Multiple dose insulin in type 2 diabetes

Levemir (Detemir) & Lantus (Glargine) & quick-acting insulin before meals

adjusting insulin dose pages from DAFNE

Introduction Metabolic control   Insulin QA = quick-acting insulin long-acting insulin injection sites, absorption food and insulin dose carbohydrate count & portion = CP     snacks step-wise approach hyperglycaemia Physical exercise links         Illness (link)   hypos       Hypos (link) alcohol     Driving (link)   abbreviations     simulations

David Kinshuck, an ophthalmologist & Good Hope Diabetic team

• Introduction
• Controversy
• How do Levemir/Lantus work
• Quick acting insulin for food
• Insulin resistance, Metformin and Lantus
• Lantus or Levemir dose if used once daily
• Adjusting once daily Levemir/Lantus dose
• Do you need Levemir once or twice a day?
• Judging the dose of twice daily Levemir
• Dose of quick-acting insulin
• Adjusting your quick-acting insulin, table
• Target glucose levels
• Common problems
• Exercise
• Levemir/Lantus advantages
• Disadvantages
• Testing glucose levels
• Diabetes education and the XPERT program

 

Introduction

pages for type 2 diabetes

type 2 diet/tablets type 2 starting insulin (often once day) type 2 insulin users (when once daily insulin use HbA1c > 7.5%), this page

This page is aimed at people with type 2 diabetes needing multiple dose insulin (basal bolus).  

If you have a fair amount of insulin from your pancreas still, you will not need this intensive insulin  regime, and may just need tablets or once daily insulin as opposite.

If your type 2 diabetes is quite severe, and you have very little remaining insulin, then your diabetic control is similar to type 1 diabetes. This page discusses intensive insulin control, and this is taken further in the insulin dose adjustment pages above. You naturally need to speak to your diabetes nurse and doctor for individual advice.

If you have no or very little remaining insulin from you pancreas, and are prone to hypos, then your diabetes is nearly equivalent to the type 1 diabetes patient, and you may benefit from the same intensive insulin 'regime'. This is discussed on this page below and the adjusting insulin dose pages taken from the DAFNE Program.

Complex insulin regimes do lead to better glucose control, fewer hypos, and better weight control than twice daily insulin (NEJM 2009).

 

Controversy

The two long acting insulins are Levemir (detemir) or Lantus (glargine). Levemir is shorter acting, with a peak 9-12  hours. Lantus generally has no peak in the first 24 hours, and its action may take 3 days to complete. Therefore anyone with a slightly irregular lifestyle in theory will be better off using twice daily Levemir rather than once daily Lantus. At present, this decision is usually made by diabetes doctors and nurses.

If you do use once daily Lantus, and your glucose levels fluctuate, then you should consider twice daily Levemir instead.

 

How do Levemir/Lantus work

Generally Levemir is used twice in this regime, Lantus is used once a day. These insulins are 'long acting', and provide your body's basal insulin needs just to keep you alive. This enables your body get its energy when you are not eating. Generally twice daily Levemir (detemir) will lead to better diabetic control, and is part of the DAFNE regime, and the adjusting insulin dose pages on this site. The Levemir/Lantus dose will be about 50% of the total insulin dose.

Levemir/Lantus can be given any time of day, but it is best to give it them at the SAME TIME OF DAY each day. If given twice daily, there should be about a 12 hour gap.

 

Quick acting insulin with food

The dose of the quick acting insulin before meals should match the amount of food that you eat. Measuring the amount of food to determine insulin here and here. This insulin regime is called 'basal-bolus' or multiple dose. It is very helpful if you want to achieve very good control. The quick-acting insulins before food are Humalog (lispro) or Novorapid (aspart) or Apidra. The total dose of the quick acting insulin (~3 meals) will be half the total dose, very approximately equal to the total long-acting insulin dose.

The quick-acting insulins are used for meals, and are generally given just as you start (or occasionally during or immediately after) a meal/snack.

 

Insulin pumps

Insulin pump treatment generally achieves even better control than basal bolus insulin as on this page, but these are not generally used in the UK in type 2 patients.

 

Insulin resistance, dose & metformin

If you are overweight you will be resistant to insulin, and need higher doses than thinner people. In the long term you need to lose weight, but it is still possible to control your diabetes even if you are overweight, though this is not ideal. See reducing weight.
Insulin resistance means that your body needs extra insulin than if you are a normal weight.

Metformin (a tablet) helps reduce insulin resistance and is now recommended for such patients, in addition to insulin. You will need less insulin if you start metformin.

Insulin resistance and the dose of insulin are reduced by exercise . Exercise is critically important in diabetes excellent review.

 

Lantus or Levemir dose if used once daily

• To achieve good control you need to be prepared to test your glucose levels and adjust your dose; your doctor or nurse should show you how to do this.

• If your diabetes has been badly controlled you are best to control it very gradually. But if your control has been poor for a long time and you have a little retinopathy, improving control quickly can make your retinopathy worse in the short term (you may need extra laser).

• If used once daily the dose of Levemir/Lantus can be judged by the fasting glucose level first thing in the morning. Ideally aiming for 5.5 - 7.5 mmol/l in the morning look starting lantus up.

• So if your fasting glucose first thing in the morning (after your regular dose of Levemir/Lantus the night before) is 8 mmol/l 3 days on the run, you need to increase the dose of Levemir/Lantus (see adjustment table).

• Similarly if your glucose is 3 mmol/l (fasting, first thing in the morning), you needed less Levemir/Lantus the night before, so if this happens 2-3 days on the run, reduce your evening Levemir/Lantus.

• 4 mmol/l first thing in the morning is too low for most patients, with a risk of hypos and rebounding glucose levels at other times. Aim for 5.5 - 7.5 mmol/l in the morning.

 

Adjusting Levemir/Lantus dose once daily

This table explains how to adjust once daily Lantus dose. Levemir would be similar if used once a day. This table is slightly different from the insulin dose adjustment/DAFNE program which discusses this in detail.

Blood testing time	Blood glucose level	Blood glucose Level	Blood glucose level	Blood glucose level	Blood glucose level
Before breakfast	Less than 4mmol/l (Hypo)	4-6mmol/l	6.1-8.0 mmol/l	8.1-9.9 mmol/l	Above 10 mmol/l
Adjust Insulin	Reduce insulin by 2 units	Good control	Increase insulin by 2 units	Increase insulin by 4 units	Increase insulin by 6 units

 

Levemir/Lantus at night

• You do not need a bedtime snack.
• Aim for 6.6-8.0 before bed. If you are used to 9mmol/l, may be start off with 9, but gradually try and get your before-bed glucose lower.
  
• Therefore as you try and reduce your before bed glucose from 9 to 6 you may need to occasionally test your glucose in the middle of the night ...ideally you want to go to bed with levels 6.6-8.0 and wake up with levels 5.5 - 7.5.
• Thus if you are used to going to bed with a glucose of 9mmol/l with a snack, stop the snack, when on Levemir/Lantus, then start aiming for 8 before bed, then 7l.
• Naturally if you have a lot more exercise one day than usual you may need less Levemir/Lantus that night (and should reduce the evening dose), and it may be best to test your glucose in the middle of the night as well, perhaps at 3am.

 

Do YOU need Levemir (detemir) once daily or twice daily?

• Levemir is best used twice daily, especially those with a less regular lifestyle
• Consider a case: You use Levemir at night with quick acting insulin with meals. Your fasting glucose first thing in the morning is good (4-7mmol/l), but no matter how hard you try adjusting the doses your glucose starts to rise in the late afternoon, at 5 pm. You have tried with your diabetes nurse/doctor to get this 5pm glucose lower, and have had no success. It sounds as though you should try using the Levemir twice daily.
  Really you should only try such a change if your diabetes nurse is happy, but you should discuss this issue with them, showing them this page.
• Some type 2 patients are more likely to need twice daily long-acting insulin:
  • If you are overweight and use high doses of once daily long-acting insulin, you may be better using the same dose, with some in the morning and the rest in the evening as above.
  • If you regularly have long bouts of exercise, at various times of the day, especially if you exercise before meals (after meal exercise...reduce the dose of the quick acting insulin).
  • If you have some days which are much more active than others.
  • Twice daily Levemir enables type 1 patients to control their diabetes very well, and if you have very little insulin from your own pancreas, and are prone to hypos, then your diabetes is equivalent to the type 1 person. The type 1 insulin dose adjustment regime (DAFNE) may be ideal for you.

 

Judging the dose of twice daily Levemir

This is a little more difficult. Using twice daily Levemir adjust the morning dose so your afternoon glucose is about 4.5 - 7.5 (this is pre-evening meal, about 5 hours after lunch).

Usually the total dose of the two Levemir injections will be that same as the long-acting dose used once daily. Generally the once daily dose is split into two doses with 40% about in the morning, and 60% at night.

 

Dose of quick-acting insulin

• Detail

• You should take your quick-acting insulin as you start eating. The dose of insulin depends on your own body's requirements, but also what you eat. If you have a large slice of pizza, you will need more insulin than a small piece. So you have to try and predict what you eat. See DAFNE .

• But with these new quick-acting insulins, if you have enough insulin for a small piece of pizza, and then decide you want an extra piece, you can inject more insulin. This is covered here but you must also have this explained to you as an individual by your doctor or nurse. Thus you can inject your insulin after you eat....it is not ideal, but does work (see for professionals and DAFNE approach).

• You then test your glucose 2 hours after the meal. If the glucose is between 7-9 mmol/l you got the dose right.

• If the glucose level is above this (>9 mmol/l  2 hours after a meal) you know for next time you needed a little more insulin.

• Even the shapes of pasta make a difference...thin pasta is absorbed more quickly so you get a quicker and higher glucose level. Thicker pasta is more slowly absorbed. This is related to the glycaemic index of food. Adjust the insulin dose according to the amount of carbohydrate in the meal.

• If your glucose is lower than 5mmol/l 2 hours after a meal, you had too much insulin.

• If you test again 4 hours after a meal, glucose levels would ideally be back to the 'fasting' level 4-7.5 mmol/l.

• Eventually you will get the hang of which food causes the highest glucose readings and which foods the least, so you will not have to test your glucose so often. To ensure good control this carbohydrate counting is very important, see DAFNE and food. Whether your glucose is high or low at this time you can take corrective action. Correcting levels 3 mmol/l or less is a hypo and it is important to correct this..have something extra to eat/drink.   hypos.

• If you are using the DAFNE regime for very tight diabetic control (and this will help your eyes and kidneys) you may want to have a small dose of quick-acting insulin with snacks. You really need to be taught this by your doctor or nurse. If you are overweight snacking (other than fruit) will make you put more weight on, so is not recommended. Ideally, for good control, you should use a carbohydrate counting scheme such as DAFNE.

• At the beginning you will need to do regular blood glucose tests as advised by your diabetes nurse. Dose adjustment is individual, the information below will guide you, but additional advice may be necessary from your diabetes nurse if you are unsure about doing it or having problems. How to calculate your dose DAFNE.

• You will need to know how your insulin works and how long it works for to adjust it safely.

• DO NOT adjust your regular dose of insulin if you have only one high or low reading. Generally you should not adjust regular doses insulin more frequently than 2-3 days. So you would need 3 days of highs/lows to make an adjustment.

• Night-time hypos..reduce dose after a single hypo..unless there was an obvious cause for the hypo.

• Your quick acting insulin will have worn off after 3.5-4 hours. High or low glucose levels after that will seldom be due to the dose of the quick acting insulin. High or low readings more than 4 hours after quick acting insulin may be due to the previous Levemir/Lantus dose, exercise, stress, illness etc.

 

Adjusting your quick acting insulin, table

This table reminds you how to adjust your quick acting insulin, excluding exercise adjustment. Exercise adjustment needs to be included, and is discussed below. This is very approximate...if you only need a low dose of insulin, you may need to make a smaller adjustment. But if you are more insulin resistant and need higher doses, you may need to make larger adjustments (so the percentage change of each dose is similar).

 

Blood Testing Time	Blood Glucose Level
	Less than 4 mmol/l	4-7 mmol/l	7.1-12.0 mmol/l	Above 12.0 mmol/l
Before Breakfast	Refer to guide on adjustment of slow acting insulin	Refer to guide on adjustment of slow acting insulin	Refer to guide on adjustment of slow acting insulin	Refer to guide on adjustment of slow acting insulin
Before Midday Meal Adjustment needed to breakfast dose of insulin	REDUCE By 2 units	GOOD CONTROL No change to insulin	INCREASE By 2 units	INCREASE By 4 units
Before evening meal Adjustment needed to lunchtime dose of insulin	REDUCE By 2 units	GOOD CONTROL  No change to insulin	INCREASE By 2 units	INCREASE  By 4 units
Before supper/bedtime Adjustment needed to evening meal dose of insulin	REDUCE By 2 units	GOOD CONTROL No change to insulin	INCREASE By 2 units	INCREASE 4 units

 

target levels (from DAFNE)

pre-breakfast      5.5 - 7.5 pre-other meals   4.5 - 7.5 pre-bed              6.6-8.0 4 hours after a meal   5.5 - 7.5 2 hours after a meal   <9.0

Target glucose levels

 

 

 

 

 

Common problems

• My glucose levels are 6 mmol/l first thing in the morning (fasting, with night-time Levemir/Lantus) but go up to 10mmol/l at 6pm before supper. This may be because you had too little quick-acting insulin at lunch time, or too big a lunch, or not enough exercise. (Or less commonly, you need twice daily Levemir as above & a slight dose adjustment.)

• The opposite case: my glucose levels are 6 mmol/s first thing in the morning (fasting, with night-time Levemir/Lantus) but down to 3mmol/l at 6pm before supper. This may be because you had too much quick-acting insulin at lunch time, or too small a lunch, or more exercise than normal, or too much Levemir/Lantus the night before.
  (Or less commonly, you need twice daily Levemir as above & a slight dose adjustment.)

• A similar case: my glucose levels are 4-5 mmol/s first thing in the morning (fasting, with night-time Levemir/Lantus) but down to 3mmol/l at 12pm before lunch. If this happens regularly it suggests too much Levemir/Lantus the evening before and you should reduce the dose 1-2 units. You may have had an unusual amount of exercise at around 11am.

• One patient found she had hypos several times a week when at work. By reducing her Levemir/Lantus by one unit, she could work without any hypos. One her weekend non-working days she would have an extra unit of Levemir/Lantus (the night before).

• One patient had regular hypos at 5pm. Her other glucose readings were fine (5-7mmol/l). She used aspart insulin at meal times 8am, 1pm, & 7pm and used aspart insulin before each meal. She also used once daily Lantus in the morning. She was advised to try reducing her pre-lunch aspart insulin. If that did not work, she may be advised to reduce her morning Lantus
  However, this paper suggests that aspart insulin has worn off 4.5 hours after a meal .....suggesting that the Lantus dose should be reduced. (The same comments would apply to Levemir.)

• One patient reported widely fluctuating glucose levels (10-14mmols/l) with highest levels in the afternoon and fasting, despite trying hard to control them. He was giving his quick acting insulin 20-30 minutes before a meal, and it was felt this was one of the causes..the time interval was too long and causing hypos etc.
  It was suggested he inject no no more than 10 minutes before a meal and 10-15 (or even 20) minutes after a meal (these are the standard times for quick acting insulin). Also, one of his injection sites was very knobbly (lipohypertrophy), and he was told to avoid injecting in this site,  as this may be contributing to uneven absorption. He was told to alternate arms, outer thighs, and buttocks.
  He was told to increase does of quick acting and Levemir insulin. (He is age 32 and is also using ramipril and simvastatin, has severe retinopathy and some neuropathy.)

• Alcohol increases the likelihood of a hypo in the middle of the night ....carbohydrate before and after the alcohol makes this less likely.

• If you try adjusting and problems continue you need expert advice: you may need to use twice daily Lantus or Levemir, for example.

• This wonderful paper  is an essential read for professionals, and goes into details why some people have difficulty controlling their diabetes. There are the physical aspects (people need a good regime/the right regime for them) ; and the psychological aspects, and both have to be addressed.
  Persistent poor glycaemic control in adult Type 1 diabetes. A closer look at the problem DeVries/ Snoek / Heine 2005

• You should not inject into lumpy tissues. If you are, and your diabetes is not well controlled, change to an injection site that is not lumpy ...but you may need to reduce your insulin dose by up to 30%.

• You should not mix Lantus insulin and Novarapid in the same syringe. One patient did this, and he needed 20u Novarapid. But when he injected separately he only needed 5u Novarapid (the effect of the Lantus was not that different).

• Stress affects glucose levels in an unpredictable way!

• Many patients using once daily Lantus find their glucose levels different to control...consider twice daily Levemir as above instead.

 

Levemir/Lantus & quick-acting insulin & exercise

How do you cope with exercise if your diabetes is tightly controlled using Levemir/Lantus and quick-acting insulin?

• See this in diagram form.

• see adjusting insulin...DAFNE advice

• This book is very helpful 'The Diabetic Athlete', Sheri Colberg .

• If you are well controlled you need to test your glucose a lot at the beginning to work out the effects of exercise.the better controlled you are, the more risk of hypos. Test before you exercise and every hour at first. Naturally your are best taught how to do this by your diabetic specialist.....this written account is not helpful enough

• You may need some extra food before and during your exercise, such as a sandwich or banana. This method of avoiding hypos is important, but it may help you put weight on. See diagram

• Alternatively, if you exercise 2-3 hours after a meal, you should reduce the dose of your pre-meal quick-acting insulin. This is the best method if you do not want to put weight on. You may need to halve the dose of your pre-meal quick-acting insulin. See diagram
  This method is not very effective if you exercise before meals..by then your quick-acting insulin from the previous meal will not be having such an effect.

• If you are having a lot of exercise every day you may be able to reduce your Levemir/Lantus dose, but generally you still aim for a fasting glucose reading of 5-6mmol/l when you wake up in the morning.
  If you have a lot of exercise one day you may have a 'debt' to pay off...that is increasing your carbohydrate stores (glycogen) ...so you may need to reduce your Levemir/Lantus dose that night (after the exercise). See diagram.

• If you are very well controlled, and particularly if you exercise before meals, and have more than 30 minutes reasonably hard exercise, you are likely to develop a hypo. Make adjustments or consider a pump as elsewhere on this page.

• After a lot of exercise, if you do not adjust your Levemir/Lantus that night, you may become hypo in the night. If you take a lot more exercise than you are accustomed to it is still safer to test your glucose level in the middle of the night.

• If you have an average amount of exercise and your diabetes is well controlled, and then one day (or you go skiing for example) you have a lot of exercise, ideally you would reduce your Levemir/Lantus dose the night before. See diagram. Some people can stop the Levemir/Lantus, but generally this is not advisable (it is usually best safer to reduce the Levemir/Lantus dose by 25-50%, not stop it) as you should reduce your quick-acting insulin a lot during the day if you are getting a lot of hypos or low readings.

• How much do you reduce the Levemir/Lantus the night before? Naturally this depends on how much exercise you will be taking the next day, but may be as much as 25-50%.

• If you have a lot more exercise some days than others, you will need less Levemir/Lantus on the nights before you are going to take the exercise.

• If you do not know in advance which days you will need a lot of exercise, you must expect hypos, and test more. Such patients may be best on an insulin pump.

• If you are young and take a lot more exercise some days than others, an insulin pump may be best for you.

• So Levemir/Lantus and exercise can be a problem. The worst times will be exercising before lunch or before your evening meal ..reducing the quick-acting insulin dose the meal before won't have a major effect (or you will have had hours of a high glucose).
  So at these times you are best to test and perhaps eat a snack before you exercise. This may make you put weight on .

• If you are putting weight on, try and change the time you exercise, so have the exercise after a meal and reduce the pre-meal insulin, OR have your meal a couple of hours early and reduce your pre-meal quick acting insulin.

• An insulin pump may still be best if you have no remaining insulin from your pancreas and want the best control possible and are happy to test your glucose levels 4-6 times a day (not provided for type 2 patients in the UK).

 

Testing glucose levels

This is reviewed in recent Nice guidelines, (page 47, I mb pdf), with an extract here. The optimal targets for short-term glycaemic control are:

• a before-meal blood glucose level of 4.0-7.0 mmol/l (4-8 children & young people)

• an after-meal (2 hours after) blood glucose level of less than 9.0 mmol/l.
  (children & young people < 10 mmol/l )

• Your testing technique and how you use the results to adjust your insulin should be discussed with you by your diabetic nurse/doctor yearly.

• You need to adjust more at certain times, for instance if you have an infection (you may need more insulin) and a lot of exercise (you will need less insulin).

• You may even be best to test in the middle of the night. For instance, as above, if you have had a lot more exercise that day than usual or have been ill.

• Stress and other life events also influence your insulin requirement.

• To achieve very good control (HbA1c 6.5-7.0%) you need a fasting pre-breakfast less than 5.5 - 7.5, pre-meal levels at other times less than 4.5 - 7.5 mmol/l, and post-meal levels (2 hours after a meal) less than 8.0 mmol/l. These levels cannot be achieved in all patients.

 

Diabetes education and the XPERT program

If you want good diabetic control, the main type 2 diabetes education course is the XPERT program. This course is very helpful: it helps people come to terms with their diabetes, you learn from others, help others, get to know other similar patients well, learn how to take control of your diabetes, learn how to adjust doses, and are advised by an expert nurse.