Should we correct before bedtime lantus?

[Pudlane]

Hello Everyone

This is my first post so hope you don't mind me asking a question straightaway and hope it hasn't been asked many times before!
My 6yr old daughter has had T1 since Feb07 and we are coping well enough with her injections of novorapid and Lantus.
At her last quarterly check up her HbA1c had risen to 8.0, it has risen slowly since diagnosis.
My question is after her last test normally at 18.30 after dinner she still can be quite high +12mmol/l if we haven't given her enough novorapid.
We had been told originally to leave this and not correct her by giving her anymore novorapid but to give her lantus as normal.
Would anyone suggest that a correction of novorapid should be given in order to bring her down. We normally give her the lantus (10 units) around 19.15 just before bedtime.
Any thoughts would be most welcome as we would like her Hb to start decreasing again.

Many thanks
Chris

[UpNorth]

I think it depends on if your daughter drops overnight or if she's stable. Around what level does she usually wake up after being that high in the evening?

[Pudlane]

Hi there

That was quick!

If she is over 12mmol at night then she normally is around 9,10 or 11 in the morning.
We have recently upped the lantus to 10 units with the consultants agreement as she had been high most days (ie over 8).
If she is over 16 then we would correct normally but it's the thought of her being between 8 and 15 from after dinner until she drops that concerns us.

Thanks

[UpNorth]

Ok, then she's not dropping very much overnight. Are you testing her through the night too? Do you know how much 1 or 0.5 unit will lower her? If you know how to correct those highs quite accurately, i'd say go for it. Everyone who lives with diabetes knows how much it sucks to be high, especially being high in the morning...
But yeah, try small corrections, and keep a close eye on her bloodsugars. But the best would of course be to talk with her diabetes team first and see if they can come up with good suggestions about doses and stuff.

[Pudlane]

Hi UpNorth

Thanks for the responses.
We know that 1 unit drops her just under 3, so we do know how much to give her, and no we don't test her through the night.
As she can't really describe how she feels it hard to judge whether to correct her, but as you say and I can imagine being high is not a nice feeling.
I would prefer to correct her, it's just hard giving her yet another injection in a relatively short space of time. But I suppose it is better than being high through the night and in the morning.
She hasn't complained of being low through the night, but I guess it's because we edge on the side of caution before bed.

Thanks again

[fgummett]

Hi Chris, Welcome to DF!
It must be so tough on you as parent. :) While you are of course right to err on the side of caution you have to balance that against her A1c which you say is 8% (equivalent to an average BS of 11.53 mmol/l or 207.5 mg/dl) and has been rising since diagnosis. If the idea of too many injections is getting in the way of effective treatment, you might consider an insulin pump. :)

[UpNorth]

I'd personally correct a reading of 12 before bed, because if i don't, i'll wake up at least above 10, and i feel all yuck if i'm 10 or higher at any given time...
So one unit lowers her by about 3mmol/l? If so, then i'd consider it safe enough to correct a reading of 12 since she's not sinking too much overnight. But to be on the safe side, go and check on her once or twice during the nights when you have needed to correct before bed. If you have a pen with 0.5 unit increments it could be even easier to correct, or give more accurate doses for a child- maybe as little as half a unit extra with dinner could do the trick so the before bed readings are better. But the most accurate is of course a pump. Might be worth looking into getting a pump for her as it will only mean needles every 2-3 days for the set change, and then the fingersticks of course, usually MANY fingersticks...

But yeah, again... Check with her medical team first to be on the safe side. If i happen to take one unit too much insulin, it won't do much difference for me, i might just need a tiny snack, 1 unit is really a fart in space of my TDD. But if a child is given a too much insulin, even as little as one unit can have a rather massive impact because children have smaller doses than adults.

[Pudlane]

Hi Frank

Thank you for the welcome.
Injections are fine, we have not discussed pumps with our consultant as we think we are doing ok at present. It's a case of trial and error! Hopefully we can start going down again soon. It's just 6 yr olds like sweets and ice creams and it's hard to say no everytime!
I just wondered if leaving her high was, amongst things causing the increase and if we should really act with a correction before giving the lantus.
I guess we should now we know what correction works, just needed some knowledgeable people like your goodselves to back me up!

[fgummett]

Hey Chris... no need to explain... my son Josh is now 17 (no D fortunately, although I guess he has it in his genes) but I still remember how he was at 6 years old... like it was yesterday. It is so true what they say about treasuring every moment because they do really grow up so fast. Work with you health care team, keep on testing and doing the best you can by her, and before you know it you will wish you had started saving up for her wedding already :D

[Pudlane]

Lol
Diabetes I can cope with!(well nearly)
Thinking about her getting married is another thing. That is just too scary.

[Gary_W]

Hi Chris,

Upping the overnight lantus to cope with a morning high is fairly typical NHS advice. I would never adjust Lantus without doing basal testing. Its job is to keep you level in the absence of food or rapid insulin. If she's going to bed high and waking up high then the Lantus is actually working perfectly. If the Lantus is dropping her overnight, it is possible she is actually getting too much already and increasing it is not going to be helpful.

For me, the answer lies with insulin profiling of your rapid and also basal testing.

If she is that high at 7.15, it may be no bad thing depending on what she ate, when she ate it and how long the rapid insulin works in her.

I use Apidra as my rapid insulin. In me, this lasts 4 hours and then is all gone. I know from experience that at the 2 hour mark after injecting I'll have 30% of it left. So I then blood test 2 hours after eating and work out if it's going to come right or not.

My fear for you is that she's eating between 4 and 5pm, so when you blood test at 7pm she's may well be a little higher than ideal but that's not always a bad thing; she will still have some active rapid insulin in her which will hopefully soak up some of that spare glucose. If you add more insulin before bed, it could tip her over into a night hypo.

The safe way to approach it is (unfortunately) lots of blood testing which is not going to sit well with a 6 year old. Test at 7 as normal, give the lantus as normal. Wake her up and test at 9 and 11 to see what it does. Repeat a few times and this will give you a really good idea on what is a safe number to correct and what isn't.

IMO, correcting the high with rapid is a better idea than trying to bring it down with Lantus (too much Lantus syndrome is the bane of many peoples lives and could end up being a problem for you). But adding extra rapid is not a good idea before bed if you're not 100% sure about what her body is doing.

Hope all the above makes vague sense...

Good luck and welcome to the forums :)

Gary

[Pudlane]

Hi Gary

Thank you and yes it makes sense.
The increase in lantus was a general thing rather than the night highs. We are continually adjusting as she is growing.
I think we should do some testing as you suggest at 9pm etc to see how the rapid is working.
She does normally eat at 4.30 so there maybe some rapid still working (could have forgotten that bit, ta)
She is fine with the testing bless her so that shouldn't be too bad and I'm sure she will appreciate it.
I have read that lantus is not thought of too highly by some, these forums open your eyes thankfully.

Right time to go inject after tea, hope I get it right so I don't have to put these ideas into practise.

Many thanks
Chris

[JenBarker]

Hello Chris
Gary's given some splendid advice there, and I agree that the best way forward is probably to work out if she is being kept level by the slow-acting (basal) insulin. If she is, then I wouldn't fiddle with it :).
I understand your worries about the HbA1c, it seems to be a habit of English doctors to allow young diabetics to run high.
About injecting - she won't remember. Its better to inject than to have her be high :), and I can barely remember injecting yesterday, let alone jabs from 20 years ago :D. I can, however, remember being in and out of hospital all the time because my control was so poor.
Can I also say, congratulations on being a great mum and coping so well! Support and good advice are really essential in keeping a young diabetic (and err, slightly older diabetic ;) ), healthy. Three cheers for You, and hugs to your little girl.
Jen

[Pudlane]

Hi Jen
Yes Gary's advice was spot on, and we shall try when/if the time comes again!
I shall have to look into the basal testing as I've not heard too much about that?
The consultant didn't seem to think that 8% was too bad, but when you see that means her average is then 11mmol then even I see that is not good for her!
We take pride in getting her lower and have been working hard with her school aswell to adjust her rapid. They have been great too which eases the worry slightly.
Thanks for the kind words even tho I'm Dad, but i shall forgive!

Cheers
Chris

[Gary_W]

Hi Chris,

Admiration goes in your direction; I have two daughters, the eldest of whom is 6. Let's just say that I'm glad it's me with the diabetes as children present plenty of challenges anyway without this kind of stuff...

Basal testing isn't too pleasant for an adult, but unfortunately worse still for a child. As I'm 39 and only learned how to do it 18 months back then I'm not able to advise a suitable way to do it with children though I'm sure other parents here will be able to help. But I'll tell you the principals as applied to an adult.

But first, what does basal insulin do? You may already know but I'll explain as the doctors didn't bother telling me.... Well my (simple) understanding is this. Your muscle tissue needs glucose to function. When you eat, loads of glucose gets put into your blood. Most of this needs to be stored for use later as your muscles can't use it all at once. Some is stored in muscles, but most of it gets stored in the liver. The process involved in storage needs insulin, so that's why we do a bolus injection when we eat. Without insulin, the glucose just hangs around in the blood and makes you ill.

Once the glucose is stored in the liver, it steadily releases it into the blood. The blood transfers the glucose to the muscles where it is needed. The problem is that the muscles cannot use glucose for fuel without yet more insulin.

What the basal insulin does is counteract the slow released insulin from the liver and enables the muscles to use it.

If you have too much basal insulin, your blood glucose level will constantly tick down. If you have too little basal insulin, you blood glucose will constantly rise. Too much Lantus causes over-eating and ultimately weight gain. Too little causes hyperglycemia.

The trick with the basal dose is to get it to match your liver's output as closely as possible. You can never get it 100% with once a day Lantus as your body's needs vary at different times of the day so you can get some times of day where you drop no matter what and others where you rise. My own body is very, very problomatic with this and has benefited from pumping. With a pump, you can alter the basal rate insulin up or down throughout the day and night so it has a better chance of matching your own body's needs. On Lantus, it's still do-able in most people but it's never going to be spot on. For this reason, keep an open mind about pumping as knowing what I do now about the subject I would urge anyone with diabetes to consider it.

So the testing bit. Go to bed with NO active food OR BOLUS insulin active. Test before you do. And then test every couple of hours through the night through till the next morning. In an ideal world, the figure you go to bed with is the same as you wake up with. If it isn't, adjust the Lantus in the appropriate direction and re-test a few days later (when you can stand it again). Keep in mind that any Lantus adjustments take 3 days to settle down, so don't fiddle with it too often.

Once you have the overnight basal OK, you can then test other periods of the day. So you would miss breakfast and the breakfast injection. If your basal is working correctly, your blood glucose should not significantly rise or fall. How you persuade a 6 year old to miss a meal is beyond me, I'm afraid. So it may be better to do the overnight one (the most important with once a day Lantus) and once that is bang on, call it a day with the basal testing.

Once the basal is set right, most of the other figures will start working a lot more consistantly and sensibly.

Hope this helps

Gary

[cheryl]

I'd suggest buy the book using insulin....by John Walsh, yes it is good to keep with your diabetic team, but sometimes you have to be your own advocate, my Mom and I listening to doc's most of the time my whole life.....I was high all the time a1c's in the 11's and 12's and them telling me I was bad, and just a mess of things...

I would invest in books and syringes or if you use pens that dose in .5 incriments so you can start correcting slowly.....might be she needs more novarapid at dinner time or that her lantus does not last 24 hours in her system.....or like me I have to eat dinner before 6pm sorry I do not know how to use military time as we in the states call it. LOL....if I eat later then 6pm, I have to adjust to it accordingly..but if I do, I stay up for 4 hrs....and move around the first two hours.....my life is usually very active but for some reason if I become less active my blood sugars rise I have noticed this particulary right know, there are no sports at night, so I am just home after work....so its a bit of a hassle for me....

Learn how her body works now trust me, Because when hormones start a hitting boy it's not gonna be fun, Ask my Mom LOL...

Cheryl

[Pudlane]

Hi Gary & Cheryl

Still trying to get my head around the basal testing, do you mean she should skip her last meal of the day and the reading before bed should be around the same throughout the night and before breakfast?
Gee that's going to be good fun....but as you say a necessary evil I suppose!
I thought lantus would bring her down very slowly...is this not the case, should it remain constant?
The reason she is high before bed is down to too little novorapid given to her after her meal. This is fine to sort out, we know pretty much what her body will do(yeah right!), so in an ideal world we would be doing ok.
We are pretty proactive in what is happening with her and though we listen to what the docs say, we know what works best for her.
It's all one big learning curve as you all are showing by continuing to do your own research which is great.
Keep up the good work and friendly advice, It is very much appreciated that you have given your time.

Enjoy the weekend

Chris

[xMenace]

Chris,

We have two sources of blood sugar and we use different insulins to cover each. A division of duties. Basal sugars are constantly released by your liver. We try to cover those with basal insulins. We cover food intake with bolus insulin.

In a perfect world each does it's own job perfectly. In the real world it rarely, if ever, happens.

The problem in identifying what's what is both occur at the same time. How can you determine which is off and by how much? You could try varying meal sizes and use statistical analysis to determine gaps, but this is frought with variables, not the least of which is meter variability.

The simplest way is to eliminate the food and bolus variables. Test the basal component on it's own with no food influences. From there you can use this baseline to more accurately adjust bolus ratios and augment your basals with corrective doses.

[UpNorth]

It sure is one big learning curve to live with Diabetes. You never know EVERYTHING about it, and can never be 100% sure your body will react the way you want it to when doing a correction or eating something to either treat a hypo or just as a snack. It's pretty predictable most of the time (for me anyways), but sometimes a high or low just sneaks up from behind, catching you when least expecting it, and you have no idea where that one came from. That's where frequent testing comes in...

But you're really doing a great job treating your daughters diabetes! :) I'm sure her readings will be better than great once those dinner doses have been adjusted, and a working correction dose for the evening (if needed) has been set :)

[Real4]

Maybe, I've missed something, but it sounds like you are giving a fixed amount of Novorapid for each meal. That just doesn't work well. The per meal insulin should be adjusted to the amount of carbs in the propective meal with a individualized ration. Doing that, PLUS, corrections can lean to almost normal blood glucose levels.

[Erin]

Chris,

Not sure if this has been said before, but I find middle of the night testing very useful for any issues I'm having in the evening and or at wake up.

A test at 2am is annoying to execute, but will tell you what is happening overnight. Middle of the night highs cause A1c's to rise without any apparent reason. Middle of the night lows cause a "liver dump" and have you end up waking up high in the morning. Neither of these are good things. I wouldn't do this test every day, but I'd do a 2am test for a week if I was noticing problems.

Also I'd get into the habbit of testing your daughter's bsl right before bed. I notice that your last test is at 18:30, but lantus and bedtime aren't until 19:15. (I also can't believe how early bed time is! but then again, I don't have kids) There is 45 minutes there, and a lot could change in 45 minutes. I'd be tempted to test at both times, and in this way be able to see the direction the bsl is moving in.

just a thought.

[Pudlane]

Hi
You must have missed something, because we do calculate every novorapid injection according to carbs eaten and any high readings. As you say that would not work well, only the lantus is fixed.

Ta

[Gary_W]

Hi Gary & Cheryl

Still trying to get my head around the basal testing, do you mean she should skip her last meal of the day and the reading before bed should be around the same throughout the night and before breakfast?
Gee that's going to be good fun....but as you say a necessary evil I suppose!
I thought lantus would bring her down very slowly...is this not the case, should it remain constant?

Chris

Hi Chris,

Lantus should indeed keep her constant; its only real job is to take up the slack of what the liver puts out. It is not there to mop up the glucose from meals. That SHOULD be the sole job of the basal insulin. You should theoretically be able to miss a meal and be none the worse for it from a blood glucose point of view. I'm not suggesting that anyone should skip meals (except for testing) but having the basal set up right allows you to be flexible with mealtimes without the basal biting you.

The whole point of basal testing is to find out what is going on, but the testing shouldn't be that painful. The overnight one doesn't need any meals to be skipped so do that one and see how you go. Once you get things adjusted for this period, you MAY decide that the more troublesome tests aren't worth the effort at this time.

To do the overnight basal Just give her a fairly early evening meal (4ish). Do the lantus and bed as normal. Start the basal testing at 9pm, and do 9pm, midnight, 3am and then see what she is at breakfast (6-7pm). The reason for starting the basal testing at 9 is that you've then had a 5 hour gap since she last ate and (in theory) you shouldn't have a whole load of bolus insulin or food still active which would foul up the results.

If you wanted to do a 'morning' basal, all you do is get up and blood test. Don't have breakfast, don't inject. I blood test every 30 mins when I do these, other people just test every 2 hours. Anywhere in between is OK :) See what the blood does through this period.

You can do any meal like this. But IMO just do the overnighter and get that right. Don't go putting her through the rest unless it's really needed. How do you know if it's really needed?? Well, if she has unexplained highs or lows in the afternoons, for instance, start to suspect her basal. In short, if you are convinced that you carb counted correctly and things just aren't working, incorrect basal is a possible cause (amongst other little pleasures, but it's a good starting point).

Gary

[Alice]

I've had much better results taking Lantus in the morning. For one, I can fast for several hours past lunchtime to see the rise in action (remember Lantus takes 4 hours to hit 100%)

Secondly, I don't like that rise to occur when I'm asleep. Yes, that morning dose is working as I sleep, but if I find my pre-meals are running low throughout the day for some reason, then I can snack accordingly before bed. Or not snack.

I've never understood the reasoning of night Lantus doses except imagining they wanted that "warm up" to occur while we slept. That's a mixed blessing at times.

Mornings are my preference. You are asking great questions.

[Lizzie G]

Hi Jen
Yes Gary's advice was spot on, and we shall try when/if the time comes again!
I shall have to look into the basal testing as I've not heard too much about that?
The consultant didn't seem to think that 8% was too bad, but when you see that means her average is then 11mmol then even I see that is not good for her!
We take pride in getting her lower and have been working hard with her school aswell to adjust her rapid. They have been great too which eases the worry slightly.
Thanks for the kind words even tho I'm Dad, but i shall forgive!

Cheers
Chris

Hi there Chris

I have to say that here in the UK it seems like many consultants say that higher than ideal HbA1C's are ok, particularly in children. I guess their stance is that how could they live with themselves if something dreadful happened to one of their patients as a result of suggesting aggressive management of diabetes. I totally understand where they are coming from in saying this but I do think that in reality if you work with all the resources available to you, ask the right questions, and in particular read the book 'think like a pancreas' by gary schneider which you can get for about a tenner on amazon, you can aim for much tighter control without compromising your child's safety. i think a lot of us are motivated by fear particularly in the beginning, but once you isolate all the different factors at play (which is surprisingly easy if you are patient observant and sensible whichit sounds like you are!!) it is surprisingly easy and you will reach a point where you child's blood sugar is 7 before bed and you give her a half unit to bring it to 5.5 and she will be at the same level in the morning. actually, thats another thing, i dont know about anyone else, but since improving my overnight levels i sleep far better, wake up far less in the night, and feel much more rested, so its definitely worth striving for these goals even if the medics dont think they are necessary. sorry for huge long rant and i hope everyones advice and support is helping you a little. ps buy the book!!!

[Pudlane]

Hello All

Many thanks for all those replies, I've been reading them through and making sure I understand them. I also have a few books to look through, so thanks for the suggestions.
I think we are at that point where we will be bringing her down with a rapid correction, if she is high before bed and get her to around the 6/7mmol range.
We will be careful though as Gary has pointed out, there still will be some rapid working from the last meal.
This will be followed by a test through the night to be sure things are ticking along fine.
I like the thinking of bringing her down from 7 to 5.5 Lizzie but not sure we are that brave yet!
Now she is off school I may have a go at the basal testing to see how things are(I can get her to eat at 4 now!), so thank you Gary for the suggestions, I may come back with the results to see how they look.
We shall ask the consultant about the morning Lantus Alice when we next go, and see what they say is the reasoning?

Thanks once again
Chris

[Eddy]

I build my insulin regimens as follows:


Stabilize my overnight drop at about 0.5 mmol/L;
Be certain that my overnight drop is stabilized at about 0.5 mmol/L;
Adjust my daytime basal to be as close to flat as possible;
After that, the rest is "easy".


Don't get too frustrated if overnight drop varies. I found Lantus less consistent than Levemir. Also, a younger person with higher insulin sensitivity will have bigger swings. (Don't get me started on why insulin should be more dilute than U-100...) That's part of the reason to have some safety margin, but I feel right rotten if my waking BG is even 7.5 mmol/L.

[Eddy]

I don't like the thought of a 3 mmol/L overnight drop. Given a 30 U needle, you probably can guesstimate to 1/3 unit... which for the "1 U = 3 mmol/L" bit means you hopefully can tune with approximately 1 mmol/L precision and accuracy.

If she's dropping 1 mmol/L overnight, I would not increase the Lantus dose. Rather, I'd look at one or more of: moving some/all of the basal to morning, switching to Levemir, using supplemental NPH/isophane. It all depends how crazy you want to get. ;)

To expand on what Alice said: If your daughter is prone to overnight drops, yet spikes by day, morning Lantus [and extra breakfast bolus if numbers prove a need] might serve her well. Lantus does not have the "perfectly flat" profile that some claim:

http://www.diabetesforums.com/forum/diabetes/29395-basal-lantus-vs-levemir.html?highlight=lantus+levemir

Eating last meal at 1630? When is bedtime? She might still have some bolus flowing, or she could be completely cleared. I'd lean toward the latter, unless her bedtime is fairly early.

Feh. I need to get off my lazy buns and collaborate with Shiftzor to write some software that helps with all this.

[Lizzie G]

I don't like the thought of a 3 mmol/L overnight drop. Given a 30 U needle, you probably can guesstimate to 1/3 unit... which for the "1 U = 3 mmol/L" bit means you hopefully can tune with approximately 1 mmol/L precision and accuracy.

If she's dropping 1 mmol/L overnight, I would not increase the Lantus dose. Rather, I'd look at one or more of: moving some/all of the basal to morning, switching to Levemir, using supplemental NPH/isophane. It all depends how crazy you want to get. ;)

To expand on what Alice said: If your daughter is prone to overnight drops, yet spikes by day, morning Lantus [and extra breakfast bolus if numbers prove a need] might serve her well. Lantus does not have the "perfectly flat" profile that some claim:

http://www.diabetesforums.com/forum/diabetes/29395-basal-lantus-vs-levemir.html?highlight=lantus+levemir

Eating last meal at 1630? When is bedtime? She might still have some bolus flowing, or she could be completely cleared. I'd lean toward the latter, unless her bedtime is fairly early.

Feh. I need to get off my lazy buns and collaborate with Shiftzor to write some software that helps with all this.

hiya - as regards supplementing the lantus, thats something i do; i have a pronounced 'dawn phenomenon' meaning that my liver pumps out loads of glucose over night and my basal requirement is far higher overnight than during the day, so before bed i take 4 or 5 units of isophane (known as insulatard in the UK) in addition to my lantus to hold me steady. it seems to work for about 8 hours i think so is perfect for me. as with anything involving self management in the UK i did have to push and push and fight a barage of nurses saying it was ok to wake with a BG of 8mmol, but i got there in the end and it was well worth the fight (you are probably noticing already that diabetes in the UK involves a high degree of picking your battles!)

[Eddy]

Apologies for the thread bump. It seems that enough basal questions exist that I'm trying to aggregate various bookmarked threads into one easy location. Hope this helps.

http://www.diabetesforums.com/forum/diabetes/36850-ramblings-about-basal-regimen.html