Levemir split dose peak

[SBee]

Firstly, apologies if this doesn’t make sense, I’m really foggy after a 3am hypo!

I’ve been having a number of those around the 3-4am mark. I know that it means that I have too much IOB, and especially since they are definitely in the peak hours of Levemir. I split my Levemir dose. I have it 12 hours apart.

As I’m still a newbie with my cgm, I had increased my daytime dose, as I found with my cgm data, I was going high after lunch and staying high. So I upped that by only 2 units and that has been working well. My DE tried telling me that I should increase my night dose as well, but I did the opposite and reduced it, by the same amount that I increased my day dose, so that my daily basal stayed the same. Now that I have been having a lot of overnight hypos, I’m going to pull right back on the night dose, but I’m wondering if the 5-6 hour peak would be more ‘potent’ considering that technically Levemir is supposed to last for 24 hours?

I do have a large drop overnight. I was 10.8 mmol when I went to bed, shortly after having my night dose, and the low alarm woke me at 3am with a 3.5 mmol and I dropped even further half hour later, to 3 mmol (which was probably my choice of hypo fix - jelly babies are taking too long to be suitable anymore).

[Eric]

Hi @SBee,
I made a spreadsheet that is useful for looking at basal numbers. It lets you put in the various times and doses and also the amounts, and it shows you a graph of how the basal’s start and stop and if they are stacking, like if you have two on top of each other.

Levemir’s duration is dose dependent. The more you take (per kilogram of body weight), the longer it lasts!

We can go through this if you would like. It could be that just reducing the nighttime dose will fix it. But it could also be that your two doses are stacked.

It looks like this, here is just an example:

If you want to dig into this and don’t mind sharing dose amounts, we could plug it in so you can see how it looks.

If you don’t want to share dose amounts, I could email the spreadsheet to you (we are unable to upload spreadsheets).

The one personal issue is this…with Levemir, the duration is dose dependent, based on units/kilogram of body weight. So in order to get your duration, I would need to be rude and ask your body weight.

So if you didn’t want to do that, I could email it to you and then you could put in all the numbers yourself.

Anyway, happy to work through this with you if you’d like.

[SBee]

@Eric, thankyou so much! Really appreciate it! I am currently taking 30u in the morning and 24u at night, although I was thinking of reducing it to 20u tonight, because I’ve had 3 overnight hypos in 6 days. I have no issue telling you my weight, but thanks for the courtesy anyway I’m 75kg.
I should also say that I mistook the time of my hypo this morning, it was 4am that I had it. I took the dose of Levemir at 10 pm (I aim for 9:30am & pm, but I was a little bit late last night).
Really appreciate you taking the time to help!!

[SBee]

I should note that I do also take Metformin at dinner. 1000mg XR. I have been told that my i:c ratio is ‘tight’ for someone if my size too which, to be honest, I’ve never really understood. It’s 1:5. Not sure if you needed that info, but I’m pretty much an open book so…

[bkh]

@SBee

and 24u at night, although I was thinking of reducing it to 20u tonight, because I’ve had 3 overnight hypos in 6 days.

Reducing the overnight basal does sound like the right thing to do. Safety first, then optimization if you’re up for it.

[Eric]

Hi @SBee
Putting in your numbers (30 units at 9:30am and 24 units at 9:30pm), your morning dose has a duration of about 20 hours, and your evening dose has a duration of about 17 hours. Those durations are based on the studies that show the duration of Levemir based on dose.
(Reference here:
A double-blind, randomized, dose-response study investigating the pharmacodynamic and pharmacokinetic properties of the long-acting insulin analog detemir )

This makes a few assumptions which are not exactly correct, but just an approximation! This graph is assuming a flat profile for Levemir for the duration of the dose. That is not exactly correct, but just gives an idea!

When I put in your dose amounts, duration, and dose times, this is what it looks like. So just as a general idea, see if this graph somewhat matches your experience and if this seems somewhat close to where you are now.

(Keep in mind, this graph is the estimated amount of Levemir you have in your system, this is not BG. So it is somewhat opposite of a BG graph. Higher amounts on this graph would correspond with lower BG numbers.)

Let’s see if we are on the same page so far.

[SBee]

Fantastic! Thanks @Eric! I can definitely see similarities. I’ve done a comparison of the last 2 days. The top one is yesterday, the 20th Dec, and the lower one is the day before.

I purposely allowed my bsl to go high without correction last night, 16.9mmol prior to bed, but didn’t change the 24u. I woke up this morning to 8.8mmol. So you can see the dramatic drop, which doesn’t really happen at any other Levemir peak times that I can see. Even going back in my history a couple of weeks, I drop dramatically overnight, but most days I am pretty steady.

[Eric]

Something to consider. If you are taking more Levemir for the daytime versus nighttime - yes, it is possible you need more basal during the day. But it is also possible that the daytime basal is needed to cover some of your food intake, because maybe you aren’t taking enough for meals. Have you considered that?

Do you want to consider different times and amounts? I can easily plug those in to show you what they look like.

Here is a comparison when you take less both morning and night, and take it earlier in the morning. Keep in mind, if you take less in the morning, you will need more insulin for your meals during the day.

[SBee]

I’ll consider anything @Eric . As I said previously, my i:c ratio is currently 1:5 (NovoRapid). My ‘breakfast’ is generally just coffee, so only 10g of carbs there, with perhaps a second one mid morning. My lunch is usually a sandwich, so 28g. My dinner has been something that I have tried to minimise the carbs in, although lately, I haven’t really been following my own rule. So it can vary between 10g, up to 60g.
My complication is periodontal disease, so I have pretty crappy teeth, no infections currently to muck with my levels, but it certainly limits what I can eat, as does affordability being that I’m on a disability pension.

[SBee]

Here is the week overlay to compare also. The really high one was when I went out for lunch and had rice - my nemesis!

[Eric]

The rise in the middle of the day is probably food. So perhaps just focusing on the nighttime first. It is easier to figure things out with only one change at a time.

Perhaps either a reduction in the nighttime dose OR taking it a little later in the evening, like right before bed? Just try one or the other and see if that makes the nighttime drop less significant?

I kind of like the idea of trying it later in the evening, because that might also help reduce the spikes you see after lunch.

[bkh]

Those CGM graphs show pretty significant drops overnight, 12 to 8 in less than 4 hours, and 8 to 4 in 3 hours or sooner, twice. I’d say you need to make a change that gives you less insulin overnight.

[SBee]

@Eric, I think I might try the later time to start with. Would you suggest that I also change the time of my morning dose? I’m imagining that even with the time change I may probably need to reduce in the future as well, but a 5:30-6am hypo seems better than a 4am one (especially as where I live, this time of year first light is at that time of day).

[SBee]

@bkh yes, I’ve always dropped dramatically overnight. Prior to getting the cgm, we didn’t know how much or how often I did. It was one of the reasons I switched from Lantus to Levemir (and a decade plus before that from Protophane to Lantus) and also why I went for the cgm as opposed to the Libre. I had to split the dose of both the Lantus when I was taking that, and the Levemir, because it would run out before I took the next day’s dose. I suspect that I will definitely need to drop the amount, however I will only change one thing at once. I’ll give @Eric 's suggestion a go first and then look at changing the dosage if that doesn’t alleviate the issue.

[Eric]

@SBee

@Eric, I think I might try the later time to start with. Would you suggest that I also change the time of my morning dose?

Yes, actually that could really help too. It would somewhat reduce having the two doses on top of each other.

I think having the morning dose earlier will reduce the two basal injections sitting on top of each other.

It depends on when you wake up. I mean, nobody wants to set an alarm just to take their insulin shot and then go back to bed. So maybe first thing when you wake up, if that makes it a little earlier for you. Like 7:30am or 8:00am or 8:30am, something like that might help.

@bkh has a good point about reducing the nighttime dose too. That might also be necessary.

In general though, if you make too many changes at once, it becomes harder to know which did what. These things take time to get them fine-tuned.

[incidentals]

I am hoping i do not end up with you issues…

interestingly I understand your units I have a terable problem getting my head around american units.

The doc wants me to go onto levemir as I can spike upto 22+ before bed take 20 lantus and be 2.8 by 03:00 without any correction.

The reason for the change is that my graphs look fine, shape wise, just all running above where we want them to be. so increasing Lantsus looked like an approach.

Big problem is the interesting crashes every evening at 3 am so Levemir 14 day 10 evening - once they get the prescription emailed to the GP

[SBee]

So, I’m back again, and wondering if you would please email me that spreadsheet @Eric?

The changes I made 6 months ago, definitely worked for me over the warmer months, but now that cooler temperatures have arrived, I’m back to dropping overnight AND having issues during the day as well.

In the past, I’ve required more insulin over winter, not less. I certainly seem to be more sensitive to temperature than I ever have been before. I can’t get in to see an educator or endo for a while, so I need to look at stuff again myself. I’m tired of having to eat so many carbs and have even skipped insulin doses, which of course then sends me the other way.

I’m sure you can see by my language, that I am incredibly frustrated right now!

Anyway, if you’re still happy to share that spreadsheet, I would be very grateful.

[Eric]

Hi @SBee
Yep, I can send it to you. Let’s get back up to speed on it.

This is what it looks like. The ONLY things you enter into it are the yellow & red cells of the spreadsheet. Everything else you leave alone and let it calculate it all.

First you enter your different dose amounts and times, and you enter your weight (in kilograms!!). Make sure it’s kilograms!!

And the dosage times are entered in 24 hour (military) time, in 00 or 30 minute increments only.

Like 6:30 would be 6:30am. And 18:00 would be 6:00pm. Those are fine. But only use 00 or 30 minute increments, because if you enter something like 9:20, it won’t work with those numbers (this is just a primitive version, nothing in here has been made bullet-proof).

For estimated duration, look at the green cells and use those as “estimates” based on your dosage amounts and weight. You can put whatever duration you want in the red/yellow duration cells, but the estimations are shown based on the studies of Levemir units per kilograms and the various duration associated with it. So those are good places to start with at first, and then adjust it based on your experience with it.

So does all of that make sense so far?

[SBee]

Makes perfect sense so far, thanks @Eric.

[Eric]

@SBee,
I sent you a PM for you to send me your email address, and I can send you the spreadsheet, since we are not able to attach Excel files here.

Alternatively, @Chris maybe that is something you can allow me to do in this case?

Keep in mind, this spreadsheet gives only a rough idea. The basal dose in the spreadsheet ramps up and drops off much quicker than it does in actual use. But I think it’s helpful to allow you to tinker with the times and dosages and see it. Much easier to do it that way than to have to try it out by using it.

Changing the numbers on the spreadsheet has no consequences. You can do it a 100 times with all kinds of different time of day and amounts entered, and there are no repercussion. For that reason, I think it is a useful thing to look at before making the actual changes.