Will be switching from Lantus to Levemir and need advice, suggestions

Treatment Insulin
#1

Hello,

I was diagnosed Type 1 diabetic May 2013. Since then I am on MDI using Novolog and Lantus. I will be switching to Levemir very soon. Right now I take 17 units of Lantus at night. This seems to hold me for 24 hours. I assume I will take 17 units of Levemir. My doctor wants me on 30 units of Lantus and then switch to the Levemir and take 30 units of that once a day. My blood sugars range from 85-125 on the Lantus at the 17 unit dose, so I am not willing to increase the basal insulin. I do have lows in the 60's periodically at the 17 unit dose, so for the life of me I do not know why he wants to increase the basal. My total Novolog dose for the day is 16 units.

I think, but am not sure if 17 units of Levemir would be considered a low dose, and should be given in a split does twice a day. Any suggestions would be greatly appreciated. I am a very motivated diabetic and work very hard to keep my blood sugars as normal as possible, following a very low carb diet: 30 grams per day total.

If anyone thinks I should split the doses, can you give me an idea how much per injection.

Thank you for any advice.

Joan

#2

Like everything else related to diabetes, this is a completely individual thing. There is no rule that fits everyone; your body will tell you what you need.

That said, if you are experiencing lows already, nearly doubling your basal dose would seem a strange thing to do, all else being equal.

Dosing insulin, no matter what kind, needs to be based on what is effective for you, not someone else. In my case, I am a very insulin-sensitive T2. I use 5 units of Levemir a day. Any more would get me in trouble. But that offers no useful information about what you or anyone else might need. Testing is the only way to know what's right for you.

#3

I agree with David on this. You will need to be the one to learn your own insulin requirements. How are your A1Cs? If your blood sugars are almost consistently in the 85-125 range, then you will likely experience more frequent lows by doubling the basal rate. Do you use a continuous glucose monitor? I was already using a split dose of lantus when I switched to Levemir. I did need to maintain twice daily injections of basal in order to avoid rising sugars toward the end of a daily dose with Levemir. However, I was also using a CGM by that time which helped me to reduce my basal insulin from 12 units of lantus in the am and 8 in the pm to just 4 units of levemir twice daily! Clearly, I had previously been using some of my basal insulin the way a bolus should be used - and having plenty of low blood sugars as a result. Perhaps you are only using long-acting insulin, which will of course mean that you will need more each day to handle the few carbs that you get. As David says testing is the only way to make sure your sugars are good throughout the day and if you can combine that info with a CGM, all the better. Looks like you are trying to achieve tight control by your numbers and a CGM will help more than anything else with this. I am much more free with my carb intakes (sometimes as high as 400 Gms/day,) but my Dexcom has allowed me to maintain my A1Cs in the 5% range with the help of Multiple daily injections.
Good luck and try to enjoy the challenge of learning what works for you.

#4

Sorry about missing the mdi & novolog bit at the beginning. I need to slow down and digest an entire message. Now, of course, I’m even more puzzled why your md is advising the big increase.

#5

Hello Bob,

I don't really think my MD knows what he is doing with diabetes, but I really only go to him to get prescriptions, and have been doing my own thing. I do not have insurance so I cannot get a CGM, as I am sure that is prohibitively expensive. I do test frequently, sometimes 12 times a day, and if I think something is wrong I test immediately.

My only real question is: Does Levemir provide adequate coverage with a once a day injection of 17 units, or should I really split the dose? From reading, it seems that is considered a low dose.

Right now I give one injection of Lantus at night, around 11:30pm and that has provided 24 hours of coverage for me.

I read that Levemir should be given in the morning and according to Gary Scheiner it is best injected twice. I am just looking for what folks here seem to be doing, and I will still make up my own mind. I am leaning toward giving 60% of the dose of Levemir the first night, and then giving the remaining 40% in the morning.

My doctor does not like anything I am doing and thinks the 85-125 blood sugars are not a good idea. He also thinks Lantus and Levemir are exactly the same, and I know that is wrong.

I am concerned about a low blood sugar while sleeping, as I very well may not be aware of it and would hate to have a bad experience as I am alone.

It is also possible that I am making a "mountain out of a molehill" and should just inject Levemir like I have been injecting the Lantus and not worry about it.

Thank you for any hints, tips and ideas.

Joan

#6

Joan, I expect you're getting tired of hearing this :) BUT . . . like everything else, the answer to the once-a-day-or-twice-a-day question is individual. I know many people who need to split the dose to get even coverage. In my particular case, that doesn't seem to be necessary. So either answer could be correct. The only way to know which one is right for you is . . . you guessed it. Test and track.

- David

#7

I realize that I'm sensitive to insulin... I'm Type 1 and take a total of 8 1/2 units of Levemir daily: 4 units in the morning, 4 1/2 at bedtime. If I were to take the total amount once a day, I'd go low when it reached it's "peak", although in fact, Levemir has a much smaller peak than Lantus. My understanding us that most people (David (dns) excluded!) take Levemir in two doses because it (usually) doesn't quite cover 24 hours.

I think you'll like Levemir. I didn't like Lantus because it gave me a constant headache and even dividing it, I had to eat to cover it's peaks.

#8

Hello Trudy,

Thank you for replying. I seem to be quite sensitive to insulin as well. Joan

#9

Yes that would be because Trudy you may still be making some of your own insulin. I've been T1 for over 33 years and it took a long while to become totally dependent, about 23 years. For the last 10 years I have used an average TDD (Total Daily Dose) of 15u-20 and even gain at 20u when inactive. When active, the dosages go down too. I agree with all the above people have said, including your own strategy, Joan, as it seems similar to mine where you plan to be the manager of your health and not fall into the trap of "eating to feed the insulin" as wise Gerri mentioned a few years ago and I really liked that phrase. I don't fall into it.

#10

Hi Janina, I was dx'd in 1993, and I probably do make a little insulin between the hours of noon to four. Not much... Along with the 8 1/2 units of Levemir, I take something like 20 units of Apidra. I'm eating a low-moderate carb diet.

#11

Here are a couple of links to web pages comparing the action of most commonly used forms of insulin. Not too much difference between Lantus and Levemir according to these sources. That said, I (and others) have found that the Levemir activity does not last a full 24 hours which is what drove me to twice daily injections. It's great that you're testing so frequently. That will help you to determine what therapy is best for you. It sounds as if you're working hard to understand and control your blood glucose, so I'm surprised that your doctor does not recognize that and try to work with you to achieve the best control. Keeping your blood sugar in that narrow range is a challenge, but one that I bet will give you great long-term health. Like Trudy, I've had t1d for just over 33 years and although I've been keeping my A1Cs at or near normal for most of that time, I began to experience some tingling in my toes and fingers a couple of years ago - early signs of neuropathy. That freaked me out enough to double down on my carb counting and together with the help of my CGM, I seem to have been able to reverse the neuropathy: no pins and needles for several months now! I've set my high and low ranges on the CGM at 120 and 60 mg/dl with alarms for both so I can respond immediately. Perhaps you already use a glucose tracking application like "Glucose Buddy" or "ManageBGL," but if not, I'd strongly recommend starting in on one of those also. Glucose Buddy is free and sufficient; Manage BGL is pricey, but offers better support and a "virtual" continuous glucose monitor function that is helpful. I find that food is so enjoyable that I need the discipline of recording all the carbs that I eat in order to exert control over my intake. Tracking software also provides a handy way to look back to see how yesterday's insulin doses/carb intakes worked to help predict what you should do next or whether you'll wake up within a good range. Good luck, Joan!
http://courses.washington.edu/pharm504/Insulin%20Chart.pdf
Insulin action curves

#12

One word of caution: the response curves shown in the links above -- or, for that matter, in any book or published source -- are averages. Each individual's physiology is potentially unique, and the actual action of a paticular insulin can very considerably from person to person. For example, Apidra (glulisine) starts working in about 15 minutes for me. Novolog (aspart) takes closer to 30. Everyone is potentially different.

The point is, only testing will reveal how a particular medication affects you. There is no substitute for testing and keeping records. It's your response that counts, not anyone else's.