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Questions:- Levermir and Lipohypertrophy

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Cheesecake

Active Member
Relationship to Diabetes
Type 1
Hello,

I’ve a couple of (unrelated) questions which I thought I’d bung together rather than swamp the forum.

1) I‘m using a split dose of levemir, I normally wake about 7am, go to bed at 10pm. Is it best to do it at these times or 12 hourly? So evening dose at 7pm rather than bedtime at 10pm?

2) I think I might be experiencing lipohypertrophy in my thighs and bottom, but I’m not sure. I’m trying to rotate as much as possible, use a fresh needle every time. It’s not like lipohypertrophy like I’ve had in the past from area over use. It happens every injection site and it’s quite painful and sore for a day and then goes. I can tell exactly where I’ve injected in the last 24 hours. I wondered if it might be cellulitis? My levels seem ok, no exceptional highs or lows, which is another thing that makes me wonder it’s not lipohypertrophy?
 
Firstly, your Levemir doses should ideally be ideally 12 hourly. If you inject your morning dose 7 hours after your bedtime dose, you are adding insulin to insulin already on board. That’s not necessarily a bad thing, if your control is fine.

Second thing, it’s not cellulitis. It’s probably just old injection sites moaning. You didn’t mention abdominal injections. Have you tried rotating round your abdomen? Really you could inject anywhere you can reach that has a layer of subcutaneous fat.
 
It may depend how you split your doses. I take 2.5 to 3 units at 10pm, and 5 units at 8am. So 10 hours apart, (yours are 9hrs apart, I don’t know where Mikeyb got 7hrs from) This seems to work for me, if the morning dose does overlap a bit with the bedtime one, it’s coming at a point where I need an extra boost to counteract the Dawn phenomenon. And also, my bedtime dose is so small, I suspect it’s all but spent by 8am.
 
I inject my morning Levemir at 7am and I was injecting my evening dose at bedtime which could be anywhere from 11pm-1am and that worked fine for me for ages. Like @Robin my doses were a very uneven split with much less for the evening dose. Just recently my levels have been going high on an evening around 8-10pm which is clearly a basal issue because I often skip meals and I have Libre to monitor it and I have been having to inject corrections of quick acting insulin at bedtime to bring levels down which wasn't ideal. I have now started injecting my evening Levemir earlier to help counteract that problem and increased the evening dose slightly and decreased the morning one correspondingly and that seems to be helping, so whilst the official advice is to split Levemir 12 hours apart, like everything diabetes related, it is worth experimenting to find out what works best for you. It was convenient for me to inject at bedtime and that worked for a long time but now the goal posts have moved and it doesn't work anymore so I have had to go back to 12 hours apart for now which is not perfect, but working better.

As regards the lumps when injecting, could it be you are hitting small blood vessels. I had one yesterday which caused a right bleb in my buttock which has almost gone now but can still just feel it and it was sore! I would be surprised if that is happening often though. Is it just with the Levemir or your bolus insulin as well? If just the Levemir, could it be an allergic reaction?
 
Thanks!

I’m not sure if I made my timings clear, sorry. I inject 18U Levemir when I wake, around 7am and, currently 16U when I go to sleep, around 10pm, so 15 hours. I was wondering if I should aim for 12 hourly, so moving from 10pm to 7pm?

I’ve been doing the BERTIE course and following the advice there, levemir into thighs or buttocks and Novorapid into stomach. I currently not got an issue with MDI into my stomach. I’m currently on a ‘pump holiday’ from my Omnipod due to site issues, my thighs should of had a 5 year rest so I’m a bit worried they’re reacting so quickly.
 
I was asking my DSN about Lipohypertrophy recently as I had read we were all likely to experience it after injecting for 10 years and I had not noticed anything after 17 years. She told me it would be very noticeable if I had lipo lumps and not something I would be questioning.
 
Cheesecake said:
I inject 18U Levemir when I wake, around 7am and, currently 16U when I go to sleep, around 10pm, so 15 hours
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Yes, but just 9 hours between injections during the night which was what was being commented on. This sort of timing used to work well for me although I needed much lower dose in the evening otherwise I hypoed. If that is working well for you and keeping levels steady then no harm in continuing with that spacing.

If you are only seeing problems in your Levemir injection sites then I would wonder if you are having an allergic reaction to it, especially of you haven't used those sites for 5 years. Did you use Levemir as a basal before you started pumping or were you on another basal?
 
Ah ok, I’m not hypoing overnight and often wake up with differing levels, I have young children and often get woken in the early hours. I’ve always struggled with my waking levels. I think it was what I used to do when I was on MDI before so I didn’t question it, but now we have to be quite set timings on my sons medications and I know more about the impact this can have, so I wasn’t sure what the advice was. When I first went on levemir is was a once daily like Lantus.

I did used to use levemir before, and you’re right, I hadn’t realised but it’s my levemir sites which are the issue. I think I have had lipohypertrophy before, it was never sore or painful like these are. I might try my levemir in my stomach for a few days and see what happen?
 
I’ve grabbed a picture of the worse one, not sure if that helps though! The others are more feel than to look at.

D3DE767A-1667-4789-8F1F-39ED81194B54.jpeg
 
That does look like a nasty weal. Is it itchy at all or just sore? I think you should discuss it with your DSN if every injection of Levemir is doing that. It clearly isn't that you are hitting a blood vessel, so looks like some sort of reaction but don't think it it Lipohypertrophy. Let us know how it goes with your stomach?
 
Not itchy just very tender. I’ve done my dinner novorapid in my thigh, deliberately in a different location and I can already feel a slight lump. Will try my levemir in my stomach tonight. I’m not noticing my levels are high in all of this, which is what I would expect if it was lipohypertroph? I wondered if it’s the needles? I’ve also changed my levemir cartridge to one from a different batch.
 
I wondered if it might be the needles but if you are not seeing the same problem in your stomach then unlikely. I can't see why they would cause a problem in your thighs and buttocks but not in your stomach but I believe I have read that some people have had adverse reactions to the needle coating when they have changed brands.
 
I think this is an injection site reaction as opposed to lipohypertrophy
 
Thanks, I guess I’ll try to talk to my team next week.

To put it into context, I was having issues with my sites on my Omnipod which is why I took a break and went back to MDI. I was finding when I changed a pod, within a few hours, I was extremely high and often had ketones. This was happening with every 3rd pod on average, across all sites (apart from arms). I was finding I was getting ketones more and more easily and was exhausted. I was missing meals as I was too high or too worried to eat. I’d only just moved from the old Omnipod to a Dash, but asked if maybe I should try a tubed pod with different cannula options. I was basically told that I didn’t have ketones, or if I did they were fasting so were normal (they were actually after breakfast) and that I’d signed for 4 years with the Dash so had to stay with it unless I could prove it was causing the issues. At that point I was back on MDI and I didn’t want to go back on the pod just to prove it wasn’t right.

Sorry for waffling. I guess to sum it up: I think my skin is causing issues regardless of method of delivery and I don’t feel my team listen or have time for me.
 
This doesn’t look like the lipo issues I’ve had, those haven’t really been anything to look at and not something I’d noticed but something that the DSN could feel under the skin. That round circle looks like a reaction to the insulin or the needle. If you try injecting your rapid insulin into your thigh (away from the levemir), do you get the same thing happen or is that fine? If it only happens with levemir then I’d suggest trying a different basal. If it happens with both levemir and novorapid then it could be the needles.
 
I’m becoming more & more convinced it’s an allergic reaction, just to the levemir. I injected last nights and this mornings doses into my stomach (where I normally do my novorapid) and they’ve both reacted. They’re also itchy. I did my novorapid into my thigh, and while I had a small lump, it’s now gone and it nothing like the others. I’ve tried levemir and needles from different batches but the outcome feels the same.

This is all fairly recent (the last 6 weeks or so) and I wonder if it could be stress? I’ve had a lot on. I’ve got terrible indigestion for the first time ever as well as feeling really tired and have a headache.
 
Cheesecake said:
This is all fairly recent (the last 6 weeks or so) and I wonder if it could be stress? I’ve had a lot on. I’ve got terrible indigestion for the first time ever as well as feeling really tired and have a headache.
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I believe those symptoms can also be allergic responses. I would be surprised if stress would cause weals just at injection site. I could understand it if you came out in a general rash over an area of your body but unlikely to cause such a localized response.
I wonder if the coating on the needle may be creating a reaction in combination with the Levemir. I believe different brands of needles are coated with different lubricants to help them glide in more comfortably, so trying needles from a different batch would be unlikely to help. I would ask to try a different brand of needles and see if that stops it. Out of curiosity, which needles are you using and are these the same brand as you used before going on to a pump?
 
I can’t remember when I went back to MDI, but it definitely was a few months ago, the reaction isn’t connected directly, unless it has been building slowly over the months.

I‘m using BD Viva (?) 4mm needles now, I can’t remember what the ones were from before pump, it was 2015. I’ll ask for a different brand.

Thank you
 
Cheesecake said:
I‘m using BD Viva (?) 4mm needles now, I can’t remember what the ones were from before pump, it was 2015. I’ll ask for a different brand.
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Hope a different needle brand does the trick for you @Cheesecake
 
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