New world order
On the fourth day of my last infusion set I picked up a Levemir Flexpen and a NovoLog Flexpen. And a box of pen needles. At 6pm I set a temporary basal rate of 0.0 units per hour for ten hours. The plan was to take the basal shot at 10pm. Suspending the basal drip four hours up stream would ensure all the old juice was out of my system before the new stuff started.
I was nervous. I’ve started, I dunno, probably close to 100 folks on Levemir, including poor T-1s like myself who can’t afford pumps. But it’s different when you are starting yourself. On top of that I’d never personally used Levemir at all. In my pre-pump days Levemir did not exist yet. I used NPH at night, but that seems too stone age and I’ve seen what a good job the “green juice” does.
I took a mid-evening correction on the pump, and then in its last gasp of service I pumped dinner. The plan when awry when too much after dinner exercise (sword fight with the little one) triggered a mild hypo followed by the inevitable rebound hyper. When 11pm rolled around I was around 200.
I uncapped the Levemir pen, pulled the paper backing off of a pen needle and threaded it on to the pen. I pulled the outer cover off and threw it to Kaki to play with. I carefully removed the needle sheath and dialed in a two unit dry shot to get the air out of the system. Nada. One unit more and a clear drop of life-saving miracle fluid appeared at the tip of the needle. Time to go back to my roots.
My most recent pump basal was seventeen point something units per day. I increased that by 20 percent and rounded off for a starting Levemir basal of 20 units per day. I’ve moved a couple of people from shots to pumps, but never the other way around. I assumed if I did all the math backwards it would work out OK.
I pinched up a little skin, slid the needle in and pushed in the “plunger” at the dial end of the pen. 20 units is a long push. The disposable Flexpen, while a wonderful device, does not exactly have the movement of a Swiss Watch. It was slow and sort of…. grinding? Well, that’s not quite right, but you get the idea. I relaxed my pinch, rested the nose of the pen against my skin for a count of ten and slipped the needle back out of me and re-sheathed it. Very un-eventful. Of course I take lots of “shots” of saline and the like demoing pens for new inductees into our club, so it’s not like I haven’t taken a shot for years and years.
By the time I hit the hay my BGL was at 220, but I was in no mood to add a correction bolus to a new insulin.
Then, I slept. And I didn’t die in my sleep. OK, so three positive experiences. When I woke up, the first thing I did was dig around in my sheets and comforter to find the Guardian. The six hour graph looked like the heart monitor on an ICU patient who has gone on to the next world. Absolutely flat. Amazing. I scrolled up to the 12 hour graph, to see that the bedtime 220 leveled down to 200 within an hour of my head hitting the pillow and for the next 8 hours my SG (Sensor Glucose, the new BG) drifted gently between 188 and 212. Quite amazing. I know from looking at BG logs of our many Levemir users that it has a pretty flat profile; but most of that crowd are T-2s and you never really know what’s happening between finger sticks. This is the first time I’d seen a continuous graph of Levemir. Gotta say, I’m pretty impressed.
Now wait-a-cotton-pickin-minute some of you are saying. You were at 200 all night long and you are happy? Are you fricken nuts? Well, I might be fricken nuts, but that has nothing to do with the conversation at hand. This was a fabulous performance. Basal insulin’s job is to keep the boat on a steady keel. It’s not the fault of the green juice that it went in to the game high. If I had gone to bed at 120 SG I have every reason to assume I’d wake up the same.
Now, of course, it has not even been 24 hours yet. I can’t say what the afternoon has in store. Much to early to tell if the 20 unit hit is really the right amount or not. But I’m not scared anymore. I’m ready for this new challenge life has thrown me. But I’m sure glad I’ve got Guardian-Girl along for the ride though.
After reviewing the night’s lack of action on the Guardian’s screen I broke out the orange juice. Not that kind. NovoLog pens have an orange label and cap and Levemir pens have a green (some say teal) label and cap; thus orange juice and green juice. The pens are otherwise identical. The colors are supposed to make sure you don’t take the wrong stuff at the wrong time. Hasn’t stopped some of my patients from nearly killing themselves. Local celebrity CDE Virginia Valentine likes to tell her patients to link the color orange to eating an orange. Use the orange insulin when you eat. That’s pretty good. After one of my MDI (Multiple Daily Injection) Type-2s got confused and took 60 units of NovoLog instead of the Levemir I’ve been telling people that orange is DANGER and that any time you have an orange pen in your hand you need to think about what you are doing.
Where was I? See? I go off on so many tangents that even I get lost. Oh yeah. So I broke out the OJ to take a correction first thing in the morning before breakfast. Gotta keep your head in the game a lot more with pen syringes. You can’t just glace at an insulin on board screen or double check you last bolus.
Actually, the folks at Lilly just introduced an insulin pen with a memory. And it does have the action of a Swiss Watch. I could easily write myself a script for it and have my boss sign off, but there are a few problems. It is a bit bulky (not as bad as the old OmniClick from Lantus) and it takes Lilly HumaLog cartridges. I’ve never used HumaLog, and I have to reason to suspect there is anything wrong with it. My problem is different. The good folks at Novo literally flood our state with samples. I know a lot of Docs so I can always mooch a Flexpen. Confession time: in my entire career as a diabetic I’ve only actually paid for insulin one time. Paid for plenty of other stuff to support my diabetes, but I’ve been really lucky with the insulin. So I can (most likely) use Flexpens for free or pay whatever my co-pay would be for the Lilly cartridges.
So I un-capped an orange pen and got out a calculator. 200 current SG minus target of 125 equals 75 divided by my best guess average correction factor of 35 points per unit equals 2.1428571 which of course I average to a two unit hit to start my day. One challenge I’ll need to face is that when I’m in a rush I often drink a Slim-Fast Low Carb Diet shake. They have less than 5 carbs which, as you probably have forgotten, you then bolus as 5 carbs. Of course, that’s half a unit of insulin, which is a problem. Again, Lilly has a beautifully crafted half-unit pen with the same problem noted above. Novo makes a Junior pen that delivers half units too, but they never seem to sample them. Maybe I need to make friends with a couple of Pedio Endos.
All things being equal though, this could have started off much worse and I’m feeling more up-beat than I expected to.
So that’s about it for today. What? My pants? Oh yes, an unexpected pleasure was that this morning, for the first time in years, I was able to pull up my jeans and tuck in my shirt like a normal person. No getting tangled up in my infusion set hose. No pump falling off the belt.
It was so fast.