Hi All,
So before I do the pump as my last option, I'm wondering if anyone could provide some advice about switching FROM 2 doses (AM & PM) Levemir to 1 dose/shot (PM) of Lantus, or could I take 1 shot Lantus in the AM only? I can't get my numbers down, especially during the night and huge rise in the AM. How would I go from two shots to one and should I take the lantus in the PM? I'll ask my endo,too.
THANKS!
I used Lantus for many years before switching to Levemir a few years ago. I found I needed to take two doses of Lantus a day, the same as I do now of Levemir. To switch from two of Levemir to two of Lantus, just change over from one bottle to the other. Switching from two shots a day of one insulin to another is easy - just swap out the bottles and test more to be certain you aren't more sensitive to one than the other.
I wouldn't expect one shot a day of Lantus in the morning to work very well for you, although there is nothing wrong with trying it. I say this because I found one shot a day of Lantus tailed off as I was approaching time for my daily shot. If you are taking your one shot a day in the morning, it would be tailing off just when you are already experiencing a BG rise in the morning.
Before switching insulin, have you really experimented with your Levemir dosage and timing schedule? Is your BG increase before you wake up, or after you wake up? Is it predictable and how serious is it?
I can't get my numbers down, especially during the night and huge rise in the AM.This right here says that if you're having trouble over night especially, that a single dose should definitely be before bed, rather than in the morning. This will maximize the insulin as much as possible from the Lantus/Levemir.
For most people, though, both are pretty flat through almost all of their working duration; it's the duration that seems to vary the most from person to person. Some people get close to 24h of efficacy; most seem to get something between 18-22 hours. So, splitting the dose will result in a pretty consistent level with two "dips" where the background basal will decline over a few hours to about half your target basal, until you take the second 12-hr injection.
Regardless of how many doses you plan to split it up into, if you're having problems over night one of the injections should be at bedtime.
I find that my morning and overnight levels are better if I take lantus in the evening instead of morning
I'm also one who needed two doses of Lantus a day. One dose ran out at about 20 hours and (since I took it at night) my blood sugar would go really high after dinner and at bedtime. Switching to two shots of Lantus per day fixed that problems and helped my blood sugars throughout the day to stay more stable.
I had slightly better results splitting my lantus but it was too much trouble to remember to take the shots twelve hours apart, and I prefer on shot in the morning anyways. The act of jabbing myself with insulin doesn't bother me anymore, but just remembering to do it twice a day was a bother, once is so much easier for me. My endo doesn't know yet, might mention it next time I see them. :p
Thanks, everyone. Jeff, why are you not on pump..just curious? So, it's bad, CGM attached (sorry, my printer is running low on ink). I can't seem to combine the two doses of levemir. I can't tell if this is not enough PM dose and thus the middle of the night AM rise, too much and the drop then rise, if it's DP? What the heck...UGH! My endo just told me the same thing, I'll probably end up with two doses of lantus, too. Only a pump will help with this.
How is MDI basal supposed to work during the day, how does one know if it's working; say one's 130 (or whatever) 2 - 3 hours after a meal, then what's supposed to happen if the basal AM dose is correct. Is it supposed to bring us back down to a good fasting number? Thanks to all! :)
809-CGMJune.jpg (487 KB)injected long-acting is supposed to provide a steady, fixed-level of background insulin throughout it's duration of action. The duration varies from person to person; once you know how long it lasts in you, you figure the dose by multiplying your basal rate by the duration. This simple model works for non-overlapping injections -- a.k.a. once a day.
So, if you needed 0.25U/hr, and Lantus lasted 20hr for you, you'd inject 5U once a day.
Of course, this leaves a 4 hour gap that's got to be covered, leading to two or three overlapping injections, so the math gets a little more complicated. I'll work it out on paper and post a follow up.
How is MDI basal supposed to work during the day, how does one know if it's working; say one's 130 (or whatever) 2 - 3 hours after a meal, then what's supposed to happen if the basal AM dose is correct. Is it supposed to bring us back down to a good fasting number?In a perfect world, basal insulin serves only to keep your BG stable (i.e. unchanging) when your body is fasting. Meal-time glucose coverage should all come from bolus insulin.
So, if bolus is not consistently getting you back to your starting point before eating within 3-4 hours postprandial, you're not using enough bolus insulin to cover the carbs -- your IC is a bit off.
If, in compensation, you've adjusted to having basal slowly bring your BG back down, then you're taking too much basal, and risk hypos, especially when you're asleep.
Have you done basal testing, Sarah? That's not only for pumpers :-) Sounds to me like your TDD is shifted a bit too much to the basal side, and not enough on the bolus side, given the issues you're having overnight, and with DP. I took that, combined with your comment about basal bringing things slowly down after a meal to draw that conclusion.
Thin gruel to pass judgement on, so take it with that in mind.
thanks. but it's just not linear like that. people post they run out of their basal on one shot..how does one know if it's running out in the evening or just not the correct amount of bolus for meal? You state basal is supposed to keep us stable, but we have to get the correct amount to get to the fasting stable point, this is what I don't understand. What would be a good example of a good basal profile overnight, say if one goes to bed at 120 (no food / bolus after 6pm) they wake up to what ________? Our bodies don't stay flat overnight. Mine seems to go up and down all night. I seem to go higher towards bed time, can't seem to correct because I have a huge drop (seems to be when my PM dose of levemir kicks in or is it just my 'body' and diabetes)around 12am , wake up and have to eat, sometimes not really aware of it and only cheese, within an hour or certainly by 4AM I'm rising to 200's and then rise the minute I wake up in the morning. Too much, too little, DP, not combined doses correct. I don't know. If I only take 4 units PM levemir dose it will keep me flat but then I just rise around 4AM anyway. If I take more then 4 u PM dose, I drop and rise anyway, too. UGH! And it also matters what amount we're taking in the AM which reflects on our PM numbers. I'm just messed up with this and can't ever sleep through the night. Or, let's say one goes to bed at 180 and wakes to 180. Well, that PM dose is keeping one flat overnight but it's too high to stay at and wake up at, so, we could correct that bedtime number, but once that correction bolus burns out in 3 - 4 hours, one will go right back up to 180. So, is that 180 at bed a wrong bolus calculation not enough AM dose of basal, etc..? I can't figure this out. THANKS!
i switched from levemir to lantus and had to go from one to two shots a day, which was fine. what surprised me was how i had to DOUBLE the dosis of the levemir to match what lantus did. so maybe you might have to be patient to get the dosage right? might be a bit different to levemir.
Gosh, Sarah, that's exasperating!
To be clear, what's "flat" is the level of active insulin in the bloodstream from latest-generation long-acting (currently only Lantus and Levemir, to my knowledge). Despite what others may have said anecdotally, the pharmacokinetics of these preparations is well know and well characterized. One of the revolutions of these newer "long acting" insulins was the lack of any peak in their delivery.
Now, does this mean BG is going to stay flat too? As you frustratingly experience, no. The liver seems to have a mind of its own, and dumps glucose into the blood at seemingly pointless times. Mine does the same thing (I've got a G4 too).
It took me probably six months before I really understood what patterns were there, and the triggers that cause some of them. Once you know this, a pump is pretty much the only way to counter it -- long-actings are a very "blunt" instrument.
In any case, my advice given all the variability your seeing is to do some detailed, very controlled basal testing. If you're not familiar with the details of what's involved, TuD can help!
One thing to keep in mind about splitting long-acting doses: The total dose over 24h must equal your total 24 hour requirement.
When thinking about basal, remember there is a "base level" of insulin you need to have all the time. To make the math easy, let's say it's 1U/hr.
Your doctor would then prescribe 24U of lantus 1x day. The idea being that that 24U results in about 1U of active insulin at all times.
What happens in the real world is this stuff varies a bit from person to person because of the biochemistry by which it is "time released", which varies slightly from person to person. So, it may only last 20 hours in you, for example.
This means that, nominally, you're getting 24/18 = 1 1/3U per hour, and after 18 hours it's falling off heading toward zero (not immediately).
Now, splitting doses of long-acting basal is tricky, especially for a T1. If you split it in half and overlap at the 12h mark, you're only getting 1/2 the amount (1.33/2 = 2/3U) an hour for the first 12 hours. This will be insufficient to meet your fasting basal needs (remember, 1U in this example), so your BG will slowly climb, you'll correct with fast-acting, it will drop, then slowly climb again, on and on.
This is because you do not have enough basal insulin.
Finally, at the 12h mark, you take another 12U injection. Since the Lantus works in you 20h, this will stack on the previous injection, getting you now to 1.33U (remember, because of the shorter total duration, we're basically over-administering a little bit). Now what happens?
You're BG slowly falls, and keeps falling while you're fasting, because you only need 1U/hr, and your getting 1.33. This can take you to hypo territory, where you correct. Then, hours later, it happens again. In fact, this situation will persist until you reach the 20 hour mark from the whole start, at which point (first-order approximation) you'll drop back to 2/3U for 4 hours and BG will start to slowly rise again. Until the next shot 4 hours later.
All this happens because:
Without measuring and accounting for these factors, but instead just estimating it based on the Prescribing Information the doctor uses may result in the rollercoaster described above if the patient is not a true 24h miracle in which Lantus actually does last that long.
Thanks, everyone. Jeff, why are you not on pump..just curious? So, it's bad, CGM attached (sorry, my printer is running low on ink). I can't seem to combine the two doses of levemir. I can't tell if this is not enough PM dose and thus the middle of the night AM rise, too much and the drop then rise, if it's DP? What the heck...UGH! My endo just told me the same thing, I'll probably end up with two doses of lantus, too. Only a pump will help with this.How is MDI basal supposed to work during the day, how does one know if it's working; say one's 130 (or whatever) 2 - 3 hours after a meal, then what's supposed to happen if the basal AM dose is correct. Is it supposed to bring us back down to a good fasting number? Thanks to all! :)
Hi, I'll reply down here since it will otherwise get lost in all the above. I question how relevant some of what was written above may be for you since you are a T1 and not a T2. I have personally never seen any evidence of "liver dump" in my own results - I believe that is much more of a concern for T2's.
Why don't I use a pump? After decades of T1 with volatile BG and A1c's in the mid to high 7's I actually came close several years ago but was able to significantly improve my control by using the information contained in "Pumping Insulin" by Walsh and "Type 1 Diabetes" by Hanas. So the short answer is that I found I don't need one (good enough control without it or a CGM), and by not using them now I'll have less scarring and more sites available for when a true artificial pancreas (like the one being developed at BU) is ready.
I highly recommend reading Pumping Insulin if you haven't already. In the meantime I'll do my best to help you start to analyze your numbers if you can supply some more info. Did you wake up and take correction doses of insulin at about 4am on the days shown in the CGM? What times and amounts are all of your injections (basal and bolus both) on those days shown in the CGM, and what foods (protein and fat as well as carb) did you eat and at what times? Or if you didn't record all that, do so in the next couple days and attach your CGM results from days that have all that info.
Could you provide some info about the dosage and timing of the levemir?
I question how relevant some of what was written above may be for you since you are a T1 and not a T2. I have personally never seen any evidence of "liver dump" in my own results - I believe that is much more of a concern for T2's.
DP is very much a problem for T1's, there has been a great deal of research about it. Finding such information, both scholarly research articles as well as anecdotal discussions is a simple Google Search away: DP information
Surveying these references you'll find that the term, "liver dump" is not uncommon as a lay shorthand for what's going on.
A scholarly article titled, Thirty Years of Research on the Dawn Phenomenon: Lessons to Optimize Blood Glucose Control in Diabetes in Diabetes in the ADA journal Diabetes Care, December 2013 vol. 36 no. 12 3860-3862, covers DP and it's impact on diabetics both T1 and T2.
Just because you don't personally experience something doesn't mean it doesn't exist.
My endo had me on a single nightly dose of 30 units of lantus. Every single night I would bottom out and every single day before dinner I would be 200-250. Keeping in mind that I had no interest in what was happening, I basically let this continue until I had a severe hypo and nearly ended up dead in bed. That was a wake up call amazing how facing ones' mortality can have a sobering effect. I joined here in June or July 2012 and after reading like crazy and gathering all the information I could I started splitting my lantus dose which had an immediate benefit. The hypos and hypers that had plagued me continually finally stopped. I split the dose 20 units in the morning and 10 units before bed which seemed to work fine, but after a lot of fine tuning I discovered splitting it evenly was better for me. After an unfortunate mix up with Apidra and Lantus pens in a dark car one night, I asked my endo for a sample of levemir and absolutely loved it so much better than lantus. For me it was much smoother and since I was taking 2 shots a day anyway there was no big change. Of course now it's a moot point but I still have a levemir pen in my fridge in case the pod malfunctions.
I would ask your endo and see what his/her opinion is. Maybe you can just switch to one right away but since you drop a lot night you said I think you might not want to take a large dose at night. I think you might want to stick with 2 shots since your dp is so bad?
I take 7 units at 5 pm and 3 units at 2am now because 3 am wasn't stopping dp as well. Last night I forgot to take my 2am dose but I logged it as taken. By 4-5 am when my dp usually starts now and around when I was going to sleep I was at 135. I took 1 unit and then tested an hour later. I was at 167. I checked my novo pen echo which I have my levemir in and saw because it tells me the last dose amount that I had not actually taken the 3 units. I am sure this was dp or some other unknown cause because it happens around the same time and in this case it happened several hours after eating any food. I went hypo the day before around the same time in a similar situation. So with no am dose and no fast acting I'm guessing I would have been at 200 and up. In spite of the am dose helping dp, I still have to take 1 unit doses when I wake up if I'm above 100 because I can still spike a lot usually starting around 12-2pm as my next basal shot at five pm nears and basal runs out.
I switched from lantus to levemir and the dosing is the same for me, I had already split the dose by that point for dp. My endo thought levemir would keep me more stable, he agrees basal doesn't keep me stable, but it hasn't- at least I stopped gaining weight.
Dawn phenomenon in T1 is a predictable daily response to hormones (growth hormone, etc.) that increase insulin resistance. I've never seen DP referred to as a "liver dump". In my experience "liver dump" is used to refer to one's liver unexpectedly producing glucose at unpredictable times of the day, which is what I assumed you were referring to.
In any case her graph does not look like a "liver dump" or Dawn Phenomenon since her BG goes up but crucially it also goes down significantly shortly before she wakes up. Unlike T2's, T1's do not produce any of their own insulin so her BG would not go down unless in response to some of her injected insulin. That is the point that I was trying to address before you decided to side-track my discussion again.
Just because you think T1 and T2 are the same disease doesn't mean they are.
Just because you think T1 and T2 are the same disease doesn't mean they areI don't.
before you decided to side-track my discussion againWhy are you such a hostile person? What is wrong with you?
This is a public site, these are public discussion forums. Not only do I have every right to comment on a public posting of yours, it is the essence of what TuD is all about. Community.
Seems completely natural that I would respond to your comments on what I wrote, which I didn't see as you "sidetracking" my discussion with Sarah (what: We own discussions now?), and honestly welcomed the dialog.
Time to grow up and get over the little kerfuffle from what -- months ago? We disagree over what is, and is not similar between the two etiologies. I have no problem with it -- you seem to carry a grudge for reasons I can't begin to fathom.
As I've said before: Please don't take out your personal grudges here for all to have to wade through. If your hatred for me is so intense you can't interact in a civil manner, how about refraining?
TuD would be the better for it.
Dawn Phenomenon since her BG goes up but crucially it also goes down significantly shortly before she wakes up.I recommend you review some of the research literature. This precise phenomena for T1's is described in many studies (see the ADA article I reference), and in fact when a T1 is using long-acting to cover basal -- as opposed to a pump -- the dip an hour or two after 3AM is very common, because that is the time of the morning that glycogenolysis in the liver is at its nadir. Further, insulin sensitivity is higher in the early morning hours than later before waking. Both these factors -- increased sensitivity, and reduced glucose production by the liver -- will act to lower BG over night when on a steady-state level of insulin. From the ADA article:
In T1D, the magnitude of BG elevation at dawn first reported was impressive and largely secondary to the decrease of plasma insulin concentration overnight (1), commonly observed with evening administration of NPH or lente insulins (8) (Fig. 1). Even in early studies with intravenous insulin by the “artificial pancreas” (Biostator) (2), plasma insulin decreased overnight because of progressive inactivation of insulin in the pump (9). This artifact exaggerated the dawn phenomenon, now defined as need for insulin to limit fasting hyperglycemia (2). When the overnight waning of insulin was prevented by continuous subcutaneous insulin infusion (CSII), even at single rate (10); intravenous infusion of albuminadded insulin by pump (11,12); or by the long-acting insulin analogs (LA-IAs) (8), it was possible to quantify the real magnitude of the dawn phenomenon— 15–25 mg/dL BG elevation from nocturnal nadir to before breakfast (Fig. 1). Nocturnal spikes of growth hormone secretion are the most likely mechanism of the dawn phenomenon in T1D (13,14). The observation from early pioneering studies in T1D (10–12) that insulin sensitivity is higher after midnight until 3 A.M. as compared to the period 4–8 A.M., soon translated into use of more physiological replacement of basal insulin (CSII and the nearly peakless LA-IA [8] as compared with NPH) to reduce risk of nocturnal hypoglycemia while targeting fasting nearnormoglycemia (Fig. 1).
