How To: Know How Different Insulin Regimes Compare

This section is for everyone.

Basal insulin holds the blood sugar steady between meals and during sleep. A bolus is a dose of fast acting insulin given to cover meals or to reduce a high blood sugar.

Here are some popular ways of using these insulins.

Two mixed doses

Eg Novomix or Mixtard.  The basal and bolus insulin is premixed in a fixed combination so that only two injections are needed in a day.

A high level of consistency is needed for meals and snacks. What is eaten and when it is eaten can be manipulated to give good results. The difficulty is that there is very little flexibility and you can’t just miss meals or eat more than usual and get away with it.

If your blood sugars are running high with this regime the main technique to get back in track is to give the injection and wait till the blood sugar has dropped before eating. Lows can also occur and you need to develop snacking routines to even these out.

This regime is often used for people who need help with their injections or who want to avoid injections such as younger school children and in the elderly or visually impaired.

Where money is an issue mixtard is cheaper than then newer analogue insulins.

The best coverage with this insulin is at breakfast and the evening meal. The injections are usually given 15-45 minutes before these meals depending on the type of fast acting insulin used.  A lower carb meal can be eaten for lunch to help keep sugars normal. Alternatively a separate injection of regular or a rapid acting analogue can be given before lunch.

Morning mixed with evening split

Eg Mixtard am, Actrapid pm and Lente bedtime.

This regime covers the dawn phenomenon quite well because of the duration of the lente insulin. The mixed insulin in the morning means that injections during the school day can be avoided.

The minus points are a tendency for lows before lunch and high blood sugars after lunch.

This regime is not used frequently but it can suit some people very well. I know of a teenage girl who has a degree of intellectual impairment.  She has  a considerable dawn phenomenon.  She uses this regime to avoid having to give insulin injections while she is at school.

Multiple daily injections with long acting basal

Eg Humalog for meals and snacks with Lantus once or twice a day.

This regime gives much more flexibility for meals than mixed insulin regimes.

The disadvantages are the number of injections. There can be 4-10 a day.  Insulin pens are generally easier to carry but are more expensive than vials and syringes. The insuflon device can be useful for babies or toddlers on a MDI regime as the insulin is put in the same channel for a day or two so can be less uncomfortable.

This regime is the most popular for most older children and adults. In the USA all children are started on an intensive regime from diagnosis. In Europe there is more tendency to use a mixed regime at least to start with.

When it comes to advanced insulin techniques this is the method that I will mainly be discussing.

Insulin Pump Therapy

This is also known as a continuous subcutaneous insulin infusion system or CSII. It has been developed in the US and is much more popular there  than in the UK.

Plus points are that finer tuning with insulin is possible with this technique particularly due to the ability to alter basal rates.  Most people need to change the insertion device every 1-3 days.  Once this is done there are a greater variety of bolus patterns you can use without having to have another injection.  Many users love their pumps and greatly prefer it to the MDIs especially once over the first few months.

Disadvantages are that it is comparatively expensive. It costs about  £5000 for a pump for five years use with an additional £1000 a year for sterile consumable supplies. You still need to have pens or vials and syringes handy  in case of pump failure.  It is available in some UK centres but the cost is not borne by the NHS and must be paid for in person or from a charity.  A great deal of learning and monitoring is required to use this method successfully.

There are also problems that can occur on the short and long terms. Pump failure through the night can result in you going to bed with normal blood sugars and waking up in diabeticketoacidosis.  Long term scarring at the infusion sites and the occasional abcess can also be problems that result in users going back to MDIs.

Quick Quiz:
There is no quiz for this section.

Reference Info:
Acknowledgements to Dr Gary Scheiner’s Think Like a Pancreas.

Where to Next?
Please all continue to the How To: Calculate My Insulin Sensitivity section.

How To: Use Insulin to the Best Effect

This section is for everyone.

In this section I am aiming to give you information on  what you need to know to use insulin not just to keep you alive, but to keep you as well as you would want to be if you didn’t have diabetes.

I will be discussing different sorts of insulins and different sorts of delivery devices.  Most basic techniques are covered in your diabetic clinic but here I want to help you take things further. I want to try to help you get the best match possible to cover your daily rhythms and food intake.

As in most of this course self experimentation is the key. Various techniques are described and you have to decide if you would like to use this technique to control your blood sugars or not.  You then need to change what you do in a gradual and controlled way.  Whenever you are experimenting with new food, exercise and insulin patterns you need to test more frequently and be prepared to adjust things according to the results you are getting.

I hope that you will have started to count up how much carbohydrate you are eating each day. You may still be seeking some more information before you begin to reduce it and this is okay.  Arm yourself with lots of test strips for this section!  And lets begin.

What is insulin?

Insulin is a big protein made by the beta cells of the pancreas. It controls several functions in the body.  The most important ones for diabetics are:

Insulin tells certain cells to take in sugar from the blood stream and so drops blood sugar levels.

Insulin tells your liver to reduce the amount of sugar it is making from protein.

Insulin is a growth hormone.

Insulin is a fat storage hormone.

High insulin levels tend to stiffen and age your blood vessels.

In 1922 researchers in Toronto, Banting and Best discovered how to extract insulin from animals to give to humans.

Fine tuning did not really exist until blood monitoring was popularised in the 1980s for all type one diabetics. Since then genetically engineered insulin has been produced from yeast and the e coli bacteria which is structurally identical to human insulin.

Different action times of insulin have been developed by altering the chemical structure of the insulins or by the addition of stabilising substances.

Syringes and vials have been supplemented by pen injectors, pumps, and now inhaled and oral insulins.

There are different potencies of insulin with different onsets and durations of action. Eg rapid acting, regular insulin, intermediate acting and slow acting.

Modern analogue insulins tend to have a more predictable pattern of action than some older insulins. Unfortunately their popularity and higher price has resulted in some older insulins becoming less profitable and there has been a decrease in the range of insulins available as a result. One of the most noticable is the lack of human  regular insulin available in pen form. You can use Novonordisk actrapid in vial and syringe but need to use a pork or beef derived actrapid to have this duration of insulin in pen form. This is available from Wockhardt in the UK and the Owen Mumford Autopen Classic is the delivery system but is only available in one and two unit increments.

In general the total carbohydrate content of a food is a more important consideration than the amount of sugar in it. Whether it is a starch or a sugar that is present the same amount of insulin is needed to deal with it and both types raise your blood sugar pretty fast. Your major challenge is to carefully match your insulin intake to your carbohydrate intake. There are also factors like exercise, stress and illness to be considered.

Where do I inject?

One of the best sites to inject insulin is in your bottom or on the fat pad above your trouser line. These areas usually are quite fatty and tend to hurt the least. You are also most unlikely to mistakenly inject into a muscle.

Other sites that you may use in public are your abdomen or your thighs. You can adjust your clothing or inject through it.

Some people prefer to inject in a washroom and others will be happy to inject at the table in a restaurant or plane.

How do I inject insulin?

If using a vial and syringe the best technique is to draw up the insulin smoothly and quickly and inject it smoothly and quickly.  Dr Bernstein has a video of this in his CD series.

If you use a pen you need to count to ten slowly, “one thousand, two thousand…” etc.  Otherwise the insulin tends to leak a bit more than you would like.

For pump users they need to change the site anything from daily to every three days. The abdomen and  rear trouser line are the most popular. Special hygeine routines are helpful in preventing infection.

If you are using plain needles you don’t need to clean the area with an alcohol swab. You just inject.

The needle depth and fineness can vary.  6, 8 and 12 mm needles are available in the UK.  If you are pretty thin or using your thighs a smaller needle is often used. If you are fatter or prefer your backside the longer needles are better.

In some circumstances you may want to put the needle into muscle. This could be for the purpose of achieving a more rapid effect which you may want to use if correcting for high blood sugars.

Basal Insulin

The basal insulin level should be matched to the liver’s normal secretion of sugar.  Because the liver tends to produce different amounts of glucose at different times of the day and night the insulin requirement will also vary. The right basal rate is one that keeps your blood sugar at a fairly constant level when you have not eaten or bolused for several hours and are not exercising.

An insulin pump gives the most flexibility over basal insulin dosages at different times of the day.

For people on a multiple daily injection regime the main analogue basal insulins are Lantus and Detemir known in Europe as Levemir.   Lantus should not be mixed with other insulins because it depends on its action for its acidic pH.  Detemir has 75% of the potency of Lantus. It is not acidic and does not sting like Lantus can when it is injected.

Lantus lasts about 22 hours in most people and Detemir lasts about 16. Either insulin can sometimes be given once a day successfully for some individuals but most people get on better with twice daily injections for both of them.  The best time to give them is right before bed and when you get up in the morning. If you have a marked dawn phenomenon no more than a 9 hour gap between the night and morning injection is recommended by Dr Bernstein.

It can take about three days for your blood sugars to stabilise after altering your twice daily basal so it is best to keep changes to three days apart or more so you can get a true reflection of the results of your insulin adjustments.

Older insulins have been stabilised so they last a long time such as  the Lente and Ultralente insulins. They are sometimes combined with shorter acting regular insulins so you can reduce the number of daily injections.  If you have a  cloudy insulin such as this it needs to be mixed thoroughly before injection. Rolling the vial or pen gently up to 20 times is advised.

Protecting Insulin

Your insulin stores can be kept stable for years in  a correctly maintained domestic refrigerator but once out and about insulin needs to be kept at room temperature or a bit cooler to retain its potency.

It can go off rapidly if overheated eg from being left in a car on a hot day.  Lantus is particularly fragile and light can affect it too. Lantus lasts in good condition for about 3 weeks and most others last about 4 to six weeks.

When you are going to be in a hot environment you can store your insulin in a frio wallet. These are available in the UK from Boots online. They are more widely available in the US. These come in different sizes and can hold insulin pens or vials.

When you travel on a plane you must keep your insulin in your hand luggage. If it goes in the hold it could freeze without you being aware of it and this too will seriously impair its effectiveness.

When you go skiing or out on a very cold day keep your insulin next to your body to prevent freezing too.

Missed a dose?

If you miss your basal by only a few hours you may simply give it as usual. If you are more than 4 hours late however the action you take may vary.  Let us assume you are awake during the day and sleep at night.

You miss your night basal which you normally give at 10 pm and remember when you get back from the party at 3am.

Check your blood sugar. You are a bit high. Give a proportion of your basal let say half of the usual dose and go to  sleep. You  probably need to sleep before work tomorrow more than worry about whether any correction dose you are thinking about is going to drop you too low through the night, especially if you have had more than one alcoholic drink.

You are likely to have to give a correction dose along with your morning basal but monitoring your sugars is easier during the day when you are awake. Put it down to experience.

You can even write essential tasks or times on ball point pen on the back your hand. Usual handwashing takes about a day to clear it and if you want to wipe off your “to do” list   little alcohol swabs come in handy.

You miss your morning basal You took your basal insulin with you to a friend’s last night and remember in the morning that it is still in your bag which is in her car. She lives across the city, and the pharmacy does not open till 2pm, and you have no spare because you have not been paying attention to the advice you were given in the organising your supplies section.

Give yourself a series of correction doses during  the day before your meals. You can use novorapid or humalog and these last about 3 and a half hours.  If you have regular insulin this is  even better as it lasts 5 hours.  Start your basal again with the night injection.

Missing a day dose is usually easier to deal with because you are awake and you can correct any lows easier.  Keeping a notebook or having one of the new pens that records your doses can be helpful. Because looking after your diabetes becomes so automatic you can easily get muddled up about whether you took the dose or not. When you are one of two parents or carers and not the diabetic person it is even more important to record what you do.  Without this it can be  even easier to make mistakes and give an infirm person or a child two doses of insulin or none !

It is human nature to muddle up from time to time. When you do, the most important things are  forgive yourself,  calm yourself down, and  THINK !


Quick Quiz:

Have you got it?

1. In a restaurant three of these places are suitable for insulin injections…

a In the washroom.
b In the abdomen at the table.
c Through your clothing.
d Hiding underneath the table.


2.The Glycaemic Load of a food is …

a Its relative effect on your blood sugar.
b A measure of the percentage of carbohydrate it contains.
c A measure of how much insulin is needed to cover the food.
d A measure of how much the food fills you up.

3. The Glycaemic Index…

a Has been extensively tested on diabetics.
b Tells how fast your blood sugar will go up with certain foods.
c Should be the basis for a sensible eating plan in every diabetic.
d Needs to be verified by personal experimentation.

4. For insulin users you need to monitor you blood sugars in three of these situations…

a Before and after exercising.
b Before you drive and at hourly intervals when driving.
c Before you go into a public place like a cinema.
d Whenever you feel hungry or suspect you could be running higher or lower than normal.

5. Three helpful tips for type one youngsters include…

a Have your bracelet, insulin, tester and food when you are on an outing.
b Carry a charge mobile phone.
c Carry money in case you need to buy food.
d Avoid telling your mates you are diabetic so you will fit in better.

6. Three of these statements about insulin are correct. Which one is not correct…

a Lantus must never be mixed with other insulins because it depends on its acidic pH for it’s action.
b Cloudy insulins must be mixed thoroughly before injecting.
c Detemir has twice the potency of Lantus insulin.
d Humalog and Novolog have 150% of the potency or regular insulins.

7. Three statements about basal insulin are true…

a It is used to cover meals.
b It should be matched to the liver’s normal secretion of sugar.
c It is needed to keep the blood sugar level steady between meals and during sleep.
d Can be most accurately obtained by using an insulin pump.

8. At college don’t bother with one of these…

a Testing your sugar before exams.
b Eating food when you drink alcohol.
c Getting your flu shot every year.
d Going to parties.

9. When you go on holidays it is silly to do one of these…

a Go to a theme park and forget a rendezvous point.
b Carry extra food and drinks on planes.
c Test draught drinks with diastix.
d Work out how you will deal with time zones before you go.

10. Advantages of being a type one diabetic can include three of these…

a Getting a fridge in your room at college.
b Getting a room nearer the kitchen at college.
c Sleeping in on the mornings on days off.
d Getting a pass to skip long queues at some theme parks.

Have you got it?
1. D is taking secrecy too far! Although many people still prefer the privacy of a washroom it is entirely acceptable to inject at the table. With the rise in the number of people with diabetes you can expect to see this happening more frequently.

2. A is correct. The GL is and indication on what effect you can expect that food to have on your blood sugars. The carbohydrate index is the percentage of carb a food contains. This can be a helpful technique in carb counting.

3. D is correct. Its all about self experimentation. The GI was tested on healthy non diabetics. It is a rough indication of how fast sugars are released and diabetics are wise to steer clear of very fast acting carbs. The precise rate of release however depends on so many factors such as quantity, chunk size, temperature and what sorts of foods are eaten along with them that personal experimentation is the only way to find out how a food that you eat regularly will affect you.

4. ABD are musts. Use your own discretion in other situations.

5. ABC are sensible. Not telling your mates isn’t!

6. ABD are all correct. Detemir is weaker in effect than Lantus unit for unit. Detemir has around 75% of the potency of Lantus. As these are both basal insulins it is unlikely that you need to remember this unless you swap one for the other for a particular reason.

7. BCD are correct. Pumps can be adjusted for the dawn phenomenon and exercise patterns with much more versatility than basal injections. This is one of their major advantages. There are trade offs in other respects of course. Bolus injections are used to cover meals.

8. D. Parties can be quite a challenge for young diabetics away from home. Always drink moderately and avoid drugs. Let your mates know about how to detect and treat hypos. If you have passed out they must get you to hospital.

9. A is correct. It is also sensible to write down exactly where you have parked the car! Diastix were originally used to detect sugar in urine but they can be very handy for testing whether your cola is the diet version or not.

10.ABD are correct. And you didn’t think there were ANY advantages to being insulin dependent did you? Unfortunately having a lie in is not on. You must get up at the usual time to test and give yourself your basal insulin at the very least.

Reference Info:
Acknowledgements to Dr. Bernstein’s Diabetes Solution and Dr Schiener’s Think Like a Pancreas.

Where to Next?
You could be a bit tired out by that long quiz. Take a break and lets all meet back at the How To: Know How Different Insulin Regimes Compare section.

How To: Know if My Insulin is Still Good

This section is for everyone.

Never use insulin that doesn’t look right. Humalog, Novorapid, Regular, Lantus and Levemir/Detemir should look clear.

Novorapid lasts six weeks.
Lantus can go off after 3 weeks and is the most vulnerable to going off if exposed to heat or light.
Most others last a month.

If your sugars are going a bit high consider if old insulin may be the problem and open a new vial. New insulin can be more potent than month old insulin.

Heat can cause long lasting insulin to act like short acting insulin and give you low blood sugars. Leaving it in a hot car can cause this effect.

Get a big cin bin from a pharmacy or your diabetes clinic to dispose of your sharps. Take it back for a new one when it is full.


Quick Quiz:
There is no quiz for this section.

Reference Info:
Acknowlegements to Spike and Bo Loy. 487 Really Cool Tips for Kids with Diabetes

Where to Next?
Please continue to How To: Be the Star of Your Diabetic Clinic