The Mix mix-up
In the beginning there was death.
Then insulin was discovered. First it came from various animals: it was crude, brown, unpredictable. But heaps better than death.
Next came a long line of “improvements” to insulin. Each generation better. Each generation more expensive.
Now we live thanks to the black-magic preformed in Big Pharma’s factories. God-only-knows-what goes in on one side of the factory; and liquid gold for the stock-holders comes out the other.
But a few steps down the evolutionary ladder from where we cling to life today, in the days before 24-hour basal insulins like Lantus and Levemir, there was an insulin called NPH. It had a medium-range duration of action and was often used to get us through the night alive. At some point it was “mixed” with fast-acting to reduce the number of shots we had to take in a day.
Recently, for reasons totally unclear to me as mix is rarely prescribed anymore, Lilly created a new 50/50 mix. It is half fast-acting and half NPHish insulin. It seemed like an unlikely product when my Lilly Rep dropped off a few pens at the clinic. They languished in my fridge for months.
Then, as some of you know, a change of insurance cost me my life as a pumper. Back to taking multiple daily shots I got to thinking about Mix. I wondered if it might work as a poor-man’s combo bolus. A combo bolus (dual wave to you Med-T speakers) is a pump bolus for a carb load followed by increased basal pumping for a period of time. Works great for pizza and other complex foods that have a carb spike followed by a long duration digestive element. (Read high fat, in general).
So I was thinking that the 50% fast might cover the sugars in the pizza crust and sauce; and the NPH might help knock down the secondary spike brought on by the meats, cheeses, etc. I brought a pen home and downloaded the volumes of fine print available on the product from Lilly’s web site.
The fine print convinced me that my idea wasn’t too good after all. I had it in my head, wrongly, that NPH lasted 4-6 hours. Nope. Much longer. I shelved the idea and now the 50/50 pen languished in my fridge in my office at the Lab, rather than languishing in my fridge in my office at the clinic. I actually forgot it was even there.
We took a trip up to Denver last week. I packed frantically after my 12.5 hour clinic day and at the last minute I realized my Humalog Turbo was almost empty. I grabbed a fresh Grey & White on our way down the driveway.
Two days later I was down to 20 units of Humalog. I took out the spare pen to put a pen needle on it before heading out to the aquarium with Rio and his God-parents, who were visiting from Jersey. I uncapped the pen to find the insulin foggy, cloudy, white. What the fuck?
It had been so long since I’d seen NPH I’d forgotten what it looked like. At first I was trying to figure out what catastrophe had wiped out my insulin! Then, with a sinking feeling, it dawned on me. I took the wrong pen from the fridge. In my hand I was holding a 50/50 Mix pen. Far from home. On a weekend.
We’d just bought a big box of Einstein Brother’s Bagels (I think I’ve mentioned before that I’m a piss-poor role model). If I use the fast-acting I have left, I won’t make it back home. Damn if I’m going to pay $175 for Humalog at retail even if I can convince a pharmacy on a Saturday to give me some without a script. Besides, even if I tried to, the credit card machine would explode in my face when I swiped my debit card. I’m in Denver with $5.12 in my bank account back home. I resolve to give the mix a try, what’s the worst that can happen?
We all know that Death rides a pale horse. It turns out that the Hypo Reaper rides a grey and white one, as does his girl-cousin the Hyper Reaper; and as you will soon see, they will both visit me within the next 24 hours.
Back to the bagels. Ever had an Einstein Brother’s bagel? Like potato chips, you can’t eat just one. I take 10 units. Soon my day becomes….. sub-optimum.
My blood sugar shoots up to over 300 in an hour. Crap. Then, hours down stream, the drop begins. And it’s bad. The most aggressive hypo I’ve seen since…. Well since I use to use NPH, as a matter of fact. I just could not turn the fucker around. I kept upping the carb ante every fifteen minutes and every fifteen minutes the BGL was lower. In the low 50s I was beginning to get…. Concerned.
Oh screw that, I was scared out of my pants.
It is a long story involving cell phones, a rendezvous in a parking lot, and getting the kid safely to where he couldn’t see what was going on. Sorry, but I see no point in giving myself a post-traumatic stress attack relating it, but I owe a debt of gratitude to the Dole Juice Company for their fine carb-packed Pineapple Juice product. After ingesting something in the order of 200 carbs I got back up to 130, where upon I crashed again. It was a thoroughly rotten day, and by the end of it I felt like the LAPD had beat the crap out of me.
It also shook up the wife, the kid, and my mother—none of whom have ever bothered to really learn anything about diabetes, don’t understand it, and have deluded themselves into thinking I’m really healthier than I am. Right after the discovery of insulin one of the early diabetes Docs called us the “erstwhile dead.” And that is true, we are really zombies kept alive only by the magic of these pricy chemicals.
The next day was the drive home. I thought I had enough Humalog left to cover the one meal on the trip. I was wrong. Tricky to properly guess the last dredges in those throw-away pens.
Then a crazy idea struck me. Mix really isn’t a mix at all. NPH and regular really don’t mix all that well. There is a whole ritual you have to got through rolling and flipping the pen to make it happily homogenous before you shoot up. I set the pen on end and let the heavy white NPH settle to the bottom. Ahhhhh…. Did I have pure Humalog on the top? I injected upside down and was very proud of myself.
Until the shit hit the fan.
More clear fluid from the pen top.
This is not looking good for the home team. We are now in the waste lands of northern New Mexico on a Sunday night. BGL now 507.
In hind sight, the thick layer of NPH only took up a quarter inch in the bottom of the pen. I’m not really sure the rest was insulin. It could be distilled water at the top for all I know, and it sure acted like it. (I later learn that Mix pens contain free and suspended fast-acting insulin, mixed in with a good deal of inert filler fluid.)
As the sun sets and long shadows race across the barren prairie, I discover my blood ketone test strips expired in July. Crap. My stomach is turning summersaults. Stress or ketones? Hmmmm…. Hard to say. I’ve been in dangerous territory for five hours by the time we get home.
I grab a Humalog pen as soon as we get to the top of the driveway, making sure it IS a Humalog pen. They should really make the mix pens some other color for crying out loud.
I don’t want to screw around with a sub-q shot. I want IM, straight into the muscle, a much faster way to bring a hyper down. An IV shot would be even faster, but I’ve never done one on myself. Every frickin heroin addict can do it, but I don’t have a clue. Something we should teach in diabetes boot camp, huh?
Pen needles are too short to reach muscle even in a spaghetti-armed skinny like me. After some frantic searching I find an old-fashioned syringe. Needle isn’t as long as I’d like, but should do. I have Deb pinch up my deltoid to get the muscle as close to the surface of the skin as possible. I stab the needle in, pushing as deep as I can. It hurts like hell, a good sign we hit our target. I start to inject 10 units, but we have a miscommunication and she lets go of my arm early. The needle slips out and we have no way of knowing how much juice hit the target.
There is nothing to do. If most of the insulin went into the muscle a second shot would be…. Bad. If most of it when into the fat it will work…. At some point. If I don’t go DKA first.
For the next 20 minutes the BGL continues to drift upwards. I re-program a Precision Extra meter, lying to it about the date so I can use the expired ketone strip. It shows negative for ketones but with a strip a half-year out-of-date, I don’t know if I can trust the result.
Then slowly at first, then faster, faster, faster, faster my blood sugar begins to drop. To plummet. I lose 100 points in 15 minutes. My body is racked with terrible cramps. My arms turn to granite. My toes seize up with incredible pain. I frantically rub in aspercream, down valiums, and pray I don’t go hypo.
I stay up as long as my exhausted and excursion battered body can stand it. 3.5 hours down stream of the IM shot Guardian shows as solid level-out in the low 170s. A finger stick shows that it is actually in the mid-200s; but I trust the trend. The mind-numbing drop has stopped. The IM shot was a good call, though not easy on the body. I’m back in safe territory.
I take two more units sub-q, take my basal and collapse into bed; hoping to wake up in the morning but too damn tired to care one way or the other.