp to high BG levels.

I'm not talking from personal experience, but having been around this and other forums for so long I'm quoting anecdotal information from a fairly large number of people that Fiasp "turns to water" with higher level corrections. However, it is reputedly so much quicker than Novorapid which is actually very slow, that I wonder if you could adopt your approach of multiple small corrections using the slower insulins.

 

[rebrascora]

I'm not talking from personal experience, but having been around this and other forums for so long I'm quoting anecdotal information from a fairly large number of people that Fiasp "turns to water" with higher level corrections. However, it is reputedly so much quicker than Novorapid which is actually very slow, that I wonder if you could adopt your approach of multiple small corrections using the slower insulins.

Yes, that was the main reason I went back to trial Fiasp a second time, despite my first 3 month trial frustrations. It is the corrections which are so important for me with my diabetes management system but Fiasp clearly didn't respond as well as I had hoped on that front until I got really frustrated and consequently "heavy handed" with it. I still hesitate every time I do a correction and usually add an extra little bit (half or one unit extra) to the correction I intend to make because I still resist needing so much insulin at levels which are essentially not that high (8-10) and then I reason that I would rather over egg it and need to eat a JB later to carefully land my BG where I want it, as need to stick another needle in myself to bring it down a bit more. I do see it quite like "piloting" my levels up and down to get it to the altitude where I want it.

I should also say I really dislike the term "Sugar surfing" as I think it feeds into the whole diabetes "Sugar" misconception, but I use it because it is a recognized conception.

 

[everydayupsanddowns]

Is that 7 bolus units or just 7 units of any insulin? .... Just thinking I may need to grow another buttock to accommodate a third injection for my basal

Ah yes weirdly I never worried so much about basal injections. Something to do with Lantus making a reservoir of crystals when its acidity normalises kinda felt like it was exempt!?

I still try to aim for 7-8u boluses, as a rule of thumb, and often this works well as a maximum part of a split / dual wave / combo on the pump too 🙂

 

[Bruce Stephens]

Is that 7 bolus units or just 7 units of any insulin?

I must admit I'm skeptical that this is a significant factor. If it were, surely we'd all be told about it (and our smart pens would all be calibrated to a maximum of 10 units a go (and would recommend splitting doses, whereas currently they recommend against doing that))?

A quick search shows me information on splitting doses for large meals and things (so splitting across time), and splitting basal doses and mixed insulins, again both across time. And https://www.healio.com/news/endocri...g-in-two-sites-improved-blood-glucose-control which looks like more extreme cases (people who need >60 unit doses in regions where U500(!) insulins aren't available).

I didn't see anything that would be relevant to me possibly injecting my 22 unit day time Levemir in a single dose, or a 16u Novorapid in one go. (Maybe I'm missing it, of course.)

 

[PattiEvans]

I know you guys on pumps don't inject basal but all your insulin goes into the one site and I imagine you occasionally bolus more than 7 units and clearly no option to change sites unless you get a pen out and supplement.....

The thing is that on a pump you need much less insulin because of the way it is delivered. e.g. I was using 28u total Levemir as a rule, whereas on a pump I am only using 9.6u basal per 24 hours. My TDD is less than 20u daily (usually 17 or 18u whereas it was in the high 40s on injections.

I must admit I'm skeptical that this is a significant factor. If it were, surely we'd all be told about it (and our smart pens would all be calibrated to a maximum of 10 units a go (and would recommend splitting doses, whereas currently they recommend against doing that))?

Probably because they are ultra conservative Bruce. They are still horrified by bolussing ahead and yet many of us do it and know it works.

 

[helli]

,@rebrascora isn't that particular to Fiasp?

There are two things to consider with regards to insulin resistance: needing a higher dose of insulin and the time it takes to work.
In my experience, it is my body that needs the extra dose but Fiasp that takes the extra time. This is based on my observations with Humalog, NovoRapid and Fiasp.

 

[nonethewiser]

Apologies Patti. Only just seen this comment.
I believe that insulin resistance does increase with higher BG levels regardless of the insulin you are using. I certainly find that Fiasp turns into a bit of a wimp when faced with a tall opponent (high BG 🙄 ) but it is so long since I used NR and of course my body has changed since then (honeymoon period has ended I think) that I can't remember/don't know if NR would act similarly poorly but perhaps not so extremely as Fiasp to high BG levels.


Is that 7 bolus units or just 7 units of any insulin? .... Just thinking I may need to grow another buttock to accommodate a third injection for my basal
I know you guys on pumps don't inject basal but all your insulin goes into the one site and I imagine you occasionally bolus more than 7 units and clearly no option to change sites unless you get a pen out and supplement.....
Obviously there are also people with insulin resistance who inject much larger doses and it would not be practical for them to split it into that many injections, so just wondering if there is any real use in that information. I know Berstein's approach is low carb so it would be another good "reason" to follow his "teaching".
It was my own reasoning which caused me to split my large basal dose in two, but just interesting to know that someone other than Bernstein also sees this as a "real" potential issue and if there has been any studies on it or if it is mostly anecdotal. I would guess that the more insulin you inject into what is, essentially, a mildly pressurized system (the human body), then there is the potential for some to be squeezed or leak back out as the needle is removed, especially if there is a bit of bleeding and of course, the dose is larger. It just seems logical but with so many things affecting BG levels I imagine it would be pretty difficult to assess it's impact, with no 2 injections having the exact same outcome, even when the dose is the same. Maybe ignorance is bliss sometimes!

It's long time ago when consultant suggested using split dose, we were talking then about basal dose at time, lantus in fact.

As Mike says above, on pump most high bolus doses are split anyway, some upfront rest delivered over few hours, this is why pumps are so great that you can do this for meals that are high carb high fat high protein or combination of all 3.

Like on injections you do have to rotate sites as they do become skanky, currently my pod on side & more round my back.

 

[Bruce Stephens]

They are still horrified by bolussing ahead and yet many of us do it and know it works.

You're being unfair, there. My DSNs were certainly not against pre-bolus, and if I do a quick search on Google for "pre-bolusing" I get lots of hits about that on sites I think look believable. I've not looked specifically for research on it but I'd say it's mainstream by now and I'd expect to find some research if I looked. Here's one, for example: https://integrateddiabetes.com/prebolusing-improves-a1c/

For splitting doses (apart from the exceptions I noted)? Nothing.

 

[rebrascora]

I think many HCPs believe the blurb (rep information) about insulins, particularly the newer ones and will tell patients that "Fiasp" or Lyumjev" or whatever, don't need prebolusing because they act so quickly, when for many of us they still do. I think the problem with clinical advice is that it is based on theory and in practice things are very different for all of us. Whilst they will generally advise people to prebolus it is usually 10-20mins and certainly no more than 30mins, when in practice there are people who need considerably more, especially at breakfast time.
I think that this is one of the areas where hopefully Libre can change clinicians understanding of the variation of different patients' experiences and hopefully they will be a bit more flexible or tailored in their advice or at least encourage patients to cautiously experiment to find what works for them, rather than give guidance which can sometimes feel like the 10 commandments.... "Thou shalt not stack insulin!" and put the fear of God into people to prevent them even trying it or understanding why it can be dangerous but doesn't have to be. That sort of thing.. 🙄

 

[Bruce Stephens]

Whilst they will generally advise people to prebolus it is usually 10-20mins and certainly no more than 30mins,

Yes, I can believe that. I'm pretty sure my DSNs would recommend the same, but when presented with personal evidence they'd be fine with longer periods. For safety you wouldn't want to recommend longer periods generally, similarly with stacking insulin: as a general principle it's good to avoid such things, and be careful when you do do them.