Type 1 Lantus... AGAIN UGH help please!

[alphabeta]

Hi... my BG was 19.5 before taking Lantus/after 2.5 hours of dinner. Just in matter of 3 hours it managed to drop to 13.1
I have been getting a lot of these 2 hours drop and this is soooo unusual!!!! It drives me crazy and depressed!
Now emotions aside I have came up with few hypothesis:
1. Low fat area? I tried rotating but still I got drops.
2. Too much Lantus? First, it shouldn't drop me within 2 hours that fast. Lantus barely starts working by 2 hours and I know this from testing and comparing my BG data. Second, I am on 10 units Lantus now which account for about 25 to 30 percent of my TDD. I tried basal testing and I had drops through the night but then rises through the morning.
3. Building on basal testing results, I seem to have 2 basal ratios, low for the night and high for the day. (Correct me if i am wrong) should I ask for for a different basal or simply split Lantus? (My appointment is due on November 9th)
4. Knowing that Lantus stops the breakdown of fat (glyconeogenesis???) Can such a small dose be enough for me to gain weight?

I am totally lost and can't continue like this till November 9th. Weight is 57kg and dropping height is ~175cm
Correct me if I'm wrong at any point and share your thoughts. Much appreciated.
Edit: Am I on the path to a pump? I really can't do that... Is it possible that my body doesn't simply accept Lantus anymore?

 

[kitedoc]

Hi @alphabeta, Based on experience as a TID, not professional advice or opinion.
Just to clarify: you took your Lantus in the early evening and your BSL 2 1/2 hours after your evening meal was 19.5 mmol/l and then at the 3 hours mark (? 3 hours after the meal or is it 2 1/2 +3 hours = 5/ 1/2 hours later) your BSL was 13.1 mmol/l. But what was your pre-meal BSL ?
What about short-acting insulin ? was this taken before your evening meal also? For instance, my Novorapid seems to peak at 3 hours after a meal and unless I delay eating for say, 45 minutes or more, my BSLs can tend to 'escape' the Novorapid's full effect.
The Novorapid seems (always a guessimate) to last up to 5 1/2 to 6 hours.
Also if I eat quick-acting carbs (years ago!! e.g. sweet biscuits etc) my BSL rises quickly , might peak at nearer1 1/2 to 2 hours and still stay high for for sometime before being dealt with and have no sustained effect, compared to if i have Indian food where my BSL tends to peak nearer the 3 to 3 1/2 hour mark and gradually falls over 2 more hours.
On your given insulin figures you have a Lantus dose of 10 units and your short acting insulin per day is about 24 to 30 units.
So do factors like the type of meal or the dose of short acting insulin or the relative proportions of basal to bolus insulin, one or several, have something to do with your results ?
What does your dsn or doctor say? Answers to the above questions might help untangle things ?

 

[Alison54321]

I think @kitedoc is asking the right questions here. 19.1 is rather high, was that after your evening meal? how much fast acting did you take? It might be that that is causing the drop.

You could move your Lantus dose to the morning, it does tend to have a bit of a peak a few hours after taking it, and you wouldn't have that at night if you moved it to the morning.

 

[alphabeta]

Hi @alphabeta, Based on experience as a TID, not professional advice or opinion.
Just to clarify: you took your Lantus in the early evening and your BSL 2 1/2 hours after your evening meal was 19.5 mmol/l and then at the 3 hours mark (? 3 hours after the meal or is it 2 1/2 +3 hours = 5/ 1/2 hours later) your BSL was 13.1 mmol/l. But what was your pre-meal BSL ?
What about short-acting insulin ? was this taken before your evening meal also? For instance, my Novorapid seems to peak at 3 hours after a meal and unless I delay eating for say, 45 minutes or more, my BSLs can tend to 'escape' the Novorapid's full effect.
The Novorapid seems (always a guessimate) to last up to 5 1/2 to 6 hours.
Also if I eat quick-acting carbs (years ago!! e.g. sweet biscuits etc) my BSL rises quickly , might peak at nearer1 1/2 to 2 hours and still stay high for for sometime before being dealt with and have no sustained effect, compared to if i have Indian food where my BSL tends to peak nearer the 3 to 3 1/2 hour mark and gradually falls over 2 more hours.
On your given insulin figures you have a Lantus dose of 10 units and your short acting insulin per day is about 24 to 30 units.
So do factors like the type of meal or the dose of short acting insulin or the relative proportions of basal to bolus insulin, one or several, have something to do with your results ?
What does your dsn or doctor say? Answers to the above questions might help untangle things ?

Hello kitedoc always good to see you!
To answer your questions, my BGL was 11.8 before dinner at 9:00 PM. Took my Humalog for my meal and it was 19.5 at 11:15PM (I find that Humalog is faster than NovoRapid, more consistent and quickly absorbed). By 11:15PM Humalog is done reducing my BG and I took my Lantus. 1 hour after taking Lantus my BG was 18.4 and 16.0 on a different meter (I trust the 18.4). Another hour later it was 16.3. Another 30 minutes it was 13.1 after which I corrected with fast acting sugar and went to bed feeling all sorts of different stuff. Now, you might say that 13.1 is not low, well true but it was plummeting at an increasingly faster rate, and my sugar doesn't usually drop within 2 hours!. If anything, it rises! So to see a drop just after taking Lantus that's totally mind-twisting!
I have another theory, is there a kind of counter reaction due to low dose in which Lantus does try to compensate against?

 

[alphabeta]

I think @kitedoc is asking the right questions here. 19.1 is rather high, was that after your evening meal? how much fast acting did you take? It might be that that is causing the drop.

You could move your Lantus dose to the morning, it does tend to have a bit of a peak a few hours after taking it, and you wouldn't have that at night if you moved it to the morning.

My Humalog dose is pretty much consumed by the time I take Lantus. Moving it to the morning seems like an idea and will consider it. Thanks Alison!

 

[urbanracer]

Hello kitedoc always good to see you!
To answer your questions, my BGL was 11.8 before dinner at 9:00 PM. Took my Humalog for my meal and it was 19.5 at 11:15PM (I find that Humalog is faster than NovoRapid, more consistent and quickly absorbed). By 11:15PM Humalog is done reducing my BG and I took my Lantus. 1 hour after taking Lantus my BG was 18.4 and 16.0 on a different meter (I trust the 18.4). Another hour later it was 16.3. Another 30 minutes it was 13.1 after which I corrected with fast acting sugar and went to bed feeling all sorts of different stuff. Now, you might say that 13.1 is not low, well true but it was plummeting at an increasingly faster rate, and my sugar doesn't usually drop within 2 hours!. If anything, it rises! So to see a drop just after taking Lantus that's totally mind-twisting!
I have another theory, is there a kind of counter reaction due to low dose in which Lantus does try to compensate against?

Couple of things....Humalog activity peaks at about the 2 hr mark for most users. It carries on working for up to 2 hours more.

Google 'Humalog insulin profile' for more info. (If I wasn't in my phone I'd give you a link.)

Lantus is known to cause sudden BSL drops. I am not sure if the details (and I might be talking rubbish ) but if my memory is up to scratch, it can sometimes crystallize under the skin and then dissolve suddenly thus causing a large drop in BSL's.

 

[alphabeta]

Couple of things....Humalog activity peaks at about the 2 hr mark for most users. It carries on working for up to 2 hours more.

Google 'Humalog insulin profile' for more info. (If I wasn't in my phone I'd give you a link.)

Lantus is known to cause sudden BSL drops. I am not sure if the details (and I might be talking rubbish ) but if my memory is up to scratch, it can sometimes crystallize under the skin and then dissolve suddenly thus causing a large drop in BSL's.

Humalog does last for 4 hours as maximum but the lowering effect ends about after 135 minutes for me. I know this by testing.
Regarding the Lantus drop, any idea how to solve this? I tried new batch new pen etc.. still no positive outcome

 

[urbanracer]

Humalog does last for 4 hours as maximum but the lowering effect ends about after 135 minutes for me. I know this by testing.
Regarding the Lantus drop, any idea how to solve this? I tried new batch new pen etc.. still no positive outcome

Are you receiving any professional guidance with your insulin dosing? It seems to me that something isn't quite right with the numbers you've given here.

I'd suggest that if your BGL rises by 8mmol after eating then your carb to insulin ratio is wrong. The only reason your Humalog stops working after 2 hrs is because you have not taken enough.

Regarding Lantus, where on your body are you injecting long acting insulin? Do you use a different site to short acting insulin?

 

[alphabeta]

Are you receiving any professional guidance with your insulin dosing? It seems to me that something isn't quite right with the numbers you've given here.

I'd suggest that if your BGL rises by 8mmol after eating then your carb to insulin ratio is wrong. The only reason your Humalog stops working after 2 hrs is because you have not taken enough.

Regarding Lantus, where on your body are you injecting long acting insulin? Do you use a different site to short acting insulin?

I have been given guidance but I am totally okay with Humalog, it is just I ate extra bread that requires 2 extra units. I do know how to calculate my doses properly. I use different injection sites for long and short. I am going to test a new theory tonight which is splitting 10 units into to different sites. 5 units in each thigh. What do you think?

 

[kitedoc]

Hi @alphabeta, To make best sense of things a 24 hour period of pre-meal plus 2 hours post meal BSLs would probably help. And as others have suggested: basal testing.
I could not find any reports about sudden or unexplained low BSLs for those taking Lantus but am happy to be proved wrong.
Some medications seem to increase the blood sugar lowering effect of Lantus so any history of other medications taken regularly could help sort things out.
Conditions like poor kidney function can affect the breaking up and removal of insulin from the body of insulin leading to increased and sometimes longer insulin effects. (see monographs of most insulins).
Higher BSL levels might be associated with ketones formation. What if the lisopro was working against high BSLs and some ketones and the last effects of the Lispro and the beginning of the Lantus was associated with relatively increased insulin sensitivity? Add to this: had you undergone any exercise in the hours late afternoon/early evening before having your late dinner? Such exercise might have caused BSL lowering hours later.
I hope that is clearer than mud !!

 

[urbanracer]

I have been given guidance but I am totally okay with Humalog, it is just I ate extra bread that requires 2 extra units. I do know how to calculate my doses properly. I use different injection sites for long and short. I am going to test a new theory tonight which is splitting 10 units into to different sites. 5 units in each thigh. What do you think?

I doubt it will make any difference personally.

You cannot expect to see meaningful results from daily changes to basal insulin, it doesn't work that way in the body. Usual advice would be to keep basal changes at least 4 days apart to accurately assess the effect.

 

[alphabeta]

I doubt it will make any difference personally.

You cannot expect to see meaningful results from daily changes to basal insulin, it doesn't work that way in the body. Usual advice would be to keep basal changes at least 4 days apart to accurately assess the effect.

My point is to keep the 10 units the same but injecting at different sites because less Lantus will probably pool better in each injection site. I want to test a hypothesis that maybe Lantus is not pooling properly thus causing these fast drops within an hour. Then I could build based on the outcome.

 

[urbanracer]

Hi @alphabeta,
....................I could not find any reports about sudden or unexplained low BSLs for those taking Lantus but am happy to be proved wrong.
...............

I just had a quick look and came up with this although not exactly scientific.........
https://www.healthcentral.com/article/lantus-lows-continued

@alphabeta , there are a couple of other things that might be worth reading :-
https://www.diabetes.co.uk/forum/threads/lantus-and-hypos.59350/

You guys, how's the memory!............
https://www.diabetes.co.uk/forum/threads/lantus-crystallization.155605/

 

[alphabeta]

I just had a quick look and came up with this although not exactly scientific.........
https://www.healthcentral.com/article/lantus-lows-continued

@alphabeta , there are a couple of other things that might be worth reading :-
https://www.diabetes.co.uk/forum/threads/lantus-and-hypos.59350/

You guys, how's the memory!............
https://www.diabetes.co.uk/forum/threads/lantus-crystallization.155605/

Hahaha the memory is still okay I can remember important events in my diabetes journey! Other than that I barely remember what i had for breakfast
I have read the second thread but something is telling me that this is not my case because I did very very well on 19 units before bedtime previously. I am theorizing the low fat hypothesis since I lost so much weight! Thus lower fat... I lost weight due to high BGL and faulty stupid Lantus. I will check tonight and post my results here to keep a record for future buddies

 

[alphabeta]

Update: today at 2 AM I took 10 units of Lantus, split into 2 injections 5 each. I injected offset to the right side of my right thigh from the center line and offset to the left side of my left thigh from the center line. The injection was the smoothest ever because I don't inject in that area. My sugars went down from 21.0 to 19.5 in 2 hours (I was running high because I was not able to access any insulin since lunch time 12 hours earlier and consequently no dinner) then down to 15.2 by 8:30AM (this drop is expected because I didn't have dinner the night before) then down to a minimum of 10.3 by 11:30 AM. This confirms that Lantus was not pooling properly thus causing these fast drops. And now the fun of basal testing begins AGAIN!
@kitedoc I am interested in your opinion on this matter

 

[tim2000s]

You might want to read these. They discuss how Lantus has a higher risk of hypos and why:

https://www.diabettech.com/lantus/h...hy-you-should-try-tresiba-if-youre-on-lantus/

https://www.diabettech.com/diabetes/lantus-lethal-or-lifesaver-doc-gbdoc/

You might also want to have a read of this about how long insulin lasts. I can guarantee you that you will still have active Humalog in your body at 135 minutes, as fast acting insulins take around 55 minutes to clear 50% of what you've injected: https://www.diabettech.com/insulin/...n-action-dia-times-we-use-and-why-it-matters/

Coming back to your original question, I moved to Levemir from Lantus once I'd identified a similar problem, and was able to use it as a split dose effectively. It brekas down very differently from Lantus, and if you are exercising and finding that you have different overnight needs, it clears from your system much more quickly, so would offer you the ability to be more flexible in your dosing.

For what it's worth, 10u at 2am dropping you from 21 to 10.3 9.5 hours later doesn't necessarily indicate that you're having too many problems with absorption. That is more likely to signify that your dosage is wrong. When Lantus doesn't pool correctly, those drops occur over a few hours (less than three in my experience, and you can find yourself going from 12 to 3 in that time.

 

[alphabeta]

You might want to read these. They discuss how Lantus has a higher risk of hypos and why:

https://www.diabettech.com/lantus/h...hy-you-should-try-tresiba-if-youre-on-lantus/

https://www.diabettech.com/diabetes/lantus-lethal-or-lifesaver-doc-gbdoc/

You might also want to have a read of this about how long insulin lasts. I can guarantee you that you will still have active Humalog in your body at 135 minutes, as fast acting insulins take around 55 minutes to clear 50% of what you've injected: https://www.diabettech.com/insulin/...n-action-dia-times-we-use-and-why-it-matters/

Coming back to your original question, I moved to Levemir from Lantus once I'd identified a similar problem, and was able to use it as a split dose effectively. It brekas down very differently from Lantus, and if you are exercising and finding that you have different overnight needs, it clears from your system much more quickly, so would offer you the ability to be more flexible in your dosing.

For what it's worth, 10u at 2am dropping you from 21 to 10.3 9.5 hours later doesn't necessarily indicate that you're having too many problems with absorption. That is more likely to signify that your dosage is wrong. When Lantus doesn't pool correctly, those drops occur over a few hours (less than three in my experience, and you can find yourself going from 12 to 3 in that time.

I will read your articles later
I didn't say that the drop from 21 to 10.3 over 9.5 hours is an absorption problem! I did have the problem with absorption as you said that I get a drop by 5 to 6 mmol/l within 2 hours. I latter is an absorption problem. The update included a note explaining that the drop over 9.5 hours was expected because I had no dinner and I fasted unwillingly from 2 pm yesterday till my breakfast today at 11:30 AM. Sure thing Levemir seems a better bet but honestly I just want to continue with Lantus in the mean time because I am really tired of all the drama lately with my diabetes. I want to sleep so bad and I have midterm exams next week (I'm a college student so sleep is super important). With all the drama, changing to Levemir also adds to it. I am thinking of switching to Tresiba but I want to gain my health, both physical and mental, back and I have to focus on my studies now.

 

[kitedoc]

Hi @alphabeta, As suggestions, not professional advice or opinion, what @tim2000s has to say and quote is well worth reading.
I had not come across the comparison trial of Tresiba vs Lantus ( his first reference) and the results appear to me to be disturbing regarding Lantus's tendency to cause more hypos.
A trial comparing Lantus to Levemir and Levemir to Tresiba would have been nice to have if that had been possible!!
I have never been prescribed Lantus as my doctor at the time opined that Levemir had a more flexible dosing and adjustment regime, as @tim2000s mentions, and there was concern at the relative tendency for Lantus to stimulate cell growth compared to Levemir. mcgill.ca Insulin analogues and cancer: a cause for concern or cause celebre? Pollak and Russell-Jones Int J Clin Pract 2010, 64, 5.
The second reference about onset of earlier than expected and more severe hypos with presumed injection of Lantus into muscle, instead of subcutaneous tissue is something I believe you may have experienced (trying to remember the thread?). What I would query is whether the same problem would occur to the same degree with injection of any long-acting insulin into muscle. The admonition to avoid injection of insulin into muscle seems clear (at least unless specifically ordered with short-acting insulin).
The third reference and point raised about duration of insulin action and the fact that with basal-bolus regimes there are insulin on board type effects whenever a short-acting insulin is injected during the concomitant action of basal insulin. That fact and the graphs illustrating it may help explain your BSLs in your initial post of this thread.
My further take on things is that you seem to have varying times that you take your Lantus, you mention the episode (? or more) of lack of access to insulin and the pressures of study.
Although basal-bolus/ multiple daily insulin doses gave me greater flexibility in my early working years, in order to keep control of my BSLs I still needed to have regular timing of injecting my basal insulin and ensure I did not become sleep deprived.
I would not expect my long-acting insulin to deal with high BSLs alone and knew from experience that high BSLs took time to be corrected even with use of short-acting insulin. The longer and higher the BSL remained to more risk over time of later problems.
I would suggest your ability to achieve and manage your study is unlikely to be helped by continually high BSLs, an irregular insulin regime and ? irregular meals. It cannot be denied.
I know this may not be what you wish to hear but in my early working life as a trainee doctor in hospital where things can easily become chaotic it was clinging to as regular an insulin and food regime as possible that make it possible for me to survive.
Please see/find a dsn and doctor who you can discuss your diabetes management with, who can discuss with you the pros and cons of your current insulin and regime and how to keep as much balance as possible on the tightrope of diabetes control.
Sincere and Best Wishes !!

 

[alphabeta]

Hi @alphabeta, As suggestions, not professional advice or opinion, what @tim2000s has to say and quote is well worth reading.
I had not come across the comparison trial of Tresiba vs Lantus ( his first reference) and the results appear to me to be disturbing regarding Lantus's tendency to cause more hypos.
A trial comparing Lantus to Levemir and Levemir to Tresiba would have been nice to have if that had been possible!!
I have never been prescribed Lantus as my doctor at the time opined that Levemir had a more flexible dosing and adjustment regime, as @tim2000s mentions, and there was concern at the relative tendency for Lantus to stimulate cell growth compared to Levemir. mcgill.ca Insulin analogues and cancer: a cause for concern or cause celebre? Pollak and Russell-Jones Int J Clin Pract 2010, 64, 5.
The second reference about onset of earlier than expected and more severe hypos with presumed injection of Lantus into muscle, instead of subcutaneous tissue is something I believe you may have experienced (trying to remember the thread?). What I would query is whether the same problem would occur to the same degree with injection of any long-acting insulin into muscle. The admonition to avoid injection of insulin into muscle seems clear (at least unless specifically ordered with short-acting insulin).
The third reference and point raised about duration of insulin action and the fact that with basal-bolus regimes there are insulin on board type effects whenever a short-acting insulin is injected during the concomitant action of basal insulin. That fact and the graphs illustrating it may help explain your BSLs in your initial post of this thread.
My further take on things is that you seem to have varying times that you take your Lantus, you mention the episode (? or more) of lack of access to insulin and the pressures of study.
Although basal-bolus/ multiple daily insulin doses gave me greater flexibility in my early working years, in order to keep control of my BSLs I still needed to have regular timing of injecting my basal insulin and ensure I did not become sleep deprived.
I would not expect my long-acting insulin to deal with high BSLs alone and knew from experience that high BSLs took time to be corrected even with use of short-acting insulin. The longer and higher the BSL remained to more risk over time of later problems.
I would suggest your ability to achieve and manage your study is unlikely to be helped by continually high BSLs, an irregular insulin regime and ? irregular meals. It cannot be denied.
I know this may not be what you wish to hear but in my early working life as a trainee doctor in hospital where things can easily become chaotic it was clinging to as regular an insulin and food regime as possible that make it possible for me to survive.
Please see/find a dsn and doctor who you can discuss your diabetes management with, who can discuss with you the pros and cons of your current insulin and regime and how to keep as much balance as possible on the tightrope of diabetes control.
Sincere and Best Wishes !!

Hello @kitedoc
I understand what you are saying completely. I do agree with what you said and yes I had a scary experience with Lantus before, but to be honest it was my mistake because I injected into the top of the upper arm (imagine you are seeing me from the side, your eyes would be directly on the top of my upper arms). I injected 19 units directly into a muscle not into a fatty area and that was because I simply didn't know to be honest. Afterwards, I learned that I have to inject in the back of the upper arms. I do seem to have an irregular scheduale regarding my basal and that's due a simple reason: I have a weekly commute from my city to my parent's house at Friday night and back to my city at Sunday night. There is no specific time when I leave and when I return. By the time Lantus is due, I'm on the highway. I do inject my basal as soon as I arrive and that was my case yesterday where I arrived back pretty late! Regarding my high BSL, believe me, I do not like it, it is ugly, and constantly thirsty. Throwback to previous spring, I had a very very tight control over my BG because I understood completely how each unit of insulin affects me without even carb counting! The highest sugars I had were before bed (when I inject Lantus, usually around 10-12 mmol/l then i wake sometimes below 5 mmol/l) and before dinner around same range sometimes a bit higher if I delay my dinner. You might think 12 isn't a great number. Well indeed but it is MUCH better than the spikes from <8 mmol/l fasting to 17+ after breakfast! I was like this for 9 years ever since I was diagnosed in 2009 till January 1st 2018 then I switched to basal/bolus on Jan. 2nd.
My doctor didn't even care to tell me that it is wrong! I actually thought that all diabetics are like this until I came here and saw that some folks don't even go above 7.0. If it wasn't for dawn phenomenon, I still wouldn't be here probably. After spring ended this year, my bolus decided to die (expired March 2018) and my Lantus to spoil by heat (I keep it in the fridge all the time now). It wasn't until 25th August until I knew that my Lantus is spoiled by heat. I managed it better, then had to change the apartment so more stress and skipping meals. Now I have settled, I have learned from my mistakes and I think I am better equipped to fight diabetes. Sorry for the veeery long reply but it helps to pour my troubles out. I do feel sorry for what happened to me with the bolus because I have lost so much weight (64kg to 56.5kg lowest!!) After having a dream control I never achieved before... I can only hope it goes better and tomorrow is a new day

 

[tim2000s]

What I would query is whether the same problem would occur to the same degree with injection of any long-acting insulin into muscle.

It won't. the way that Levemir and Tresiba work is outlined in that article. They have no need to form a precipitate and can circulate in the blood happily, as the way they work is to cause the body to "unfold" them over a period of time, negating the risk of fast absorption.