According to the experts - Lantus

So, in my life, the "experts" on diabetes are the ones living with it. Fortunately, I have access to a steady stream of "experts" where I work. Teaching exposes you to dozens, if not hundreds, of families every year, some of whom you get to know pretty well. Until I taught in public school, however, I had never had a student with type 1 diabetes.

It must be fate then. My first year teaching public school was the first year I had a diabetic student. It was also the year my daughter was diagnosed at the age of 11.

I remember cornering the poor student I had in my class on the day I returned from the hospital. I asked her if I might pick her brain for diabetes information. She was eager to help. Thus began my history of asking kids what their diabetic experiences are like.

Now I know an adult with whom I can speak as well. This adult is a parent of one of my students, and he has type 1 diabetes. He is a big advocate of the pump. After talking to him, and the parents of one of my students with type 1,  I am for the first time considering the pump option seriously.

Just a note: M has been considering seriously for much longer.

For those of you with only a rudimentary understanding of D-life, the insulin pump is a device that looks like a pager or an ipod. It holds a reservoir of insulin, and has a little computer in it. It also has tubing that extends from the device to a port (needle-y thingy) that enters the skin. Most pumps are also accompanied by hand held remote devices that communicate with it, thus eliminating the need to take out your pump and fiddle with it.

Of course, in New England our bellies are way whiter than this.

Before getting the pump, you have to test your bg more frequently so that you and your medical professional can get a baseline about your high and low cycles. After testing and recording your bg six to ten times per day for a proscribed period, you might now consider whether the pump is right for you.

This is where it gets tricky.

All of this information get plugged into your pump or your hand held device, and the pump sends a tiny dose of insulin regularly, throughout the day, through the tubing and into your skin. When you are ready to eat, you enter the number of carbs you are planning to eat into the device, and it gives you a pre measured bolus of insulin based on your carb ratio, which is how much insulin you take per carb you eat.

Now, I have read many blogs by pump users, many of whom have spoken of errors in their pump use. In all honesty, most of them have been user errors, not device errors. But still, reports of such errors make me nervous. One famous (in the D community) blogger wrote about fighting traffic in Boston to get to her specialist. When her blood sugar climbed and climbed, she couldn't figure out why. She was nervous and sweaty. When she arrived at her appointment, she learned that her tubing had separated from her port, and the sweat she felt was actually insulin dripping into her armpit, not entering under skin, thus the rise in bg.

Mishaps like this make me a little nervous. I mean, if a 30something diabetic can make these mistakes, then so can M.

I spoke to Ddad - the parent of my student who has had diabetes for 43 years. He told me that "nearly every problem people have with pumps is their own fault." He has had the pump for years, and feels much healthier. In fact, he thinks Lantus is dangerous. Lantus is the long acting basal insulin that M uses. In theory, it is supposed to keep your bg in range over a 24 hour period. That's assuming you don't eat. When it is time to eat, you have to inject the bolus, or fast-acting insulin to cover the carbs.

The fact is, however, that the Lantus doesn't really keep the bg within range. It can only do so much. The bolus given at meal time also acts as a "correction" for how far out of range you are. Thus, at each meal you have to calculate your correction factor as well.

There is some complicated math involved with M's current regimen. It involves figuring out how much insulin she needs to correct what the Lantus doesn't cover, and calculating how much insulin she needs to cover the carbs she eats. As with everyone, M has cycles of higher and lower bg, so her correction factors and carb ratios are different for every meal. Sometimes she needs to inject 2 units of insulin. Sometime she needs to inject 9.5 units of insulin. Sometimes she needs to inject more.

So why might Lantus be dangerous? I had never thought about it, but after talking to Ddad, I get it. Lantus is always in your system. You can't stop it from working for at least 24 hours. It actually may have effects for a few days, which I knew.

M, when active, is very susceptible to lows. For example, M had a bg of 140. She then ate a full lunch without taking a bolus, because she knew that she would be playing lacrosse for four hours. At the end of the fourth hour, she was looking pretty bad. We gave her some smarties and checked her bg. It was 29. for those of you not in the D world, this is very bad. I am glad she didn't pass out.

Why did this happen? Because even with the added carbs and without the bolus, M still had her dose of basal insulin in her body, doing its best to keep her bg under control. Lantus is not smart enough to stop working when you are exercising, but presumably you are smart enough to remove a pump when you won't need it.

A pump only uses fast acting insulin in constant, small doses. If you shut off your pump, or remove it, the effects of the insulin last pumped into your body continue for maybe a couple of hours, not for 24 hours or more.

The truth of Ddad's observation was clear. I hadn't considered life without basal insulin before. With M's activity level, maybe a pump would be safer.

Maybe a 29 during lacrosse season can remain a thing of the past.

Ahhh, that's more like it.