Anyone with experience with Type 1 diabetes in the clinical years

[Nightengale]

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I went and got myself diagnosed with diabetes last week after a month of increasing classic symptoms. I took my last exam of third year, walked down the street to my FPs office and had a fasting accucheck of 388. He thought it was Type 2, I suppose because I'm 30, and gave me some metformin, but the next day I ended up in the ED in DKA and spent the rest of the week in the hospital getting stablizied. We are pretty sure now it's Type 1, which based on my being underweight, my family history and my Hashimotos makes more sense, and at any rate, I seem to need insulin no matter what type they are calling it. I managed to time the thing beautifully for my vacation week and didn't miss any school.

BUT I have fourth year rotations starting Tuesday. In fact, I'm starting off with an elective where I leave for the hospital an hour away on a shuttle bus at 6 each AM, not to return until 6 PM. I'm a bit anxious about juggling a brand new insulin/food/testing regimin with being gone 12 hours a day, and having to carry all this extra stuff around with me. Obviously I can't skip or indefinitely delay lunch anymore. . . Luckily I don't have night responsibilities for this rotation, so hopefully by the time I'm taking call again, I'll be better controlled.

Any experience? Any advice? Thanks.

 

[epalantequevoy]

I went and got myself diagnosed with diabetes last week after a month of increasing classic symptoms. I took my last exam of third year, walked down the street to my FPs office and had a fasting accucheck of 388. He thought it was Type 2, I suppose because I'm 30, and gave me some metformin, but the next day I ended up in the ED in DKA and spent the rest of the week in the hospital getting stablizied. We are pretty sure now it's Type 1, which based on my being underweight, my family history and my Hashimotos makes more sense, and at any rate, I seem to need insulin no matter what type they are calling it. I managed to time the thing beautifully for my vacation week and didn't miss any school.

BUT I have fourth year rotations starting Tuesday. In fact, I'm starting off with an elective where I leave for the hospital an hour away on a shuttle bus at 6 each AM, not to return until 6 PM. I'm a bit anxious about juggling a brand new insulin/food/testing regimin with being gone 12 hours a day, and having to carry all this extra stuff around with me. Obviously I can't skip or indefinitely delay lunch anymore. . . Luckily I don't have night responsibilities for this rotation, so hopefully by the time I'm taking call again, I'll be better controlled.

Any experience? Any advice? Thanks.

pmed you.

 

[velo]

I have no personal experience but obviously the tightest control and most convenience would be found with the insulin pump. You'll have to see what kind of help you can get with your insurance converage, I believe they're ~10k and last ~4yrs. Good luck, a lot of med students/physicians live with chronic disease so it can be done!

 

[tkim]

Classmate of mine was dx with type I during MSII, and he got a pump. Seems to be doing okay with it, though he does keep snacks handy throughout the day. Might be the thing for you if you want tight control, adjust on the fly, and have the discipline to use it.

 

[nibrocli]

i also recommend trying the pump. a very close friend of mine got diagnosed with type I during undergrad. i think she paid about $1500 out of pocket for it, insurance covered the rest. expensive, but she really prefers it to traditional injections. she has great control over the disease with the pump, which is of course the main goal. good luck.

 

[Nightengale]

Thanks everyone.

I ultimately do want a pump. Both my dad and a friend of mine have them, and I hear nothing but good things from both of them. And every single doctor who saw me in the hospital told me how excellent a candidate I'd be.

That's at least a few months down the road, though, so for now I am muddling through the old fashioned way. Of course trying for tight control and also a regmin that will help me regain some weight. And also trying to see a few patients. . .

 

[rah223]

I'm an MSIV, and I've been a type 1 diabetic for 11 years. My biggest advice is this: your health comes first. Eat when you're supposed to. Everyone understands, believe me. I've gotten nothing but support while being in the hospital. Don't be afraid to check your FS anywhere and everywhere. Don't waste time trying to hide it because it's part of who you are! My only other suggestion off the top of my head would be to ALWAYS keep food (like lifesavers) in your pocket. That way if you realize that you're hypoglycemic in the middle of rounds, you can just eat right then and there and not have to run back to the team room. PM me if I can help ya out anymore!

 

[DadofDr2B]

I'm an MSIV, and I've been a type 1 diabetic for 11 years. My biggest advice is this: your health comes first. Eat when you're supposed to. Everyone understands, believe me. I've gotten nothing but support while being in the hospital. Don't be afraid to check your FS anywhere and everywhere. Don't waste time trying to hide it because it's part of who you are! My only other suggestion off the top of my head would be to ALWAYS keep food (like lifesavers) in your pocket. That way if you realize that you're hypoglycemic in the middle of rounds, you can just eat right then and there and not have to run back to the team room. PM me if I can help ya out anymore!

My daughter is a MSIII and was diagnosed 14 years ago. We went through the needles, 10,000 shots before going to undergrad.

One big thing is to do what you need to do and be damn with those who are watching. If you are scheduled for a shot, do it even while sitting at a dining table. You can read your blood sugar now with a prick to the forearm and a single drop of blood. My daughter had to prick her fingers.

Get a pump. Use Novo log insulin. It is the only FDA approved insulin for a pump. The other tends to stop up the tube to your site and will not always deliver properly. Email me for more information if you wish.

 

[Nightengale]

Thanks!

I'm checking my glucose pretty much everywhere and in front of anyone. My machine can do arm or finger but I haven't tried arm yet.
Injections in public I'm not so sure about. . . don't especially feel like disrobing in front of people to reach either thigh or abdomen.

I'm getting a pump. Started the required intensive insuiln therapy classes yesterday to that end. Is Novolog really that different from Humalog? (which is what my dad uses in his pump)

 

[DadofDr2B]

Thanks!

I'm checking my glucose pretty much everywhere and in front of anyone. My machine can do arm or finger but I haven't tried arm yet.
Injections in public I'm not so sure about. . . don't especially feel like disrobing in front of people to reach either thigh or abdomen.

I'm getting a pump. Started the required intensive insuiln therapy classes yesterday to that end. Is Novolog really that different from Humalog? (which is what my dad uses in his pump)

Call FDA and ask which one is approved to be used in a pump. Novo log only. No one wants to fight Eli Lilly over this including insurance companies and others who see Lilly as the best at fighting this disease. They control the media because of their advertising dollars and they control doctors by funding research.

We called the FDA and Novo Log was the only one approved. The insurance company wanted up to pay the higher tier price because they claim Humalog is cheaper and just as good. If it is just as good, why isn't it approved by the FDA?

Would like to hear what your endocrinologist says about prescribing non FDA approved medicine when FDA medicine is available.

 

[rah223]

I don't know what the fda says but, I used humalog in my pump for 4 years. I now use novolog. There has been no difference. There is anticdotal notes of novolog causes less hypoglycemia but that's it. No trials that I know of have shown a real difference. I use whatever my insurance company will approve.

 

[FieldDoc]

I know that I'm a freak and probably the only one who will say this, but I hated the pump. I had just as good A1Cs with shots as with the pump. My pump was always in the way and I was always allergic locally to the adhesive from the sets. I was swimming a lot when I started to use it and I had to disconnect it for these times and by the time I would go to bolus at the end of the workout I was so high that I felt like junk. I hated being on a set meal schedule and could manipulate things much better on my own with a mix of long and short acting insulin, but maybe I just didn't pay attention enough in my little class on the bugger. During times of shift work, the shots worked best for me.

Another turn-off for me was when I was working as a paramedic and I saw patients who were unconscious with those little suckers still pumping away. It was kind of unnerving. On the plus side though, this little device is a walking nametag stating that you are a diabetic and if you are down and out, I promise you that it is easier to find an insulin pump then some marks or petechial type bruising from injection sites on a physical exam. Its a great way to be an out of the closet diabetic rather than hiding things. I've heard that the little devils have undergone great improvements in the past few years though, so maybe things have changed.

Key points. Definitely carry food/glucose/cake icing and once you go low a few times you will figure out what your signs are and learn to fix it before its a problem. I may be the lazy, been-a-diabetic-too-long person, but I just give my shots wherever, whenever. Medical personnel have seen belly's before, I promise.

As a side note, even in turnout gear pumps do not survive a working fire. FYI, if you are a firefighter, don’t wear the pump into the fire. All I have to say is oops.

 

[fab4fan]

As a side note, even in turnout gear pumps do not survive a working fire. FYI, if you are a firefighter, don’t wear the pump into the fire. All I have to say is oops.

LOL! Hope you weren't hurt, though.

 

[DadofDr2B]

I don't know what the fda says but, I used humalog in my pump for 4 years. I now use novolog. There has been no difference. There is anticdotal notes of novolog causes less hypoglycemia but that's it. No trials that I know of have shown a real difference. I use whatever my insurance company will approve.

You are allowing an unauthorized person give you medical care.

 

[rah223]

I did a quick websearch from the FDA site and found that humalog was approved for pump use in June 2004 (click on the link by 6/2/04 new route of administration).

http://www.accessdata.fda.gov/scrip...x.cfm?fuseaction=Search.Label_ApprovalHistory

Novolog received approval in 2001 (Click on the link by 12/21/01 new route of administratoin).

http://www.accessdata.fda.gov/scrip...seaction=Search.Label_ApprovalHistory#apphist


I'm curious myself, which is why I even bothered looking. Am I missing something?

 

[DadofDr2B]

I did a quick websearch from the FDA site and found that humalog was approved for pump use in June 2004 (click on the link by 6/2/04 new route of administration).

http://www.accessdata.fda.gov/scrip...x.cfm?fuseaction=Search.Label_ApprovalHistory

Novolog received approval in 2001 (Click on the link by 12/21/01 new route of administratoin).

http://www.accessdata.fda.gov/scrip...seaction=Search.Label_ApprovalHistory#apphist


I'm curious myself, which is why I even bothered looking. Am I missing something?

I am glad Lilly went through the process. In 2000 we had a knockdown fight with the insurance company over the use of non FDA medicine. The insurance company ruled against us placing the Novo Log insulin into a catergory of less reimbursement versus Humalog which was not approved at the time. The pump manufacturer and the FDA said Novo Log was the preferred insulin. The insurance company did not want to pay at the same rate. At that time which insulin would you give your daughter?

 

[VentdependenT]

intra nasal insulin spray should be available in the next few years. Now they just need a bloodless way to check glucose.

 

[VFTW]

I don't know what the fda says but, I used humalog in my pump for 4 years. I now use novolog. There has been no difference. There is anticdotal notes of novolog causes less hypoglycemia but that's it. No trials that I know of have shown a real difference. I use whatever my insurance company will approve.

The concern is with the humalog crystallizing in the pump tubing. Lots of endos only allow Novo in pumps.

 

[MZimmer]

Thanks!

I'm checking my glucose pretty much everywhere and in front of anyone. My machine can do arm or finger but I haven't tried arm yet.
Injections in public I'm not so sure about. . . don't especially feel like disrobing in front of people to reach either thigh or abdomen.

I'm getting a pump. Started the required intensive insuiln therapy classes yesterday to that end. Is Novolog really that different from Humalog? (which is what my dad uses in his pump)

I've had T1DM since age 10... curently 3rd Yr at Med Coll of WI.

How about a little Pharm review?...

Starting with Regular insulin.... exact same AA sequence as endogenous human insulin. In theory works just as well. There are 2 reasons why it's onset is longer than endogenous insluin though. 1) transit time from inject site, through ECF, to blood, then to receptors... not a whole hell of a lot can be done about this. and 2) Regular insulin forms hexamers (or pentamers, or dimers, I forget the actual number that associate) in solution. These hexamers then have to dissociate to monomers after injected before they become bioavailable. Thus Regular insulin has a slower onset of action than does endogenous insulin.

Then, manufacturers added Zinc to the solutions... and out came NPH. The insulin associated with the Zinc, and thus had an even slower duration of action.

Then, rDNA synthetic insulins made their way to the market. The two notable ones in this forum are Humalog (Insulin Lispro) and Novolog (Insulin Aspart). So, Humalog and Novolog are two very distinct synthetic insulins. Two different companies made two different synthetic AA substitutions of the original insulin, but both were attempted to solve the same problem, that being the dimerization (or hexamers, whatever) in solution. Lispro (Humalog) changed the endogenous Pro-Lys somewhere in the sequence to Lys-Pro. Aspart substituted an Aspartic Acid in for, I think, a non-polar amino acid. Both substitutions ended up decreasing the amount of dimerization, etc and thus consisted of more monomers in solution, thus the onset of action of both Lispro and Aspart is faster than Regular insulin.

I assume that this business of people mentioning "crystallizing" is referring to the fact that Humalog probably still forms dimers in solution, but then dissociates at body temp of 37C. Don't know for sure though.

Also, regarding people using Humalog before it was "FDA approved"... my thoughts are "who cares?" As med students, we should all know by now that there are many off-label indications/uses for many drugs out there. If Humalog has worked fine for somebody, then by all means continue using it.

Sounds like you're doing well... my only piece of advise is to keep one pocket of your white coat stuffed with Lifesavers, etc. Also, when you feel low and you have your pump on, just set the temp basal to 0% for 30 min. Just a suggestion.

Take care.

-Mike ([email protected])