Considering a layered basal approach.

[Subby]

So, a weeks pump holiday using Levemir, and now back on the pump I have made some observations, and I'm considering an approach to get a little of the best of both worlds for me. I wanted to type it out to see if anyone has tried it or has opinions.

First, Levemir "felt" like a good insulin for me, low on side effects I find with most other insulins. When my BG was good, I felt really good, strong, confident both mentally and physically. The only weird effect was feeling a bit tingly and finding it harder to wake up in the morning, something I remember a lot from Lantus days.

Second, I need a whole lot of Levemir to equate to my normal 50u of pump basal. Like, about 80u. That said:

My weight goals are to drop about 10-15kg to get back to my ideal weight. I'm not overly concerned with it: but I'd like to be moving that way, I feel better with a bit less weight for a start, and any IR from weight I can do without. Interestingly, I felt less liable to "bloating" and feeling rotund in the stomach, with the Levemir: I felt like I was slimmer and that the weight was coming off. Indeed, I lost a couple of kgs in the week, although I had put up my physical activity so not sure what is responsible for what.

Third, Levemir gave me some curviness to try and deal with my curvy basal through the day - but there is just not enough ability there for decent control for me. In the end I went back on the pump purely for BG control, as I felt worn down by the effects of a week with more persistent highs than I'm used to or want to see and could not correct or adjust to near as fast as on the pump.

On going back on the pump, from the next day I felt bloated and "heavy" as per normal, and I don't feel as great in general - even with good control. I put this down to having 60 - 80 units of Novorapid in me instead of the around 20 I used while on my holiday. (Yep, I've tried all other rapids, they give worse side effects).

I've been a bit down in the dumps about this conundrum - much better BG control through the pump and basal rates (amongst other things): but lost a feeling of well-being, and feeling bloated and that my weight issue is "stuck" with the Novorapid. But today I thought, why not take Levemir, a smaller dose than I need, and modify my pump basals to be like a reactive "surface" to my basal regimen? It might take some adjusting, but it's just a jigsaw puzzle to work away at.

This way I might get a result of reducing my Novorapid, not as much as the holiday, but perhaps by 40 or 50 units. Assuming the Levemir is reasonably consistent in action day to day (something I do not know at this stage) I should not be at much more of a disadvantage than if just using the pump. EXCEPT the problem of not being able to set temp basal down as effectively... which could indeed be a consideration.

I've heard of people using Lantus and the pump just for boluses, but what about layering the basals this way? Anyone tried this?

[foxl]

No experience, just a supportive, why not give it a try?

You are seeing a new endo this week, too, right? GOOD LUCK, SUBBY! You have one heck of a time of it, I hope this endo will prove helpful.

[Subby]

Thanks Linda, I guess that is a good way to look at it. I can't see much danger in there at least, (well the transitions will be fun but testing is about as 2nd nature to me as eating) and if it doesn't work I can just abort.

The endo is in 2 days and I know nothing about this endo except they are pump savvy (which is a good start). We know what I want, a metformin trial... will I get it? Stay tuned... I will try my best to lead it that way. If not, line up the next endo, I'm coming :)

[fgummett]

Good Luck Subby!

Just an observation but we are really on the cutting edge here in DF... there's you as a Type 1 asking for Metformin while Linda is trying to convince her Doc that it might be time to try insulin :)

I've said it here before but by being proactive, we really do know more about OUR OWN D than our Doctors ever will ;)

[Subby]

Thanks Frank. You know, I think that patient-endo meetings or relationships can be especially difficult and fraught with pitfalls, that can make things all the more tricky. I think endos would come across day after day of apathy and denial and be used to dealing with it, and possibly see it all too easily, and find it hard to shift gears at times. I also think diabetes is a complex condition and there are often a few avenues to go... and if the patient has an opinion, it's not always going to be the doctor's. The role of the condition holder is so important for diabetes, probably a lot more than other conditions... and that does not always sit well in our medical model. Lots of things can be going on. Here's to happy patient-endo relationships, may they be ever more fruitful in the future.

[fgummett]

All good points Subby... I have been very lucky with my Doctors or perhaps they just accepted early on that it was too much trouble to argue with me ;) but I do hope that as they see more and more folks taking an active interest in their own care, the Doctors may become less of the gatekeepers and hopefully less jaded.

[jenb]

Hi Subby.

I've been using Levemir since diagnosis in 2007 and can report that it is very consistent once you find the optimal dose / schedule. Not sure if you mentioned this in your OP, but are you splitting your dose? This seems to be important with Levemir. I started out with 2 shots; my original Endo said time of day was not important, which I have since discovered is incorrect. I've posted this many times, but it bears repeating here...after weeks of testing I found that I need my largest dose at around 10:15 p.m., a moderate dose at 6:15 a.m. and a small "kicker" at around 2:15 p.m. (total dose is only 18 units in 24 hours). Based on the study graphs that are included in the Levemir box, you are taking large enough doses to have a long duration of action, so the 3rd little shot is probably not necessary. But don't count it out. As you know from your pumping, your basal rates can be wildly different at different times of the day.

Since I've not taken any other basals I can't address the sense of well being that you mention. But it's certainly feasible that having better control leads to more peace of mind. Or perhaps it is physiological, and the chemical make up of the Levemir is less disruptive for your system. Hormones are mysterious things!

Good luck with your quest. I'm interested in learning what develops.

Jen

[fairyblood]

I have used lantus and the pump at the same time. Mostly I used the basal with the pump for dawn phenomena but it was helpful to have a more variable basal then lantus can provide but the advantages of lantus as well. I have heard it being called the Un-Tethered Regimen, if you want to look it up and see how other people have gone about it. Hope it works well for you.:)

[sarahspins]

Is there a reason you can't do both? Use Levemir for "most" of your basal and use a pump basal to make up for the needs that Levemir can't match? You'd still be using less Novolog..

[Subby]

Thanks for the feedback Jen, and your previous posts about this really helped me think it through. I started with taking the Levemir 2 split in two, at the start I was thinking about a third as I suspected there might have been a bit of a gap in the morning, but as I upped my "main dose" it seemed to increase in length, like you suggest. I wouldn't rule out the 3rd in the future, as you suggest...

In broad strokes, my basal profile is low through the morning from 1am on, climbs like a mountain from 10am to 5pm, drop suddenly, and then climbs in a smaller echo, from 8pm to 1am. I suspect a dose around 2 or 3am would have been perfect, but I am a heavy sleeper and it was too risky, I also sleep in sometimes, so I decided to take it at night before sleep.

So I took 3/5 of my dose at midnight which seemed to be ramping up at 10am - 2pm, I also supplemented this with 10u rapid at 12pm and 5u rapid at 2pm, needed such is my "spike" there. Then, I took 2/5 at 2pm which seemed to be ramping up at about 9pm, for my smaller basal spike. Night time worked OK.

After tweaking, this wasn't too bad. What was wonderful is that I could time those peaks to at least coincide with my basal peaks, and the valleys to coincide with my times of lower needs. I did not suffer crushing unavoidable lows in the afternoon or early morning as would happen with the flatter Lantus split or not. Things did, however, tend to spin out of control due to the sort of factors like specific work conditions or stress or not feeling well, that on the pump I can tend to try and cater for or react better to.

I did need to rapidly change dose from 40u total to 80u total in a few days... a bit harrowing and intensive, but I felt I had to move fast to find improvement as I just wasn't going to put up with shocking numbers with my pump sitting there waiting to give me control.

As for feeling better on Lev/away from Novorapid, I can only report or consider how I felt: I guess explanations might help but in a way are irrelevant :) Seeing I have noticed it with other insulins, some very strongly, it's something established for me that I can seem to get different effects on different insulins. I think (and hope) I'm not in the majority with this. In a way my control was quite a bit worse while holidaying, so I don't think I was feeling better from my BGs, this time!

So in general terms I found using Lev was positive in the sense of at least a rough following of my basal needs, which is much better than my previous long acting experiences. But it's things like having a heightened temp basal for stress like work or reducing for activity, that makes a huge difference for my daily control, so it will be interesting if perhaps I can harness Levemir as the workhorse and to provide "Novorapid relief" but have the pump also contributing part of the basal, to provide the changing control I need.

[Subby]

Is there a reason you can't do both? Use Levemir for "most" of your basal and use a pump basal to make up for the needs that Levemir can't match? You'd still be using less Novolog..

That's what I was thinking Sarah! I guess, I can't think of a reason not to, especially if the Levemir should be pretty consistent with effect per shot. I just couldn't really assess that with a week (and most of that week tweaking heavily).

[SueM]

As you are having so many problems with the analogues can you not try regular insulin in your pump?
From the studies I have read in the past there seems to be no advantage A1c wise with using analogues in pumps.
I use regular in my pump with no problem at all.

[Subby]

Sue, it's a good point. Unfortunately I had issues with human regular as well. I have not tried the animal insulins, you've mentioned that to me and it may well be something I bring up with the endo. Thanks for reminding me.

[jenb]

After reading through this again I'm wondering if having Novorapid constantly in your system is responsible for your feeling of unease (my word, not yours;)). I find that when I take a series of Novorapid boluses for things like dinner parties I get a little bit of a "speedy" feeling. Like so many aspects of insulin therapy this is completely anecdotal of course. Many other things could be responsible, but I just wonder if the continual exposure to Novorapid via your pump could have something to do with it? The idea of using your pump for boluses and injections for basal is very interesting. To some extent it even seems easier, since you always know when and how much basal you've done (maybe you do anyway, but to a non-pumper this seems a confusing aspect of the whole thing!). Everything else is short acting. I know folks love their pumps, but I somehow don't feel I lack control using MDI. A combination approach really seems viable.

Jen

[AngelKitty]

Hi Subby,

Sorry to hear your pump holiday wasn't as much fun as you'd thought, but at least it has given you a few ideas for tackling some D issues.

I hope your new Endo prescribes Metformin for you, as you will have to lower your basal amounts when you take it - not by a dramatic amount, but it could make a real difference in helping with your situation.

Fingers crossed for you.

[Subby]

Thanks Vic. In the back of my mind, metformin if it works for me plus using some Levemir as basal filler, might really make a big difference together.

I'd ask you how you are doing with the met but I know there are other threads for that, I'll find one (or can you update us?)

[SCC]

Just catching up. What an interesting thread this is! It reads like a good detective novel.

The layered approach makes total sense to me. Makes me think of some of the hybrid car technology.

[xMenace]

I haven't read all the follow-ups, but yes it sounds like a plan. Test the heck out of your daily low points, those times when you take the least basal. Target your Lev to give you the same levels, then use your basal rates to augment the rest of the day.

Sounds like fun :top: :stupido:

[Subby]

After reading through this again I'm wondering if having Novorapid constantly in your system is responsible for your feeling of unease (my word, not yours;)). I find that when I take a series of Novorapid boluses for things like dinner parties I get a little bit of a "speedy" feeling.

Jen, that's pretty much my thought too, and it makes sense to me that it's likely the insulin type creating these issues. And, unease and slightly speedy/jittery is a perfect word to describe what I think too much Novorapid does to me. Thanks for describing your experience! :)

Thanks for all the comments people, it's great to get some feedback. I think this might travel, and I'm likely going to chew over approaches to transitioning and adapting, and then launch into it sometime. That is, if I don't trial met first, in which case I'll probably leave the layered thing on the backburner for a little while.

[foxl]

I hope you can try met Subby, and I hope it works for you. It is a great drug ... when it works without side effects!

[lark 27]

Suby,

Way to think outside the box! I have absolutely no personal experience as to whether this would work or not, but it seems like your logic is sound. I just met a distant family member who's been pumping for several years and I tried to gain some insight from her and was just shocked to find out that she has no real grasp of modifying her basal and bolus rates properly and that she has a CGMS but really never uses it because she isn't able to calibrate it well. I tried to give some tips but was limited. Anyway, I mention this just because I'm amazed at the specific trends and needs you can identify just from doing a 1-week pump holiday and figuring out the need for an additional 30U per day to cover basal dosages. Keep up the hard work and I hope you'll be rewarded with a more manageable regiment for y you.

[rak1978]

I hope you can try met Subby, and I hope it works for you. It is a great drug ... when it works without side effects!

Agreed! I know that typically type 1's don't use met, but for those of us with IR and type 1, it's a great tool! I have had much success with it (with the exception of the past few weeks that have been crazy).
Good luck with your experimentation! I hope you can find something that works for you.

[Subby]

Thanks Rachel! Well, got a prescription for met off the endo today, woohoo. He wasn't convinced at all about it helping but after some thrust and parry he didn't object. Did he listen to me or was it just the path of least resistance? Not sure. Who cares, now I can just try the stuff.

Some notes on that visit: having a few weeks of tests and notes including diet notes, a week of CGMS both overlay and daily, printoff from carelink of carb usage, basal rates etc, and current and history of blood tests at hand, helped immensely. WIth those at hand we just dealt with each issue as he brought it up quickly and efficiently. Having someone else quetly along, not even talking (in this case my father) also I think kept things a lot more civil and I think it meant less dissmissal.

[AngelKitty]

Well, got a prescription for met off the endo today, woohoo. He wasn't convinced at all about it helping but after some thrust and parry he didn't object. Did he listen to me or was it just the path of least resistance? Not sure. Who cares, now I can just try the stuff.


That's great news Subby!
Which Metformin did you get a script for and what dosage did your Endo give you?
Now we can compare notes! :)

[Gary_W]

Hi Subby,

I haven't read through all the replies either, but as it seems to be the Novo that is making you feel a little unwell, have you considered either Apidra or the Lilly stuff? I really like Apidra as it gets in dead quick and is all gone after 4 hours so (IMO) it's a really nice insulin to pump with...

[Gary_W]

That's great news Subby!
Which Metformin did you get a script for and what dosage did your Endo give you?
Now we can compare notes! :)

I briefly flirted with Metformin many years ago when I was suspected of having insulin resistance. I didn't actually have IR - it was just I had no clue what I was doing so it fixed nothing for me personally. Hope it works out for you and Rob.

I was of the opinion that metformin was a good, cut down description of its main property. Met is short for 'Methane' and formin is 'to make something. So Metformin means 'to make methane'. Which is exactly what it did for me.

I was really no fun in a car or a lift.

[AngelKitty]

I was of the opinion that metformin was a good, cut down description of its main property. Met is short for 'Methane' and formin is 'to make something. So Metformin means 'to make methane'. Which is exactly what it did for me.

I was really no fun in a car or a lift.

Gary, you crack me up! :laugh:

[Subby]

Gary, I've given those insulins a go, no banana. Novorapid is the mildest and meekest of the bunch for my body.

AK, thanks to the timely discussion about ER/EX versions, as he went to write me a script for it I requested the extended release form. It's Metex XR, the tablets are 500mg. He suggested 1 pill for 1 week, 2 pills for the next week, 3 from the 3rd week. He suggested taking in the morning as my overnights BGs are pretty good and my big difficulties are in the day. I have no idea if any of this makes good sense. It's just what he suggested.

If all I get is hot gas, I will try and use the weapon for good, not evil.

[Subby]

After a week trying, I've passed away the levemir. Basically it does not give me consistent action - at all. I think I've read other levemir threads where some found this. Even given some changes and instability in my needs due to metformin transition at the moment, it was very clear that 40 units of Levemir might equal an effective 40 one day and 25 the next. Major bummer! I'll be looking forward to new basals coming out to try.

I found on going back on full pump dose of Novorapid it definitely seems to have a dragging effect on my body. I can't prove a link, but I immediately started having mild asthma problems again as well, and that fits with observation that when I tried other rapids, I had more energy and could exercise longer. For now I guess I will need to keep trying medications for that.