II’m working through some effective solutions to address a situation where I get daily spikes after breakfast, caused by, to all available evidence, what I can only describe as Lantus fade or falloff. I take Lantus twice a day, at 10am and 10pm. Dinner coverage seems to be solid, but I am having consistent problems with after breakfast spikes that are timed at roughly 22-23 hours since my last AM Lantus dose.
One approach has been to bump my mealtime bolus up to help provide coverage for the lagging Lantus.
Another approach I am trying is substituting Novolin R instead of Novolog for my breakfast bolus, which has a longer duration curve that theoretically would extend into that fading Lantus timeframe.
Initial efforts with the Novolin R are not appearing to be any more effective than just routine Novalog dosing, with no additional bolus for the fade.
And in my research on why this might be, I’ve come across a discrepancy in how Novolog vs Novolin R duration curves are compared.
Some folks equate the effectiveness of Novolog and Novolin R as roughtly equal, with a delayed peak and longer duration, as evidenced by this chart.
Other folks represent the duration curve with a pronounced lesser effect when comparing Novolog vs Novolin R, although with the expected delayed peak and longer duration curve.
In real life usage, does anyone have any input on whether or not there is an actual lesser effectiveness curve for Novolin R vs Novolog? All published advice seems to suggest that they are interchangeable on the one hand, but there are numerous charts that seem to suggest otherwise.
Are there other possible solutions for addressing this Lantus fade effect?
I’m pretty much locked into the timing on the 2X daily Lantus dosage, due to lifestyle constraints, which is why my first approaches have been to attempt to ‘patch’ those spikes with a preventative bolus dose, since they are so predictable in their timing.
For the solution to your problem you might try Tresiba as your basal insulin. I went from two inadequate injections of Toujeo ( improved version of Lantus) to one effective dose of Tresiba.
As far as your curves are concerned, novolin R is quite unpredictable as far as duration is concerned, and I can see you getting into trouble with three types of insulin.
I would love to have the option to try other long term basal insulin options.
Sadly, my insurance will only cover Basaglar in disposable pens, and Lantus in vials.
The Novolin R option was picked simply because I could pick up a vial to try out with minimal out of pocket expense.
And I do agree that the more insulins there are in the mix, the increased chances of something going astray.
At this point of my testing phase the Novolin pen is kept on my breakfast table, right next to where I would normally have breakfast. At all other times it is effectively out of reach, for other meals, or other corrective bolus doses.
If it turns out that the Novolin’s different duration curve doesn’t really provide a solution, then there is no reason to continue to try using it for my morning bolus. Just not sure that an increased dosage compared to using Novolog is the next step, or if that is just more likely to walk me closer to a hypo event since it’s not going to clear my system as quickly as the Novolog will.
I’ve seen on other discussion boards that others with similar problems even resort to 3X daily Lantus dosing, but that would almost certainly have to be an option of last resort for me.
It probably depends on what you are eating for breakfast. I’m experimenting with Regular insulin. I find it is a good substitute for when I would use an extended bolus on my pump, meaning that I do not use it as a substitute for rapid-acting insulin, but in combination with rapid (unless I am not eating carbs). For example, I will bolus Regular alone for a low/no-carb breakfast, such as eggs. If I were to eat eggs and toast, I would use Fiasp for the toast and bolus 1 to 1.5 units of R at the same time to cover the later protein rise and gap between Levemir doses.
Another option for you might be to take your Lantus earlier, so it kicks in by the time your night dose wears off. For example, take it at 8am in the morning instead of 10am to give it 2 hours to kick in.
I disagree, it’s very predictable, and I actually think from my experimenting so far that using R in addition to Fiasp/Novolog/Humalog makes perfect sense for MDI. It’s not the same as NPH or Lente insulins which are suspensions. It’s the only way I’ve been able to mimic extended pump boluses, which I always thought was a huge limitation of MDI. I don’t think taking multiple shots of rapid is always practical, as often protein/high-fat meals digest hours after I’ve gone to sleep (up to 6-8 hours after eating).
@Scotteric With all due respect, I have several emergency room bills that attest to R’s variability. I’ve been diabetic for almost 48 years, and I can vouch for duration variability in R and novolog within that time frame.
Fair enough, my experience with R is limited. I find it very gentle though, it could be because I’m taking it in small amounts to supplement my meal boluses, and not as my primary bolus insulin. I’m sure taking it in combination with NPH was much more difficult as well.
In my experience I had spikes after breakfast because insulin (any kind) has far less effect for me in the late evening, overnight, and early morning. For breakfast I need the same bolus that would deal with a decent lunch+correction at lunch just to get a decent correction in the morning. Breakfast doses seem to be somewhere around 1/2 to 1/3 as effective as doses delivered at lunch or dinner for me. My solution was just to stop eating breakfast, or at least eat minimal or no carbs at breakfast. Anyone else notice time-dependent insulin effects like this?
Yes, but we attribute the huge spike in insulin requirements in the morning to the Dawn Phenomenon. For our son, we don’t skip any meals or cut any carbs, we just test like crazy as many times as it takes to figure how much insulin is correct for him in the morning times. No one (diabetic or not) should have to go without meals if they don’t want too…since the body is known to exhibit these traits in the early morning, I would advise just figuring what that right combination of bolus/basal is for you in the early morning so that you can enjoy breakfast.
Yeah, it’s probably the dawn phenomenon, but that name seems a bit of a misnomer since for me it starts the evening. All I really need in the morning is my coffee, so I’m OK skipping breakfast and I’ll have eggs or protein-heavy food if I’m hungry (which is better for satiety anyways). Besides the insulin having less effect it also takes much longer to do anything in the morning, so my system has evolved into dosing as if I was eating a full meal as soon as I wake up (5:30AM), get ready for work, commute to work, then by 9 or 10AM IF my sugars start to go down low enough (which can be rare or common depending on my activity level) then I’ll have a small nut bar with very few carbs. Works for me, but your mileage may vary.
