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Insulin question for my T2 dad starting on Lantus

Discussion in 'General Discussion' started by Charlotte'sMom, Dec 9, 2013.

  1. Charlotte'sMom

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    My dad is a T2 diabetic and is supposed to be starting insulin this week. Since I'm the insulin expert in the family, he's asked me to help him.

    Some background-- he's 71, was diagnosed some 20 years ago and has never done much to take care of himself aside from taking his oral meds. He rarely ever tests himself. My mother is losing her battle with breast cancer, which adds to his stress (and he's a stress eater!) and it's all finally going to hit the fan.

    His doctor prescribed 2 units of lantus each day with a pen. If he got more instruction than that, he hasn't said.

    So, my question is, for a 300+ lb man with insulin resistance, is 2 units of insulin even going to do anything? I know he needs to be testing himself at least several times a day, but should he also be carb counting? It seems like if your carb intake varies wildly from day to day, find finding the right Lantus dose would be really hard even for a T2 diabetic.

    I know how I would treat this it were me taking the insulin, but I know my dad can't or won't do what's required to really get his blood sugar under control. So while I would love to be aggressive and get his blood sugar down (which is likely in the high 200s and 300s) I wouldn't want to risk lows for him either. I want to help him, but I'm already discouraged. I know he'd inject the 2 units of insulin and think it's enough and continue with his poor eating habits.
     
  2. AliciaM

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    I was told by my endo to start at 2 units (when I started on lantus) and then raise it every 3 days by 2 units until I start seeing my am numbers go down.
     
  3. Charlotte'sMom

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    I just talked to him and it sounds like he does have more instructions from the doctor that we wants me to help him go over I guess he's just waiting for me to help him to work up the courage to inject himself!
     
  4. GChick

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    Disclaimer: I am not a type 2... nor do I know a lot about type 2s situation.

    However, in an attempt to answer some of your questions, yes 2 units of Lantus per day is quite small for a 300 lb man... I myself (a 145 lbs or so woman) take a total of 17 units per day...

    However it is quite possible that being a type 2 that your dad may still be making some insulin. Also, for a man that age, it is probably seen by doctors to be better to underestimate and deal with a few highs until you get all the kinks worked out than to overestimate and have to deal with super low lows... and beyond that, everyone's insulin needs vary.

    You also asked about carb counting. While indeed your father should be "watching" his carbs in general... for a Lantus (long acting) insulin, carbs don't really play as much a part in the dosing as just regular body size, activity level and general needs do.

    With short acting insulins, which I'm assuming he is not on yet (humalog, novalog, apidra etc) it is much more important to be basing the dose on the amount of carbs he is eating.

    But you have stated that there are indeed further instructions, so I'm sure some of it may be cleared up by those.
     
  5. TheFormerLantusFiend

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    I recently read a study on insulin action profile in non-diabetics and it said that injecting a healthy adult with up to 0.05 u/kg in a single dose is unlikely to cause hypoglycemia.

    So do I think 2 units will do much to a 150 kg man - a dose of less than 0.02 u/kg and of a long acting insulin? No. But maybe the doctor wants to start where he's pretty sure it won't cause lows and work up from there.

    The Lantus manufacturers suggest a starting dose of 10 units up to 0.2 u/kg for insulin naive patients (meaning people who haven't been on insulin before). For a 300 lb exactly person, 0.2 u/kg would be 27 units. So the Lantus people recommend a starting dose in the range of 10-27 units.

    http://www.lantus.com/hcp/dosing-titration/dosing-calculator.aspx

    P.S. The dosing calculator does not allow you to enter in weights below 110 lb, where 0.2 u/kg = 10 units. For folks like me who weigh less than 110 lb, the calculator refuses to calculate (but it is meant for t2s anyways).
     
  6. mom24grlz

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    Are you sure he heard correctly? 2 units probably wouldn't make a dent in his bs. I post on a couple boards with type 2 adults and most of them are on 35 units and upwards when it comes to lantus or levemier. Type 2 s normally need a lot more insulin compared to type 1s because they are insulin resistant vs insulin sensative.
     
  7. Charlotte'sMom

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    He had remembered wrong. His instructions said to start at 10U, which he did yesterday evening. Then until his fasting bg is 140-170 he's supposed to up it by 3 units every 3 days. His 2 daytime numbers after eating yesterday were in the 300/400s. :(

    Thank you Lantus Fiend for the link. So those are the starting doses? It's probably likely he'll need much more than that then. I wonder how aggressively we could up his dose and still be safe. ??

    We've tried for years to help him take control of his health and I feel like he's a ticking time bomb.
     
  8. Charlotte'sMom

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    There's probably nobody reading this still, but if anyone is/does and wants to offer insight...

    Since starting my dad on insulin, we've been upping his dose much faster than the 3 units every 3 days that was suggested. He's now up to 50 units in the evenings, but his blood sugar is still averaging 250-330 in the mornings. (He's also on 1000mg metformin 2x day) He's not testing any other time of day. He's been having trouble sleeping at night lately, and admits to snacking during the night, so his morning numbers aren't after hours of fasting, either.

    If it were me, I'd go on a zero-carb diet for a few days and do some basal testing... but he's not likely to do that. I'm also half-tempted to give him some Apidra just to get his blood sugar down. But I'd be pulling dose amounts out of thin air, and I don't want to do that either.

    I'm guessing that he probably does need fast-acting insulin in addition to basal. However, he's really stressed out about my mother's health and getting him to change his eating habits at this point is not going to happen. As morbid as this sounds, I think he's just trying to live long enough to take care of my mother. But he's really stressed out about living without her, and I'm not sure he even wants to.

    Anyway. I did a little bit of searching on other forums and it looks like some T2 diabetics take as much as 100U lantus daily. :eek: But I'm guessing my dad could get close to that. I'm feeling okay about how we're upping the dose. So far it's been about 5 units every 2 days. I figure as soon as we see any improvement in his bg numbers we'll slow down the dose increases. But it's starting to stress me out that his bg has been so high for so long.
     
  9. GChick

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    Once again, I really have little insight into type 2s (other than having a friend who has a father who is one)... but I think you are doing fine.

    When it is not your life, or your child's life you are dealing with, there is only so much you can do. The fact that you notice that the increases obviously have to be more than is usual is a good start.

    And I wouldn't be too worried about getting him into "normal" ranges for the moment, but just on the high side of "normal", which is what it looks like you are aiming for. When you are dealing with someone who will not/can not change their eating habits, that is all you can do... as the last thing you want to do is send him low on an odd day that he doesn't eat as much.

    Good luck and good job. Hope it all works out for the best and he is more willing to contribute to his own care (even if that is just eating less), even though it may be difficult.

    [edit:] You may also wanna take a stab at testing him at night a few times (just to make sure he is not going too low at that times and to confirm if the highs are consistent through the day or just a night time problem). Many people find that they have higher sugars at night than during the day. maybe changing time of day of his shots may be the ticket?
     
    Last edited: Dec 24, 2013
  10. TheFormerLantusFiend

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    I think taking it in the morning instead might be more helpful, on the theory that often it really does have more impact in the hours you take it and that his pancreas could use more assistance during the day.

    I also think that as a stand alone insulin in a T2 diabetic, NPH is better than Lantus because a single shot of NPH (taken before breakfast) can better cover basal for the day plus a meal. Lantus' own data shows better A1cs in people on NPH.
     
  11. Charlotte'sMom

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    Thank you for both of your replies. GChick, after reading your comment I realized that if his Lantus dose is based on him snacking during the night, it might send him low when it doesn't! Hopefully after the holidays we can get the junk food out of the house and help him start eating better and then if he can be more consistent I'll feel better about his dose.

    LantusFiend, I'm curious about the NPH. I have no experience with it whatsoever. A quick google search says it can last up to 24 hours, but there's a peak between 4 and 14. ?? Is that right? So I'm assuming it's taken in the morning to cover the meals during the day? I'll have to run that by my dad. He did just fill a prescription for 5 lantus pens, but maybe after he uses those up we can talk about it. Or do you need to be on Lantus as well as NPH?
     
  12. TheFormerLantusFiend

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    NPH taken in the morning generally covers lunch plus snacks. It might or might not cover other meals. If you want to be sure that it will cover breakfast, it can be mixed with another insulin. You can buy it already mixed or you can mix it yourself.

    So you could take one shot of 70/30 premixed NPH with Regular, and it would cover 1 meal when the regular kicks in about half an hour later, plus a second meal when the NPH peaks about 4 hours later. It would additionally provide basal coverage for the day.

    NPH in some people covers basal for a full 24 hours but not in others.

    There are people who take Lantus and NPH or Levemir and NPH, but I wasn't suggesting that.
     
  13. Charlotte'sMom

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    My dad called to say his blood sugar was 180-something! It's the first number under 200 we've seen! Yay!! He's giving himself 70 units-- 35 in the morning and 35 in the evening. He's also losing weight, which I was kind of surprised by. But we're excited to finally see some progress.
     

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