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Splitting Levemir

G

gkinrade

Newbie
Messages
4
Location
Ashford, Kent
I'm fairly new to all this so bear with me! (T1 diagnosed Dec 2010)

I'm currently injecting 18 units of Levemir at bedtime but I'm beginning to think that it's not lasting as my afternoon / evening levels are too high and I'm having to take larger doses to bring my levels back down. Initially it seemed to be lasting but I think I'm coming out of the honeymoon period - total insulin has increased from around 28 units/day a couple of months ago to around 38 or 40 units/day over the last week.

As a result I'm thinking of splitting my Levemir into two doses as mentioned by my DSN but I had some questions:

1) Would I have to take both doses 12 hours apart? Or would at breakfast and at bedtime be ok? (about 7am and 10.30pm ish)

2) Would it just be a case of halving my current dose? (9u am & 9u pm?)

3) Would I expect my first BG the morning after I started this to be high?

Cheers

GK
 
Hi GK

I did this about 4 years ago. In answer to your questions,

1) Breakfast and bedtime is fine if it works for you. It works for me and many others and you already take it at bedtime, so I'd suggest sticking with that (just changing the dose) unless it doesn't work. You probably already know its important to stick closely to the time (10pm or whatever) rather than when you actually go to bed.

2) Start by halving your dose. But do lots of tests (including around 3am) and be ready to adjust the proportions as needed, as you may end up needing a dose that's far from an even split.

3) Yes, but don't worry about it. Its just for one day, you know why, and things will settle over a few days. It'll take some time to settle on the right doses so don't read too much into your first day's readings after splitting the dose. If you know how much bolus you need to correct a high reading, you can increase your mealtime bolus accordingly to keep BG in single figures.

Good luck!
 
Hi GK

Best thing i ever did. I used to take 14u before bed but split it to 12u before bed (about 11pm) and 6u with breakfast (about7am) and reduced the humalog with b'fast, lunch & dinner. It did take a few days to settle, with some bad hypos and highs, so i'd stongly recommend doing it over a weekend and keeping you're diary clear if possible.
 
When splitting there are several things to bare in mind..

When deciding on times of split do take into consideration what time you really want to get out of bed every morning to inject, if you like a lie in at the weekend take this into consideration...

I would start off with a 12 hour split, you might find after a while that you get better results with an off set timed split..

It sounds as though yes your insulin needs have gone up due to coming out of the honeymoon period.. But also be aware over our life times our insulin needs may and often do this just things like growing older changes your activitiy patterns, a move, change of job etc can all lead to having to rethink our control..

As to your percentage of spit, your DSN will be able to give you a good guide to best split to start with if you show her/him your BG results..
 
Thanks for all the advice on this - after speaking with my DSN I have split my doses to twice daily. As for timings, she suggested that I take the morning dose with breakfast and the evening dose with dinner as I tend to have them roughly 12 hours apart. This seems to be working quite well as, whilst I am now doing 5 injections a day, I am only injecting at 3 times of the day.

One thing I either forgot to ask or can't remember the answer to is how do I know if either dose of levemir needs adjusting? I'm working on the assumption that if my morning levels are too high then the evening levemir needs to go up a bit (DSN also suggested checking sugars in the night to make sure that I wan't going low overnight and then waking up with high sugars as a result) but what about adjusting the morning dose?

The DSN said that the QA insulin (novorapid) controls after meal levels and BI (levemir) controls before meals levels - I'd not heard it put like that before - is that something that others have heard / know and if so should I be looking at before lunch and before dinner levels when thinking of adjusting my morning dose of levemir?

Final thing (I promise!) - do people here tend to have a 50/50 split overall between QA & BI? Mine at the minute is more like 60/40 QA/BI....

Cheers

GK
 
Gk,

Everything your DSN has explained is spot on. Your levemir deals with the slow release of glucose from the liver during fasting as where your novorapid deals with the food (carbs) you eat at each meal, provided your insulin to carb ratio is correct at breakfast and lunch then your bg should be pretty much the same as it was before each meal providing you haven't included a correction dose.

The DAFNE (dose adjustment for normal eating) course teaches type 1's to work out their insulin/carb ratio correctly and advises on fasting tests etc, ask your DSN if one is available in your area.

Nigel
 
I have been referred to DAFNE actually but the waiting list in my area is ridiculous (IMHO anyway) - it looks like I could be waiting 18 months...

I'm still a little confused as to how to know if my BI dose needs tweaking...

Thanks

GK
 
Hi GK...several ways to find out whether you need to tweak...depends what you think the issue is, that youare tweaking to avoid really!

As your nurse said...if you are high befoer meals, tweak levimir, if it is after, tweak novorapid. For over night, well, I am afraid the only way I found of tracking whether thisngs were working or not was testing every couple of hours overnight...you are looking to see, what happens when your evening meal and novorapid clear your system. If you stay pretty constant (within, say 2 mmol) then teh dose is OK...even if you start high and end high, this just means that you need more novo for your evening meal. If you see a slow, or indeed rapid increase, or decrease in your levels, you need to tweak your levimir accordingly.

It really is trial and error I am afraid.
 
That's really helpful - thanks :)

Yes - being a mathematician at heart I'm not so keen on trial and error and prefer answers but I'm beginning to embrace a little more uncertainty!

Thanks again

GK
 
A few things about tweaking background insulin;

If you have a hypo during the night, do not wait for a pattern to appear, reduce your next evening dose immediately, you want to avoid those like the plague of course!

I'm not exactly sure how similar levemir is to lantus (i think it may be how it's broken down) so please someone correct me that is experienced with levemir, with lantus (another Background insulin) it's recommended you wait at least 3 days for any changes to have taken effect. It may be the same or different with levemir, i just wanted to raise that point incase it was something you should take into account.

Novorapid has a life of 2-5 hours in most people, so if you go low within this time frame after taking novorapid then it's likely to be your ratios.

If you go low after this timeframe then it is likely to be your levemir that's the problem, it's also the same as not having enough you are likely to see a rise in BG at certain times of the day (which you already spotted hence wanting to split the doses)

You could do a basal fasting test which is pretty straight foward, choose a time block, say breakfast to dinner, basically you eat either carb free foods or no food at all, and you test hourly throughout this, if your BG's stay within 1-2mmol between each test then your basal is good. However if you have a high reading or a hypo then you will hae to abandon the test as it's important you correct these first. Try the same test over around 3 days and you will be able to see if your basal is sufficient or not.

Also regarding the spilt between basal and bolus 50/50 is meant to be ideal, i'm not quite sure why to be honest, i think i asked my nurse before and she babbled on about an indicator of balance, i think it's meant to indicate good control, but i know that not everyone hits this. I certainly don't i take 23.4 units of novorapid as basal, and about 1.5-2 time that much as bolus. It's just the way my levels are i guess, if i were to try to get mine to 50/50 it would be likely to cause havoc for me, i know my nurse would probably like it to be nearer to 50/50 but all she is bothered about is that i'm happy and healthy on my insulin pump :)

I was told my DAFNE waiting list was big too, i had a word with my boss (not sure if you work or not) and explained i NEEDED to go on this course and would they let me have the time off for it if it came up last minute. they kindly agreed. Then i told my nurse i was able to do this at very short notice so if anyone pulled out could i take their place. She said yes. not long after i got a phone call on a thursday i think, could i go the following monday, YES I COULD :) wahoo.

Could be an idea if your able to work around it, if you mention it to your nurse i'm sure that if someone did drop out she would automatically think of you like my nurse did :)

It's well worth going on, i've never heard anyone say it didnt benefit them!

goodluck
 
Hi GK,

I was switched onto Levemir with split doses a few months ago and haven't looked back.
I won't go through everything else again since everyone has already covered everything and you seem to have got it.

You mentioned that you are mathematician at heart and don't like to titrate up/down to what you should be using. Well I'm an engineer (in practice and at heart :) ) so know the feeling. I found a way that works for me though I wouldn't call it good mathematics but it is at least an empirical method.

First off you need to have a reasonable idea of what 1U of insulin does to your blood sugar.
In my case 1U = -2mmol/l.
Given that value you can look to see what your overnight blood sugars do and then adjust up / down based on the fall/rise in BG.
Daytime gets a little trickier but I used the carb free meal option to get an idea by having a cooked breakfast that was carb free and working in the same way.

When I first started Levemir I was on 50/50 but it is actually closer to 30/70 now. Everyone is different.

One thing I will say is that if you see overnight hypos then the rule of thumb is to immediately back off the evening levemir a bit to avoid the night hypos.

Good luck

A
 
My daughter is currently having 2 lots of Levemir a day instead of the original 1, she ha sthem at roughly 7-8am and 7-8pm.

Her ratios seem to be really out compared to everyone else though :?
Currently the Levemir is 10units twice a day and Novorapid is roughly 3units, 3units, 5units.
So her total daily is 20units Levemir and 11units Novorapid
Works out at 64.5/35.5
 
Interesting thread. I originally had a split dose but it was driving me mad, injecting at work or injecting first thing stopped working for me.

I went onto a single dose with my evening meal of 27 units. I find this is enough to cover me for 24 hrs. I guess everyone is different and insulin affects us all in different ways.

I do find, that any change made the night before makes an instant difference. If I wake up with a 9 or 10 for 3 consecutive days, then I'll add one unit, which is enough to bring it down by 2. As long as I keep my exercise consistent then how much each unit lowers my BG's also stays consistent. At the moment thats 2mmol per unit.

If split doses work for you, then for sure that it the way to go.

G
 
g-man said:
I do find, that any change made the night before makes an instant difference.
Click to expand...

I find that is one advantage levemir has over lantus, with lantus it can take 2-3 days before the changes are noticeable.

Nigel
 
I've used both Lantus and Levemir, Levemir changes do take effect quicker.

With regard to timing, I take my morning dose around 7am. On work days this is after breakfast, when I take other medication anyway, whereas at weekends its as soon as I wake up. In practice it may be a little later at weekends, but never by more than 30 minutes. This way I can have a lie-in without compromising my dosing regime.

As I used to take it at bedtime before the split, I did it this way to allow time to remember before I left the house just in case I forgot to take it after breakfast, though I never forgot.
 
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