# Can insulin be too strong?



## EmmaNew (Dec 29, 2015)

Hi. So I had gestational diabetes 5 years ago and controlled it extremely well with diet only. However after yearly checks earlier this year my GTT was too high and after treating me for type 2 with increasing (up to maximum) doses of Gliclazide and Metformin they decided to try insulin by injection (first on Novorapid which I was allergic to and now Apidra). My dad is type 1 and fantastic at keeping good bg so it's not Alien to me and I have really good knowledge of foods. However after finding that 1 unit to every 10g of carbs was way too much for me I started to reduce it to 50 %-75% of 1 unit per 10g but I find that the insulin seems to rush in and my bg comes tumbling down way too low and I end up eating like it's some kind of race just to get the food into my system as quickly as possible and then when it does finally get in I go high again. It's like I need the full dose but it just works too fast. My consultant agrees with me that injecting after food is not a good idea. Does anyone know if I would benefit from an analogue instead? Sorry if tmi but it's driving me mad and now I start to panic every time I take it


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## AlisonM (Dec 29, 2015)

Hi Emma and welcome. It does sound as though you are very sensitive to the insulin. The only thing I can think of is to inject half what you think you need before you eat and then top up after in small increments if you need more. But I'm no expert and I'm sure some of the other T1s may have better advice for you. Analogue is certainly an option worth considering if you can't find any other solution.


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## EmmaNew (Dec 29, 2015)

Thanks Alison. I think next time I get a check up my consultant may swap me onto an Analogue. I think the only reason he didn't last time was because he'd literally just swapped me from the Novarapid. Are there any side effects with an analogue do you know or are they just slower acting?


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## AlisonM (Dec 29, 2015)

I honestly don't know. I'm on Lantus and Novorapid and doing well with them. Again, one of our 'proper' T1s should be along soon and may be able to tell you.


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## khskel (Dec 29, 2015)

The only time this has happened to me is if I've had a higher than normal carb content in my meal and the insulin has hit before all the carbs. It may be worth trying splitting your bolus as Alison suggested to give the insulin 'hit' a smoother profile. I know 60/40 pre post eating ratio has been suggested before but we are all different so experimentation may be in order. I've only ever used Novorapid so can't comment on the difference between that and other insulins.


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## Copepod (Dec 29, 2015)

Novorapid, Apidra and Humalog are all short acting analogue insulins, so Humalog might be an option for you. The important thing is to match your insulin maximum effect with when carbohydrate hits your blood stream. So, if that means injecting after eating, surely that must be worth trying?

There's a graph of insulin action here:http://dtc.ucsf.edu/types-of-diabet...therapies/type-2-insulin-rx/types-of-insulin/ lispro / 
lyspro = Humalog; aspart = Novorapid; glulisine = Apidra. So, there's not much to choose between these for profile of action.


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## Matt Cycle (Dec 29, 2015)

Hi Emma

Analogue insulins are altered forms of insulin so include long, medium and short acting.  NovoRapid, Apidra, Levemir etc are all insulin analogues.  If you think about it the normal working pancreas simply produces insulin it doesn't produce different types for different situations.  With MDI to try and replicate this there is a long acting (basal) and a short acting (bolus) to cover meals.  In a working pancreas it constantly drips insulin as a background and then releases it when carbs are eaten to cover that.  This is what pumps try to do and hence only use fast acting insulin - the drip for the basal and then a release or a split release for meals.  To do that on MDI you would have to be injecting all the time! 

Do you only use Apidra? i.e. no long acting insulin?


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## trophywench (Dec 30, 2015)

I wonder what ingredient you are actually allergic to?

Of the 3 normal bolus insulins in common use - Apidra is the fastest acting - it whizzes in, in 10 minutes flat when it's working bang on for you and you appear to be mega insulin-sensitive.   Novorapid and Humalog both start a bit slower than that -20/25 ish minutes after you inject.

They all also last for different times too - Apidra c 3.5hrs, Novorapid c 4 hrs both tailing off nice and gradually and Humalog seems like it finishes after 4 hrs the same but often has quite a 'sting' of activity in it's tail, so nearer 5hrs.

You probably need to jab Apidra in, in the middle of eating if you stay on MDI - but IMHO - you would do brill with a pump because you could have an extended bolus with every meal.

Anyway - you haven't tried Humalog yet !!

Where's Pumper Sue - she can't use any of those 3 - and uses animal insulin still, in her pump.  Whilst most of the rest of us have to seriously delve into the backs of our brains to remember what the heck they used to behave like for us - she is brill at it as it's entirely currect info for her.  And it is much slower onset than any of the modern ones - to get the same effect you always have to inject about 15-20 mins before your dinner is ready - I used to say 'When I put the spuds on, is when I have to jab'  There are also possibilities with mixed insulin, but you do have to have a pretty set lifestyle for those which really doesn't suit an awful of people.   So you haven't reached the end of all the possibilities by any means - yet !


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## EmmaNew (Dec 30, 2015)

Matt Cycle said:


> Hi Emma
> 
> Analogue insulins are altered forms of insulin so include long, medium and short acting.  NovoRapid, Apidra, Levemir etc are all insulin analogues.  If you think about it the normal working pancreas simply produces insulin it doesn't produce different types for different situations.  With MDI to try and replicate this there is a long acting (basal) and a short acting (bolus) to cover meals.  In a working pancreas it constantly drips insulin as a background and then releases it when carbs are eaten to cover that.  This is what pumps try to do and hence only use fast acting insulin - the drip for the basal and then a release or a split release for meals.  To do that on MDI you would have to be injecting all the time!
> 
> Do you only use Apidra? i.e. no long acting insulin?



Thanks for your input. I take Lantus - just 6 units at bedtime which works perfectly for me as I wake up between 6.5 and 10 regardless of what I fall asleep at. As you can tell just 6 units is nothing and I must be quite sensitive to that too.


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## EmmaNew (Dec 30, 2015)

So when I tried Novarapid my tongue swelled - even with as little as 4 units so I think they were concerned if I took a larger amount I could go into anaphalactic shock. Apparently it is the preservatives that people can be allergic to. 

Just as a for instance a big meal with 150g of carbs and bg at a high of 15 before I start taking 8 units (half the advised dose) brought me to a 3.8 1 hour after food and the jab of Apidra. 3 sugary sweets and 10 minutes later 3.4 a couple more sweets and 30 minutes later creeping up to 4.4. 3 hours later 22.3.  That's what happens every meal. If I start my meal on a 7 or 8 I'm really reluctant to inject 5 or 6 units as it just sends me through the floor.


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## trophywench (Dec 30, 2015)

Well - alter your carb ratio and correction ratio again then!  These things aren't graven in stone and aren't even always the same at all times of day. 

Or - you might need to change what you do for such a high carb meal perhaps.  150g of crab is more than I have all day, most days.  There is a theory that if you actually jab more than 7u, you just take it as more than one jab anyway, as higher doses don't seem to be absorbed so well - but you have the opposite problem anyway!  LOL


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## Matt Cycle (Dec 30, 2015)

That is quite a drop!

Agree with TW in trying to reduce carbs and seeing how that works out.

The other option is an intermediate acting insulin.  You would however lose some of the flexibility you currently have on Apidra and Lantus.


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## HOBIE (Dec 30, 2015)

Welcome !  A T1 your pancreas does not work. A T2 it could work 80% or 20%. Hope you can find out what is going on


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## EmmaNew (Dec 30, 2015)

trophywench said:


> Well - alter your carb ratio and correction ratio again then!  These things aren't graven in stone and aren't even always the same at all times of day.
> 
> Or - you might need to change what you do for such a high carb meal perhaps.  150g of crab is more than I have all day, most days.  There is a theory that if you actually jab more than 7u, you just take it as more than one jab anyway, as higher doses don't seem to be absorbed so well - but you have the opposite problem anyway!  LOL



Even in a low or no carb meal 2 units will rush in and drop me far too low and then I'll rise too high later. The insulin definitely works too fast but it appears I need a little more than I can take.


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## HOBIE (Dec 30, 2015)

I don't ever think I have ever had 150g meal before !  70g at most.


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## EmmaNew (Dec 30, 2015)

Lol! not even starter main and dessert?


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## HOBIE (Dec 30, 2015)

I hate deserts. & honest I don't think I have ever had a meal with more than 70g. I have been T1 for very nearly 50yrs. I could & have had 2 lots of starters & main.


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## EmmaNew (Dec 30, 2015)

I think I had garlic bread then pizza that day with a cakey dessert. Maybe I'm over estimating my carb intake but that wouldn't explain the later highs. Grrrr.   I'll get there. Thanks for your advice.


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## AJLang (Dec 31, 2015)

Hi welcome to the forum.  The meal that you've just described is very high in fat as well as high in carbs.  A high fat meal will delay the absorption of food into your system so the insulin is working faster than the fat/carb being absorbed. This would explain what is happening to you because your insulin is working before the food is hitting your system. As others have said 150g carb is a lot for one meal to be able to balance blood glucose levels.  Maybe sometimes but you might want to reconsider this is suitable for you on regular basis.
I know that some people split their bolus insulin for high fat meals so hopefully they will be able to explain how they do this.  Also you say that your lantus is working because of the overnight levels but have you done basal testing for during the day to check if the lantus is working effectively for 24 hours?  A lot of people find that two injections of Levemir a day (plus a bolus for food) helps them to smooth out their levels better.


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## AJLang (Dec 31, 2015)

EmmaNew said:


> Even in a low or no carb meal 2 units will rush in and drop me far too low and then I'll rise too high later. The insulin definitely works too fast but it appears I need a little more than I can take.


If it is a no carb meal then you shouldn't be injecting any bolus.  Have you been taught carb counting?


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## EmmaNew (Dec 31, 2015)

Hi. Thanks for your advice. I have the carbs and cals book and app and use it every meal to record everything.I know about the absorption of carbs when eating a high fat meal and as you'll know this was a one off meal and not something I regularly eat which is why i took half the dose the app suggested, but as you can see a drop of 12 points in 1 hour is rapid and quite scary! I think as a few have said I need to ask about splitting my dose as regardless of the meal I eat I always drop far too low before picking up.x


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## trophywench (Dec 31, 2015)

EmmaNew said:


> Even in a low or no carb meal 2 units will rush in and drop me far too low and then I'll rise too high later. The insulin definitely works too fast but it appears I need a little more than I can take.



Well of course it will with a No Carb meal!  You don't take any insulin for it, if you aren't eating carbohydrate. 

30g of carb is for example, a sandwich using 2 slices of large, medium sliced bread.  That's about the extent of my entire lunch most days and has been since I was about 11 ! - but there again I have always had a sedentary job since I was 16, though the 5 years of that when I was still at school, obviously my day might include an hour of hockey, netball, tennis, gym, mixed athletics etc and in adult life I've done a couple of hours at the gym, or doing aerobics or running - during those times, I would have my evening meal afterwards.

Presumably you have a half unit pen so you don't have to always round your doses up?  I never had a half unit pen because in those days they were very new and they only issued them to children whereas now they're available for everyone.  (not disposable pens - the ones you use permanently with cartridges)  Incidentally, when I used to have to round up/down on MDI, I only would go up if it was 7 or more - at 5 or 6, I would round down.  Are you doing that bearing in mind you know your sensitivity?


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## EmmaNew (Dec 31, 2015)

Because I am always well into double figures before I eat I have to take a unit or 2 before I eat a low carb or even no carb meal to help keep it down! And no I don't have a half unit pen and I don't round up or down I take half the recommended dose as I said before!


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## Copepod (Dec 31, 2015)

Just realised that different injection sites haven't been mentioned. Do you always use the same places?


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## EmmaNew (Dec 31, 2015)

Yes I use my tummy. One side for short and the other for long acting. Would changing the site change the absorption? ​


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## SueMC (Jan 3, 2016)

EmmaNew said:


> Hi. So I had gestational diabetes 5 years ago and controlled it extremely well with diet only. However after yearly checks earlier this year my GTT was too high and after treating me for type 2 with increasing (up to maximum) doses of Gliclazide and Metformin they decided to try insulin by injection (first on Novorapid which I was allergic to and now Apidra). My dad is type 1 and fantastic at keeping good bg so it's not Alien to me and I have really good knowledge of foods. However after finding that 1 unit to every 10g of carbs was way too much for me I started to reduce it to 50 %-75% of 1 unit per 10g but I find that the insulin seems to rush in and my bg comes tumbling down way too low and I end up eating like it's some kind of race just to get the food into my system as quickly as possible and then when it does finally get in I go high again. It's like I need the full dose but it just works too fast. My consultant agrees with me that injecting after food is not a good idea. Does anyone know if I would benefit from an analogue instead? Sorry if tmi but it's driving me mad and now I start to panic every time I take it


I was gestational also at age 34. Started with oral meds 5 years later, then byetta was added  when that stopped holding me steady. Levamir was added. Byetta with Levamir may work better for you.


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## KookyCat (Jan 3, 2016)

Hi Emma
I'm very sensitive to insulin, I react very quickly to it and so I can only take very small doses.  The maximum mealtime dose is 3 units which for me is 60g of carb or 75g in the evening, but I have to be feeling pretty brave to go higher than 2 units in the evening because I'm very prone to nighttime hypos.  The basal testing might be a very good next step for you if only to rule out the possibility that you either don't need basal at all, or you need more.  Once you know the baseline is correct it's easier to come up with strategies.  I started out last year on a ridiculous amount of basal (30 units) and was hypo and then hyper constantly.  I take 6-7 units of basal now.  It was very hard work getting to the root of the problem though because i was rebounding a lot.  I'm lucky my liver is quite keen and shoves out glucose to rectify the lows but it did obscure the problem quite a lot. 

Incidentally I frequently inject mid meal which you may find helps as a short term solution it gives the food time to get going before the insulin hits.  Longer term I did the following to find the actual problem.  Fixed carb meals for a while, preferably if funds allow something carb counted independently (I used the M&S balanced meals because they're easy, and resemble actual food). If funds or family circumstances don't allow that then weigh everything and use the packets or carbs and cals to make sure you've got the exact amount of carb.  That rules out one factor, namely that you're not estimating carbs correctly.  I went for food that was mid level on fat, so there wasn't the high fat complication in the mix.  Go for around 40-50g of carb, on the basis that the amount of insulin for that amount should be conservative enough to prevent a hypo.  Pull your ratios right back, I went to 1:30 to start with but you might want to do 1:20 say and then test every 30 minutes (to see how you respond to food and insulin which helps to work out if it's just a timing issue rather than a dose issue).  This most likely won't be enough insulin but even the high reading later will tell you something.  If you're like me then the reading you get  after the meal will be lower than you're used to which shows you that you were rebounding before.  I was actually rebounding most of the time, then I'd having major hypo clusters, which I now realise was when my body was depleted of glucose stores.  Its counterintuitive to take less insulin when running higher blood sugars but I was going utterly insane with it all, and like you feared injecting rapid because it was it was like trying to control a tsunami (that might be exaggerated to some reading this but I was at breaking point by this stage).  I wish I could say my medical team provided lots of help and advice but they didn't, they were pretty useless because honestly I don't think they had any idea about insulin sensitivity.   The exercise above helped me identify the issue and once I'd got my ratios sorted (not the 1:10 the DSN and consultant insisted was perfect) it helped me prove to them that I knew how to count a carb, that the maths wasn't beyond me, and I wasn't hysterical.  Which was actually the starting point for useful help from them.  It's also how I worked out where my ceiling is for insulin amounts.  I did so basal testing first though and reduced the basal quite a bit before that point.

Anyway not sure if any of that is helpful, but I wanted to write it because I empathise with how you're feeling right now and wished someone had told me that we don't all conform to the same model when I was at the end of my rope


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## trophywench (Jan 3, 2016)

I've never ever had anyone say 1u to 10g was 'perfect' Kooky - I was always taught that it's just an easy (ie the maths is easy) place to START dose adjusting when learning to carb count and dose adjust - which you thereafter fiddle with constantly till you get to the point (ie the correct insulin to carb ratio) that is in fact right for YOU personally 9 times out of 10.  (I'm a bit gobsmacked as to how anybody who works with a reasonable number of different diabetics, could possibly make that statement!  Aren't you, knowing what we both know now - and bearing in mind you and I aren't doing it 9-5, 5 days a week?)  (Yours etc, Disgusted, Tunbridge Wells LOL)

Emma - I just thought half units make it easier for people not needing that much insulin, that's all.  And surely everyone has to round up or down on MDI - what would you do if it adds up to eg 17g or 28g carb?


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## Copepod (Jan 3, 2016)

EmmaNew said:


> Yes I use my tummy. One side for short and the other for long acting. Would changing the site change the absorption? ​


Generally, insulin is absorbed more slowly from bottom and thighs, more quickly from tummy and arms. However, injecting into legs before exercise will result in faster than usual absorption.


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## trophywench (Jan 3, 2016)

Had you considered that 2u as a correction only (you didn't say it was for a correction so it appeared you'd taken it for the meal) was too high to correct the high, therefore your insulin to correct, ratio needs to change, as well as your carb ratio, don't you think?

Also the site thing - if one side is for fast and the other for slow, you are having at least 3x as many jabs in one side of your tum than the other, aren't you?  OTOH for the purpose of jabbing the tummy actually stretches from just under your underwires and doesn't stop till it reached the top of your pubes, except for a 1.5 ins circle round your navel, so even on a shortarse like me, there's quite a bit of room!

Actually - most places that are virgin sites wherever they happen to be - are usually good absorption areas since multiple jabs in the same-ish area, builds up scar tissue within the dermis itself and can cause either total loss of fat there or nasty lumps.


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## KookyCat (Jan 5, 2016)

trophywench said:


> I've never ever had anyone say 1u to 10g was 'perfect' Kooky - I was always taught that it's just an easy (ie the maths is easy) place to START dose adjusting when learning to carb count and dose adjust - which you thereafter fiddle with constantly till you get to the point (ie the correct insulin to carb ratio) that is in fact right for YOU personally 9 times out of 10.  (I'm a bit gobsmacked as to how anybody who works with a reasonable number of different diabetics, could possibly make that statement!  Aren't you, knowing what we both know now - and bearing in mind you and I aren't doing it 9-5, 5 days a week?)  (Yours etc, Disgusted, Tunbridge Wells LOL)
> 
> Emma - I just thought half units make it easier for people not needing that much insulin, that's all.  And surely everyone has to round up or down on MDI - what would you do if it adds up to eg 17g or 28g carb?



I have a great deal to be disgusted about TW not least that they dispatched me from hospital with blood sugar that only registered as hi on my meter, so I'm fairly used to it   In this instance though it was an argument about where to start not wher they thought I'd stay, 1:10 was the starting point they wanted with very slow moves up or down.  To be fair to them I don't think they were prepared for quite how resilient my liver was in compensating.  Any how a half unit pen is a godsend so I heartily recommend it.


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## Redkite (Jan 5, 2016)

In addition to all the above advice, have you been tested for coeliac?  If you are type 1 (and also since you have autoimmune conditions in the family with your Dad being type 1), you have an increased risk of coeliac, and this can cause delayed absorption of food, which could lead to some of the problems you are having.  Worth ruling this out!


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