[Lizzie G]

Hi everyone

Im wondering if anyone can help. Im on Lantus which I presently take around 8 or 9 in the evening, and I am pretty sure that a)it's activity is peakless in me and b)it pretty much lasts out 24 hours. My problem is that my basal needs vary vastly. Through a lot of testing and calculating I have established that during the day my blood sugars are held steady by what would be 8units for 24 hours, whilst the equivalent night would be 14units for 24 hours.

So, I have a problem that I either a)take 8 or 10 units but wake up higher than I would like, or b)take 14 and have my blood sugars 'sucked' all day, making boluses difficult to calculate because of all the excess insulin floating around, and b) cause me problems when exercising and make driving hazardous.

Im not going to be able to see the specialist now until October due to our fantastic service here in the UK, and General Practitioner is unable to alter my insulin prescription, so adding a lump of medium acting at night isnt an option for me. I also think splitting the lantus will not help at all since it all lasts 24 hours so unless I vary the patterns to give me uneven coverage theres no difference (and thats also complicated and bound to get it wrong).

My only thought of how to go on (which is currently what I am starting to do) is to wake myself up at around 2 am when my amazingly strong 'dawn phenomenon' starts kicking in, and give myself a unit of novorapid.

Does anyone else use this type of method in this situation or would you say no dont do it? Im very adamant about not having the high basals in the day yet I dont wish to compromise my night-time control either....any thoughts?

Liz

[shiftzor]

Originally Posted by Lizzie G

Hi everyone

Im wondering if anyone can help. Im on Lantus which I presently take around 8 or 9 in the evening, and I am pretty sure that a)it's activity is peakless in me and b)it pretty much lasts out 24 hours. My problem is that my basal needs vary vastly. Through a lot of testing and calculating I have established that during the day my blood sugars are held steady by what would be 8units for 24 hours, whilst the equivalent night would be 14units for 24 hours.

So, I have a problem that I either a)take 8 or 10 units but wake up higher than I would like, or b)take 14 and have my blood sugars 'sucked' all day, making boluses difficult to calculate because of all the excess insulin floating around, and b) cause me problems when exercising and make driving hazardous.

Im not going to be able to see the specialist now until October due to our fantastic service here in the UK, and General Practitioner is unable to alter my insulin prescription, so adding a lump of medium acting at night isnt an option for me. I also think splitting the lantus will not help at all since it all lasts 24 hours so unless I vary the patterns to give me uneven coverage theres no difference (and thats also complicated and bound to get it wrong).

My only thought of how to go on (which is currently what I am starting to do) is to wake myself up at around 2 am when my amazingly strong 'dawn phenomenon' starts kicking in, and give myself a unit of novorapid.

Does anyone else use this type of method in this situation or would you say no dont do it? Im very adamant about not having the high basals in the day yet I dont wish to compromise my night-time control either....any thoughts?

Liz

What balance of basal/bolus do you have with 8units/14units? 55%-60% basal is usually a good balance for people. Maybe you need 14units of Basal and reduce your bolus dramatically throughout the day. Do you not have a GP who can change your prescription? If not find one, most would be happy to change it. I have seen people talk about taking something like NPH in the evening but I don’t know much about it other than it is a 12 hour insulin. Pumping would definitely help you out here. The other thing is that your diabetic clinic will probably have a number to phone; I know mine does and I should use it more often. This forum is great but getting specific advice for me is harder over a forum than a phone call, sometimes it’s great to have a “wakeup call” or at least an enlightening conversation.

[grace girl]

I have some pretty wildly varying basal needs myself, and I ended up splitting the lantus and varying the doses. It took a lot of time and a lot of basal testing to finally get it right.
I'm currently taking 14 units at 9am and 6 units at 6pm and it's the best results I've ever had.
If that ends up being your only real solution I would advise you to be prepared for it to take some time to get it all worked out.
But hopefully someone else will come along with a different idea for you. I can't imagine getting up at 2am every night for a shot. I'd be afraid I'd mess it up due to not being properly awake.

[Gary_W]

Hi Lizzie,

Just want to say that you're not alone. I'm afraid I don't know how to fix it, though

Since I've started pumping, I can now see why Lantus gave me such grief. My basal needs slow down at around 10pm at night, get slower still at midnight and my body needs almost no insulin at all for a 3 hour period of the night. If Lantus were to cope with my needs during those 3 hours, I would only be on 1.8u of Lantus per day (assuming a flat 24 hour profile as you are assuming). Early hours of the morning is when I need the full whack that equates to 13u per day of Lantus.

If I used to put in the full amount at night, I would have to feed my face before bed to cope with the large BG drop in the night. Going to bed with a BG below 10.0 (180) was not sensible. The alternative of splitting in me caused my daily bolus shots to lose potency. I cannot really get my head around why this would be as basal testing still claimed that all was well. What I do know is that splitting Lantus sent my control so far downhill that I prefered the huge BG drop overnight.

I'm afraid I don't know how best to fix it on MDI. That's why I went with the pump. I really do wish I had looked into it years ago; whilst most of my basal problems appeared out of the blue quite recently, I'm now starting to realise that I haven't slept properly in years. The quality of sleep I'm getting now is a huge contrast to MDI...

If you do wish to consider a pump, call your clinic NOW. It can be a long process which usually starts with seeing the pump nurse at clinic. You can get that bit done now rather than waiting to see your guy in October.

Even if you don't want to pump at present, they WILL get you in for some one to one advice before October if you are having problems. The regular appointment is just a check up and if you need help, you need help. Call and ask nicely. If that doesn't work, demand.

Gary

[rzrbks]

1)perhaps a snack before going to bed would stave off the DPs

2) the other thing you might mess with is your bolus ratio during the day

some folks on here (including your truly) have to adjust their ratio based on the time of day.

If I eat breakfast before 10am, I use 1:4 or 1:5 depending on what I have and then go back to 1:15 for lunch and supper.

If I skip breakfast or sleep so late as to not want it, I just use regular 1:15

but then you probably know all this and I'm just giving you useless knowledge.

[xMenace]

I'd probably up it to 14 and try to reduce my boluses. A big problem you might have is this forces you to eat, perhaps too much.

I think some NPH at dinner or bed might work best. BlueSky knows NPH very well. GP won't be altering your prescription. He'll be adding to it: augmenting it Check out OTC prices too, if they sell it there.

[duck]

Originally Posted by rzrbks

1)perhaps a snack before going to bed would stave off the DPs

2) the other thing you might mess with is your bolus ratio during the day

some folks on here (including your truly) have to adjust their ratio based on the time of day.

If I eat breakfast before 10am, I use 1:4 or 1:5 depending on what I have and then go back to 1:15 for lunch and supper.

If I skip breakfast or sleep so late as to not want it, I just use regular 1:15

but then you probably know all this and I'm just giving you useless knowledge.

I've read that a shot of hard liquor before bed works wonders for some as well (no joke...alcohol inhibits the liver from releasing glucose).

Also, as some stated, consider splitting your dose: From what I can see here it would seem Lantus lasts about 20 hours for most people. Knowing that, you can try to calculate when you need to most "coverage" and when you need the least, and time your shots based on this.

[Lizzie G]

Thanks guys for all your advice.

In answer to basal bolus ratio i generally seem to take about 10 units of lantus and maybe about 8 novorapid, both can vary by a couple of units either way but not insanely.

im very keen not to raise my basal; i do a lot of sport and most of this takes place early in the evening when i seem to need very little insulin at all and feel a 'pull' from my basal even at lower doses, this effect is quite pronounced even at 12 units. at that time of day my carb ratio is insanely low, 1:25 at the moment whereas early in the day is can be as much as 1:10. also i have worked very hard to lose a lot of weight and a higher basal stimulates my appetite noticeably as well as the physical requirement to eat more, so its an approach i would really prefer not to take unless it can be avoided!

i cant remember who it was that said they have a UK GP that will change their insulin - mine wont, which is very annoying. maybe i should change my GP; i feel no particular attachment anyway, but in the meantime i think i will call the nursing team and ask about NPH or something like that - if Blue Sky is out there and can tell me more about it that would be great. i know it sounds crazy, but i really dont want a pump. its a psychological thing really, i just cant deal with that constant reminder of diabetes. when im in the water swimming i just feel so normal, and people around me can think im good at swimming and comment on that and not know anything about the diabetes. whereas with the pump it would be visible, and people would ask and know and all that stuff and i want to be good at something in the context of normal rather than people making their very kindly meant comments about how well i do despite diabetes and all that stuff. i guess i do have some issues here about dealing with it and i want to keep the diabetes private. does anyone else wrestle with their emotions on this type of subject? or am i a freak?! (dont answer that...)

big sigh from a sad lizzie

but thanks so much for advice everyone...

[Gary_W]

My GP will change insulins; he's very good. His brother is T1, and he is of the opinion that the patient knows best when it comes to diabetes. When I wanted to try Apidra, he just did it. I can't remember if you managed to get on Apidra in the end, but this is option 3 as (in the unfortunate event of waking up high) it should at least bring you down a little quicker than Novorapid.

Regarding the pump, I can see where you are coming from from the mindset point of view. My fears were spookily similar. What I can report is that I am reminded LESS about diabetes than I was on MDI. The reason for this is that I suffer far less from the basal variations and generally keep on a much more even keel. I personally find if I'm feeling physically well that diabetes becomes a non-issue in my life. Yes, I know I'm wearing a pump but I would never go anywhere without my insulin pens. The made a bigger impact in my pocket than this thing does on my belt Also the psycological freedom at a meal with colleagues to give 3 'injections' without anyone being any the wiser was liberating to say the least. As is giving a bolus in a supermarket once you know the carbs in a sandwich. As for swimming, you can take it off for an hour so no-one needs to know.... You can take it off for a bit longer if you give a shot before disconnecting. If you're on a swimming-fest and are in the water for a couple of days you can always MDI it for that period.

Gary

[BlueSky]

Originally Posted by Lizzie G

... i think i will call the nursing team and ask about NPH or something like that - if Blue Sky is out there and can tell me more about it that would be great. ......

Lizzie,

Because I have this crazy DP, and because I am not able to get a pump, I have come up with an interesting insulin coktail to keep my blood glucose on an even keel. I use a combination of Lantus, NPH, Regular and Novorapid. I will describe my insulin regimen, just so you can see how I went about customising it. Maybe you can use a similar approach.

I inject 8 units of Lantus in the morning. It gives me a flat basal action over the 24 hours (or most of it). I inject 9 units of Protophane (NPH) at night. It is getting up to speed by the time the DP kicks in at around 3am. The NPH ensures that my FBG is in the target range, but it it is not sufficient to cover basal insulin needs later in the morning. I can't increase the NPH because it would make me go hypo at night. So I cover a low-carb breakfast with 8 units Actrapid (Regular insulin), which I inject as soon as I wake up. I usually cover lunch and supper with Novorapid.

It works quite well. My last HBA1c was 6.0%. But a pump would do a much better job. It sounds like your basal profile is a bit different. But mixing and matching the insulins should enable you to achieve the result you are looking for. Good luck with it .

[shiftzor]

Originally Posted by Lizzie G

Thanks guys for all your advice.

In answer to basal bolus ratio i generally seem to take about 10 units of lantus and maybe about 8 novorapid, both can vary by a couple of units either way but not insanely.

im very keen not to raise my basal; i do a lot of sport and most of this takes place early in the evening when i seem to need very little insulin at all and feel a 'pull' from my basal even at lower doses, this effect is quite pronounced even at 12 units. at that time of day my carb ratio is insanely low, 1:25 at the moment whereas early in the day is can be as much as 1:10. also i have worked very hard to lose a lot of weight and a higher basal stimulates my appetite noticeably as well as the physical requirement to eat more, so its an approach i would really prefer not to take unless it can be avoided!

i cant remember who it was that said they have a UK GP that will change their insulin - mine wont, which is very annoying. maybe i should change my GP; i feel no particular attachment anyway, but in the meantime i think i will call the nursing team and ask about NPH or something like that - if Blue Sky is out there and can tell me more about it that would be great. i know it sounds crazy, but i really dont want a pump. its a psychological thing really, i just cant deal with that constant reminder of diabetes. when im in the water swimming i just feel so normal, and people around me can think im good at swimming and comment on that and not know anything about the diabetes. whereas with the pump it would be visible, and people would ask and know and all that stuff and i want to be good at something in the context of normal rather than people making their very kindly meant comments about how well i do despite diabetes and all that stuff. i guess i do have some issues here about dealing with it and i want to keep the diabetes private. does anyone else wrestle with their emotions on this type of subject? or am i a freak?! (dont answer that...)

big sigh from a sad lizzie

but thanks so much for advice everyone...

Ye, don't feed your insulin its not worth it. I to have problems with sport, usually end up taking tiny amounts of bolus and a meal to counteract my basal. Don't forget you can disconnect a pump, novo rapid peaks at what 2 hours, that’s a long time to swim swimming would keep your bg down anyway, so you could probably go for a lot longer. If I was you I would change GP, I will be soon, fed up with a constant argument over strip supplies. I think if you went for it and tried NPH, you could quiet easily start on a tiny does until you got comfortable with it. Would require a lot of waking up at night to ensure you don’t have any hypos though. About using NPH i found this:

Getting the most out MDI by using other insulins - Diabetes Daily Forum

I still am sensitive about diabetes, but I am not afraid to inject in public I just tend to choose who I tell or inject in front of. I don't care about friends/family but strangers I would choose not to tell them and probably not to inject in front of them. So you’re not completely weird or at least you’re not alone

Garry I am loving your poem, I can imagine getting that tube tangled on your “nees” would be a bit painful.

[Lizzie G]

Originally Posted by BlueSky

Lizzie,

Because I have this crazy DP, and because I am not able to get a pump, I have come up with an interesting insulin coktail to keep my blood glucose on an even keel. I use a combination of Lantus, NPH, Regular and Novorapid. I will describe my insulin regimen, just so you can see how I went about customising it. Maybe you can use a similar approach.

I inject 8 units of Lantus in the morning. It gives me a flat basal action over the 24 hours (or most of it). I inject 9 units of Protophane (NPH) at night. It is getting up to speed by the time the DP kicks in at around 3am. The NPH ensures that my FBG is in the target range, but it it is not sufficient to cover basal insulin needs later in the morning. I can't increase the NPH because it would make me go hypo at night. So I cover a low-carb breakfast with 8 units Actrapid (Regular insulin), which I inject as soon as I wake up. I usually cover lunch and supper with Novorapid.

It works quite well. My last HBA1c was 6.0%. But a pump would do a much better job. It sounds like your basal profile is a bit different. But mixing and matching the insulins should enable you to achieve the result you are looking for. Good luck with it .

Thanks BlueSky. I just had a chat with the diabetic nurse. Im not sure what to think really so I will try to summarise (not my strongest point so bare with me!!!). ok, the past couple of months I have felt my control hasnt been very good for a number of reasons. in part because i have been building up to about 12 (216) pre exercise each day and had been doing so maybe 1.5 hours prior to exercise (i have now worked with a dietician to get a better routine going which involves going to about 8 or 9 and only about 30 minutes prior). i also had flu and a holiday in florida where my eating habits were a little on the unhealthy side. my HbA1c came out at 6.6.

So, when I spoke to the nurse I described my basal issues and said that I would like to take NPH at night to cover the period of higher insulin need. She said that I should consider taking more lantus, i said no, daytimes would be problematic and id lose my ability to know what my blood sugar is and testing would produce more surprises etc. anyhow, when i told her what my increase is over night, from 5 to 7, she said i need to give myself a break, that my HbA1c is great (i disagree) and that waking up at 7 (126) isnt terrible and I should relax. she also said she wouldnt like me to go on NPH and run the risk of nasty hypos.

anyhow, i had a think about this. and i came to the conclusion that whilst i disagree about my A1c being excellent, i realised that i do have pretty decent control (which will be improved by the little changes im making to exercise etc) and i dont live in fear of hypos. so im thinking perhaps if i continue to take care on the little things within my control maybe i dont NEED to take on the more agressive approach to managing it and messing around with different insulins, accept i wake up a bit higher than id like but not think its too much of a problem?

im not sure whether i should keep pushing on the issue of mega mixing (!) or accept what im being told that im doing well and i dont need to change. incidentally, the nurse told me that target HbA1c for diabetics at our hospital is 7.5. i thought that was rather high???? id like my personal target to be to achieve an HbA1c that is close to normal but that doesnt involve constant worry and obsessing...so i figure 6 would be a nice goal??

[BlueSky]

Originally Posted by Lizzie G

... when i told her what my increase is over night, from 5 to 7, she said i need to give myself a break, ...

I think an HBA1c goal of 6.0% is a good standard to set. But don't get too upset if you don't achieve it. I agree with the nurse in that rising from 5 to 7 overnight is really not that bad. But if you are having difficulty covering breakfast and you find that your BG is continuing to rise in the morning, adding some NPH into the mix could help improve your control. An HBA1c of 6.6% corresponds with an average blood glucose of 8.8mmol/l. So you must be going high at other times of the day. It may be useful to consider what other opportunities there are for making that improvement. And have fun doing it!

[Lizzie G]

Originally Posted by BlueSky

I think an HBA1c goal of 6.0% is a good standard to set. But don't get too upset if you don't achieve it. I agree with the nurse in that rising from 5 to 7 overnight is really not that bad. But if you are having difficulty covering breakfast and you find that your BG is continuing to rise in the morning, adding some NPH into the mix could help improve your control. An HBA1c of 6.6% corresponds with an average blood glucose of 8.8mmol/l. So you must be going high at other times of the day. It may be useful to consider what other opportunities there are for making that improvement. And have fun doing it!

Wow - I didnt realise 6.6 corresponded to such a high average, 8.8 really is high and leads my mind down the road of thinking its the timing of my boluses i might need to work on. and probably cutting back on coffee wouldnt be a bad idea.

im not too bad with mornings, yes im definitely insulin resistant in the morning but like you i have a light low carb breakfast - i normally have a pot of unsweetened greek yogurt with nuts and seed and a teeny bit of dried fruit. i think its around 20g carb and if my blood sugar is 6 before i take 1.5 units which takes me back to 6 again later, or if im a bit higher i take 2 units which pretty much does the same thing; so i guess im alright with that but could probably do with looking a bit more closely at what im doing an hour after i eat and timing shots a little better if necessary.

its such an ever changing set of goalposts, you're just getting used to your latest routine then your body reacts differently and you have to re-adapt again and again - keeps you on your toes. and its really helpful to have everyones advice. i think on this one i am going to work with what i have for the next 3 months, get an HbA1c, if I havent brought it down a little then find a physician that is willing to prescribe NPH!

thanks

[shiftzor]

Originally Posted by Lizzie G

Wow - I didnt realise 6.6 corresponded to such a high average, 8.8 really is high and leads my mind down the road of thinking its the timing of my boluses i might need to work on. and probably cutting back on coffee wouldnt be a bad idea.

im not too bad with mornings, yes im definitely insulin resistant in the morning but like you i have a light low carb breakfast - i normally have a pot of unsweetened greek yogurt with nuts and seed and a teeny bit of dried fruit. i think its around 20g carb and if my blood sugar is 6 before i take 1.5 units which takes me back to 6 again later, or if im a bit higher i take 2 units which pretty much does the same thing; so i guess im alright with that but could probably do with looking a bit more closely at what im doing an hour after i eat and timing shots a little better if necessary.

its such an ever changing set of goalposts, you're just getting used to your latest routine then your body reacts differently and you have to re-adapt again and again - keeps you on your toes. and its really helpful to have everyones advice. i think on this one i am going to work with what i have for the next 3 months, get an HbA1c, if I havent brought it down a little then find a physician that is willing to prescribe NPH!

thanks

You sound like me, I am taking 1unit to cover 20g of carbs in the morning (I was 1.5units but stress has changed everything). One thing I have noticed is that I spike badly after breakfast which usually leaves me thirsty and at the 2:30 hour mark I come back into range. I am considering trying Apidra in the morning to see if I can combat these spikes, pre-bolusing doesn't seem to work (although not extensively tested it yet) and I don’t trust that I will snack with a super bolus. My breakfast is muesli (homemade) with milk. Anyway enough about me, maybe you are experiencing spikes which are raising your A1c in the morning and combining that with a high waking BG could be messy. Just an idea.