Quick facts: I´ve had T1 for 31 years
Got on MDI when it came on market - never understood how it worked
Last 20 years (or more?) on a pump using Humalog since it came out
Transplanted islet cells two years ago, got off the pump
Meds that went along with transplanting cells didn´t sit well with me
Gradually started on MDI since october 2012, NovoRapid and Lantus
Got my first CGM, a Dexcom G4 november 2012
Stopped taking all transplant meds 01.01.2013
I have no insulin production on my own anymore.
I use an app (RapidCalc) on my iPod touch to keep track of my IOB.
I split me Lantus in two, 10U at 7am and 7U at 10pm.
My TDD before transplanting was 20-25U, 12U for basal (Humalog/pump)
This is what I need help with: If BG goes up in the afternoon (4-5-6pm and through the evening) is this the Lantus dose injected in the morning beeing too small so my BG tells me its no more basal in my body?
Is this how Lantus works? Uses all the juice it´s got until it´s no more and then the BG starts to spike?
It´s so strange. I don´t eat regularly and no matter what time in the afternoon I have a relly low carb snack or a real meal and bolus for it, my BG really spikes like it never ever does at any other time of day. Just in minutes I can go from 5-6mmol/l -> 12 mmol/l or even higher and this BG is really, really difficult to bring back again. Insulin is like water when this happens. It seems like it can´t bee the food because it happens so fast.
Thanks for all replies. I have so little experience with both Lantus and NocoRapid, so your experience will be of great value to me.
I think of Lantus as an 24 hour insulin with an unevenly distributed potency. For me it will degrade significantly at the 22 hour mark. With two injections I try to compensate this deficit. The two shots will combine to make sure that the degradation is only half of the degradation I had with one shot.
Your first shot (10U) in the morning will have to cover 15 hours and the next (7U) 9 hours. Mine is more 13:30 to 8:30 hours with 8 and 5 units. I would recommend to take the night shot about two hours earlier and perhaps to increase the lantus dosage of this shot. At the same time I would change the I:C for dinner to inject less bolus. The idea is that the morning shot starts to degrade around 6pm. At the same time there is still lantus from the previous injection present. Not much but in combination still important. By increasing the dosage of the night shot you increase the amount that is still present at this time. In summary: you take the night shot earlier to make the gap in coverage less wide. Then you slightly increase the dosage for the night to have more insulin active around the gap. For example 10U at 7am and 8.5U at 8pm. Half a unit can make the difference between going low and good numbers. So a half unit pen might be helpful too. This is balancing act and perhaps it will fail.
I have read statements that for some the Lantus needs three shots per day. In this situation I would try to switch to Levemir. You are already on a two shot pattern thus the transition will be easy for you. Normally the dosage will be equal for Lantus VS Levemir. Ask you endo about a sample vial. Within one or two weeks you will know if Levemir makes your life easier or harder. I would recommend to investigate the difference between Lantus and Levemir before you invest in a half unit pen.
Thanks you so much, Holger. I will try what you suggest but don´t understand it fully yet. What I don´t understand is how you get your split-timing between injection to be "13:30 to 8:30 hours with 8 and 5 units" because that adds up to bee 22 hours. Can you explain this to me please? If I do as you suggest and inject my evening Lantus at 8pm instead of 10pm, I will have 11 hours before the morning dose, that´s almost an even split. I try to get the gap at night to be no more than 9 hours because I´ve heard that could beat the morning phenomenon.Only reason I do it.
I already have a half unit pen for NovoRapid, but does it exist for Lantus/levemir too?
I have read about this woman here at Tudiabetes that injects equal dose of Lantus every 9th hours no matter what time of the day. That was the only think that worked for her. I tried to add a Lantus dose at 3pm for a while but never got any reliable results from it, so I went back to twice a day. Do you think splitting the morning does in two can have something to say? Because of Dr Bernsteins rule of never inject more than 7U at a time, I inject 5U twice. Could this be a factor of some sort? I forgot to mention it.
I have thought about trying Levemir if I can´t get Lantus to work, and I already have a prescription in case I want to try it. If I do, do you suggest that I split the Levemir in three?
And finally, I don´t understand why I suddenly require so much more insulin than on a pump. 25% more as they say is definitly not it for me, and I eat low carb and are far from overweight. Do you have some words on that topic too?
I never had Lantus/ Levemir, since I went from NPH---> a pump. When I adjust basals, I usually make smallish adjustments to a time period, which I can't do, but usually .025U/ hour "nudges" until it flattens out. This would work out to about .6U more/ day so I wouldn't adjust by much more than a unit of Lantus at a time and would try it for 3 days, similarly until it works out. I also agree with Holger's suggestions on the split, just based on what I've read. I have a Medtronic CGM and generally use the fasting BG as indicators of the propriety of basal insulin and post-prandial as showing the ratio. You mention the low carb snacks pushing it up which makes me think maybe counting the protein---> carb conversion at 50% and bolusing for that might also help make things go smoother? The other option is to not eat and do formal basal testing but I haven't ever done that as I'm quite fond of eating.
I had a return to NPH on the occasion my pump blew up because it was a holiday weekend and I figured it would work out ok and I didn't want to bother going to the doc to get an RX. I calculated the TDD that way and just kind of winged it and was pretty active on top of it and things were fine.
It is not uncommon to require less insulin on a pump, the insulin is much more efficiently delivered just when you need it and the right amounts, reducing the amount that your body clears from your blood stream as waste.
I have to tell you, I'm not sure you have a basal problem. I put together a basal profile calculator based on the chart below (which shows NPH, Levemir and Lantus).
When I plug in your profile, 10U at 7am and 7U at 10pm, I get the following profile:
It shows that you should have more insulin in the afternoon. And I don't think the splitting of your 10U injection makes any difference. What I do think might be going on is either your snack is causing the rise or you may have gastroparesis.
A low carb snack can generate a blood sugar surge from the protein or from the volume (Bernstein calls this the Chinese Restaurant effect). If you still have a rise even without the snack, that indicates the snack is not really the problem.
If you have gastroparesis, it may cause delays in digestion and you may see a rise 3-5 hours after your meal. You would expect to see a similar rise after dinner. Do you have a similar rise?
ps. Basal levels are YMMV. Some people need a flat basal, others need a basal profile with higher levels during certain times of the day (like overnight).
My second shot for the night does cover 10:30 hours not 8:30 as I wrote. So 13:30 plus 10:30 is 24 hours. Sorry for the confusion.
You are right that an even split can lead to a more pronounced dawn phenomen. That is part of the balancing act. Try it and you will know for sure.
I would not distribute the dosage of Lantus as Bernstein recommends. His idea is to speed up the absorption of the bolus insulin to prevent a spike. However for basal insulin you want the absorption to work slowly and constantly. Due to its nature Lantus is designed to connect to the fatty tissue in your skin. If it sits in a bubble or not does not make a difference in my opinion. It will connect to the fatty tissue anyway. With Levemir the argument is the same. This insulin binds to the albumin of the blood. If it sits in a bubble in your skin or is already active in your blood it still will bind first to the albumin and that slows the insulin down in its reaction. In short apply the Bernstein rule just to the bolus insulin. I personally do not follow this rule because I want some of the bolus to come later. This slower part of the bolus will cover the part of the food that will be digested later.
I would split the Levemir just in two. First you need to find out how your reaction to this basal insulin is. It works very different in comparison to the Lantus: albumin binding instead of fatty tissue binding. It has the potential to work surprisingly well. On the other side it can perform less effective than Lantus. It is very individual. For me the Lantus is a little bit more even in its activity and I needed one unit less. Others have reported that they need less units with Levemir.
I think you need more insulin on MDI because basal insulin is less effective. It floats around for a long time being inactive because of all the bindings it can have. Perhaps the kidneys will just filter some of that out before the basal could become active? Perhaps some of the basal insulin becomes decomposed with time?
Sorry for late reply, Brian (bsc). How do you put together a basal profile calculator? I would really love to have that tool! Can you please show me?
My basal has changed since I wrote this post and everything is more stable so I guess I eventually will figure it out. Nowadays it´s 7 units Lantus at 7 in the morning and 4 units Lantus at 10 in the evening. Changed back to Humalog for meals and that suits me better. No more spikes in the afternoon.
So-ooo...If you would like to share with me how to make/use a basal profil calculator I would be really happy.
Thanks, acidrock23. I finally have become more stable thanks to all the advice I get from you folks at TuDiabetes. I strictly reduced my carb intake and diciplined my eating behaviour just to reduce the number of factors and fially my basal has become pretty good. I hope to try out a pump again soon to see if the infusion sets agree with me this time around.
I started taking chromium picolinate, strictly reduced my carb intake and diciplined my eating behaviour (no snacking, no heavy or late meals). For the moment I eat in a very disiplined way just to have some predictability. Hope this answered your question, Sarah.
