Thursday, February 10, 2011

How to Identify Bad Insulin

The suspects





Over the past few years, I’ve had a great deal of practice at identifying bad insulin, unfortunately.  So much practice that I’m about to give up on Apidra entirely.  When it works, it’s great.  It’s turned my Dexcom shots from Charlie Brown’s tee shirt to gently rolling hills.  BUT I’ve gotten bad batches from at least 3 different pharmacies.  So either the local distributor is bad, or the insulin itself is so flaky they can’t control the strength.  Add to that, it’s off formulary for my new insurance, so my copay is five times what it used to be, for something that more and more frequently just isn’t doing its job.
In a perfect world (scratch that, in a perfect world I wouldn't need insulin)...In a reasonable world, there would be a test to check your insulin.  It doesn’t have to be a perfect test (hmm, this bottle scored a 93 and my last was a 96).  I would settle for something from the insulin Dark Ages, involving tablets, fizzing, urine (even someone else’s urine!) and ambiguous color changes:  Now it says chartreuse is good, but this is more of a celadon...
Anyway, I’ve unfortunately had to come up with my own checklist, because we’re all conditioned to assume it’s our bodies, not our insulin, that is the problem.  See “litany of blame” in this post.


Here it is:

  • Clue #1 - unexplained spikes from “safe” meals - I eat the same breakfast every day.  It usually does the same thing (if by usually you mean about 70% of the time): I gradually climb 100 points or so, hover 15 minutes, then drop like a rock around 10am, which I stave off with a single Dove Dark (hey, whatever works, right?).  Final result, nice and level in the 80s just before lunch.  So when my typical breakfast launches up like the space shuttle, peaks around 300, then drops like the spent fuel tanks, I start to wonder...
  • Clue #2 - basal creep - this can take two forms.  The first is the “that’s odd, I’m 20 (30, 60) points higher than I usually am at this time of day” reaction.  Correct and move on, right?  The second is the “Hmm, maybe I’m coming down with something.  Let’s set a temp 170% basal for a few hours and see if that helps”.  Eventually basal creep leads to 150+ point rises overnight, which is when I start getting suspicious.
  • Clue #3 - corrections don’t help - Darn it, I corrected for that 240 hours ago - why am I still 208???  
  • Clue #4 - altitude changes -  My gentle hills on the Dexcom change to the Rockies and then the Himalayas.  Sometimes it looks like a normal day, only shifted upward by 80 points.
  • Clue #5 - site changes don’t help - you pull the site, nothing’s bent, bruised, puffy, bloody, or leaking.  Repeat as needed.
  • Clue #6 - rage boluses DO help - It says I only need 1 unit to correct, and there’s a half unit still active - let’s do the whole unit anyway.  No, two.  Three!  Bwah-ha-ha-ha!!!  Then your BG goes back where it is supposed to be, and your poor brain, already in diabetes overload from a few days of troubleshooting, tells you the problem is solved, we’re all back to normal, and turns off.
  • Clue #7 - “overtreated” lows - if your rage bolusing sends you low, your normal low treatment looks like you emptied the entire fridge.  So much for hitting the normal range for more than twenty minutes today...
  • Clue #8 - injections don’t help - after a few needless site changes, you break out the needle and try that (sometimes combined with a rage bolus, because at this stage you are grasping at straws).  It lowers your BG - a bit.  Maybe 60% of what you expect.  What the heck is going on here?
  • Clue #9 - new bottle DOES help - You grab a fresh bottle, do a site change - and it works!  You go from being tied to the mast in a hurricane, with alarms ringing, waves that threaten to swamp you, and dragons swooping down to poop on your head,  to a paddle boat in  a park, with rainbows, unicorns, and puppies.  Why on earth did it take so long to figure this out??? 
  • Clue #10 - it starts all over again - If your fresh bottle was from the same batch, there’s a good chance it slowly turns once opened.  If you’re unlucky, like me this month, “slowly” becomes quickly.  
This months 3 bottle supply of Apidra went down one right after the next.  Bottle #1 lasted 4 days before the weird symptoms started showing.  I jettisoned it 3 days later.  Bottle #2 gave me 12 hours of blood sugar nirvana, then turned to dishwater by day 4.  Bottle #3 kept me level at 80 for 4 hours.... then launched into the stratosphere with a single sandwich and my usual bolus.  Tomorrow I take all 3 back to the pharmacy, but I don’t think I will be replacing them with more Apidra at this point.  I figure staying in the Rockies is better then alternating between gentle hills and Himalayas...

6 comments:

Lorraine of "This is Caleb..." said...

Hi Val. I've been trying to trouble shoot what I think is an insulin issue with Caleb for months. I'm trying to piece together what I'm seeing with Caleb to what you have seen. I have a difference - sight changes DO help. I tend to think that Apidra is clogging his cannula. He went back to Novolog for about a month and we saw highs come at the end of day three, but now back on Apidra and seeing this odd spike tonight after only 24 hours. I'm distraught at 1am so probably not making much sense. Guess I just wanted to say hi!

Val said...

Hi Lorraine -

I did see a *slight* improvement with site changes, but I suspect it was more of a fresh absorption area. Changes were dramatically better with a new bottle, though. I did have a long period where I would do fine the first two days and lousy on the third, so I tended to change sites after 2 1/2 days on average...

I did eventually just give up on the Apidra and go back to Novolog though - my breakfast spike is much worse, but the rest of the stuff seems to have settled down.

Hope you guys have some luck tracking things down!

Jen said...

Val,
I wondered what you thought about this urine test that may be rolling out that can supposedly diagnosis the difference between type 1 diabetes, type 2 diabetes, and rare genetic forms of diabetes. As such, the test can offer an accurate diagnosis, leading to critical changes in treatment and, in some cases, termination of insulin treatment.
http://www.dailyrx.com/news-article/key-pee-12168.html
It sounds to be on par with blood draw analysis.

mark pederson said...

Your observations are brillantly and creatively described. My experience mirrored yours to a T (shirt). I used Apidra for 2 months and almost the entire time I had poor blood sugar control. I didn't suspect that my insulin was the culprit until an alert nurse asked me if any of my prescriptions had changed recently. She suggested that I change back to Humalog in myinsulin pump. Wow, in a day or two I was better.

This experience was very disturbing for me. I went through 3 different prescriptions of Apidra and failed to make the connection because my initial experienc with Apidra was alright for 2 weeks. Your blog is wonderfully written and was confirming for me.

Thank You!

Emily said...

Hi Val,
I have been on Apidra for over a year and half now with my pump. I got it from Walgreens for over a year, then my insurance changed. So I've been forced to buy from CVS, which is when my trouble started. I am continually getting bad bottles of insulin that begin to turn after 12 hours of being opened. I think that CVS distributors, or even the pharmacists, aren't storing them at the correct temperature. My question is this: what am I supposed to do about it? How do I get them replaced? I obviously shouldn't keep using bad insulin, but I can't expect my insurance company to buy me another 3 month supply, when I just got this supply less than 2 weeks ago. Do you have any suggestions?

Thanks,
Emily

Val said...

Hi Emily - sorry your comment was caught in my spam filter. I think you can just take a mostly-unused bottle of insulin back to the pharmacy and claim it does not work and they will exchange it. Of course, if I did that with every apidra bottle that went bad on me, they'd start refusing after a while...

I gave up on apidra a while ago, and have had much fewer issues on novolog...