levimire

[tkidwell1]

does it matter if I take my 24 u all at once (10pm) or should I split it? what is the difference?

[DanG]

does it matter if I take my 24 u all at once (10pm) or should I split it? what is the difference?

I will offer a very contrarian answer for you.
I take my lantus in the AM before breakfast.
I used to do the basal insulin (I use lantus which is essentially the same as levemir) in the evening - like the doctor told me to do. I had frequent early morning lows - very disruptive to my REM sleep at 3AM to be awakened needing to drink some OJ. So, without consulting the doctor, I switched to taking my lantus in the morning, along with my breakfast humalog.

I doubt if my doctor knows - I don't know if I told him. However, I established my relationship with this doctor early on 4 years ago, saying, I want to be the person in charge and in control no matter what you may say, I live this diabetes thing, you don't. He acted a little offended, but he understands and deals with me that way. Early on he wanted me to be doing blood pressure and cholesterol drugs and I said no thanks. I like my doctor as a consultant - not as someone I need to tell me how I should be living.

As to taking lantu in the morning with my humalog, there are days I do notice a bit of a blood sugar low about 2 hours into the morning. I don't mind a bit of a snack then - just a little bit of a snack, and a little slowdown in activity - I don't want to fall over at work and let anyone at work know I am diabetic! So, if you decide to take levemir in the AM, watch out for that type of activity. If you look at the published profiles of basal insulin, it operates very flat - no peaks. As I understand it, in real life the profile is not usually flat. Basal insulin is also supposed to last 24 hours. Basal insulins do not last 24 hours in most persons. Hence, some people split the dose, like you are asking.

Here is my reasoning - if my basal insulin does not last 24 hours, guess which hours it is not in my system? - 2AM to 7AM. I am sleeping during those hours and I am not in a mood for food, nor do I need insulin, I would rather have my REM sleep. So, that is why I like taking basal insulin in the morning. If you take basal insulin in the PM and it does not run for 24 hours, you are without basal insulin 6PM to 10PM - when you may need basal insulin and/or food, as you are awake and alert. Plus, taking your basal insulin in the PM when you are ready to sleep, any basal insulin peak will ruin your sleep - like it did for me many times. I started dropping my PM basal amount, but then I had no basal action - I like to have a bit of feedback from basal, so I know it is there, but not there in my face like the humalog.

My experience with split basal - the paramedics were here at 3AM on day 3 in that try. I did not continue with split dose basal.

These are opinions - somewhat rational, but somewhat not. Think it through, and continue to ask questions here - DF is great place to ask.

[BlueSky]

does it matter if I take my 24 u all at once (10pm) or should I split it? what is the difference?
Levemir has a pronounced peak 6-10 hours after injection. So if you take it all at once, your blood glucose could drop at this time. If this happens, splitting the dose between evening and morning shots would help. On the other hand, if you have a strong DP (rising blood glucose in the early morning), it could work well for you to inject all of it before going to bed. You just have to experiment and see what works best. Most people get better results when splitting the dose. It also improves the consistency of insulin absorption and action. Here is a graph that shows the action profile of Levemir (the line in the middle) :

http://i288.photobucket.com/albums/ll181/stratplan/basalinsulincomparison.jpg

[xMenace]

On the other hand, if you have a strong DP (rising blood glucose in the early morning), it could work well for you to inject all of it before going to bed.

Mark, I'm curious about what your sugars tend to do between midnight and 5am. Mine plummet. I never did find a balance with Lantus. I know much more now though.

Levemir can also run out before 24 hours, especially if you are underdosed. I've seen something somewhere that suggests most basal insulins are over-dosed anyway, Splitting it will cover these low gaps.

It is all about matching up with your rythms, your peaks and valleys. Basal testing is always recommended to gain a better understanding of yourself.

[BlueSky]

Mark, I'm curious about what your sugars tend to do between midnight and 5am. Mine plummet. ...
My blood glucose surges in the early morning, big time. I have a strong DP, and it outruns Lantus. I used to wake up to high blood sugars when I injected Lantus before bed. Which is why I inject NPH before bed (I would use Levemir if it was funded here) and Lantus in the morning.

Even the NPH doesn't do it for me. I cover breakfast with Regular because it extends the NPH peakand stops blood glucose rising before lunch. When I was trialling the pump, I increased the basal rate from 0.5 units/hr to 0.95 units/hr at 2:00am, and I only started bringing it down again at 10:00am.

It is interesting that your blood sugars plummet at this time, John. I guess it goes to show that we are all different. I haven't always had such a strong DP, I don't think. I have tried to make sense of the situation in terms of the aging process. Our insulin requirements decline over time, as the metabolism slows down. But we lose insulin sensitivity at the same time. One would expect the net result to be increased bolusing requirements, a stronger DP, and a reduced basal requirement during the rest of the day. Which is essentially what appears to have happened with me. :o

[LancetChick]

Blue Sky, what the heck is a glucose infusion rate, and what does it have to do with how each insulin behaves? According to the chart, the three insulins seem to be very similar, but in reality they are no such thing (although I have never tried Levemir). Insulin absorption rates vary considerably from person to person, but NPH lasts, in general, on the order of 14 hours, while Lantus lasts, in general, 20 or more hours. Over on the ADA board they're talking about Levemir lasting only 12 hours, and some (not many) are taking it 3x a day. That's quite a difference, but it doesn't seem to be reflected in your chart, which I (somewhat intelligent, or so I thought) can't make heads nor tails of. :embarasse

[tkidwell1]

I only take levemir once a day and Endo says it lasts 24 hours, I think I might ry splitting it. So confused

[BlueSky]

Blue Sky, what the heck is a glucose infusion rate, and what does it have to do with how each insulin behaves? ....
To establish the action profile of insulin, they inject a fixed amount of it and "clamp" the T1 patients' blood sugar (normally at 100mg/dl) by infusing glucose through an IV drip. The "infusion rate" is the rate at which glucose has to be infused to maintain blood glucose at the clamped rate. It is measure in milligrams of glucose per kilogram of body weight per minute. It is the only way to accurately measure the action of insulin over time.

You are right about the insulin action profile being different for different people. The graphs show averages for a group of T1 patients. The NPH graph looks about right to me. I used it for many years and used one shot a day. The Lantus graph also looks about right, based on my experience. I have never used Levemir, but I can see no reason why it should be out of line.

What struck me about the Lantus graph is that it is so different to the advertised action profile. Here is the graph Sanofi-Aventis distributes for its Lantus product :

http://dailymed.nlm.nih.gov/dailymed/fda/image.cfm?id=3283&type=img&name=lantus-image02.jpg

Note that the X axis is also the glucose infusion rate. Compare the graph with the one I posted previously (above). It shows Lantus action to be a lot flatter than it is, and NPH to be a lot shorter action and peakier than it is. Could this be a case of misleading advertising?

[LancetChick]

To establish the action profile of insulin, they inject a fixed amount of it and "clamp" the T1 patients' blood sugar (normally at 100mg/dl) by infusing glucose through an IV drip. The "infusion rate" is the rate at which glucose has to be infused to maintain blood glucose at the clamped rate. It is measure in milligrams of glucose per kilogram of body weight per minute. It is the only way to accurately measure the action of insulin over time.

You are right about the insulin action profile being different for different people. The graphs show averages for a group of T1 patients. The NPH graph looks about right to me. I used it for many years and used one shot a day. The Lantus graph also looks about right, based on my experience. I have never used Levemir, but I can see no reason why it should be out of line.

What struck me about the Lantus graph is that it is so different to the advertised action profile. Here is the graph Sanofi-Aventis distributes for its Lantus product :

http://dailymed.nlm.nih.gov/dailymed/fda/image.cfm?id=3283&type=img&name=lantus-image02.jpg

Note that the X axis is also the glucose infusion rate. Compare the graph with the one I posted previously (above). It shows Lantus action to be a lot flatter than it is, and NPH to be a lot shorter action and peakier than it is. Could this be a case of misleading advertising?

Thank you, that makes perfect sense, and is interesting to boot. As far as whether or not the Sanofi-Aventis graph is misleading, I have to say that that is EXACTLY how NPH and Lantus work for me! On the other hand, I'm the only one I've ever heard of for whom Lantus does work that way, so it wouldn't surprise me if they did a little bit of "unofficial" finagling to find a magical group of "my kind" to trial.

Well, maybe not, since that would be totally unethical, but they do finagle with words in their written claims, saying in banner headlines that Lantus is a once-a-day insulin, and then in the fine print (which doctors don't read) that it can last up to 24 hours, and that it should be taken at night (presumably because when it runs out during the day, you can be fooled into thinking your I:C ratios are off and use a fast-acting to cover or correct Lantus's shortcomings). Never having tried Levemir, I can hardly compare, but I would certainly read the fine print on that pamphlet as well, and take what they say with a grain of salt.

[tkidwell1]

since i take my Lev (24) at night, if I were going to have a snack, would I take my novolog for the snack, then also take the levamire?

[DanG]

since i take my Lev (24) at night, if I were going to have a snack, would I take my novolog for the snack, then also take the levamire?

If you are going to do anything on your own - you are on your own.

If you are going to do as the endo wants you to do, do it the way the endo wants you to do.

It seems to me these two manners of living with diabetes are somewhat mutually exclusive?

btw, I also take 24u lantus - the same amount as your levimer - only I take it AM, no split. I do not like lows coming on me while I am asleep at 3AM. If you split the dose, be very careful - as when I split the dose, I woke up with paramedics at 3AM - I already said, I don't like that.

You may want to ask about the DP - or what I understand to be dawn phenomenon. I am thinking, based on what BlueSky has said here, that I do not have DP of any sort, therefore the AM lantus works fine for me.

tkidwell may not have a significant DP either, as tkidwell has said there are numerous lows in early AM, in which case you need to be careful about split or PM levimer.

If I were to guess, the manufacturer is probably assuming more patients than not, have a recognizable DP. If I had any DP, it has completely disappeared, or, could it be that I have trained my body against DP? Can we (diabetics) train our bodies in certain profiles of insulin usages such as this?

[LancetChick]

since i take my Lev (24) at night, if I were going to have a snack, would I take my novolog for the snack, then also take the levamire?

Since you're going low at night, you might want to skip the Novolog, but if your basal were perfectly set, you'd need to take a Novolog bolus in addition to the Levemir.