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Help with Lantus, split dose?

Discussion in 'Parents of Children with Type 1' started by LNC, Feb 27, 2014.

  1. LNC

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    My 12 yo son chose to use Lantus instead of his pump for basal. He is on a school and travel baseball team and the pump site gets clogged with sweat, dirt, pus even with frequent changes. Just doesn't work for him as a basal, though he uses it for boluses.

    He has been high every afternoon at practice which impacts his performance. We have been playing around with his carb ratios and correcting highs but it doesn't help. He also has been eating lower carb to lose a little weight, so he needs less bolus anyway. I think the problem is his basal from a nighttime cose of Lantus wearing out. Could that be it? He gets his Lantus st 9pm and is low in the middle of the night and wakes up high - high 200s. Most days lately, we have trouble getting it back down.

    Should we try 1/2 dose Lantus with bedtime snack and 1/2 dose with breakfast? Has that made a difference for anyone?
     
  2. Sarah Maddie's Mom

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    Can't advise on the lantus aspect, but I'd be concerned that the infusion set, if it's as big a mess as you indicate, it won't be very effective for bolusing and that may be contributing to the highs. Which pump and what infusion set is he using?
     
    Last edited: Feb 27, 2014
  3. LNC

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    Thanks for the reply. My son was diagnosed at 4yo too.

    Maybe about the infusion set. We change it every other day bc it gets clogged so easily. We think he also has a semi allergic reaction to basal novolog causing the pus (as well as the sweat issues). It doesn't happen as often with bolus. But one day this week he took off his site to change it after a day of highs and blood poured down over his torso. He had to apply pressure to stop the bleed. Sites do NOT agree with him, it is so frustrating. We only tried the continous glucose monitor for a week bc under the adhesive and surrounding area got so red, swollen and hives ish.

    Medtronic Paradigm pump
    Medtronic Mio
     
    Last edited: Feb 27, 2014
  4. Sarah Maddie's Mom

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    Sound like maybe an adhesive allergy since both the infusion sets and sensors are reacting. He's been pumping a long time, right? Is the issue with the infusion sets new?
     
  5. Mish

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    yes, splitting your lantus might help.

    But I think you're seeing clogged and infected sites because they're not being used enough. There's no way he could be allergic to novolog delivered by basal and not by bolus. An allergy wouldn't know the difference. When a site has a constant infusion of insulin being sent through it, it is less likely to clog and cause issues. And "gushers" happen to all of us at one time or another. It's frightening when it does happen, but it is fairly normal. But it certainly was what was causing his high blood sugars, because all that blood was backing up into the canula, making boluses ineffective.

    I'd do a few things:
    Split your lantus dose but also keep a SMALL bit of basal running through the pump at all times. Your doctor could help you figure out the dosing, but I think you can go as low as .025 per hour on your pump, so that would only account for about .6u in basal.
    Try a different type of infusion site
    Protect his skin under the infusion site with a barrier wipe.
     
  6. Lakeman

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    We do a split dose of lantus. If you are testing to see if it is a lantus issue the key is figuring out when it starts acting after the dose is given, when it peaks, and when it runs out. For some people it seems like the shot does not even start until about six hours after given (it takes time to be absorbed depending on the difference in the PH of the lantus and the bloodstream). Then it might peak 3 or 6 hours after that (this is where you see lows) which leaves a later period of time with less lantus (highs) and then it runs out around hour 22 -24 (more highs).

    Imagine that you made of graph of that. It might look like a right skewed bell shaped curve. When you split the dose the the two graphs would overlap so that the peaks on one are covered by the valleys on the other resulting in a more even effect. Some people will split it so that a larger dose is given in the AM and a smaller dose in the PM and some might split it so that the two doses are equal (that's what we do). Generally put the smaller dose before the time period where you want to avoid lows.

    I am pretty sure that all pumps require a steady dose of insulin at all times so the pump will always be doing some of the basal.
     
  7. Mish

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    This is completely false. The pump that the OP is using is able to run with no basal.
     
  8. wilf

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    Is it possible that he's going low and rebounding overnight, leaving him insulin resistant and high in the mornings?

    This happened with DD, and led us to move her Lantus injections to mornings.
     
  9. MEVsmom

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    We do MDI, but we split our Lantus dose a couple of weeks ago and it made a dramatic difference in our control. We started with morning then switched to night. That didn't solve our problem with highs. It just moved it around to a different time of day. Splitting the dose really helped.
     
  10. LNC

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    Thanks everyone. We think he does get low in the middle of the night bc we check the last two nights and he was very low. He has been high when he wakes up so we weren't considering that until now. But if he is just rebounding in the morning it doesn't seem like he would stay high all day long? I think we will split the dose tonight and see where we are. He came home from a 2 1/2 hr hard practice at 227. That is crazy - he should be low and needing sugar while exercising that hard. We see the our ped endo next Fri so I think we will split now and see what she thinks after a week of numbers.

    And yes we do run a tiny basal through the pump continuously.
     
  11. shannong

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    My son has allergic reactions to every adhesive we have tried. Barrier wipes (we use All Kare) help a lot with this. Also, my son had similar site reactions to your son (pus, infected looking sites) and we switched to the steel cannulas. Some of his sites still have issues, but way less and certainly manageable. They can look a little red and inflamed, but since switching to steel, we have had no pus issues. The steel cannulas do cause more hard bumps, so changing them ever 2 days helps too.

    I think if your son is waking up high, it can be difficult to get them back in range. Especially from a rebound, I would think that you would be dealing with a lot of insulin resistance. If he is going low from the dose at night, perhaps splitting the dose would be helpful. We did split doses of Levemir (similar long acting) and my son would get 80% of his dose in the morning and only 20% at night, because he just didn't need as much at night (of course there is also some overlap action).
     
  12. nebby3

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    It sounds like you are dealing with rebounds but I did want to say that kids that age often go high towards morning and just changing when you give lantus might help.
     
  13. suzyr

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    How often does he check during practice? Are you correcting after practice?
     
  14. wilf

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    Ok, so now you know what your problem is. In children who have not lost this defensive mechanism, after a hard low there is a sharp rebound in blood sugars coupled with increased insulin resistance that can last 12-18 hours (which will make them seem "stuck high" well into the next day). Ask your endo to help you move the Lantus to mornings.

    As for the post-practice number, that happens during hard (anaerobic) practices. They will finish high, but then drop down by themselves within the next 6-12 hours. Do not correct the high, just bolus for carbs..
     
    Last edited: Feb 28, 2014
  15. suzyr

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    Thats wilf that is what I was thinking

    One other thought if you are having a snack one hour before intense exercise do not bolus for the entire amount....got us a few times if we forgot. We do no more than half bolus for carbs within 1 hour of practice :)


    editing to add that is what we have found works for us, and it really does change from day to day. It was just a starting point that our cde recommended when we started our sport.
    Your endo team would have some advise if you contact them.
     
    Last edited: Feb 28, 2014
  16. Sarah Maddie's Mom

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    I'd have to know how "low" you mean in the overnights but I don't think it looks like rebounding. Rather, I think he needs more insulin in the early morning hours. Or you could be over treating the middle of the night lows.

    It's very common for my kid to run high after practice or a game. We usually do 1/2 a correction.

    I'd seriously consider experimenting with other infusion sets and trying to get to the bottom of the adhesive allergy - which I think is the root of your problem - so that he can take better advantage of the benefits of pumping.
     
  17. sincity2003

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    We just did a weekend sports camp with Sam Fuld and one of the things he (and the pediatric endo who was the chief medical director for the weekend) told us was to not correct a high right before a practice, during a practice or up to an hour after practice unless keytones are present. All kids react differently to practices/games, some go really high with anxiety, some kids go low (and you can correct lows). My DS goes low, and plays his best baseball at the 80-90 range, but it's so hard to keep him there. I don't have any experience with splitting Lantus, but I wanted to just tell you what we were told about practices/games :)
     
  18. Christopher

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    Interesting how we hear different advice. I was always told if bg is high you should not exercise. It seems like the advice you were given is it is ok to exercise if high (ie: don't correct a high before activity). I agree logically it doesn't make sense to do a correction if high before activity because "normally" activity will lower blood sugar. It is just hard to know what to do when, and what bg number is too high before exercising.
     
  19. sincity2003

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    The question came from a father whose son plays football and before every big game, his BG shoots up to the 275-300 range and he said they were correcting him but then he would go low halfway through the game. In our case, we notice that DS goes low a lot right before a game or practice, and up to 2 days after if we don't decrease his basal, but we also saw the high numbers (250) right before a big tournament last year and we treated it and he went really low (like 32 low) halfway through the 2nd game, so our CDE told us at that point not to dose for at least an hour because of adrenaline. They did say that if your child is lethargic or ketones are present, then to treat the high, but otherwise, just keep an eye on them.
     
  20. RomeoEcho

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    The important thing is "don't exercise with ketones" since if there is an actual insulin deficit, exercise will put demands on the body that you need insulin to process. A long time ago, the advice was simplified to "don't exercise if over 250 twice" which was the criteria to be worried about ketones. I have seen this get translated to "don't exercise over 250." If you know the high is from food, or is intentional in anticipation of an exercise drop, it's not a problem and is generally a good thing. If it's unexpected and you think there might be ketones, fix the problem first. As soon as there is insulin on board, it's fine though.

    I worked with an exercise physiologist CDE back in college as a runner and rower. For a while, her advice was to get over 250 before competition because I was dropping too much. We eventually got to where I could start at 180-200 and stay there. But if it wasn't intentional, I was supposed to check for ketones first.
     

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