Lantus problems and going round in circles

And on and on and on...

When we began writing about our experiences of living with Diabetes it was, at least in part, in response to a nasty overnight hypo brought on (I suspect) by the action of Lantus glargine. From some reading I have done since it appears I am not alone in this. That there are other people with diabetes using Lantus and injecting their dose at night time (recommended by the manufacturer and for most people the best option) who find they sometimes go low overnight, or wake up low in the morning.

One of the difficulties in managing diabetes with MDI (multiple daily injection) basal-bolus is that if you don't get your basal (background) dose correct then everything else becomes incredibly difficult to manage. You have no firm footing on which to start your day.

I think the late-at-night injection timing is suggested because it puts Lantus's onset period (perhaps an hour two until full strength) at a time when you have finished eating for the day and are usually if not actually asleep, then pretty much at rest. When I moved my injection to the morning, though my overnight levels were suddenly very steady and reliable, I had problems with high blood glucose spikes after breakfast. In response I began to split the dose, morning and evening, having a little just before bed, and the rest at breakfast. My hope was that this would spread the activity more evenly over the day. Sadly though, after a few months I can see that this has caused more problems, and not really solved anything. I found I was waking up low again, or waking slightly clammy having gone hypo overnight. On several occasions my liver then took matters into its own hands and began dumping glucagon into my bloodstream as it's own emergency measure. I would wake high, inject rapid-acting insulin and wait until my levels dropped before eating breakfast. After 2 hours or so I would give in, my levels still stubbornly high, eat a fraction of my usual breakfast and wait to see how things were going at lunch. Not only that but if the smaller Lantus dose didn't send me hypo overnight, then it had run out of steam by breakfast anyway and I was heading for spike central again after breakfast. Smaller doses you see, tend to act over a shorter time. With no Lantus hanging around, and anything from 15-45 minutes for Humalog to get going even a fairly low GI breakfast was going to cause problems. What my neice might describe as an #epicfail.

So I've gone back to Lantus in the morning. Suppertime and pre-breakfast readings are more constant. The post-breakfast problem still exists, of course, but at least I've lost the overnight hypo and liver-dump double whammy. Last time I didn't spend much time experimenting with the timing of my breakfast bolus (rapid-acting) doses. My hope is that with enough time between injecting and eating I might be able to stay out of the teens between breakfast and lunch.

Maybe.

Basal driving me bonkers

This is ridiculous.

Perhaps I've brought it on myself with a few smug posts about feeling that I'm doing a little better lately, and how I finally seem to have wrestled Lantus into submission, but diabetic readers will be unsurprised to know that it's gone a little pear-shaped over the last few days.

Most annoyingly of all, my recent successes with Lantus have evaporated and I've been waking to early morning test results around 3.5mmol/l again. Starting the day a little low invariably has a knock-on effect for my control for the whole rest of the day for me, and I've been struggling to rediscover my recent run of good form. Diabetes is like walking a tightrope with complications on one side and hypo-induced coma on the other. Tricky enough if your balance is good to start with, but if you start out wobbly you're in for a difficult time.

So I'm basal testing again to see if I can discover the new magic numbers.

The technique I've come across goes like this:

1. Choose a day when you are not doing anything particularly strenuous and your fbg is in range
2. Take basal and any other medication as usual but miss breakfast and don't inject any bolus insulin.
3. Don't eat anything and drink only water until lunchtime and test every hour or two
4. If your basal dose is correct you should remain within 1 or 2 mmol/l of where you started
5. Repeat the test for another 2 days (they don't have to be consecutive)
6. Then move on to missing lunch, then evening meal
7. If you are really hardcore you can also test every hour or two overnight (I confess I've never quite managed this part of the process, and have always been able to convince myself that my dose must be about right, surely?)
8. If you notice a consistent rise or fall in bgs during the tests consider making (or talking to your doctor about) a modest change in your basal dose, perhaps 1 or 2 units up or down
9. Then start the testing process again
   

Not a perfect day to start the test today as fbg was 3.5, but I'm going for it anyway. I also had coffee rather than water which will also muddy the waters a bit (lactose in the milk will push bgs up a bit).

I'll let you know how it goes.

Update: Day 1 test went well despite the wobbly start. Completely solid bgs from mid-morning onwards. Now, do I sloppily move on to lunchtime? Or do it properly and complete the morning test a few more times? Hmmmmmmmmm...

Update: Lantus problems and going round in circles

And there was evening, and there was morning...

Just a quick update on the ongoing Lantus experiment... If you've popped by before you may have read that I recently changed the timing of my Lantus injection to combat fairly frequent, low-level morning hypos.

After the initial euphoria of my new-found pre-breakfast bg stability had worn off, I began to notice an unfortunate side effect of the new system. True, I was no longer waking up hypo 3 times a week, but I began to find that after breakfast my blood glucose levels would 'spike' - rising steeply and peaking way higher than I'd like.

When I'd suggested shifting my Lantus dose to the mornings to the DSN at the hospital, she had said that in her experience it merely 'moved the problem'. While this wasn't exactly true in my case (as I wasn't having consistent late afternoon hypos) it did appear that I'd simply swapped one problem for another.

My overall control has always been pretty good. A few swings here and there, but on the whole, fairly respectable HbA1c's (the test that reveals how 'normal' your blood glucose levels have been over the previous 12 weeks or so - below 7% is the guideline). One of the things I'm noticing about my renewed focus on tighter control is that you quickly move your own goalposts. I know for sure that one of the ways I've kept my HbA1c's in check is by having rather too many low-level hypos to counteract the high readings over the same period. Good control is not about constantly swinging from high to hypo, but as with all average-based assessments the HbA1c can hide the true picture.

In short, I was not happy to constantly spike after breakfast especially since I was now missing all those pesky morning hypos that would have kept up the illusion of good control in my HbA1c.

So for the last week or so I've been splitting my Lantus dose, half at about 10pm and the rest at around 7am the following morning. My reasoning was this... Lantus takes a good 3-5 hours to get going (this is why it is often recommended that you take the dose last thing at night). It also lasts around 18-26 hours, depending on the person - I think it's around 20-22 hours for me. What I think was happening with my breakfast time dose was that yesterday's had run out, and today's wasn't kicking in until mid-morning at the earliest. This meant that my breakfast bolus was having to cover basal requirements as well as whatever I was eating. By injecting half and half I now have two activity curves running out of phase so that the onset of one is covered by the activity of the other.

I have to confess that the timings of the doses are based more on convenience and the likelihood that I'll remember them than any complicated graph-based calculation of perfect timings, but for the last week or so both fbg (pre-breakfast blood glucose level) and post breakfast readings have been pretty much bang on target.

Well apart from the day I forgot to inject that is... but that's another story.

Update: Basal driving me bonkers