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Medical Forum / Diseases and Disorders / Diabetes / October 2006Lantus
I recently saw Dr. Bernstein on DLife recommending an unusual approach to taking Lantus. He recommended dividing the dose between one evening shot and one morning shot. I believe he said the approach offered better control. This recommendation flies in the face of the Lantus directions which call for a single shot at night. I had three new bottles in the fridge and was a little reluctant to stop taking my familiar and reliable mixtures of 50/50 and or 70/30 (I mix in the syringe), but started Lantus the next evening and followed his advice. So far, everything is working well with the evening and morning shot. I'm rarely using a fast insulin with meals as the Lantus keeps me on a even keel all day. Comments welcome even from the Bernstein haters. Oh, heck. Let me add a clarification. I'm not mixing Lantus in the syringe with anything else. This makes Lantus unreliable. >I recently saw Dr. Bernstein on DLife recommending an unusual approach to >taking Lantus. He recommended dividing the dose between one evening shot [quoted text clipped - 13 lines] > > Comments welcome even from the Bernstein haters. >I recently saw Dr. Bernstein on DLife recommending an unusual approach to >taking Lantus. He recommended dividing the dose between one evening shot and >one morning shot. I believe he said the approach offered better control. I'll stand up and say that yes, splitting the dose works better for me than injecting it all at once. I'm up to 30u/day of Lantus: I inject 15u at breakfast, 15u after dinner. My overall control is vastly better this way than it was injecting 30u at bedtime. I also don't have that pesky leak thing working that I did with 30u; 15u goes in and stays in, while with 30u a bit would always spurt back out when I pulled the needle. Now I'm dealing with morning weirdness again because I've started thyroid replacement therapy. Synthroid must be taken on an empty stomach, with no food for at least an hour afterwards. I get up at 0500, drop my Synthroid and go back to bed until 0615. By then I'm having a bit of a liver dump so my FBG is falsely elevated. I'm experimenting with the timing of the Synthroid, the AM Lantus, and my breakfast. I don't see a workable resolution so I may have to resign myself to an early morning liver dump... >This recommendation flies in the face of the Lantus directions which call >for a single shot at night. Not all metabolisms are created equal. Lantus is supposed to be a zero-peak 24-hour insulin. I spent 6 weeks doing a single injection at bedtime and still had elevated FBGs. When I split the dose (of my own volition and without consulting my doc) my FBG came right down. My post-prandials also smoothed out considerably and I was able to reduce my bolus insulin by a few u per meal. My endo encourages me to do whatever works and she writes my Rxs accordingly. > I'll stand up and say that yes, splitting the dose works better for me > than injecting it all at once. I'm up to 30u/day of Lantus: I inject [quoted text clipped - 3 lines] > and stays in, while with 30u a bit would always spurt back out when I > pulled the needle. I sometimes get that little leak, too. I don't recall getting it with other insulins. Kudos on finding the right approach, WoolyGooly. > Now I'm dealing with morning weirdness again because I've started > thyroid replacement therapy. Synthroid must be taken on an empty > stomach, with no food for at least an hour afterwards. That's a pretty strict interpretation. In the real world if you have some food around it's not quite as effective, but the dose can be boosted to make up for this. The absorption of synthroid is most easily predicted if there's no food before/after, but it's not the worst thing in the world to have some food around. I speak as a synthroid user for a couple of decades, NOT as a doctor or pharmacist. > I get up at > 0500, drop my Synthroid and go back to bed until 0615. By then I'm > having a bit of a liver dump so my FBG is falsely elevated. I'm > experimenting with the timing of the Synthroid, the AM Lantus, and my > breakfast. I don't see a workable resolution so I may have to resign > myself to an early morning liver dump... The official synthroid information is sort-of assuming that there's no other medical conditions/need to eat/constraints. What people say here about liver dumps and food timing is also often done in ignorance of other constraints and real life. In the real world we've got all sorts of things going on, some medical and some non-medical but interacting with our medicines, and you cannot possibly ever comply with what everyone wants at the same time, so you apply some creativity and personalization to make everything work best for you. > Not all metabolisms are created equal. Lantus is supposed to be a > zero-peak 24-hour insulin. I spent 6 weeks doing a single injection [quoted text clipped - 3 lines] > reduce my bolus insulin by a few u per meal. My endo encourages me to > do whatever works and she writes my Rxs accordingly. Pretty much matches my experience. While the pharmacy computers and other computers and even some people seem to believe that all medications must be taken according to some strictly numerified schedule, in the real world everybody tweaks things to work best. I suspect your endo would acknowledge that if your synthroid and insulin and food can be adjusted/slided around in dosage or timing to make things better for you, it should be done. Tim. > > Now I'm dealing with morning weirdness again because I've started > > thyroid replacement therapy. Synthroid must be taken on an empty [quoted text clipped - 8 lines] > food around. I speak as a synthroid user for a couple of decades, NOT > as a doctor or pharmacist. What my doctor told me is that the single most important thing is to be consistent in how you take the thyroid supplements (I take Armour, but the same conditions apply as with Synthroid). Ideal is no food before or after, but before breakfast is OK, if the timing and amount of breakfast is pretty constant. She takes Synthroid herself, and can therefore appreciate the juggling of medicine, breakfast, and real life.  Signature"and the snark alert level has reached "fuschia"" ---zig zigalo homes in on the meat of the matter >The absorption of synthroid is most easily predicted if there's no food >before/after, but it's not the worst thing in the world to have some >food around. I speak as a synthroid user for a couple of decades, NOT >as a doctor or pharmacist. When I'm starting a new med I attempt to take it per instructions for a while. I've had my dose titrated upwards twice since I started taking the stuff. While I still don't seem to be at my ideal dose I'm at the point that I'd rather get my FBG back where I want it and THEN fiddle with the Synthroid dose, hence my experimentation. This morning I ate two saltine crackers and 8 almonds when I got up to take my Synthroid, my FBG at 0615 was smack in the middle of my average range. Tomorrow I'll eat one cracker and 4 almonds and see what happens. I may just need one bite of *something* to keep my liver sleeping until breakfast at 0630. I am very much aware that handling a combination of conditions and medication requirements means I'll be juggling for the rest of my life. At least I had most of two years to get used to juggling the requirements of my diabetes before I had to nuke my thyroid. > Now I'm dealing with morning weirdness again because I've started > thyroid replacement therapy. Synthroid must be taken on an empty [quoted text clipped - 4 lines] > breakfast. I don't see a workable resolution so I may have to resign > myself to an early morning liver dump... I take my thyroid meds in the wee hours when I get up anyway for a few minutes. Do you sleep solidly through the night? if not, it might work for you too. bj I hope it works for you! :: I recently saw Dr. Bernstein on DLife recommending an unusual :: approach to taking Lantus. He recommended dividing the dose between [quoted text clipped - 14 lines] :: :: Comments welcome even from the Bernstein haters. > I recently saw Dr. Bernstein on DLife recommending an unusual approach to > taking Lantus. He recommended dividing the dose between one evening shot and > one morning shot. I believe he said the approach offered better control. > > This recommendation flies in the face of the Lantus directions which call > for a single shot at night. It's sort of like breakfast cereal. There's a wonderful enlarged picture on the front of the box showing fruit etc. but in real life the way it's actually served usually doesn't exactly match the "serving suggestion". Same goes for insulins: there's some concept that's being sold along with it, but lots of times we bend the concept. I do believe that somewhere in the insert/prescribing info the duration is described as "up to 24 hours" and not exactly as 24 hours, and there is acknowledgment that the once-a-day won't work for everyone. For me, I found that twice a day is the golden ticket, and I did struggle a bit with once-a-day (I "gave it its best shot") before going to twice a day and seeing real improvement. > Comments welcome even from the Bernstein haters. Lots of what Bernstein promotes is not his invention, and I think this is the case here. There's nothing wrong about him promoting what others have been doing for years but it's a bit odd to see his name associated with the concept. Tim. > Lots of what Bernstein promotes is not his invention, and I think this > is the case here. There's nothing wrong about him promoting what others > have been doing for years but it's a bit odd to see his name associated > with the concept. Many good points. Thanks for the info on the Lantus info language re 24 hours. I should hasten to add that Bernstein didn't tout this approach as anything original with him. He's a modest guy. >> Lots of what Bernstein promotes is not his invention, and I think this >> is the case here. There's nothing wrong about him promoting what others [quoted text clipped - 3 lines] >Many good points. Thanks for the info on the Lantus info language re 24 >hours. The package insert on my Lantus shows a graph which shows steady release over 24 hours. Oddly, the graph stops at 24 hours, and never shows any indication of how the Lantus tails off, or how much longer than 24 hours it continues to keep dispersing into your system. That's odd, that they wouldn't finish out the graph so that we could get a more accurate idea of how long a Lantus dose takes to be absorbed. My sense of it is that it keeps going for a while after the initial 24 hours -- when I've been off Lantus for a few days, I found that taking one shot per day according to the directions showed a gradual change over 2 or 3 days -- I didn't seem to get the full effect until I had been taking it for 2 or 3 days. I'm assuming that the Lantus continues being absorbed longer than 24 hours, and that there is, consequently, a little build-up of the effect over several days. Alan ============================ I am TERRIBLY cruel to my cat. I tease him with a vine tendril until he either jumps up in the air to bat at it or zooms around in a circle until he gets too dizzy to stand up. What is cruel about it is that I don't do it nearly as much as he wants me to. ============================= Alan Moorman@visi.com wrote in message ... >The package insert on my Lantus shows a graph which shows steady >release over 24 hours. [quoted text clipped - 14 lines] > >Alan The clinical test results published during the early trials showed that, in some folks, the Lantus absorption curve was still relatively flat at 30-34 hours after the injection. IIRC, one study just quit measuring at 34 hours, some of their subjects had longer lasting absorption. However, Lantus has a fairly high Coefficient of Variation from patient to patient. That variation means that some folks see activity "ceasing" after only 19 hours. I read an assertion by one user that he only got 16 hours after his dose. Talk about YMMV. COV = standard deviation/mean. Aventis publishes a patient to patient COV of 84%. That's really high (None of the other injected insulin COV that I have seen are very encouraging). Regards Old Al > I recently saw Dr. Bernstein on DLife recommending an unusual approach to > taking Lantus. He recommended dividing the dose between one evening shot and [quoted text clipped - 12 lines] > > Comments welcome even from the Bernstein haters. not unusual at all, in fact many diabetes doctors and DSN nurses in the UK are now recommending splitting Lantus into two doses to ensure maximum coverage and minimal peaking. Ratty >> I recently saw Dr. Bernstein on DLife recommending an unusual approach to >> taking Lantus. He recommended dividing the dose between one evening shot and [quoted text clipped - 18 lines] > >Ratty Huh. The package insert with my Lantus shows a virtually flat trace for 24 hours -- that there aren't any peaks or valleys. Alan ============================ I am TERRIBLY cruel to my cat. I tease him with a vine tendril until he either jumps up in the air to bat at it or zooms around in a circle until he gets too dizzy to stand up. What is cruel about it is that I don't do it nearly as much as he wants me to. ============================= Uncle Enrico wrote in message ... >I recently saw Dr. Bernstein on DLife recommending an unusual approach to >taking Lantus. He recommended dividing the dose between one evening shot and [quoted text clipped - 10 lines] >rarely using a fast insulin with meals as the Lantus keeps me on a even keel >all day. It's a bit unusual but recommended by a lot of docs. A big problem with all injected insulins is variability in absorption rates. Even Lantus has a fairly high Coefficient of Variation**. As a practical matter, that means different patients report durations of activity ranging from 16 hours to over 30 hours and individual patients even report some day to day variations. If you're personal absorbence behavior is consistently over 24 hours, you won't see any serious benefits from splitting your dose. However, if you're one of the 16-23 hour absorbers, you risk "basal fade" during the interim between today's single injection and yesterday's single injection. That might be troublesome, it might not. Basal Fade for a T1 can produce a 300 mg/dL sugar in 30 minutes. Splitting the daily dose reduces the effects of a high COV. (**From Aventis literature: http://products.sanofi-aventis.us/lantus/lantus.html ". . . .Between-patient variability (CV, coefficient of variation); insulin glargine, 84% and NPH, 78%. . . ." From http://www.diabetesincontrol.com/modules.php?name=News&file=article&sid=1 ". . ..[Among individual patients] the coefficient of variation . . .was [NPH] 46% to 68%, [Levemir] 23% to 27%, and [Lantus] 36% to 48%, respectively. . .") Regards Old Al > I recently saw Dr. Bernstein on DLife recommending an unusual approach to > taking Lantus. He recommended dividing the dose between one evening shot and [quoted text clipped - 12 lines] > > Comments welcome even from the Bernstein haters. Some here have reported that they split their dose of Lantus because they don't feel it covers them for 24 hours. I don't because mine seems to last that long. The only thing I'd suggest to you is that you not change your medication based on what someone says on a TV show. Any change in your medicine should first be discussed with your own doctor, who knows your personal needs. Kurt : > I recently saw Dr. Bernstein on DLife recommending an unusual approach to : > taking Lantus. He recommended dividing the dose between one evening shot and [quoted text clipped - 21 lines] : : Kurt I started taking Lantus within a month of it being FDA approved. I took 70/30 for 4-5 months, had beyond crappy control, major highs and lows. Then took NPH/R for another 6-9 months after that. Had MUCH better control but still wasn't swift. Then started taking Humalog and Lantus, found that I was "okay" with the Lantus but developed problems with Humalog. Switched to Novolog and Lantus and did much better. Then after 4th month on Lantus found out that mid afternoon I was starting to have "highs" again. Doctor didn't understand.. I called Aventis and spoke with the research team and they confirmed that Lantus doesn't last some 24hrs. So, they suggested that I split my dose. Which I did. Soon found out that even with switching it that I still was having a lapse in coverage. Went back to one dose and began to suppliment with NPH before bed to cover the lapse. After careful experimenting I found that max I got from Lantus was 19hrs. After the 3rd CGMS, my Endo felt Pumping would be the better option for me since I have such variable bg's and insulin needs throughout the day. Sadly, no one has a constant Insulin need. Lantus is split over 24hrs. I was taking 18u a day, which breaks down to .755u per hour. My average daily insulin need is .625u per hour. Which my Endo felt I was actually going low all the time and my liver was just in a constant dump. Unless I eat or over do things.. I can go 24hrs at the basal rate I'm at now and never go over 95mg. So, my basal is perfecto! I'd suggest anyone having a difficult time with insulin adjustments instead of stressing, just ask your Endo to hook ya to a CGMS... the results are VERY interesting in the end. SignatureReisa, T1, Animas IR1250 Pumper DX-5/00 ASD-7/00 A1C: 6.2% (8/24/06) Daily CHO: 150-200gm TDD: 34-38u > The only thing I'd suggest to you is that you > not change your medication based on what someone says on a TV show. > Any change in your medicine should first be discussed with your own > doctor, who knows your personal needs. I don't disagree with your general premise, but in my case, I'm a big fan of Bernstein, have read his book, I frequent his website and I credit him with helping me achieve A1C's in the low 5's both with respect to diet and insulin use. I consider him one of my two doctors. I am new to insulin use. My sister is also and wasput on Lantus at night, and morning ... they were having trouble gettng her under control, but after a few days, she is getting much better. Rainbow |
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