help with basal doses

RussG

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Hi hive mind (nods to AndyS)

I was hoping to get some views on morning fasting levels from some other lantus / levemir users. I’m fairly well controlled at the moment (latest HbA1c is 5.1, but I’m trying to bring that up slightly) but my morning levels are stubbornly higher than the rest of the day. Not mega high, but just higher. I moved over to Levemir a few weeks ago to be able to split doses and help with weight gain. I ended up taking 22u of lantus in the morning, but dropped that to 14u after a suddenly going hypo crazy due probably to a honeymoon.

What I realised looking back was that I kept upping my dose of lantus every week or so to try to get my fasting levels down but I was only really pushing my daytime levels down. This was also confused by the fact that I was eating fairly low-ish carb and thus basal was 70-75% of my insulin load.

When I switched to levemir, I kept to my lantus dose of 14u, and split 50:50, 12 hours apart. I’m still taking 7u in the morning, and this may still be a little high, as I’m low 4s by lunchtime and again low 4s by early teatime, both about 5 hours+ after apidra but before I eat my main meal. I’m eating more carbs and exercising more, albeit not with a regular frequency. However, I’ve been creeping my night time levemir doses up due to what feels like stubborn fasting readings. Having graphed it, it looks like something else is at work as the increase dose doesn’t really seem to be pushing my levels down as much as I’d expect. I expected levemir doses to be higher than lantus, but my am doses aren't really massive. I'm currently on a 28%:72% am:pm split.

I often read a little high when I go to bed as I don’t eat until late, however I’ve gone to bed at 4.8 and woken at 6.1 one day and gone to bed at 11.0 and woken at 6.8 a different day. On the day I went to bed at 11.0, I tested at 2am as my son woke me up and was 5.6; I woke up at 6.8.

I suppose my two questions are: a) any thoughts on cause? My levels aren’t really that high, so I was hesitant to suggest DP, and b) what should I do basal dose wise? June’s avg fasting was 7.1 on roughly 10-13u, July’s has been 7.2 on 18u. Should I just accept a fasting level of 7ish and take the lower dose? I guess I should do some more testing at 2am but any thoughts?
 

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noblehead

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Difficult one to answer Russ as I once changed from lantus to levemir and had a awful time trying to get the balance right, even after split dosing I would be fine one day but the next either sky-high or struggling to keep my levels from dropping into hypo territory, overall I just found the unpredictability of levemir difficult compared to the flat 24 hour coverage that lantus provides.

Your slightly raised bg in the morning may well just be DP as your levels are fine in the early hours (2am testing) but increases as the morning moves on, however I would be reluctant to increase the pm dose as you say you are in the low 4's by lunchtime the following day, as I understand it Levemir typically lasts for 18 hours so will still be working by lunch along with your morning dose....hence why I suggest you be careful here.

Given what you have achieved since the switch I think you are doing really well, hopefully someone who uses levemir will be along soon to advise you on how best to resolve these problems.

Nigel
 

Geoff

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Hi Russ- I have been using Lavemir for the last 4 years and have found it very predictable to manage, I split dose using 8units at around 11am and 6umits at around 10pm. I have fin tuned my dosage to fall between a morning reading of 5.8-6.1mmol/lt 95% of the time, the only time that I have higher readings is if I eat a meal later than 7.30pm, then it becomes a bit of a lottery.

Why don’t you tray eating your last main meal a bit earlier than usual and see if things change, my last meal of the day is now always not later than 5.pm, and I just have a light snack if required until I go to bed.
 

ebony321

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Hi,

I find it extremely odd that you have increased from 10u to 18u with little effect?

Have you considered moving your evening dose to a different time? a 12 hour split doesn't always work for everyone.

It may help in preventing what may be an overlap, if you move your evening dose earlier, this will enable it to work more during the night, maybe bringing your fasting levels down, it will also prevent what seems to be an overlap, it seems that it as it's trailing off, your morning dose is starting to work and bringing you lower during the day?

If you want to experiment with moving your doses to a different time, i would advise you do check your BG's through the night as a a rule!

Just a thought, not for everyone but maybe worth considering, especially as your doses are climbing rapidly with what seems to be little effect.
 

RussG

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Thanks guys,

I tend to eat late as I have a young son and it's about 2030 when we've got him to sleep and can start getting our evening meal. I have been having a small snack about 1830 when my son eats as I have been low 4s at that point. I might try shifting that to my main meal and having a small snack later.

I have also shifted my evening injection later actually for the last couple of days. I forgot it about three days ago and only remembered about 2100. I had a better result the next morning so thought I'd try it. It's not made a huge difference so I will consider moving it earlier instead.

I think I will try testing a bit more during the night and see if my levels are okay or high. Very confusing though!

Thanks for your advice.

Russ
 

iHs

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Hi Russ

Unless your bg levels mid morning or mid afternoon are above 9mmol, think about eating a small snack in between meals to ward off low bg. It's hard I think to get bg levels all ok by eating just 3 meals per day and use basal/bolus. Would be great if we could get a straw and suck the insulin that we didn't want to carry on working out :lol:
 

RussG

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401
Hi iHs,

Good advice. I don't really snack if I can help it but I think that's a good suggestion. Will try some of these ideas and report back.
 

Jgos

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Russ

Having read through your posts it sounds very familar. I have ended up going over to the new Omipod pump which is an external pump - I change it every three days and have a CGM as wel, so two things on my arm that dont bother me at all. It takes out the Lantus or Lavemir. Now just on Humalog in the pump 24/7 and no canular probs. Just a thought. The only thing is to keep arms clean. Have a look at the Type 1 cycling team.
Gos