If you jumped your lantus up by 38% (say over 3 days and stayed at that level) what would happen?

[Binky21]

Still struggling with the Lantus vs Humalog debate I am having with my Dr.

I am obese, food intake is up to 150gms of carb a day. I wake at 9.0 BG to 11.5BG mainly depending on how long I sleep. If I wake after 5 hours my BG will be 9.0, after 10 hours as high as 12. I usually go to bed at about 8 - 8.5 BG. I eat 4 times a day, 1 small meal, 1snack, 1 larger meal and 1 larger snack. Food is consistent between about 15gms Carb to 50gms of Carb depending on which meal I am eating. I dont exercise. Morning food intake is usually 25grams. 2 L/C Toast and a coffee with milk (15g +10g). I take 44U Humalog and it comes down to about 10.4BG most days.

Dr told me to drop Humalog by 20% (the 44U mentioned above) and to increase Lantus which I did by 30 units or about 38%.

Nothing noticeable happened vis a vis the Lantus but after meal bloods went up from the 8's to high (9 and even 10s). I am still struggling every day with the lower level of Humalog (Almost never see a reading below 8.5 after meals).

So in practice what does this mean (with 38% increase) I am taking 75U Lantus a day and seeing no significant change in my numbers and no low lows. (Below mid 5's in the afternoons if i dont eat for 5 hours).

So is this solely insulin resistance? Or should I push my Lantus up further? or do I tell the Dr to stop being so hung up about which type of insulin I take and insist I get more humalog? I tried empagliflozin and unsurprisingly after a lifetime of candida it was a non starter. I am also on Trulicity that works well and lowers waking bloods by about 14%.

Does anyone else find that they need very large doses of insulin to make a difference to BG? And if so, what is better healthwise? Or are all amounts of insulin equal and the type doesnt matter?

 

[SimonP78]

All insulins should be the same, I don't think it matters from a health point of view, though I can see that trying to bring the average down with basal insulin is probably safer/easier than trying to overlap bolus shots to achive the same effect, perhaps that is why your doctor is suggesting this approach.

Interestingly a change in basal has much more effect per number of units than a change in bolus (e.g. if I spread those units across the day) for me - if I've been really inactive and have upped my basal by say 2U (which is ~10%) and then start doing stuff again I'll be running low all day long and eating like crazy. This doesn't really tally very well with what would happen spreading 2U of extra bolus across the day (i.e. not very much). I've no idea why this is, though perhaps it's different for you.

Sounds like you have dawn effect if your BG is rising in the morning before you get up. Do you carb count, also are you T1 or T2 (description doesn't say currently)?

I certainly find I have to take more bolus insulin in the morning to cover foot-on-the-floor and even then my insulin to carb ratio is different (I need more insulin) unless I can do some exercise straight after eating breakfast.

 

[Chris24Main]

@Binky21 - yes, please confirm whether you are type 1 or 2 - it's pretty critical, because while blood glucose could be similar, almost everything about insulin is the opposite.

 

[searley]

The main reason they want control of your main bg level with lantus is there is less risk of hypos

Also as lantus has a slower absorption rate you won’t get the fast fall fast rise

So the general idea is that the lantus is increased to a level that your bg stays stable over extended periods without food

Then the humalog is taken with food to deal with the fast rise from the food and at this point is where you would take any correction dose for high bg

The reason for this is that unless you get the basal(lantus) right you will constantly yoyo between high and low and would be at longer term risk

The reality is, insulin is insulin the different types just absorb at different speeds.. a pump user would only use the humalog but they would be getting it drip feed in constantly to control the basal requirements in the same way lantus does

In short what the DR is say is correct in that general control should be done with the lantus..

 

[Chris24Main]

@Binky21 advice for type 1 (who is not creating any insulin themselves therefore by definition has not enough) - is totally different to what is appropriate for type 2 (who is almost certainly insulin resistant, generating quite a lot of insulin, and taking more to overcome the resistance).

OP mentions insulin resistance, but we need to know for sure whether type 1 or 2 - Basal and bolus just don't work the same way for a type 2 because you have to realise that your Pancreas has other ideas...

 

[Binky21]

All insulins should be the same, I don't think it matters from a health point of view, though I can see that trying to bring the average down with basal insulin is probably safer/easier than trying to overlap bolus shots to achive the same effect, perhaps that is why your doctor is suggesting this approach.

Interestingly a change in basal has much more effect per number of units than a change in bolus (e.g. if I spread those units across the day) for me - if I've been really inactive and have upped my basal by say 2U (which is ~10%) and then start doing stuff again I'll be running low all day long and eating like crazy. This doesn't really tally very well with what would happen spreading 2U of extra bolus across the day (i.e. not very much). I've no idea why this is, though perhaps it's different for you.

Sounds like you have dawn effect if your BG is rising in the morning before you get up. Do you carb count, also are you T1 or T2 (description doesn't say currently)?

I certainly find I have to take more bolus insulin in the morning to cover foot-on-the-floor and even then my insulin to carb ratio is different (I need more insulin) unless I can do some exercise straight after eating breakfast.

Thanks for that Simon, i was quite surprised to hear that Type 1s get DP too but I suppose when you think about it, the need for greater insulin is a side effect of the cortisol surge so that makes sense. As to your comment on exercising in the AM first thing, I have to admit the only person I know who suffers significantly from it manages to keep it at bay by jogging for 45 mins in the early morning.

I am Type 2 BTW

 

[Binky21]

Chris and Searley. Type 2 for 20 yrs but obese and dont exercise because I am 5 years overdue for a double knee replacement which I cant have for various reasons.

I have always used Humalog in this way because I have a weird pattern of insulin distribution which has not lent itself well to lantus. Initially for a few years, I only needed insulin first thing because I have a fairly severe case of DP. And this would take care of it. After a couple of years. I started taking it with dinner then eventually moved on to Lantus as well. Why i resisted lantus for quite a while is that it is not conduciive to my natural pattern. Which is very high in the AM and then low about early mid afternoon, normalish at Dinner and my fourth snack of the day became a necessity as I would be low going to sleep. So every time I upped my Lantus, I would be struggling with lows twice a day when I could be using insulin 2 to 4 times a day and get no lows and know what my blood was doing throughout.

A few years ago, I was offered the patch meter trial. Decided afterwards it wasnt worth it as I was only out of range (and then not by much) on 2 occassions and only had 1 reading I didnt expect. Otherwise my meter was telling me exactly what i was expecting. Thus it was working well for me despite me having to take hefty humalog doses especially at the AM. Over the last five years, I have gone on to Trulicity but have still seen a real decline in my bodies response to insulin. It could be age related (post menopause) but most likely due to the fact, I dont even move around much because of my knees. I know longer shop or do vacuuming or gardening etc and my weight has been creeping up not hugely but maybe another 5 kgs in the last 5 years,

So 5 years ago, I was on about 100 Humalog a day and maybe 25 of Lantus, Over the intervening time, with it speeding up (the decline which has paralelled my mobility state - now noticeably more limited than 12 months ago), Humalog rose from 100 to 135 and Lantus from 25 to 45.U.

Several months ago went to the GP and said I need to go to 165 Humalog a day because I'm running out of Insulin each month. She said,, no you shouldnt be having that much. What I want you to do is reduce Humilin by 20% and take Lantus up by 30%) so I did that.

What i found was that morning insulin was still very high but with a lower amount of insulin to deal with it, it remained high for 6 -7 hours rather than 3.5 hours. After the 7 hours my blood would crash to the 3s and I would then eat and maybe not have to take insulin at all as I only have a tiny midday snack. Dinner was back to normal but staying higher for longer because of less insulin. 2 hours after my Supper snack, my blood would be down to 7 to 8 before bed with the occasional low in the 5s. So I concluded that taking the lantus up from 45 to 70 was less effective (and more dodgy because of the lows). Next step I took my breakfasts down to 5 to 10gms Carbs (but you get sick of it really quick) in an attempt to get my BG down iunder 8 within $.5 hours, I then also substituted as many foods and food ingredients that I could to lower my overall carb intake across the day. I also rotated sites better which helped a bit.

Now several months later, I am back to 60 units Lantus and maintaining the 20% less Humalog protocol but I hate seeing all the daily readings at 10, 11 and 12 peppered across the day. I like to see my blood at 6, 5 to 7.5 but now I only see that at my late midday snack whilst waiting hungrily for my 5 hours to pass before I can eat again.

At the moment on 60 Lantus, at dinner I pump about 1g of carb for 1 g of Insulin and still see it settle at 9 or more after dinner. In the morning it is 48U of insulin to usually 25g carb and the reading is always 10 or more after 2 hours and will take another 2 or more hours to get down to in the 6s so I can eat again. Re: Trulicity its main value to me has been a lessening of the incredible hunger I was getting from pumping so much insulin as well as about a 1 point drop in my Rising BG reading.

So am I now into peak insulin resistance and insulin isnt the answer. Am I right to think Humalog is more effective for me. Should I try and score a pump to manage the inherent peaks and troughs of BG that I face. Really dont know what to think at this stage. Do I take more Lantus?

 

[Binky21]

I'm assuming it is insulin resistance but is it what I have described?

 

[Chris24Main]

@Binky21 - thanks for the really detailed context. It's very clear that you think deeply about this, and are struggling because of your lack of mobility. I should say that while I have taken insulin for a while (in the past) - it was under the impression that I was type 1, so while I relate to the gist of what you are saying - my situation is very different, and I currently take zero meds (and am definitely type 2).

Insulin resistance is super complicated, and mainly because insulin is super complicated - there are lots of ways to develop insulin resistance that have nothing to do with what you eat, and lots of consequences that have nothing to do with blood glucose. Insulin affects every cell in the body, and has about 100 different effects, and overall is better thought of as being responsible for energy management.

One of the ways of thinking about insulin, as I think you are relaying, is that too much for too long, leads to it being less effective, therefore needing more and more to do the same job (of clearing blood glucose). This leads to higher blood glucose and higher insulin levels.

It also drives up the level of blood glucose that your body treats as "normal" - the energy thermostat if you like. This happens slowly of course.

You describe being intensely hungry. Often, this can be more of a stress thing than a food thing. Your brain needs its share of energy too, and works with it's own energy thermostat - so when it senses less fuel, it triggers a release of stress hormones that essentially go "look! stop everything, I'm hungry and I want you to do something about it now!!". That sounds to me like what you are describing, and driving your need to snack.

All of that is my best understanding of metabolism - I may of course be totally wrong. I also cannot turn any of it into advice. You will understand that I really cannot go anywhere near talking about your dosages.

That said, you may also already know that the way we are set up to feel satiated is more associated with the quality of fats in our food, and that many here have had great success with the effects of both reducing carbs and increasing fat (as proportions) - and that both sides of that equation are important - you talk about the amount of carbs, and I think you get that the lower the carbs, the lower the insulin need (again, over time, some changes are slow).

For me, periods of fasting and increasing fat (with the exception of vegetable oils) in my food was at least as beneficial as reducing carbs and led to discovering lots of foods and ways of cooking that I'd always ruled out.. rich sauces, cheeses, nuts, learning to cook a good steak.. I'm still discovering more good stuff than I'm cutting out, but having done a calorie controlled couple of years ago - and living with that kind of chronic hunger you describe, I'm much happier now not having to feel hungry.

 

[SimonP78]

Are all T2 diabetics seen by GPs rather than hospital consultants? It does sound like with a very variable insulin sensitivity across the day you may not benefit from increasing basal if it's then making you run low (and then need to treat the low). It would be interesting to see what happens in the absence of food (not all in one go, but different time periods split over a number of days). If you can establish when you require the basal insulin to be active, which you may be able to do just from experience, then an alternative might be to move to a "less flat" basal/long acting insulin (e.g. isophane, though I'm no expert) which has a longer activity than the fast bolus insulin (and therefore lower risk), but a much peakier and faster action than lantus (to potentially better suit your requirements).

 

[Binky21]

Interesting. I have never heard of Isophane so will find out more about that. Also interesting to find out that insulin resistance is not just to dp with what you eat and presumably the amount of insulin your body takes in from both internal and external sources so I'll definitely look more at that. I'd assumed that the main problem was obesity - fat cells draw in insulin and therefore you need more insulin to overcome this effect. So it'll be interesting for me to have a good read up on it to see if I am right in my thinking and therefore options. Obviously food is a major one.

Where I live, I have only gone to see a diabetes specialist once in 20 years. The best treatment I ever got was when our surgery trialled a Pharmacist Practitioner and she was up on all the medicines and rules for obtaining them. So for complex issues like diabetes, heart disease and a few others, she would do the prescribing on behalf of GPs (Had to get the GPs sign off) and then off I'd go. i learnt more from her about the medication aspects than I had in years.

Thanks all for your help.

 

[SimonP78]

Interesting. I have never heard of Isophane so will find out more about that. Also interesting to find out that insulin resistance is not just to dp with what you eat and presumably the amount of insulin your body takes in from both internal and external sources so I'll definitely look more at that. I'd assumed that the main problem was obesity - fat cells draw in insulin and therefore you need more insulin to overcome this effect. So it'll be interesting for me to have a good read up on it to see if I am right in my thinking and therefore options. Obviously food is a major one.

Obesity is certainly an issue afaiu, though I don't off hand know the reason why - I'm lean so it's never been something I needed to know. Exercise also increases insulin sensitivity (which is why people often comment about going for a walk after breakfast to reduce FotF and DP effects.) I realise from you said above that this is problematic - is swimming an option out of interest, perhaps not that easy to fit in, but certainly the insulin sensitivity effects last for longer than the immediate duration of the exercise (potentially up to 48h - I find my BG rises across the board if I don't do anything for more than 4 days, so it's likely there are non-acute effects that last for even longer, for me at least!)