Discussions that mention levemir

Diabetes board


I think you are very knowledgible about diabetes. I would like to ask you another question....I am taking levemir 54 units --10pm...my sugar is still high in the morn. My endo has cut me back to 42 but with no luck getting my numbers down. I have gone low in the middle of the night with the 54 units...

My A1c 6.7% Dr has said I might have to "trade off" my high morning for the good A1c...huh??? and not going low....

Here is my question----I take rapid ---sliding scale---before meals. Usually 8 -10-18. My PP readings are sometimes high. Like today after my lunch it was 14.3 mmol---1 1/2 hour after....Very high. Should i inject more rapid to make this number go down or just leave it and inject at next meal time according to my reading using sliding scale of 2 units for every 2 mmol it is over 10 mmol...

Hope I am getting my question across to you....

I have heard of some people making "an adjustment to the insulin" to accomodate those high numbers.

Thank you in advance for any input on this subject.:confused:
[QUOTE=tfkeel;3704984]ok - I think I understand your question. and I think I also understand what your doctor is saying about the "trade-off".... your doctor is saying that it's the time-product of the sugar level that's important, and if you keep your numbers low during the day, it is going to be relatively unimportant if you have a high morning.

For your morning high, try a small snack right before you go to bed. Not a large deal, maybe a small fruit or couple of crackers or cookies. My hope is that this will "smooth" the action of your Levimir during the night and your liver won't get "spooked" and dump a load of glucose.

My recommendation is that yes, you can be more aggressive with your rapid. During the day only, though, until you see where this is going to lead.

I am assuming you use one of the analogs like Novolog or Humalog for this purpose which has a very quick release.

As a first "shot".... I would just try beginning your sliding scale at 8 instead of 10. Subtract 8 from the reading instead of 10. You can make that 7, too
if you find you need to.

Don't "chase" your postprandial sugar reading with the rapid, especially if you are going to use the aggressive scale we are discussing. Stay on the program of measuring before you eat and shoot according to that reading.

If you take the 1-1/2 hour reading after eating, it will likely be in the sky but it won't remain there. So the time-product of that reading doesn't affect the long-term processes very much. And, you don't want to create a low-sugar crisis for yourself.

You can shoot first thing in the morning, too. I am usually a little less agressive with that one because I sometimes don't eat much at breakfast.

Oh, and BTW ...congratulations on the 6.7 !!!!


I think I get what you are saying. Just a bit confused with the first shot thing (morning)? 8 instead of 10? I inject 8 units in the morning, 10 at lunch, 18 at supper...I do not quite know what you mean by subtract 8 (7) from the reading. Say my reading is 13 FBS do I subtract 8----that would be 5 units I inject???? If my FBS is 13 I would inject 2 units for every 2 mmol I am over 10. That would be 3 units more, so 11 units .....Am I confused or what. That is what I am doing now....

If my lunch reading is 6mmol, I inject 10 units, but, if it was higher than 10mmol I add 2 units for every 2 mmol.....above 10 mmol.....Am I thinking along the right track?????
Same goes for supper--I inject 18 units and 2 more for every 2 mmol over a 10 reading....
Am I on the correct thinking?????

Yes, I take levemir at night and novo rapid during the day....

Thankyou for any help.....

I am just concerned my numbers are increasing during the day and should I be increasing my units too.....instead of what the endo set me up with...
Hi Twokatss,
I think we've discussed this before...at least we've discussed the morning highs, which I believe are definitely rebounds from going low at night. If you keep going low at night, you will keep being high in the morning.

One of the things that might help prevent the morning highs while still keeping your daytime numbers reasonable would be to split the levemir dose and take half at bedtime and half in the morning. Not sure if this would work, but it might give you more even coverage.

The other problem I see with your regimen is that your dose of rapid is fixed and appears to be based on time of day rather than the number of carbohydrates ingested. I know it's yet another thing to learn (and heaven knows, it certainly can be overwhelming), but I really think you would do much, much better if you were counting carbs and injecting rapid according to an insulin to carb ratio. If so, you could probably reduce the levemir even a bit more, but you might increase or decrease your rapid dose depending on what you were planning to eat.

Certainly your A1c is really good, but that may be being influenced more by the lows you're experiencing at night than by overall good control. And it's no fun physically to be bouncing from low to high and back again. Counting carbs and tailoring your insulin more closely to your meal requirements, while reducing the levemir, could help you avoid the yo-yo effect.

Ruth
[quote]Am I on the correct thinking?????


I don't think so. And, I agree with SamQKitty about using a units-to-carbs ratio. That will give you the smoothest control of any methods being discussed. But it is another thing to learn, as Sam said. And, I agree with Sam that you are "bouncing" and those fixed doses of 8 - 10 - 18 that you are using are the cause. If we can get your control smoother you will feel better and you will probably lower your fasting reading, too.

What I suggested was this....although Sam's suggestion is better...and I will be happy to help you do it her way, too....it is more complex...

Let's take a few examples....

First, do not take the 8 - 10 - 18 doses of rapid. Take only doses that are based upon reading data at your mealtime. And don't use postprandial readings to shoot by. Use only the pre-meal reading.

Say your lunch reading (before you eat) is 12 - first, subtract 8 = 4, then multiply by 2 = 8 units. Take this shot before you eat.

Ok, dinner time. Your reading is 11 - subtract 8 = 3, then multiply by 2 =
6 units.

Bedtime. If you want, eat a small snack. Not a lot. Couple of crackers or a small fruit. Shoot your 42 units of Levemir. Don't even bother to finger-stick now, because I am asking you to NOT COVER at bedtime until we see where the program takes you in a week or two.

Awake. Take your fasting reading.... 14 - subtract 8 = 6, multply by 2 = 12 units.

Breakfast.... don't cover again, you already did it when you awoke.
My Family DR told me split the levemir also. And watch carefully my readings after my main meal at supper. I could have a low at that time he thought.....??

Will keep you posted....
Hi Twokatss,
Yes, it is getting way more complicated than it needs to be.

Right now you're on a sliding scale. Back when I was on a sliding scale, the scale took into consideration an average amount of carbs per meal, plus what you might need for a correction depending on how high you were before the meal.

Your sliding scale appears to be rather fixed. The problem is...it just plain is NOT working for you! As long as you stick with this regimen, you are either going to be chasing highs after meals, as well as dealing with those overnight lows.

I know there's quite a learning curve as far as counting carbs goes, but really, it only takes a few weeks to get the basics, and after a couple of months, one gets pretty good at it. My suggestion would be for you to start learning how to count carbs now (without necessarily changing your insulin regimen just yet) then, once you feel comfortable with counting carbs, work with your doctor to establish a new insulin regimen.

You've already pretty much determined that your morning highs are most likely rebound highs, since you've mentioned being low during the night. So I think your Levemir dose is still too high. The only way to test long-acting insulin is to fast. If your long-acting dose is correct, you should not go either low or high if you don't eat. You can test this with just one day of fasting, checking your numbers at intervals throughout the day.

The next thing to tackle is your short-acting insulin. As I've reiterated, the regimen you're currently using just isn't working well for you. You're always going to be either too low or too high when you take a fixed amount of rapid before meals without considering the amount of carbs you'll be eating. Once you learn how to count carbs, you work with your doctor to figure out an insulin-to-carb ratio (hopefully it'll be 1 unit to 10g carbs, as that's the ratio with the least amount of math to do!). But it could be 1:8, 1:12, etc. Then, you estimate the amount of carbs you'll be eating. Let's say you're eating 50g of carbs and your ratio is 1:8, then you'd take 6 units of rapid to cover your meal. The other thing you'd have to work to establish is your correction ratio. For me, 1 unit will bring me down about 30 points. So, if your goal was 120 before dinner, and you were at 150, and you were going to eat 50 grams of carbs, you'd divide the 50 g by your insulin/carb ratio (let's say 1:8), which would mean 6 units, plus you'd need one more unit to lower your bg by 30 points.

I know it sounds a bit confusing, but really...it's not all that difficult. Just as easy as the math TF is suggesting. And this way, your numbers would be much more even. Also...if you find yourself too high at any time during the day, you'd use your correction ratio to figure out how much insulin you need to bring you back to normal.

I'm not sure if you can get an insulin pump,Twokatss, but all of this is WAY easier if you can...you still have to learn this stuff, but then you program the pump and it does the math for you. Not sure if Canadian health care system will cover them for T2's, but it's definitely something to look into now that you're on multiple daily injections.

I hope I'm not overwhelming you with information...please feel free to ask about anything you don't quite understand. Ask as many questions as you need to...heck, you can ask the same question as many times as you need to...until you feel you understand this. I'm just sorely afraid that without some changes in your insulin regimen, you are always going to be chasing highs and lows, and that really can make you feel worn out.

Ruth
THANKYOU, THANKYOU, THANKYOU --- there is hope....I understand what you are talking about Ruth. Big words confuse me....

I am halving my levemir ---night and morn. I do know how to count carbs and I am good at math too.....figuring my units won't be a problem....

Our benefit plan will pay for the pump....I need my DR to write a script for it....

What one do you use. I know you are happy with it...I could suggest and DR might agree.....do not know of anyone who has one though. I know alot of diabetics T2 but most are on meds and injections or both.....because of no health insurance benefits....

I also know I have to be more diligent with my eating habits---especially while dining away from home...

Will let you know how all is going...I had a real bad week last week, but this week was alot better.....that seems to happen every few weeks....HORMONAL MAYBE.....hhhmmm
Take care of yourselves also...Gayle:)
Hi Gayle,
Wow...you already know how to count carbs? Then you are in GREAT position to start basing your short-acting insulin on carb count. Not only will that help smooth out the high/low roller coaster ride, but it'll give you way more flexibility in terms of what and when you eat.

If your plan will pay for the pump, I highly recommend it. I personally have the Medtronic Paradigm 522, which has a 180 unit reservoir, but they also make a 722, which has a 300 unit reservoir. You might want to get your numbers/insulin under better control before going on the pump so you can really determine which size you'd need. Usually, you only change the site once every 3 to 3.5 days, so you'd take your daily average, multiply times 3, to determine what size reservoir you're going to need. You probably will use quite a bit less insulin on the pump, but you want to make sure you get the right size because it's a very expensive mistake if you don't get a big enough reservoir.

There are some other pumps on the market, but your insurance company may limit which ones you can get...best thing to do would be to call them first, even before you talk to the doctor, and find out which ones they'll pay for. Then you can do an internet search for sites that compare pump features. Then talk to your doctor.

Once on the pump, you'd use only one type of insulin, and it would be rapid-acting. There are so many great features to pumps. For example, I am more insulin-resistant at night, so I need more insulin per hour after 10 PM...on the pump, I can set two (or even more) basal rates...and it'll just automatically switch. I have a basal of .95 from 10 PM to 9 AM, and a rate of .70 from 9 AM to 10 PM. When I go on vacation I'm usually more active, so I can set a temporary basal rate that's even lower during the day if I need to.

Also, I since I'm more insulin-resistant at night, my correction ratio is greater at night. During the day, 1 unit will bring me down about 30 points, but after 10 PM, 1 unit will only bring me down about 15-20 points...that's programmed into the pump so if I need to make a correction, the pump automatically figures out which rate I need depending on the time of day and figures the correction units for me.

All of this takes some work...and there's a LOT of tweaking the first few months, but once you've got it set up, life is just such a breeze compared to MDI. I think you'd really love it.

Oh, and you mentioned hormones...yes, many women find their needs change depending on where in there menstrual cycle they are. There's another great use for the temporary basal rate.

But for now, just see if you can get the levemir dosage tweaked. As I mentioned before, you might have to do some fasting to verify if you're at the right dose. Sometimes you can split up the fasting...like, fast until lunch one day, then a few days later fast from lunch to bedtime, etc. It's very difficult to tell if your basal rate is correct when you are eating, because you don't know if it's the food or rapid insulin that's making you go high or low.

And keep coming back, Gayle. I've watched you struggle with this for a few months now and I have felt so badly that it's been such a struggle for you. It would really please me to see you get this under better control...but not half as much as it would please you, I bet!!!

Ruth
Another question for Ruth or TF: Could insulin NOT work for a person....I am thinking especially about Long lasting.....
After dividing my Levemir half and half I have seen no changes in my morn reads YET...or any other reads actually....Because I get itching and red raised spots on the injection site, I am wondering if this is is right insulin for me...

Maybe I need a different one...

Am seeing ENDO next week and I am going to pose this question to him..

Any thoughts????

Some times we know our bodies better than they do...:confused:
Well, I wouldn't expect that there would be any change as a result of dividing a Levemir dose half-and-half, except that it might keep you from going too low during the night..... which was the reason you made the change.

Because, 42 units of long-acting insulin in one dose is much the same as two 21-unit doses over a day's time, when the active period of the levemir is 24 hours. Except, that your "lows" might not quite be as low. But the insulin taken versus the food eaten has not changed....therefore, the results probably didn't, either.....

I wasn't too concerned about your high morning reading....because you said your HbA1c was pretty good. This is the real indicator of the efficacy of the management program, and not a single reading..... especially one at that time of day in which your liver may have just outputted a load of glucose overnight.

Ruth suggested to you a method which you seemed to be in favor of adopting..... which I believe, would radically "smooth" your control and give you a lower morning reading over 1-2 weeks of time.....and Ruth is expert-level on this and can guide you superbly with it......are you trying that method now? Counting carbs? Are you taking readings 4 x a day and letting your meter keep the averages for us so we can know how you're doing on this?

You are headed for wonderful success on this. Don't give up.... You are going to add years to your life and life to your years and feel good....
Gee, TF...thanks for the compliment. I'm not sure how "expert" I am...but I have been to the School of Hard Knocks for many years, so I guess I'm about ready for a degree by now ;)

Gail...it is possible to be sensitive to the insulin or, more accurately, it's usually to the substance in the long-acting insulins that makes them long-acting. Many of them use protamine to delay the absorption of the insulin. You might want to check to see if Levemir and Lantus use the same substance and, if not, try switching to Lantus.

And TF is correct that merely splitting the dose may not help...but by splitting the dose, you can tailor it a bit better to your needs. Apparently you need a bit less during the night, because you said you're going low. How about splitting the dose evenly at first, and then just decreasing the nighttime dose by 2 units at a time until you stop going low during the night and stop the corresponding rebound morning highs? That might work better for you than just decreasing the entire dose of levemir.

Ruth
I was going low when I was taking 55 units of Levemir ....I also was having flu like symptoms also. That was when my endo put me on 52 units. My numbers were still high...
Now I injecting 30 units night and 15 morn.
I am so frustrated by all this I feel like not taking Levemir at all and see what happens. DR told me he doesn't have any patients taking as much as I am. Most are 20 unit max....maybe I should just do 20 units at nite and try the Gliclazide in the morn.....This is my family DR not the endo. I have more faith in the family DR than the endo. He did not want to listen to me....every time I went to him I got a new drug for something.--including Xenecal and I am not over weight at all.....5' 8" 170 lbs...but I had put on 10 Lb when I was put on insulin but since have dropped back 5 lbs...I think my body is in a state of confusion not knowing what is going to hit it next. My fasting this morn was 12.7 mmol but my fasting blood test was 10.4, I think...My Aic went up from past 2 reading of 6.7 % to 7 %.

I will carry on with my carb counting--told the DR--that was OK with him....

Will give this a month to see if it helps and if not I will be alot more aggressive with the DR than I have been. We have a diabetes specialist who works at a pharmacy that I can contact also if i want....

Thanks Ruth for being here....:angel:
Hi everybody: Since Sept. 15 this is what has gone on. The Levemir was the culprit....I was having an allergic reaction at the injection site, red , itching and getting worse. I asked to be taken off the Levemir and put on Lantus. Well after 2 weeks on Lantus my sugars were down in the morning and my day time readings improved too. The Levemir was not working for me....The endo I was visiting thought Levemir was the best insulin going and even after I told him my problems he did not offer to change it....in fact he increased, decreased and nothing helped my morn highs. ( I think they get kickbacks from the industry).... My family DR has helped me more than a specialist had....

Now I am shooting 20 units bedtime Lantus......no itching or redness....

I am counting carbs and am having alot more favourable numbers like 6 - 8 mmol

Still taking the glicizide pill 30 mg mornings. All seems to be going much better...


HOPE IT KEEPS GOING GOOD FOR ME .

Thanks all....:)