Lantus - what's protocol here?

[Spiker]

Correction ratio of over 1u:11 mmol/L is very insulin sensitive. Particularly given that her underlying BG seemed to be rising.

 

[mirror]

I'D Like to try the split dose ( husband who wants to half lantus might agree as we'd do it his way - ie 3 units at 10. then in morning I can suggest another 3?
What's my logical argument guys ( coz I will need one - he's a smart cookie)

 

[Spiker]

I'D Like to try the split dose ( husband who wants to half lantus might agree as we'd do it his way - ie 3 units at 10. then in morning I can suggest another 3?
What's my logical argument guys ( coz I will need one - he's a smart cookie)

She is going low in the morning and high in the evening. Clearly a single dose is not covering both situations. Split into two doses and (a) the second dose may now last long enough to cover the highs, (b) even if it doesn't initially cover it, you can adjust both doses independently until both situations are covered. For example, you can adjust the first dose down and the second dose up. Try doing that with just one dose...

 

[ConradJ]

The DUK forum is a one way broadcast system for out of date NHS dogma.

Whereas this DCUK forum is open and allows debate, multiple viewpoints. Much better

Glad I'm not the only one to say that out loud!

 

[ConradJ]

She is going low in the morning and high in the evening. Clearly a single dose is not covering both situations. Split into two doses and (a) the second dose may now last long enough to cover the highs, (b) even if it doesn't initially cover it, you can adjust both doses independently until both situations are covered. For example, you can adjust the first dose down and the second dose up. Try doing that with just one dose...

If she's on such low doses and still having major hypos and can't manage it herself then I think she needs to go on a pump asap - the Accu Chek Insight would suit your situation because the PDA can be worked by you and your husband, and the circadian profile algorithms can be matched to her hourly biorhythms.

What's the "off licence" med she's taking? It sounds like it may be causing some interaction with her insulin requirements - 40 mg steroids is still quite high and they're known to send BG levels up.

 

[Spiker]

In case the objection is made that you can't use Lantus twice a day:

http://www.ncbi.nlm.nih.gov/pubmed/16911626

It's actually better when it's used twice a day.

Evidence for the small doses lasting less than 24hrs - well it's very hard to find the dose response curves for Lantus. (I had them once but I can't find them). Sanofi don't seem to want you to know them - they publish the dose response curves for rival detemir (Levemir) but not for their own drug. Not exactly transparent of them! However the Sanofi patient information leaflet (PIL) for Lantus gives the low end of the action time of Lantus as being 10 hrs, citing "clinical studies" that they don't reference. (This is where they claim the median action time is 24 hrs). If you look at what Sanofi do publish, it's for massive doses of Lantus - up to 300u - they really do try hard to sustain the view that it lasts 24 hours. But there it is on their own PIL - it can last as little as 10 hrs.

Your daughter is now on around 0.1u/KG of Lantus. By comparison, 0.1u/KG of detemir has an action time of less than 6 hours vs the normal 11-12 hrs. Detemir and glargine are reported to have similar dose response curves that are "critical" (highly dose dependent) and linear.

 

[mirror]

Gonna monitor today and think about splitting tomorrow
She had 3 units last night
Went out for tea as I knew she would eat. Had nachos starter and hunters chicken with chips as main estimated 80g carbs
No novorapid
Bed bm 10.7
3.30am bm 9.4
6.50 am 8.4
Will keep track and see

 

[Spiker]

If you are skipping meal bolus it's important to take the immediate pre meal BG and then +2 and especially +4 hours later to verify there is no rise from the meal.

 

[Spiker]

At 3u/day she's now on around 0.05u per kg Lantus and no quick acting. That's like a newly diagnosed honeymooning diabetic. No idea what's going on there. What a mystery.

 

[ConradJ]

At 3u/day she's now on around 0.05u per kg Lantus and no quick acting. That's like a newly diagnosed honeymooning diabetic. No idea what's going on there. What a mystery.

I agree; plus she's on steroids, which tend to send BG levels up.

I think she needs to be tested for islet cell activity - just in case you were right in a previous comment @Spiker.

 

[Spiker]

A pump is an excellent idea. Ideal for someone with very high insulin sensitivity. Tuning long acting insulin is very difficult in such cases and a pump makes it much easier to fine tune small doses on an hour by hour basis.

 

[mirror]

Pm spiker

 

[mirror]

Right
What's the consensus for tonight guys (at 10 ish when lantus decision made)
Will post the bms etc
12.30 (out at a carboot) bm 21.6 (earlier bms around 8-9 7am no brekky)
Get home 1 unit lantus 1 unit novorapid - novorapid having brought her down by 11 yesterday over 4.5 hours no food)
2.20 bm 16.2
2.40 70 g carbs
4.30 bm 12.6
6.00 bm 6.7 75g carbs
8.00 12.2 bm

 

[mirror]

Had previously decided NOT to bother with split dose then thought 'oh ****, shudda done it)

 

[ConradJ]

@mirror
Those bg ( blood glucose) levels are very high. Ideally, they need to be between 5mmol / ml and 7.8.

You say you gave her 1 unit of lantus but at what time?

Did you give her any Novorapid at mealtimes? If so, how much?

 

[mirror]

No novorapid
Lantus at 12 40 pm
Bm now 5.2

 

[ConradJ]

What dosage of lantus did she have last night?

Is she still on the steroids?

Is she still on the "off licence " med?

Oh, and what was her bg this morning?

 

[Spiker]

As you said @mirror, the data is stacking up to do 2-3 u of Lantus twice a day. Well, the good news is we were looking for the low point and now we've found it, so we can build up again. Much safer to have high BG and increase insulin than the other way round.

Try 2-3u Lantus 2/daily and see if we can get to the point where we are also giving bolus doses.

Any idea of her carb ratio? With a correction ratio of 1u:>12 mmol/L I expect her carb ratio will be similarly very high, because both things reflect insulin sensitivity and her insulin sensitivity is insanely high at the moment, for whatever reason. So be very cautious on the bolus doses if and when we get to them. Like start at 1u:30gCH or 1u:25gCH, something like that, and work up slowly from there.

 

[ConradJ]

If, as @Spiker observed, she is going hypo in the morning and then rising in the evening, then I would split her doses: bedtime being one third (1/3) of the total daily dose of lantus. Then give her the second dose 12 hours later.

Therefore, if she's on a total of 6 units I would give her 2 now and 4 at 10.30am tomorrow.

If she's on 5 units then I would split it 2 units now and then 3 tomorrow morning... if she hypos at night or early tomorrow then I would reduce the bedtime lantus but consider raising her morning dose depending upon her daytime results.

 

[Spiker]

I can't believe how fast she is dropping on just 3 u of Lantus, and I can't believe how fast she is rising when it runs out either.
I do also think she does need bolus insulin with food, but it's tricky to even begin to calibrate the right carb ratio until the basal is at least roughly right.