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Lantus low? Help me work it out

Discussion in 'Type 1 Diabetes' started by EllieM, Oct 4, 2020.

  1. EllieM

    EllieM Type 1 · Well-Known Member

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    50 years T1. I'm on a basal/bolus regime, 16-17 units of lantus before bed, 1unit humalog to 3g carb of carb in the day (ratio varies a bit with exercise and time of day), self funding a dexcom due to poorish hypo awareness, particularly whenever my hba1c goes below 50. Hba1c's been running between 47 and 52 for the last couple of years, current estimated hba1c (from dexcom) is about 48. I've been very happy with my post dexcom control, generally not going below 3.8 and though I occasionally have teen readings at night my levels usually stay where I want them. 2-3 hour sessions at the gym per week, plus daily dog walk of 45 minutes to one and a half hours, fair amount of gardening. Lowish carb (50g to 100g a day because I am quite insulin resistant, T2 dad and a bmi of 29).

    So, I was pretty happy with my current diabetic control, but I know have had 2 incidents of what I fear are lantus lows.

    The first one was 4 months ago, my blood sugar plummeted after taking my nightly lantus, and I ended up taking about 50g of glucose tablets as I watched my levels fall (using a glucometer so as to see real time levels after warning from dexcom). It was as though I'd injected the equivalent dose of humalog, and I assumed that it was possible that I had accidently injected humalog instead of lantus. Normally 1 glucose tablet raises me by 2mmol/L so I rarely need more than 2 to raise my levels.

    Last night I had my main meal (indian curry- beef in yoghurt plus plus cabbage in carrot plus a small amount of rice) at 8pm plus 9 units of humalog, blood sugar went from 6.7 before meal to 4 at 10.45, so I obviously underestimated the carbs in the meal and had 2 glucose tablets to push my levels up, and at 12.10am it was 5, and I had my lantus (16 units).

    At this point my bg went into free fall and I got the dexcom low blood sugar warning at 12.25. I pulled out my glucometer, which started in high 3s but went progressively lower as I knocked back glucose, ending up with 40-50g worth of it before my bg started to go back up (dexcom read low and meter about 2.5 before my levels started rising). My dexcom now shows 2.4 as my lowest level, so maybe the LOW was just an encouragement to take more glucose. My lowest reading was at 12.43 and 2.3 according to my glucometer. My blood sugar started climbng at 12.48am and was at 8.5 at 1.30 and at 2.20 up to 11, at which point I had a correction dose of 2 units humalog and the rest of the night it hovered between 11 and 9.

    So, this is what is confusing me. If I had a lantus low, ie all the lantus acts in one go instead of over 24 hours, why did my levels stay steady overnight once I'd corrected the overshoot? I was expecting to have steadily rising levels over night....

    If it wasn't a lantus low, what happened? Yes, I'd had a hypo 2.5 hours after my meal but the humalog should have been out of my system by midnight, not throwing me into a sharp downward descent. But if I had a lantus low, why do I still have basal in my system now (10.20 am in New Zealand).

    Suggestions gratefully received. I've already phoned my DN who has no clue what happened..... Though she did suggest I might have injected humalog earlier into fat (I do have some lipotrophy) and that it was caused by delayed humalog not lantus.

    Only other thought, I've been working on trying to reduce insulin resistance via low carb and exercise, could it have suddenly gone down?

    Will post tomorrow with what happens today, so far everything seems normal, other than a high start of 10.5mmol/L.

    Help?????
     
  2. Antje77

    Antje77 LADA · Moderator
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    To my thinking, most of the Lantus is likely to have ended up where it belongs, doing its thing with fatty tissue to make it work for 20 hours or so. If my thinking is correct (and it's only speculating!), you're now having a reduced dose of Lantus in your system, which nicely fits the waking up higher than usual.

    But again, I'm only thinking out loud here, please don't take my words as gospel.

    In my experience, the one time I had a Lantus low and was sure I wouldn't wake up again, the reaction to the Lantus was a lot quicker than Novorapid would have acted. So it seems there is more to it than Lantus 'only' acting like a bolus insulin.
     
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  3. MarkMunday

    MarkMunday Type 1 · Well-Known Member

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    Not sure what to think about this. That there is not a consistent effect makes figuring it out difficult. While not the same, I also have problems with Lantus. We really should have another choice of basal insulin here in NZ, like Levemir. That could be an option for you. Keep a journal that demonstrates the problem and ask your endo to do a Pharmac NPPA for you (Named Patient Pharmaceutical Application).
     
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  4. EllieM

    EllieM Type 1 · Well-Known Member

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    I like your thinking but the level's been pretty steady overnight.... it just started out higher because of the hypo overcorrection. (Really, it's a miracle I didn't rebound much higher).

    But I was in the process of gradually reducing my lantus again, so I like the idea that maybe just some of it acted fast and the rest is still here.....

    Just nervous about taking lantus now..... I am so glad I have a dexcom.
     
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  5. EllieM

    EllieM Type 1 · Well-Known Member

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    I was hoping you'd post. Do you know what's available? I just phoned my pharmacy and they seemed to think that lantus was all they could get. I could self fund but that won't do any good if there are no other insulins available in the country.....

    Just sitting here in total bewilderment. All that's different is that I haven't had any alcohol for a few days and no cheese (normally snack on cheese and have alcohol every other night...)
     
  6. Antje77

    Antje77 LADA · Moderator
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    Can you switch to another insulin?
    The Lantus low I had scared me enough to pretty much demand it, but I have no idea how this works in other countries.
     
  7. EllieM

    EllieM Type 1 · Well-Known Member

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    NZ only has 5 million people and the pharmac dictated list of available drugs is pretty limited (particularly so for T2s though I hadn't realised that there was only 1 basal for us T1s). Apparently lantus is the only basal available. I don't want a pump because of skin allergy issues.

    I could maybe inject lantus twice a day on the grounds that I'd then only have half the insulin acting fast?

    Make sure my bg is at least 6/7 before injecting lantus, wait 30 minutes (and inject a correction dose of humalog after that if necessary?)

    Never inject lantus until at least 4 hours after my evening pre-meal bolus? (But that pretty well never happens anyway and didn't happen last night)

    Does anyone know how low you have to go before you pass out? (I woke my husband and warned him that he might need to dial 111 if I passed out). I actually didn't feel too bad last night at 2.5 (which is a bit of a worry), but I very very rarely go lower than high 3s because I know my hypo awareness gets much worse if I have too many hypos....
     
  8. MarkMunday

    MarkMunday Type 1 · Well-Known Member

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    Lantus is the only Pharmac funded modern insulin in NZ. The old insulins, Actrapid (Regular) and Protophane (NPH) are funded and I have tried them. Protophane simply has too much within-person variability to be useful. I have found that reducig my Lantus to half of what it was and using Actrapid 3 times a day to fill the basal gap and cover meals works quite well. But I will ask the endo to go through the NPPA process and get me funded Levemir next time I see her. I have used it before and I liked it. Levemir is shorter acting than Lantus and often needs to be injected twice daily, but much more flexible and with reduced risk of unexpected hypos.
     
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  9. EllieM

    EllieM Type 1 · Well-Known Member

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    Thanks, do you think that pharmacies will be able to source levemir though? Both of mine seemed to think that if it wasn't on the pharmac list they couldn't get hold of it, even if I had a script and self funded.... My DN had no real suggestions, had never heard of lantus lows, and wanted it to be because of some left over humalog injected into a fatty deposit.

    Now I'll go and pore through my medical records and find out what I was on pre lantus.....
     
  10. MarkMunday

    MarkMunday Type 1 · Well-Known Member

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    Yes, the pharmacy just has to order Levemir from the supplier (Novo Nordisk) and pay the full price. Novo also supplies Novorapid, Actrapid and Prtophane. I think the Levemir full retail price is NZ$220 for 5 disposable 3ml pens.
     
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  11. Fairygodmother

    Fairygodmother Type 1 · Well-Known Member

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    Hi @EllieM, it’s possible that if you’d underestimated the carbs in your evening meal you’d still have had some Humalog in the system, and a little more than is still active at 4 hours post meal. That would explain the low, not the Lantus, and your liver dumping glucose to help counteract the low blood sugars would explain why you then rose to double figures?

    https://www.diabetes.org.uk/resourc...20of%20Leicester%20-%20Insulin%20Profiles.pdf

    On this chart it looks like Humalog lasts for 5 hours.
     
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  12. Jaylee

    Jaylee Type 1 · Moderator
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    Hi,

    Lantus, oddly with the lows & no fast acting insulin on board for me I can get recurring hypos when treated with just fast acting carbs. Other days my basal is bang on..
    Oddly, on a gig night. (Call it excersise.) normaly haven't eaten since midday or 1pm. I can still drop to the mid to low 3s or stay in a "holding pattern" in the late 4s when my basal should have tailed off hours ago. (Basically 2/3hours late for the shot.)

    Had you started a brand new cartridge when these events happened??
     
  13. EllieM

    EllieM Type 1 · Well-Known Member

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    It's not the fact that I had the low that is the issue, it's the fact that it was so steep and took so much glucose (50g) to pull out from it. Normally a low would take 5g or 10g. 50g is 16 units of humalog for me. Not at all worried by the double figures, as I was knocking back glucose in a panic while I watched my glucose drop lower and lower. I honestly expected it to go up to 15 or 16.

    But there's definitely been some basal in my system today, though maybe not as much as normal - had to do a correction this afternoon as my levels were gently drifting up..... So maybe you're right, I certainly hope so. I can certainly believe that humalog might have caused a hypo then, just not that it would have caused such an extreme one.

    Very very confusing.
     
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  14. EllieM

    EllieM Type 1 · Well-Known Member

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    NO, I'm half way through a cartridge. But I did get my lantus down to 13 earlier in the year, pre lockdown, and had to gradually increase it over the New Zealand winter. I had been running a bit low for a couple of days, so reduced it to 16 from 17 last night.

    Curiously, I find that if my lantus is too low (just by one) then I end up having to give several units of humalog during the day as a correction dose, but I guess that is just because I have much higher insulin resistance when my bg is at 10 rather than when it is 6....
     
  15. Jaylee

    Jaylee Type 1 · Moderator
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    Yep, I get that with Lantus 13 in the hot weather & possibly heavy grafting. 14 when cooler.
    I've no issues with Novorapid corrections, even if I trailblaze the stratosphere. It always seems to be 1u for every 3mmols.
    If I find I'm doing too many correction doses during a day, I ditch the Lantus cartridge for a new one for the next shot.
    Every now & then, one looses potency half to two thirds the way down the cartridge?
     
  16. EllieM

    EllieM Type 1 · Well-Known Member

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    Hmm, I use two cartridges a month (assuming same quantity as lantus.) Not impossible, assuming that the supply chain isn't impacted by covid? It's certainly a lot cheaper than dexcom.
     
  17. EllieM

    EllieM Type 1 · Well-Known Member

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    I've had that, but then found that there was a crack in the cartridge and I hadn't been getting the correct dose for a while.

    I think I'm going to make sure my bg is 6 or above when I go to bed tonight, and it's at least 5 hours since my evening humalog, Plus I'm going to be very careful about my injection site.

    Wish me luck everyone!!!
     
  18. Antje77

    Antje77 LADA · Moderator
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    If I only had access to Lantus, I think I would try the things you are proposing here.
    @MarkMunday mentioned NPH being available, this might be something to look into as well if you want to get rid of the Lantus. I have been on NPH for a couple of weeks before I was changed to Lantus, but this was right after diagnosis so I have nothing sensible to tell on how it worked, I was changed to Lantus because my practice nurse thought NPH was a ridiculous choice.

    After I had my Lantus low and figured out what must have went wrong I decided I'd go back to NPH if my nurse wouldn't agree with a switch to either Tresiba or Levemir. I actually used my old NPH for one night because the thought of taking Lantus again terrified me. This in turn terrified the practice nurse into prescribing me Tresiba the next day, I was very lucky with my practice nurse.

    If you look up the action profile of NPH compared to other insulins, it looks like it has a rather steep start, tapering off over the next 12 to 16 hours. My guess is that it would take quite a lot of hits and misses getting it to work the way you want, likely taking it twice a day and possibly adjust the timing to your meal times as well, and it may well be this affects your mealtime doses too.

    As for how low you need to go before passing out, I think it varies, as I have read from people in the 1's who didn't pass out. For myself, I think I was in the low 2's when my last thought before the light went out was "now don't put your head on that pillow or close your eyes, Antje, you might never wake up again'. Woke up some 2 hours later, thanks to all the sugar and carbs I'd already had, fighting this hypo before passing out. Was around 3 when I woke up again, if I remember correctly.
     
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  19. bmtest

    bmtest · Well-Known Member

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    I have had similar with lantus now in late 50s so i split dose in 2 and it works for me. 8 units b4 bed 8 units at breakfast. Im 40+ years of t1 i have never passed out with hypo but very nearly did one night. Did I inject a full 16 units of Novo rapid ? I dont know but that hypo took me to different planet luckily the kitchen quarry tiles took the pool of sweat. I presume now with hormone changes insulin resistance kicks in as when younger i did not get high readings with low blood sugar carb corrections.
     
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  20. EllieM

    EllieM Type 1 · Well-Known Member

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    Normally I don't have too much issue with highs after hypos, but I only need 5g or 10g to pull me out of it. The problem with my two (suspected) lantus lows is that my bg was going down so fast I just kept knocking back the glucose till my levels started to rise. (Though I did stop at the amount that would cover the full amount of insulin I'd injected if it were humalog instead of lantus). Maybe I should limit the amount of glucose I take, but honestly I'd rather go high afterwards than go into a coma during the experience. Also, it's hard to be that logical when panicking as you watch your levels drop into the twos....

    Last night I injected lantus on a level of 9 4 1/2 hours after my evening humalog (after correcting with a biscuit for a level of 4.4f 3 hours after evening meal). I then waited 30 minutes (no crash) and did a humalog correction dose to put my levels at a steady 6 to 7 over night. Not pretty, I would like to avoid the corrections in both directions, but it did work. Honestly, over the last 48 hours more than half of my carbs have been in glucose tablets. Yuk. I hate hypos.
     
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