[vrocco1]

Hi folks, I'm pretty new to this forum, and have not posted much, but have been lurking for a while now. Seems to me that there is a good number of type ones on this forum. Hopefully someone can help me.

I just started using lantus and humalog in January. In just a couple of weeks I had great control (A1C was 6.5 3 months ago). However, recently I started experiencing a few odd hypos right before lunch and dinner (5 hours after the previous bolus). I was using 32 units of Lantus in the morning, and Humalog (based on BGL and carbs) before each meal and my evening snack.

Well, the better half was not happy about the hypos, so I discussed it with my internist during my visit this week. He suggested cutting the basal from 32 units to 25 units, which seemed like a huge difference to me. Then I thought about it, and realized that was only 1/3 of a unit per hour, which did not seem like much. However, my BGLs have been through the roof (fasting at 250 this morning) since then, and I have not gotten much sleep. I have not made much of an adjustment to my carb/humalog ratio, because I was already being fairly aggressive there (1 unit per 12-13 grms).

I guess what I am looking for is some input from other MDI users. Should I slowly increase the lantus, or should I adjust the bolus doses? I have to get some sleep!

BTW... I'm a 44 yo man, been type one for about 23 years.

[DeusXM]

Given the original lateness of your hypos, I'd say you were right to adjust your Lantus dose rather than your bolus. However I think you've been advised to drop it by too much. If you're running that high on your new dose then I'd suggest bringing your Lantus back up to 29 or 30u, and then if that still causes hypos then drop it down a bit, to maybe 28u or 27u.

You're right that cumulatively, your dose drop isn't a massive change, but basal insulin adjustments seem to have far more dramatic effects than similar adjustments with bolus doses. Trust your own judgement - from what you've discussed in your post it sounds like you know what you're doing anyway.

[MarkMunday]

vrocco1,

DeusXM has given some good advice. I have a couple of additional comments, based on the numerous adjustments I have made to the timing and amount of Lantus shots.

Of all the basal insulins I have used, I find Lantus to be the most effective. But finding the right dose is really tricky. Changing the dose by more than a couple of units at a time causes confusing results. And after making the change, you have to let it settle down for a few days before judging whether it is working or not.

So I would suggest that you don't change the Lantus dose by more than 2 units at a time. And don't do it more than once a week. That way, your test-and-measure experimentation will lead you to the right Lantus dose. You also may find that, because you have reduced your basal level, you need a bit more Humalog before meals. So test your 1 hour and 2 hour post meal blood sugars.

You can test you Lantus dose by skipping a meal and the corresponding bolus shot. Your blood sugar needs to be in the target range to start with. And if your basal level is right, your blood sugar shouldn't move out of the target range after skipping the meal. Lunch and supper are thge best meals to skip. Skipping breakfast can produce confusing results because of the Dawn Phenomenon.

It is almost immpossible to find a level that puts your system into equilbrium. But you will be able to see if you have it in the right ballpark. I have pitched my basal level so that my blood sugar declines slowly in the absence of a meal/bolus. It means that I can eat the occasional between-meal snack without bolusing for it.

Once you have got your Lantus dose right, you are well placed to figure out your mealtime bolusing requirements. You may require more than 1 unit per 12-13 grams of carb.

I have found that my bolusing needs have increased steadily over the years. And it is not because of insulin resistance. I am convinced that it is the result of post-prandial release of hepatic glycogen. My beta cells stopped producing insulin many years ago. But elements of the counter-regulatory system have been deteriorating more slowly. My bolusing insulin to carb ratio is 1:3-5. If I understand the dynamics of all this correctly, Symlin should help as it inhibits the release of glycogen by the liver at mealtimes. And I am looking forward to it becoming available in this part of the world.

Cheers,

Mark

[vrocco1]

Thanks guys, I noticed that after I reduced the Lantus by 7 units, I did not really see a change for two days. I agree that you need to move slowly. I think I am going to move upwards slowly. I increased it by two units this morning, and I think I'll try that for a week to see how it works out. I live on a small farm, so the weekends are hard labor. Not a good time to judge the results I guess, because I had a few hypos today. The thing that worries me is the overnight high BSLs. I'm up all night running to the bathroom, and just don't get the sleep I need. I do bolus with a snack before bed, but I hesitate to increase that so I don't end up hypo over night.

I appreciate the input, I really did not know which way to go! Thanks again.

[MarkMunday]

Varying amounts of exercise play havoc with control. Fine tuning the insulin regimen is really difficult because the goalposts keep on moving. Sounds like a pump may suit you better. You would be able to program different basal rates for weekdays and weekends, taking into account the different levels of activity.

Keep up the good work and good luck with it.

Mark

[vrocco1]

Yeah I was thinking the same thing (about the pump). I woke up at 159 today instead of 250 like yesterday. That is exactly what it was when I went to bed, but I took 4 units of Humalog. I would have thought I'd end up hypo? Of course I ate like a lumberjack last night to make up for the day's activities. Very frustrating, but I'm going to give it a few days before I increase the lantus again. Once I get back to work, things will change.

I see you do 1 unit per 5 carbs?

[Simons]

I have been on lantus for several years now and have really l8ked it. Use Lantus and Novolog prior to meals. The past couple of weeks my bs' have been terrible I just can't seem to control them. Every couple of days I increase my lantus by two units. Have gone from 13 to 22 and don't know what else to do.
I have a history of terrible sugars occasionally for a week or few days at a time but than i revert back to where i originally was but this time is more difficult.
Any suggestions?
Simons

[MarkMunday]

Simons,

That is a massive increase. Could the vial have gone bad? I monitor results carefully when a cartridge is over a month old. Because once potency starts to deteriorate, it loses strength very quickly. I use only 8 units at a time. So a 3ml cartridge lasts 37 days. I see you are also on a small daily dose. If you keep it in the fridge, you can get more than the 28 day advertised useful life out of it. But sometimes it lasts longer than others and you have to be careful. Lantus is the only insulin I have had this problem with.

Mark

[Mick]

Let us not forget our trusty old "TDD Calculator" formula. This old physician's formula has been used for years to judge a T1 diabetic's Total Daily Dose of insulin, and is based on body weight. Of course, other things will effect YOUR dose, such as food intake, activity, sensitivity to insulin, and body fat percentage--BUT--it will generally get you at least in the ballpark. Here it is:

Take yourt weight in Kilograms--to get that, take pounds and multiply times .45. I'll use my weight for an example--I weight 140 lbs, so that would be 63 kg. Take that nunber and multiply times .6 For me, the result would be 38. That should be my TOTAL (basal and bolus) dose per day. Approximately half that should be basal and half bolus, so my Lantus dose should be about 19 units. In fact, it is 17 units, but I am an extremely thin and muscular person, so that would decrease my insulin need. My bolus doses should also total about 19 units per day--but they generally do not, again, for the reasons already given above. I use between 10 and, if I've totally pigged out for the day, maybe 15 units. But I don't eat very much, and I exercise a lot. So, at a muscular and lean 140 pounds, I take 17U Lantus and 10 or 12U Novolog, for a TDD of 27-29U, well below my expected 38U TDD, but for understandable and explainable reasons. I know where I SHOULD be, I have a place to begin my calculations, and I know why I fall below my expected dose. Of course, as we all understand, this is NOT a science--it's an art, with a bit of voodoo thrown in, and a lot of luck needed for decent results, and still consistancy is never dependable!

Michael
T1 since 1965

[vrocco1]

Michael,

I must be a totally average person in every way. I did your calculation and came up with 59.5 units. Right now I take 27 units of lantus, and about 10 units of humalog with each meal. Throw in another 3 for my evening snack, and I am at 60 units plus or minus a couple! Pretty cool!

[birds_eye]

Hey Mick, that TDD calculation is pretty cool in theory. But I'm like you, my TDD is 46u, but I'm currently on 20u Lantus and 4+4+6= 14u Humalog. So that leaves me 12u shy of my TDD. Also I'm very active though, and but I do eat alot, I think the exercise keeps my requirements low, and decreases insulin resistance.

Symlin should help as it inhibits the release of glycogen by the liver at mealtimes. And I am looking forward to it becoming available in this part of the world. quote MarkMunday

I just recieved my August Diabetes Forecast mag, and read about that Symlin drug, but would like to know Mark if you would consider taking another injection at mealtimes?

[MarkMunday]

I have often wondered about that TDD formula. I weigh 71 Kg. So, according to the formula, my TDD should be about 43 units. My actual TDD is 36 units. My basal and bolus insulin requirements should be about 23 units each. But my actual basal daily dosage is 12 units (8 Lantus and 4 NPH). And I use about 23 units of Novarapid daily (9 before breakfast, 8 before lunch and 7 before supper).

My body weight is in the middle of the normal range (BMI of 23). And I am not particularly active. But my actual TDD is 16% lower than it should be, based on my weight. And my actual basal is only 33% of my actual TDD. It was even lower (as a percentage) before I went on a low-carb diet. Go figure.

birds_eye, I don't relish the thought of another injection before meals. But if it gives me better control over post-prandial blood sugars, I will do what it takes. Breakfast is when I have the most difficulty. So I would definately inject Symlin beforehand. I am not so sure about lunch and supper.

Cheers,

Mark

[jdstein11]

Wow. According to the TDD formula, I weigh 195 lbs = 88 kg = 53 units / day. I've been on insulin for just over a month, and have hit that once. As a matter of fact, I average 78 units / day, but I eat a pretty high-carb diet, for now. By changing my breakfast cereal (Quaker Oatmeal Squares: 44 carb / serv. to Grape Nut Flakes: 24 carb / serv) I've noticed that I can reduce my morning shot from 34 to 18, which is the ONLY way I can get close to that formula.

I suppose eating less, exercising a bit more and lowering my carbs would help too, right?

As for the Lantus, I've been instructed to only take it at night and have averaged 11 units. Do others take a lot more? I use Novolog before all meals, averaging about 20 per meal and 4 per snack.

[bashboza]

High, I have a really short experience with Lantus so I am far from being exper there but I have few comments.
1. On the Lantus on the paper comming with the box of cartridges I read that one should not store an already open cartridge in the fridge. Don't know how it affects insulin potency, but that's what I've read. They may have written it in order to protect users from the idea that by keeping it in a fridge it may be used more than a month after it was open.

2. The action profile of Lantus in my experience is quite different from what they promote over the net. That's kind of specific to me maybe, because all the insulins I've used and I am using work with me non standartly the rapid ones act slowly than they are designed and the basal ones work faster and for shorter time. My particular experience with Lantus today was in that direction also. Yesterday at 10p.m. I did 18 i.u. Lantus(my usual dose) and today at 10 a.m. I did 24 i.u. Lantus (something I do for the first time, experimenting with particular goal but that's a different subject). So today 2-3 hours after the 24 i.u. Lantus I got a continuos hypo that I fed with carbs for few hours. What I mean is that the today Lantus acted faster and shorter and thus stronger than the way they showed it on the action profile graphs. So your hypos might be something similar.

P.S.: Please excuse me for my poor english.

[vrocco1]

bashboza... I found that a hypo triggered by Lantus can last a long time...

I had an interesting experiement yesterday. I had to fast for 24 hours in order to prepare for a medical procedure. I took my moring Lantus at the usual time (6am). Then fasted until about 10am the next day. I was amazed at the results. My BGL stayed between 93 and 129 the entire 24 hours (It went way up after 7am the following day when the Lantus gave up). In any case, I had two very minor hypos during the day. One at 1PM and one at 8PM which I treated with a few ounces of gatorade.

Does this sound normal, or should I not even had those two hypos? To me it seemed that my dose must be pretty close to "right on".

That is my first fast in over 20 years of using insulin. I don't think I could have done that if I were still using Humulin N and R!