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Splitting Lantus Dose Type 2

In My Opinion: There Is No 24-hour Basal Insulin

In My Opinion: There Is No 24-hour Basal Insulin

by Richard K. Bernstein, M.D., F.A.C.E., F.A.C.N., C.W.S. Diabetes Health You can make any insulin last longer by injecting a large enough shot. In fact, about 25 years ago, Dr. John Galloway of Eli Lilly and Company performed an important experiment that demonstrated this very fact. In his experiment, Dr. Galloway injected 70 units of Regular insulin into the arm of a non-diabetic man. To prevent the patient from having serious hypoglycemia, his blood sugar was tested every half hour and glucose was infused into his bloodstream as needed. Given that the package insert for Regular stated that the insulin would work for four to twelve hours after injection, one might expect that Dr. Galloway could have stopped the glucose drip after twelve hours. As it turned out, however, the subject’s blood sugar kept dropping for a full week, and the glucose drip had to be continued for that long just to prevent him from going low. It certainly makes sense that a large volume of any liquid injected under the skin will require more time to be fully absorbed by nearby blood vessels than a small volume. When I was young and injected 120 units a day of NPH insulin to cover my high carbohydrate ADA diet, it would take about two weeks for the lump at each injection site to disappear. The message of Dr. Galloway’s work is apparently very familiar to modern insulin manufacturers who claim 24-hour action for their basal insulin analogues. Of course, several studies have been published to support their claims that both Lantus and Levemir last 24 hours. The single daily injection in these studies, however, is based upon using 0.3 to 0.4 units of insulin per 2.2 pounds (one kilogram) of body weight. For a 154-pound person, this comes to 21 to 28 units per daily injection. In my experience, a Continue reading >>

Insulin Glargine In The Treatment Of Type 1 And Type 2 Diabetes

Insulin Glargine In The Treatment Of Type 1 And Type 2 Diabetes

Insulin Glargine in the Treatment of Type 1 and Type 2 Diabetes Birmingham Heartlands Hospital, Birmingham, West Midlands, England, UK Correspondence: Anthony H Barnett, Birmingham Heartlands Hospital, Undergraduate Centre, Birmingham, B9 5SS, UK Tel + 44 121 424 3587 Fax + 44 121 424 0593 Email [email protected] Copyright 2006 Dove Medical Press Limited. All rights reserved This article has been cited by other articles in PMC. Insulin glargine is an analogue of human insulin that is modified to provide a consistent level of plasma insulin over a long duration. Pharmacokinetic and pharmacodynamic studies show that a single injection of insulin glargine leads to a smooth 24-hour timeaction profile with no undesirable pronounced peaks of activity. In clinical trials, this profile has been associated with at least equivalent, if not better, glycemic control than other traditional basal insulins and a significantly lower rate of overall and nocturnal hypoglycemia. The convenience of a once-daily injection, a lack of need for resuspension (insulin glargine is a clear solution when injected), and lower rates of hypoglycemia should translate into improvements in patient treatment satisfaction. This review appraises the evidence for the view that insulin glargine represents an advance in basal insulin therapy for both type 1 and type 2 diabetes patients. Keywords: Insulin glargine, basal insulin therapy, diabetes, review While insulin remains the only antihyperglycemic therapy for type 1 diabetes, oral agents have been the mainstay of therapy for those with type 2 diabetes. Oral therapies are limited in their ability to maintain tight glycemic control in the long term ( UKPDS 1995a , 1995b ). There is increasing support for the earlier initiation of insulin Continue reading >>

Twenty-four Hour Action Of Insulin Glargine (lantus) May Be Too Short For Once-daily Dosing: A Case Report

Twenty-four Hour Action Of Insulin Glargine (lantus) May Be Too Short For Once-daily Dosing: A Case Report

The insulin analog insulin glargine has a pharmacodynamic profile described as peakless and of longer duration than human NPH insulin (1). This allows for convenient once-daily dosing for coverage of basal insulin needs. We recently had the opportunity to examine whether this is the case in the following patient. T.L. is a 53-year-old man with a history of type 1 diabetes for the past 16 years. Before hospitalization, he had a history of widely variable blood glucose levels, from 50 to 400 mg/dl, while using a 4-injection regimen of premeal insulin lispro and ultralente at dinner. He has no known diabetic complications. Before admission, he had a history of heavy ethanol abuse, with a daily intake of 48–72 oz wine or beer per day. On the day of admission, the patient developed left arm weakness and progressive loss of consciousness. A computed tomography scan revealed a massive intracerebral bleed. Admission laboratory data revealed glucose of 292 mg/dl, a bicarbonate of 15 mEq/l, an anion gap of 18, trace urine ketones, and a blood pH of 7.34. After treatment of compensated diabetic ketoacidosis, the patient was maintained on an intravenous insulin infusion between 1 and 2 units/h. On the fifth hospital day, enteral feedings via a feeding tube were initiated. The enteral formula provided 2 kcal/ml, with a composition consisting of 43% carbohydrate, 17% protein, and 40% fat. The feeding rate was successfully increased and maintained at 35 ml (70 calories) per hour without residual stomach accumulation. Total nutrition intake was 1,680 kcal/day. On the sixth hospital day, the patient was given a 30-unit dose of insulin glargine at 9:00 p.m. and was weaned off of the insulin infusion over the next 4 h. For the next 11 days, the patient continued to receive continuous en Continue reading >>

Interactive Dosing Calculator

Interactive Dosing Calculator

Lantus® is a long-acting insulin analog indicated to improve glycemic control in adults and pediatric patients with type 1 diabetes mellitus and in adults with type 2 diabetes mellitus. Lantus® should be administered once a day at the same time every day. Limitations of Use: Lantus® is not recommended for the treatment of diabetic ketoacidosis. Contraindications Lantus® is contraindicated during episodes of hypoglycemia and in patients hypersensitive to insulin glargine or one of its excipients. Warnings and Precautions Insulin pens, needles, or syringes must never be shared between patients. Do NOT reuse needles. Monitor blood glucose in all patients treated with insulin. Modify insulin regimen cautiously and only under medical supervision. Changes in insulin strength, manufacturer, type, or method of administration may result in the need for a change in insulin dose or an adjustment in concomitant oral antidiabetic treatment. Do not dilute or mix Lantus® with any other insulin or solution. If mixed or diluted, the solution may become cloudy, and the onset of action/time to peak effect may be altered in an unpredictable manner. Do not administer Lantus® via an insulin pump or intravenously because severe hypoglycemia can occur. Hypoglycemia is the most common adverse reaction of insulin therapy, including Lantus®, and may be life-threatening. Medication errors, such as accidental mix-ups between basal insulin products and other insulins, particularly rapid-acting insulins, have been reported. Patients should be instructed to always verify the insulin label before each injection. Severe life-threatening, generalized allergy, including anaphylaxis, can occur. Discontinue Lantus®, treat and monitor until symptoms resolve. A reduction in the Lantus® dose may be re Continue reading >>

Should Insulin Glargine Be Dosed Once Or Twice Daily?

Should Insulin Glargine Be Dosed Once Or Twice Daily?

Should Insulin Glargine Be Dosed Once or Twice Daily? Insulin glargine (Lantus, sanofi-aventis) claims to have a 24-hour duration of action. Is there any advantage to using it twice daily? If so, what patient population might benefit from twice-daily dosing? Response from Jenny A. Van Amburgh, PharmD, CDE Associate Clinical Professor, School of Pharmacy, Northeastern University, Boston, Massachusetts; Director of the Clinical Pharmacy Team and Residency Director, Harbor Health Services, Inc., Boston, Massachusetts Since its approval in April of 2000, insulin glargine has been used successfully in the treatment of sustained hyperglycemia in patients with type 1 or type 2 diabetes mellitus.[ 1 ] Long-acting insulin formulations such as glargine offer patients a steady, "peakless" 24-hour release of insulin for blood glucose control, in a convenient once-daily dosing schedule. Insulin glargine exerts its therapeutic effects by mimicking the basal secretion of pancreatic insulin to provide around-the-clock coverage for patients with elevated fasting plasma glucose levels. As with other diabetes treatments, the goal of insulin therapy is to prevent both microvascular (eg, retinopathy, neuropathy, nephropathy) and macrovascular (eg, stroke, myocardial infarction) outcomes. Although insulin glargine is US Food and Drug Administration-approved for once-daily dosing, the actual duration of action ranges from 10.8 to more than 24 hours in some patients.[ 1 , 2 ] This fairly wide range suggests that a second dose may be necessary to achieve optimal glycemic control, although this is considered off-label use.[ 3 , 4 ] To further investigate the variability in duration of action, an 8-week, 2-way crossover study was conducted in 20 patients with type 1 diabetes who used insulin asp Continue reading >>

Getting High Blood Sugar Levels Under Control

Getting High Blood Sugar Levels Under Control

Getting high blood sugar levels under control Getting high blood sugar levels under control A 70-year-old man with a history of type 2 diabetes takes insulin glargine (Lantus) 100 units every morning (he is afraid of developing hypoglycemia at night) and insulin aspart (Novolog) 20 units with each meal. However his blood sugar is still around 250 mg/dL. Can the Lantus dose be increased, and if so, to what? Or should the patient be switched to insulin detemir (Levemir) twice daily? Can the dose of Levemir be greater than 100 units? What else would you suggest for this patient? If your patient's blood sugars are in the 250 range all day, he likely needs more insulin. Patients with type 2 diabetes will routinely need 1-2+ units/kg body weight per day. If he is requiring more than this, one should look for factors that might increase insulin resistance (infection, Cushing syndrome, etc.), noncompliance, or incorrect administration. (I have discovered that some patients who were supposed to be taking multiple shots of insulin per day were injecting air and not insulin!). There is no maximum dose of glargine per se, although at doses >100 units, I usually prescribe this agent b.i.d. In addition, we are finding that in some patients, Lantus seems to last only 12-18 hours, so that splitting the dose to 80 units in the morning and 30 units at bedtime would likely improve his morning/fasting blood sugars. Using insulin detemir b.i.d. at this dose would also suffice. Most patients on stable insulin regimens are taking approximately 50% as basal (glargine in this case) and 50% as bolus (mealtime aspart), so this patient likely needs an increase in his prandial doses. If, despite dosing adjustments that put him at 250-300+ units/day of insulin U-100, he is still not at goal, many d Continue reading >>

How Do You Use Basal Insulin?

How Do You Use Basal Insulin?

When the first long-lasting basal insulin analogs (insulin glargine [brand name Lantus] and insulin detemir [Levemir]) came out, they were supposed to last 24 hours. You injected once a day. That schedule clearly doesn’t work for everyone. Why is that, and what works for you? First of all, what is “basal” insulin? “Basal” insulin is that background level of insulin you need 24 hours a day. It’s not for the food you eat; it’s for everything else insulin has to do in your body. As I wrote here, insulin keeps glucose stored in the liver, fat stored in fat cells, and promotes cell reproduction, along with several other functions. People with Type 1 and many with Type 2 have very low or no basal insulin. Without basal insulin, your liver can pump out glucose all the time. Your sugars can go way up even if you don’t eat, like at night. So the invention of a 24-hour basal insulin was a great advance. It brought people’s A1C levels way down, but it doesn’t always work as advertised. Dr. Richard Bernstein, author of Diabetes Solution, says “In my opinion, there is no 24-hour basal insulin.” Larger insulin doses take longer to absorb. According to Dr. Bernstein, drug companies used larger-than-needed doses to make them last 24 hours. “The large basal doses needed to make ‘long-acting insulins’ last 24 hours,” he says, “[can cause] a number of undesirable consequences. These include hypoglycemic episodes [lows], weight gain, and possible [blood vessel] effects.” At the proper doses, basal insulin will frequently not last 24 hours. A study in Diabetes Care found a window of low insulin levels when the daily dose has worn off and the next day’s dose hasn’t yet kicked in. The authors suggested twice daily dosing would provide better coverage. O Continue reading >>

How To Split Lantus - Type 1 Diabetes - Diabetes Forums

How To Split Lantus - Type 1 Diabetes - Diabetes Forums

Registration is fast, simple and absolutely free so please,join our community todayto contribute and support the site. This topic is now archived and is closed to further replies. My endo is on vacation, and he just moved my Lantus from morning to evening (to 7pm from 7 am, because I was running high in the morning). Now, I am fine in the morning, but only after experiencing very bad hypos overnight. And, on top of it, now I am high in the late afternoon. So, I think we proved that the Lantus isn't lasting 24 hours. It seems to be lasting about 22 hours, maybe a little less. I tried adjusting by evening boluses down a bit to help avoid the hypos, but it hasn't really worked. Soooo- I think I need to split the Lantus. I currently take 32 units. I drew a little graph to help me understand what would be happening, and it looks to me that a 50/50 split still leaves me 4 hours each day when I am low on (but not out of) Lantus (2 x 2 hours). How should I split it? Unfortunlately there seems to be little rhyme or reason as to what works best for each person. I take Humulin N (Intermediate acting) 2x's a day. The best for me seems to be at 2pm and again at 12am. (I set my alarm), and I don't split my doses 50/50, I take more at night to keep me more level and help with morning numbers. I still hypo though at around 2-3am, so when I shoot at 12am - I eat a small snack of cheese and 2 crackers - about 7 grams of carbohydrates. This keeps me in optimum range. I split my Lantus (14 units) 50% before bed and 50% when I get up in the morning. The idea is that having at least an 8 hour gap between doses eliminates the gap in basal insulin action. You can play around with the timing and relative sizes of the doses to optimise basal requirement coverage over the 24 hour cycle. But I fi Continue reading >>

Splitting Long Acting Insulin Dose?

Splitting Long Acting Insulin Dose?

I take 40 units Lantus (long acting), and sliding scale Novolog (fast acting) insulins.My bg is always so high in the mornings, I have to take Novolog and wait for sugar to come down to eat.I've had diabetes for many years, but never knew for sure which one!My dr would switch my diagnosis all the time.But went to endo and they did a blood test, and said I'm type 1. I'm angry my dr. never did anything about this.My daughter splits her insulin dose, 1/2 in the morning, and 1/2 at night.I was wondering if this would help?Also how to do it?My dr won't help me. Thank you in advance :) Lantus is typically only dosed once a day (even though the duration of action is only about 20 hours a day.Following are some ideas to run past your dr. 1. Take your lantus at night (instead of in the morning), if you are not already taking it at night.This way, at least it will be fully active over night. 2. Split the lantus into 2 doses to get better coverage.The doses may not necessarily be the same.ie. You may need a higher dose at night than in the morning. 3. Try levemir (a different long acting insulin), which is typically dosed twice a day. 4. Ask your dr to prescribe you the new insulin Tresiba.This is an ultralong acting insulin and seems to help many people with avoiding high morning sugars. 5. Take your breakfast soon after you wake up (you will need to dose Novolog to provide both a correction and to cover the food).it will be best if your breakfast is very low carb ie. eggs or meat and some veges, to avoid further increasing blood sugars too much. Eating may actually help stop the liver putting out sugar, which it does in response to an overnight fast. 6. Set an alarm clock and take an early morning correction of novolog to counter the rising blood sugars and prevent them going t Continue reading >>

Clinical Question: Pharmacology

Clinical Question: Pharmacology

Is there evidence to support the use of Lantus® (human insulin analog glargine) administered Q12h in Type 1 Diabetes? The goal of diabetes management is to reduce the risk of long-term complications by maintaining near-normal glycemic control, in addition to reducing other risk factors. Patients with type 1 diabetes have an absolute deficiency in insulin and require exogenous insulin replacement. Lantus®, human insulin analog glargine, is the only long-acting insulin that exhibits a “peakless” action profile with duration of action of up to 24 hours(1). Because the clinical trials demonstrating its safety and efficacy involved a once a day bedtime administration, Lantus® received a FDA indication for once-daily dosing for diabetic patients who require basal insulin. Theoretically, since insulin glargine has a 24-hour action profile with no pronounced peak, the time of administration should not be significant. A 24-week randomized clinical trial(2) investigated this idea by comparing administration of glargine at breakfast, dinner, or bedtime in patients with type 1 diabetes. The study concluded that the efficacy and safety of insulin glargine was not affected by the timing of administration. Despite limited studies there have been some evidence implying the appropriateness of twice-daily insulin glargine in select type 1 diabetic patients. In August 2002, a patient case regarding the use of twice-daily insulin glargine was published(3). In this case, a 53 year old male with a history of type 1 diabetes did not receive sufficient insulin coverage with a once daily injection. Before hospitalization, the patient had a history of widely variable blood glucose levels. He was on a 4-injection regimen of premeal insulin lispro and ultralente at dinner. The patient also Continue reading >>

Glycemic Effects Of Morning Only, Evening Only Or Twice Daily Insulin Glargine In Patients With Type 1 Diabetes

Glycemic Effects Of Morning Only, Evening Only Or Twice Daily Insulin Glargine In Patients With Type 1 Diabetes

This research is a prospective, randomized, cross-over study that is being done to compare the effect of morning only, evening only and twice daily insulin glargine (Lantus®) on hypoglycemia (blood glucose level <70 mg/dL) as measured by continuous glucose monitoring (CGM) in patients with type 1 diabetes. Over the course of the 6 week study, patients will take insulin glargine in each of 3 different times: only in the morning, only at night, and half in the morning, half at night. After 2 weeks taking the insulin in one regimen, patients will be switched to another regimen. Through the whole study, patients will be injecting themselves twice daily, and neither the patient nor the treating doctor will know which vials contain the insulin and which have only saline (placebo). The vials will be labeled MORNING or EVENING. Patients will continue to take their mealtime, short acting insulin doses. Additionally, patients will wear a continuous glucose monitor (CGM) which will be masked. Before the study, patients will be taught about how to use the CGM, and keep it taped to their abdomen. The site that the CGM inserts into their abdomen will need to be changed every 5 days. We will know if a patients' blood sugar goes low even if the patient did not feel the low. Patients will still have to self-monitor their blood sugar levels at-least four times in five days, to calibrate the CGM. Study Type : Interventional (Clinical Trial) Actual Enrollment : 16 participants Allocation: Randomized Intervention Model: Crossover Assignment Masking: Single (Investigator) Primary Purpose: Treatment Official Title: Comparison of Glycemic Response to Morning Only, Evening Only or Twice Daily Insulin Glargine in Patients With Type 1 Diabetes Using Continuous Glucose Monitoring Actual Study Sta Continue reading >>

Multiple Dose Insulin In Type 2 Diabetes

Multiple Dose Insulin In Type 2 Diabetes

Introduction Levemir (Detemir) & Lantus (Glargine) & quick-acting insulin before meals 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). Controversies First 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. Second Another controversy is the use of analogue insulins s Continue reading >>

Splitting Insulin Glargine Doses

Splitting Insulin Glargine Doses

I’ve been asked (again) about optimizing how to give the dose of Lantus (insulin glargine), so I decided I’ll share my thoughts on-line. First, a disclaimer: (1) I previously worked for Aventis and later Sanofi-Aventis, the manufacturer of Lantus, in the area of pharmacovigilance (drug safety). (2) The advice given here is “off-label” (that is, it’s not approved by the FDA). Lantus is the brand name for insulin glargine, a very long-lasting insulin product that was approved by the FDA in 2000; it was first sold in the US in 2001 and is now available world-wide. It was originally marketed as “peakless”, but the marketing folks soon changed the wording to “no pronounced peak.” The whole idea was that Lantus lasts longer than a day, so if you inject it once daily, the previous day’s dose is still lingering, and smoothing out the action of the insulin. (BTW, logically, if only one dose of the insulin were to be given, and no other insulin doses, every insulin, including Lantus, would have a beginning, a peak, and then a decay to no-activity sooner or later.) However, many patients and their physicians noted that even with its long duration of action, Lantus does have peak activity at one time of day, and the effect drifts down towards the time the next dose is due. The company countered by saying that the dose could be given at different times of day: “Once a day, at the same time each day. Most people take Lantus at bedtime, but you can take it at other times if your healthcare professional says it’s okay.” But the company adamantly refused to do studies that would show the effectiveness of twice-daily dosing; I suspect the rationale for refusing was that it would spoil their marketing message that it was a once-daily insulin. Anyhow, it soon beca Continue reading >>

Is There A Maximum Insulin Glargine (lantus) Dose?

Is There A Maximum Insulin Glargine (lantus) Dose?

Is there a maximum insulin glargine (Lantus) single-injection dose? Anecdotally, I have heard that patients receiving more than 50 units should split the dose from daily dosing to twice-daily. What’s the evidence? The question of a maximum insulin glargine dose is not straightforward because it encompasses several issues: How long does insulin glargine last? Does it ever need to be given twice-daily? Is there a difference in efficacy between daily and twice-daily insulin glargine dosing? Can you administer more than 50 units of insulin glargine as one single injection? Pharmacodynamics and Duration of Insulin Glargine In theory, insulin glargine should last a full 24 hours without a significant peak effect. Glargine forms a depot effect because it is only soluble at an acidic pH.1 In the vial (pH 4), the drug is completely soluble. Once injected, the solution is neutralized to biologic pH (7.4), which causes the insulin molecules to precipitate. These microprecipitates slowly dissolve over a 24-hour period. This slow dissolution results in a slower onset and a lack of a peak effect compared to other insulins, as shown below: Efficacy of Daily versus Twice-Daily Lantus Administration Although insulin glargine should last a full 24 hours, there is some evidence that its duration of action may be reduced to 20-23 hours, particularly following injection due to its delayed onset of activity of about 3-5 hours.2 Currently, the best estimate is that 15-30% of type-I diabetics will have pre-injection hyperglycemia and may benefit from twice-daily dosing. The idea of twice-daily dosing was explored in an 8-week, open-label crossover trial of 20 patients with type-I diabetes.2 Patients received either 100% of a pre-determined dose daily (dinner) or 50% twice-daily (breakfast an Continue reading >>

Optimal Dosage Schedule For Lantus 12 Or 24 Hours

Optimal Dosage Schedule For Lantus 12 Or 24 Hours

Optimal dosage schedule for Lantus 12 or 24 hours Dear Dr. MayI currently inject 14 units of lantus at 10pm every night. My morning levels are fine at this dosage ranging between 4- 5.5 mmol. However, I generally need to snack between meals to avoid hypoglycemia. I was wondering if it may be better to split my dosage and take a 7 (or maybe only 6) unit dose every 12 hours. I have read that although the manufacturer claims lantus has an even 24 hour effect that for it to cover the full 24 hours more insulin than required is needed hence the tendency toward hypoglycemia. I was wondering what your thoughts are on best practice regarding lantus usage? Many thanks With all insulins, the bigger the dose, the longer it lasts. At your current dose, the likelihood is that the lantus does last for 24 hrs. If, however, the glucose levels start to increase prior to supper(and it is not because of snacking), then it may be that the Lantus is not lasting the full 24 hrs, in which case splitting the dose may be an option. You would need to look at your glucose profiles and discuss with your doctor before making any changes The information provided does not constitute a diagnosis of your condition. You should consult a medical practitioner or other appropriate health care professional for a physical exmanication, diagnosis and formal advice. Health24 and the expert accept no responsibility or liability for any damage or personal harm you may suffer resulting from making use of this content. Continue reading >>

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