Now for a follow-up on my previous post about Exubera.
Starting at relatively good blood glucose control I was still advised to start at the weight based dosing of Exubera and then shift from there to the more exacting one that goes by replacement of humalog (in my case lispro). That said, I am glad that I have done this, even though my blood glucose readings have been phenomenally low, although nothing dangerous I can see how they could be if not done with care and watching oneself.
Normally I have been using lispro to do carb-compensation for the net-carbs of a meal, which are the total carbs minus the carbs of fiber. For amounts of those, I would give 1 unit of Lispro. That has varied from 10g carbs to 16 g carbs per 1 unit Lispro, which has meant good pre-meal estimation of carb intake. Eating out has been a good/bad thing, but not in the insulin worries, mostly due to actually *having* enough energy to get out for a meal. Post-meal lispro has been absolutely based on a set amount due to variable blood glucose over a set amount. Thus for every 25 units (round off) over 120 mg/dl blood glucose I have taken 1 unit lispro, which at meals gets added in to the lispro for carbs. Between meals this is taken as a separate amount. Finally at below 70 mg/dl blood glucose I either take in 10 carbs if not during a meal or subtract 1u of lispro. Lovely, huh?
Good thing that is all encoded in a spreadsheet I designed to handle all of that. I made that spreadsheet so that I could vary the carb compensation per meal and also set in the basal target and adjustment factor as separate baselines that could also be varied.
Going by body mass for Exubera, those get basically put on *hold*.
For me 4 mg of Exubera (3mg and 1mg blister packs) have been the start. Then just make sure my blood glucose doesn't plummet to dangerous levels 2 hours after eating. Easy enough to do by this point in time!
And one fun thing that makes me *glad* for going this route is finding a basis for changing night-time control. That has always been a pain, even once I got it under control as it was not following either the 'Dawn Effect' or the 'Aurora Effect' each of which leads to a high morning blood glucose but for different reasons. Most bodies will release some sugar just prior to or at awakening so as to get a storehouse of energy available. Some bodies do something a bit different, which I have never thoroughly understood to get a similar effect... but mine doesn't do *that* either. So I have been left needing a night time snack, to counter the lows gargered by the basal insulin, Lantus (glargine), which has required compensating with Lispro and another insulin. NPH was a first start on that, to try and get a nice set blood glucose on awakening, but it never was able to keep a steady 2 hour and lunch reading. I switched over to Levemir which has a steadier uptake, but is not as long lasting as Lantus but longer than NPH. I prefer to have a 'glide path' of slightly declining blood glucose levels that will cover a range for hours that I might wake up at. Stay in an acceptable range over that 'glide path' and I will be set for breakfast.
With Exubera I was getting off of that 'glide path' with morning lows. So I cut my Levemir back a bit. Then a bit more. Then I cut that in *half* and voila! This morning I was back on the 'glide path'. Now, this is happening because Exubera decays off closer to regular human insulin than does lispro. Thus, by keeping some effectivity longer than lispro humalog, although not as much as regular insulin, my pattern to the 'glide path' has changed. For evenings, as I will not be needing constant night-time monitoring, that now allows me to have a low dose of Levemir along with a body-mass dose of Exubera.
Today, starting at my next meal, I will change over to the Exubera equivalent amount for what I would take for lispro, rounding up to the next size blister pack. Anything up to 3 units lispro will get me 1mg of Exubera, and keep in mind that 3mg is taken as a single, 3mg blister pack (activity of 3x1mg is different than 1x3mg, due to amount the powder being dispersed and absorbed at one time vice three separate times). Thus all those lovely Lispro calculations will now be rendered into Exubera blister packs! And I can always fall back on a body-mass dose if an unknown or not easy to calculate meal size comes around.
While having a bit too much insulin in the body does lead to some enervation, that, too, is tiring to my system and not sustainable. So back to less enervation and more, long term sustainable energy.
And, if all works out, the need for very, very little in the way of injected insulin beyond Lantus and Levemir.
Because a bit of noise is worth having in the signal as an absolutely clean signal does gain one very, very little in life expectancy or benefits once it is in the right range. Find the range, get the noise down and make sure that it is easy to do... and *nothing* is as easy as inhaling insulin.
Why anyone would not want to spend a week or two to transfer to *that* and adjust for it is beyond me. I am in the depths of the land of Grey and have little energy to do this, and yet the long term ease and lowered concern for the long haul is worth it. That gains more energy back to get the long haul sustainable. Now that I have the range, a bit of fine tuning and the signal will be as good as can be had with little of no loss that will be discernable.
[UPDATE] Note that in the pharmokinetics of Exubera they do point out that each 1 mg starts out as 3u equivalent lispro, but the actual transfer by what is lost in the packet, to the device and adhering to other mucous membranes means that you get 1.5u equivalent from every 1 mg Exubera. So, adjust accordingly! This will take some time getting used to, to say the least.
15 January 2007
Now for a follow-up on my previous post about Exubera.