Need help with Levemir troubleshooting

[Bluemarine Josephine]

Good day everyone, I hope you are all having a great day!!
I entered a new basal/bolus scheme 10 days ago, following the DAFNE course, and I need your help and suggestions please.

I am using Levemir as a background insulin. I never had any experience with Levemir in the past.
I have two injections.
One at 07:00 am of 8 units
A second, at 21:00 pm of 10 units.

The evening Levemir of 10 units holds me nicely at a steady level throughout the night so, I do not have any reason (for the time being) to make an adjustment.

Here is where my confusion occurs.
I inject my morning Levemir of 8 units at 07:00 am
I inject my Novorapid at 07:15 according to carbs counting on a ratio of 1.5:1
In the beginning, I see the usual rise in blood sugar and the drop starts around 09:00am (I suspect this is also the time that the 8u of Levemir begin to work)

I test at 12:15 where, theoretically, Novorapid has stopped working.
I test again at 13:00 – pre-lunch- and I am usually 2 mmols lower that the level that I had at 12:15. So, there is still a drop in between the hours that Novorapid isn’t there.

Additionally, as you may guess, my blood sugar is at a lower level than what I would expect from the 1.5:1 ratio. It’s not quite as low to match a 1:1 ratio, but it is lower than a 1.5:1 ratio.

I inject for lunch, use carb counting, have lunch.
My levels hold nicely and even drop a couple of mmols 2 hrs after lunch – by around 15:00
At around 16:30 my blood sugar starts to rise.
By 19:00 –pre-dinner- I am at some 3 mmols higher than my 13:00 hrs reading.

I have also noticed that by dinner-time I need a ratio of 2:1 to hold the same level which I had at 19:00 (pre-dinner).

On the basis of this pattern, I understand that, most probably, during the morning, the overlap of the evening 10 u Levemir + the morning 8u Levemir + the Novorapid, are dropping my levels more than expected but, my morning 8u Levemir, on its own (and after the evening 10u Levemir finishes by around 15:00) is not enough to hold the levels.

My diabetes nurse suggested that I should raise my morning Levemir from 8 units to 9 units.

So, my questions here are:
1. If I raise my morning Levemir, won't this affect my blood sugar by further drop up until 15:00 and how do I address this issue in order to avoid going low.

2. Would some post lunch exercise help to address the rise which occurs around 16:00 and if the case is such, can this help me in order to avoid raising my morning Levemir?

Ofcourse any other suggestions are mostly welcomed!!
Thank you in advance
Josephine.

 

[AndyS]

Hi Josephine,

A couple of observations that I noticed when I switched to Levemir, though I should stress this was just for me.
Injection site does seem to have an impact on the release profile for the Levemir, I was seeing similar profiles to you so I initially tried increasing the levemir and dropping my lunchtime ratio a touch.

This did seem to help a little but then I would see the rise before dinner suggesting that the levemir was running out.
What I do now is intentionally inject the levemir in a site that gives a slow absorption. I tend to do levemir in my backside or on occasion my thigh and this seems to resolve the longevity issue.

Everything else I address by having carb free days so that I can be 100% sure on the basal side of things since I noticed that my bolus does tend to fluctuate in terms of how long it lasts and where the peak activity is.

As a first step it is probably worth you following the DSN/DAFNE educators advice there and up your AM Basal but just be extra vigilant of hypos. If you are concerned and would like a completely clear understanding that it is probably worthwhile to do a day on your current dose but skip breakfast (if you can) and see if the results are similar.

If it were me I would do a couple days or skipping breakfast or lunch and see if the pattern persists. Then I would be what the likely cause of the fluctuation was. The trouble is you will just tie yourself in a confused knot if you try adjusting too many things at the same time without fully understanding the root cause.

Hope you get to the bottom of it and smooth out those levels.

Good luck,

Andy

 

[Bluemarine Josephine]

Hi Josephine,

A couple of observations that I noticed when I switched to Levemir, though I should stress this was just for me.
Injection site does seem to have an impact on the release profile for the Levemir, I was seeing similar profiles to you so I initially tried increasing the levemir and dropping my lunchtime ratio a touch.

This did seem to help a little but then I would see the rise before dinner suggesting that the levemir was running out.
What I do now is intentionally inject the levemir in a site that gives a slow absorption. I tend to do levemir in my backside or on occasion my thigh and this seems to resolve the longevity issue.

Everything else I address by having carb free days so that I can be 100% sure on the basal side of things since I noticed that my bolus does tend to fluctuate in terms of how long it lasts and where the peak activity is.

As a first step it is probably worth you following the DSN/DAFNE educators advice there and up your AM Basal but just be extra vigilant of hypos. If you are concerned and would like a completely clear understanding that it is probably worthwhile to do a day on your current dose but skip breakfast (if you can) and see if the results are similar.

If it were me I would do a couple days or skipping breakfast or lunch and see if the pattern persists. Then I would be what the likely cause of the fluctuation was. The trouble is you will just tie yourself in a confused knot if you try adjusting too many things at the same time without fully understanding the root cause.

Hope you get to the bottom of it and smooth out those levels.

Good luck,

Andy

Thank you for your reply Andy.
The slow absorption site sounds a good idea. I will try this.
Also, one question please. Did you lower your bolus ratio in order to tackle the Levemir overlap?

 

[AndyS]

It depends on the situation.

In a couple of instances I have dropped my bolus a little though usually when I was concerned about hypo and ability to treat one if I had one.
In most cases though I have tended to do a check first (with carb free meal or simply skipping a meal) to be sure it was a basal issue.

Bolus ratio changes I tend to approach by looking at what I need to achieve. For example I know that 1UI = -2mmol/l for me at most times of the day. Last time I changed ratios I was starting out on 1:1 but was seeing a rise of 2mmol (typical lunch for me is ~3.5CP) so where I was injecting 3.5UI I simply added 1 to give 4.5UI then worked backwards to get the new ratio 1.28:1 (UI:CP).

My method is an odd way of doing it and my Drs and Nurses tend to get highly confused by the maths but for me it seems to allow me to make a switch very quickly instead of titrating.

The absolute key things though are:
1) Being sure it is a basal or bolus change required (fasting or carb free to confirm)
2) Being 100% confident in my insulin to BG response. (This I can confirm by checking that the corrections I apply do still in fact drop my BG as expected)
3) Validating the change subsequently which can also include doing another carb free meal / fasting check.

As I said, I do things in an odd way but they seem to work well for me.

To answer your question in your instance (sorry I rambled) I would suggest that if you are concerned about a hypo it might be worth dropping your bolus however if possible I would say leave it so that you can get a clear picture of what is causing the change. Changing both inputs will mean you are having to guess as what caused the output at the back of it all. Hence the carb free lunch to just clear things up before the change.

Confidence you are making the correct change to the correct insulin is often the hardest thing to get, but worth the effort.

Andy

 

[tim2000s]

Hi @Bluemarine Josephine, I have never understood the advice to use more Levemir overnight and less during the day.Typically, in a non-diabetic, the overnight serum concentration of insulin declines overnight, as this graph shows:

It's therefore logical to have more Levemir during the day and less overnight.

What I found was that with 14u taken at around 7am and 8u taken at 9.30pm at night, I mostly avoided too much of a DP/levemir run out hit and managed reasonably flat levels. Obviously you can vary the timing. The modified timing, instead of being 50:50 also helped to manage the run-off time. I also injected the levemir into my buttocks, which seemed to provide a consistent release profile.

It's entirely up to you which approach you take of course, but this worked well for me.