My 16 year old son (diagnosed 4 yrs ago) went off the pump a couple of months ago. Instead, he takes Lantus, which is split into am and pm doses…he has dawn phenomenon so he gets more in the morning. Total Daily Dose is about 70 units. He plays football and wrestles and had figured out how to prepare for them, using a combination of temp basals and extra carbs while on the pump. Football season is starting, and we have no idea how to adjust his Lantus.
Any input is greatly appreciated. Thanks!
Actually I think that Lantus just lasts too long to allow reliable adjustments to physical activity. It is quite hard to handle extended physical activity only with extra carbs when much basal insulin is on board. Since he is already on a two shot regime I would recommend switching to Levemir (possibly with the side effect of needing less insulin). The profile of this insulin does match better to the 12 hour pattern. Thus the adjustment for sports will more likely influence just the next 12 hours and not longer periods of time. But I am not really the best advisor here. Diagnosed with 17 I could not handle physical activity very well. I took quite a while to get more knowledgeable and experienced to handle this challenge without nasty lows. What often helps is chocolate one to two hours before the extended activity - and also juice and glucose tabs for short term corrections.
Just curious, but why did he go off the pump? I’ve always been very physically active and had a really hard time using MDI when engaging in lots of physical activity. It was one of the primary reasons I went back on the pump. He might want to try experitmenting with levemir and maybe even NPH. While I know many endos don’t like NPH, it was the only basal insulin I had any success with when engaging in physical activity, so long as I timed things right to avoid the peak.
A good resource for these sorts of questions is the “Diabetic Athlete’s Handbook” by Sheri Colberg. Since Lantus is so flat, you will probably need to establish your proper dose based on the minimum needed with the training schedule. If your son is routinely going low during training, you will have to reduce the Lantus so that does not happen. Unfortunately, that means that you may well be higher than desired for the rest of the day. As other have noted you can use insulin’s like NPH to augment, in fact some people suggest that the intermediate action of NPH can work quite well to combat Darn Phenomenon. In either case, you are likely to have to decide whether to keep Lantus with a dose determined by the minimum level that avoids hypo around training and the alternative which is to switch to a different basal such as Levemir or NPH.
ps. And remember to focus on nutrition, before, during and after training. That can have as much of a role as insulin.
Mine is 6 years old and she was diagnosed (T1) 3 1/2 years ago and she’s been on Humalog and Lantus the whole time. Nobody’s ever told me what to do for exercise, I’ve figured all this out myself through trial and error. If my daughter suddenly begins exercise after a period of inactivity then she needs more Lantus. Exercise increases the amount of sugar the body releases into the bloodstream on a regular basis. So she needs more coverage at night which is what the Lantus does.
If my daughter has an extreme amount of physical activity during the day, or keeps going for hours, or gets unusually excited or goes low a few times, then her blood sugar will drop rapidly after she goes to sleep at night. It may continue dropping for one to four hours, but then in the middle of the night it’ll go back to its normal rate of descent. I’m assuming that is because her body releases sugar during the day and then collects it again after she goes to sleep.
The last time my daughter went from inactivity to getting a lot of exercise her Lantus dose started at 7 1/2 units. Her Lantus needs went up gradually. The first day she only needed a tiny bit more, but after a few days she needed a total of 7 3/4 units.
If she doesn’t exercise for one day her Lantus dose doesn’t need to change. But if she goes two days then her Lantus needs go down immediately. If I don’t reduce her Lantus at that point I end up staying up all night giving her juice boxes every hour or two. That’s how quickly it changes.
We only adjust Lantus for nighttime numbers, not for the daytime. If I’m anticipating her getting a lot of exercise I will reduce the amount of Humalog she gets during the previous meal. I usually halve it, and then give her part of her normal meal. Then she gets more food while she’s out running around. Halving her Humalog keeps her from having to stop for additional carbs constantly. But I can’t give her any less than half, or her blood sugar will shoot up and she won’t feel good. Sometimes her blood sugar shoots up right after exercise, if it does that then I give her a small extra dose of Humalog.
Oh, and I can’t usually halve her Humalog for more than one meal in a row. That causes rapid highs after the second shot. If she’s going to exercise through the 2nd mealtime I give her a little more than half, and then keep another shot ready for when she rests, because then her BG will definitely go up rapidly.
I hope you find some of this information helpful. It took me a long time to figure all this out. Good luck.
Darn Phenomenon? I think you may have inadvertently found a better name for it 
That is interesting. Exercise will have different effects on individuals and the kind of exercise also affects how your body responds. I find that aerobic exercise (like running around) makes my blood sugar drop during exercise. Anaerobic exercise (like weightlifting or football) makes it go up. For many, competitive sports (like football) also cause stress and increase blood sugar.
My experience is that most of my exercise increases my blood sugar and I have to actually bolus for my training. After training, I am significantly more insulin sensitive and can reduce my meal boluses by half. My experience is that during days and weeks of training (as opposed to times off), because I am more insulin sensitive, I need to reduce my basal levels. I think that most people will find that basal requirements overall drop during seasons of training.
ps. And I deliberately use the term Darn Phenomenon, cause I hate it.
Curiously I’m on Lantus twice daily (9+9 in summer) and I am about to persuade my insurance company to let me use an OmniPod for precisely the reasons you describe. I find that because I can’t change the basal dosage if I decide to do something strenuous I have to be extremely careful for the following few days.
Well, I could adjust the dose, at the next 12 hour period, and probably I should adjust the dose to cope with the fact that my body will spend the next 24 hours or so rebuilding glycogen that I just used, but I simply don’t know how to conduct the required experiments to determine the dose variation. I’ve sometimes dropped by a unit, but the results were inconclusive - my BG varies so much anyway that seeing an underlying basal trend was pretty much impossible.
I figure that with a pump and a CGM I can lower my basal dose after a few hours and, by tweaking it, eventually get a flat-line BG when I’m neither eating nor excercising. This remains to be seen; so far as I am concerned it’s a diabetic fantasy until I can actually try it out. Clearly it will take many months to get this right, if, indeed, it works at all.
Why did he go off the pump? He pumped successfully with an Animas 2020 for 4 years but in April and May his numbers were completely out of control…constantly in the upper 300’s and above. Being on the pump added that one extra layer of complication to figuring out how to fix it. We would decide it was basal issue and go through basal testing to re-set that and then change his infusion set and find out it was kinked. Then we were sure it was his infustion set and we would change that only to find out that there was nothing wrong with it…and sometimes we changed it several times a day and who can afford to do that? I should mention that he had a huge growth spurt last year gaining 4 or 5 inches in height and putting on about 20 pounds and I know that had to contribute to the problems. We did end up changing his insulin to carb ratio and his correction factor permanently through out the course of all this, but he just ended up being sick and tired of being sick and tired. He is a smart kid and attends a Science & Technology magnet High School and he was missing classes and not able to study and falling behind in school…and then being stressed about all the missed school work. I must insert here that his teachers were wonderful and supportive and helpful and concerned and bent over backwards for him, but there was only so much they could do. I would test him every couple of hours through the night and make corrections so that he could wake up at a decent number so he could take a makeup test before school with one of those wonderful teachers and by the time I drove him the hour to school he would be in the 300’s again…and that is after not eating breakfast…or eating breakfast…it was just never predicctable. It was stressful and exhausting and frustrating for everyone and it had to stop. We ended up figuring out the problem is most likely scar tissue affecting absorption and kinking the canulas - he was using inset 30’s. We were willing to try a different kind of infusion set - contact detach - but I will not bore you with the problems we had trying to work that out. Suffice it to say it was the perfect storm of people being out of the office, supplies damaged in shipment, and my son just deciding he didn’t have time or the energy to figure it out. The people at Animas were great and he intended to go back to pumping after school got out, but the contact detach infusion set is actually a small steel needle - not a plastic canula - and he didn’t want to play football or wrestle with that inside him…not that I think it is even recommended…and he would have to use a new one every day from August 8th (the beginning of football season) through mid-March (the end of wrestling season). He was finally feeling good again and thought he would get through the sports then go back on the pump next spring…but we were blissfully unaware of the limitations of Lantus…until now. So I think we need to re-evaluate our course of action. I appreciate your suggestions. He has not used Levemir or NPH. We obviously need to get back in to see his endo. The last conversation we had with her was that we planned to go back on the pump, and the Lantus was just a stop gap to get us through a tough time, so I am sure that is why she didn’t give us a head’s up on the Lantus. Thanks again!
I will talk to his endo about Levemir. She is out of town for the next week so we will have to do the best we can.
His football team is having 2 a day practices starting today. He started the first session in the low 200’s and 2 hours later he was 109. The break lasted 90 minutes, during which time he bolused with Novolog and ate lunch, so the insulin was peaking just as he started the second session. He did end up sitting out about 25 minutes and having some extra carbs. At the end of session two he was 169. It worked out pretty well. He plans to not give himself a full bolus for lunch tomorrow. He is notorious for excercise induced delayed hypoglycemia so he is carb loading now. I think he should reduce his morning Lantus, too, but he likes to change one thing at a time.
Thanks for taking the time to respond. We really appreciate it.
We do actually have that book sitting on our book shelf. I don’t know why I didn’t think to take it out and look at it again since he had changed to MDIs. Thanks for the reminder.
When he initially went on the Lantus and started having the Darn Phenomenon (love it)problem I of course did my research and found that one of the best ways to handle that was…the insulin pump of course!!! So frustrating! I did come up with the idea of splitting the Lantus with the different doses and was relieved when that worked. We will definitely talk to his endo about Levemir and NPH.
Thanks for your input - we need all the help we can get!
We had already figured out that Lantus is pretty forgiving within a 24 hour period. After being on the pump, it was tough to remember to even give the basal insulin so there were a couple of times he just forgot to take it. Fortunately there was not much of a difference for his BG over the next 12 hours. We conquered that challenge by scheduling daily reminders in the ever present cell phone.
Like your daughter, my son typically experiences delayed hypoglycemia after a lot of excercise. He has learned he has to carb load to replace the glycogen stores in his muscles and liver or he will suffer lows up to 48 hours later…we learned this the hard way. I make sure I test him at night to catch those scary lows.
I think I have learned that Lantus is probably not going to work for my active 16 year old and I need to get him into the endo to discuss other options. Thanks so much for sharing your experience. Diabetes is such an individual disease that nobody’s body reacts exactly the same way, but it is comforting to know that some experiences are “normal” and consistent for everyone and to have some different ideas on how to address the challenges.
Even when he was on the pump, my son had problems with delayed hypoglycemia after strenuous excercise. For instance, during wrestling season the kids have really hard 3 hour workouts every evening. He would actually take the pump off during the practice and still have overnight lows. There is no way to get around having to replace the glycogen stores, but I don’t think he spent as much time tweaking the basals as he could have. He just used it as an excuse to ask mom for a milk shake! 
I do think that Lantus tends to be “forgiving” and small dose changes would not make a big difference, which is why I came begging for help with this. I think Lantus is obviously not the best choice for my son now that sports have started again.
Good luck with the Omnipod. A pump can definitely make life easier and I can hardly wait until our insurance company covers a CGM. I think an important thing to remember in your “diabetic fantasy” is that consistent excercise and diet are the easiest thing to adust for. As I said in a previous reply, my son has experienced delayed hypoglycemia up to 48 hours after strenuous excercise, especially if it is something out of his normal routine.
Thanks for taking the time to reply.
I’m in no way consistent about anything, perhaps to the point of being foolishly inconsistent, but I had one experience many years ago that maybe informs what I do today with the basal dosage.
I was out on a whole day hike. I’d had my normal amount of long acting insulin (ultratard; it was really long acting but is no longer available) and I started to go low. It just kept on going regardless of what I ate. I ate all the sandwiches, a whole Mars bar (a truely fantastic amount of carbohydrate for me) and just kept going down. Fortunately my glucagon response is good, but what I learnt is that basal insulin is downright dangerous.
So my Lantus dose is probably, technically, too low. Certainly it is too low for several days of computer hacking, or one day of driving, however the risk of raising it is too great. This is part of what I hope to get from the Omnipod - a basal dose that can be stopped!
I always looked for length in the basal insulin - that’s why I liked Ultratard and hated having to use Lantus instead. But maybe this is actually exactly wrong. NPH has been around a long time and is non-prescription in the US, so is a lot cheaper. I started out life (well, diabetes life) on PZI, which is similar, but I’ve never used NPH. I think, maybe, if my insurance company bounces the Omnipod, NPH might be a better choice for me than Lantus.
I’m on Lantus and never adjust it for exercise. I only adjust my fast acting insulin. I either take less insulin or eat more before exercise (Depending on the type of exercise…aerobic lowers my sugar and anaerobic raises it.) I only adjust my lantus depending on how high or low my sugars over a week or so period.
You son might be getting hypo hours exercise, because after exercise your body is very sensitive to insulin (and other hormones and nutrients) because your cells are craving to be restore. If he doesn’t already, he should try taking less insulin after exercise.
Some people (and children in particular) experience post exercise hypos. These cannot be explained simply from increased insulin sensitivity. Some people believe that it is related to your body trying to restore glycogen stores. I have these sorts of hypos about two hours after exercise, but have been able to reduce/eliminate them by eating a good meal (with bolus) within 2 hours. But these hypos can occur up to 48 hours after exercise and they can occur at night. Our fellow member Cheryl posted an interesting presentation on this topic some time ago.
I shot myself 16 units of Lantus in the morning and 8 at nights. I train 5 days at weeks and is almost impossible to me adjust the night dose in order to avoid the hypos in the middle of the night. The only way that I found to solve this problem is to increase my BG before going to bed, with a glass of orange juice, no matter if my BG is 170 or 220. When I exercise my BG drop at midnight 100 - 200 points. At night my body is like a machine sucking of glucose hehe.
When I do not train, my glucose only drops 30 - 50 points.
Ugh, that sounds just horrible. I will add that puberty and diabetes is MISERABLE. Growth spurts, combined with hormonal surges, make insulin resistance a real problem. Puberty for me was just short of hell. Everything that had worked perfectly no longer worked and my body seemed to be on a roller coaster into the dark side. You may just have to ride it out with whatever works. Again, definitely give NPH a try. For me, it worked well enough (and I was a competitive athlete all through college) to keep the lows manageable and the highs not too bad.
I am a big believer in doing whatever works when it comes to managing D. If that’s MDI and not a pump, then you should stick with MDI, at least for the time being. But again, puberty makes things with D really horrible. The only thing I can say is that it should be over soon and once all those hormonal surges level out, he may find that his BGs improve dramatically. For me. my insulin requirements dropped significantly after the age of about 17 and things really evened out. My school performance also improved once I got to college because (shocking!) I was able to concentrate better with more stable BGs.
Please tell him that it does get better. I know it feels like his body is betraying him at the moment, but once he gets over this hump, things improve. Hang in there!
For the bolus I came up to these adjustments:
moderate activity: reduce the bolus by 20%
high activity: reduce the bolus by 50%
maximum activity: reduce the bolus by 80%
It is of course much more practical when the calculation is automated. Thus it is part of our Glucosurfer project to make MDI a little bit easier.
Yes, the teenage years are tough enough without all of this!
His endo is on vacation right now, but we will talk to her soon. My son is really hoping he will be able to make this work without changing from Lantus. School is getting ready to start again and he is concerned about setting up all of his doses again. I pointed out to him this morning that even if he doesn’t change insulins, he will be making adjutments anyway as his body gets used to the new level of activity and uses the insulin more efficiently.
Thanks for the support. You guys are a great resource and I am sure I am going to be back asking for more help soon!