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Levemir vs. Novolog

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#1
Sgtmaj

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I was dx in 2004 with T2 and put on meds. After trying various oral meds, diet, exercise, I was put on glucovance and Levemir last year. My FBG averaged around 165 and my before meal average was 123 and my 2 hr after meal average was 276. I had an abnormal kidney function reading, BUN and creatine were elevated. I was sent to a nephrologist who stopped my glucovance, statins and fibroid meds. kidney readings went back to normal. Sent back to GP with elevated BG levels. New Dr. put me on 1000mg X 2 glucophage (metformin) and levemir with increasing doses until my FBG averaged below 120. That goal was attained in July with FBG at 118 and levemir dosage at 120u. Went back to Dr. and we both agreed 120u was too massive a shot. He sent me to a diabetic educator (to learn how to count carbs and adjust insulin dosage) and prescribed Novolog. Since July I have gotten my levemir down to 35u AM and 40u PM and my novolog IC ratio is 1:4. My BFG is now a 2 week average of 92. My before lunch meal ave is 84. After lunch 114. My dinner averages are different but basically the same. I eat 2 meals a day (please don't give me grief, I've always eaten 2 meals a day and I'm not going to change). I exercise regularly and don't do low carb, but I do eat sensibly. My Aug, ave for lunch carbs is 63 and dinner carbs are 84. I snack occasionally when I feel a hypo coming on. I just finished reading "think like a pancreas". I hope that's enough info to ask my question.

I have found that I can lower my levemir by increasing my novolog by a few units, or I can decrease my novolog by increasing my levemir by a few units. Which is better, if any? Lowest levemir as possible, or lowest novolog as possible or it doesn't matter, any combination that gives decent bg readings is the goal?

Rick

#2
Subby

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I don't know of a reason more (or less) of one or other might be desirable over the other. If you are just talking a few units either way, I don't think it's worth worrying about. Whatever works for you.

In TLAP you will have read about basal testing. That's the established best way to determine your basal, and once that is done i:cs can be more easily and effectively found. But again, if you have your own methods or different options that achieve your desired level of control, it's all good.
20 years T1. NPH and Novorapid.
Some essentials for my blood sugar control: dosing via i:c ratio and cf • basal testing when needed • daily 40 minutes moderate exercise (or close) • carbs somewhere below 120g currently • only eating carbs and carb/fat combos that do not cause a problem spike, with or without insulin.

#3
Chanson13

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I agree that you should try to find the "correct" levemir does that will keep your BG stable when you aren't eating. Then you just use the Novolog to correct for what you eat.
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#4
Sgtmaj

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In TLAP you will have read about basal testing. That's the established best way to determine your basal, and once that is done i:cs can be more easily and effectively found. But again, if you have your own methods or different options that achieve your desired level of control, it's all good.


I re-read chapter 6 in TLAP. I don't have a Dr, that I can call, being in the military system. So, if I don't bolus for my evening meal and my bedtime bg is below 250 and my FBG next morning is within 30 mg/dl of the of the previous evening, my basal dose is in the ballpark. Did I read that correct?

#5
DeusXM

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Yeah, that sounds about right. The idea with your basal is that it shouldn't lower your BG, it should keep it as constant as possible. Making things more complex is that how much basal you need to do this will change throughout a 24-hour period, which is the ongoing challenge for anyone on Levemir or Lantus.
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#6
Chanson13

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I think you're on the right track. One other complicating factor is that when you BG is high (like 250), then insulin tends to be less effective. At least that's something i have noticed. So, better to test out your basal levels when you start at 100 or 120 rather than a high number.

I'm interested that you don't have a doctor you can call "being in the military system." I am naively hoping that our military health care system is better than that. Good luck!
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#7
Cora

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You want to make sure that your levemir is covering your basal (background) needs only. You don't want it to be covering any of your carb consumption. This can lead to problems like unexpected lows and the need to feed the insulin. You can do some basal testing by doing some fasting and making sure that your blood sugar stays stable, rather than rising or dropping.

Cora
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#8
Sgtmaj

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I'm interested that you don't have a doctor you can call "being in the military system." I am naively hoping that our military health care system is better than that. Good luck!


If you are active duty, (Marine Corps), you have to go to the BAS (Battalion Aid Station) to see a corpsman, before you see a
Dr., you can't just call unless you are of a higher rank. I am retired, but covered under Tricare Prime, which means I have to have all my medical care thru the Naval Hospital unless referred to a civilian physican. Again, you can't just call the hospital and talk to a Dr., you have to make an appointment or go to the emergency room. It's combersome, but it works so-so. The active duty side is much more responsive than the retired side and that's as it should be.

#9
Subby

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How many hypos are you having, and how serious? I'm not sure if basal bolus theory necessarily applies as strictly and automatically to a range of type 2s. The reason being you may have a hand from your own system, in dealing with the likes of post meal spikes or basal coverage. A bolus may be contributory rather than completely replacing it, and there may be leeway as to how much you take and still get a good result. There have also been a few T2s here, discuss how they can sizeably change their basal dosage, up to say 30 or 50 percent (or more), with little change in effective basal coverage. It's hard to know what is going on in such cases, but it might again be that the pancreas is willing to take up a certain degree of slack, or otherwise be more dormant. This probably wouldn't happen for people with no pancreatic contribution: and indeed it does seem that basal doses usually need to be finely tuned for T1s. If I vary my dose by 5% I can be in trouble one way or the other.

In other words, it makes sense to me, for you to be led by your nose on this. If you have a setup that gives you few hypos and good numbers, but may not adhere to strict basal bolus theory, it still sounds good. Presuming healthy activity and choices otherwise (some might question your high carb meals - but I'm not about to), yes, it's primarily about the numbers. Otherwise, be guided by TLAP (and if that's not enough, Using Insulin by John Walsh has a lot of detail) to adjust your basal correctly.
20 years T1. NPH and Novorapid.
Some essentials for my blood sugar control: dosing via i:c ratio and cf • basal testing when needed • daily 40 minutes moderate exercise (or close) • carbs somewhere below 120g currently • only eating carbs and carb/fat combos that do not cause a problem spike, with or without insulin.

#10
aggie168

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Yes, you need to get your basel (Levemir) correct and only bolus with Novolog for the carb intake. I got it easy with the pump. It give me Novolog all day as basel and my program dosage change 6 times within a 24 hour cycle to get a flat BG response. So it is a little tricky with just one or two shot of Levemir per day. :)

BTW, I am a T2 with no anti-body and low c-peptide. So my pancreas is not doing much. :)

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DX 02/2002, Minimed 530G(751) w/CGMS on Novolog
Aspirin 81mg + Lipitor 10mg + Losartan 50mg

05/2014 A1C 5.8 Chol=154 Trig=96 HDL=48 LDL=87


#11
Sgtmaj

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Ok, I ate dinner at 6:30 pm, 74 carbs. Took a bg at 9 pm and it was 196. I did not bolus for dinner. Just took my 40u of levemir at 9:15 pm, we'll see what the morning brings. If its still high in the AM, and it should be, do I do a bolus with novolog to bring it back down? I've never used novolog to correct a bg. Should I use the same amount minus a little that I would have used for dinner. I see a hypo before noon coming.

#12
Hammer

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I don't understand your method of dosing. First, the Levemir is used to lower your fasting BG levels. You increase your Levemir dose until your fasting BG levels are in the "normal" range. To me that range is in the 70-80's....others may tell you under 100.....it's your choice. Once you get the correct Levemir dose, then you need to take your Novolog dose before every meal. You said that your insulin to carb ratio is 1:4....okay, so when you eat your 74 carbs, which is a lot of carbs for one meal, then you would need to take about 18 units of Novolog before that meal. If you don't take the Novolog before every meal, then what's the point of having it? You NEED to take it before every meal. If you find that you are having lows, then that's probably because you are eating too many carbs and requiring too much Novolog. It's easy to go low if you eat lots of carbs and take a large bolus. That's why you hear us preaching about low carb....the fewer carbs you eat, the less insulin you need, so you have less chance of going low.

From what I've read here, Levemir doesn't last as long as Lantus, so you may need to split your Levemir into two doses. You may want to discuss that with your doctor. Just remember that you never want your after meal numbers to be lower than your before meal numbers. If that happens, then that means that you took too much Novolog. You never want to use the Novolog to lower your basal or fasting numbers....that's not what it's for. Novolog should only be used to keep your after meal spikes from going too high. Also, if you are spiking above 140, then you need to rethink your doses. The ideal numbers for a diabetic are to be in the 70-80's when fasting, and to never spike above 140 after a meal ( a lot of us think that 120 or less is better). If you are spiking to 250 or higher, that is way too high. Spiking that high can cause nerve damage, and we try to avoid that.

Presently taking: Hyzaar for blood pressure:
Novolog and Lantus for diabetes.
Welchol for cholesterol and diabetes
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I was diagnosed in 2003...

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#13
puzlnut

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I don't understand your method of dosing. First, the Levemir is used to lower your fasting BG levels. You increase your Levemir dose until your fasting BG levels are in the "normal" range. To me that range is in the 70-80's....others may tell you under 100.....it's your choice. Once you get the correct Levemir dose, then you need to take your Novolog dose before every meal. You said that your insulin to carb ratio is 1:4....okay, so when you eat your 74 carbs, which is a lot of carbs for one meal, then you would need to take about 18 units of Novolog before that meal. If you don't take the Novolog before every meal, then what's the point of having it? You NEED to take it before every meal. If you find that you are having lows, then that's probably because you are eating too many carbs and requiring too much Novolog. It's easy to go low if you eat lots of carbs and take a large bolus. That's why you hear us preaching about low carb....the fewer carbs you eat, the less insulin you need, so you have less chance of going low.

From what I've read here, Levemir doesn't last as long as Lantus, so you may need to split your Levemir into two doses. You may want to discuss that with your doctor. Just remember that you never want your after meal numbers to be lower than your before meal numbers. If that happens, then that means that you took too much Novolog. You never want to use the Novolog to lower your basal or fasting numbers....that's not what it's for. Novolog should only be used to keep your after meal spikes from going too high. Also, if you are spiking above 140, then you need to rethink your doses. The ideal numbers for a diabetic are to be in the 70-80's when fasting, and to never spike above 140 after a meal ( a lot of us think that 120 or less is better). If you are spiking to 250 or higher, that is way too high. Spiking that high can cause nerve damage, and we try to avoid that.


Excellent post, Hammer. I appreciate how concise and clear you are. Sgtmaj---hope you get this all sorted out quickly.
Type 2
6/10/11 A1C = 9.8 FBG = 246
8/10/11 A1C = 6.4
11/18/11 A1c = 5.6 FBG = 101
4/24/12 A1C =5.8 FBG = 109

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#14
Subby

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Ok, I ate dinner at 6:30 pm, 74 carbs. Took a bg at 9 pm and it was 196. I did not bolus for dinner. Just took my 40u of levemir at 9:15 pm, we'll see what the morning brings. If its still high in the AM, and it should be, do I do a bolus with novolog to bring it back down? I've never used novolog to correct a bg. Should I use the same amount minus a little that I would have used for dinner. I see a hypo before noon coming.


Does TLAP not go into dosing a correction, and determining what is usually called either a correction factor (CF), or an insulin sensitivity factor (ISF)? You need to determine this and use it. Adequate corrections are a third vital pillar for control, with boluses and basal.

But the really big question here is - why did you not take your meal bolus? Insulin can't work for you if it is not inside you!
20 years T1. NPH and Novorapid.
Some essentials for my blood sugar control: dosing via i:c ratio and cf • basal testing when needed • daily 40 minutes moderate exercise (or close) • carbs somewhere below 120g currently • only eating carbs and carb/fat combos that do not cause a problem spike, with or without insulin.

#15
Subby

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Hang on, I think I worked out why you didn't bolus - in the aim of basal testing overnight, right? It can't work that way - the food is still a disruptive element even hours afterwards. You need to skip the bolus and the food to basal test with a dependable result. Testing in this way is one activity where attention needs to be paid to the process. There is a good ' cheat sheet' by John Walsh on the internet for successfully basal testing. I can't dig it up now but if you want it yell, and I will give the link later.
20 years T1. NPH and Novorapid.
Some essentials for my blood sugar control: dosing via i:c ratio and cf • basal testing when needed • daily 40 minutes moderate exercise (or close) • carbs somewhere below 120g currently • only eating carbs and carb/fat combos that do not cause a problem spike, with or without insulin.

#16
Sgtmaj

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You need to skip the bolus and the food to basal test with a dependable result. Testing in this way is one activity where attention needs to be paid to the process. There is a good ' cheat sheet' by John Walsh on the internet for successfully basal testing. I can't dig it up now but if you want it yell, and I will give the link later.


I understand what you are saying, but to do the test, pg 108 2nd paragraph of TLAP says to eat dinner and do not bolus or have any snacks. Unless that means do not bolus after dinner, but it plainly says to eat dinner.
I would dearly love to have your cheat sheet, I did a google for John Walsh and all I got was the guy whose son was kidnapped and some congressman.

My AM bg was 119, so with a 196 last night and 40u of levemir, I'm assuming that's too much and should decrease by 4u and do a do-over.

#17
TommyC1

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My take from reading TLAP is that you eat dinner at least four hours before bedtime and you take your bolus for dinner. Then, when you are no longer under the influence of dinner or bolus, you check your sugar and go to bed.
I believe that you are trying to see the effect of the basal dose with no food or bolus insulin in your system.

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#18
Sgtmaj

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My take from reading TLAP is that you eat dinner at least four hours before bedtime and you take your bolus for dinner. Then, when you are no longer under the influence of dinner or bolus, you check your sugar and go to bed.
I believe that you are trying to see the effect of the basal dose with no food or bolus insulin in your system.


Makes sense - I'll try that tonight

#19
Subby

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I don't have TLAP handy, but I am 99% sure that Gary Scheiner would not have meant skip the dinner bolus! At least I would be extremely surprised because that would just cause nasty highs without a good reason. For a completely dependent that is - 50+carbs no bolus would likely land me in the 400s and possibly pushing DKA by morning.

Here's the Walsh link. It's geared to pumping, but the details about 4 hours from meals, boluses, and the details about other factors towards stability in order to get a good result, are useful. Of course, you should ignore the pump specific bits about stopping pumps or basal rates (on injections you just got your long acting in you, you are testing how that dose plays out over the period). Any confusion, just ask.
20 years T1. NPH and Novorapid.
Some essentials for my blood sugar control: dosing via i:c ratio and cf • basal testing when needed • daily 40 minutes moderate exercise (or close) • carbs somewhere below 120g currently • only eating carbs and carb/fat combos that do not cause a problem spike, with or without insulin.

#20
poem2000

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i HAD ISSUES, LIKE SHORTNESS OF BREATH WITH LEVEMIR! ANYONE ELSE EXPERIENCE SUCH?




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