NPH dosage issue! HELP!

Okay I am reading think like a pancreas as we speak. I need your guys input on my NPH dose. My daytime dose is 32 and my night time is 20. I take metformin 2x’s a day and glipizide 2x’s a day. I take my second NPH injection at 3pm so it peaks before I sleep. My problem is at around 9-10pm I bottom to 70 or last night to 45. How can I fix this. Side note I took my NPH injection late yesterday at 6 instead of 3 and dropped to 45 by 11pm(imagine if I had been asleep. Normally when I take it at 3 my blood sugar will go down to 80 or 79 I eat me snack and my before bed blood sugar is 100-150 perfect. My wake up BG is 98-120. You think that last night was a fluke since I took the NPH late?

one more thing before I took that dose of 20 my BG was 98.

I am on NPH and I’ve been interested in trying to figure out the end profile of a two injection a day regime. NPH is apparently notorious for peaking. I am a little confused about the timing of your NPH doses. Is your 3pm dose your evening dose? If I assume you take your morning dose of 32 units at 6am and your evening dose at 3pm, I get an insulin action curve that rises to a large peak at 9pm. That would readily explain your lows in the evening. Below is the graph:

Moving your dose to 6pm will help flatten the curve, but will still give you a similar high level in the evening:

Hope that helps.

I’m confused now! I take my NPH at 7am and at 3pm. It seems to start peeking at around 9-10pm. Yesterday was an off day and I took it later. My dosage is 32 in the am and 20 in the pm.

ahh wait I see now! I just re-read your post. So my evening insulin dose does not need to be changed? I will try dosing at 6pm but last night it put me at 45 reading(almost passed out) and I happened to be awake at 11pm to catch it. I no longer have the symptoms of low blood sugar so i never know when I am low unless I test. I am afraid that I might hit that low and never know while I sleep.

I use NPh and I take metformin 2x’s a day and glipizide 2x’s a day. we eat at 5-520pm every night, and I have my snack at about 8-9pm before bed. my carbs are usually 25-45 at dinner and my snack is 25-30.

So, part of figuring out how to size and time your two NPH basal doses involves understanding what your basal requirements are. In my case, I appear to have modest requirements during the day, but overnight I need higher basal levels to keep my Dawn Phenomenon under control. So in my case, I have chosen to take my doses at 6am and 8pm and I get a profile as shown below.

Despite my stacking of my overnight levels, I still don’t always get my morning levels down to where I want them and I’ll still sometimes go low around 1800 hours (6pm). In your case, if I put in the values you have given, I get the following:

if everything else is ok, but you are going low in the evening, then what I might suggest is that you look at moving your evening dose to like 7p, that will make your basal flatter and drop the peaking effect in the evening as below:

As always, check with your doctor and get appropriate advice on changing your insulin or medical regime. Anything said in on-line forums from people with bozo faces should be taken with a grain of salt.

You are a huge help. It seems my night time dose might need to be changed a little lower. During the day I do okay 120 to 88. At night since I am not eating and take the metformin and glipizide maybe I should cut my NPH back. These are my doses, not the doc’s of course you know that the endo is like well if that is working…yeah. Thank you so much!

That is fine, just remember the peak action of NPH is like 4-12 hours, so if you inject at 7pm as I’ve suggested and you reduce that dose, it will reduce your levels mostly from 11pm to 7am. You may need to watch out for morning highs since that is going to be your lowest insulin level of the day with that injection regime.

Wow! Those are great posts BSC and the graphs are great too! What they told me when I got my pump was that NPH has only a 53% chance of peaking when it’s supposed to. I sort of think that there may also be some variance in the strength of the peaks but that’s just a wild guess and i don’t have any graphs or other studies to support it? I think that splitting the shots is not a bad idea. The one reason that might argue against the 7:00 launch time might be that the peak might hit while you are sleeping? I wish I had better notes, or even any notes, from my R/N years but I think that the later I took the stuff the better? I think too though that it’s hard to make adjustments because of the variances as what worked today may not work tomorrow as you try to hit invisible moving peaks?

I was confused about how to estimate the result of multiple stacking injections so I put together a spreadsheet. You are right, all those graphs don’t mean a thing with a great deal of variability. Any precision implied by the graphs is probably misleading. And you may be right that an evening shot might peak later, but the morning injection should have worn off by then. And one should always be on the alert for overnight lows. My graphs are based on NPH studies in type 1s and actual individual reactions to NPH may well be different and variable. I’m not clear about my reaction, I tend to go a little low before dinner, surprising since that appears to be the lowest point in the graph reflecting presumably the lowest insulin level.

can i ask why you are taking NPH as opposed to a more stable basal insulin like lantus or levemir?

I have been wondering the same thing. BSC has great information on using NPH, but he is using it because he was unable to get prescribed the newer insulins. It seems like you are very motivated to work closely on your blood sugar control, and yet you are trying to do it with a very inexact tool!

I know you said you were with Kaiser and that is what you offer. I have another type 2 friend on NPH with Kaiser and there is little doubt in my mind that is their first line prescription as it is much cheaper. But I also know many Kaiser patients on pumps (which use fast acting insulin) so I know Kaiser will use more up to date treatments if they are requested.

I never enjoyed NPH and ended up spliting the daily dose into six and injecting every 4 hours or as close to that without loosing my mind.

But I actually am quite enjoying NPH. This is all relative. For years, I have had fasting blood sugars that have been higher than I wanted. Now, I can finally do something about them. Perhaps in the future I will use Lantus and Humalog and hate these days, but I’m actually pretty happy about things.

I am on NPH because my endo said that lantus is the same thing except it is once a day. She would have to prove to kaiser that the NPH is not working. Pain in the butt. I had asked her about MID and she said if the glipizide is working we will leave it there. I then asked her wouldn’t taking glipizide wear my Pancreas out more? This is where I am concerned with her answer, well all type 2 diabetics end up going on insulin because the pancreas gives out. I’;m thinking WTF? That is so false. She should have said if your fat and have not taken care of yourself, then those type 2 go on insulin. My mom has had type 2 for 20 years and is still on Metformin only. So I am concerned about that. Now tonight I took my dose at my normal 3pm time and after dinner and just now it is 90. I am having my snack and all is well. I think taking at 6 was just too late and that low of 45 could have been really bad had I not been awake at 11:30 to test. At any rate to answer the question of the whole why am I on NPH read my first few lines! I am so confused and frustrated by this insulin thing! Now my 7am shot of 32 is great I never bottom out, just night time. The only thing I can figure is I don’t eat so the insulin catches up? I don’t know.

Exactly! I graph all of my BG reading so I can see a chart. I am level through out the day, and most of the night right until the 9pm, 10pm. I have learned from my graphing that by giving the injection at 3pm my peak hits now(9:37pm my time) and so long as I eat a balanced snack I wake up with fasting okay. although some days my fasting is 120-122 and others it is 95-100. so it varies. I think this is balanced though.

Your endo is…nope, I’ll not say it! NPH is NOT the same thing as lantus…not by a long shot! I can’t believe your endo said that.

I very much disagree that “type 2’s go on insulin because they are fat and have not taken care of yourself”. In this case I do agree with your endo that “type 2 diabetics end up on insulin because the pancreas gives out.”. That is not false at all but pretty standard progression of the disease. Your mother is lucky she has gone 20 years without needing insulin. That is not unheard of, but is a fairly long time period. The pancreas does stop producing insulin in time. It is a myth that type 2’s go on insulin because “they have failed to take care of themselves” or that it is a last resort. It is a common progression of the disease.Needing inuslin much sooner as you have is more typical of LADA than of type 1

Good for you. The NPH was sure not as convenient as lantus but a lot cheaper and provided the body with zinc.

You need to remember that an insulin like NPH does not start working immediately. It takes perhaps four hours for it to reach full effectiveness. So if you take NPH at 3pm it reachs full action at 7pm and peaks around 11pm. If you take your NPH at 6pm, it peaks around 10pm and reaches full effectiveness at around 2am. Your 7am shot is still effective until like 12-14 hours later, perhaps 7-9 pm. You just need to remember your basal insulin takes a while to become effective and then acts basically all day. Your early evening basal levels (when you inject at 3pm) are a likely a roughly equal combination of contributions from your morning shot and evening shot. Below is a curve showing you the action curve of NPH.

In any case, everyone is different. You just need to experiment. I like to make changes and then spend several days seeing how it affects things. A single observation is meaningless, every day is a new adventure. Going low one evening may be an anomoly and subsequent days you may go high. A good rule is to make basal changes of 10%, then see how it goes for at least three days, perhaps longer and then decide whether the change was an improvement.