“A Little bit More” - it's all about the Bolus

It’s been a while since I posted anything about diabetes; there’s been a veritable pandemic of words and opinions throughout the Coronavirus emergency, and I have many times in recent months turned off the TV, closed or muted a person or a conversation on Twitter or just cut short a real life conversation because I am so exasperated by a surfeit of half-baked opinion.  I am, therefore, cautious to write and post anything, let alone anything medical, but if you’ll bear with me on this one, it will get to diabetes and has no direct relevance to COVID-19. 

The train of thought leading to this post started with one of the many really bad flare-ups of hay fever which I have experienced this year. Apparently, like nearly everything, the exceptionally bad hay fever experienced by many of us in 2020 can be traced back to COVID-19, in that the (very welcome) lowering of pollution, caused by the lack of road traffic, caused by the lockdown, caused by the COVID-19 pandemic, has allowed the pollen to run riot in the less polluted atmosphere. Such is the chaos theory in practice that we have all experienced this year.

Sodium Cromoglicate eye drops

I tweeted something about bad hay fever a couple of weeks ago, and was grateful to receive much sympathy and helpful advice from friends and strangers alike. Among the suggestions was that I should try antihistamine eye drops containing Sodium Cromoglicate, a mast cell stabiliser; I had previously used standard eye drops, which provide only symptomatic relief for itchy eyes. I bought some drops of the suggested type, started using them and found that not only did they relieve the itchy eyes which are such a distressing part of hay fever, but that they also suppressed other hay fever symptoms, in particular sneezing.

This made me take to Dr Google: do eye drops enter the bloodstream and therefore act on symptoms other than the eyes themselves? I was aware, from all the COVID-19 “don’t touch your face” talk, that the eyes are a potential entry route for infections, so perhaps I shouldn’t have been surprised to find, quite readily, that the eyes are indeed a route into the bloodstream:

“When you put drops in your eye, the drops can become “pumped” into the tear system if you blink. Once in contact with the vascular nasal mucosa, relatively rapid absorption of drugs into the bloodstream can occur. The drops can act as a systemic “bolus” - an infusion of the drug into the bloodstream.”[1]

There you are - I said I’d get to diabetes! The word “bolus” jumped out of that sentence from a medical website, and - perhaps like many not medically qualified people - I was surprised to see it, apparently in a new context. “Bolus” is a word all too familiar to those of us whose lives are sustained by insulin, so familiar that I had never really thought much about any wider use of the word. However, look up the word and you’ll find a definition such as this:

“a single, relatively large, quantity of a substance, usually one intended for therapeutic use, such as a bolus dose of a drug injected intravenously.”

So it’s not just we people with diabetes who bolus! I hope that other non-HCP readers will react in the same way, otherwise this blog post is an embarrassing confession of ignorance.

Being a linguist by trade, my reaction to having a word brought to my attention is to think about and research its etymology. So again, I turned to the internet to discover that the word bolus is, as expected, of Greek via Latin origin and originally meant a clod or lump of earth. Some sources suggest a connection to the English word ball, but that is far from clear.

So there you have it: that familiar word bolus is so called because we are injecting or pumping a “lump” of insulin into our bodies. It gets even better if you know the etymology of the word “dose”, because that word actually comes from the Greek word for “gift”. I love the idea - especially as it was gifted, not monetised, by Banting et al - that we inject a gifted clod of insulin!

So what about bolusing? Well for me, it is one of the arts of diabetes management at which I have become increasingly skilled, but at which I am still a long way from being proficient, and never will be. I, along with the vast majority of people with Type One diabetes, rely on injection pens for the administration of insulin (I am miles away from fulfilling any criteria for a pump), so bolusing remains for me a relatively unsophisticated - dare I say hit and miss - process of trying to whack the mole, ideally before the mole pops up. (...now where did that “whack-a-mole" analogy come from??)

I make no claim to being an expert in diabetes; quite the reverse, in fact, compared to many whom I have come to know through the online diabetes community, but I have certainly become more confident in the art of effective bolusing in recent years.

For me, two aspects of bolusing stand out.

Firstly, the timing of bolus injections of fast-acting insulin prior to eating: I was taught at diagnosis, nearly 23 years ago, that the injection of fast-acting should be just before eating (“wait until the food is on the table”) and for years I feared some kind of humiliating loss of sense and dignity if my food was delayed for more than a few minutes. However, in recent years, I have realised that for me, a bolus dose is most effective if taken well in advance - sometimes up to an hour, especially at breakfast time.

Secondly, correction doses: I used to be very cautious about injecting between meals, but these days, I willingly inject in response to a rising level, or ahead of a snack-attack. The result of this is that I almost always have more than the theoretical three doses of fast-acting a day.

I will add two very important caveats to this. Firstly that freedom to bolus with such relative recklessness is dependent on always wearing some form of CGM, which for me is the NHS funded Freestyle Libre. I have said it many times, but the ability to know more than just a snapshot BG value, but rather a clear indication of direction of travel, is life-changing. Secondly, that I am fortunate enough to be retired and therefore more in control of my time and activities than someone in a busy working life. When I was working, there wasn’t time to pre-bolus or correct, nor was the timing or nature of my midday meal in any way predictable.

I am well aware that my mastery of bolusing will never be perfect, and indeed that it could be far better with the help of an insulin pump and associated looping technology, but I am nevertheless grateful to the incremental improvement of knowledge gained through the online diabetes community, a better-late-than-never DAFNE course and of course the advice of  HCPs.

And having discovered the etymology of bolus, I am most grateful that I am able to indulge in bit of constructive mud-slinging – throwing a little bit more insulin into my body. There’s the customary song title for my post, a memory for those old enough to remember it, from that long, hot summer of 1976.

DISCLAIMER: Injecting insulin is a responsibility placed upon everyone who lives with Type One diabetes, and requires knowledge and caution. Nobody should modify dosage and timing without careful consideration of all the multiple factors affecting blood sugar levels and any changes to the timing and dosage should only be made with professional advice and guidance.

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[1] https://www.glaucoma.org/gleams/eyedrop-techniques-from-dr-andrew-iwach.php#:~:text=When%20you%20put%20drops%20in,the%20drug%20into%20the%20bloodstream.

"Do the Right Thing" - Getting insulin injection technique right

Well, January is nearly gone, and this is my first new blog post of 2019. It’s been a busy time for me, and it promises to be a busy year, not least in the world of diabetes which has become such a big part of my life in retirement.

One of the things that has occupied some of my time and attention this month has been starting my role with the newly re-constituted @FIT4Diabetes Board, a group of healthcare professionals who work under that banner, supported by Medical Technology Company Becton Dickinson, to promote best practice in technique and safety for those receiving and administering insulin injections.

FIT Board Members

I was pleased, but frankly somewhat surprised and flattered, when I was asked late in 2018 to join the FIT Board as a patient representative. I am aware that I am one of the longstanding members of the online diabetes patient community, known directly or online to many fellow people living with the condition; I am also aware that I have been something of a minority voice in that community as one of those happily managing their condition by multiple daily injections rather than an insulin pump. The very nature and demographic of the online world gives a false impression of the ubiquity of pump and diabetes technology use.

Moreover, I am also very aware that I am no expert in diabetes, despite my 21 years of living well with it. Indeed, I have often said that I’m not really very interested in diabetes, nor do I have any great enthusiasm for clever technological solutions. I am very interested in people, and in doing my bit to support and contribute to the greater good, and so my participation in #GBDoc is based very much on an interest in the people with diabetes, rather than the condition per se.

However, having attended the first meeting of the FIT Board, I have realised that I do have something to contribute to this group and their work. At our meeting, we started with an illustrated presentation about best practice in injection technique: not the most comfortable viewing when sitting there as the only patient accompanied by three DSNs, two pharmacists and a GP! I watched with a mixture of amusement and embarrassment as one by one, my occasional or permanent bad habits in diabetes management were exposed:

Wash hands? X.

Change needle every time? X.

Rotate injection sites? X.

Prime the pen? X.

Wait ten seconds before withdrawing needle? X.

Dispose of used needle immediately in a sharps container? X.

OK, so some of these I am better with than others, but I doubt if many longstanding PWD could in all honesty tick every single one, every single time. My excuse? Well, it’s that life gets in the way! We’re often told that diabetes shouldn’t stop you leading a full and normal life, and I have certainly lived as full and as normal a life since diagnosis as before it.

However, “normal life” is often very busy: I think back to my hectic working days as a teacher, often in work from 7:30am until 6pm, with literally no break. Lunch was often snatched on the go, and dressed in a suit, with formal shirt and tie, eating in a crowded school canteen or grabbing a sandwich during a lunchtime meeting is not conducive to good injection technique. It’s hardly easy carefully to choose the right site, prime the pen, leave it in for 10 seconds etc. More likely grab the pen - untuck shirt under table - jab - pen back in pocket with top on over needle. And all that was until very recently (with the arrival of FreeStyle Libre) preceded by a messy finger prick test!

I am also very aware that discreet and hurried injecting is, rightly or wrongly, rather easier for a man than a woman: a dress and tights, still commonly a staple of formal dress for women in the workplace, gives no opportunity for easy, dignified exposure of a suitable injection site, and it is small wonder that many women with diabetes inject through tights – far from ideal, but a pragmatic compromise.

But does it matter?

Well, since my watching that awkward presentation at the FIT meeting, I have to say yes. Confession time: I have become very aware that the flabby bits above my waistline are not just a touch of middle-aged spread, but actually a textbook example of Lipohypertrophy, lumps under the skin caused by accumulation of fat cells at the site of insulin injections. Not life-threatening, far from the worst of the secondary issues which can arise from living with diabetes, but nevertheless  a very real and creeping threat to living well on insulin injections.

I wonder whose tum that is?? !!

Lipos develop because of poor site rotation over the years, and injecting into them significantly reduces the effectiveness of insulin, caused by irregular and incomplete absorption rates. Since that meeting two weeks ago, I have been carefully avoiding those over-used sites, and guess what? My insulin requirement has fallen, quite significantly!

I genuinely think that Lipohypertrophy is the Cinderella of diabetes issues. We PWD are all so bothered about avoiding hypos, dealing with the uncomfortable highs, pursuing elusive “flat lines”, over-reacting to the TMI that many of us now get from our Libres and CGMs, that we overlook the insidious damage that we are doing to our too-easy-to-reach tummies.

And judging by the responses to a quick Twitter poll that we did after the meeting, checking our injection sites and advising on injection technique are a frequently missing part of our consultations with HCPs in clinic.

Perhaps it’s time we all started to think rather more about injection technique, site rotation, size of needles etc. I spent the first 20 of my 21 years with diabetes using the 8mm needles that were the norm back in 1998, blissfully unaware that current thinking among experts is that 4mm are best for everyone, regardless of their BMI. And whilst my eyes are screened annually, my feet jabbed at every visit, questions asked about my “control”, my highs and lows, my erectile functioning, etc., nobody has ever asked about, let alone examined, my (frankly rather unattractive) midriff.

So please look out for tweets and posts from my wonderful colleagues on @FIT4Diabetes. They have been brilliant in not making me feel guilty about my own shortcomings in technique, but I have to say that, thanks to them, I’m going to try very hard to Do the Right Thing.

There you go, a title for this post  - from a song, as always: a classic from the heyday of Mick Hucknall’s Simply Red. Click on the title and enjoy a bit of 90s nostalgia, then sing it to yourself while you inject.

Needles and Pins: Multiple Daily Mini Injections

One of the most annoying things you can hear as a Type One Diabetic is when people say “Oooh, I couldn’t possibly inject myself every day, I can’t stand needles”. The answer is pretty obvious and invariably said through gritted teeth: “Errm, I think you could if the alternative was death”.

Needles and pins-ah. It’s part of life with diabetes, and to those of us who have that dubious pleasure, jabbing sharp bits of metal into our fingers, tummies, thighs and bums is all part of the fun. I don’t like needles  - does anyone? - and despite the fact that I inject myself four times daily and often far more than that (more of that later...), I still don’t like ordinary injections. I look the other way when I have blood taken from a vein and the idea of injecting into a vein, as drug users choose to do, still makes me shudder. But yes, finger prick tests and insulin pen injections are just part of my world. I calculate that I’ve done towards 30000 injections in my 19+ years with diabetes, so to say it’s no big deal is a fair assessment of my attitude.

My faithful pen and needles: bolus (left) and basal (right)

I’ve been thinking about injections quite a lot recently – not that they can ever go that far from my thoughts. Until I started interacting with other people with Type One, thanks to the #gbdoc a few years ago, I just took it for granted that injecting insulin was the norm for me. I was vaguely aware of the existence of pump therapy, but knew nothing about it, didn’t know anybody who used a pump and assumed - without being told so – that pumps were not for people like me. I certainly heard no mention of a pump from my healthcare team, although to be honest I didn’t hear much from them at all. I was a “good” patient with “good” control, so was just left to get on with it.

However, once I started to talk to and meet others living with diabetes my eyes were opened to how things could perhaps be different. The fact that a disproportionate number of my “diabuddies” are younger than me probably warped the statistics a bit, but suddenly it seemed as if everybody else was either on a pump or trying to get one. I spent a weekend in Stockholm in June last year with a group of Type Ones from all over Europe and felt quite the dia-luddite in a group of pumpers, watching in wonder as my friends discreetly tweaked controls, checked numbers and changed cannulas. Conversations - real life and online - often suggest that being on a pump is easier and better, allowing the user more accurately to replicate the response of a working pancreas.

And yet.......I am absolutely fine. I’ve lived with Type One for all these years armed only with a couple of pens and a “guesstimating” method of calculating (no, I’ve never been taught to carb count, and never been offered a DAFNE course), and I seem to have coped pretty well. I started to look a bit more carefully at what my fellow Type Ones do and realised that if I watch and listen, pumps aren’t quite as ubiquitous as I thought. 

A few days ago, I was enjoying one of those wonderful occasions which many of us have enjoyed in recent times, meeting with a group of fellow diabetics. We were in Manchester for a meet up and meal based around the Diabetes UK Professional Conference. I was sitting next to my friend Emma, an outspoken, strong-minded and witty member of the #gbdoc and was enjoying finding her such a good match in the flesh to her feisty online persona. But I couldn’t help noticing that she injected herself several times during and even after our pizza meal. We were so busy chatting about other more interesting stuff that I never got round to asking her about her injection strategy.

For a start it was quite refreshing to see a young woman injecting and not pumping. Recent experience had suggested to me that virtually all Type Ones, especially the younger ones, were on pumps. But more striking for me was that Emma was apparently micro-managing her insulin with follow-up injections - just like I have recently started to do. (By the way, I have subsequently spoken with her on Twitter about her use of MDI, and got her permission to mention her in this post)

I’ve certainly started doing things that way, entirely off my own initiative, over the past year or so. I’ve even given it a name: MDMI – multiple daily mini injections. The additional M for mini is for the extra ones I add if the main pre-meal bolus hasn’t been enough. 

There’s a lot of Ms, Ds and Is in my life: Multiple Daily Injections for my diabetes, then in my working life as a university entrance advisor I know all about Multiple Mini Interviews, the increasingly common method of assessing students applying to Medicine and Dentistry courses at university. Candidates are subjected to a succession of interview “stations”, each one addressing a different aspect of the many qualities required of a good doctor or dentist. It’s like speed-dating, but deadly serious. So with MDI in my day-to-day life and MMI in my professional life, a new label of MDMI came to my mind.

So is MDMI a good alternative to pump therapy? Is it any better than MDI, or basal-bolus as it’s sometimes known, with its more vigorous and unvarying approach to dosage and timing? Well, all I can say is that I like it, and it works for me. I honestly can’t believe that a pump is worth the bother. I see people fretting about where to keep the pump, set changes, basal testing, TBRs and other hassles. For me, a quick jab with a pen seems less faff. In between injections, there’s nothing attached to me, no dangling tubes, no air bubbles.

Adding the extra 'M', the mini correction doses, is a recent refinement that for me seals the deal of preference for MDI. I inject conservatively before eating, then top up an hour or so afterwards if needed. Using this strategy, my average glucose level has fallen, my percentage time in target has increased and my estimated hBa1c is continuing to fall. How do you know, I hear you ask? 

Well if you know me, you’ll see the answer coming a mile off. I’m a known fan of the FreeStyle Libre flash glucose monitoring system, and I have to say that it’s because of the easily accessible knowledge of what my BG reading is and where it’s heading that I can micro-manage my insulin so effectively. I’m very aware that having this knowledge costs me about £100 a month, and that I am lucky that I can (just about) afford it. If I have one wish for my fellow diabetics it’s that the NHS recognise how effective the Libre can be in giving patients the information they need in order to manage their condition more effectively, and allow it to be available on prescription. 

Meanwhile, it’s Needles and Pins for me, not Pump it Up. Click on the links to hear the songs.

But one final thought: PLEASE don't think I'm having a go at pumpers. Many of the wonderful friends I've made through the #gbdoc are enthusiastic and experienced pump users, and I have watched  in admiration as others have started out on the challenging journey of pump use. As with so much else in life, it's a matter of taste, choice and circumstances. We are each entitled to treat this challenging condition in the way that suits us best.

Disclaimer: Please note that this post represents the musings of an unqualified patient, not a healthcare professional. Just because an insulin regime works for me doesn’t mean it is right or will work for others. Insulin is what keeps us alive, but can also be very dangerous if taken in the wrong dosage and/or at the wrong time. If in doubt, consult your healthcare team before making changes to your regime.