After watching me do this, it is my hope that you’ll feel more “Unlimited”
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My recollection is that particles would stick to the side of the bottle, and it looked a bit lumpy.
I used NPH, Regular from 1984-1997, using meal exchanges, 3 BG checks a day before injections only. If BG was > 240, then add 1 or 2 units Reg. This may be what is recommended to a person you are experimenting to be. I did NPH + Reg in morning, Reg only for dinner, and NPH only at bedtime, but with Reg if over 240.
In 1997 I stopped NPH, and started insulin pump using Regular, and to this day have never used Lantus, Levemir, etc. At some point switched to ‘human’ Regular insulin, with pump, and then only Novolog or Humalog.
Good luck with your experiment.
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Like I said, I only used Lente, but I think activity is about the same.
I’d probably do NPH twice daily, otherwise I think you’ll have to high a likelihood for overnight lows.
What I meant by graphing is that you make the vertical axis the insulin penetration, the horizontal axis hours. Make enough room in the hours for 48 hours. Chart your times for injection of each insulin based on when you want the maximum overlap of insulin activity. This is when you eat.
You want to make sure that there is no insulin activity overlap overnight. i.e. You may want to work out dinner so that the NPH is covering it so you don’t have to take a R injection if you like to eat late, for example.
Timing is everything with these insulins.
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I would think that with more smaller doses you’d be reducing the stacking likelihood… at the extreme end of that spectrum we have the insulin pump delivering micro doses every minute or whatever… right? Seems like 2 —-1/2 doses would be far more likely to have a roller coaster imo than 4 — 1/4 doses would
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You would think that, but you would be wrong.
Stop thinking basal and bolus. NPH is not basal insulin. It is nowhere near flat. R is not bolus insulin, it takes to long to get started and peaks long after you’re normally finished eating.
That’s why timing is so important and you have to be on a consistent schedule to get maximum results.
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Correct, but novolog is also not a basal insulin—- we create a basal effect with it very effectively by splitting it into hundreds of tiny doses throughout the day with a pump right?
@Sam, with NPH, more doses = greater chances of stackage and unexpected hypos. In my experience, NPH is not wholly predictable. It had weird random bizarre and unchartable peaks and valleys of efficacy. It generally behaved in x manner daily, then WHAMMO! it behaved in z manner for no obvious reason.
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I agree this was true with older animal based NPH. But I wonder if the newer human version is more stable. But still think the irregular slope up, then down would not be exactly the same day to day, due to variations in site of injection, and activity level. I think I had various degrees of insulin peaking when injected in legs vs arms or stomach.
Of course my A1Cs were in the 9+ range back then, and they considered that good because I wasn’t having hypos.
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@MM2 I never used (to my knowledge) older animal insulins, but have used for many years the Relion brand (Novo Nordisk) R & NPH found at Walmart. My experience with those insulins gave me a great appreciation for the newer analogs, especially for Tresiba. Going from NPH>Lantus>Tresiba was an eye opener. Like going from a tricycle to a sports car.
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Isn’t this why more smaller doses would be beneficial? If one dose acts totally wonky it’s not going to be near the problem as it would if it was 2x larger dose?
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@Sam Here’s a crude example of what in talking about
Sorry, my phone takes too high a resolution photo to upload, so I struggled to get it uploaded with a screenshot of it. You have to click on it to see the image.
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@Sam because of the duration of NPH and it’s odd behavioural characteristics, smaller more frequent doses are IMHO more dangerous. I did it that way and had a few surprises over the years. Doing 2-3 shots of NPH seemed to work the best (as I later found out using a cgm) and covering meals and spikes with R . YDMV and more may be best for you.
This whole thing is a bit funny to me. I did this “experiment” for about 20 years or so. It is no big deal to use these. I think you are right that it is completely workable. It’s just different than the other stuff. A good craftsman never blames his tools.
I still use NPH on days that I am doing MDI. I don’t use it by itself for basal, I also use Levemir and Lantus. But NPH has a unique curve that can be used to your benefit.
I have a normal increased basal need at 4am. If I am going to bed at a normal time, there is no way I can cover a 4am spike with any other basal. But I can time my NPH to hit it perfectly. That’s how I use it now.
Yes, exactly. NPH can be split up to lower the peaks. Also, since R has a longer duration than a rapid insulin, it can cover basal for you too. If you take R for breakfast, lunch, and dinner, you will have insulin working in you the entire day. The slower R can work as both bolus and basal.
Also, it is not as easy to correct a high with R since it takes longer. The trick is to take a bit more than the meal requires, and feed it just a bit as the day goes on. correcting a high with R might take hours, but correcting a low is still pretty quick. So just feed the excess a little bit at a time and avoid the highs. As long as you have small snacks available, it’s no big deal.
I think the highest A1C I ever had with NPH and R was 6.6. Most of the time I was below 6.0. It is entirely possible to have a good A1C with these. It is just done differently.
If you leave a vial untouched for several weeks, you might see a collection of the powder on the side of the vial or bottom of the vial. It settles out. But the insulin still works. Just roll it around in your hand to re-mix it, and it will be fine.
I agree. I don’t think it is all that horrible.
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It’s really becoming amusing some people are acting like it’s some crazy idea nobody’s ever done like trying to climb Everest naked or mate with a great white shark. Lol literally millions of people have managed diabetes with R and NPH… the vast vast majority of them with way, way fewer tools and resources at their disposal that even the least resourceful diabetics have at their disposal nowadays. That’s why I want to do this, to alleviate some of the fear that seems so pervasive in diabetes forums… it’s really not a big deal.
I may change my mind, but based on the way my mind currently conceptualizes this stuff, I’m going to start with 4 1/4 doses of NPH per day, and using larger, and earlier doses of R… I’m really not expecting any insurmountable problems although I’m sure there will be a learning curve…
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I think you’ll do fine. What sounds awful about it is having to live on way more of a schedule and restrict your diet in ways you don’t have to on modern MDI and pumps.
I have no doubt that’s accurate. I suspect it will not be anywhere near as convenient as what I’m currently doing.
I think the difference is the standards that you’re trying to meet. “Managing diabetes” and keeping the kind of tight control most of us here aim for are definitely not the same thing. Maybe you’ll be able to get an A1c <6% like @Eric, but that certainly isn’t an example of what most people taking this regimen experience(d). In the DCCT (where meters were available) the original A1c target was 6.0% for the tight control group, but the study ended up comparing 7.0% and 9.0% because people couldn’t hit 6.0%. So, yes, many people manage and have managed diabetes for years on this regimen, but most did not have what would be considered tight control or stable BGs. But I’m sure a CGM will make things easier.
I think most of the fear comes from the fact that a majority of us had a terrible time trying to control blood sugar with these insulins. For me, I did have pretty good control as far as A1c went (7% range), but my BGs were definitely not stable and I had to stick to an extremely strict meal plan and schedule to keep the control I had. I experienced at least 1-2 severe lows each year (where I required assistance from others), and many, many more dangerously low but otherwise “mild” lows (where I could treat myself). For some reason, R and NPH caused deep and prolonged lows that came on very unexpectedly. I haven’t had a low requiring assistance from others since switching to the insulin analogues (and I took rDNA R and NPH all along, so it wasn’t an animal/human insulin difference).
For me, I took R and NPH for 13 years, testing 3-5 times a day throughout. I took two injections of NPH per day and two injections of R per day.
A few things that have not been mentioned yet:
You must always roll (not shake) the NPH vial for 10+ seconds or so to make sure it’s well combined before injecting it. Otherwise, you could get wildly varying action curves. Also, if using syringes you must always measure the R into the syringe before measuring NPH, because if you get microscopic bits of NPH into the R vial it also alters its action.
With the regimen I took, I had to stick to a very strict meal plan and eating schedule. I had to eat the same proportions of carbs/fat/protein at each meal and snack (using the exchange system at the time). I had to eat an additional snack several hours after a meal because R was still working or NPH was peaking. I think even if you’re eating low-carb you’ll probably have to take R 30-60 minutes before eating a meal. On the regimen I used, some meals (such as lunch and sometimes dinner) were covered entirely by NPH’s peak, so I didn’t take any R. I couldn’t skip a meal or snack, nor delay it by even half an hour, without ending up very low.
To correct highs I did something like the following:
If breakfast was high, I increased the evening NPH dose
If lunch was high, I increased the morning R dose
If dinner was high, I increased the morning NPH dose
If bedtime was high, I increased the evening R dose
I didn’t correct between meals since most of the time R and/or NPH were peaking. I would sometimes skip a snack if I was really high (like 17+).
Keep in mind that, regardless of how many times you take NPH, it will peak in the middle of the night. This may not be a problem if you have a strong dawn phenomenon, but if you don’t, you’ll likely need to eat a snack of carbohdyrates and protein before bed.
I’m not sure how your idea of splitting NPH into many injections and maybe doing some carbohydrate counting with R will work out, since I never tried it. Hopefully it’ll work out better than the regimens most of us used!
I think my main concern would be to not underestimate how powerful peaks from R and NPH can be and how they can hit many, many hours after the injection and often quite randomly. I would keep glucose tablets on you at all times and would definitely wear the CGM at all times.
Good luck. I’ll be very interested in how this goes for you.
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Yes but look at how bass ackwards they were doing everything… im sure they were eating the ADA diet, following strict protocols about what they ate and how and when they dosed and probably weren’t allowed to make common sense judgements on their own behalf. They were probably only testing before meals and at the 2 hour mark, certainly weren’t using cgms or doing crazy radical things like actually adjusting their diet…
I’m 100% positive I can maintain an a1c not just in the 6s but in the 5s with ANY insulin… where the rubber meets the road though is in how difficult it becomes to do it and if it’s realistically a balance that can be sustained forever…
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Well, I don’t know what they were doing, since I haven’t read the full study. My understanding from information I have read is that they were in weekly contact with a diabetes team to go over and adjust their treatment plan. My understanding is that severe lows (not highs) were the main limitation of treatment; the tight control group experienced many more severe lows requiring assistance from others than the conventional control group. And this was 25-35 years ago…for the time, the treatment the tight control group got was state-of-the-art.
Many people back then actually ate a fairly low-carb diet compared to today. There was certainly no “eat whatever you want and just cover it with insulin” mentality that the ADA advocates today. I didn’t eat sugar, bread, pastries, candy, ice cream, or large portions of rice, pasta, or fruit growing up. I was 23 when I first heard that I could apparently eat whatever I wanted and cover it with insulin.
I do wish you the best of luck and hope you find it successful. I hope you do post details about how it goes.
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I know this was the standard recommendation back then, to put it into the same syringe, R goes in first.
The process they advised was:
- inject air into NPH vial
- remove syringe without taking insulin out of the NPH vial
- inject air into the R vial and withdraw the R insulin
- put syringe into NPH vial and withdraw the NPH
But possibly mixing the two of them is part of the reason for variability, because they also advised to not leave the two insulins in the syringe mixed for too long before injecting.
I think it’s safer to not put them in the same syringe.
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