Lantus Dosing Wisdom
Hey folks, I'm pretty sure this topic has been covered to death but what can I say, I love to hear myself talk.
Anyway, I'm considering switching from twice daily NPH injections to Lantus. I tried this once before several years ago, and the upshot is: It was one big hypoglycemia coma. So, I'm a little nervous about the idea. I've been gathering as much info as possible on Lantus and I found the official dosing guidelines here: http://products.sanofi-aventis.us/lantus/lantus.html#section-3
The advice from Sanofi-Aventis is to take 80% of your total daily NPH in Lantus. Maybe I'm nuts, but this seems like a lot of insulin. I'm taking a 2nd NPH injection daily because the 1st one only lasts about 12 hours. So, if you take 10 units of NPH twice, at any given time during the day you should have about 10 units worth in your system, never 20 (ignoring the crazy peaks of NPH). But here they are suggesting that 18 units is appropriate, to minimize the risk of hypoglycemia no less. That's nearly double the old dose. So that would seem to explain the constant lows when I tried it before.
Anyone else run into this when switching from NPH? Am I the only one that thinks this advice is just a little wacky? Could it be they suggest doubling up in order to slow absorption so the stuff will actually last 24 hours?
Anyway, I'm considering switching from twice daily NPH injections to Lantus. I tried this once before several years ago, and the upshot is: It was one big hypoglycemia coma. So, I'm a little nervous about the idea. I've been gathering as much info as possible on Lantus and I found the official dosing guidelines here: http://products.sanofi-aventis.us/lantus/lantus.html#section-3
The advice from Sanofi-Aventis is to take 80% of your total daily NPH in Lantus. Maybe I'm nuts, but this seems like a lot of insulin. I'm taking a 2nd NPH injection daily because the 1st one only lasts about 12 hours. So, if you take 10 units of NPH twice, at any given time during the day you should have about 10 units worth in your system, never 20 (ignoring the crazy peaks of NPH). But here they are suggesting that 18 units is appropriate, to minimize the risk of hypoglycemia no less. That's nearly double the old dose. So that would seem to explain the constant lows when I tried it before.
Anyone else run into this when switching from NPH? Am I the only one that thinks this advice is just a little wacky? Could it be they suggest doubling up in order to slow absorption so the stuff will actually last 24 hours?
Replies to This Discussion
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Permalink Reply by SF Pete on -
Lantus is a background insulin and has very little peak. It is supposed to have no peak, but I found that at about 6-8 hours after injection it would be a little bit more active. It's a 24 hr. insulin. I used to give just one shot at day at bedtime. There are other folks who find they have better coverage if they split the dose. The Lantus burns differently than the NPH worked. If you are giving 10u twice of day of NPH, that's 20. If they are suggesting 18 u, that sounds about right. It doesn't all work at once. It's a slowly releasing to give a steady level of insulin for the day. Lantus is more truly a background insulin than NPH. You should bring these issues up with your doctor. We all react differently to insulins. You may need to reduce your Lantus just because it works so differently.
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Permalink Reply by Jake on -
Lantus has a ramp up period (at least as far as im concerned), and a dropdown period.. Its more like a plateau than a straight line.. Splitting it can definitely help, at least it did for me, but not enough. Was still tending to have night lows, even with an uneven split.. Remember many people have different insulin sensitivity at night, and even though lantus may be an even dose, your sensitivity is usually *NOT* a constant thing.. Some people have better luck with levimir since it is almost *always* split into two doses.. and you can sort of adjust your day basal and night basal using the split relatively reliably.
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Permalink Reply by Terrie on -
Perhaps they think that you are only taking one shot of NPH. I've never used NPH that I remember but my younger Brother did and his sugars were everywhere but where they should have been most of the time. My older Brother and I were always on Lente for some reason. I found fewer problems with Lente when I was older and understood how it worked on me.
If you do not feel comfortable taking that much Lantus, then don't. It will not kill you to have higher sugars for a short while. Then increase the Lantus as needed. I also had a Bad experience when I went onto Lantus. I think it was because the Lente was still working in my body. Then add the Lantus on top...Bango!
Another thought, perhaps it is Better that you take only one shot a day of Lantus instead of the split dose that many use.
LOL! Feel free to talk as much as you like to here. We're listening.
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Permalink Reply by Charvena on -
Before I started pumping, I was on Lantus for several years. Prior to that I was on twice a day NPH. When I switched, I was taking 25 of N in the a.m. and 15 in the p.m. My initial Lantus dose was too high and I had a lot of hypoglycemia. I ended up on 28 units at bedtime and that worked reasonably well for me. Still didn't handle that 2 or 3 hours of hyperglycemia in the early morning hours and I think it only lasted about 20-22 hours for me, since my sugar would start to rise about then as well. Still, once the dose was adjusted, I had less hypoglycemia than I did with the 2 doses of N, since Lantus doesn't have a "peak" like the NPH does. My A1c stayed in the mid-7's though. Now I'm on the pump and my A1c stays under 6. I wouldn't go back, but the Lantus was better than the N by a long shot.
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Permalink Reply by Leo2 on -
Jeff,
I don't see how 80% of your 20 u NPH = 18. It looks like 16 to me.
Many folks have run into peaks with Lantus. That's why so many are on two shots of Lantus.
If 'twer me, I'd be likely to put it into two shots, 2/3 morning, 1/3 bedtime. To do that easily, I reduce the 16 to 15, and voila, 10 daytime, and 5 bedtime.
Now you start with something less likely to produce hypoglycemia.
If worried about night time hypoglycemia, do 10 and 3 and work up, rather than down.
Been there, done that. And yes, I'd be worried, too about hypos, major hypos, with 18 in my system.
Tell us what you do.
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Permalink Reply by kiva on -
Lantus in an ideal situation has a profile that lasts approximately 24 hours although in some it can be shorter. NPH has a profile that typically lasts 12-18 hours with the bulk of it gone in those first 12 hours. This is why a lot of people took NPH twice a day. So, two NPH injections @ 10u was a total of 20u over a 24 hours period. Some people find taking Lantus twice a day works better for them. I've tried it both ways and found virtually no difference in my morning BG's or per-meal.
Lantus works by forming crystals in the body after injection. These crystals slowly release the insulin over a period of time, ideally for 24 hours. Yes, you'd be injecting 16u initially but it would take ideally 24 hours to release into the body as opposed to the 12 hours or so it takes NPH to be absorbed.
Think of it this way, the peak (such as it may be) from 16u of Lantus designed to work for 24 hours at a fairly constant level is a whole lot smaller than the peak from 10u of NPH working it's hardest for the first 8-12 hours before tailing off.
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Permalink Reply by Gerri on -
I can't offer anything about NPH, but my experience with Lantus was similar to many others. Even with split doses & lowered doses, I had lows. Peaks are common with Lantus. I didn't find that it lasted 24 hours even at high doses. I had afternoon lows & overnight highs. Dosing twice daily (over the doctor's objections) helped some with overnight highs, but didn't solve the daytime lows.
Best thing I did was switch to Levemir. More stable, more level, no crashing lows. My Lantus & Levemir doses were the same. I take one dose first thing in the morning & another before bed (dawn phenomenon). My doses are relativey small--5 units each.
Another benefit of Levemir is that it doesn't expire in 28 days like Lantus. I've used the same vial for 6-8 weeks with no noticeable loss of potency.
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Permalink Reply by Jeff on -
Everyone, thanks for the great info! Right, 16 not 18 but either way it seems high.
So it seems, if you look at the action graph of Lantus, a 24 hour straight line, that is based on the notion that some of it will release sooner, and the rest later. I'm wondering if you were to take a single unit of Lantus, what would that graph look like? 12 hours? I realize this is a gross oversimplification, but is the idea that half your dose will cover you for 12 hours and the other half will release later, covering the other 12? Thus the 80% (From the guidelines it sounds like the NPH to Lantus ratio should be 1:1, they just knock off 20% in case of lows).
Terrie, you bring up and interesting point, I was taking Ultra Lente before switching to Lantus the first time. I'm pretty sure I gave it a good couple of weeks though... I can't really remember :P
The Levemir sounds good, I've thought about it but it always looked a little more reminiscent of NPH to me. Also isn't it very expensive? Somewhere in the $170-$200/vial range?
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Permalink Reply by Gerri on
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A graph showing a Lantus 24-hour straight line only exists in the pharm lit:)
Levemir & Lantus cost me the same. Actually, Levemir is cheaper because a vial lasts longer.
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Permalink Reply by kiva on
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So it seems, if you look at the action graph of Lantus, a 24 hour straight line, that is based on the notion that some of it will release sooner, and the rest later. I'm wondering if you were to take a single unit of Lantus, what would that graph look like? 12 hours? I realize this is a gross oversimplification, but is the idea that half your dose will cover you for 12 hours and the other half will release later, covering the other 12? Thus the 80% (From the guidelines it sounds like the NPH to Lantus ratio should be 1:1, they just knock off 20% in case of lows).
In theory a Lantus injection should last 24 hours regardless of how many units were injected. 1 unit injected would be released at a rate of .042(1/24)u/hour, 12 units would release at a rate of .5(1/2) u/hour or 24 units injected released at a rate of 1u/hour. After injection the Lantus forms crystals. In this crystaline form the insulin is inactive. What happens over the course of time is the crystals slowly "dissolve" releasing single "strands" of insulin if you will in the body. At this point these strands are now active providing the Basal level of insulin required.
In the real world, given the variabilty of insulin sensitivity changes throughout the course of day, activity levels and other factors this 24 hour "flat" action can vary from one to another. One of the claims of Lantus is while it may vary from one person to the next its action will be fairly consistant in any given individual from one day to the next, something that NPH sometimes had a hard time delivering, consistancy from one day to the next not to mention its hump. As for spliting doses of both Lantus and Levemir, the idea is to cover the gaps in coverage over a 24 hour period that some people experience. Lantus is about 10 years old, Levemir I recall isn't hasn't been around quite as long as Lantus.
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Permalink Reply by Jeff on
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Thanks Kiva! I find it's very helpful to know how these things are supposed to work in theory even if that doesn't materialize. Sounds like Lantus is more of a true basal insulin, so however much is required to keep the liver in check should do the job. It's also sounding more and more like NPH comparisons are pretty useless.
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Permalink Reply by Gerri on
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Lantus doesn't release as needed. Would be great if any injected insulin worked this way & the theory behind smart insulin. Lantus causes lows for many because it also doesn't work at a level/stable rate, which is the role of basal.
Levemir uses different chemicals to work slowly.
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