Another one making the big insulin switch - NPH to Levemir!

[spring]

Hello all!

I've been on NPH since diagnosis (almost ten years ago) and have been using it in conjunction with Humalog for a number of years. My last A1C was not great at 7.9, but an improvement over the 8.8 three months prior (thanks to all of you and your informative posts!)

With NPH, I've been taking it only once in the morning and have managed to have fasting levels in the 4's and 6's (I'm working in mmol/l ) in the morning (though a couple of times a week I'd get a 12 or 14 :secruity: ). Because of this (not needing a night time shot), even knowing Levemir more often than not requires splitting and doesn't claim to be 24hrs, I figured I'd start with the am shot and if my fastings were out of wack then I'd go for the split.

Today was my second day with Levemir. Yesterday I was around 7 all day - not great but not horrible and my insulin-carb ratios could well be off. Today I was around 11 all day! Gah. I went to bed with an 11 last night after my snack (evidently more than I needed) but figured I'd ride it out and see how it elevated or dipped without humalog interference overnight. I tested at 3:30am and was still 11 ('nary a point changed), but by 9:30am (I took the levemir at 9:45 the prior morning) I was 18.9! Yuck!

I figure this means I'll be needing a split but, just to account for switch over variances and the like, tonight I'm going to attempt to go sans evening snack and test around 5am and see where I'm at. If I have an ugly fasting again around 9 then it'll be day three and definitely splitting time!

Now, I'm a little weirded out by this whole splitting business. I'm taking 22 units at one time right now. If I split, that means just 11 units at 9am, 11 at 9pm. How does 11 act the same as 22 throughout the course of the day? Because of my former use of nph once a day, should I try a 2/3rds 1/3 system, with 2/3rds in the morning and 1/3rd at night and try that out for a day or just go half and half?

Advice more than welcome! :)

[duck]

You need to figure out how long the Levemir lasts for you...that can be tricky, but assume it will last at least 20 hours. After you feel like you have a handle on that, figure out when you need more basal as opposed to less, and try and schedule your shots to overlap.

NPH peaked, Levemir is steady with no "peak" to speak of.

[KMP]

I have been thinking about this since I just started Lantus today.

The question about splitting your dosage...
Correct me if I am wrong, but the first shot lasts for 20-24 hours and your second shot (12 hours later) overlaps the first shot and when you take your third shot you are on your way with Full Coverage.
It seems that the first 12-16 hours will have your blood sugars running higher than you would like them to...so at meal times you need to flatten them out with a proper dosage of short acting insulin.
once you are "overlapping coverage" everything should even out --as long as the dosage is correct for you. Everyone is different.
Be careful and Best of luck with the new insulin!!! :burnout:

[KMP]

Ahhhhhh...
I hate when I forget to type something. :embarasse:
I would guess that using the 2/3 -1/3 method is - after trying out the 1/2 - 1/2 method you find that you require less insulin at night and you eat like a good human during the day...your basil amount for nighttime would need to be less.
I can understand it but figuring out how much you need to split it up will take some testing.

[spring]

Gah.
Okay, went to bed around midnight w/ a reading of 7mmol/l (126). Woke up at 4:45am to test and still - 7 (126). 6am- 12mmol/l (216). Took one unit of Humalog and went back to bed. 9:30am - 19 (342) Yuck.

Okay so we can pretty well say that it lasts me 20 hours if I'm starting to rise between 5 and 6 and I took my Levemir at 9:30 the prior morning. Now the last thing I want is -another- morning with 19 (or to have to get up and start my day at some stupid hour :p) So I think I'd like to try splitting now.

Like I say, I'm still a bit confused to how if one needs 22 units to cover their day, taking 11 is suddenly sufficient? Is it more like 'gas in the tank'? As long as I've got enough to cover me 12 hours until the next one that's what counts? It's time for Levemir now... perhaps I'll make a call to my endo. :eek:

[spring]

Okay, Endo out of the office and well it looks like I need to split so I've just gone for it and run with the more conservative non-50/50 split of 16 units now and 6 units in 12 hours and then we'll see how it all levels out.

[duck]

Spring, post the times you take your shots and how much, if I have time I will chart it out and see if we can nail this down.

[DanG]

Okay, Endo out of the office and well it looks like I need to split so I've just gone for it and run with the more conservative non-50/50 split of 16 units now and 6 units in 12 hours and then we'll see how it all levels out.

I did the split a week ago.
I went back to single lantus.
I take lantus at night - 16 units.
With the split, for whatever reason, I had awful low in early AM. So low, the EMT had to assist wife in making me sane. Two nights before that, I took 30 minutes to get sane, but at least I was quasi coherent.
I don't really know what went awry in my experiment with split, but if there is any similarity, I would be quite careful. I guess when I went back to single dose, I also dropped my total by about 4 units also. I was at 20 and split 8/12 (evening/morning). Now I am back at single evening dose and using 16.
My split experiment lasted less than a week. I will do split again, but for now, I'm freeked.

[grace girl]

I split my lantus about 3 months ago. I tend to be VERY conservative about changes, especially since I had experienced some nasty overnight lows while taking it only at night. I reduced my total of lantus by 4 units and then split it 50/50. It took about three weeks of tweaking to get it right...now I'm taking 1/3 at night and 2/3 in the am and it's working out pretty well.

I personally feel that a conservative approach is best if you want to avoid lows, and test a lot. You'll find that the over lap isn't a big deal...and that was the biggest thing I was concerned about when I split it. My lunch time falls during the overlap, and I use a slightly larger carb ratio at lunch to compensate. Having tried using lantus at night, in the morning, and now split, I personally think that splitting it is the best way to go. You get much better precise control.

[rudi]

Like you, I had taken NPH and a short acting for years. Last year I went on Lantus and it almost killed me. Totally unexpected lows, especially at night. I was splitting, testing, snacking. It was awful. Then they put me on Levemir; it was better but not much. Apparently I am very insulin sensitive. I am now on a pump (YEAH!) and found a new Endo who has saved my life. Get off the Lantus/Levemir train and try a pump. I have never felt better. Rudi

[right2fight]

We too had a not so good experience with Lantus. My son developed large ketones and was told not to eat until bs was in the normal range, 22 hours with no food for a 12 year old boy, not much fun. Since Luke has never been hospitalized in 6 years and I found that the dosage of Lantus was no comparison to the NPH he was taken, I decided to tell the CDE, that no doctor was going to put him in the hospital. We resumed the old regimen and Luke is doing beautifully. Why change it if it's not broken?
Margaret

[duck]

We too had a not so good experience with Lantus. My son developed large ketones and was told not to eat until bs was in the normal range, 22 hours with no food for a 12 year old boy, not much fun. Since Luke has never been hospitalized in 6 years and I found that the dosage of Lantus was no comparison to the NPH he was taken, I decided to tell the CDE, that no doctor was going to put him in the hospital. We resumed the old regimen and Luke is doing beautifully. Why change it if it's not broken?
Margaret

Don't eat? Wow. In the real world, that's what a fast-acting insulin is for. Sometimes the advice I read about here worries me when it comes from professionals.

[am1977]

Yeah, I don't really understand that advice :confused:... I asked an Endo about that once, b/c I wouldn't want to eat when I was high, and he said, "Of course you have to eat...". You make a correction to bring down the high sugar level and then you take a regular dose to covr whatever you are eating. I am sure it isn't at all easy for Luke to go w/o food for that long- poor kid!

[duck]

I have asked three endos now about this: All said something to the effect of as long as you are not producing high amounts of ketones, take a correction bolus and eat. You HAVE to eat, or you may be creating bigger issues down the line.

[spring]

Thanks for all the responses.

I'm still working on titrating the dose and getting reasonable numbers but I'm not about to throw in the towel so soon. I figure six weeks is a fair amount of time to test something like this out, and it has been but a scant 6 days (and only 4 splitting).

It's hard to get a feel for what might work in a practical sense during the school term as I won't be back at University until the 8th. In the mean time I've been more sedentary than the sofa and sleeping in until some time after 9am.

What seems to have cropped up (and I feared it might) since my switch from NPH is that dreaded dawn phenomenon. For some reason the once daily morning shot of NPH was enough to last me all the way until the next day without resulting in ugly numbers, but with four days of splitting even, my fasting numbers have all been 12, 17, 14 and 15. I've been getting up at 3am and 6am each night to test and see where I'm at. I think I start to rise around 5:30, as I'm generally two mmol/l higher than what I was at midnight and three. By 9am it's as high as 17.

I'm still not taking a 50/50 split, though I hesitate to take less during the day as what I'm taking right now seems about right (I run a bit higher than I might prefer but what with my aformentioned inactivity as compared to usual that's likely something that would clear up once I'm back on my usual schedule). I was taking 16 units in the morning and 6 at night. Last night I upped it to 16 in the morning and 8 at night with no real difference noted thus far. (what with the number of 15.7 this morning). I was 6mmol/l at midnight and at 3am, 8mmol/l at 6am and then up to 15.7 by 9:20am. I'm taking my levemir around 9:30/9:45 in the morning and at 9:45pm at night. I'm going to try one more night with the 8 and then perhaps up it again.

My mother seems to think it makes sense for me to just change my sleeping schedule and get up early, but I don't want my bloodsugars to dictate my sleeping schedule like that. Ah well, on it goes!

[Gangrel]

To reduce, reuse, recycle.... Today is my first day on Levemir! (and there was much rejoicing. yayyyyyy.... (you Python fans get it))

My nurse has me splitting the dose from the get go. I was taking 30 Humilin N(an NPH) at 9 am, and 25ish at 9pm (I was fiddling for the longest time)

To be safe for the start, we've reduced it 20% for the Levemir, so I'm taking 24, now at 7am, and 20 at 9pm.

I fully expect to have screwed up sugars all week just because.... but maybe we'll luck out.

Here's a few questions tho. #1: Has anyone who switched to Levemir had their carb ratios change? I imagine mine (which is now 1:10) mayyyy change a bit just because I'm not sure if my basal amounts under NPH were every truly right..... but hopefully everything stays the same.

#2. I usually check my BS at 10 or so when I go to bed. Now, correct me if i'm wrong, buttttt if my BS is at 6.0 then, in *theory* I should wake up at 6.0 in the morning in the perfect world, correct? I just want to know what to aim for, as under NPH i would have to eat and make sure i was close to 10 when i went to bed to deal with the spike.

Alright, carry on.... i'm done, for now. ;)

[Scratch]

#2. I usually check my BS at 10 or so when I go to bed. Now, correct me if i'm wrong, buttttt if my BS is at 6.0 then, in *theory* I should wake up at 6.0 in the morning in the perfect world, correct? I just want to know what to aim for, as under NPH i would have to eat and make sure i was close to 10 when i went to bed to deal with the spike.



It's not going to be that simple. While Levemir has a nice flat uptake profile, your body's metabolism does not. Most commonly, sugar output by the liver is at its lowest rates up until around 3 AM, and then after that the liver starts waking up to get people ready to wake up.

I use Lantus, and right now for me I'm getting my best results if I shoot for a BGL of 140 at bedtime. And at my current dose, I usually will wake up around that level. So everything's hunky dory, right? So why don't I target for gooing to sleep at 100 mg'dl?

Because from the time between 11 and 2, my liver really likes to sleep. If I wake myself up with an alarm clock at around 1:30 in the morning, and I've gone to sleep at 140 mg/dl, I might test at 1:30 somewhere between 80 to 110 mg/dl. Then after that I will begin rising, and find myself back up to around 140 mg/dl, or sometimes my liver doesn't kick in too hard, and I will stay flat from 1:30 to about 6:30 in the morning.

It's going to be very important for you to do some overnight testing, find out how much you might be dropping early on during the night, and then what kind of rebound you get after that. It's a pain in the butt, but it's worth it to determine your basal dose, and what kind of numbers you want to go to sleep with and let you sleep without hypoing.

[MJM]

Thanks for all the responses.

I'm still working on titrating the dose and getting reasonable numbers but I'm not about to throw in the towel so soon. I figure six weeks is a fair amount of time to test something like this out, and it has been but a scant 6 days (and only 4 splitting).

It's hard to get a feel for what might work in a practical sense during the school term as I won't be back at University until the 8th. In the mean time I've been more sedentary than the sofa and sleeping in until some time after 9am.

What seems to have cropped up (and I feared it might) since my switch from NPH is that dreaded dawn phenomenon. For some reason the once daily morning shot of NPH was enough to last me all the way until the next day without resulting in ugly numbers, but with four days of splitting even, my fasting numbers have all been 12, 17, 14 and 15. I've been getting up at 3am and 6am each night to test and see where I'm at. I think I start to rise around 5:30, as I'm generally two mmol/l higher than what I was at midnight and three. By 9am it's as high as 17.

I'm still not taking a 50/50 split, though I hesitate to take less during the day as what I'm taking right now seems about right (I run a bit higher than I might prefer but what with my aformentioned inactivity as compared to usual that's likely something that would clear up once I'm back on my usual schedule). I was taking 16 units in the morning and 6 at night. Last night I upped it to 16 in the morning and 8 at night with no real difference noted thus far. (what with the number of 15.7 this morning). I was 6mmol/l at midnight and at 3am, 8mmol/l at 6am and then up to 15.7 by 9:20am. I'm taking my levemir around 9:30/9:45 in the morning and at 9:45pm at night. I'm going to try one more night with the 8 and then perhaps up it again.

My mother seems to think it makes sense for me to just change my sleeping schedule and get up early, but I don't want my bloodsugars to dictate my sleeping schedule like that. Ah well, on it goes!

Spring, I've had the same problem as you even on the pump. I have finally figured the right basal for this. My BS tend to drop from 9pm to 5am and then spikes from 5am to 8/9am. I have a normal basal rate of .3 per hour. At 9pm I reduce this to .2 and at 5am increase it to .8units per hr. This works most of the time. Everyone is different and as you are not on a pump I think it's just a case of test, test, test, and test until you work out the appropriat doses to use. I've gone to a situation where I had tested every hour until I was satisfied that I knew how I should deal with it. Perhaps someone on the same insulin as you might be able to give you better advise but whatever advise you get it will all end up with you having to experiment until you find the right method to use. What does your medical team have to say? Hope you find the answer quickly.