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Lantus question.

Discussion in 'Parents of Children with Type 1' started by Artgirl, Feb 13, 2016.

  1. Artgirl

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    Can someone please explain to me the function of Lantus and when the amount should be changed? My daughter takes 16 units daily and her numbers are always in range.When do i need to change it? How do i know and by how much?
     
  2. wilf

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    The liver puts out glucose 24/7 in order to provide energy to the body's cells. The Lantus is covering that glucose feed.

    The ideal dose of Lantus is one that keep blood glucose levels steady in the absence of carbs or boluses.

    If your daughter is always in range then she is honeymooning and you have it easy. Use this time by learning about diabetes - get a reference text book and read it. Type 1 Diabetes by Ragnar Hanas is my recommendation.
     
  3. Mimikins

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    The function of Lantus is to keep BG levels relatively stable (within a 30mg/dL range) when you are fasting. Our livers constantly break down glycogen (300+ glucose molecules linked together in a long chain) into glucose as a way to provide fuel for many of our vital organs (such as the brain). We use basal insulin, which is Lantus/Levimir/NPH insulin if you're on MDI or a continuous infusion of rapid-acting insulin if you're pumping, in order to "match" the glucose our liver spits out and to provide a steady supply of insulin to the body (having no insulin present for an extended period can cause DKA, which is when the body results to producing a ton of acidic ketones from metabolizing fatty acids as a result of not having any insulin present for carb metabolism).

    One of the best ways to figure out if your Lantus dose is correct is to do something called basal testing. It's really helpful for pumpers, but many recommend doing an overnight basal test for people on Lantus. Integrated Diabetes has a good step-by-step guide for the conditions basal testing should be under, how frequently to test, and what adjustments might need to be made based on the results you see. Typically, if you see more than a 30mg/dL increase in BG levels during the basal test, your daughter is receiving too little basal insulin and would need to increase the Lantus dose. If you see a 30mg/dL decrease in BG, the Lantus dose might be too high.

    During the daytime hours, figuring out if your basal dose is good is a bit more complicated. So many of the things we do can affect our BG. The general rule is that bolus insulin (Novolog/Humalog/Aprida/Regular insulin) needs to be adjusted if what you're trying to correct occurs 3-4 hours bolusing (such as me consistently starting breakfast at 100, carb counting accurately, and always end up at 200 4 hours after breakfast). If it's occurring more than 4 hours after bolusing, then it can be assumed that it is a basal insulin problem (such as me starting out at 100 for a low-fat low-protein meal, being at 100 4 hours after eating, but then at the 7-hour mark being at 200).

    One of the bigger issues with Lantus is that you're essentially "locked in" with your basal insulin for 24 hours whenever you take it. For me, one of my big diabetes issues is that I have much higher insulin needs overnight and into the early morning hours (0.37-0.38 units/hour of basal insulin), but once I am awake and moving around I need significantly less during the afternoon (0.16-0.18 units/hour of basal insulin -I'm really insulin sensitive). When I was on MDI, one of my big problems was taking enough Lantus to keep my fasting BG at a good level (which meant that I was receiving adequate basal needs overnight), but that Lantus dose would be too much for me during the afternoon, and I would end up experiencing a ton of afternoon lows. One of the ways people get around this issue is to split the Lantus dose in half and administer it every 12 hours (so for instance I could give myself 8 units of Lantus at 8PM to cover my increased basal needs overnight, wake up at 8AM and give myself 4 units of Lantus to cover my decreased basal needs for the day).

    Some of the books that I really recommend are Gary Scheiner's Think Like a Pancreas and John Walsh's Using Insulin. Both do a really good job in explaining basal vs bolus insulin and how to adjust insulin doses for different BG patterns. As always, if you have any questions or concerns about adjusting insulin (especially when you're beginning to adjust for the first time), it's a good idea to talk to your child's doctor. There have been a ton of times where I thought I needed to adjust my insulin one way for a certain pattern, I would email my endo to make sure the adjustments make sense, and they would give me a recommendation completely opposite of what I thought (when their recommendations would end up working a lot better).
     
  4. quiltinmom

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    The short answer is, if she starts waking up a lot higher than her bedtime number consistently, she needs more lantus. Increase by no more than 10%, probably 1/2 or 1 unit to start. You could increase it by as 1.5 units at her current dose, but I think it's better to increase in smaller increments. Wait at least 3 days before increasing the dose again. You have found the right dose when she wakes up in range, and not significantly lower than her bedtime/2AM number (assuming no IOB or recent food/bolus).

    Another way to tell is if you see highs at random times (no pattern) throughout the day, or if you are giving corrections about every other dose (and assuming there are no missed boluses and carb counts are accurate) that is a sign more lantus may be needed. Again, no more than 10% increase at a time, less may be better at first.

    It's not always that simple, but I think it is a pretty good guideline.

    I learned a lot from "think like a pancreas."
     
  5. Theo's dad Joe

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    So does she take 16 units just of Lantus per day? What is her weight. Also by "always in range" how tight of a range is it in the morning, like 70-100, or 70-140?

    If its 70-100 all the time then that is definitely a honeymoon, but my son would have gone into the 50s 4 hours after every meal with 3 Lantus during the peak of his honeymoon which was at about 4 months in. I had him going into the 50s with 2 units at one point WELL past (5 hours) a meal time bolus.
     
    Last edited: Feb 13, 2016
  6. Theo's dad Joe

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    I am trying to get Theo's Lantus dose right at this point. I asked the endo about this two days ago and really there is not a clear answer that they give. They simply told me to reduce it if he was low in the morning. First when he was waking up under 100 (which started in about 3 days) and then they told me to reduce it if he had 2 morning blood sugars under 70.

    In reality it has nothing necessarily to do with wake up numbers though in the honeymoon or with type 2 diabetes it is about wake up numbers because the pancreas will work as hard as it can to get to a good fasting number.

    But if a kid goes to sleep with a blood sugar of 170, three hours after dinner, after the honeymoon, then I think it is pretty meaningless what number they wake up at in the morning because they may still rise or fall from that point before the effects of dinner and dinner bolus are over.

    We are transitioning out of the honeymoon period now and the nights are very different. We used to run 80-100 all night and wake up in the 80s or 90s with minimal Lantus.

    Now if my son goes to bed 3 hours after dinner with a blood sugar of 150, he may still come down a little from his dinner bolus, but he does not correct any points at night 4+ hours after dinner bolus, and usually rises a little (I am using morning Lantus). I HAVE to know his blood sugar 4-5 hours after his dinner bolus to know how well the Lantus is working.

    What is more, because I use morning Lantus, and it gets noticeably weaker from 1:00-7:00 am, (he starts to rise after 1:00 am slowly) then he can even be pretty low around midnight and look higher at breakfast. He is on 7 units now and may go higher. Also I have to check and correct blood sugar 4+ hours after dinner again because if I don't he can go to bed at 150 and go over 180 at night. I really don't know how people do it.

    So in my opinion you have to know the blood sugar 4-5 hours after dinner to know if Lantus is right at night.

    Do most people not see post dinner bolus drops 3 hours after dinner? I do, so if Theo is 150 3 hours after dinner anything can happen on any given night. He will drop down to around 100, or he will rise off into the night. If I don't correct a 150 in bed, it is basically going to be 10 hours out of range. (its also a little hard to sort through with a recent "mild" virus he has needed 2-3 units at night through the night to stay in range. Never would have had a clue without a CGM.
     
  7. Mimikins

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    Don't forget about the Somogyi effect (too much basal causing a drop in BG overnight, the liver spits out a ton of glucose, and a high fasting BG results), which would require a decrease in Lantus. Increasing Lantus when the high fasting is from Somogyi would only make the Somogyi effect worse (and could cause a lethal low overnight). It's always a good idea to do a middle-of-the-night check when trying to figure out what is causing a high fasting as a way to rule out Somogyi (...which reminds me that I need to schedule a 2AM check tonight and see why I'm waking up in the 140-200s all of a sudden).
     
  8. Artgirl

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    Yes..she's on 16 for the day. She is in range in the morning but we are finding by lunch time she is low as well ad mid afternoon she is on the lower side. Not sure if that is an effect of Lantus or the rapid acting insulin.
     
  9. Theo's dad Joe

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    Is she "in range" like 70-100 or often in the 110-130 range.
     
  10. Artgirl

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    In the morning she is 5 to 7..then before lunch she is 3.5 to 4.5 which is low..then mid afternoon she is still 4.5 range. She didn't even bolus for lunch which was a small carb amount. Not sure what's going on.
     
  11. nebby3

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    What time of day does she get the lantus? If AM you are probably seeing it peak but if PM it is probably the short acting. Though either way if nights are good I would deal with it by giving more carbs or less short acting in the AM.
     
  12. Artgirl

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    She takes 16 units at 5 pm. Today she only took rapid acting at breakfast and was low all day despite eating meals with carbs in it without bolus.I have no clue what's going on ...ill call the endo on Tuesday.
     
  13. rgcainmd

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    5 to 7 = 90 - 126
    Great range; your daughter must still be honeymooning.

    3.5 to 4.5 = 63 - 81
    I personally don't consider 63 low, however that's getting close to 59, which I do consider low.

    What is your daughter's BG 2 hours after breakfast? If you're uncomfortable with the 3.5-ish numbers, and if she doesn't spike higher than about 180 to 190 between breakfast and lunch, you may need to adjust your I/C ratio (less fast-acting insulin) for breakfast. I wouldn't be concerned about a 4.5; 81 is not a low BG. Again, if her BG doesn't spike higher than about 180 to 190 after lunch and you are uncomfortable with a 4.5, you could adjust her lunch I/C ratio (less fast-acting insulin). Is she going low during the night? I highly recommend obtaining a CGM otherwise you really have no idea what her BGs are like during the night. If she's experiencing significant lows overnight, then I'd decrease the Lantus dose.

    Could you please fill out your "signature" under Settings? It is very helpful if people know your daughter's age, whether she's using MDI or pumping, whether she's using a CGM, what insulin(s) she is using, etc. It saves a lot of time on both sides if people do not have to repeatedly ask these questions in their efforts to answer your questions. Thanks!:D
     
  14. Artgirl

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    Ok..how do i add the signature? The thing i am confused about is i thought MDI was going to allow her to eat what she wants when she wants, and thats why we made the switch, but it seems as if she doesn't eat at least every three hours she begins to go low. We did measure the BG 2 hours after breakfast ans she is in range but drops pretty quickly after three hours. I don't know if it offers that much more flexibility that the NPH regime, or i am expecting too much from MDI? She hasn't taken any insulin today besides breakfast and is always in good range, maybe still a strong honeymoon?
     
  15. rgcainmd

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    To add a signature, click on "Settings" on the top upper right corner of the page. This will take you to a page where there are some menus on the left side of the page. Go to "My Settings". Under "My Profile" on "My Settings", click on "Edit Signature."

    You bring up a good point. You may be expecting a little too much from MDI. Pumping gives you the most freedom to eat whenever you want. If your daughter is needing to eat every three hours in order not to go low, then perhaps both her basal insulin (Lantus) dose needs to be lowered, along with her I/C ratios and/or ISF or ICF. Another possibility would be to try split dosing her Lantus: two daily doses that don't need to be equal. For example, if her BG levels are fine during the night, you could try giving her 9 units of Lantus in the early to late evening and 7 units of Lantus in the early morning. Or 10 units in the evening and 6 units in the morning, etc. Best to check with her endo first, however.
     
  16. Sprocket

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    Sounds like basal is high. If she`s eating and not bolusing and the basal is taking care of the carbs, it sounds like it`s too high. However, on the other hand, it`s handy if you keep the basals a little higher than `level` throughout the day and not have to worry about a bolus at lunch if possible. I miss that about NPH. I would ease up on her breakfast ratio of rapid though and see if she can coast nicely through the day. I never liked my DD running that low at school - especially before we got a CGM. YOu never know when gym or some unexpected event will knock them lower.
     
  17. wilf

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    So what is happening with her numbers overnight?
     
  18. mom24grlz

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    Ashleigh is on a split dose of Lantus. We just increase or decrease if her in range numbers are less than 60-70% Probably not the "correct" way to do things, but it works for us. Her A1C has been between 5.7-6.5% for the past 5 1/2 years. Last A1C yesterday was 6.2%. Her range is also pretty wide (75-149 during the day and 80-149 overnight)
     

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