Q re Lantus & Novorapid

[Georgia]

Can anyone help me please? I have tried to get advice from the diabetic nurse but she is on holiday until 8 April & the other nurse is out! Today I started on Lantus & Novorapid...

8am B/S 7.3mmol. Took shot of Lantus. Skipped breakfast
11am B/S 6.0mmol
12:30 B/S 5.5mmol. Took shot of Novorapid. Lunch:2 slices of toast & a latte.
14:45 B/S 14.3mmol (eek)
16:00 B/S 4.7 mmol

When I saw the reading of 14.3 I didn't know what to do. Should I take more Novorapid to bring it down? Or wait until dinner? Or would the Lantus work on the high reading? But Lantus doesn't peak, right? So how come I've dropped 10mmol in just over an hour?

Sorry for all the questions but seeing as I can't get in touch with any diabetic nurse I'm feeling a bit lost. I have rung my doctor & left a msg for him to call me but that could be after 6pm & I'm concerned how quickly I've dropped (& could still be dropping).

Thanks

p.s. I have been walking a lot today.

[Georgia]

It's now 4:30pm & my B/S is 3.9mmol so it is still dropping quickly. I am eating an apple. But what do I do if my B/S then shoots up because of the apple?

[jen_slc]

How many units of Lantus and Novorapid are you taking? Are you taking a set dose of Novorapid at meals or do you use a ratio and count carbs? How much Novo did you take for your toast and latte?

First off, Lantus doesn't work on high readings. It's supposed to be a peakless insulin but in my experience there is a tiny peak earlier on... it seems to vary for everyone. You will eventually discover how it works in you. (Also, despite what Aventis repeatedly states, it doesn't tend to last 24 hours either but that will vary also). But anyway, it doesn't work on high readings, you use Novorapid to correct highs.

Seeing as how you had normal bg before lunch, a high bg 2 hrs post-lunch and normal bg 4 hrs post-lunch, I would guess that maybe your latte shot you high very fast... what was in it? Some food items do that. If I drink OJ for example, I shoot up very high at 2 hrs but return to normal at 4. I think maybe with these certain foods these rapid insulins just don't work very well in the 1-2 hr range. But they do work because you did return to normal, and seem to be dropping further.

Keep testing and try to follow the 15g/15min rule until you raise your bg and keep it stable... if it looks like you overdid it and bg starts shooting up again, stop eating! :smile: I would hesitate to say anything more about correcting without knowing if you have a correction factor worked out or if you use ratios.

[Georgia]

I took 36u Lantus & 6u Novorapid - this is what my consultant suggested. He said to tweak the Novorapid as needs be but to keep the same dose of Lantus each day. I don't think this is correct & plan to test my basal rate in a few days time.

I have not been told to use a insulin/carb ratio or a correction factor (I never had this before as I was on pre-mix) - I wanted to discuss these with the diabetic nurse.

My B/S is now 4.5 so I think everything is looking better - phew!

[rzrbks]

jen_slc

How many units of Lantus and Novorapid are you taking? Are you taking a set dose of Novorapid at meals or do you use a ratio and count carbs? How much Novo did you take for your toast and latte?

THose are the KEY questions.

Are you countng carbs?

12:30 B/S 5.5mmol. Took shot of Novorapid. Lunch:2 slices of toast & a latte.
14:45 B/S 14.3mmol (eek)

Generally bread is about 12-15 carbs per slice, although it can run Much higher. The Latte, well, it could be anything from 8-10 carbs to many multiples of 8-10, which would shoot your B/G through the roof.


My CDE and I use a 1:50/2.7 correction ratio----1 unit of NovoRapid brings down B/G 50/2.7 in 1 hour(aprox.)


Today I started on Lantus & Novorapid...

It's going to take you a while to get a handle on how your body reacts to Lantus and NovoRapid-----so if your #s are high at 2 hours but are back in the good range at 3-4 hours, I would take it over with the Nurse, certainly, but I'd guess that this is just part of learning how to bolus (cover) for meals and at what ratios to cover.

The normal starting point is 1 unit of NovoRapid for 15 gms of carbohydrates.
Thus you lunch of two slices of bread = aprox 30 gms of carbs =2 units of NovoRapid

Then you would also count the number of carbs in the latte and add the total # of carbs and divide by 15 = the number of units of NovoRapid to inject.

[Georgia]

THose are the KEY questions.

Are you countng carbs?



Generally bread is about 12-15 carbs per slice, although it can run Much higher. The Latte, well, it could be anything from 8-10 carbs to many multiples of 8-10, which would shoot your B/G through the roof.


My CDE and I use a 1:50/2.7 correction ratio----1 unit of NovoRapid brings down B/G 50/2.7 in 1 hour(aprox.)



It's going to take you a while to get a handle on how your body reacts to Lantus and NovoRapid-----so if your #s are high at 2 hours but are back in the good range at 3-4 hours, I would take it over with the Nurse, certainly, but I'd guess that this is just part of learning how to bolus (cover) for meals and at what ratios to cover.

The normal starting point is 1 unit of NovoRapid for 15 gms of carbohydrates.
Thus you lunch of two slices of bread = aprox 30 gms of carbs =2 units of NovoRapid

Then you would also count the number of carbs in the latte and add the total # of carbs and divide by 15 = the number of units of NovoRapid to inject.


Hi

Yes I am counting carbs. When I was on pre-mix I'd have 40g carbs per meal & at lunch the bread = 27g & the latte 16g so I shot 6u Novorapid, but using your method it should be more like 3u :eek:

As yet I do not have an ins/carb ratio & was hoping the diabetic nurse could help me with this. I'm still waiting for the doctor to ring me & will ask him about it & also the correction factor.

Thanks

[seacomp]

I took 36u Lantus & 6u Novorapid - this is what my consultant suggested. He said to tweak the Novorapid as needs be but to keep the same dose of Lantus each day.
That Lantus dose looks high to me, especially to start. There was a thread about basal rates a while ago and most were between 14 and 24 U per day.
You are taking twice as much basal (Lantus) and bolus (Noverapid) insulin.
My own proportion is just about the opposite twices as much fast-acting as very long-acting insulin. I expect that's about what it is for most people.
With the proportions reversed, you'd expect exactly what you are seeing: a steady drop between meals, followed by a large spike after.
BTW: how much insulin did you take per day on pre-mix?

Let's hope you hear from the doctor and get thos straightened out quickly.

[rzrbks]

Hi

Yes I am counting carbs. When I was on pre-mix I'd have 40g carbs per meal & at lunch the bread = 27g & the latte 16g so I shot 6u Novorapid, but using your method it should be more like 3u

As yet I do not have an ins/carb ratio & was hoping the diabetic nurse could help me with this. I'm still waiting for the doctor to ring me & will ask him about it & also the correction factor.

I agree with seacomp, those amounts seem large, I know there are people taking large amounts of both, but that's generally after being raised to those amounts, not starting there.

Hope you and the consultant get together soon and get it straightened out.

You might ask the person why you were started out on such a high dosage of Lantus and Novorapid.

[Georgia]

Just had a hypo :o( which points to too high a dose of Lantus. On NovoMix I took 36uam & 24pm so maybe I had a bit of resistance to the pre-mix.

My doctor called back & he said to ride it out for a few days & see what happens! :ahhhhh:

Tomorrow I'll start off on a lower dose of Lantus.

[Erin]

Also, is there a reason you're taking Lantus in the morning? Most people start off taking it at night, and switch to the morning if there is a problem. I wouldn't' advise taking it at night right now, b/c i think you're taking way too large a dose and will end up hypo in the wee hours of the morning, but i just wanted to know the reason behind it.

The bonus of taking it at night is,
1) if you are on the right dose and you go to bed with a stable blood sugar of 90, you will stay there all night (1/3 of your life with a perfect blood sugar, with no effort on your part!!) and
2) as Lantus tends to "wear off" toward the end of its action period, it's nice to have that be during the day, when you are covering with fast acting insulin. and
3) you can sleep as late as you want.

Just some food for thought. I'd knock that Lantus dose SIGNIFICANTLY tomorrow.

[seacomp]

I'd knock that Lantus dose SIGNIFICANTLY tomorrow.
Agreed, then slowly increase the dosage until fasting BG is where you want it and BG is stable between meals. Slowly, means 1 or 2 u per every two days.
There more detail on how to fine-tune the exact amount and whether two shots would be better than one for you, but that can wait.

[Georgia]

Thanks for the info. Feeling a bit miffed that I've been given the pens & then left to my own devices, i.e. no help or advice. It's hard & frustrating but I will get there. When I finally manage to get through to the diabetic nurse ;) I'll discuss re taking Lantus in the evening. Cheers.

[Georgia]

Due to delayed jet lag I have only just woken up (it's 12:15pm). But I have checked my bs & it is 4.8 so that's good. Now I need to decide how much Lantus to take...think I'll dial 20u & take it from there. There's nobody I can speak to today for advice because both diabetic nurses are on holiday & my doc yesterday said he isn't that clued up on insulin, he know more about tablets. Great eh! :(

[seacomp]

But I have checked my bs & it is 4.8 so that's good. Now I need to decide how much Lantus to take...think I'll dial 20u & take it from there. There's nobody I can speak to today for advice because both diabetic nurses are on holiday & my doc yesterday said he isn't that clued up on insulin, he know more about tablets. Great eh! :(
You seem to be getting the hang of it, sooner or later you become your own expert, whether you want to or not.

[jen_slc]

That Lantus dose looks high to me, especially to start. There was a thread about basal rates a while ago and most were between 14 and 24 U per day.
You are taking twice as much basal (Lantus) and bolus (Noverapid) insulin.
My own proportion is just about the opposite twices as much fast-acting as very long-acting insulin. I expect that's about what it is for most people.
With the proportions reversed, you'd expect exactly what you are seeing: a steady drop between meals, followed by a large spike after.Georgia, usually an individual's total daily basal dose and total daily bolus dose will be similar, approximately 50:50. This thread (http://www.diabetesforums.com/type-1/5788-lantus-users.html)has a post in it by Mick about how to calculate your TDD (Total Daily Dose). Of course it probably won't be perfect, many factors will affect your ratio of basal:bolus doses (metabolism, genetics, exercise, lifestyle, etc, etc), but 50:50 is a good starting point. If you're taking too much Lantus and not very much Novolog, your high Lantus dose is probably compensating for some of your food... likewise if you're not taking enough Lantus, your Novolog requirements for food will be higher. Ideally, you'd like to find the balance between the 2. For example, I take 16 units Lantus per day and ~20 units Novolog for a total dose of ~36 units/day. It's not bang on 50:50, but if I take more Lantus I experience many lows so I know I'm good where I am. And my TDD is a bit lower than what the formula predicts because I am pretty active. You will just have to experiment and see what works for you. :five:

[Erin]

Due to delayed jet lag I have only just woken up (it's 12:15pm). But I have checked my bs & it is 4.8 so that's good. Now I need to decide how much Lantus to take...think I'll dial 20u & take it from there. There's nobody I can speak to today for advice because both diabetic nurses are on holiday & my doc yesterday said he isn't that clued up on insulin, he know more about tablets. Great eh! :(

20 u seems like a safe bet... compared to 36! Keep in mind you might need to up your meal bolus significantly with less basal action. Also keep in mind that it takes lantus dose changes a couple of days to take effect, so keep it where you are for two days before going up or down 2 units or so (unless you're close to where you want to be, then only adjust by 1 unit)

Good luck with all of this! I can't believe nobody is monitoring your adjustment onto Lantus. I had an overabundance of help (I was one of the first people in the US to go onto Lantus... part of a research study... dude the paperwork was insane) i suppose it is feast or famine when it comes to D support.

[Georgia]

I appreciate the support & advice - will check out the link Jen :) that is interesting re the guide of TDD 50:50.

Pre-lunch my bs was 6.9 & I had 15g carbs & bolused 3u Novorapid. 2 hours later my bs is 8.7..will see what it is in an hour. Apparently the diabetic nurses are back on Monday :thumpdown so I'll speak to one of them.

Thanks everyone :thumbsup:

[Georgia]

+3h after lunch it was 8.2 & +4h it was 7.5.

This is the confusing part...I ate a small chunck of cheese an hour ago & my bs was 8.4 & have just tested & it's now 9.8!! How come I've jumped 1.4? All I've eaten today (besides the cheese) is my lunch of 15 carbs & that was 7 hours ago.

I will be having dinner in an hour or so & will bolus a bit extra to tackle the high bs.

[seacomp]

This is the confusing part...
Erin's advice above is sound; wait a day or two for the new dosage to settle in and a pattern to become clear. Then depending on whether your BG is rising or falling between meals (after 4 hours), adjust your Lantus up or down.
When you think your Lantus is about right, you'll have to test it by skipping a meal and seeing how your BGs react.
Good luck.

[Erin]

I just realized one problem with the advice I gave you before... ONLY change one variable at a time... I said you'd probably need to change your novolog doses, and you probably will, but don't do that at the same time you're adjusting your Lantus... otherwise you won't be able to see what is causing the changes. (It is ok to correct, but use the same ratio / dose that you usually would)

From what you've said I think you are going to need to increase your lantus dose, as you're drifting upward between meals, but give it another day just to make sure that is actually the pattern.

[Georgia]

Well, pre-dinner my bs was 9.3 so I had my dinner & took 2u extra of Novorapid when I bolused. It's now an hour & a quarter since dinner & I thought I'd check my bs (now wish I hadn't) & it's 20! :( Gawd. Will do the +2h & +3h checks to see if it's coming down.

Tomorrow I'll still take 20u of Lantus in the morning & will see how my bs behave throughout the day. Cheers :)

[seacomp]

Well, pre-dinner my bs was 9.3 so I had my dinner & took 2u extra of Novorapid when I bolused. It's now an hour & a quarter since dinner & I thought I'd check my bs (now wish I hadn't) & it's 20!
How much Novorapid did you take? 5? And how many carbs in your dinner? From what what you indicated earlier (15 gms, 3 units), your carb to insulin ratio is about 5 to 1. If your dinner was near 25 carbs then 5 units is great, but if it was 60 carbs, then getting a spike is to be expected.
:itsme:

[Georgia]

How much Novorapid did you take? 5? And how many carbs in your dinner? From what what you indicated earlier (15 gms, 3 units), your carb to insulin ratio is about 5 to 1. If your dinner was near 25 carbs then 5 units is great, but if it was 60 carbs, then getting a spike is to be expected.
:itsme:

I took 4u to cover my dinner (jacket potato & salad = 40 carbs) & used a 1:10 ratio as I thought the potato may spike my bs, plus the extra 2u for the high bs. I tested +2h after dinner & it was still 20mmol. I didn't want to go to bed with a reading of 20mmol so I took 5u Novorapid but 7.5 hours later I am at 2.6mmol! 30 mins later I'm at 4.2mmol.

On reflection it would have been beneficial if I could have checked my bs +3h post dinner but I couldn't stay up any longer as I was shattered. I'm thinking the potato made my bs rise sky high but then after a few hours it steadied off & as I'd taken extra Novorapid my bs plummeted.

Will see how today goes ;)

[HelenM]

Did you weigh your potato? A 175gm one (which is quite small) has 50gms carb and its very high on the glycaemic index so raises bs quickly.

[Simon]

Skipping berakfast is not a good idea. By lunch your liver will be dumping so well that you sensitivity to insulin drops sharply. When you do eat your bs then rises sharply which then stops the liver dump so you get a delayed response to the insulin you took with lunch.

[Georgia]

Did you weigh your potato? A 175gm one (which is quite small) has 50gms carb and its very high on the glycaemic index so raises bs quickly.

Yeah I did weigh my potato - I wasn't very hungry so it was a very small one!


Skipping berakfast is not a good idea. By lunch your liver will be dumping so well that you sensitivity to insulin drops sharply. When you do eat your bs then rises sharply which then stops the liver dump so you get a delayed response to the insulin you took with lunch. Ok will try to eat breakfast from now on to see if that helps my numbers - thanks for the tip.

[jen_slc]

I think you said your docs hadn't worked out any meal ratios or correction factors for you yet? It looks like based on last night that 1 unit of Novorapid could drop you about 63mg/dl or 3.5mmol. You could use this as a starting point for corrections, but it will only be an approximation since your Lantus and meal ratios still aren't figured out and those likely played a role too. When I eat dinner late, go to bed within a couple hours and test a bit high at that point, I avoid taking any corrections because it's only been 2 hours, there's still some action left and I know that my post-meal bgs take longer to return to normal. I don't like doing that, sitting at 200+ after a late meal/at bedtime, but I always wake up normal so I know if I had corrected I would have gone hypo.

[Georgia]

I think you said your docs hadn't worked out any meal ratios or correction factors for you yet? It looks like based on last night that 1 unit of Novorapid could drop you about 63mg/dl or 3.5mmol. You could use this as a starting point for corrections, but it will only be an approximation since your Lantus and meal ratios still aren't figured out and those likely played a role too. When I eat dinner late, go to bed within a couple hours and test a bit high at that point, I avoid taking any corrections because it's only been 2 hours, there's still some action left and I know that my post-meal bgs take longer to return to normal. I don't like doing that, sitting at 200+ after a late meal/at bedtime, but I always wake up normal so I know if I had corrected I would have gone hypo.

That's right I don't have a meal ratio or correction factor worked out yet so I've been guestimating based on what you guys have advised. I managed to speak to someone at the hospital today & it was a total waste of time as she didn't have any constructive advice to offer. All she said was to persevere as I am & I will need to discuss it with the diabetic nurse on Monday. I mentioned my high bs of 20mmol last night & she told me not to use a correction bolus or change any of my insulin amounts until I manage to speak to the nurse. Huh? I'm not happy leaving a 20mmol overnight. But I do understand what you are saying jen in that after 2 hours I will still have Novorapid acting. At the moment my bs is 5.2 so that's a relief!!

[jenet]

I'm not sure this is any help, but my CDE advised me to not correct based on the 2 hour reading and to wait until the 3 hr mark. Generally speaking, she has been right. If I panic and adjust at the 2 hr mark, I am quite often low by the 4 hour mark. The other thing is that my insulin sensitivity/correction factor is higher at night than during the day. I would take less insulin to correct a high at 10 PM that I would at 10 AM.

I hope you're able to get some help on Monday. In the meantime, you have my admiration for hanging in there with so little support from your medical team.

cheers,
j

[seacomp]

Enought advice for now.
In the meantime, I agree with
you have my admiration for hanging in there with so little support from your medical team. :congrats:

[Georgia]

I'm not sure this is any help, but my CDE advised me to not correct based on the 2 hour reading and to wait until the 3 hr mark. Generally speaking, she has been right. If I panic and adjust at the 2 hr mark, I am quite often low by the 4 hour mark. The other thing is that my insulin sensitivity/correction factor is higher at night than during the day. I would take less insulin to correct a high at 10 PM that I would at 10 AM.

I hope you're able to get some help on Monday. In the meantime, you have my admiration for hanging in there with so little support from your medical team.

cheers,
j

Thanks for the advice, Jenet, what you have said makes total sense to wait until the 3hr reading before deciding whether to do a bolus correction.

I managed to speak to the diabetic nurse this morning & she said that if my morning bs are in a good range it seems that my basal insulin is about right & as my bs tends to run higher pre-dinner I should up my lunch bolus. Will see how this goes.

[Georgia]

Enought advice for now.
In the meantime, I agree with
:congrats:

Aw thanks seacomp...but I have had so much support from you guys, which I really appreciate :)

[Simon]

Hi Georgia,

Are you recording now much carb is in each meal? You will need that info to work out your carb ratio over time.

[Georgia]

Hi Georgia,

Are you recording now much carb is in each meal? You will need that info to work out your carb ratio over time.

Hi Simon

Yes I am thanks - I have rather detailed records of bs, insulin doses, carbs eaten & exercise taken, which are helping me to work out my ratios :)

[Georgia]

Okay, got another question...

When I started off on 20u Lantus my bs seemed to rise late afternoon & this was 4 hours after I'd taken my Novorapid or eaten, which suggests my basal was insufficient. Therefore I upped the dose to 22u & my late afternoon readings improved, but not to where I want them, so I upped it again to 24u but I then experienced a hypo late afternoon & 5am the next morning. So, I am thinking my basal is about 22u-23u & I need to up my Novorapid at meals to bring down the higher readings? What do you think?

[Simon]

I would drop back to 22 u and wait a few days. It takes about 3 days for your bs to settle after a change in Lantus dose so don't rush it.

[jen_slc]

Is there a reason why you're changing your doses in 2 unit increments? If 24 sends you into hypos and 22 isn't enough, try 23 units, that could be the magic number. But like Simon said, every time you change the dose wait a couple days to let things settle. Get the basal sorted out, then play with your ratios. Once the basal is correct (high enough to keep bg normal and stable but low enough to prevent hypos), you can compensate for the times of the day where your insulin requirements might be higher with your meal boluses. The whole idea of finding that magic basal number is that you shouldn't have to compensate too much with your Novorapid, but everyone is different and you may find that you just need more insulin at certain times of the day and the (almost) peakless action of Lantus just doesn't cut it.