Combining NPH and LANTUS?

[hstavisky]

I am finding that the 20 units of Lantus I use does a fine job during the day (beginning around 1 PM), but, somehow, it drops my sugar at night and then cannot handle the pronounced dawn phenomenon (and I mean pronounced !).

I have been reading a book "Using Insulin" which suggests moving the dose of Lantus to dinner time and then adding a dose of NPH at bedtime to handle the Dawn Phenomenon.

Any recommendations? My pharmacist suggested this, but I am clueless as to dosage.

[BlueSky]

I had a similar problem with the Dawn Phenomenon. When I switched to Lantus, my morning blood sugars were vey high. Combining Lantus and NPH sorted that out. I used to inject NPH before bed, to deal with the DP. And I injected Lantus in the morning. It meant that I had basal coverage throughout the day and extra coverage when I needed it in the morning. Doing it this way also means that the gap in Lantus coverage is filled by the peak in NPH action.

Taking the Lantus at dinner time may work better for you if your blood sugar is dropping in the evening. Its just a case of trying out the different permutations until you find what works best. Good luck.

[cheryl]

This one girl had to take NPH, at bedtime because for some odd reason, she would shoot up in the middle of the night with blood sugars of 600, yikes, and just prior to this happening her a1c was under 5.5.....weird, so she decided to take NPH, at night about 2hrs before she goes to sleep and now she is level and takes her lantus during the day.....

Cheryl

[hstavisky]

Thank you. This is just what I needed. I will start NPH at bedtime (today) with 10 units and take Lantus in the morning (20 units). This should take care of the gap? Now... the question.... I will need to adjust the NPH, as Lantus 20 units seems to be working fine throughout the day.

One final question: I am gaining a lot of weight. I gained 10 pounds in two months! I am already overweight. Any suggestions on a diet that would work best? I have tried them all, and the low carb ones were good for blood sugar control but my toe nails were cracking.

[BlueSky]

T... I will start NPH at bedtime (today) with 10 units and take Lantus in the morning (20 units).....
Mmmm ... that is a 50% increase of your basal insulin. It may be necessary if your morning blood sugars are very high. But be aware that using too much insulin often causes weight gain. As you are having this problem, you need to be looking for opportunities to reduce your insulin. I found that reducing my Lantus by the amount of NPH I started injecting before bed worked well for me. I suggest you use this as a conservative starting point and increase the dosage if it turns out to be inadequate.

I don't use NPH anymore, mainly because my DP has weakened. I have achieved this by getting into a regular exercise routine. Exercise increases insulin sensitivity, so the amount of insulin required reduces and the DP effect weakens. You may also want to try this as an option. :)

[Gary_W]

Lantus is supposed to be peakless. It isn't, though in most people it is a lot flatter than NPH. Because of a couple of other things you've said, I would not add NPH at this stage without trying other things first. You are talking of making changes without knowing all the facts which can lead to trouble. It may be that you have considered the things I'm about to write but just haven't mentioned them here. If that's the case and you already know the answers to all of the following then please ignore me and accept my apology for getting the wrong end of the stick.

If I'm understanding you correctly, you inject your 20u of Lantus in the morning. You go low in the night, but then skyrocket before dawn. This COULD be caused by having too much Lantus (causing the low) in addition to Lantus lasting less than the advertised 24 hours. In lots of folks it only lasts 18-22 hours. Also, you haven't said how you've treated the lows in the middle of the night. Another possible cause of your morning BG rise could be too much hypo food in the night as opposed to DP.

As a theory to illustrate, let's say you inject at 8am and the dose is actually too high. Let's also assume that Lantus lasts 20 hours for you. What this will do is cause your blood glucose to constantly tick down throughout the day, which it isn't supposed to do; it's supposed to remain stable. You go to bed at 11pm which is hour 16 as far as the insulin goes. It continues to drop your BG from the time you go to bed until 3am when it runs out. At that point, your liver keeps on putting out the glucose and may even squirt out extra for DP. You have no Lantus left and you get huge blood glucose.

Now this is pure theory. To test it, do a fasting blood glucose test. Inject your normal amount of Lantus in the morning, your normal rapid in the morning and eat breakfast. Make this 7 or 8am. When you would normally have lunch, test your BG and write it down. Do not eat and do not inject rapid. Test your BG every 30 mins through until your evening meal when you finally get to eat. If your Lantus dose is correct then your BG should not rise or fall during this period. If your Lantus is too high then your BG will drop. You can do exactly the same test with any of your meals, but I'd avoid the night shift at the moment if you're having drops there. The lunchtime one here is a lot more sociable and will point you in the right direction.

Once you find out if 20u is the correct dose for you, then you can move to the next stage. If the theory about <24 hours coverage for you is correct, you can fix this in two ways I know of. You can try and put your full dose in at night. Say you inject at 11pm each night, you will have good basal cover until (for example) 7pm the next night when it will run out. As this will coincide with evening meal being digested, you can do an extra shot of rapid to take up the gap. Another way of doing it is splitting the Lantus dose in two to ensure 24 hour coverage; there are several posts on the boards about splitting Lantus dose.

I would honestly try the above before the NPH trick. It's a great idea, though I'm not convinced you've got all the answers to go down that route safely. If you are going low in the night anyway then injecting NPH before bed may make that worse to the extent you might be woken up by paramedics if the peak of the NPH comes on quicker than you think. If you establish that your Lantus basal IS correct and you try altering the dose time and you still have the same problem then try the NPH idea. However, rather than just adding NPH to the same amount of Lantus, I'd take the Lantus dose down by a similar amount to the units of NPH added. Adding basal insulin without understanding what it really does / knowing if the dose is correct is what caused me most of my past problems.

For the record, my Lantus dose used to be far too high and it caused hypos in strange places. Since I've got the dose correct, I've lost a lot of weight which went on when I started Lantus and also feel very well.

Post back with how you treat the night hypos and also your typical doses of Rapid so others here can help you more.

Gary

[xMenace]

Very interesting concepts here.

I'm concerned with the extra basal too, so dropping the Lantus somemay be necessary. If it's sending you low in the night, 20u will likely continue to drop you despite the timing.

My suggestion is to drop the Lantus dose, go slow and try to basal test.

[Alice]

I would suggest splitting your Lantus dose...I do this with larger dose in morning and small dose at night (my nighttime does has been cut in half recently...body chemistry just changing)...now I'm on 21 Lantus a.m./5 Lantus bedtime.

I was taking 17/8. I'm having perfect to slightly low mornings. This morning was 99. It's going to be a good day...

[hstavisky]

First, thanks for the reply. I take Lantus at around 6PM (now 20 units). Treating the extreme hunger in the dawn has been a problem, and I would eat an Atkins Bar or 2 tbs of peanut butter. Last night, I tried the NPH trick, and at 5:00 AM, the BS was 109, but at 9AM, it was 204. No clue what happened, except that I felt very nauseus at 5 AM.

I need to start all over. Should I begin with 10 U Lantus at night and try to establish the dose better? My doctor said to start at 20U, and I did a fasting test, and my BS in the morning were
135 150 113 (starting at 6, then 8, then 10:30). This was fasting. Also, with the 20, I injected 5 units H at 6 with breakfast which consisted of 2 eggs, no carbs. BS Still went up to 150.

Other than NPH, how could I handle the NPH. My BS are great in the afternoon with 10 Units of Lantus. It's just the morning.

Would you inject Lantus in the morning, bedtime or dinner?

[Gary_W]

What I would do is change as little as possible until you get a better handle on what's going on. I would stay with the 6pm 20u Lantus shot and do the testing acordingly.

The morning numbers make little sense unless you know what your before bed number is. In an ideal world, your morning BG should be the same as your night-time number. I'm fortunate these days in that I can go to bed with a BG of 5.0 (90) and wake up pretty much the same. What COULD be happening with you is that you are going hypo in the early hours and, whilst you sleep, your liver dumps hence your high waking BG.

Not nice for a good nights sleep, but have you considered setting an alarm for every couple of hours to get an idea what is happening (or more frequent if you can stand it?).

Whatever changes you make to Lantus do take a few days to work. If I were you, I'd stop the NPH for now, leave things for a few days to settle then do the test above. Only change the Lantus by 10% at a time (2 units) and leave it to settle for a few days before trying again.

Gary

[hstavisky]

I will do that. But I sense that I went hypo last night, so I will split the 20 u dose and try again.

[BlueSky]

.... Would you inject Lantus in the morning, bedtime or dinner?
If you want to use NPH to deal with the DP and close the Lantus action gap, you need to inject NPH before bed and Lantus when you get get up in the morning. The NPH needs to peak in the early morning to counteract the DP. And it should be injected about 8 hours before Lantus to bridge the action shortfall. Doing it any other way won't work, INMHO. I suggest starting with 10 units of each, and keep the Lantus dose the same for at least 3 days before changing it. It takes several days for the body to get used to a changed Lantus dose.

[hstavisky]

Will try that. Did not go hypo on Lantus 20 U last night. However, my DP was severe -- blood sugars up to 178!

[Oradev]

Like the others have said, your Lantus dosage might be running out. For me, the Lantus dose lasts around 21 to 22 hours. That is why I’ve had to split my dose.

I've found a few ways to combat the dreaded DP. I used to have it REALLY REALLY REALLY bad!!

1.) My current regimen is 8 units of Lantus when I wake up (6 am) and 11 units of Lantus before bed (10 am). The high dose at 10 pm seems to cover me at night and the 6 am pretty much covers me throughout the day.

2.) Dinner is usually my smallest and healthiest meal of the day. I eat very low fat and protein for dinner. This keeps my blood sugar in normal range 2/3/4 hours post meal. Also, I tend to eat lots of veggies for dinner.

3.) I try to eat dinner around 5 or 6 pm each night. I usually go to bed around 11 pm, which means that my dinner has enough time to digest. If you eat late, your dinner tends to digest while you are sleeping; therefore, DP is more prevalent.

4.) Exercise! Exercise!! Exercise!!! Exercising at night has completely changed the way I feel and my overall blood sugar readings.

5.) I never ever eat anything after dinner. If I go low, then it is a different story. I only drink water or iced tea after dinner. Not only does this help my morning sugars, it also helps maintain my current weight.

Hope this helps.

Adam

[Oradev]

I would suggest splitting your Lantus dose...I do this with larger dose in morning and small dose at night (my nighttime does has been cut in half recently...body chemistry just changing)...now I'm on 21 Lantus a.m./5 Lantus bedtime.

I was taking 17/8. I'm having perfect to slightly low mornings. This morning was 99. It's going to be a good day...

Alice,

What times do you take you Lantus doses?

[Alice]

Oradev, sorry I'm a little delayed in answering...it's moving week for me!

I take my 21 units at 7 a.m....give or take...this a.m. was 6:30 and I've been as late as 9 a.m. but usually between 7 & 8 a.m.

My evening dose is at 9 p.m....my doctor said anytime before bed, but I find if I don't aim for a certain time, I get tired and fall asleep. So, 9 is late enough, but not too late.

Apparently, my "split" is not very even...21/4-5...I adjust the evening according to whether I'm running low fastings. Four units sounded like nothing to me (I was splitting with 8 at night)...but I was having too many morning lows...which seems to be the opposite problem of many people.

Even at 5 I can go too low. It depends on whether I have a long-active carb in my system from dinner.

But, if I decrease overall Lantus, my pre-meals are too high. So, this is what works for me...with a lot of trial & error.