Hello, Goodbye

Apidra week from Hell - normally these range bars are short and close(ish) to the green happy-zone. 😦

First a little background as to why I decided to try out Apidra:
I’ve mentioned before that I participated in Joslin’s Why WAIT? program. It was accomplished through a combination of increased exercise, decreased food intake, and the addition of Symlin to my D-regimen. These things combined to cut my total daily dose of insulin in half, and then some. Originally the team had wanted to switch me from Humalog to Apidra because it peaks faster and would theoretically have made blousing with Symlin a bit easier. But, I had 10 vials of Humalog in my fridge, no real job, and switching just wasn’t an option.

Fast forward to last month, about 4 or 5 months post Why WAIT?, to my endo appointment. I approached my endo about switching to Apidra since my humalog supply had dwindled, and, although she wasn’t sure the benefit would be significant, she didn’t see any reason not to try it. So, I walked away with a prescription for a three months supply of Apidra.

After some trouble getting things straightened out with my new online pharmacy, I finally received the Apidra two weeks ago and began using it last week, on Feb 28 at 7pm. And then it began.

Day 1: Hello Apidra. My BG is running high all day; I wake up with a BG of 120, eat nothing and by the time I’m at work an hour later my BG has jumped to over 250. I do correction bolus after correction bolus to no avail and spend the entire work day over 250, even after eating a carb-free salad for lunch. Promptly at 5pm, when I normally head home from work, all of the boluses finally catch up to me and I drop almost instantly to about 55. I correct and make it home with a BG hovering around 100. Dinner is chicken and brown rice. My BG stays flat until bedtime but as soon as I fell asleep, Dex begins to wail. I probably test and correct 5 times overnight and my BG stays flat around 200 all night until an hour or so before dawn when it levels off around 100.

Day 2: Site change in AM. Repeat of day one.

Day 3: After the last 2 days of BG hell , I increase all rates and ratios by about 10% (except the post work/before bed ones) and shorten the IOB time on my pump so I can bolus more aggressively. I also add Symlin to most meals. My BGs level off a bit but they still sit well above my happy zone all day and require frequent corrections that seem to have no effect. I go low overnight.

Day 4: It is like Day 3 never happened and is a repeat of Day 1, again. (Only I have a low-carb, high fiber dinner that send my BG up to over 400!) In the middle of the night I have a low that requires 3 juice boxes and I still wake up the next day with a BG of only 75.

Day 5: Increase all rates again. No change. At this point I realized that I should be monitoring for ketones and luckily find none.

Day 6: Realize that I can’t fix this problem on my own and call Joslin for help. I upload my pump and Dex data from the last week and send it after work. At this point the 5+ days of highs have given me a terrible headache that I can’t quite shake. I officially hate Apidra. However, having a carb-free dinner has allowed me to sleep an entire night without any complaints from Dex. (Although he caught a low before bedtime that I corrected with ice cream perfectly – flat at 100 all night!!)

Day 7: After talking with the nurse educator and experiencing my 8th BG over 400 in less than a week (which is a number I haven’t hit in years!), we decide that I will switch back to Humalog immediately after work today.  Good bye Apidra.  You will not be missed.

So, unless this was some sort of ill-timed, un-related BG surge (which I doubt), everything should be straightened out soon.  And I can’t wait.

However, I now have 5 bottles of Apidra that I don’t know what to do with.  does anyone know of a place to “sell” (It would be great to get some part of the $60 copay back) or donate unopened bottle of insulin?

Symlin

I’ve been taking Symlin for a few months now.  I began taking it in April as part of a comprehensive weight-loss/diabetes management program at Joslin called Why WAIT?   Symlin is a synthetic verion of amylin which is a hormone secreted by a normally functioning pancreas along with insulin and it functions in three ways: First, it slows digestion, which increases the time that food spends in the stomach.  Second, it decreases the release of glucagon at mealtime which then decreases the liver’s release of stored glucose.  Lastly, it effects satiety, the sense of fullness which means that you feel full sooner and eat less.  A constant dose of Symlin is injected at meal time in addition to the meal time insulin.

Here are my thoughts and experiences regarding Symlin in bullet form (the good, the bad, then the ugly):

• Good: With the help of Symlin, I cut my daily bolus down to a quarter of what it was previously.  This was partly due to my eating less because I feel full more quickly and partly due to my need for insulin to combat the liver glucose went down.  My basal rates were also was cut almost in half.  Less insulin computes to huge monetary savings between the cost of insulin and pump supplies.
• Good:  I lost almost 30 pounds while taking the Symlin.  Some of this weight was a result of my increased physical activity and better diet, but some was definitely a direct result of the Symlin.  For example, I had a couple weeks in the middle of the Why WAIT? program where I stopped following the meal plan and stopped exercising but I still lost an average of 2 pounds per week.
• Bad:  The only method of delivery of Symlin is via injection.  I’ve been pumping for almost 10 years by now and one of the biggest upsides to the pump is the decreased number of injections.  Shots suck.
• Bad:  Symlin is outrageously expensive.  Luckily my insurance was willing to foot the majority of the bill but the cost could easily be a hindrance.  I calculated the cost of Symlin for a year without insurance (using 2-3 pens/month) and I would need a full time job just to pay for it.
• Ugly:  Symlin delays the release of food from the stomach.  Thus it also delays the BG peaks that we all know and love.  So, blousing appropriately get really difficult.  If I take my  insulin with the meal/Symlin I find myself crashing severely low immediately post-meal.  These lows are hard to treat because, 1) I’m full and don’t want to eat, and 2) The carbs I consume for the low are also somewhat held up in my stomach due to the presence of the Symlin and take longer to take effect.
• Ugly:  For this reason, I skip the Symlin anytime my BG is below 100 prior to any meal.  This doesn’t sound like such a terrible thing, but when I without Symlin my insulin to carb ratio increase by 10-20% so I end up having to bolus more when my BG is low.  This is so counter-intuitive that I often don’t increase my bolus for fear of going lower and have to deal with the frquent wicked high that results.
• Ugly: So, like I said, meal time insulin cannot be taken with or before the meal per usual.  Instead I’ve had to figure out the appropriate delay in order to keep my postprandial numbers in check.  Bolusing approximately one hour after eating seems to work really well.  The problem with this is that insulin pumps are not designed to delay a bolus.  I have to find ways to remind myself to take this post-meal bolus.  As one might expect, this often results in my forgetting until I see Dex start to creep upward and the resulting highs can be almost as devastating as the crazy lows.

So, for me, the result is an obnoxious medication that is difficult, at best, to deal, with but produces results above and beyond what I had hoped.  I plan to continue using it for the time being but I’m thinking of reducing my use down to one meal a day.  Ultimately, the beauty of Symlin is that I don’t need it to survive so I can make the choice to take it or leave it.  For now I’m going to continue to take it.

I am not a doctor and am not trained in any medical field.  Please consult your doctor before making any changes to your own diabetes management routine.  Your diabetes may vary.

Leafing It

As of yesterday, I am leafing it.  In the past 3 years, I have gained 40 pounds, mostly in the first year.  I attribute the massive weight gain to a combination of rapid A1C reduction, new birth control pills, a discovery of my love for cooking, and a new boyfriend with a ridiculous sweet tooth.  At the beginning of all of these things my A1C was over 9 (the lowest it had been for quite some time), I was single, and at my lowest weight since before puberty.  Currently my A1C is down to 6.1 (!), M and I have been together happily for over 2 years, and I am at my all-time high weight.  A year or so ago, when I really noticed the weight gain, I tried working out but with my new-found lower BG levels but I couldn’t work out for more than 10-15 minutes without going wicked low.  I tried all kinds of things to keep my blood sugar up, but was too overwhelmed and quickly stopped trying.  Truthfully, I have never been one to work out.  Actually, I hate it.  With a passion.

Anyway, back to that new leaf.  I started going to the Joslin Clinic, here is Boston, three months ago.  For the first time in my D-life I had an entire diabetes team, not just an Endo.  They quickly zeroed in on my problem areas and helped me to at least exist in Boston without going incredibly low every time I step outside.  After a session or two with my exercise pathologist, she recommended the Joslin Why WAIT? program.

I was reluctant at first – I’ve never dieted, and I certainly have never seen myself as fat.  (No daddy issues thus good self-esteem.)  But after some consideration and long conversations with M about the cost/benefit ratio, I decided to give it a try.  I couldn’t deny the extra weight any longer and figured this was going to be the best, if not only way, to really deal with it.

So, as of Wednesday, I am on a 1500 kcal diet, substituting breakfast and lunch for a Boost Glucose Control shake (lunch also comes with a salad), cooking the 600 kcal dinner entrees (600kcal is A LOT of food!) that have been provided for me, and spacing 400 kcal worth of snack throughout the day.  I’ve also started taking Symiln before all three meals, and exercising regularly.  I will do my best to keep the blog updated with my progress and any helpful tips that I pick up along the way.

I have high hopes that the program will solicit some positive changes.  After just one day of the new diet and the Symlin, my total daily dose of insulin has dropped from around 75u to 35!  And I wasn’t hungry at all throughout the day.  Although my numbers were trending a bit low for my liking, my Dex graph was nearly perfect for the last 24 hours and I didn’t take a single correction bolus.

So, the new leaf has turned, and I’m hopping for a happy outcome!