How to deal with evening highs on MDI

[shannong]

Hi there, My 6 yr. old son is on MDI and gets Levemir once in the morning. It is supposed to last at least 18 hrs, but I find by 7pm his numbers begin rising which is only 12 hours later. I have read a lot of posts that split dosing helps, but I am not sure when to split the dose - should I split it at dinnertime to cover the rise that begins by 7pm? Or should I give it at bedtime? Also, his numbers during the day are good, so should I just be adding in a dose in the evening and keep his dose in the morning the same? Just to give you an idea of what happens: last night 2 hours after dinner he was at a 4.7 (this was around 7pm). I know that he usually will begins to rise around this time, so we had no snack and still by 8:30pm he was 10.8 with no food whatsoever. It's a pretty dramatic rise, so something with the basal must be off. Then I checked him at 3am and he was 10.1 and by morning he was 8.0. Any suggestions? Thanks!

[Lakeman]

We use humalog and we use a split dose.

Splitting the dose lowers the peaks and arranges them so that they fall at different times. It also means that there will be no period where there is an absence of long acting insulin. When you give it depends on when the peaks occur and when you want them to occur. My guess is that times during the day when he tends to run lower are the times when the long acting insulin is peaking and times when he runs higher are when it has run out. Counting the hours from when it is given will tell you when it will peak and run out - hopefully. Our doc suggested giving a larger dose during the day and a smaller dose at bedtime then adjusting as needed. We also found that we needed far less long acting insulin to achieve the same results.

[LantusFiend]

So the insulin is lasting (he wakes up lower than he was in the night), it's just that he has a higher need for insulin in the evening. Or are you giving large correction doses and barely seeing a drop?

I suggest insulin with a snack two hours after supper, and giving slightly more insulin than you'd think he'd need for the snack, so that it covers the basal rise. Barring that, I suggest giving a small dose of fast acting insulin roughly 2-3 hours after supper.

[katerinas]

I calculate the duration of Levemir at around 12 hours and it has worked for us really well. We give a little bit more in the morning and less in the evening before he goes to bed. Once you split it you can decide which hours need more basal. But even with the split my son would rise from 11-3 at night , and when we gave more he would go low at around 5-6 in the morning. What has really helped is the use of regular (actrapid) insulin that I give at around 10

[shannong]

Great idea, I'm going to try that. Thanks for your response

[LantusFiend]

Originally Posted by katerinas

What has really helped is the use of regular (actrapid) insulin that I give at around 10

I like regular but it didn't do what I wanted it to, when I wanted it to last longer. For me it's gone in about 4 hours.

I want to point out here that regular has more names than most insulins.
In the United States, regular is sold as Novolin R and Humulin R (different brands), as well as in mixes with NPH.
In Canada, regular is sold as Novolin ge Toronto and as Humulin R.
In the UK and Australia, regular is sold as Actrapid, and I think it's also sold as R.

[katerinas]

What did you want it to do? We use novorapid to bolus for food and if there is a lot of fat or slow carbs I give some regular 1.5 -2 hours after food. Regular starts to work 35-40 min after injection so during the evening it starts to work at around 11 till 3 . I also calculate that it lasts for about 4 hours

[LantusFiend]

I wanted it to catch the later tail on my suppers- I was having an issue where my blood sugar would start to rise about two hours after supper. I mixed Regular with my Novolog (Novorapid) and it didn't help. So I tried Regular by itself to see what it does in my body. In my body, Regular kicks in in about 15 minutes, maybe less, and is out of my system by four hours. It doesn't have the same curve in action that Novolog does- for me it is active at a pretty steady rate for four hours, whereas Novolog kind of builds up steam for a couple hours, is most active in the third hour, and doesn't do much in the fourth. For me, Regular has been easier to work with. And at half the price! I switched to using only Regular, after a period of mixing the two.

[katerinas]

I find regular doesn't have the steep peak that novorapid has. I usually give two injections for foods that leave a trail, Novorapid first and after regular. What if you did two injections of regular 1.5-2 hours appart?