Two months on insulin   (July 16, 2009)

So you were started on insulin two months ago, and have your next doctor's visit coming up soon. Starting insulin was a major step in improving your health, and it's time now to get beyond simply knowing how to "shoot up" -- it's time to do even better!

Here are some thoughts to discuss at your next visit to your doctor, if you haven't already discussed them with your diabetes team:

* It's about time for another A1C lab test. A1C testing is typically done every three months, and if you've been on insulin for the past two months, it's quite likely that an A1C level done at the three-month mark will be lower than it was before you started on insulin.

* Whether you are on insulin by needle-and-syringe, or by insulin pen, discuss about the opposite option. There are pro's and con's for both ways to give insulin. And ask if using an insulin pump might be a good idea for your case.

* Has your weight increased? Typically, folks on insulin can easily gain weight (insulin allows excess calories to be stored away very efficiently, as extra flab). If your weight is increasing, talk to your diabetes team about how to adjust your meals, exercise, and insulin doses to avoid continuing problems with weight gain. And that's important to discuss, even if you had lost considerable weight due to out-of-control diabetes before starting insulin. If you haven't discussed your meal plan recently with a diabetes dietitian, ask for a consultation to do so.

* How often should you be checking your BG levels? If the levels have stabilized since you started insulin, probably less often than before, but plan to do more if illness strikes or if your insulin doses are changed, or other medications are needed.

* How often should you call to report BG levels? The first few weeks on insulin, you probably were on the phone fairly often, but now that things are settling into a routine, it's still important to call. Ask about what would be appropriate reasons to call: how high or how low would be a worry; what about acute illnesses, etc.?

* If you were started on a single daily shot of a long-acting insulin (in which case it probably was Lantus, Levemir, or NPH), and your BG levels are bouncing around from one time of a day to another, ask about whether your BG levels could be even better by splitting the single shot to two shots a day, or by adding a rapid-acting insulin such as Humalog, Novolog, or Apidra.

* If you were continued on diabetes pills when starting insulin, it may be time to cut back on their dose, especially if you have been having hypoglycemia now and then.

* If you didn't get a prescription for a rapid-acting insulin already, it's time to ask for one. Even if your BG are perfect on one shot per day of a long-acting insulin, you may someday have some acute illness where using rapid-acting insulin would be needed, so having a vial or pen in the frig is a good idea.

* And if you didn't get a prescription for glucagon already, it's time to ask for one. Be sure someone else is taught how to administer this treatment for hypoglycemia -- it's only for use if you are knocked out from a severe hypo, so someone else would have to give you the glucagon shot.

* If you are planning a trip, get a letter from your doctor about the medications you are taking. See Travel Letter and Your Traveling Medical Record for more details.

* Should you get your pneumonia shot? Pneumonia shots are probably needed only once (unlike annual flu shots), and most people with diabetes should get one. Maybe you can get it at the same time as your flu shot this coming autumn, but perhaps you should get it sooner.

* Do you have identification that indicates that you are now on insulin? MedicAlert is one option that I strongly recommend, but if you don't have anything else as ID, ask your doc for a wallet card and other forms of ID (such as a plastic "dogtag") that he/she may have available to hand you as a freebie.

* How often should you be visiting your personal doctor or your diabetes team? For most folks on insulin, it's recommended every three months.

* If you are seeing a general physician who hasn't yet referred you to a diabetes nurse educator and a diabetes dietitian, ask about whether it might be helpful to get an evaluation from a diabetes team. And if your control is more of a mess now than before insulin was started, you should probably be referred to a diabetes team that includes a endocrinologist who specializes in diabetes, as well as a diabetes nurse educator and a diabetes dietitian.

Sure, this sounds like a lot to go over. But you can print out this list, and mark the ones that are most important for your situation. And maybe even fax the list to your doctor before your visit, so the staff knows what questions are most important for you to have answered.

And congratulations on your success on insulin!