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Changing Basal Insulin - Observing what happens and hopefully providing some "lessons learned"

Discussion in 'Insulin' started by tim2000s, Jan 8, 2015.

  1. tim2000s

    tim2000s Type 1 · Expert
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    Having been a little tired last night, and not really thought about it, one of the benefits of the Levemir change should be in the bulking phase of my training, when my carb intake increases. On days when I am training, I'll need to be eating around 80-100g of carbs per day, as opposed to the ~30g at the moment. As a result, my basal requirements will increase. This will have the effect of extending the duration of the levemir dose I am taking (I expect it to become around 16u per dose), so I should start to see the insulin lasting the full twelve hours. This will only be on the training days though, so I will be going up and down a little in the Levemir stakes. Again, the Libre graphs will be extremely helpful in this scenario.

    Boy can managing Diabetes be full on sometimes. Now tell me again why I need DAFNE?
     
  2. donnellysdogs

    donnellysdogs Type 1 · Master

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    I think you would find a pump much easier!!!

    Personally I worry that you are having to analyse the backside out of living with diabetes... It really shouldn't need that much time consuming analysis to be honest.... I understand you want the best control possible but there is life beyond analysis!!

    I wondered the other day what I would do with my 15 mins a day of testing if I didn't have to do it...

    My consultant and dsn told me off for over analysing and trying to get perfection and to relax... So now I do my results are so much better...
     
  3. tim2000s

    tim2000s Type 1 · Expert
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    I think I'm just focusing on this right now because it is a change and I don't want to end up all over the place @donnellysdogs. I tend to gather as much info as I can when doing something like this and I'm in that phase at the mo. I suspect that in a week or so, it will be done and dusted and I'll be bored!
     
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  4. smidge

    smidge LADA · Well-Known Member

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    @tim2000s I can't find the Levemir trial data - somebody on the forum posted it for me when I was questioning why Levemir didn't seem to last very long for me earlier this year - I'll try to find it again later. However, you might find the following of interest. I'm not sure I fully understand it, but the comparisons with NPH in terms of profile and required dosage of both basal and bolus are interesting. As an LADA trying to keep my remaining beta cells as long as possible, I'm also a bit worried about the reference to increased antibodies with Levemir.

    http://www.medsafe.govt.nz/profs/datasheet/l/Levemirinj.pdf

    Smidge
     
  5. tim2000s

    tim2000s Type 1 · Expert
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    Thanks @smidge, will take a look. Further in the basal change saga, I hit the gym tonight just after the levemir theoretically had worn off and saw a roughly 2 mmol/l drop in my bs readings before they started climbing again thanks to whey protein shake. I think the plan is to run 8u over night/6 after the gym, then maybe dose a higher level of levemir earlier in the morning and deal with the effects later in the day. For all the 'flexibility' of this insulin, lantus seems like it was easier to manage at this point in time.
     
  6. tim2000s

    tim2000s Type 1 · Expert
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    A quick update on where I've got to, as weekends seem to be the best time to observe behaviour and fast. 16u daytime to extend the levemir doesn't really work as well as I'd hoped as I spend the day fending off hypos. I'll drop down to 15 before going back to 14, but I think I'm going to have to live with a correction bolus towards then end of the day.

    Of course this also means my carb/insulin ratios are somewhat out of kilter and I've been experiencing the need, with levemir at 16, to only use 1u per around 18g carbs compared with the usual 1:12. Slightly frustrating.
     
  7. tim2000s

    tim2000s Type 1 · Expert
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    It feels like it's been a while, but the progress has been good. I seem to have settled on 6u/8u for overnight (gym/no gym) and 14u during the day as values that provide a suitably flat levemir profile for the majority of the day. The overnight dose doesn't really have the duration and I do have to correct between 7.30 and 9.30 am, but the effect of increasing the daytime dose is that it becomes a struggle to manage late morning/early afternoon hypos. Very pleased with what I've seen this evening!

    [​IMG]
     
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  8. smidge

    smidge LADA · Well-Known Member

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    Hey Tim, I always found a single finger of dark chocolate kit Kat fixes the issues of mid morning hypos. About 7g carb.

    Smidge
     
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  9. tim2000s

    tim2000s Type 1 · Expert
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    Only a single finger? Damnit!
     
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  10. bhk

    bhk Type 1 · Well-Known Member

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    It's nice to read stories like yours. I did start levemir yesterday, as I was on lantus before for something like 9 years. Since 2 years, lantus just did not work anymore ; it was creating a lot of very bad lows. There even was a situation where I had to take more than 200 g. of carbs because of a low that happened 1 hour after I injected the lantus.

    As I do a lot of sports and hard training to keep a good health and a good diabetes management, I realized that for some reason, with my body, especially when I train intensely on a day, my cells will easily recognize lantus and "make its magic work" in an hour or so. The worse part is it is never acting the same way, so I was sometimes taking only 8 units, waking up at 5 am with a big low, sometimes taking 25 units without having any problem. I got so frustrated at lantus...

    However, in 24 hours, things have been kind of good with levemir; i sleep at 9 mmol (170) with an 8 units dose, i woke up at 5.3 mmol (100), and took a second dose of 6 units and it worked pretty fine, without causing any lows. The only thing that I noticed is my body was especially sensitive to insulin when I was at the gym today. (This is another story, but it seems so complicated to do sports as a diabetic; you need to to help managing your sugar and make the insulin more efficient, but it creates unexpected lows at unexpected moments during the day...).

    Shall I also share this information that I red (but haven't verified). Apparently, the duration of the levemir action varies from 6hours to 21hours depending on the dose taken. The stronger the dose, the longer the effect. As our hormones start to make our liver produce sugar at 6-7am, if the dose is too small before sleeping, it might be only to cover the night (something like from 11pm to 5am) which is kind of pointless...

    Anyways, up to now, I have not experienced at all this "I am taking so many units and I wake up with highs" everyone is talking about...

    There we go. I just wanted to share a part of my experience, if it may help anyone to consider important points or hypothesis while solving a diabetes management problem...

    Hopefully levemir will be good... even if as you guys know, anything could change, at any moment...!
     
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  11. tim2000s

    tim2000s Type 1 · Expert
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    @bhk Thanks for your feedback. I wonder whether your issues with Lantus were similar to those I had elsewhere where it wasn't forming a reservoir correctly and then shoots through and causes dramatic lows - there are a few of us on the forum who have experienced this.

    If you look at one of my earlier posts in this topic, there is an operational surface that demonstrates the effective length of operation of Levemir in different doses. I have found that I do better thinking of Levemir as two basals. One for the day and one overnight.

    My overnight dose is 8u when not exercising and 6u when exercising previous to the injection. I find this keeps a flat blood glucose level overnight when fasted. It doesn't seem to provide twelve hour coverage though, so I've come to the conclusion that I need to cover the last 1-2 hours with a correctional dose of fast acting.

    My daytime basal is 14u, as during the day, I do consume carbs, although in small amounts. At 14u, with low carb consumption, I have determined that my glucose levels remain reasonably flat. Again, I don't think the levemir lasts a full 12 hours though, and unless I am at the gym of an evening, I find that I need to provide a correction dose to keep myself on an even keel.

    I've arrived at these levels over a couple of weeks of basal testing and a bit of trial and error. It seems to work. My biggest issue is that to push the duration of the insulin up, I have to increase the dose to a level where managing my levels becomes that much harder. This can at times be frustrating!

    I do wonder whether I should run my daytime basal slightly higher anyway and allow it to account for the gluconeogenesis that I see due to the protein content of my diet instead of managing it with boluses. Neither really seems optimum.
     
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  12. smidge

    smidge LADA · Well-Known Member

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    Glad the Levemir's settling for you Tim.

    I've sort of settled on 5.5 units of Insuman Basal at night and 7 units Levemir in the morning. The Insuman seems brilliant at catching the late protein rise and any DP. I sometimes need a chocolate or jelly baby mid morning, but other than that I seem to have got rid of most of the lows by reducing the Apidra slightly and letting the Insuman help cover breakfast. I've also had to reduce lunch time Apidra but I'm not sure why. I've also only needed one correction bolus in the last month whereas I was using quite a few when only on Levemir as my basal. Not too sure why this regime is working for me, but it does seem to be. I had intended to try replacing the morning Levemir with Insuman, but I think I'll leave well enough alone for now and continue with the three insulins. I think Insuman lasts longer for me than Levemir for some reason.

    Smidge
     
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  13. tim2000s

    tim2000s Type 1 · Expert
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    As I mentioned on the thread "Lantus Users", the other thing I've noticed is that the blood glucose levels are actually just more stable on Levemir than on Lantus. I won't go into the reasoning in this thread but anyone reading can find out why here: http://www.diabetes.co.uk/forum/threads/lantus-users.67760/
     
  14. tim2000s

    tim2000s Type 1 · Expert
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    Another observation from looking at Libre patterns is that I've discovered that I do get dawn phenomenon from just about when the alarm goes off. Under the lantus, my bg levels were so variable that I couldn't see it. The more time I'm spending on levemir, the more I'm appreciating the lack of control I was really seeing with Lantus. That is a rather scary thought.
     
  15. tim2000s

    tim2000s Type 1 · Expert
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    Finally downloaded the libre data and taken a look at the reports. The results are really quite interesting.

    The Libre has revealed some surprising results. On the Lantus, the 10th-90th percentile breadth of readings is significantly wider than on Levemir (there are more higher and lower readings, and the higher ones are significantly higher.

    From what I can see from the data, I seem to have less variance and more consistency across the day. This is the set of results on Lantus:

    [​IMG]

    And this is the set for the last month of Levemir:

    [​IMG]

    For me what is interesting is the bandwidth of the results has clearly narrowed, and early morning Hypos have reduced. There is a noticeable increase compared to Lantus at the 10am timeslot, and this is as a result of the overnight Basal running out with Levemir, which I've clearly not fully tamed yet. Bringing that in line will be hugely helpful.

    The other thing of note is the shape of the 10th-90th percentile band versus the median. With the Levemir, the 10th to 90th (10/90) clearly tracks the median, whereas with the Lantus, there is a noticeable difference the pattern. This might relate to the variable absorption I was seeing with the Lantus.

    The other thing I note is that the Libre is now estimating a normal Hba1C, which I'd be very pleased with. Just need to get the variance under control...
     
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  16. tim2000s

    tim2000s Type 1 · Expert
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    As a somewhat late addition to the topic, having now been running with Levemir for 2.5 months, I thought I'd come back with an update. The Libre provides some useful information, and I think it's fair to say that I have a much better level of control compared with where I was with the Lantus. I'll update the graphs once I have attached the reader to my PC.

    More importantly, over the last thirty days, my average glucose levels have been reported at 6.8mmol/l, which is an Hba1C of 5.9% and will end up as my lowest ever:

    [​IMG]

    What's probably more important is that on the daily patterns, the number of lows below the 3.9 mmol/l mark I've put as my lower bound has reduced significantly, and I think my variability is substantially better. Okay, it's not the tight line of someone on a strong LCHF run, but I'm pretty pleased with it!

    [​IMG]
     
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  17. crumpy

    crumpy Family member · Well-Known Member

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    What levemir split do you do now Tim? Those results look really good.
     
  18. tim2000s

    tim2000s Type 1 · Expert
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    I'm still working to 14u daytime basal, 8u night time, 6u on gym nights.
     
  19. iHs

    iHs · Well-Known Member

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    @tim2000s

    Im afraid that I wouldnt want to try to achieve an a1c as low as yours unless I had cgm but even then I think I would more or less be kissing my driving licence goodbye as without cgm, I would be at grave risk of not being able to recognise the hypo feeling until bg levels had dropped extremely low and no consultant is going to want that for anyone in the name of good control. So, good luck with levemir and the Libre.
     
  20. tim2000s

    tim2000s Type 1 · Expert
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    @iHs, that's completely understandable. Having the Libre has meant that I pick up blood glucose dropping symptoms better, when not in Hypo, and am able to treat earlier, which has been a very useful revelation.
     
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