Lantus/Levemir - Trying Discussion Again..ugh!

I do not agree with your statement that basal insulins are not reliable. A generalization to "can have a 30 to 40 percent variation in utilization from one injection to the next" is not helpful here.

Sarah...I think most suggestions here have been covered pretty well. One thing Id like to add is it may help to introduce NPH into your regimine. I also deal with DP, and if I were on MDI I would add a small amount of NPH at night. The nice thing about NPH is it DOES have a peak at about the 6-8 hour mark, then settles back down. That would be an effective way to combat thos early morning liver dumps. Sure, it would add a third insulin to your tool belt, but it could be very effective.

As always, YMMV, and talk to your doc before changing anything in your care.

Good luck.

OK, thanks SO MUCH guys! Holger, yikes...sorry you woke up to 188, not fun. So, I will take everything advised here and start today at 5/5 at 10am - 10pm and stay at that for 3 days at least. I totally agree, it's the wrong amount and wrong times and I think too that an equal divided levemir dose is the best way to go, my endo did say that, 'to split dose evenly' as it's easier on the body. It seems, if I take any more then 5u either way then my AM dose runs into my PM dose and I have a HUGE drop at 12 - 1AM and then a huge spike, like 100 points (so, something liver wise or whatever is happening there). Thank you again SO much! You guys are simply AWESOME! :)

I haven't read any of the replies, but if you are rising in the early morning (like 3am - 5am) without first going low, then that's the dawn phenomenon. What you are describing with having to get up in the middle of the night to take rapid insulin and still being high is the exact (and really only) reason I went on the pump. Long acting insulin can't help with a strong dawn phenomenon because their profiles are essentially flat. You might try waking up a bit sooner, like 3am, to take insulin and see if that heads off a rise. The only way I could control my dawn phenomenon on Lantus (split injections) was to get up at 3am every night and take a 3-4 units of Humalog. I wasn't willing to do that forever, so that's why I asked my endo about a pump.

Hi Jen....THANKS! that's the thing, I do believe you're actually correct and that was my question(s) in the beginning...does this look like DP or just not enough Levemir? I was also told levemir can't help with DP..but, I'm going to try 5/5 and see if it helps at all (maybe that too will be too much and I'll just drop and rise anyway). It just seems no matter what amount of Levemir I give, I can't get that rise to stop (but it's a huge nearly 100 point rise and very quickly, it seems) and taking more levemir has never worked. I too have to take novolog middle of night to combat it. This too is the reason for a 'pump' for me. THANKS!

Note that it isn't necessary to move your AM levemir dose just because you are moving your PM levemir dose. If your day-time coverage is good (and based on that one CGM graph you showed it looks like it is), then I would inject your AM levemir the same as you are doing now - which I assume is when you first wake up.

For future reference, here's a link to that earlier (closed) discussion where you present your CGM graph: LINK

SERIOUSLY?? Holy macaroni - I'm odd??? Sarah, I have been observing and sometimes offering suggestions to your shenanigans for over a year. From your IOB target range on the POD in april 2013, and then your Highs and Lows in the Middle of the night in may 2013 where you also said you were going to start the Revel next day, and then your F Bomb at the Endo in June 2013 and you were back on MDI still not able to get your basal set up........

There are threads non stop with the same issues. I also notice the same folks keep offering the same suggestions and advice. And those are all threads YOU started. The number of other threads with replies containing your advice and additional questions is likely unreckonable.

Thank you for offering me an education on basal, Not that it matters but my basal patterns set just fine as are all of the necessary settings to manage my diabetes on a pump. It does take some work, but I can assure you it did not take a YEAR plus for me to get it together.

I have suggested you do some basal testing. I have asked what you eat. I realize that I don't use Levimer or Lantus but I do know how to basal test and match my insulin to my food choices.

I hope you get there. You've been "trying everything" for a long dang time. Good luck with your UGH!

oh and yes, Gary has some very amazing and helpful information. My own favorite is Gary’s Top-10 (no, make that 14) DIABETES TRUISMS

Maybe stress from an unconscious recurring nightmare? Maybe you press the device in your sleep causing an errant graph? Maybe you sleep walk and eat? I bet that bionic pancreas would respond to level the blood sugar. I don’t want to be flippant but the level of technical expertise! I saw a recorded lecturer who said there were instances when less insulin helped a similar situation. But the details are beyond me.

This is probably a silly notion— but have you consistently double checked the bizarre Cgm readings with your real meter? The reason I ask is that during the brief period I used a Cgm, for me, it went crazy every time I laid down… Plummeting lows, skyrocketing highs, anything but level-- and the readings were never valid. Whenever I checked with a meter was always where I wanted to be. My doctors only thought was that because I have very little subcutaneous fat that laying down caused enough fluid shift or whatever in my body to throw the sensor into fits. Sounds like you’re quite thin too so just thought I’d mention my experience…

Sarah, my suggestion to you is to consider using Gary Scheiner's Integrated Diabetes Services. http://integrateddiabetes.com This is an online consulting service with the super detailed attention that I think you would benefit from.

Most of us know about Gary Scheiner as the CDE of the Year last year. I have never used his services but I do know of others who have and have raved about the assistance they have gotten. I've heard great things about all of his staff. Gary has Type 1 as do his staff members. Check out the website. My understanding is that you provide him/them your logs, meter downloads, etc. and then have appointments through Skype. This is something that you can do totally independent of your endo or choose to have Gary share your information with your doctor.

It is self-pay although you can file the billings yourself through your insurance if CDE services are covered.

I know you've struggled with pumps and trying Levemir and/or Lantus and I'm not sure that you're getting the help/info you need from TuDiabetes people or your doctor. Type 1 is a constant battle and it is a folly to seek perfection. But I do think that things can be better for you and Integrated Diabetes Services might be the help you need. Check out the website and think about giving it a try. Have you watched any of the TuDiabetes videos with Gary? I think that Emily interviews him once a month or every other month.

Yep, sounds exactly like what I went through with Lantus. I took more Lantus at night than I did in the morning, but that still didn't help. Before starting on the pump I had 90% of morning readings over 180 (and many were much higher, like 250-300+), and it was almost unheard of for me to wake up below 140. The only way I could achieve that was to get up in the middle of the night and take Humalog. I documented this for my endo by testing before bed (having not eaten since dinner), testing at 3am, and testing when I woke up. It showed that most of the time I went to bed in range, was in range at 3am (virtually the same BG), but woke up 100-150+ points higher by the time morning came. If I tried raising my Lantus dose I just ended up going low in the middle of the night. The pump vastly improved my morning readings, but my control is general is still somewhat unstable.

Karen, I think it's your insistence that "liver dump" in T1s is a myth that is getting the pushback. Reason being there is plenty of scholarly literature out there dealing with it as a very real phenomena for T1s, your opinion and that of others here not withstanding.

It’s sort of a sidetrack though as all you can do is take more insulin or less insulin.

I think you need to look into what you're eating the night before, and also double check your cgm with a finger stick. Like first of all, look into if you're eating a lot of fat and carbs in your dinner/late night snack/whatever your last food is of the night. If you're not, then check your cgm. Check if you're laying on it funny or something. Verify anything on your cgm with a finger stick if it seems odd. I know people have suggested it but that's something you have to consider first before assuming something's actually wrong with your body and not what you're doing. It could be some habit or some foods don't agree with you before bed even if they agree with you all day otherwise.

Dave, I don't care what it's called. WE don't take basal to stop the liver from dumping. WE take basal to keep our bg in the desired range at all times. It is clear that there is a problem with the basal either the dose or the timing. But in fact there could be other issues that apply and I have found that asking after food, activity, blood glucose readings, etc. get no response.

I do not participate in the discussions to receive lessons from a diabetic who has no idea how to manage hers. I actually am trying to help. Or at the very least understand. More than a year of this is too long.

Pushing scholarly literature to prove liver dump is real is no help in getting the basal corrected. Sure, the bg starts to rise when we wake and often well before, this is not a shocker. Basal can cover it - it's that simple!

Finally - I can't help but chuckle where article city / and ez articles are the references for this information. They are neither scholarly or proven. Some freelance author and internet researcher is not what I would call a trusted source. And in fact, I have met a boat load of them right here!!

Hey Karen -- it's all good. The only reason there has been some argument is because when the term was mentioned, apparently some thought it important enough to engage a side-debate about it.

Is it important? Maybe. It does make a difference if the problem is due to hormone-induced insulin resistance, or increased glucose secretion by the liver. How the whole system is going to react to insulin will also be different.

Pushing scholarly literature to prove liver dump is real is no help in getting the basal corrected. Sure, the bg starts to rise when we wake and often well before, this is not a shocker. Basal can cover it - it's that simple!
Please, seriously. I'm not some sort of evangelist "pushing" anything. I commented on the problem, based on my knowledge, was challenged regarding that knowledge, so naturally turned to the medical literature to back up my assertions. What's wrong with that? Can't we disagree in a friendly way, e.g. refraining from derogatory characterizations of motives or rhetoric?

I'm just fine with you disagreeing with me. Call the existing studies/literature suspect, or even bogus. I'm fine with that. Say that it doesn't exist, and that's an entirely different matter, and I'm likely to say, "does too!"

As for the relevance to Sarah's problem, I respectfully disagree. It matters whether her BG is rising because insulin is temporarily less effective (IR), or because a lot of glucose is being released by the liver.

In the former case, getting BG to go down over the subsequent 4-6 hours will be very difficult, until the underlying IR condition resolves. In the latter case, insulin is still effective, and more standard strategies for correcting based on ISF calculations are reliable.

In any case, regardless of the cause basal insulin needs vary throughout the 24-hour day for everyone, PWD or not, T1 or T2. Long-acting injections are a very low-resolution solution, generally unresponsive to varying fasting BG levels. Only with complex overlapping multiple injections can a varying basal delivery be achieved, similar to what one can do with a pump -- except once turned "on", it can't be turned "off".

Cheers!

WARNING! GEEKSPEAK ALERT! [klaxons blare]

This whole discussion got me thinking a lot about this problem of varying basal needs vs. the flat, long-acting action profile. These are essentially square waves, with a fixed period of 18-22 hours (24 if you're Sanofi Marheting :-))

In signal theory, an arbitrary waveform -- which is what the actual varying basal insulin need is -- can be reconstructed by the combination of a set of simple periodic waveforms scaled and added together. One common form of this some here may have heard about is Taylor Series.

Given a particular desired basal insulin profile over 24 hours, and the known duration of action for the individual in question, it is possible to calculate via some pretty basic math the right overlapping injection dose and timing for multiple injections to yield pretty much any desired profile.

Now, this likely wouldn't be very practical, as anything more complex than a 2 or 3 peak profile would probably require many injections at all sorts of weird times of the day, but the idea in intriguing.

I may play with this in Excel...

It would probably work great to split the dose into 24ths and take 1/24th of your dose every hour, like a pump! Although I cheated and have set my pump in 1/2 hour increments, so I can "cheat" smaller increments. It's worked really well. I might take a couple of weeks off in July and switch to shots as I want to try surfing again. I got up for about 3 seconds in an hour class in NC a couple of years ago but, if I pound my head at it for 2 weeks....

Re the insulin, I think the condition described in the original post sounds very much like DP. It takes insulin. I've had some DP lately, although a twitch of the pump got rid of it, it was annoying. I agree with the suggestion, maybe JohnG, that if you can find the peaks in the Lantus/Levemir and time them correctly, that's the way to go. I had better results in college with N but I am not a big fan of it as it's not very regular.

Sarah, this can get very confusing, so make sure you run through it over and over to get it down well!

One thing to keep in mind that I mentioned in that other discussion is that splitting doses can leave you with periods where you are well below your nominal basal insulin needs, and this will cause you to see a BG spike. Not because of DP, liver dumping, or anything else. Because you don't have enough basal insulin.

Here's a graphical picture to help understand. For this example, assume this person has a nominal basal requirement of 1U/hr. Lantus works in him for 19 hours, at which time its action falls off over the next hours or so. It is gone at the 20 hour mark.

Standard dosing would be to prescribe 24* 1U = 24U of Lantus, 1x a day. If administered that way @ 6AM every day, this person would expect to see their BG start to rise about 2AM, getting quite a ways up there by 6AM, when the next Lantus injection occurs (as well as a big correction bolus).

Now, let's split that dose into two 12U injections, taken at 6AM and 6PM. We'll ignore the bootstrapping* problem for the moment, and assume Lantus has been taken in this manner steady-state (i.e., there was not starting point -- there's already Lantus in the person from a previous injection with each subsequent injection).

At 6AM when the morning 12U is taken, this adds 0.5U/hr to the existing 0.5U/hr from the injection 12 hours prior, for a total of 1U/hr. That's good -- that's what we need.

However, 8 hours later, at 2PM, the evening injection from the previous day wears off. Now only the most recent injection is active. So the basal rate drops to 0.5U/hr for the next 4 hours -- from 2PM to 6PM -- when there's another injection. This person is going to see their BG rising all afternoon, and be correcting correcting correcting, until they inject Lantus again at 6PM.

The same dip will occur from 2AM to 6AM, for the same reasons -- which could certainly look like DP. Here's a graphical view of what basal levels look like in this theoretical individual for single, 2, and 3 evenly split doses:
Now this is a very crude approximation of what's going on, but it serves to illustrate the point: Basal levels are not constant when using long-acting and splitting doses. You will have several points in the day where "inadequate" basal is available (in fact, with evenly split doses, the number of dips is the same as the number of injections).

Also, we can clearly see that the more doses you split the total into, the less severe the dips.

This offers some options for someone willing to MDI on their basal. It may be easier, from a convenience/timing standpoint, to split into 3 or 4 doses, spread evenly. This will have the added advantage of raising the low points of insulin availability, reducing high BG excursions. The 3-dose approach works well with human sleeping patterns -- dose right before bed, again in 8 hours when you get up. Sleep through the night. Dose again in another 8 hours, and then another 8. Repeat.

The math behind all this is too much for most people (including doctors), so no one bothers. However, it's not snake-oil -- you can split your lantus into 10 doses a day (if they aren't less than 1U), and everything works out fine -- if you don't make a mistake.

Anywho, a little more food for thought. I'd be happy to help out with the math, etc. in dialing this in for you once you know what your own pharmacokinetics (how long Lantus works for you) and your nominal basal needs.

thanks, jen. yep, that's about my % of morning highs, too; rest of the day, I'm good! Woke up to 192 at 3AM this morning, too and it feels like crap. My endo is fully aware of DP, as all are also smogeyi effect does exist, too. i think most type 1's have to take more insulin upon waking up, it's just simply our bodies responding to 'waking up' without the natural balance of hormones to regulate it. more levemir simply doesn't seem to help...i'm still trying, though...ha! I just have such reluctance (fear I guess) of going on a pump...ugh! So, it's not an inaccurate rolled on CGM, these are my actual blood sugars when I check them during the night.