Insulin apparently "going off"?

[Greyman]

I've been a reasonably controlled type 1 diabetic for almost 40 years and have benefitted, for the past few years, from a CGM device.

Something I've noticed over the past year or so, is that I get occasional runs of higher readings and that these come out of the blue and often coincide with me loading the fifth and final Fiasp cartridge in the box. Switching this cartridge out, for a cartridge from a new box will invariably bring those readings down.

After this had happened a couple of times, I paid particular attention to the temperatures in my refrigerator, with an electronic thermometer sensor right next to my insulin and they seemed to always be in range. I did get a rather dismissive response from the pharmacy, when I mentioned this, but on a recent visit to my pharmacy, perhaps a little sooner after I had asked for the prescription than usual, they had to fetch the insulin out of a delivery crate "in the back" and the box felt nowhere near as cold to the touch as it should. I've just got to the final cartridge of the previous box and my readings have climbed yet again, with corrective injections not appearing to act as fast or as effectively as they normally do. Let's say I won't be too surprised if the same thing happens when I get to the end of the latest "warm" box.

Given the recent warm temperatures, this did get me wondering about how long the box would need to be left out of the refrigerator, before the life, speed and effectiveness of the insulin would be compromised? Oh, I've not noticed anything significant with my basal insulin, Tresiba, but that might just be longer lasting?

Has anyone else experienced anything similar?

I might just have to switch pharmacies and see if things improve.

 

[PhoebeC]

Haven't noticed anything similar. It is a month at normal (out of fridge) temperatures so I suppose if their back of the fridge is not at the right level this may then be consider "out of the fridge" and it would need to be used within the month. However this month is likely a guideline, I don't imagine that on the exact date a month later it suddenly goes bad. But if you have noticed this trend its worth keeping an eye. Could it be any other factor?

 

[Natalie123]

I use Fiasp too but I've never noticed a problem. I use vials and they are usually out of the fridge while I am using them for about a week, maybe up to 10 days and they don't go off in that time.

I am wondering where in the fridge you are keeping your insulin? I know you are using a thermometer which probably means it's fine, but if the insulin gets pushed against the back or side of the fridge it may get colder than the air temperature that the thermometer is measuring. I keep mine in the fridge door with the milk, that way it can't get accidentally moved! Do you share the fridge with anyone? Might they have moved your insulin and then moved it back (not on purpose obviously, but if they don't know much about insulin then they might not know how important temperature is)?

That being said, you've obviously noticed a pattern which does imply that something is going wrong with that last cartridge. If changing pharmacy puts your mind at rest, give it a try. Or could you ask your GP to prescribe 4 cartridges instead of 5 at a time and you can order them more often?

 

[helli]

Or could you ask your GP to prescribe 4 cartridges instead of 5 at a time and you can order them more often?

That would require the pharmacist to share a partial pack which they tend to be reluctant to do.

 

[Greyman]

There could be another factor(s) and I might well be guilty of a bit of confirmation bias, but these runs of high readings do seem to coincide with the last cartridge and changing it to the first one, from a new box, seems to fix it. The word "seem(s)" here is possibly does indicate a lack in a clear correlation, so I'll see if I can build more evidence for any future incidents, using my CGM/finger-prick test readings history.

My life has a pretty regular routine, with at least breakfast and lunch being pretty constant, insulin dosages not moving too much and similar levels of daily exercise. It is therefore quite unusual and noticeable for the readings to suddenly climb.

My Fiasp dosages tend to make the pen last about a week, out of the fridge and not all boxes are affected, but I've now had probably around half a dozen boxes that apparently have had apparent issues with the last cartridge. I store my insulin in the fridge door too, by the way, and the temperatures do appear to be reasonably stable and well within the 2-8C range, recommended for the insulin and normally 4-6C.

I've seen the "28 day, out of the fridge at room temperature" manufacturers recommendations, but what really adds to my doubts is the fact that the pharmacy, probably like most if not all others, now seem to get their prescriptions filled by a third party. I've seen transit vans pulling up outside the pharmacy and the driver bringing in a van full of boxes, presumably with some items that need to be stored chilled. If those containers have spent a lengthy time in the back of a non-refrigerated van, particularly on hot sunny days like the ones we've seen recently, and then left in a back room of the pharmacy, before being put into a fridge, temperatures well above room temperature might have been reached.

Thanks for the replies.

I'll have another word with my pharmacist and see if I can get any reassurance.

 

[PhoebeC]

There could be another factor(s) and I might well be guilty of a bit of confirmation bias, but these runs of high readings do seem to coincide with the last cartridge and changing it to the first one, from a new box, seems to fix it. The word "seem(s)" here is possibly does indicate a lack in a clear correlation, so I'll see if I can build more evidence for any future incidents, using my CGM/finger-prick test readings history.

My life has a pretty regular routine, with at least breakfast and lunch being pretty constant, insulin dosages not moving too much and similar levels of daily exercise. It is therefore quite unusual and noticeable for the readings to suddenly climb.

My Fiasp dosages tend to make the pen last about a week, out of the fridge and not all boxes are affected, but I've now had probably around half a dozen boxes that apparently have had apparent issues with the last cartridge. I store my insulin in the fridge door too, by the way, and the temperatures do appear to be reasonably stable and well within the 2-8C range, recommended for the insulin and normally 4-6C.

I've seen the "28 day, out of the fridge at room temperature" manufacturers recommendations, but what really adds to my doubts is the fact that the pharmacy, probably like most if not all others, now seem to get their prescriptions filled by a third party. I've seen transit vans pulling up outside the pharmacy and the driver bringing in a van full of boxes, presumably with some items that need to be stored chilled. If those containers have spent a lengthy time in the back of a non-refrigerated van, particularly on hot sunny days like the ones we've seen recently, and then left in a back room of the pharmacy, before being put into a fridge, temperatures well above room temperature might have been reached.

My prescriptions come from Pharmacy2U via royal mail. This is normally okay, I have had 1 delivered to another street, she brought it round within a few hours of delivery and the cold packs in it where still cold as was the insulin.

My last box I had the delivery message from royal mail "Delivery Attempted - Address Inaccessible". When it arrived the next day the cold packs where no longer cold, the insulin was room temperate, I did put them into the fridge and I have used these bottles first. I have treated this insulin as out of the fridge while being in there, I am on the second bottle now of 3, it was delivered on 30th May, not sure the 3rd bottle will be useable, but also it cannot be used by anyone else or returned. Will see how it goes, I plan to still use it and as soon as it seems to be misbehaving I will change the insulin.

Hope you work it out and get it sorted.

 

[Sally71]

I think the month out of the fridge only means time actually out of the fridge, so if you leave it out of the fridge for a week but then put it back in again the clock stops and you’ve still got 3 weeks left after you take it out again. So if you are unsure whether insulin has been out of the fridge for long on its way to you, but is working fine, then you can safely assume that others from the same batch which you have now put in the fridge will still be ok whenever you come to use them. Up to the expiry date of course. Even then, I think the 28 days rule is only a guideline so you may get away with longer (i.e. they can’t guarantee that it will last longer than that but it might)

 

[Greyman]

I think the month out of the fridge only means time actually out of the fridge, so if you leave it out of the fridge for a week but then put it back in again the clock stops and you’ve still got 3 weeks left after you take it out again. So if you are unsure whether insulin has been out of the fridge for long on its way to you, but is working fine, then you can safely assume that others from the same batch which you have now put in the fridge will still be ok whenever you come to use them. Up to the expiry date of course. Even then, I think the 28 days rule is only a guideline so you may get away with longer (i.e. they can’t guarantee that it will last longer than that but it might)

Yes, my concern was that any time at a perhaps way elevated temperature might just reduce the effective life of the insulin in the 5 cartridges in the box and as the final one will have spent the longest time in the box, that would be the one most likely to cross that potentially limited lifespan.

It might well be that there is another, coincidental, reason for my so-far unexplained increases in readings, so I was interested to hear if anyone else might have experienced anything similar. I'll pay more attention to potential other factors, as and when it happens again, but I can't get away from the fact that switching to a new cartridge seems to correct the apparently slower and less-impactful effects of the older cartridge.

 

[trophywench]

Well, it has been 'silly hot' where we live (near Coventry) and more so this last week on a rally (near Telford) until yesterday when we came home again but a bit like 1976 the heatwave seems to be over and we've also mostly had some quite stiff breezes so even the times when they were warm breezes, I didn't actually feel stifled for very long periods.

 

[helli]

While I know the "time out of the fridge" is a month, I have found that Fiasp starts to "fade" earlier if left out of the fridge.
I use a pump so fill from a vial.
A pump change from a new vial is more "powerful" than a pump change from an older vial.

 

[trophywench]

@Greyman - dunno how long you've had T1, but this January I had a new insulin pump. I had to because I had one they decided to stop making so although mine didn't instantly completely die once it reached 'replacement date' (some of them do, or did, years ago) the dear ole NHS asked me what new one I'd like, saying that if I decided on a certain make, it was the only one I could have very soon. I could have almost any one, but it would take longer was all.
Just weirdly, (cos frankly I've never been quite so easily satisfied!) I was all but decided on that very pump! - if I'd got to learn to operate entirely new to me technology aged 74 well blow it then - might just as well be the one I could have sooner rather than later, hadn't it?

Now then, the shortest cannulas available for my old pump, were 6mm ones - and I had any number of possible cannula sites that very often just didn't absorb anywhere near as well as they used to and of course since it takes at least hours if not longer to decide 'This place isn't working - try another place asap' I was exceedingly doubtful when I discovered the clinic recommended I start with 4mm 90degree steel cannulas - only ever in my life used the Teflon, flexible ones before.

WOW!! I'm suddenly as sensitive to insulin as I was when I was 35, 2 stone lighter and being able to run in 3inch heels - I also wore 4 inch ones when dressed up, but not at work needing to run up and down 3 floors to see other dept's or clients. I was a stock size 12, sometimes a size 10 but like my mama any amount of my flab has settled downwards now I'm nowhere near as active so frankly my belly and bum cannot be described (if they ever were ...) as a joy to behold!

Practically everything about the internal workings of my body that I gradually learned over the previous 50 years of T1, has changed. My insulin to carb ratio, especially so. Just batty!

 

[Greyman]

@Greyman - dunno how long you've had T1, but this January I had a new insulin pump. I had to because I had one they decided to stop making so although mine didn't instantly completely die once it reached 'replacement date' (some of them do, or did, years ago) the dear ole NHS asked me what new one I'd like, saying that if I decided on a certain make, it was the only one I could have very soon. I could have almost any one, but it would take longer was all.
Just weirdly, (cos frankly I've never been quite so easily satisfied!) I was all but decided on that very pump! - if I'd got to learn to operate entirely new to me technology aged 74 well blow it then - might just as well be the one I could have sooner rather than later, hadn't it?

Now then, the shortest cannulas available for my old pump, were 6mm ones - and I had any number of possible cannula sites that very often just didn't absorb anywhere near as well as they used to and of course since it takes at least hours if not longer to decide 'This place isn't working - try another place asap' I was exceedingly doubtful when I discovered the clinic recommended I start with 4mm 90degree steel cannulas - only ever in my life used the Teflon, flexible ones before.

WOW!! I'm suddenly as sensitive to insulin as I was when I was 35, 2 stone lighter and being able to run in 3inch heels - I also wore 4 inch ones when dressed up, but not at work needing to run up and down 3 floors to see other dept's or clients. I was a stock size 12, sometimes a size 10 but like my mama any amount of my flab has settled downwards now I'm nowhere near as active so frankly my belly and bum cannot be described (if they ever were ...) as a joy to behold!

Practically everything about the internal workings of my body that I gradually learned over the previous 50 years of T1, has changed. My insulin to carb ratio, especially so. Just batty!

At not quite 40 years since my T1 diagnosis, it would appear that I'm a relative newcomer, but things have certainly changed dramatically since I started. To remind you of where the tech was at that time, we had syringes, albeit disposable, colour-coded blood testing strips (BM IIRC), strips to pee on and far slower acting/mixed insulins. Dietary information on food was pretty good and I do remember having a fairly thick, ring-bound carb-counting manual, for apparently every food on the planet. Those were the days. 😉

CGM, albeit not perfectly accurate, is for me probably the biggest life-changing development. As for insulin pumps and particularly the so-called closed loop, that was a dream I'd had when I was first "enjoying" a 10-day stay in a since closed specialist diabetes specialist care home, all those years ago. I've yet to go down the closed-loop route though, as it does still make me nervous even using my sensor readings for manual injections and I tend to still use finger-prick tests before meals. However, as far as I am aware, a closed loop system has yet to cause anyone any major harm, so I'm guessing that they are probably playing it on the safe side with the automated injections?

 

[Lauren]

Hi, former Pharmacy Tech here. Deliveries to pharmacies are always by third parties and happen once or twice per day, this is normal and has been happening since at least when I started working in pharmacy back in 2008.

These deliveries include what we call 'fridge lines' - insulin, eye drops and inhalers among other items - which come in special cold packaging (within the totes you have seen being delivered) and are almost immediately put into the fridge, within minutes of arrival, once they have been checked into stock. They are handed to a member of pharmacy staff by the delivery driver and must be signed for.
It may be worth checking the fridge line policy of your pharmacy but these items are a priority, partly down to the expense.

Insulin is a 'bad drug' and so should not be used, once taken out of the fridge long enough to warm up to room temperature, after 30 days - even if you then put it back into the fridge.

Interesting to see your experience with Fiasp.

 

[Greyman]

Hi, former Pharmacy Tech here. Deliveries to pharmacies are always by third parties and happen once or twice per day, this is normal and has been happening since at least when I started working in pharmacy back in 2008.

These deliveries include what we call 'fridge lines' - insulin, eye drops and inhalers among other items - which come in special cold packaging (within the totes you have seen being delivered) and are almost immediately put into the fridge, within minutes of arrival, once they have been checked into stock. They are handed to a member of pharmacy staff by the delivery driver and must be signed for.
It may be worth checking the fridge line policy of your pharmacy but these items are a priority, partly down to the expense.

Insulin is a 'bad drug' and so should not be used, once taken out of the fridge long enough to warm up to room temperature, after 30 days - even if you then put it back into the fridge.

Interesting to see your experience with Fiasp.

That's great to hear thanks and what I suppose I would expect to see for such lines. I guess that on the recent occasion where they got the box from out back, along with my non-fridge items and that had obviously not been refrigerated for some time, had somehow slipped through the net. I suppose that the pharmacy might be sticking rigidly to such a procedure, but if the boxes had become overly warm during their time in the non-refrigerated delivery van, it might have taken some time for them to cool down again.

I will mention it again to the pharmacy and, as you suggest, check that they are indeed following some sort of fridge line policy. I know that they are very busy, with a mentioned customer base of over 35,000, so that would probably explain the masses of boxes/totes I've seen being delivered and stacked in just about every bit of spare floorspace in the building, while I've been awaiting prescriptions.

Right, that's my conspiracy theory out of the way and as I appear to be in a fairly small minority, of one, I'm really starting to think that it must be something else that I'm missing that is affecting my control. 😉