Lantus vs. Lente / Ultralente

Radioactive Man <[email hidden]> wrote on Wed, 26 Nov 2003 06:51:47 GMT:

Quoted message said:

I have been studying some insulin activity curves over the last few days, although I haven't been
able to find any raw data. From looking at the curves, it looks like you could get a fairly stable
basal rate by injecting the L/U insulins at ~12 hours apart (at breakfast and supper for most
people). If you're mixing insulins, you'd be able to get by with only 3 injections per day instead
of 4. Anyone who does multiple daily injections have experience to make the comparison?

Quoted message said:

The biggest disadvantages of Lantus are the high cost and the fact that it cannot be mixed with
other insulins. I would also suspect that some with type 1 have actually been able to take
advantage of the Lente peak in order to prevent the dreaded "dawn effect", correct?

The other disadvantage of Lantus is it's incredibly fragile - trawl the mhd archives, and you'll
find many posts saying that things like "sometimes lasts 3 months, sometimes it's dead within a
fortnight". Lente, along with the other traditional insulins, is robust indeed. 40°C (104°F) is no
problem at all for it, merely it's shelf life at such a constant high temperature is reduced to a
few weeks.

For the "dawn effect", Semilente is excellent stuff, if you can get it.

--
Alan Mackenzie (Munich, Germany) Email: [email hidden]; to decode, wherever there is a repeated
letter (like "aa"😉, remove half of them (leaving, say, "a"😉.

Radioactive Man wrote in message <[email hidden]>...

Quoted message said:

I have been studying some insulin activity curves over the last few days, although I haven't been
able to find any raw data. From looking at the curves, it looks like you could get a fairly stable
basal rate by injecting the L/U insulins at ~12 hours apart (at breakfast and supper for most
people). If you're mixing insulins, you'd be able to get by with only 3 injections per day instead
of 4. Anyone who does multiple daily injections have experience to make the comparison?

The biggest disadvantages of Lantus are the high cost and the fact that it cannot be mixed with
other insulins. I would also suspect that some with type 1 have actually been able to take
advantage of the Lente peak in order to prevent the dreaded "dawn effect", correct?

Exactly right. I shoot 3 shots of Ultralente per day. Two spaced 14 hours apart to handle the bulk
of my basal needs, then one "kicker" at 5 pm which goes after my morning effect. In theory, the 5
pm shot starts to peak at about 1 am, and hits max around 5 am when the bulk of the morning effect
occurs for many folks.

I have a fierce morning effect. Forget a basal shot and I shoot up by 100 mg/dL between 3
am and 7 am.

I get close to 6 weeks out of an Ultralente vial. Many posters assert that their Lantus becomes
erratic after 4 weeks and often must be tossed based on "time" rather than "consumption". Since in
my area, Lantus costs a bit more than twice as much as Ultralente, the ability to use an Ultralente
vial longer results in about a three-to-one cost ratio between the two at my dose level.

Then I add 4 - 6 daily shots of Humalog to the routine. I never mix Ultralente and Humalog in
the syringe.

That routine lets me "beat" some pumpers with my 7 - 9 shot average daily regime (always in 5% club
when using Ultralente)

Ultralente is difficult to inject. Its slow absorbence is based on the large sized insulin-zinc
crystals in the suspension. However, those large-sized particles will start to settle out as soon as
you stop shaking the vial. Thus, I find it necessary to shake - stick the needle in the vial -shake
again then immediately (and I mean immediately!) draw up my dose.

Insulin Detemir (soon to be Insulin Levemir) mimics the absorbence pattern of Ultralente but doesn't
have that suspension problem. Also, since Detemir doesn't contain all that zinc, there would be no
reason not to mix Humalog and "Levemir" in the syringe. . .unless there's some pH problem they
haven't mentioned yet. However, you're back to the high priced insulin again, i.e. trading
convenience for cost.

Regards
Old Al

Wed said:

I have been studying some insulin activity curves over the last few days, although I haven't been
able to find any raw data. From looking at the curves, it looks like you could get a fairly stable
basal rate by injecting the L/U insulins at ~12 hours apart (at breakfast and supper for most
people).

or L (or a L/U combo) at bedtime if you're one of those with high morning basal needs, together with
a shot of U (at roughly noon)

you'd dose the bedtime shot (i.e. amount) for both the U content (L has 70% U in it) *and* the SL
content (to cover high morning basal needs)

Quoted message said:

If you're mixing insulins, you'd be able to get by with only 3 injections per day instead of 4.

agreed

Quoted message said:

Anyone who does multiple daily injections have experience to make the comparison?

likely quite a few

i'm currently trying pork-L 2x (with rigid 12 hour spacing) within an MDI routine. it works really
well. 🙂 which is good <g> coz i've recommended to several others that it would work as well as 2x
of "human"-U

i'm using roughly half the background insulin that i was using with my 1x of beef-L. of course, i
was dosing the beef-L for the U content at 24 hours, whereas i can't do that with pork-L coz the pork-
U (that's in the L) isn't flat at 24 hours with 1x dosing. of course, with 2x of pork-L i'm no
longer dosing for the U content (i'm letting the 30% SL help with covering my basal needs), which is
why my overall L amount is way down

"human"-L is a bit peakier than pork-L, so i think your focus on using mainly "human"-U (taken 2x)
is the correct approach for a t1

Quoted message said:

The biggest disadvantages of Lantus are the high cost and the fact that it cannot be mixed with
other insulins.

imo lantoss is a disaster, pisspro too. so i think the moral of the story on insulin is be careful
what you ask for coz there's a good chance you won't like what you get

but hey! the big pharmas are happy... all the way to the bank. 🙂 too bad there's not much profit in
"human" insulin anymore

Quoted message said:

I would also suspect that some with type 1 have actually been able to take advantage of the Lente
peak in order to prevent the dreaded "dawn effect", correct?

very good insight! 🙂

maybe because you said it, t1 jim dumas will finally pick up on it and try it. 🙂)

bill t1 since '57, ex 8-yr pumper, pork-L 2x, simple MDI/DAFNE

willbill said:

Quoted message said:

I would also suspect that some with type 1 have actually been able to take advantage of the Lente
peak in order to prevent the dreaded "dawn effect", correct?

very good insight! 🙂

maybe because you said it, t1 jim dumas will finally pick up on it and try it. 🙂)

Yeah! Be nice, Bill. I'm still out here in the ether! (But been busy with free stock market
technical analysis software that runs on autopilot under linux. Emails buy/sell signals to me while
on the road and runs on a small embedded [no keyboard, mouse or display] system. With the market
popping these days, you really need to know when to sell to preserve capital. This system will keep
up with the market while I drink beers at the beach.)

In any case, I still prefer NPH at bedtime to control my dawn phenomenon. I like the 4-7h peakiness
and fast tail of human NPH in the morning. I also want to keep my immune system desensitized to
protamine just in case I need to use NPH as a basal in an emergency (if Lilly pulls ultralente, for
example). I also really like the ease of mixing NPH with R (if hyperglycemic) as well. If I look at
my daily schedule, I want high maintenance dosing before breakfast and before bedtime. During the
day I use Humalog on the run and R for pizza/pasta.

So it ain't broke and I don't need to fix it (yet). But watching as always,
--
Jim Dumas T1 4/86, background retinopathy, rarely hypoglycemic: <1/mo. lispro+R+U+NPH daily,
moderate exercise, typically <6% HbA1c

Wed said:

For the "dawn effect", Semilente is excellent stuff, if you can get it.

one more thing that we can't thank our not so lovely FDA for

unless, of course, you have the brains to see that it's still there, hidden in the "human"-Lente

bill

Alan Mackenzie said:

The other disadvantage of Lantus is it's incredibly fragile

Just to say that I'm using Novolog (to get rid of it) that has expired
3/2003. It's clobbered me twice this week with hypoglycemia. If this were Humalog, I'd have to
increase the dose to compensate for the faster degradation (shorter shelf-life). So I can
clearly say Novolog is much more robust than Humalog. It's just too slow for me as it peaks
3-4.4 hours post dose and has a much longer tail than Humalog, (by at least 2-3 hours for
my metabolism with suspected anti-human-R antibody cross-binding to Novolog).

So Novolog potency is impressive post-expiration,
--
Jim Dumas T1 4/86, background retinopathy, rarely hypoglycemic: <1/mo. lispro+R+U+NPH daily,
moderate exercise, typically <6% HbA1c

Wed said:

... and R for pizza/pasta.

one of the nice things about using "human"
U/L/N for background is that you get the R for "free" (i.e. without having to work at having "human"
in your daily routine, since you already have it in your routine (via the background))

whereas if you use lantoss for background and aspart or pisspro for meals, you don't get the R. at
least, not without having to work at having "human"-R in your daily routine

bill

Wed said:

willbill wrote:

Quoted message said:

Quoted message said:

maybe because you said it, t1 jim dumas will finally pick up on it and try it. 🙂)

Quoted message said:

Yeah! Be nice, Bill.

🙂

Quoted message said:

In any case, I still prefer NPH at bedtime to control my dawn phenomenon.

you're such a hard case, i can't hardly begin to belive it. 🙁((((

maybe you're just not seeing it?

the KEY reason to use L at bedtime (or a L/U combo) is to have 2x of U, coz 2x of U comes close to
being flat thru 24 hours, whereas 1x of U is nowhere close to being flat (assuming that your routine
is MDI/DAFNE)

the SL at bedtime is the best for controlling high(er) morning basal needs
(a.k.a. "dawn phenomenon)

to give some t1 examples:

1. those using 8u (or less) for background: are likely to have flat needs and better to take 2 equal
shots spaced 12 hours apart

even if they don't have flat basal needs, the

upon us (in the USA), does not lend itself to anything other than taking equal amounts

those t1s using more (say 20U or more) for background:

2. use equal amounts when taken upon rising and 12 hours later

3. use 11/9 when taken at noon/bedtime (everyone has higher morning basal needs, and using Aida
shows that taking these U amounts gives a fairly flat cure with slightly higher basal amounts in
the early AM)

4. use 11/9 U at noon/bedtime, but use L (or a L/U combo) for the bedtime 9U

so if you used only "human"-L at bedtime, you'd then use 11U at noon and 13L at bedtime, which
gives 11/9 of U at noon/bedtime, and 4 of SL at bedtime

and yes, if you needed more than 4 of SL at bedtime, then you'd have to do something like using N,
like you do. but i'm betting that you don't need that and that the issue is simply for you to *try*
it (L) for real. 🙂

bill t1 since '57, ex 8-yr pumper, pork-L 2x, simple MDI/DAFNE

willbill said:

coz 2x of U comes close to being flat thru 24 hours

Flat basal doesn't work for me.

I need a peak at night.
--
Jim Dumas T1 4/86, background retinopathy, rarely hypoglycemic: <1/mo. lispro+R+U+NPH daily,
moderate exercise, typically <6% HbA1c

Thu said:

willbill said:

coz 2x of U comes close to being flat thru 24 hours

Flat basal doesn't work for me.

I need a peak at night.

try re-reading what i wrote. 🙂

if a U/L noon/bedtime peaks too late for you, then move the shot times to a few hour earlier

and minimize yer evening meal. that's one of the key things that most t1s do wrong (i.e. eat too
great of a carb count in the evening) that causes them to mistakenly think that they need more
background insulin in the late evening/early morning

bill t1 since '57

willbill said:

try re-reading what i wrote. 🙂

if a U/L noon/bedtime peaks too late for you, then move the shot times to a few hour earlier

My goal is to carry one insulin for prandial requirements and dose basally at home. This requires
basal dosing before breakfast and before bedtime.

So doseing L or U before dinner fails this requirement. (period.)
--
Jim Dumas T1 4/86, background retinopathy, rarely hypoglycemic: <1/mo. lispro+R+U+NPH daily,
moderate exercise, typically <6% HbA1c

Thu said:

My goal is to carry one insulin for prandial requirements and dose basally at home. This requires
basal dosing before breakfast and before bedtime.

So doseing L or U before dinner fails this requirement. (period.)

interesting how closed minded you are

bill

On Wed, 26 Nov 2003 08:52:22 -0500, "oldal4865" <[email hidden]>

Quoted message said:

Radioactive Man wrote in message <[email hidden]>...

Quoted message said:

I have been studying some insulin activity curves over the last few days, although I haven't been
able to find any raw data. From looking at the curves, it looks like you could get a fairly stable
basal rate by injecting the L/U insulins at ~12 hours apart (at breakfast and supper for most
people). If you're mixing insulins, you'd be able to get by with only 3 injections per day instead
of 4. Anyone who does multiple daily injections have experience to make the comparison?

The biggest disadvantages of Lantus are the high cost and the fact that it cannot be mixed with
other insulins. I would also suspect that some with type 1 have actually been able to take
advantage of the Lente peak in order to prevent the dreaded "dawn effect", correct?

Exactly right. I shoot 3 shots of Ultralente per day. Two spaced 14 hours apart to handle the
bulk of my basal needs, then one "kicker" at 5 pm which goes after my morning effect. In theory,
the 5 pm shot starts to peak at about 1 am, and hits max around 5 am when the bulk of the morning
effect occurs for many folks.

That's why I'd like to find some actual raw data for insulin activity per unit injected as a
function of time - I could put that in a spreadsheet and model the effects of various basal
injection regimens.

In your case, I suspect you are using the small lunchtime dose of ultralente to add a tail where the
humalog drops off, right? Depending on what foods I eat, I sometimes have a problem with the lack of
a tail on Novolog - I get normal or slightly low numbers after 1 hour, but highs 2 or 3 hours later.
For that reason, I choose to use regular insulin as a pre-meal bolus whenever it is possible, the
exptions being when I don't get a 30 minute heads up on the next meal or if I'm eating a higher-GI
meal. Novolog works very well with the whole-wheat pancakes I often eat in the mornings, but not so
well with salad bars and such.

For handling the dawn effect, have you had better or worse results with Lente than Ultralente? From
looking at the charts, I can see that Lente has and earlier peak than Ultranlente.

Quoted message said:

I have a fierce morning effect. Forget a basal shot and I shoot up by 100 mg/dL between 3 am
and 7 am.

I get close to 6 weeks out of an Ultralente vial. Many posters assert that their Lantus becomes
erratic after 4 weeks and often must be tossed based on "time" rather than "consumption". Since in
my area, Lantus costs a bit more than twice as much as Ultralente, the ability to use an Ultralente
vial longer results in about a three-to-one cost ratio between the two at my dose level.

I've been using the same vial of Lantus (6 - 8 units per day), since I was diagnosed in the summer.
Since my own pancreas is still making enough insulin to handle the basal requirements, I don't
really know how effective that Lantus still is. I almost always wake up with numbers in the 70 - 100
range, but I don't really know what of that is due to the Lantus and what is due to natural insulin.

Quoted message said:

Then I add 4 - 6 daily shots of Humalog to the routine. I never mix Ultralente and Humalog in
the syringe.

Has mixing the two insulins caused problems in the past? From what I've read from the endocrinology
texts, pharmceutical brochures and such, I would have thought that would be permissible.

Quoted message said:

That routine lets me "beat" some pumpers with my 7 - 9 shot average daily regime (always in 5% club
when using Ultralente)

Well, it is hard to say we're "beating" the pumpers if we're injecting ourselves 7 - 9 times per
day. In my case, the usual is 3 or 4 and the max is 5 or 6, but I do not yet (and hopefully never
will) have full-blown type 1.

Quoted message said:

Ultralente is difficult to inject. Its slow absorbence is based on the large sized insulin-zinc
crystals in the suspension. However, those large-sized particles will start to settle out as soon
as you stop shaking the vial. Thus, I find it necessary to shake - stick the needle in the vial -
shake again then immediately (and I mean immediately!) draw up my dose.

Insulin Detemir (soon to be Insulin Levemir) mimics the absorbence pattern of Ultralente but
doesn't have that suspension problem. Also, since Detemir doesn't contain all that zinc, there
would be no reason not to mix Humalog and "Levemir" in the syringe. . .unless there's some pH
problem they haven't mentioned yet. However, you're back to the high priced insulin again, i.e.
trading convenience for cost.

Regards
Old Al

Radioactive Man wrote in message ...

Quoted message said:

On Wed, 26 Nov 2003 08:52:22 -0500, "oldal4865" <[email hidden]> wrote:

That's why I'd like to find some actual raw data for insulin activity per unit injected as a
function of time - I could put that in a spreadsheet and model the effects of various basal
injection regimens.

In your case, I suspect you are using the small lunchtime dose of ultralente to add a tail where
the humalog drops off, right? Depending on what foods I eat, I sometimes have a problem with the
lack of a tail on Novolog - I get normal or slightly low numbers after 1 hour, but highs 2 or 3
hours later. For that reason, I choose to use regular insulin as a pre-meal bolus whenever it is
possible, the exptions being when I don't get a 30 minute heads up on the next meal or if I'm
eating a higher-GI meal. Novolog works very well with the whole-wheat pancakes I often eat in the
mornings, but not so well with salad bars and such.

For handling the dawn effect, have you had better or worse results with Lente than Ultralente? From
looking at the charts, I can see that Lente has and earlier peak than Ultranlente.

Quoted message said:

. . . (snip). . .>

Quoted message said:

I've been using the same vial of Lantus (6 - 8 units per day), since I was diagnosed in the
summer. Since my own pancreas is still making enough insulin to handle the basal requirements, I
don't really know how effective that Lantus still is. I almost always wake up with numbers in the
70 - 100 range, but I don't really know what of that is due to the Lantus and what is due to
natural insulin.

Quoted message said:

Then I add 4 - 6 daily shots of Humalog to the routine. I never mix Ultralente and Humalog in the
syringe.

Has mixing the two insulins caused problems in the past? From what I've read from the endocrinology
texts, pharmceutical brochures and such, I would have thought that would be permissible.

Quoted message said:

That routine lets me "beat" some pumpers with my 7 - 9 shot average daily regime (always in 5%
club when using Ultralente)

Well, it is hard to say we're "beating" the pumpers if we're injecting ourselves 7 - 9 times per
day. In my case, the usual is 3 or 4 and the max is 5 or 6, but I do not yet (and hopefully never
will) have full-blown type 1.

. . .(snip). . .

Quoted message said:

Quoted message said:

Regards
Old Al

Some points of discussion, easiest ones first.

"beating some pumpers" That was a reference to HbA1c. My highest HbA1c on H + U has been 5.9, I
normally run closer to 5.7. IOW, by accepting all those shots, I almost attain pumpers' freedom of
diet yet attain lower HbA1c than some pumpers, i.e I "beat" some of them.

Lente vs Ultralente:

Never tried Lente. Probably never will since the rumor is that it will be discontinued.

Mixing Ultralente and Humalog in the syringe: The literature says it can be done. I am suspicious. I
am fairly certain (38 years employed in Chemistry ) that holding the two in contact long enough will
slow the Humalog. So how long would that be and is contact within my fat layer the same as contact
within the syringe? I had two suspicious incidents when I first tried mixing them so I stopped
mixing them.

"Using the same vial of Lantus for several months" I can only quote other posters: Highly unusual!
Many posters have reported that Lantus self-destructs in a month or less though the endo and two CDE
that I have personally asked assert they haven't run into the extra-short vial life.

"Using lunchtime Ultralente to provide a tail for when Humalog wears off"

We have a differing philosophy on this subject. I totally separate my basal and bolus
calculations. My basal stands alone, providing me with sufficient basal to handle basal needs
24 hours a day. That's the beauty of a modern slow-absorbing basal. By allowing one to
separate basal and bolus considerations, all the calculations are simplified and one has more
freedom of diet.

In general, I size my basal, by trial and error, to provide two "basal" functions:

a. Guaranteeing that my circulating insulin level is always higher than the 8 - 12
microUnits/mL minimum which triggers a low-insulin liver dump in non-insulin resistant T1

b. Attempting to provide a level bG whenever I have an empty stomach,
b.a. not particularly rising or falling at night, or just before a meal when my stomach is empty
and my previous bolus is about pooped out.

My bolus stands alone. I never consider any basal needs when calculating a bolus shot. Bolus
handles food and instantaneous bG with no regard to any interactions with basal.

I handle the Glycemic Index - UltraRapid Humalog balance via "Leading" and "Lagging". I will shoot
early before a high G.I. meal and late before a low G.I. meal. I have (rarely) shot after a really
low G.I, meal rather than before.

Pumpers study these matters in detail and fiddle with their basals for months. Simple MDI regimes
like mine just approximate their basal optimization. I do enough optimizing to minimize Morning
effect and prevent low-insulin liver dumps. I am certain some of my basal is helping my bolus at
times, and perhaps some of my bolus is helping my basal at times but the only way I can tell is by
fasting for 24-hours.

I am too lazy to do that though when the doc demands fasting blood tests or the dreaded anal probe,
my basal is sufficient to hold bG fairly steady through the night until close to noon.

BTW: I shoot Ultralente at 7 a.m., 5-6 p.m, and 9 p.m.

Regards
Old Al

willbill said:

interesting how closed minded you are

That's a double-edged sword. I can say the same about you.

I'm happy with my current regimen. So stay the course,
--
Jim Dumas T1 4/86, background retinopathy, rarely hypoglycemic: <1/mo. lispro+R+U+NPH daily,
moderate exercise, typically <6% HbA1c

willbill said:

Thu said:

My goal is to carry one insulin for prandial requirements and dose basally at home. This requires
basal dosing before breakfast and before bedtime.

So doseing L or U before dinner fails this requirement. (period.)

interesting how closed minded you are

bill

This has got to be the funniest thing you have ever posted!!!!

Still love ya !!!

Gary

P.S. Keep on posting!

Thu said:

Still love ya !!!

i don't love you too

bill

Thu said:

willbill said:

interesting how closed minded you are

Quoted message said:

That's a double-edged sword. I can say the same about you.

i'm not closed minded about using different insulins and/or dosing strategies. my 46 year diabetic
"career" shows that in spades

on insulin, i mainly have an issue with big pharma insulin bigots, like biggs, who used to slyly
tout "human" to us (over beef and pork), but who now touts the 3 analog insulins (soon to be 5)

too bad there's not much profit in "human" insulin anymore

bill t1 since '57, ex 8-yr pumper, pork-L 2x, simple MDI/DAFNE

Thu said:

P.S. Keep on posting!

by the way, do you pay out of pocket fer yer lantoss?

given that yer in business fer yerself, my hunch is that you do

50 bucks a bottle

whooooo!

but enquiring minds want to know. 🙂

bill