Help please with Levemir/basal insulin

[lauraw1983]

Hi guys, I need your help, I feel completely confused!

I switched to Levemir from Lantus about 10 days ago, and it's not going well.

I was on 13u Lantus at bedtime, so when they switched me to Levemir we went for 7u/7u split 10.30am and 10.30pm. Knew it would probably need to be more but was the safest option at first.

With Lantus it was running out a bit before the 24 hours (more like 18?) and I wanted Levemir as it's more flexible for exercise etc.

My levels are terrible. VERY up and down (big swings which upsets me!) and even upon studying my DAFNE diary I cannot make head nor tail of WTF is going on with it all. I am having random hypos (another one last night through the night too) and then I will test my BG between meals/for driving and it's nearly always in double figures!! It's not sitting steady barely at all?!

I feel like I have no idea what I am doing, my DP problem seems no better on this than Lantus (which I was hoping it might help with ) All I feel like I am doing is thinking about it most of the day, it's affecting me mentally too and the high BG are making me feel rubbish.

Is it common that I would need a LOT more Levemir? Current dose is 13u this morning, with 12u last night though a hypo last night means I am reducing that back to 10u tonight again.

Is there an easy way to post my DAFNE diary on here for people to look at and see if they can spot where I am going wrong - I feel like I have just been diagnosed again!!

Will be emailing my DAFNE DSN my diary to look at on Monday too but in the meantime over this weekend it would be good to know your thoughts here too. Thanks to anyone with any advice! x

 

[Northerner]

Laura, I'm sorry, I have never tried changing basal insulins so can't advise from any personal experience. I'm wondering though if you need a more uneven split, with the lion's share in the morning to help deal with your DP and daytime highs?

 

[lauraw1983]

Laura, I'm sorry, I have never tried changing basal insulins so can't advise from any personal experience. I'm wondering though if you need a more uneven split, with the lion's share in the morning to help deal with your DP and daytime highs?

Yeah that's kind of my thinking tonight, I think I do need more in the day but am clueless how to split it if not 12 hours apart! Maybe I need to do the Levemir when I get up rather than 10.30am.

I thought taking more at night would help, but it's just causing night hypos so that's not the answer. Going to try 10u tonight and do a 3am test....then maybe up to 15 tomorrow morning. No idea if that's right or wrong though!?

The problem is because I am rarely in target range at all, there are constant correction doses of Humalog which make the picture harder to work out really.

I am also doing a billion tests a day and my fingers hurt and my GP will probably wonder why I have used so many strips lately! Hey ho.

Just absolutely confuddled with it all! Feel like a novice again!

 

[robofski]

Laura,

Sorry you're having such a tough time!

I can't offer any real advise except to let you know what I'm doing, I take 24u of Levemir and I'm 81kg, I split 16am and 8pm, am dose is around 7am, and pm dose is around 11pm but I can often be several hours different on both injections. I find I am VERY stable with this setup, I can wake at 7am with a BG of 6 have nothing to eat until 7pm and my BG will be around 6.

I hope you find the right dose and timing for you soon 🙂

Dan

 

[everydayupsanddowns]

Sorry to hear you've had a rough ride with the switchover

It was something I considered, but never actually did so I dont have any hands-on experience. Are you able to run any fasting tests yet? Have you any understanding of how long Lev is lasting (and whether your doses might be overlapping slightly?

 

[everydayupsanddowns]

Forgot to say Laura - have you seen this snazzy 3d graph that plots average duration/peakiness by units/kg body weight?

http://www.diabetesdaily.com/wiki/Levemir_Speed_Versus_Dose

 

[lauraw1983]

Sorry to hear you've had a rough ride with the switchover

It was something I considered, but never actually did so I dont have any hands-on experience. Are you able to run any fasting tests yet? Have you any understanding of how long Lev is lasting (and whether your doses might be overlapping slightly?

No idea really.

Last night I went to bed on 8.3, hypo at 2.20am so had a mini can of coke (15g carbs) and went back to sleep. At 7.45am this morning it was 6.4 (one of the best morning readings I have ever seen and I thought I'd maybe cracked it a bit!) Took my son to school etc, got back to have breakfast and tested at 9.45 at 12.9.

From then the day just becomes about chasing my levels about, while still trying to love normally - I have places to take my children, friends to see - and at the moment there seems no rhyme or reason to it!

The day followed as this:

10.30am - 13u Levemir
12.38 - 9.8 (before I drove somewhere)
13.20 - 11.9 (a 2mmol rise in 30 mins?!) Ate 45g carbs, took 7u plus 2u correction of Humalog
17.43 - a curious check....13.5 Took a 4u correction as wanted to try to drive those levels down!!!
19.45 - HYPO! 3.0 ! Mini can coke.
20.05 - 4.4. Had dinner, 36g carbs, took 5u Humalog to cover that.

And now sat here waiting to take Levemir again before bed! Will do 10u and a 3am check.

Any ideas?!

 

[lauraw1983]

Forgot to say Laura - have you seen this snazzy 3d graph that plots average duration/peakiness by units/kg body weight?

http://www.diabetesdaily.com/wiki/Levemir_Speed_Versus_Dose

Ooh that is snazzy.........but I wish I could work it out!!! It's late....my BG is crazy....that's my excuse!!😱

 

[lauraw1983]

No idea really.

Last night I went to bed on 8.3, hypo at 2.20am so had a mini can of coke (15g carbs) and went back to sleep. At 7.45am this morning it was 6.4 (one of the best morning readings I have ever seen and I thought I'd maybe cracked it a bit!) Took my son to school etc, got back to have breakfast and tested at 9.45 at 12.9.

From then the day just becomes about chasing my levels about, while still trying to love normally - I have places to take my children, friends to see - and at the moment there seems no rhyme or reason to it!

The day followed as this:

10.30am - 13u Levemir
12.38 - 9.8 (before I drove somewhere)
13.20 - 11.9 (a 2mmol rise in 30 mins?!) Ate 45g carbs, took 7u plus 2u correction of Humalog
17.43 - a curious check....13.5 Took a 4u correction as wanted to try to drive those levels down!!!
19.45 - HYPO! 3.0 ! Mini can coke.
20.05 - 4.4. Had dinner, 36g carbs, took 5u Humalog to cover that.

And now sat here waiting to take Levemir again before bed! Will do 10u and a 3am check.

Any ideas?!

Or even to LIVE normally!!!!!!! Crikey me, what a typo! ROFL!

 

[MaryPlain]

No idea really.

Last night I went to bed on 8.3, hypo at 2.20am so had a mini can of coke (15g carbs) and went back to sleep. At 7.45am this morning it was 6.4 (one of the best morning readings I have ever seen and I thought I'd maybe cracked it a bit!) Took my son to school etc, got back to have breakfast and tested at 9.45 at 12.9.

From then the day just becomes about chasing my levels about, while still trying to love normally - I have places to take my children, friends to see - and at the moment there seems no rhyme or reason to it!

The day followed as this:

10.30am - 13u Levemir
12.38 - 9.8 (before I drove somewhere)
13.20 - 11.9 (a 2mmol rise in 30 mins?!) Ate 45g carbs, took 7u plus 2u correction of Humalog
17.43 - a curious check....13.5 Took a 4u correction as wanted to try to drive those levels down!!!
19.45 - HYPO! 3.0 ! Mini can coke.
20.05 - 4.4. Had dinner, 36g carbs, took 5u Humalog to cover that.

And now sat here waiting to take Levemir again before bed! Will do 10u and a 3am check.

Any ideas?!

Hi Laura

I feel for you - it's very frustrating when things won't go right! From the information you've posted it's difficult to see what is going on because there's so much happening. How confident are you of your ratios and correction factors - is it just the basal that you're worried about?

When I was on MDI I found that the action of my basal insulin was quite complicated when I split it into two doses because each dose was lasting more than 12 hours, so there was some period of overlap. I also found that the duration of Humalog was a lot longer than 4 hours. Once I realised this it became easier to work out what was going wrong. For example I discovered that the night time hypos I was putting down to the Levermir were actually the tail end of the humalog for my dinner - as it was my main meal I was having quite a large dose and larger doses seemed to take longer to be out of my system.

Have you tried missing a meal to find out what is going on when there's only the Levermir working? It's a slow process but once you get there hopefully it will all get easier.

 

[PattiEvans]

Hi Laura

Once I realised this it became easier to work out what was going wrong. For example I discovered that the night time hypos I was putting down to the Levermir were actually the tail end of the humalog for my dinner - as it was my main meal I was having quite a large dose and larger doses seemed to take longer to be out of my system.

Have you tried missing a meal to find out what is going on when there's only the Levermir working? It's a slow process but once you get there hopefully it will all get easier.

Lauralaw, are you still within 36 hours of quitting Lantus? If so then wait for 3 days before doing anything, Lantus does tend to hang around.

You will "probably" need a higher total dose of Levemir than Lantus. Levemir for me lasts approx 16 hours. I inject at bedtime and on waking and it doesn't matter what time those times are - it's very forgiving. Wait a couple of days before trying to find out what's happening, get the Lantus out of your system and then perhaps we can advise how to cope.

 

[trophywench]

Well frankly I'd reduce the overnight because of the hypos and up the morning dose, plus I would have the morning dose when I got up. Not wait to 10.30.

I have told you before on several occasions how utterly lopsided my levemir doses were - 3x as much in a morning as at night (14u and 4u) and it wasn't a 12 hour split, that didn't work at all. Neither did bedtime. Approx 7.30 to 8 am on weekdays; approx 9.30 to 10pm at night.

However if I got up late I'd have it late and if I forgot at night I'd jab at whatever time I remembered or went to bed - which caused me to remember.

Re graph make your screen resolution about 400%, then you can follow the lines easier - or print it because real lines are easier to follow with eg a red or blue pen. You divide your weight in kgs into your dose.

So my am dose - 14u I would divide by (I think) 56 which gives 0.25u per kg. So find 0.25 on the left hand axis and follow the line from that. More or less finished at 14-ish hours but does drag on to 16 hours.
Evening dose - well you can't tell. There was most certainly none of it left when I got up but it was certainly sufficient whilst I was asleep and then for perhaps 10-15 mins after I got up as long as I did get up then. If I stayed in bed not asleep for more than 2 or 3 minutes - I'd pay for it with far too high BG when I did surface. Like I could get up and go to the loo as long as I was still zombie-like when I got back in bed. But if I was more alert, not.

It wasn't ideal. There is no ideal. It certainly worked a lot better than anything in the previous 34 years!

 

[lauraw1983]

Lauralaw, are you still within 36 hours of quitting Lantus? If so then wait for 3 days before doing anything, Lantus does tend to hang around.

You will "probably" need a higher total dose of Levemir than Lantus. Levemir for me lasts approx 16 hours. I inject at bedtime and on waking and it doesn't matter what time those times are - it's very forgiving. Wait a couple of days before trying to find out what's happening, get the Lantus out of your system and then perhaps we can advise how to cope.

Nope been about 12 days now. Lantus will be completely gone.

 

[lauraw1983]

Well frankly I'd reduce the overnight because of the hypos and up the morning dose, plus I would have the morning dose when I got up. Not wait to 10.30.

I have told you before on several occasions how utterly lopsided my levemir doses were - 3x as much in a morning as at night (14u and 4u) and it wasn't a 12 hour split, that didn't work at all. Neither did bedtime. Approx 7.30 to 8 am on weekdays; approx 9.30 to 10pm at night.

However if I got up late I'd have it late and if I forgot at night I'd jab at whatever time I remembered or went to bed - which caused me to remember.

Re graph make your screen resolution about 400%, then you can follow the lines easier - or print it because real lines are easier to follow with eg a red or blue pen. You divide your weight in kgs into your dose.

So my am dose - 14u I would divide by (I think) 56 which gives 0.25u per kg. So find 0.25 on the left hand axis and follow the line from that. More or less finished at 14-ish hours but does drag on to 16 hours.
Evening dose - well you can't tell. There was most certainly none of it left when I got up but it was certainly sufficient whilst I was asleep and then for perhaps 10-15 mins after I got up as long as I did get up then. If I stayed in bed not asleep for more than 2 or 3 minutes - I'd pay for it with far too high BG when I did surface. Like I could get up and go to the loo as long as I was still zombie-like when I got back in bed. But if I was more alert, not.

It wasn't ideal. There is no ideal. It certainly worked a lot better than anything in the previous 34 years!

I'll look at the graph again later. So far this morning...

10u Levemir at 10.30 last night, bed reading 9.4

3am - 8.2

8am - 9.4 Took my Levemir now, to try taking it earlier - took 15u this morning so upped by 2u.

8.50am - breakfast time, 10.7 Had 2 slices toast with peanut butter and low sugar jam, 3.5 CP, took 8u Humalog so tried 2:1 ratio plus 1u correction

10.52 - driving 15.7

13:04- 13.1

Completely stumped and fed up.

What I want to know is even though last night was more stable overnight (yay!) how do I try to drive down the starting/finishing levels to between 5-7mmol?? Is it with QA or with basal that should be doing that?

If I knew I could easily skip meals and have steady levels (which is the point of a basal insulin surely!) I'd feel much happier but at the moment things are just far too high.

 

[lauraw1983]

Aaaaaaaand just to confuse things further.....now at 13.40, before lunch I used a different meter I got at got 9.3 !!

So then, checked my own meter and now down to 10.6 on that - how has it dropped 3mmol in that short time?!?!

ARGHHHHHHH!

 

[randomange]

Aaaaaaaand just to confuse things further.....now at 13.40, before lunch I used a different meter I got at got 9.3 !!

So then, checked my own meter and now down to 10.6 on that - how has it dropped 3mmol in that short time?!?!

ARGHHHHHHH!

Hey Laura. First of all *hugs* I know this sucks! But I suspect that when you manage to get your levemir doses and timings right, everything else will start to make sense. The hard part is getting to that stage!

I'm not hugely surprised by the drop of 3 mmol - your QA wil lbe in full swing two hours after you've taken it, and I saw people at my DAFNE group with a similar profile.

I think you're right in that your overnight BGs look quite stable, and I think once you get your starting number down, you'll be sorted. In terms of getting that number down, it could be two things: if your day time levemir dose isn't right, then that could be what's causing you to be higher before bed; the other option is that your evening ratio is off. Given that your overnights seem to be a bit more stable, you could take a small correction to get down to a lower number by morning.

Can you do some fasting tests? The easiest and simplest way to see if your basal is working is to skip a meal, test often, and see what your BG does. If it stays stable, then great, your basal is doing it's thing. However, if it changes, then you need to adjust your basal before you start thinking about looking at your ratios.

It's difficult, I totally appreciate that, and I think it can take a while to get things sorted out. It could be that your ratios will be different with levemir as your basal, and it's making it much harder to sort things out. I have to admit that I didn't get on very well with levemir, but my numbers were much higher than yours, and I had ketones to boot. I have faith that you just need a bit more tweaking and things will fall into place! 🙂

 

[lauraw1983]

Hey Laura. First of all *hugs* I know this sucks! But I suspect that when you manage to get your levemir doses and timings right, everything else will start to make sense. The hard part is getting to that stage!

I'm not hugely surprised by the drop of 3 mmol - your QA wil lbe in full swing two hours after you've taken it, and I saw people at my DAFNE group with a similar profile.

I think you're right in that your overnight BGs look quite stable, and I think once you get your starting number down, you'll be sorted. In terms of getting that number down, it could be two things: if your day time levemir dose isn't right, then that could be what's causing you to be higher before bed; the other option is that your evening ratio is off. Given that your overnights seem to be a bit more stable, you could take a small correction to get down to a lower number by morning.

Can you do some fasting tests? The easiest and simplest way to see if your basal is working is to skip a meal, test often, and see what your BG does. If it stays stable, then great, your basal is doing it's thing. However, if it changes, then you need to adjust your basal before you start thinking about looking at your ratios.

It's difficult, I totally appreciate that, and I think it can take a while to get things sorted out. It could be that your ratios will be different with levemir as your basal, and it's making it much harder to sort things out. I have to admit that I didn't get on very well with levemir, but my numbers were much higher than yours, and I had ketones to boot. I have faith that you just need a bit more tweaking and things will fall into place! 🙂

That was 4 hours after my QA this morning though? I took it at 8.50am and that was just after 1pm. Then 40 mins later when I was actually going to eat lunch it tested at 10.7 - do we presume then that Humalog lasts longer than 4 hours for me then?? 🙄

The problem with corrections at night, I have done this in the past, but I don't often eat more than 4 hours before I go to bed (busy life with young kids!) so am always a bit more cautious about insulin stacking at that time and peaking when I am asleep!

I was doing a 1:7 ratio for carbs before DAFNE and I think that's confused things a lot too, so today I have gone back to working out my doses the way I was before, dividing by 7 rather than their CP's.

Correction of 1u Humalog bring me down 2mmol usually.

I just had 34g carbs for lunch, took 5u QA for that and a 2u correction.

We'll see where things are at in a couple of hours again.....off out with the kids just now!

I'm quite staggered at the amount of Levemir I need it though (compared to Lantus) and at the moment I'm not sure I'll be sticking with it but will give it a bit longer!! 🙄

 

[trophywench]

So why when your BG was 10 pre brekkie did you only have 1u correction?

You needed at least 2u. You already needed it when you got up! I'd have had it then if I knew it was going to be 30 mins plus till I ate. By the time you've bodged about for half an hour plus, any DP has really got itself entrenched and will prove stubborn*.

Pre bed - no fast acting working and 9.7 - I would correct. But at bedtime, I would only correct down to 7.5. So 1u fast acting would have done it for you, because that Levemir dose did hold you steady overnight otherwise (should be a difference of no more than 1.7 either way in an ideal world) (that's the one none of us live in most of the time)

* I think of what I was told when I had my hysterectomy and had a morphine pump. Doc said I was to give myself a dose of it THE MINUTE I felt pain. He said if you wait till it's got really bad before doing it the morphine will be fighting a losing battle and you need commensurately higher doses to stop it.

High BG after a certain level and insulin are much the same ..... because 1u of my Novorapid normally reduces my BG by 3.0, that's my safety margin. More than about 3.0 over what I want to be (5.5 please) and none of it left in my body from the previous bolus - I'll have a correction. Do that first - then try to work out why it happened after.

Humalog (anecdotally) often lasts a bit longer than Novorapid - Patti reckons it lasts her 5 hours if that's any help? I've never been on it so have nothing to offer myself.

 

[lauraw1983]

So why when your BG was 10 pre brekkie did you only have 1u correction?

You needed at least 2u. You already needed it when you got up! I'd have had it then if I knew it was going to be 30 mins plus till I ate. By the time you've bodged about for half an hour plus, any DP has really got itself entrenched and will prove stubborn*.

Pre bed - no fast acting working and 9.7 - I would correct. But at bedtime, I would only correct down to 7.5. So 1u fast acting would have done it for you, because that Levemir dose did hold you steady overnight otherwise (should be a difference of no more than 1.7 either way in an ideal world) (that's the one none of us live in most of the time)

* I think of what I was told when I had my hysterectomy and had a morphine pump. Doc said I was to give myself a dose of it THE MINUTE I felt pain. He said if you wait till it's got really bad before doing it the morphine will be fighting a losing battle and you need commensurately higher doses to stop it.

High BG after a certain level and insulin are much the same ..... because 1u of my Novorapid normally reduces my BG by 3.0, that's my safety margin. More than about 3.0 over what I want to be (5.5 please) and none of it left in my body from the previous bolus - I'll have a correction. Do that first - then try to work out why it happened after.

Humalog (anecdotally) often lasts a bit longer than Novorapid - Patti reckons it lasts her 5 hours if that's any help? I've never been on it so have nothing to offer myself.

Hi again, sorry v busy weekend just getting a chance to catch up with this! Thank you for your reply, v helpful as ever!

Yes, you are right about the 2u correction of course, my reasoning for it was because of upping the basal and taking it earlier, I was a bit more cautious with the correction just until I found a steady footing with it - I was taking both my children to a birthday party 10.30-12.30 and with driving I'm always a bit more careful! when things are more predictable I'll have more confidence in better corrections!

However the day went on like this:

10.52 - 15.7 (eeek!)
13.00 - 13.1
13.50 - 10.6 Lunch - 5u to cover carbs plus 2u correction
15.49 - 5.7
19.26 - 5.9 Dinner - 8u to cover carbs
22.40 - 7.7

Had a couple of large glasses red wine with dinner....

03.00 - 3.4 (red wine me thinks!) Ate 3 jelly babies
09.01 - 5.3
09.38 - 7.4 (grrr!) Breakfast. 6u to cover carbs plus 1u correction (more aggressive with it!)
11.50 - 7.6 (driving)
13.30 - 8.1 Lunch - 4u to cover carbs plus 1u correction
16.57 - 6.2 (driving)
19.35 - 10.8 (because I nibbled a few things before my dinner so this was expected!) 8u for carbs plus 2u correction
20.00 - Decided to have a dessert 😱😛 9u to cover dessert (!)
23.55 - 9.8 Bedtime - took 1u correction

this morning...10.8 at 7.40am. Took 3u humalog and will check in a while when I am having breakfast.

Have also been taking my Levemir as soon as I get up instead of waiting until 10.30am.

Note to self - don't do it when too sleepy still though, the needle slipped out a bit this morning and some of it ended up down my leg - doh! 😱


Soooo a better day yesterday with it and hoping today will follow suit too...time shall tell!

 

[DeusXM]

Is it common that I would need a LOT more Levemir? Current dose is 13u this morning, with 12u last night though a hypo last night means I am reducing that back to 10u tonight again.

YES.

There are some people out there for whom Levemir simply does not work. I'm one of them. I switched from 26u of Lantus to Levemir. 70u of Levemir every day later, and I was still having to do compensatory Novorapid jabs every two hours just to keep my BGs near 12. My total daily dose of insulin went from around 45u to 120 while my control got worse and worse.

After a week and half of this, I just gave up and went back to Lantus.