NICE guidelines say must have Lantus!!

[pippaandben]

Saw my nurse today and asked to change from Humalog mix 25 to a basal/bolas regime - preferably Levemir and either Novarapid or Humalog.
She did accept all my arguments over the change and I demonstrated I already had a good understanding of carb counting. From the details on here I have the carb counting ready reckoner and the "picture" book showing portion sizes.
Have had absolutely rubbish readings for the past month due to going on holiday to the Red Sea before Christmas( temperature 75-85), catching a stinking cold towards the end of the holiday and then Christmas and New year and so definitely feeling NOT in control at all. According to OH I've been having mood swings and finished up crying in front of the nurse which is not me at all.

She saw GP an they have agreed to change my regime but want to wait a fortnight to make sure I am fully recovered from any effects of the cold which is understandable. What I do not understand is that accxording to the GO the NICE guidelines say that I MUST go onto Lantus rather than Levemir. I said that I wanted freedom to split the dose if necessary, that I had heard Lantus makes you gain weight - which I am desperate not to put back on and that the injections are supposed to sting some people. No comment. So I asked if Lantus was cheaper and the nurse said no comment!!

So questions. Do I have any say? I want to be in control so feel I want the ability to use half or single units - Is this possible? Or are there a variety of pens which may be offered to me. Currently I have the Humapen HD but unless they prescribe Humalog for the fast acting then I will be given another - that is a waste of money. Can anyone provide me with the exact link to the relevant Nice guideline they are quoting? She is proposing 10 units Lantus in a single dose - don't know if am or pm. I think I read on here that Lantus can also be split? She says 5 units Breakfast, 5 units lunch and 8 units dinner for fast acting BUT surely I will be counting for that adjustment?

For the next 2 weeks I am going to carb count and provide the nurse with the details as to what corrections and dosage I would have given myself if I had been on the new regime to prove to her that I do understand what I need to do to look after myself. Have also done the BEDC diabetes learning programme on line.

What other info or arguments can I provide? Why do we have to fight every inch of the way? Uuuuuuurgh. Feel better now!!

 

[Pumper_Sue]

If that's the case then ask to see the guidelines
Also if that was true no other insulin would be on the market.

 

[Northerner]

I found the following document, which only seems to discuss lantus (insulin glargine):

http://www.nice.org.uk/nicemedia/live/11482/32518/32518.pdf

However, I also found this document, which when talking about basal insulin says both insulin glargine (lantus) and insulin detemir (levemir) :

http://www.nice.org.uk/nicemedia/pdf/CG87ShortGuideline.pdf

The latter document is dated May 2009, the former December 2002, before levemir was approved. I'm guessing there's a document somewhere that says they are interchangeable, will have a hunt! We've had lots of MDI T2s here on novorapid and levemir, I reckon they are out of date with their nkowledge at your GPs!

edit: No the second document is the one - see page 44 of the document:

Recommendation 1.1.21
Consider switching to a long-acting insulin analogue (insulin detemir, insulin
glargine) from NPH insulin in people:
who do not reach their target HbA1c because of significant hypoglycaemia

 

[everydayupsanddowns]

Quite right Alan

An update to the guidelines is currently in progress. If I understand correctly there was no Levemir on the market when the earlier one was written!

The scope for the latest update will include other insulins that have become available in the meantime (degludec?)

 

[novorapidboi26]

I might be wrong but Lantus may be cheaper than Levemir and so they might want to put you on that first........

Some people manage just fine on Lantus, even though it is a lot less flexible for things like alcohol and exercise......

I would give it go seeing as your coming straight off a mix, it will allow for less variables when your getting used to testing the dose.....

Good luck........😎

 

[trophywench]

Not very much difference in price, frankly -

Injection, insulin glargine (recombinant human insulin analogue) 100 units/mL, net price 10-mL vial = ?30.68; 5 ? 3-mL cartridge (for ClikSTAR? and Autopen? 24) = ?41.50; 5 ? 3-mL Lantus? SoloStar? prefilled disposable injection devices (range 1?80 units, allowing 1-unit dosage adjustment) = ?41.50

Injection, insulin detemir (recombinant human insulin analogue) 100 units/mL, net price 5 ? 3-mL cartridge (for NovoPen? devices) = ?42.00; 5 ? 3-mL FlexPen? prefilled disposable injection device (range 1?60 units, allowing 1-unit dosage adjustment) = ?42.00; 5 ? 3-mL Levemir InnoLet? prefilled disposable injection devices (range 1?50 units, allowing 1-unit dosage adjustment) = ?44.85

 

[pippaandben]

I found the following document, which only seems to discuss lantus (insulin glargine):

http://www.nice.org.uk/nicemedia/live/11482/32518/32518.pdf

However, I also found this document, which when talking about basal insulin says both insulin glargine (lantus) and insulin detemir (levemir) :

http://www.nice.org.uk/nicemedia/pdf/CG87ShortGuideline.pdf

The latter document is dated May 2009, the former December 2002, before levemir was approved. I'm guessing there's a document somewhere that says they are interchangeable, will have a hunt! We've had lots of MDI T2s here on novorapid and levemir, I reckon they are out of date with their nkowledge at your GPs!

edit: No the second document is the one - see page 44 of the document:

Thanks for the link Northerner. Have found several appropriate quotes eg p.69 "There were situations in which glargine or detemir could be recommended after a trial with NPH" and P75 "no convincing evidence to recommend one long lasting analogue in preference to another"
Will print off the relevant pages for the surgery. Can you confirm if lantus can be split dose?
The only cost linked evidence I could find in the guideline was that levimir base is 0.52 u/kg and lantus 0.44u/kg - and this would appear to be minimal. Has anyone on here started on Lantus and then changed to levimir - why and how difficult was it?

 

[Northerner]

Thanks for the link Northerner. Have found several appropriate quotes eg p.69 "There were situations in which glargine or detemir could be recommended after a trial with NPH" and P75 "no convincing evidence to recommend one long lasting analogue in preference to another"
Will print off the relevant pages for the surgery. Can you confirm if lantus can be split dose?
The only cost linked evidence I could find in the guideline was that levimir base is 0.52 u/kg and lantus 0.44u/kg - and this would appear to be minimal. Has anyone on here started on Lantus and then changed to levimir - why and how difficult was it?

Yes, a lot of people split lantus because of differing needs during the day and night, or because the lantus doesn't last the full 24 hours it's supposed to for them. The only difference between splitting lantus and levemir seems to be that the effects of a change to levemir become apparent more quickly than lantus. With changes to lantus they normally recommend only making changes once every two or three days, with levemir no need to wait more than a day.

Lots of people here have changed between the two - more usually from lantus to levemir I think. As TW states above the costs are negligible unless you are using gallons of it, and even then not a huge difference. I would personally hold out for levemir since you are only just starting out as it seems to be easier to predict 🙂

 

[pippaandben]

Yes, a lot of people split lantus because of differing needs during the day and night, or because the lantus doesn't last the full 24 hours it's supposed to for them. The only difference between splitting lantus and levemir seems to be that the effects of a change to levemir become apparent more quickly than lantus. With changes to lantus they normally recommend only making changes once every two or three days, with levemir no need to wait more than a day.

Lots of people here have changed between the two - more usually from lantus to levemir I think. As TW states above the costs are negligible unless you are using gallons of it, and even then not a huge difference. I would personally hold out for levemir since you are only just starting out as it seems to be easier to predict 🙂

Thanks for that. Another ickle question, I currently use the Luxura humapen HD which I would be able to continue with if they give me humalog for basal. I am used to it and like the fact that not only is it in half units but I control the speed of injection rather than a spring injection.

Do you know what pen systems are available for Lantus (or Levemir) that use a similar system and also measure in single or half units. I just need to know my options. I am not interested in disposable pens but 3ml cartridges which I am used to.

 

[Northerner]

Thanks for that. Another ickle question, I currently use the Luxura humapen HD which I would be able to continue with if they give me humalog for basal. I am used to it and like the fact that not only is it in half units but I control the speed of injection rather than a spring injection.

Do you know what pen systems are available for Lantus (or Levemir) that use a similar system and also measure in single or half units. I just need to know my options. I am not interested in disposable pens but 3ml cartridges which I am used to.

The pens for lantus all only deliver in single units (or two units)and have a very poor reputation for build quality. Levemir can be used in the same pens as novorapid, so you can use half-unit pens like the Echo, plus you control speed of delivery - the only thing you need to be careful of is getting the pens mixed up if you use both novorapid and levemir! 😱

 

[trophywench]

Yup, me!

Lantus wasn't addressing my basal needs, always hypo in the early hours whatever I did with it, however I split it. Plus it always stung, not ewhen the needle went in, but immediately I pushed the plunger down, whereas that didn't happen and hadn't happened before with any other insulin ever in the preceding 30+ years. I'd have put up with the stiging if it had done it's job.

So more or less in desperation I changed to twice daily Levemir, with the number of correctioins I was having to have all the while, I was already on far more than 5 jabs a day anyway ......

More or less instant relief. I found Levemir a LOT more predictable and thus, far easier to adjust. None of this waiting 3 days to see if the adjustment had worked, I knew withing max 12 hours whether it had with Levemir. OK so I wouldn't correct the dosage again for a few days ever on any insulin and have always made very conservative changes when I have altered it (but generally on such low doses anyway, a very small adjustment can make a huge percentage difference - like they say limit it to max 10% at a time - eg when one of my doses of Lev was 4u at night, the smallest adjustment was (then) 25% of that ! The morning dose landed up at 14u - so 1u was 7%)

The words I use to describe the advantage for me of Lev over Lan, is that Lev is much more 'biddable' - ie responds to changes well, without kicking up a fuss.

 

[Abi]

On the one hand you may well ( and in fact probably will) be fine on lantus
However it seems as if nursie is pushing this upon you as she lacks knowledge regarding levemir.
If you are type 2, even if the product does not always give 24 hour cover, it is quite possible that residual endogenous insulin would kick in at the tail end of the dose if it was not lasting
Many people can get good control on lantus once daily plus rapid for meals

However it is totally unacceptable for a health care professional whose job it is to advise diabetic patients, to be unfamiliar with the range of insulins and when splitting the dose might help
Would anyone accept an oncologist who denied a cancer patient necessary chemotherapy due to lack of familiarity with that drug or combination?