I had my endo appointment yesterday. It went well, but my endo "hates" my use of NPH. And I agreed to try Levemir, but I'm a bit concerned about split dosing. Right now, I use NPH and split my dose into two highly staggered and uneven doses. I take 14 units at 6 am and 40 units at 10 pm. I think that gives me about three times the basal rate overnight as during the day.
My endo suggested that I just use the same timing and dosing for Levemir, but I'm concerned that won't work. Levemir has a slower onset and markedly longer duration of action. I think that if I stick with my current timings and dosings, I'm going to get a totally opposite action and have a much higher rate during the day.
I'm kinda inclined to just evenly split my dosing at 12 hours apart and make adjustments with basal testing from there. What do you all think?
Does anyone else split their Levemir unevenly or stagger the times?
Hi bsc. I've written this before, so you may have read it already. Anyway, I make a little insulin between approx. noon and 3:30 PM, so I have to take my basal to work around these hours to avoid lows. I take my Levemir at exactly the same times as when I took NPH, later Lantus, now Levemir: 5 units at 9:30 PM, 2 units at 8:30 AM, and 1 1/2 units at 2:30 PM. (As I recall, I take the same amount of insulin with both Lantus and Levemir, but I had some bad side effects with the Lantus.) Of the three insulin basals, I found that Levemir has the least peak, but still has a small one. I think you have to experiment to find what works for you, starting a bit conservatively. Good luck!
I don't know how applicable my situation was with Lantus, but I tried a lot of different dosing strategies with varying results.
The thing that I will say though is that anything I ever did with Lantus was a vast improvement over NPH. I did not realize how much of a pain in the a$$ using NPH was until I was off of it. From what I understand, Levemir's action is way more predictable than Lantus. I think you will be happy you made the change and I'm happy you found an endo who will work with you on your insulin regime.
Levemir is great!! Back in the day I was using NPH & Regular....bad peaks. Went to Ultralente and then to Lantus (peaks with both) and finally went on Levemir. I had to do alot of adjusting. But, for me it was worth it. I take 15 units of Levemir at 8am and 10 units between 9-10 pm. Humalog for meals, corrections. You will need to do a basal testing. Good luck...and once you get it figured out, it is SO much better then NPH.!!
I see a post like yours from time to time, bsc. I would say give it a try.The reason I say this is because we all change as we get older, and maybe change is something you could monitor closely for a few days. I did use use Lantus myself and was satisfied with that basal for a few years. Just one injection at night. Used R for my meals of course. I can't say if your dosing of NPH is OK or not, since I don't know your history, but I would at least try Levemir. And yes, Levemir has a "long tail", so to speak, and it could surprise you. Test like crazy.Good luck!
Levemir is very different than NPH, so start 50% and then you see where to adjust. What insulin do you use for bolus ? Perhaps during the day your NPH basal was lower because you where covered by long tail regular ?
Long long ago (30+ years) I did NPH and also two really lopsided doses. Like, 35 units in the morning and 5 at night.
Then about 26 years ago I started MDI with NPH for the basal and split it 4 ways, 5 units each shot, 20 units total each day. I was pretty happy with that and did it for a long time.
Today I use Lantus and split it evenly between two shots, 10 units each shot, 20 units total each day. I feel it's more consistent than NPH, not by a super amount, but by some.
The big beneficial change came from not doing NPH twice a day anymore with lopsided shots. For the first time ever I felt like I had some control after going to MDI. At the same time my insulin doses dropped a lot. I would guess if you are doing 56 units NPH every day right now in a lopsided regime... you probably need a lot less in Levemir units in an even regime.
well, i think that's great...levemir works differently, of course, for everyone and from what I've read, far different than the older insulins. For some, it's very flat...for me it PEAKS at about 7 - 8 hours after injection..big peak...so, i'm still adjusting my split dose until I start my pump in two weeks..I now do less in pm (3 units) and more am (4.5) units..
In case this helps, I don't use Levemir evenly. I take one dose immediately before bed. If BG is a tad high, I take slightly more than my usual dose. Second dose is after breakfast, so not 12 hours apart. My evening dose is larger than the morning dose to tame the DP beast.
Starting at 12 hours apart & splitting it 50-50 is probably the best way to approach it & tweak from there.
I really have not seemed to be bothered by the NPH peak. I still have some endogenous insulin production which smooths things out. It looks like you had stacked a bit for overnight as well.
I've been very fortunate. I've not had peaking problems, no bad hypos. And I'm not unhappy with my current control. But my endo is apprehensive about my use of NPH. And I am also pleased to have an endo that will work with me, it is a much needed change over the last one. And I am really starting to think that Robyn is just right, I should just do the basal testing.
I changed from Protaphane to Levimir about two years ago. I always needed less basel during the day than at night. However, I in general need less units of Levimir than what I needed using Protaphane and especially my sugars in the morning improved a lot. It was definitly a good idea to switch. Right now I am using about 18 units at night which I take around midnight and 10 units in the morning which I take around 8:30. I definitly would reduce the amount of units in the beginning and then see if it works out. Cheers
This is interesting and informative. I have thought that my lopsided doses are needed to deal with darn phenomenon, but perhaps some of it is highly variable absorption. You were able to move to a flat even dosing and perhaps I can do the same thing.
Sometimes doses get lopsided as we adjust them to solve a problem but maybe (especially with long or medium lasting insulins) we are making the problem worse.
It's easy to recognize the rollercoaster with a short acting insulin but sometimes with the long acting insulin the rollercoaster turns into a self-reinforcing feedback loop with a period of 12 or 24 hours. It can be gnarly.
The textbooks all want you to think that insulin works linearly, that twice as much works exactly twice as well, but that's not really true. With large doses the absorption time gets lengthened and in my experience it becomes less effective (per unit) than smaller shots. Thus my dose was much lower split 4 shots a day evenly, than when 2 shots a day lopsided.
Others here get miffed when their docs make comments about the mixes of long acting vs short acting. But really, sometimes in the past I have benefited from "rebooting" doses according to some rules of thumb.
Speaking of rules of thumb... the "rule of 1700" is pretty damn on the money for me.
BSC, did you start the Levemir yet? I am having some problems with my Levemir. I started having some problems after starting a new box. I called the Levemir people yesterday and they said they could get a new box to my pharmacy in 3-5 business days. After I told them I couldn't wait that long, they checked with my pharmacy and they had a new box to give me from a different lot. That still isn't working. On Sunday, I started using Apidra every 2 hours and that works great except I need to get some sleep so I am thinking of using NPH at least overnight until I can get Levemir that didn't come thru the same distributor in case there is a problem with them.
I am curious if you started the Levemir how you adjusted your doses so I can do it in reverse.
My endo gave me two pens. I started a little more than a week ago. I found Tim's advice compelling and dropped my dose 33%. I had been taking 54 units/day and started with a simple regime 20 units twice a day, 12 hours apart at 6am and 6pm.
And surprisingly my blood sugars responded well. In fact, after 2 days I concluded that I needed to reduce my dose, so I moved down 10% and then another 10% down to 16 units, twice a day. But now my fastings are drifting up so I have moved back up to 17 units/day. I am still adjusting.
I'm not sure what to tell you about the Levemir. It seems strange that it would just stop working. You can develop a reaction to certain insulin's (antibodies) that will over time render them ineffective, but it generally doesn't just happen overnight. I would not immediately suggest that you take my experience as an indication that you should use more NPH. It is probably better to be conservative and think that they have a similar strength. In fact, it might be prudent to try NPH during the day to gauge your response before trying it overnight.
I am still working out the kinks on my Levemir, but it has demonstrated that it can tame my Darn Phenomenon without causing daytime hypos. So I'm probably going to switch.
You can develop a reaction to certain insulin's (antibodies) that will over time render them ineffective, but it generally doesn't just happen overnight
Never heard of this, one certainly can become insulin resistant, but it's not the said insulin..if one develops antibodies from insulin...it would be some type of allergic antibodies, I would think?
I'm still adjusting my levemir...been doing this for a year..ha! Thankfully, I'm going on a pump in 2 days and NO MORE basal..yahoo! Sounds like you're doing great though..congrats.
Some people develop an immune reaction to insulins. Animal insulin's often created this effect, but it can occur with modern analog insulins. There is a test, anti insulin antibodies that can be used to test for a large immune reaction. The antibodies actually go out and deactivate the insulin, essentially resulting in your needing more insulin (hence insulin resistance).
