Basals and the art of frustration

[Gary_W]

Evening all,

Many of you posted some very helpful advice recently about splitting Lantus; many thanks to all concerned :)

My problem was that my usual 14u of Lantus each day given before bed had suddenly decided that it would send me hypo at around 3-4am. Unless I went to bed with a BG of 10 (180), I wouldn't be confident of waking up feeling good. And going to bed as a 10 is not something I want to do.

I ended up splitting the Lantus, and eventually found that 7 before bed is just right as my BG neither raises nor lowers significantly. Fine. I'm putting the other 7 in with breakfast.

My problem is that my (usually) super-rapid Apidra now works at a snails pace for breakfast and lunch. It's really weird. I've had to change my ratio slightly, but whereas it did get cracking after 10 mins, it now seems to take 2-3 hours to peak and then a nasty tail comes along at hour 4... Prolonged high, then it drops.

Previously, my days were very good indeed. I was at a 1:10 ratio for carbs all day and it just worked. I could eat anything, and be down at a 7 or better at the 2 hour point. I even remember going for a huge curry and testing throughout. Didn't even hit double figures despite bread, potatoes, rice, sugar in the curry etc.

I had fish and chips today at lunchtime; round at my folks and it was what they wanted. I carb counted pretty accurately. Two hours after eating, I was 18.5 (333!!). I didn't correct as I knew I'd got the carbs right and figured I'd see what would happen. At hour 4 I was down to 5.0. I had injected 20 mins before eating to give it a head start.

This is crazy. I am seriously considering going back to the 14u at night (or at least upping it to the point where it drops me in the night) and snacking before bed. It just seems like the extra active Lantus in the AM and around lunch seems to make the Apidra work a whole lot better.

Any thoughts gratefully received.

Gary

[BlueSky]

Don't jump to any conclusions here, because you could end up just increasing the confusion. It is not unusual for the way we respond to carbs/boluses to change. And the only good time to change basal insulin is if it is not satisfying basal insulin requirements. Your recent experience with Apidra is mystifying. But to blame it on the Lantus would, IMO, be a mistake. Before making any changes, I would test the basal rate by skipping meals.

[xMenace]

Are you by any chance mixing them? Lantus should never be mixed.

[Gary_W]

Thanks for these.

BlueSky - I'm trying not to jump to conclusions. Difficult at the moment... The thing is that (skipping meals aside) if I put in more than 7u of Lantus in an evening, my BG drops overnight. Until recently, the 14u at night resulted in a perfect overnight basal and (proven by testing) perfect basal until lunch. I'm sure that the 7u isn't enough to keep my basals even through the morning at the moment, it's just that any more sends me hypo overnight. Which is tricky :( I'll see if I can stand a basal test in the AM; it's 12.30am here now and I'm currently quite hungry. BG of 6.5 currently, so I'm not doing anything as far as food or insulin goes.

I cannot understand this recent experience with Apidra either. Since this started happening, I've had a new batch of insulin so it's nothing to do with that.

xMenace - No, I'm not mixing them. I have seperate pens for each and the Lantus always goes in my legs. The Apidra either goes in arms or abdomen depending...

Gary

[xMenace]

http://members.tripod.com/diabetics_world/images/lantus.gif

Your morning Lantus is not helping your DP at all anymore, 5am to 10am, more-or-less. Previously your whole dosage was fully active. I can't explain your lunch and afternoons.

I think you have to do what's best for your 2am numbers with the Lantus then workaround the rest of your day. Nighttime hypos are awful things. I do believe your Lantus never kept you flat. I think it's no longer flat and your humps & valleys have changed.

I wonder if a midnight or late evening shot might work best.

[Emm]

That's an interesting picture Xmenace - is the surrounding info available online? I'd like to know how that was tested.

Certainly shows just how 'flat' Lantus is hmmmm! But I think a lot of us have learnt that it's not as flat nor as long lasting as they suggested. It's still really good stuff though - especially in comparison to Protophane (NPH).

Gary: Are most of your meals fairly high in carb lately? This only matters if you've changed things... but high carb meals will work faster and beat the insulin, making for bigger spikes. Not sure if this is at all helpful but it's the only thing I can think of.

Injecting 20 minutes early always gets me through a Fish & chip meal so I'm at a loss!

[xMenace]

[/url]

These basal insulins can end sooner thatn expected if the dose is less than optimal. That's from a Levemir rep I talked with. I think the key thing here is the reamp-up time. It doesn't take efect immediately, so taking it in the mornings will not help a big DP.

Pumping is so much frickin easier. I hope I never have to go back on MDI.

another

http://www.medscape.com/content/2004/00/46/61/466194/art-cmro466194.fig2.gif
[url]http://www.medscape.com/viewarticle/466194_4 (http://members.tripod.com/diabetics_world/lantus_activity_curve.htm)


yet another
http://www.ispub.com/xml/journals/ijen/vol4n1/insulin-fig3.jpg
Insulin Detemir and Its Unique Mechanism of Action (http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijen/vol4n1/insulin.xml)

Here's a cool looking one

http://www.endotext.org/Diabetes/diabetes24rosenstock/figures24rosenstock/figure5.gif
Endotext.com - Diabetes, Insulin Strategies in Type 2 Diabetes (http://www.endotext.org/Diabetes/diabetes24rosenstock/diabetes24rosenstock.htm)

[jen_slc]

I'm sorry, Gary, I sympathize. You're almost left with a choice of the lesser of two evils: 1) higher basal with eating at bedtime/potential nighttime lows but not as pronounced DP or 2) lower basal with no nighttime lows but significantly altered daytime BG readings.

For me, I chose #2. It wasn't worth it to me to constantly have to feed the Lantus. So yes, I (still) struggle with my Apidra boluses during the day and am considering adding some Regular to the regime because Apidra doesn't last very long for me - although it still works better than either Humalog or Novolog did.

If this isn't something you're willing to test and play with, the only other option I can think of would be pumping. Or go low/no-carb. I cannot go low-carb and I will never go back to pumping, so I am doing everything I can to perfect my Lantus and Apidra... and if I ever somehow figure out a way to deal with this exact issue, you will surely know!

[grace girl]

When I switched from one shot of lantus to two a day, I also found that everything changed. Everything. However, I don't use apidra so I can't comment on that. I know that doing some basal testing really helped me to get a clearer picture of exactly what the lantus was doing for me throughout the day and night, and it helped me to make adjustments to the humalog that balanced it all out.
About the only other suggestion I can make is this: if you are seriously considering going back to one shot of lantus again, consider taking it much earlier so that the peak has finished before you go to sleep. If (as I suspect it is) the peak is what is causing the hypos, backing up the injection time should help prevent that.

[BlueSky]

I agree that basal testing is really important. And you need to do it at all times of the day. Only then will you know where the gaps are. When you know this, there are a number of variations you can try. One is to replace one of the Lantus shots with NPH, and to time it so that the 6-10 hour peak corresponds with increased insulin need. Injecting some NPH before bed is good for controlling the DP. You can use Regular in a similar fashion, except that it peaks in 3-5 hours and needs to be injected during the day. I inject Regular when I get up in the morning and find it effectively keeps the 2nd half of the DP in check. If you have a strong DP, you could also try taking metformin before bed. It enables you to reduce that night time Lantus shot and still get good morning numbers. You could also try switching to Levimer. It's shorter action profile gives you more flexibilty in manipulating the split-dose overlap.

[Gary_W]

Thanks again for alll the replies, everyone. This place is a life saver :)

I did do a basal test this morning. Whilst my morning numbers were far from flat, they were not bad enough to explain what is going on IMO though I'm of course open to other interpretations ;) .

I tested immediately before bed last night and was 6.9.

Tests this morning:

7.30 6.6
9.00 7.6
9.30 7.5
10.00 7.6
10.30 8.8
11.00 8.0
11.30 6.8
12.00 6.8
12.30 7.1

I called it a day there. I actually whacked the other 7u of Lantus in at 7.30. Reason for an hour and a half gap in the testing was that my wife got up with the children and granted me an extra hour in bed. Basal test or not, I wasn't turning that down...

My results the rest of today have been remarkably civilised. Worst I've been is an 8.0, which is lovely.

To answer a few of your posts...

xMenace - many thanks for the profiles. It is very interesting to see the suposed profile of Lantus. Weird thing for me is that I typically inject at around midnight and the usual time for the hypo would be between 3 and 4am. Also, looking at my basal test this morning, my numbers started to come down again around 4 hours after injecting. Leap of faith I know, but it may suggest that (in me) Lantus has a bit of a peak at 4 hours. This could be good to know in terms of timing the shots. The dificulty I have is that injecting during the day is tricky as I always do the lantus in my thighs and I travel all over. There are a lot of times when I'd have dificulty finding somewhere to drop my trousers...

Emm - My meals do tend to be high in carb compared to some folks. I probably eat 200-240g of carbs each day. Until very recently, this has worked out fine. My HBA1c is 5.8 at the moment and (apart from fouling up the carb counting occasionally) I would always come right within a couple of hours of a meal. If anything, I'm eating less carb now to try and help the spikes. I'd rather go back to the way things were but time will tell on that score.

Jen - thanks for the thoughts. It's a shame it's such a struggle to get this stuff right. I have got an appointment this Thursday afternoon which is to learn a little more about pumping, but whether I will qualify over here or not is another matter. I've mixed feelings about pumping, but I can see how my current situation would not be a situation if I pumped, so that probably trumps the 'I don't like the concept of being hooked up to a machine 24/7'.

Gracegirl and BlueSky - You're both right on the basal testing. Much more needed at this end. It's possible at weekends, but weekdays are mostly crazy at the moment and not overly condusive to experimentation. Once I understand exactly how Lantus is peaking for me (this week, anyway :( ) then I can see if I can find a time that (a) works and (b) is possible for me to do no matter where I am.

Gary

[Jan B]

Gary,

Look at your basal tests, and look at the similarity in my basal rates to take care of DP and keep constant bg.

12a - .6
5a - .65
6:30a - .7
7:30a - .75
10a - .7
12p - .65
2p - .6

I wish you the best; I know you've been working hard on yourself!

[BlueSky]

.... looking at my basal test this morning, my numbers started to come down again around 4 hours after injecting. Leap of faith I know, but it may suggest that (in me) Lantus has a bit of a peak at 4 hours. ...
It could also mean that the DP is over by 11:00am. Your blood glucose comes down because you are becoming more insulin sensitive. Injecting Lantus at a different time of day would probably produce a completely different profile. ;)

[Gary_W]

It could also mean that the DP is over by 11:00am. Your blood glucose comes down because you are becoming more insulin sensitive. Injecting Lantus at a different time of day would probably produce a completely different profile. ;)

You're probably bang on the money here. It is finding said time of day and ensuring I can always do it then.... I recon about 3pm would be perfect as the peak from the Lantus would take up the slack of the evening meal and hopefully it will have calmed down during the night. Unfortunately, at that time of the day I will typically be in front of a customer or hurtling down a motorway. If I can find a time that is good in terms of ergonomics and action then I'll go with it.

All bets are off at the moment regarding sorting this out. I now have a pretty horrible cold (AKA Manflu) and a manky finger. No idea how that happened, but my little finger is swolen, red and horrible. I am now on 500mg of some antibiotic that I have trouble pronouncing (doctor almost gave me the last rights due to the fact I'm diabetic and have an infection, he was going to do the 250mg stuff but gave me the diabetic special...:D ). Strange thing is that the post breakfast and lunch spikes have been fairly kind today (at least compared with the last week or two).

Due to aforementioned bugs, any testing I do at the moment is to keep myself on an even keel. It will be interesting to see how it settles down after the cold goes and the antibiotics have gone. Perhaps they'll kick out whatever else may have been lurking around. So many little nasty bugs floating around at the moment around here. Our youngest daughter has a sickness bug at the moment that caught both us and the carpet unawares yesterday. Poor little girl looks absolutely wiped out :(

Gary

[Eddy]

Gary: Are most of your meals fairly high in carb lately? This only matters if you've changed things... but high carb meals will work faster and beat the insulin, making for bigger spikes.


I beg to differ, and would say "YMMV". (For me, high-CHO meals work _slower_... and I tend to go hypo unless I change some of my reg-R to reg-N.)

[Eddy]

I agree from your basal test that you seemingly have a Lantus peak around 4h. This also could help explain the hypo.

Any chance you could do evening Lantus a few hours earlier... abdominally? I use central abdomen for glargine, and more toward the sides for my boluses; this seems to work well.

It's nice to see someone else (BlueSky) using reg-R and reg-N to cover glargine "rough spots". I do the same, although on a different timescale. I'd be in big trouble trying to use protophane for a basal, but it's great for "spot coverage" and certain boluses.

The detemir suggestion also seems reasonable. However, I'd probably tinker a bit more with what you have before trying to switch basals.

Hang in there... and keep us posted...

[Eddy]

Injecting Lantus at a different time of day would probably produce a completely different profile. ;)


Ohhhh, yes. Even a few hours can make a substantial difference!

[Gary_W]

Thanks, Eddy. Once the cold etc has died down I'll tinker some more. I did have pretty much perfect control until fairly recently and I'd ideally like it back again. Life was a lot nicer when it did as it was told and followed the instructions...

[JJM335]

Gary:

There are lots and lots of posts discussing the problems getting 24 h coverage from Lantus (or 12 h from Levemir). I had a really interesting experience recently trying to adjust my Lantus dose which convinces me that a lot of the problem is not that the insulin doesn't give "flat coverage", but that basal insulin requirements vary HUGELY over a 24 h period.

In my case the deficiencies in my basal were the other way round from yours (nice flat BG's overnight but dropping like a stone from mid morning onwards until about 7 pm). I have posted the details on another board, but in brief, assuming that I could deal with the afternoon drop by reducing my basal dose, I dropped my Lantus from 20 u (split 13/7) to 18U (split 12/6). This had a totally disasterous effect on my BG's in the evening. Like you, my I:C ratios went haywire and I was going up to >15 mmol (don't normally see these numbers), with as few as 40-50g carbs (bolused correctly). Again like you corrections stopped working. Interestingly, I was dropping even more precipitously during the afternoon. After about a week, I upped to 20U Lantus and everything went back to "normal".

My take on this is that basal requirements can differ by a lot at different times of day. I suspect that if you cross the threshold into "too little basal" at a time when your requirements are high (in my case eveninings, but perhaps in your case during the day). Your body starts to react extremely badly resulting in liver dumps, insulin resistance etc.

Some of the pumpers have basal levels that vary by as much as about 5-fold depending on the time of day. I suspect that pumping may be the only anwer to this.

Joel

[xMenace]

Gary:

There are lots and lots of posts discussing the problems getting 24 h coverage from Lantus (or 12 h from Levemir). I had a really interesting experience recently trying to adjust my Lantus dose which convinces me that a lot of the problem is not that the insulin doesn't give "flat coverage", but that basal insulin requirements vary HUGELY over a 24 h period.

In my case the deficiencies in my basal were the other way round from yours (nice flat BG's overnight but dropping like a stone from mid morning onwards until about 7 pm). I have posted the details on another board, but in brief, assuming that I could deal with the afternoon drop by reducing my basal dose, I dropped my Lantus from 20 u (split 13/7) to 18U (split 12/6). This had a totally disasterous effect on my BG's in the evening. Like you, my I:C ratios went haywire and I was going up to >15 mmol (don't normally see these numbers), with as few as 40-50g carbs (bolused correctly). Again like you corrections stopped working. Interestingly, I was dropping even more precipitously during the afternoon. After about a week, I upped to 20U Lantus and everything went back to "normal".

My take on this is that basal requirements can differ by a lot at different times of day. I suspect that if you cross the threshold into "too little basal" at a time when your requirements are high (in my case eveninings, but perhaps in your case during the day). Your body starts to react extremely badly resulting in liver dumps, insulin resistance etc.

Some of the pumpers have basal levels that vary by as much as about 5-fold depending on the time of day. I suspect that pumping may be the only anwer to this.

Joel


I think we agree.

My lowest is 0.45 and my highest is 1.85, a 4.1 fold variance.