Lantus Questions

[Human Pin Cushion]

This is a wonderful resource for Type I's...often a minority in support groups, IMHO.  My first posting to the forum although I've been type I since age 7...now a healthy 45 year old (female).

I am mostly happy with the current combination of Humalog Pen and Lantus.  My questions are in regards to Lantus:

I understand the "non-peak" aspect...but personally dropped very low in early a.m.'s (about 4-6 a.m) after injecting on a regular basis at 10 p.m.  To the point that I would load up on carbs before bedtime, never going to bed with a "normal range".  Even still, I would wake with 30's-40's, even with cutting back on Lantus.  Cutting back hurt my overall numbers.  Lantus info in package shows graph of effects...there is a climb to an even level at around 5 hours.  This is the peak I've been struggling with.  Does anyone else have this effect in early a.m. after taking Lantus at night?  Last doctor was neutral on the subject.

Now in a different city and new endocrinologist.  After discussing, she saw no problem taking Lantus in morning instead.  (I'm puzzled why I read everywhere that it must be taken at night)...now my problem is high a.m. readings of around 225 or so.  This is with a great bedtime, several hours after a meal, of 90-110.

I increased Lantus from 18 units to 21, gradually...now that I'm not facing the sleep lows.  I see an increase in morning readings even though the Lantus has increased.  Athough I personally prefer a high a.m. quickly corrected with Humalog than lows during sleep.  Does Lantus taper off in less than 24 hours?  

[JDRF-Team-wak]

I am not a physician, but the mom of a type 1 child.  I would check with your endocrinologist or CDE.  The peak times that are in the package, are the averages, each person is different.  Some people the insulin might last 20 hours others 24.  I would check with your doctor on how to adjust your insulin to avoid the highs and lows.  For example, Humalog is supposed to peak in 2 hours. In my daughter it seems to peak in 3 hours.

Your doctor can advise you as to how the Lantus is affecting you, and how to adjust your food, and time you take the insulin.  You might also want to ask about the insulin pump,  Which does the same as the Lantus. It gives you a base line of insulin and you just dose your self when you eat according to the amount of carbohydrates you eat.

[JDRF-Team-LRS]

Hi HPC,
I'm also not a physician.  Like you, I'm a long time DMer, and have had DM for almost as long as you.

I'm glad you switched your Lantus to the morning.  I'm assuming docs recommend it at night (if possible) because some folks won't like taking two shots in the morning.  As you probably know, Lantus CANNOT be mixed with short acting insulins in a single syringe.  Many folks report good success taking the shots in different body parts, too.  

I have also read that Lantus doesn't quite stretch out to 24 hours.  You've probably also read about the Dawn Phenomenon, which seems to get us DMers in the early morning hours.

I haven't heard anyone report the suggestion I'm about to make, so please do talk it over with your endo/CDE as WAK suggests.  What if you take your Lantus at lunchtime? and then use your morning breakfast shot to cover any need for extra longacting.  If you normally take your morning shot at say, 7am and a lunchtime shot at, say 12 or 1pm,...the 5 hour interval might just be right for you to be able to cover your waning Lantus with some fresh breakfast insulin.

I have read about splitting Lantus doses, too -- I'll try to find the reference again, but the bottom line on the single research study I saw was that overall BG control didn't improve.  I suspect that individuals being what we are, some of us might have good success with a split dose.  If you do decide to split and take some insulin in the evening, then perhaps you can talk to your endo about taking it at dinner time instead of bedtime -- that way the rise will come while you're awake AND you might be able to lower your dinner short-acting shot to keep from going too low.

Hope this has given you some options to consider... Let us know what you & your endo/CDE decide .. and how it goes!  Good luck!

[Markie]

The publicised action profile for Lantus is typical for "most" users. But many of us have a different experience. Like you, I have found that Lantus has a definit peak at about 5 hours after injecting. I also found that Lantus doesn't last the full 24 hours with me.

I have got around this by splitting the Lantus dose into morning and evening shots. I use 7 units daily, 4 in the morning and 3 in the afternoon. The peaks for each shot are fairly small. And I time the injections so that I am able to actively monitor my blood sugar afterwards.

The morning shot is at 6:30 am and peaks in the late morning. I normally have a snack in the late morning anyway, so it is not a problem. I take the evening shot about 12 hours later, at approx 6:30pm. And it peaks about the time I go to bed. As long as my bs is OK when I go to bed, it is fine for the rest of the night.

You may want to experiment with method. It is a bit more work. But the improvement in control makes it really wortyh it.

Cheers,

Mark

[Human Pin Cushion]

Thanks everyone for the quick feedback!  Yes, I visit endo on a regular basis (I use an endo for primary care, so to speak) and will be visiting her office Thursday.  I think more info from endo's needs to be given than "it's a non-peak insulin"...I've been puzzled by this for over 3 years now.  

Although my new endo (who is very aggressive and I like) first insisted that there is no peak, I stood up for my own personal patterns.  There have to be more like me, it's just hard to sit there alone in an endo's office, and not know what is really happening with the overall populations on Lantus.  I do agree that there is almost no peak for most of the duration, just at the "kick-off"!  

Went to bed last night with bg of 77, woke up with bg 143.  Compared with other mornings, this was a good one!  I'm still trying to break the "snack at midnight" habit from when I took Lantus at night.  It was like a security blanket!

[Christie2004]

When you were taking your Lantus at night, I noticed you mentioned you would carb load late at night to try to prevent the lows.

Did you include adequate protein/fat with your carbs?  These items reduce the rate at which carbs are metabolized, and might serve to mitigate the lows you were experiencing.

[Human Pin Cushion]

I can't say I focused on adding protein/fat to prolong absorbtion of carbs, but I would say most of the carbs I consumed contained some fat grams...Also, I drank 2% milk vs. skim (fat free) for that reason...It is really hard to accurately measure how much carbs are delayed...I know it is a popular theory in "diets" these days, but not sure I can measure...regardless, since lows were happening 5-6 hours later, I'm not sure if fat/protein additions to carbs would make a huge difference.  But, yes, I agree it makes a difference.

BTW:  I learned on this forum on another topic about the at-home A1C tests (Walgreens)...another tip not learned at the doctor's office.  I still do the labs every 4 months, as recommended for insulin dependent DM's, but it's nice to be prepared for a doctor's visit.  

I had always averaged 6.5 prior to my Lantus issues, but had shot up to 9.3 or so recently.  (High for me)  Today, at-home testing showed a drop to 8.2, so I think I'm on a good track to continue the AM Lantus injections.  Im also increasing my Humalog to equal 1 unit for every 10 g. carbs vs 15.  Depends on what activities I'm doing.  Also, I am taking a sliding scale 1-4 additional Humalog units in a.m. to cover high fasting bg...in addition to covering breakfast carbs.  It seems to correct well, and I'm off to a better day overall.  I was worried it was "way" too much, but I have to say, I haven't had too many lows since adding units in morning.  (This sliding scale addition is for fasting only)

I'm curious to see A1C in a full 12 weeks.  I tested after only 6 weeks, so results aren't too dramatic.

One nice thing about moving frequently, you are forced to re-evaluate your old habits with new endo's...new dosage changes can be good...I think we sometimes get too "comfortable" in our zones, especially after so many years of relative success.  I also think some endo's are more passive than others.  True for all doctors I'm sure.  I am looking forward to getting my A1C down more...will keep you posted!

[JDRF Team SGG]

I, too, am a long-timer who uses Lantus. I am prone to hypoglycemia and my endo recommended right away when I started the Lantus insulin that I take it in the morning instead of at night. My reading about this insulin tells me that it does peter out some in between 20-24 hours, which makes sense, for it has no timer that automactically turns off a switch at the 24-hour mark. I believe that this is why most people take it at night, so that their quick-acting Humalog or Novalog can cover their evening meal since the Lantus would be petering out by evening if they do an evening Lantus shot. I, like you, have noticed a definite peak between 4-5 hours after taking the Lantus, so taking it in the morning makes this peak mean that i require less morning quick-acting insulin to cover my breakfast. Like you, also, I noticed elevated morning sugars, and I have fixed this problem by doing the spilt dose. so some insulin is working well through the night. In my case, I take my larger dose (2/3 of my total) in the morning, and I take 1/3 of my total daily dose at bedtime. This keeps me even-keeled at night without having to eat a snack before bedtime. The numbers stay pretty much perfect for me this way, and I can go to bed with a normal glucose reading knowing that it won't rise or drop at night unless hormones are affecting my insulin absorption or I ate something that digested so slowly that my evening dinner shot did not cover it completely. You may want to look at the 1/3 - 2/3 split. Some people split the dose half and half, but my fears of night lows keep me preferring to err slightly on the side of not enough insulin while I sleep than too much, so this 1/3 - 2/3 split solves the problem for me. You will need to discuss this with your doctor and be prepared for trial and error while adjusting the dose. I started by taking 1 unit at bedtime, with my usual dose in the morning, figuring that 1 unit would not be an overdose. Then, the next morning, I took 1 unit less of the Lantus morning dose. That evening I continued the 1 unit of Lantus, so that I had almost two full days on the new split dose before adjusting it again. The next night, I increased the evening Lantus by 1 unit again, and decreased the morning Lantus by 1 unit the next morning. And so on until the numbers are staying stable for you while you sleep. You may wish to set the alarm and get up once during the night while adjusting to see if you are dropping 5 hours later into the hypo range when it does its mild peak, or whether this small amount of insulin is not causing a problem. The split dose seems to work well for many of us, but the proportions of the split are different for each person. You just have to do it one unit at a time until you hit the correct split for your body. I wish you well.

[Human Pin Cushion]

Thanks for the detailed info...I like the idea of 1/3-2/3 split and see your logic.  I will wait a bit longer before changing (from new switch to 100% in morning)...if needed.  I find I have to track for a length of time, no two days are ever the same in my life!  I think my numbers are always wacky when I first make a change in dosage patterns.  The night into morning numbers seem to be getting better.  
Catherine