In my second blog I have covered some of my personal memories of the 35-year period using an insulin mix of short and long-acting insulin. In this third blog I will tell you about a more recent and impactful change. The switch to another insulin therapy, also changing my lifestyle.

A modern diabetic after all

Upon my relocation from Austria to Germany in 2017, again I soon was on the look out for a general practitioner to subscribe my medication Novomix and Candesartan (blood pressure drug), pen needles and test strips. In all honesty, I used to be under the care of an internist for a relatively short period after my diagnosis. After my first relocation (away from my place of birth) I have always had general practitioners for the HbA1c assessments and for the prescriptions. In my previous blogs I have told you about my disciplined life on 2 daily injections and 6 meals. 35 years, with sporadic searches for potential new developments in diabetes treatments. In Vienna I had a fellow-diabetic in my team, who, in my opinion, tested her glucose level quite often and gave an extra injection as a result of it. She would join the rest of the team eating cake that was brought in by another colleague, whereas I would always say ‘thank you, but no thanks’.

The assistant of the targeted general practitioner in Germany (conveniently close in the same street!) informed me that the practice did no longer accept new patients. I did not want to leave without a ‘fight’ and started a friendly chat about how difficult it is to find your way having moved from abroad and that my search for a doctor was on the top of my list. She started apologizing and mentioned that the practice had specialized on treating diabetes patients, …. Bingo! And maybe she was a bit resentful, but she could not refuse diabetics, and for the first time in a very long time I had an appointment with a diabetes-expert.

After two weeks, holding the letters from my Austrian practitioner (list of HbA1c values and medication I was on), I was first examined by a nurse. Potential nerve damage was assessed with a feather tickling my feet: all was fine! HbA1c was determined on the spot using a finger prick test – thusfar I was used to giving up a vial of blood to be sent to the laboratory for analysis. The result was 5.8%. Excellent! Weight 85 kg – also fine with my 6’4 height. Blood pressure was despite my medication (Candesartan) somewhat high: 160/110. In the morning I had had a rather unpleasant conversation with my supervisor; after only a few weeks I was sad to realize that the company culture was not like what I had anticipated – maybe that had resulted in elevated blood pressure values.

At the doctor’s I was asked to handover my glucose meter (OneTouchVario), which he connected to his computer. He mainly observed relatively high and low values – I tried to explain that I do not test at regular intervals but tend to only test when I suspect either high or low blood sugar levels. He then wanted me to prepare day curves over the next weeks, testing every 2 hours, and writing down how many bread units I consumed during the day. He sent me home and to consider a new insulin therapy, more contemporary and not as old-fashioned to only use mixed insulin.

Two weeks thereafter back at the doctor’s the curves looked reasonable well, including the registered meals and carbohydrates transferred into Bus (bread units: 1 BU = 10 grams carbohydrates). From the still significant number of low glucose values he concluded that I would have had more and lower values in case I had not consumed additional food – I explained that for 3 years I was used to eat in-between-meals/snacks. Personally, my lesson was that frequently testing blood sugar helped me to prevent too low levels; in that respect I agreed with the doctor that I used the tool food to compensate. He went on to tell me that, though a relatively well-established diabetic, nowadays most diabetics are treated with two types of insulin. One injection with long-acting insulin and several injections with short-acting, depending on how often you eat and what. He asked me to consider (I am sure he had been attending a “change-management-course”), but I immediately agreed. The only thing I proposed is to start if and when I could monitor my blood glucose continuously without having to damage my fingers; the previous year I had, at my own expense, tried the FreeStyleLibre sensor from Abbott. I still had the reader so I only needed to order a few sensors for this experiment. And then it started.

With the arrival of the sensors, the doctor prescribed Toujeo as the long-acting and Fiasp as the short-acting insulin. We had some debate about the tie of the Toujeo injection, because the doctor preferred injection in the evening in the belly area, always at the same time. My preference is to have this injection in the morning in the upper leg; it was akay. I planned to use the belly skin for the Fiasp injections. He also prescribed pen needles, much shorter than the 8 mm that I was used to. The 4 mm needles would allow for 90-degree angle injections into the skin, whereas with the 8 mm needles I had been used to 45-degree angle injections into a fold of skin and use a cotton swab when pulling out. Wow, this would take some time getting used to!

The change was and still is enormous! The doctor had given me an initial scheme with a fixed dose of Toujeo and several different doses of Fiasp depending on what he called the bread-unit-factor (BUF). During the first two weeks, using the FreeStyleLibre measurements, I have been having quite a few correction injections, but with the new 4 mm needles that was no problem for me at all.

I finally nailed the dose of Toujeo refraining from food and Fiasp injections after the morning injection. I am currently using 14 units that ensures my blood sugar to be in a steady state, day and night.

Having switched from 6 meals at regular times to 3 (relatively larger) meals I no longer have to stick to a schedule. Depending on the blood sugar values I inject Fiasp; with values between 5 and 8 mmol/l there is no correction required and I inject 1 unit for every bread unit I plan to eat; this so-called BUF may differ per person and over the day. In case of values >8 I add a correction-dose in order to bring the value down to 7: 1 unit to reduce 2 mmol/l. For example, I eat 5 sandwiches (5 BU) and the meter indicates a value of 11 mmol/l (200 mg/ml) then I calculate: to bring the value down from 11 to 7 mmol/l it needs to reduce with 4 mmol/l for which I need 2 units; for the 5 sandwiches I need, with my BUF (of 1) 5 units: I therefore inject 7 units in total right before this meal.

What a difference when compared to how I dealt with this before – I simply would not eat with a blood sugar of 11.

In case the meter shows a value below 5 mmol/l (90 mg/ml) then I start eating first, before injecting Fiasp after approximately 10 minutes.

It appeared to be an enormous lifestyle change, after 35 years as a disciplined diabetic on mixed insulin, to switch to one daily injection with long-acting insulin and several meal-depending injections with short-acting insulin. Because of the new, short pen needles, the discomfort of the increased number of injections is low. It definitely provides for more freedom – for sure that there is no longer a need to eat at scheduled times is ‘liberating’. Also, the principle that I can actually eat what and how much I want (from a sugar/carbohydrates-perspective) is an advantage – if I want I can simply use my Fiasp-pen in case I choose to eat a piece of cake.

Previously, when people would ask about my eating habits (I used to bring a bag of bread to work – that is without any filling) I would reply that I simply eat to keep my blood sugar in check, but that dinner was the time to really enjoy. Nowadays I am also looking forward to lunch time! Nice!

In my ‘former’ life I have controlled my diabetes, mainly by feel and infrequent finger prick tests, beside the more regular HbA1c assessments, using the increase/decrease of food as a tool. As mentioned before, the new insulin therapy has resulted in a lifestyle change in a short time. This new lifestyle, however, kind of made me addicted to continuous monitoring of my blood sugar values. I honestly don’t know if I could have successfully made this switch without the FreeStyleLibre. I learned, for example, through constant monitoring, that now and then I injected too little Fiasp – a new pen would inject some air before insulin; that certain sports activities are affecting/draining my muscles the night and even the next day after the activity, and send my blood sugar levels toward 2-3 mmol/l; and there are more examples of how continuous monitoring allows you to intervene and control blood glucose.

In the Netherlands CGM (continuous glucose monitoring) devices are not reimbursed, so you either stick to finger pricks or to personally pay for the costs. Like I said before, I currently live in Germany and my ‘Kranken Kasse’ pays for the FreeStyleLibre sensors.

To conclude:

In my work, but secretly also privately, I am fascinated by managing changes. To make people realize that the change will have not a negative but a positive impact. Moreover, the next step-by-step process to actually implement the change.

But why, and this question keeps bugging me, is it that I have opened up so late to this change to my insulin therapy? Why did I not hear this before, or did not want to hear?

This question is also at the centre in one of my next blogs, about a sudden change to my lifestyle with respect to food and nutrition.


FURTHER READING

Toujeo

This is a long-acting insulin, glargine, from Sanofi, that is delivered to your body slowly and continuously over 24-30 hours resulting in a steady-state.

Fiasp

Fiasp, from Novo Nordisk, is also called a mealtime insulin, to be injected right before or up to 20 minutes after the start of a meal. Maximum activity is reached somewhere between 1 and 3 hours after injection and it wears off after 3-5 hours. Fiasp = Fast-acting insulin aspart (NovoRapid).

Candesartan: Angiotensin 2 antagonist inhibitor resulting in relaxation and dilatation of vessels; it also stimulates excretion of natrium (salt) via urine. Both effects help to lower blood pressure.

In my first blog I have touched on my personal memories of the time shortly before and after the diagnosis with diabetes and on the the changes it brought about. In this second blog I will tell you a bit more about my memories of some of the periods in which my lifestyle changed as a result of having the disease.

Conservative therapy with mixed insulin requires discipline

Definitely according to modern therapies, I was conservatively established on a therapy with mix insulin, Novomix 30. One injection before breakfast and the second before supper. Three main meals and three ‘snacks’ in between. I am not sure whether or not I was already a disciplined person before my diagnosis, but I have never skipped a single injection or meal in all those 35 years. This implied that often I would decline food when, for instance, people would offer treat to celebrate, and often enough I would start eating when nobody else did, just because it was time for my snack or because my blood sugar was dropping.

I realized only much later that other therapies may have advantages, for instance using long acting insulin and injecting short acting insulin before eating.

More about this in blogs to follow.

My lifestyle, the first 35 years, was quite old-fashioned, as a diabetic, that is. Focus was for me to prevent high blood glucose levels, no consumption of sweet food and limited carbohydrates. I considered a low glucose level of e.g. 3 mmol/l (<60 mg/ml) a much better outcome than a relative high value of e.g. 12 (>200 mg/ml). Also, a low level was an opportunity to eat candy, like a mars, or have a sandwich with syrup.

At home, my mom was, and is, the queen of homemade apple-pie – really delicious, especially when right out of the oven! Until not so long ago, a whole pie would be baked just for me, without sugar, but with candarel sweetener (the powder is mostly used for warm meals, whereas the liquid sweetener is better in cold dishes). Still, the rest of the siblings claims to be upset when looking at the homemade apple pies and the largest one being mine, upon celebrations where we tend to meet each other at the family home. I am sure they are just kidding… or aren’t they?

In the early days of my diabetes it was recommended to have your blood glucose levels >3 and < 10 (>54 and <180 mg/ml), but my current doctor (in Germany) classifies every value below 4 mmol/l (72 mg/ml) a hypo. I tried to find the (Dutch) ‘>3 and <10 campaign’ on the internet. Nothing there. Although not a very frequent self-monitor of my blood glucose, I did stick to the 3-4 monthly analyses of my HbA1c by the laboratory. The value was almost all the time around the 6% (people without diabetes have a value of 4-6%; diabetics should aim for values below 7%), telling me that the mean blood glucose levels were in range for the last 2 to 3 months. That was comforting news, although it is possible that the relatively solid values were the result of many/long-lasting low values (“Sie unterzuckern” is what my current doctor says). To check that I should have made more day curves and monitor glucose levels every 2 hours – see next blog for more.

Sports and jojo-effects

At the time of my diagnosis I played some tennis; in my first blog I mentioned to have taken on fitness, when I was losing so much weight.

When starting the insulin therapy, I remained playing tennis, increased fitness frequency and intensity – I increased weight at high speed, from 59 kg towards 90. I also decided to start playing basketball and field hockey, bringing my average of sports activities to 4-5 times per week. Not just for fun, but also helping me to burn energy/sugar to retain low blood glucose levels.

I have ended up in some bad situations because of it. As a young man I could deal and function pretty well still with blood glucose levels of around 3 mmol/l (54 mg/ml); in case the low levels remained for longer periods I kind of switched to auto-pilot, functioning in some kind of dream world. Now and then I have really given my body a beating with all the sports activities. Like the time I was stationed as a postdoc at the MD Anderson Cancer Center in Houston, Texas, playing basketball almost every night with the med-students at the campus courts. It happened a few times, getting to bed at home afterwards, that I woke up in the ambulance. Whatever sweets I ate or drank during and after the games, the muscles apparently wanted more and more sugar from the blood resulting in hypoglycaemia, which for me indicated that my blood glucose levels must have been under 2 mmol/l (36 mg/ml) for quite some time.

No fun! Especially not for my next of kin. When, after a glucagon injection, I would regain conscience, in an ambulance or not, I would be overwhelmed by a tremendous sense of guilt. I should have monitored my glucose levels more frequently, I should have eaten more, I should not scare my wife and children so badly, …

Having diabetes never stopped me from travelling, neither privately nor work-related. In case of transatlantic flights to the U.S. I would remain on the European time schedule with my two Novomix injections for as long as possible, and would take one extra injection before American supper. To calculate the extra units of insulin I did the following. The total number of insulin units of one day divided by 24 hours would give me the number of units per hour – with a time difference of 8 hours (the west coast is 8 hours behind) I would inject 8 times that number of units. On the return trip I would reduce the total amount of insulin with that number of units. Always seemed to work quite well.

 

With today’s knowledge …

With an active lifestyle, travel and/or sports it can be of benefit to have an insulin therapy that fits that lifestyle and is flexible. Although I have been able to live my life the way I wanted with a mixed insulin therapy, in hindsight I think it might have been easier if I had made a switch sooner, to a treatment with separate long-acting and short-acting insulins.

 


FURTHER READING

Novomix 30

Novomix 30 is a mix containing 30% fast-acting insulin aspart, and 70% long-acting insulin aspart protamine crystals. The insulin mix starts working within 10 to 20 minutes and the fast-acting insulin reaches a maximum effect between 1 to 4 hours after injection, whereas the long-acting lasts up to 24 hours (steady state).

Hypoglycaemia

The term hypoglycaemia is used when blood sugar level drops to below 3.8 mmol/l (70 mg/ml). The symptoms and the severity can vary per person. With the body trying to increase blood glucose you may experience shaking and sweating. When still capable, best remedy is to consume sugar (monosaccharides), like Dextro Energy. You can purchase glucose/dextro tablets that are easy to carry with you – also effective, but with a lesser fit in your pockets are the so-called high-energy sports drinks. When eating or drinking is no longer possible, glucagon can be injected. Glucagon is a hormone acting on the liver via the blood to release glucose.

 

HbA1c: HbA1c

Red blood cells transport oxygen in your blood using the haemoglobin (Hb); during their lifespan of approximately 3 months Hb will bind sugar: the higher the blood sugar the more will be bound and the higher the HbA1c value.