Lantus - what's protocol here?

[Spiker]

Yes I would go with what @ConradJ said. It's important to split the doses but also important to keep the quantities low. She is dropping so fast when the Lantus kicks in, it's incredible.

Do you have a pen that does half units? They probably don't even exist for Lantus. But you can use Lantus in a Novopen junior pen (child's pen with half unit markings) if you take the top of the insulin cartridge (or maybe that's the other way round). Quite a few pens have half unit doses and I think you are going to need that very soon. If not a pump.

 

[ConradJ]

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.

Agreed.

I suspect your previous quip that the "off licence " med has some unexpected effect on diabetes may be closer to the mark than we're prepared to believe - perhaps it's 'kick started' islet cell activity or increased her sensitivity to the point of an olympian???

 

[Spiker]

Without saying any more about the off licence med, another possibility is that it has shut down her normal basal glucose (glycogen) output from the liver, which is more or less the only reason us T1s need basal insulin at all, otherwise we would just use bolus insulin.

 

[ButtterflyLady]

Without saying any more about the off licence med, another possibility is that it has shut down her normal basal glucose (glycogen) output from the liver, which is more or less the only reason us T1s need basal insulin at all, otherwise we would just use bolus insulin.

I am learning so much about diabetes via this thread! And I keep watching it because I am interested in how mirror's daughter is doing after her near miss experience in hospital. I want to know she is doing well and I will be interested to see if any action can be taken against the hospital, because whatever led them to give her way too much insulin needs to be addressed in case someone else gets hurt.

 

[tim2000s]

Is it possible that Lantus is not pooling properly for some reason? That would explain the rapid drop.

 

[Spiker]

Is it possible that Lantus is not pooling properly for some reason? That would explain the rapid drop.

This is also what I've been thinking. I can't quite think how it would be happening unless what's in the cartridge isn't actually Lantus.

 

[Spiker]

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

OK I missed the 1u of Novorapid
This (and maybe the 1u of Lantus but I doubt that) dropped her 15 mmol/L in 5.5 hours despite taking on 70g of carbs during that time. This is insane insulin sensitivity.

Anyway I need to rethink what I was saying about her sensitivity to Lantus as I missed the 1u of Novo.

Please give times on everything from now on. From the above it was unclear when the 1u of Novo 1 u of Lantus was between 1230 and 1420. In a later post you clarified it was 1240 for the Novo. I know you are under a lot of pressure but the details will help us help you.

 

[Spiker]

What was the reason for the 1u Lantus at 1240 by the way? Her normal 1/daily Lantus dose is at around 10pm right?
It will not help to nail things down by chucking random bits of Lantus into the mix. A very important principle in getting blood glucose profiles right is to only change one thing at a time, until you have proven a pattern, and only then move on to changing some other factor. We are already hugely bending the rules by making one change every 24 hours, rather than one change every 3 days, and that's only justifiable because we are trying to avoid the acute danger posed by hypos.

So please, no more than one change, in one thing, per 24 hours.

I would still go with Conrad's advice and split to something like 2u/4u at bedtime / waking. So not a 12 hr even split, an 8hr/16hr time split with a one third / two third dose split. If that's what Conrad was saying, I may have misunderstood. Anyway the important thing is not the timing so much but the unequal dose size split.

 

[mirror]

Ok I misunderstood on the timing of the split
She got to 12.30 and I thought #hit, I should have done the split dose!
So we got home about 15 minutes later and gave a unit of novorapid (to bring the bm down)
And a unit of lantus (to keep it falling to bedtime- as it'd been rising in the day previously )
Anyway bm at bed (10.55 pm ) Was 3.4, at 11.30 was 5.4

No lantus given as at this point we're worrying and thinking about correcting highs with novorapid
2.30 am bm 3.1
I know I've probably done the wrong thing again inadvertently trying to do the right thing.
It's bank holiday weekend and I want to keep her out of hospital if humanly possible.

 

[mirror]

5.00 seizure 2.7bm
Glucagon

 

[ButtterflyLady]

5.00 seizure 2.7bm
Glucagon

Sorry to hear.

 

[ConradJ]

Sorry to hear.

Likewise.

I hope you are all recovering (this must be so frightening and stressful for you, let alone horrible for your daughter).

@mirror

Without knowing the off licence med (and I'm not asking you to divulge), I'll go with @Spiker 's suggestion that it's stopping liver production of glycogen, in which case you should go with a really low dose of lantus for nights.

At this point, I would give no more than 1 unit; but if you have a syringe or pen that can do 1/2 units then only give 1/2 a unit.

I would also inject the lantus at 7 pm as the earlier lead time will help you gauge it's effect before you all crash for the night; it might also increase the early hours levels slightly as the lantus wears off earlier.

The other option - if the presumption about the off licence med is correct, would be not to give her any lantus at night and monitor her levels hourly, giving a very small dose of Novorapid if they start to rise too much.

As @Spiker said, you don't want to change more than one thing at a time; at this point, with such risks occurring during the night / early hours, it is crucial you solve the night - time. (For your health as well.)

That said, the effect of daytime actions will be affecting the night; I do think you need to reduce the carb content of the meals to a maximum of 50 grams - testing both before and 2 hours afterwards.

Post those events and that should help us all get a better picture of how things are working.

 

[mirror]

Her 7 am bm was 8.2
Didn't have lantus last night
Will give a unit of novorapid when bm is in the 20s due to the big drop that will occur
As far as g of carbs in the food - definitely can do bm pre food and 2 hours after but not going to be able to limit meal to 50g
It's Hard for me to get her to eat most of the time
We'll have to take what we get.

 

[Spiker]

I know I've probably done the wrong thing again inadvertently trying to do the right thing.

Don't worry we've all done that, many times. Comes with the territory really with diabetes.

 

[Spiker]

5.00 seizure 2.7bm
Glucagon

Oh ****. :-(

 

[Spiker]

:'-(

 

[mirror]

Just got to say nhs 111 are great.
Rang up to ask for an out of hours doctor to give a prescription for more glucagon (got one left but just in case)
Had a call back within 20 mins and told to go to our local tesco at 10am when it is open and 2 glucagon would be waiting
No begging or huge explanations needed

 

[Spiker]

I agree with ConradJ again. I was going to say the same things.

 

[Spiker]

You need a half unit pen or failing that a bag of U100 disposable insulin syringes. You should be able to get these from a chemist if you take the insulin prescription. Preferably your regular chemist. Explain she has become highly insulin sensitive and you need to reliably deliver doses of less than one unit multiples.

 

[Spiker]

Here is something that is probably contributing to the problem that I want to be sure you are aware of. After a hypo the body has depleted its own glycogen (what Glucagon releases). Its next priority is replenishing this glycogen because it is the last line of defence. So after a hypo you see a rebound - first a BG rise due to the glycogen, then a BG fall due to the restocking of the glycogen. She will actually need carbs and insulin for the restocking. But her apparent insulin sensitivity will be extremely high during the post hypo restocking of glycogen.

It's possible to get into a cycle of continuing hypos because of this seesaw mechanism.