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440, No Ketones..what to do?

Discussion in 'Parents of Children with Type 1' started by danielsmom, Nov 28, 2011.

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  1. Amy C.

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    She logs on every day. I would imagine she doesn't quite know what to say. There are a lot of posts on this thread!
     
  2. danielsmom

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    yes there are many replies here...some I agree with and some I don't...I appreciate all your answers...just when things start sounding judgemental(to me) I prefer not to reply. Again I thank you for taking your time to respond.
     
  3. Brenda

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    I posted the note about Dr. Chase (and he was not the sole person who did the study) to indicate that the mixing of insulins had been researched. I was not familiar with the other study about the mixing of insulins.

    As for "why would you post this when the insulin manufacturers recommend not mixing?" (not sure of the exact wording), I guess I could point out that many parents are also told the following: change the lancet for every BG check; never re-use a syringe (I don't know if this is done or not; in a pinch, most would re-use if there were no other option.); do not inject through clothing; test for ketones every time the BG is 240 mg/dl or higher, etc. Over the years, CDEs, nurses, endos, parents, etc. have "bent the rules" many times. I am not advocating anyone do anything dangerous. In fact, I did not advocate that the OP or anyone else mix rapid acting analogues and long acting analogues, merely reported on a study that indicated it was ok to do. I try to let people know things that have been the subject of formal studies.

    For those who do not have acces to PubMed, here's the text of both studies:

    Mixing rapid-acting insulin analogues with insulin glargine in children with type 1 diabetes mellitus.
    Fiallo-Scharer R, Horner B, McFann K, Walravens P, Chase HP.
    SourceBarbara Davis Center for Childhood Diabetes, University of Colorado Health Sciences Center, Denver, Colorado, USA. rosanna.fiallo-scharer@uchsc.edu

    Abstract
    OBJECTIVE: To determine whether mixing insulin glargine (IG) with a rapid-acting insulin (RAI) analogue in the same syringe had any deleterious effects on glycemic control in children with type 1 diabetes mellitus.

    STUDY DESIGN: Data from 55 children mixing the IG with a RAI analogue was collected for 6 months before and 6 months after the insulin mixing began. Data from a control group of 55 children not mixing the insulins was collected at similar intervals. Parameters evaluated included hemoglobin A1c (HbA1c) values, number of non-severe and severe hypoglycemic events, number of diabetic ketoacidosis (DKA) events, and blood glucose distribution patterns.

    RESULTS: After 6 months of study, HbA1c values were equivalent for the control and test groups (8.54+/-1.14 vs 8.61+/-1.14, respectively; P=1.0000). Percentages of blood glucose values in, above, and below the target range did not vary significantly in the groups. There were no significant differences in the groups in the occurrence of non-severe or severe hypoglycemic events or of DKA events.

    CONCLUSION: There were no significant differences in glycemic control between children who mixed IG in the same syringe with a RAI analogue compared with children who took separate injections.

    AND

    Early pharmacokinetic and pharmacodynamic effects of mixing lispro with glargine insulin: results of glucose clamp studies in youth with type 1 diabetes.
    Cengiz E, Tamborlane WV, Martin-Fredericksen M, Dziura J, Weinzimer SA.
    SourceDivision of Pediatric Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA. eda.cengiz@yale.edu

    Abstract
    OBJECTIVE Clinicians who treat children with type 1 diabetes often try to minimize the number of daily injections to reduce treatment burden and improve compliance. Despite the manufacturer's cautions against mixing glargine with rapid-acting insulin analogs, clinical studies have failed to demonstrate deleterious effects of mixing on glucose excursions or A1C levels. However, no formal glucose clamp studies have been performed to determine whether mixing with glargine has an adverse effect on the early pharmacodynamic action of rapid-acting insulin in humans. RESEARCH DESIGN AND METHODS To examine this question, euglycemic glucose clamps were performed twice, in random order, in 11 youth with type 1 diabetes (age 15.1 +/- 3 years, A1C 7.6 +/- 0.6%) with 0.2 units/kg lispro and 0.4 units/kg glargine, given either as separate or as a single mixed injection. RESULTS Mixing the two insulins shifted the time action curve to the right, with significantly lower glucose infusion rate (GIR) values after the mixed injections between 60 and 190 min and significantly higher values between 270 and 300 min, lowered the GIR(max) (separate 7.1 +/- 1 vs. mix 3.9 +/- 1, P = 0.03), and markedly delayed the time to reach GIR(max) (separate 116 +/- 8 min vs. mix 209 +/- 15 min, P = 0.004). The GIR area under the curve was significantly lower after the mixed injections. Mixing had similar effects on plasma insulin pharmacokinetics. CONCLUSIONS These data demonstrate that mixing lispro with glargine markedly flattens the early pharmacodynamic peak of lispro and causes a shift to the right in the GIR curve changes that might lead to difficulties in controlling meal-related glucose excursions.


    As for whether or not people choose to mix the insulins, that is their choice, with the advice of their diabetes team.
     
  4. danielsmom

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    I agree Brenda.. thank you..
     
  5. Beach bum

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    I hope you are able to get some useful info out of the replies and apply it to your routine so that it can work for you.
    Being so new to this it is hard not to feel overwhelmed by everything, things will fall into place, but it takes work. What may work one day doesn't necessarily mean it will work the next, and that is one of the most frustrating things of all. I think the hardest part is making sure diabetes doesn't control you, but also that you don't control it to the point where it is all consuming in your life.
     
  6. nanhsot

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    Hmm, yes, BUT, re-using a lancet means you may not get enough blood....or re-using a syringe means you may have a tougher skin poke/more pain...not testing for ketones at a certain level...well, for my son ketones are pretty obvious, so testing is a no brainer, generally speaking...he throws ketones very rarely and when he does, he knows it. I guess what I'm saying is that you have to weigh the consequences of your choices.

    Consequence of mixing insulins is that it may lower the effectiveness and response of one of them. MAY lower. May not. Clearly stating that I have no clue.

    If I was mixing insulins (which I am not), and I had a child who was dealing with highs after the mixing of said insulin, I would want, as a test case, to try two shots instead. It would be worth it, for me, to see if that altered the result.

    That's what I've heard as advice. May help. May not. But worth a trial, IMO.

    I guess I never quite understand the digging in the heels of anyone wrt diabetes management. It's all trial and error at some point, and we all find what works for our family/self/child. IMO it's bad advice to insist that mixing insulins is NOT the problem, cause it may very well be. Or not! That's what is so tricky. We all have to pick and choose and find what works.

    If this were my child and I were reading this thread, I'd probably do a bit of an experiment. I would definitely try two shots with pizza, as most of us have found that to be helpful. I'd definitely try not mixing insulins (on a different night). I'd definitely try to skip snack. We have lots of variables here to work on. I'd see which one made a difference.

    Sadly, however, I'd also probably see that that changed in a week....
     
  7. Sarah Maddie's Mom

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    This relationship only works if folks post and then actually listen to what other members offer. If you see things as "judgmental" then we can't offer anything but the pat, "oh, it's so hard", and " yeah, right with, you type 1 sucks" which at the end of the day is comforting, but useless in terms of actually advancing one's d management and moreover, one's life.

    No one here judged you. We simply have been paying attention to your threads and have noticed some recurring issues. We comment to help. We comment because we've all been there. If you don't want to hear the membership's opinions then how can we possibly help you in any meaningful way??:confused:
     
  8. caspi

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    I have to say, I find this offensive to the many, many posters that have been nothing but nice and helpful to you in your numerous posts. You may not always hear what you want to hear, but you WILL get the help you need, if you are willing to heed the advice.
     
  9. Christopher

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    I don't think comparing a manufacturer's warning to advice from an endo on when to change a lancet is really a good comparison. Also, I have never heard anyone say it is a good practice to reuse a syringe.

    No, you did not directly advocate it. But by posting the one study you tacitly made it seem like it was OK to do it. And instead of researching it and presenting both sides of the issue, you choose to only present the one side.

    Look, my main point in all this was to voice my concern about the OP mixing insulins AND to say that just maybe, that could be part of the reason she is experiencing some of the problems she has been seeing. The OP never responded to either of my comments and that is fine. I tried and now I will stop.
     
    Last edited: Nov 30, 2011
  10. Flutterby

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    I honestly didn't see any replies that are judgemental, just people trying to help. I learn the most from people who point things out, maybe they have a different way of doing something that works well for them, I'd much rather have people be honest and frank with me instead of just telling me everything is a-ok and its 'just' the way diabetes is, sometimes it is, and sometimes its not and there are better ways to do things. Thats sometimes hard to hear but its also the times where you learn the most.

    You've gotten some great advice, no judging, just advice and questions. The more information people know the better they can help.:cwds:
     
  11. lil'Man'sMom

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    My son is also very sensitive to fatty foods (pizza/restaurant foods). We have been at this for 4+ years and still see times of struggle with pizza. Undoubtedly when on MDI two shot were necessary, sometimes three. Pumping we have gotten better at fat but it really is trial and error.

    Thin crust or homemade works best for us. Unfortunately our favorite home town pizza place is the absolute worst. This past weekend I was able to bolus for it and only see a small spike of 220, this helped him not to be so insulin resistant and we were able to get the 220 back into range in record time for us and pizza.

    Another thing that works is activity. If he eats pizza and goes out to play we rarely see a spike, we do still give "extra" insulin but the activity takes care of the spike.

    It can be very scary to give the extra insulin but keeping a log of how he reacts a few times after pizza will let you see how to split the insulin and feel OK with it.:cwds:
     
  12. Sarah Maddie's Mom

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    So true! It is scary to have to dose up for these foods, but keeping a notation of how it went last time can really help take that abstract mega dose out of the scary zone and put it in context.;)
     
  13. Lenoremm

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    I agree that the suggestions made here are intended to help you learn to manage with your son and not intended to judge you.

    It is easy to be sensitive when we feel someone may second guess how we are caring for our child. This is particularly true when we bust our back side to do what we believe is right and what we have been told is right by the endo.

    I learned early on that no matter how hard I try diabetes will humble me, the endo can be wrong (or misunderstood), and often the practical advice of the parents on this website will teach you more than the cde.

    And two shots works better for pizza. :cwds:
     
  14. Becky Stevens mom

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    I honestly dont think that Brenda or anyone here was putting links to studies to say or imply or suggest that mixing insulins was ok:confused: You stated earlier that it was "dangerous" there is nothing "dangerous" about it and that is why study links were provided. Posters shouldnt be made to feel that they are doing something dangerous when they have been instructed to do these things by their diabetes team or endo. Its probably not a good idea to mix Levemir with humolog but certainly not "dangerous" and wont cause harm to a CWD and I for one wouldnt want people thinking that. I think its a mistake to tell people to stop mixing insulins if their childs endo has told them to do that. It's fine to suggest that they discuss this with the endo ASAP as the package insert says to not mix Lantus or Levemir with fast acting insulins
     
  15. manda81

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    Maybe it's just me, but when you ask "what to do" and people give you a plethora of answers to your question, and instead of realizing that what you are doing is not working, and trying something new, you decide to walk away... the only person that hurts is your CWD, and yourself.

    I don't know how you can "disagree" with a suggestion you haven't tried, or refuse to try.
     
  16. Becky Stevens mom

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    And I cant understand why people say things like this:confused: No where has the OP said she wasnt going to try the things that have been suggested. Or maybe I missed that:confused: I'd appreciate if you showed me where the OP said she wasnt willing to try some of these things to deal with her son's issues with pizza and it appears to me that she hasnt walked away. It appears to me that she was taking some time to read everyones posts and glean whatever info might be useful for her. I just got done reading alot of her threads and cant seem to find all the ones that say that it doesnt really matter or Oh well. I am still so damn thankful that i didnt have internet 4 months after my kid was diagnosed:rolleyes:
     
  17. mandapanda1980

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    Heres my suggestion..

    1. Try to figure out the pizza issue by trial and error. Log what happens. If one way doesn't do it for you, try another and so on...pizza seems to be a big meal in his diet, which is fine, but I think finding the root of the problem is necessary.

    2. Consider talking to your endo about mixing the long acting and short acting. (can't remember which 2 you use) if anything, this thread should raise questions, and it would be best to have those questions answered. Clear up the muddy water :)

    3. Kill this thread.

    P.s. If I missed an issue, insert it between number 2 and 3, then kill the thread. Theres so much going on, I may very well have missed something ;)
     
  18. danismom79

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    Becky, seriously, go look at all the previous posts about pizza (there are a lot), read all of the comments about splitting the dose, read the responses about Daniel not wanting more shots, read about the inevitable highs with the "oh, well, that's diabetes" attitude. Not even so much the attitude, she actually says "oh well" a lot. She hasn't outright said she's unwilling, but she hasn't tried another solution either. Yet she keeps complaining about the pizza spike. I don't get it.
     
  19. manda81

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    This is pretty much exactly why I said what I did. Over and over the same responses have been given to the same question. Over and over the OP has refused to use any of the advice given, only to return with the same question a few days later. People are trying to help, only to be told,

    No one was judgmental. People have offered suggestions, suggestions that we have all used and know will solve the problem. We've all been there with a newly dx kiddo, struggling with certain foods, activities, etc... we come here for advice. If you ask a question, and get a multitude of people saying the same thing, and what you are doing isn't working... take the advice. Likely it will solve the problem, and if it doesn't? ... well then you're no worse off than you were to start with. But just saying, oh well, I'll keep doing what I'm doing? That makes absolutely no sense to me.
     
  20. StillMamamia

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    You know, it is with the best of intentions that people here are trying to help. You may choose not to heed some suggestions or you may choose to. That is your call. But keep in mind, even if it may come across as judgemental to you, the suggestions/advice were made by people who took the time to present a different point of view, because they truly want to help.:)

    I would suggest going back and making a list of each advice and seeing what you can use right now, and which you can come back to.

    I remember coming on here all frustrated because I couldn't manage BGs anymore, and someone mentioned "Hey, you just need to increase basal all around!". At the time I was a bit taken aback because I *master of all things D related* :rolleyes::rolleyes: thought I had covered everything in my attempt to improve things, but no. I had missed one basic thing. :eek:

    Take a deep breath and know we're just trying to help, each in our own different way to expressing things.
     
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