GREETINGS --
The following is a description of the Insulin Normalization process that I went through in establishing the exact dosage of Lantus I needed. As background, Lantus starts to act 1-3 hours after it is injected. Its peak action (although it has very little peak) occurs 8-10 hours after injecting and it ceases to have an effect 18-24 hours after injecting. It is significantly more efficient as a basal insulin that Novolin N (NPH) as evidenced by comparing the attributes of both. NPH starts to act 1-3 hours after it is injected. Its peak action (it has a significant peak) occurs 8-14 hours after injecting and it ceases to have an effect 14-20 hours after injecting. The body's basal insulin needs are generally constant for most people; requiring no peak. The presence of a peak can result in low blood sugars.

The purpose of this exercise is to minimize the dose of Lantus required to get the job done -- which is likely to be different with each individual. You should review the use of Lantus and the following procedure with your MD so that he/she understands what you are trying to accomplish. This presumes that the normalization will be done using a bedtime injection strategy. If you have any questions after reviewing the information please send an Email to me.
wambo1941

Lantus Insulin Normalization
DOSAGE CALCULATION –
Your principal goal here, as a first step, should be to establish the smallest possible dosage of Lantus that works for you, to determine how long a shot of Lantus works in your body, and to determine an injection schedule that best serves your needs. In the case of the dosage size your efforts may be complicated initially by two factors; the unknown effect of any other meds you are taking on your body's resistance to the insulin and any possible elevated early morning (fasting) blood sugars. The non-diabetes meds should be treated as "givens" and you should not expect the Lantus to address any early morning highs if they exist. What is needed here is to minimize any unanticipated fluctuations in your blood sugars.

It took me about one week when I first started for my body to get used to the change (from Humulin N to Lantus), but that should not be a factor in all cases. Also, I have found that I realize my best BS control when my Lantus makes up 50-55% of my total daily insulin dosage. This allows me to skip or delay meals and still keep my BS relatively level. That is why I went through the fasting exercise when I normalized my Lantus dosage. As a Type 2 diabetic presumably your pancreas produces some insulin so it will be important to normalize the Levemir insulin before trying to normalize the Humalog insulin.

I have also found out that even one unit of Lantus can make quite a difference so I purchased some 3/10 cc BD syringes w/ half-unit increments marked on them.

It is important to minimize the variables in the Lantus normalization process and thus the fasting exercise. I also suggest that you suspend your exercising regimen during the testing periods and do the test on a day when you not working.

The following steps are involved in the normalization process:

1. Measure your blood sugar at least four hours after completing supper (so the effect of the food and Humalog (five hours if using Humulin R or equivalent) are minimized)(It takes that long for the food and bolus insulin to work their way through your system). Then inject your initial Lantus dosage.

2. When you arise in the AM (at your normal time) measure your blood sugar and take whatever non-diabetes meds you normally take and plan on not eating until late afternoon or early evening. Drink water but no other liquids during the test.

3. Continue to measure/record your blood sugars hourly for the duration of the test -- that will last nine hours if successful. If your blood sugar drops below 60 mg/dL or rises more then 30 points above the first AM reading at any point discontinue the test, eat some food, and proceed with your normal day. If your test is successful then you have established your basal dosage. If it is unsuccessful you should allow your body to adapt for a day or so (using the same dosages of insulin) before trying again with a higher or lower dosage.

4. If the first test is unsuccessful (and it probably will be) you want to try and "bracket" what will ultimately be the correct dosage so you can do some fine tweaking. If your initial dosage is too small you should increase the Lantus dosage by 2-3 units (depending on how rapidly his blood sugars increases) and proceed to the second test following the same procedures as the first test. If your initial dosage was too large you should decrease the Lantus dosage by 2-3 units and proceed to the second test following the same procedures as the first test.

5. Once you have established a good bracket (i.e., the trend established during the testing process is reversed by the latest test) you should conduct one last test to confirm that the dosage is correct following the same procedures as the first test.

6. Once you have established the correct dosage he should then determine the period that Lantus remains active/effective in your body. This portion of the test does not require fasting. The test involves taking your blood sugars on an hourly basis starting 17 hours after your Lantus shot – which is likely to be about mid-afternoon if you injected the Lantus before going to bed. If Lantus is not effective for the full 24 hours in your body your suppertime blood sugars are like to be higher then they should be (assuming that your Humalog insulin is properly dosed). If this is the case you have some options. You can increase your supper Humalog dosage to cover the elevated blood sugars (but be careful of hypoglycemic event), you can try splitting your Lantus dosage (50% at bedtime and 50% 12 hours later), and/or you can try changing the time of your Lantus shot to a time that works better for your body.

7. Once you have conducted the other tests you might want to look at the advantages/disadvantages of various injection schedules. I tried three different injection schedules during the last few months (night, morning, and split). I now inject at midnight which I selected for convenience as much as anything. I have a target BS of 100 mg/dL at bedtime and the same numbers when I awake in the AM – and this happens for me, on average six times a week. I found that the Lantus shot lasts for 24 hours in my case so I am lucky. I noticed slightly better control with a split dosage, but I had trouble remembering to take the AM ½ of the dosage (my alarm clock only worked as a reminder when I was around to hear it) so I gave up. I can think of only two other reasons to split his doses of Lantus; if the effective life of the Lantus in your body is less than 24 hours or the dosage is large so the Law of Small Numbers (Dr. Bernstein) kicks in.

8. There are some other idiosyncrasies of Lantus that you will need to learn if you haven't already discovered them. These are things you learn from use and are probably not in the directions that accompany the vial of insulin. First, Lantus should be refrigerated between shots because it is temperature sensitive. Otherwise it will lose its potency over time. Second, you will need to be careful about Lantus losing its potency after 28 days that will result in the upward "creeping" of his blood sugars. I often end up trashing a vial that is still 1/3 full for this reason. Third, once you establish a schedule for your Lantus injections you should keep it religiously. Otherwise you will start getting unpredictable results with your blood sugars. Fourth, over time, assuming your body's sensitivity to insulin changes, you may need to tweak your dosage (upward if you gain weight (10 pounds in my case) or lower if you lose weight).

In conclusion the whole process of normalizing Lantus insulin involves a lot of scut work (another term for trial and error testing), but the results are worth the effort (having reliable/predictable blood sugar levels during much of each 24 hours).
wambo1941

GREETINGS --
The establishment of a strategy to calculate your appropriate Humalog dosages will be somewhat complex, but still quite manageable. It will involve the following three sets of trial and error tests:

· Determining the amount of Humalog insulin needed to cover the carbohydrates you consume at each meal;
· Determining the amount of Humalog insulin needed to cover the protein you consume at each meal (protein is also a source of glucose); and
· Determining the amount of Humalog insulin needed to lower any elevated blood sugars at any time to the target level you have established.

In many cases a sliding scale is provided by your MD, based on the pre-meal blood sugar reading -- and often with an arbitrary adjustment for the food you intend to eat. This strategy is likely to result with a blood sugar reading at the next meal that is higher or lower than your target blood sugar. The normalizing process should fix that situation. Therefore, it is important that you review this procedure with your MD before proceeding.

A starting point here is based on research done by Dr. Bernstein (and outlined in his book "Dr. Bernstein's Diabetes Solution"). This will serve as the basis for the first set of trials. Generally, one unit of insulin (Humalog in this case) will lower the blood sugar of a Type I 140# non-pregnant diabetic adult 40 mg/dL. This ignores any insulin resistance and the effect of any Dawn Phenomenon on one's breakfast dose of insulin – both of which will be dealt with elsewhere if appropriate. If you are a Type 1 who weighs more/less than 140# then you will need proportionately more/less insulin. For example, if you weigh 210# and you are a Type 1 one unit will lower
your blood sugar about 27 mg/dl.

If you are a Type 2 diabetic (your body is still producing some insulin) the process will be more complex. As a Type 2, I started with an assumption that the blood sugar of a 140# non-pregnant diabetic adult will be lowered 50 mg/dL by one unit of Humalog. If you weigh more/less the same adjustments apply as were appropriate for Type 1 diabetics.

This test would best be done on an empty stomach in the morning. First, test and record your blood sugar reading and compare it to your "target" fasting blood sugar level –say 100 mg/dL or some target established in consultation with your MD. For demonstration purposes lets say your blood sugar reading is 200 mg/dL or 100 points higher then the target. You would then inject 2 units of Humalog, wait an hour and take another reading and record it, wait another hour and take a second reading, and wait another hour and take a third reading. If the third reading is at or near your target you have your correction dosage rate. If your blood sugar is too high you need to proportionally increase your dosage and repeat the three-hour testing procedure. If the blood sugar is too low then proportionally decrease your dosage and repeat the three-hour testing procedure. With any luck you should get close within two iterations. If not you can either continue or suspend the test until the next morning and pick up where you left off.

The second phase of the test will involve establishing the dosages required to cover the carbohydrate and protein you consume at a meal. This test will probably take parts of two days and will require that you eat the same breakfast, lunch, and dinner each day for testing purposes. The approximate calculations used to start with are based on the numbers of the 140# individual above. I unit of insulin will cover 8 grams of carbohydrate and one unit will cover 1.5 ounces of protein.

Start the process by measuring your pre-breakfast blood sugars and calculate the dosage you need for any correction, then calculate the number of grams of carbs and ounces of protein in the meal and calculate the estimated dosage you will need to cover each. Next you will combine the three dosages into one injection and then give yourself the shot a few minutes before you eat. Repeat the cycle for lunch and dinner – recording all three pre-meal blood sugars, increases or decreases in blood sugars divided by 40 mg/dL (or proprtionately more or less depending on your weight) and changes in doses rounded off to the nearest ¼ of a unit of insulin. Repeat the process the second day using the revised dosages for each meal and the same menu to confirm that your calculations are correct.

In order to calculate the carbohydrate I suggest that you use some type of reference rather then relying on the food labels. The reference I use is a table you can access on the internet at the caloriecountercharts.com website. I am sure you will have a lot of questions so please feel free to send them and I will do my best to reply. I am still learning daily.

Remember to BE PROACTIVE
Wambo1941

Wow! That's quite a process. I'm a middle school teacher by day, so I think I'll wait until the summer break to try a process this extensive. I'm going to copy and paste these directions into a document so I'll have them. Thanks for taking all the time to explain this to me.

I'm really confused about my numbers today. I'm still in a good range and well under 200, so I'm not going to worry, but sometimes my body is strange.

I do have the dawn effect, and I have it BAD. This AM, my BG was 133. I took my humalog and my meds. One hour later, I went to make breakfast. All I had had was water, meds, and the shot. MY BG was 159! But two hours after breakfast, my BG was 144.

Since I'm below 200, which is a major accomplishment for me, and I'm not going low, I feel safe tinkering with the dosages of the insulin. But I think I'm going to stop tinkering until the weekends. My weeks are just too crazy to test as frequently.

GREETINGS --
There are more things than Dawn Phenomenon than can cause your morning blood sugars to be higher than your bedtime blood sugars. One posibility is that your nighttime N insulin dose expired and your AM dosage had not started to take effect. Have you ever checked your blood sugars to determine an accurate action period for N in your body. Although N theoretically acts for 14 hours before expiring its action has a peak meaning its full strength may not be available. Also, your morning dosage of N will take one hour to start acting and some more time for the peak to build up..

In the case of Dawn Phenomenon, your morning blood sugars will typically stay normal throughout most of the night and then start to rise just before you normally wake up. The best way to confirm th presence of Dawn Phenomenom is to test your blood sugars just before you retire, and then at two hour intervals throughout the night. If you are susceptible to Dawn Phenomenon your blood sugars will slowly decrease during the night (once your bedtime N insulin takes effect and then will increase just before you would normally awaken (say 6:00 am).

If your blood sugars slowly increase over the course of the night it means your body has inadequate circulating insulin. If your blood sugars decrease during the night an drop too low then cortisol will be dumped into your system and your blood sugars will rise. The appropriate fix will depend on the actual problem, not what you think it might be.

wambo

Wow! That's quite a process. I'm a middle school teacher by day, so I think I'll wait until the summer break to try a process this extensive. I'm going to copy and paste these directions into a document so I'll have them. Thanks for taking all the time to explain this to me.

I'm really confused about my numbers today. I'm still in a good range and well under 200, so I'm not going to worry, but sometimes my body is strange.

I do have the dawn effect, and I have it BAD. This AM, my BG was 133. I took my humalog and my meds. One hour later, I went to make breakfast. All I had had was water, meds, and the shot. MY BG was 159! But two hours after breakfast, my BG was 144.

Since I'm below 200, which is a major accomplishment for me, and I'm not going low, I feel safe tinkering with the dosages of the insulin. But I think I'm going to stop tinkering until the weekends. My weeks are just too crazy to test as frequently.

Hi! My diabetes story is similar: diagnosed at 26 w/early onset type 2, treated with tablets, lost 100 pounds, controlled with diet alone for some years, gained weight, had four miscarriages, after which insulin treatment began (about 12 or 13 years ago). I had been horribly mistreating my body and ignoring my diabetes for about the past year or two, taking only fast-acting insulin and blowing off the long-acting (I know, it sounds really weird) until it turned out that I have developed (very, very mild) diabetic retinopathy, which scared the bejeezus out of me and sent me straight to the doc/diabetes nurse (diabetes care is really very good here in Sweden). I began carefully monitoring my BG and taking all insulin doses on time and in the right amounts (very carefully controlled because I must be careful to bring my diabetes under control slowly and carefully. Started Atkins three days ago and my BG levels have plummeted! (I measure with the European system of millimoles, so will leave out the numbers). I spoke to the nurse today and we agreed on new dosages and an appointment next Friday.

Which brings me to my suggestion: please, please call your doctor or other diabetes care team member and consult with him or her before you do anything. Also, since you have had such high BG values for such a long time , it would be a really good idea to go in and have a full eye examination *including retinal photography* to make sure that you do not have any retinopathy. If you do, don't panic - get your sugars and your BP under control and it may never get any worse. BUT if you do have even very mild retinopathy and drastically and rapidly lower your BGs and get your diabetes under control too fast, it can trigger uncontrolled proliferation of retinopathy. My doctor, nurse, and a specialist in retinopathy told me that I have to take six months to a year to bring my diabetes under control to protect my eyes. Best of luck - Rsmry (Rosemary)

Hi again - just reread your post more carefully and saw that you have actually been diagnosed with retinopathy. Sorry I missed that, I was so worried about retinopathy after reading the beginning that I jumped the gun and started writing about it right away. Anyway, the retinopathy does make it very important that you bring your diabetes under control very slowly and carefully. They do not know why a sudden transition into "good control" can cause uncontrolled proliferation, but it is a very real concern. Best, Rosemary

I had never heard about the problems that "speedy" control can cause. Of course, I'm not really in control. My BG values are hovering between 120-145, which is lower than the 265 before, but they are not in the normal range, which is 80-110 for me. I'm going back to see my eye doctor for a second glaucoma test (the first one was borderline), so I'll ask him about that. And I'm going to fax in my recent numbers and see what my doc thinks.

I tried not taking as much insulin (half or two thirds) for three days. And I lost three pounds. But then I was stressed because the work week started again and I figured I better go back to what the doc prescribed as my sugars were creeping up a little, so I went back to injecting 50 units in the AM and 20 at night. I gained back the three pounds! I'm still holding steady with my weight, and my BG readings have stabilized again in the 120-145 range. Except for tonight. I was 3 hours late with my shot, and my BG was 195. Still not bad for me, but I'm seeing that I need a pretty high basal dose. I'm wondering if I should talk to my doctor about the pump, Lantus, or just taking more frequent shots? Anyway, I'm going to fax him my readings and see what he says. Which may be nothing until my next appt. in July.

There is quite a lot of information out there about how sudden control of BG can temporarily exacerbate retinopathy (which could lead to the need for laser surgery, etc.). Naturally, the best thing is for you to consult your own physician. The doctor who advised me is a professor of ophthamology at one of the largest eye specialist centers in the world, attached to the world-renowned Swedish medical school and research institute, "Karolinska Institutet" in Stockholm. Glucose control is absolutely imperative, according to him, but since I had been in poor control for so long, I need to get into good control gradually - and then stay there. After five days on Atkins, I have reduced my long-acting insulin (Humulin) by 16 units a day and my rapid-acting insulin (Humalog) by 15-20 units a day. It's a miracle and I only wish I had done this long ago. After a few weeks at these levels, I will certainly be able to lower the dosages even more. My goal is normalization of BG without insulin (however long that takes). Best of luck to us both!

GREETINGS--
Congratulations on your effort to normalize your blood sugars. You will find as you continue to lose weight that the insulin resistance your body built up due to weight gain will get less and less. One additional suggestion I have, however, is that you talk with your MD about switching from Humulin to an insulin that is better suited as a "basal" insulin. The body needs basal insulin to support functions 24 hours per day and that need is constant throughout each 24 hour period. Humulin insulin has an action peak that could result in hypoglycemic events if you try to normalize it. There are two insulin products available in the US and many other countries that are much more efficient as basal insulins. These are Lantus (insulin glargine) and Levemir (insulin detemir). I have been using Lantus and Humalog for about four years and once normalized (in combination with a low carb diet) I was able to reduce my total insulin dosages by more than 30%.
wambo1941

Thanks Wambo. I have an appt with my diabetes nurse on Friday (my birthday) and will ask her about it. Here in Sweden, diabetes care is a team effort and your first point of contact is a highly trained RN specialized in diabetes - and they often understand the disease better than than the non-specialist MDs. Anyway, I will ask her what she thinks. As things are, I take two doses of Humulin, 12 hours apart, and the Humalog before each meal. As of now, five days after starting Atkins, I have had to reduce the Humulin by 50% (!!!) to stay at the BG level recommended for me and my particular situation with the retinopathy, while at the last two meals I experimented with not taking any Humalog at all before eating, and my one hour post-prandial BG did not go over the recommended level and started dropping again by two hours. This week is a bit of a trial-and-error process to find exactly the right levels of insulin vs food to bring about a slow and steady decline to controlled diabetes with as little (preferably zero) insulin as possible.

You have a lot of advice already. I am a type 2 diabetic on insulin and metformin (Glucophage). I told my dr. I was going to a low-carb diet. He was pleased with this decision and told me that I could probably go off my insulin if my blood sugars are consistently lower. I have reduced from 35 units a day of Toronto to 10 units a day. I don't take the Metformin because it can cause the "green-apple quick step" without notice. I am told that metformin can assist in weight loss, however. (Probably as a result of the green-apple quick step action...)

Since you've lower your blood glucose with diet, why not gradually lower your insulin. You are testing, so you will see the results. Any Dr. will tell you that it is better if you can manage on the the least amount of medication necessary. You will not cause any lasting harm if you gradually reduce your insulin doses and remain vigilant with your testing.

Like a recent poster, I too am on insulin. I have been for almost 40 years. I have seen programs come and programs go, but still have good eyes and all my limbs, so probably better off than a lot of people. I was originally diagnosed as Type 1, of course, but later came to realize that I was type 2 with a huge insulin resistance.

We tried pills for a while. I took the maximum and it worked for a bit, but then didn't. I am in Canada, and have a diabetes education clinic close to me, so went there, and tried the diet, and took more insulin. I actually need three types of insulin and take metformin on top of that...That is 6 shots a day and a test before and after each meal + a fasting and a bedtime check.

Three years ago, I found Atkins, and by cutting back on my insulin, carefully, and splitting excersise up into smaller periods etc. etc., managed to lose 58 lbs. I have kept them off, but the blood sugars are getting worse and worse.
Diabetes Educators told me that Atkins was dangerous. So, I went to see a specialist. He did all the tests known to man but told me the damage from uncontrolled sugars and larger and larger insulin shots was probably the greater risk.

He mentioned that he had a family member with diabetes, who had great success with Dr. Bernstein's approach and suggested I try that. I ordered the book yesterday from Amazon.com, but do have a bit of printed information from the earlier version of the website.

So here I am, hoping to lose a few pounds more, and control the blood sugars to feel well. I have two small kids counting on me right now + a husband, and we want our grandchildren to have both of us

I have used Lantus and really did like it. The problem with it, for me, is that the Canadian Government does not 'cover' it in various programs and neither does my health insurance. I just couldn't afford the bill...however, if you use the Low Carb program and get it right (not easy I know) you can effectively use the other kinds of insulin. I am no expert, believe me, but for sure a person can use a variety of insulins and get that same result.

They are *finally* starting to do studies here in Sweden (where some of the best, cutting-edge diabetes research in the world is done) on what they call a LC diet but is Atkins by another name and the results have been extremely promising. After a year on Atkins, the experiment group had lost more weight and improved all significant values (HBA1C, etc.) compared to the control group on a higher carb/lower fat diet. The same hospital has just published the results of a similar study of type 1 patients, also with good results.
http://www.ltblekinge.se/BLS_doc/La...Improvement.pdf
Rosemary

GREETINGS to sprucerose--
I am sorry to hear about Canada's decision and I presume that the insulin Levemir, new to the market (by Novo Nordsk) and like Lantus, will probably have the same limitations. However, you might want to check it out. I have been a fan of Dr. Bernstein for several years for I discovered him about the same time that I discovered Lantus and Humalog insulins soon after the came to market. If you have not already done so you might want to review Post # 17 above which covers Humalog Normalization.

wambo1941