Friday, January 9, 2015

Exercise, Lantus and Levemir comparison

 Let's go back to the initial purpose of this blog which was to document our adventures in sports and diabetes. Allow me to stress once again that what we are sharing here is our personal limited experience. We all must remain constantly aware that with type 1 diabetes, one size does not fit all!

I will also skip our usual monthly report. Max HbA1c was tested on the 24th of December (you can see our latest data on the right) and I was of course pleased to see a good result. The question "what is a good HbA1c" is a complex one. Personally, I would like to obtain a slightly higher result - between 5.5 and 5.9 - but that is a personal impression rather than a firm opinion.

The Lantus issue


I have talked earlier about the issues we had with our Lantus injections. In order to keep our dawn phenomenon under control, we had to increase our Lantus dose. But doing that, we were unfortunately increasing the frequency and intensity of our early nights lows. I also began to suspect that the Lantus was responsible for the tremendous amounts of carbs we had to consume during some intensive sport sessions. In one case, we were even forced to quit the tennis training despite having taken 60 grams of non covered carbs an hour or so before the training began. It looked as if the sugar was just evaporating into thin air. Since we were already using very little Novorapid, it couldn't be the reason, and we had very little room for tweaks in either its dose or its timing.

We took advantage of the second week of the Holiday period to attempt a switch from one 17 U Lantus injection to two unequal Levemir injections. Let's see what the results where in a typical example. What I am sharing below are two traces of two extremely similar days in terms of activity, meal content and timing and exercise. 

The Lantus day

The Lantus day begins with a slighlty reduced Lantus dose (16U instead of 17U) in order to avoid the early night low. We are quite successful, hovering for a while in the 90 to 100 mg/dL range but a little before 3AM the Dexcom high alarm flags a steep rise(confirmed by the Libre) and we are forced to correct with a significant dose of 4U Novorapid (based on our own algorithm, taking into account the projected increase during the time the Novo will act). If we were on a 150 flat, in a pattern that would not be predicted to rise, 1 or 2 units would have been enough. Around 5 AM, most of the Novorapid activity has occurred and we are back were we aimed, around 100 mg/dL. The dawn phenomenon restarts so much that morning meal, taking at 7:50 AM doesn't even show a spike. Max may have eaten a tiny bit less than optimal or moved a bit too much and has to correct a small low at the school recess. Good timing for a snack anyway. We then continue with a small noon meal because we know we'll have to preload carb for the tennis anyway. We pre-load generously, tolerating a transient high that we know will disappear and go to the training. You don't need to be a specialist to see that, by the end of the session, Max can barely run. More annoyingly, despite constant correction and reduced evening doses, he'll keep crashing repeatedly until very late in the evening. We end up with a nice looking average of 101 mg/dL which is in fact very bad. SD is at 41, at the limit of the acceptable. But we have 17% of lows. That's definitely not acceptable.

The Levemir day

The overall profile of the Levemir day is visually very similar to the Lantus day, but there are actually a ton of differences. After 13 U of Levemir, we start smoothly sailing around 80 mg/dL and end-up rising smoothly to 120 mg/dL at wake up time. By the way, can you spot the 3-4 sensor compression events in our nightly curve? NOTE: we correctly ignored the 1:30 LOW alert as a compression event. If we had panicked and shot "a juice", we would have been above 250 at 3 AM and we would have entered a new approximate correction cycle. The dawn phenomenon follows its course, the morning meal spikes a bit. Our second Levemir injection consists of 9U The noon meal is similar, again with a possible slight overshoot or under-eat situation. We load less carb pre-tennis, don't hit any significant low, see a muted evening meal spike and again hit a small actual low that is easily corrected with 4.5 grs of carbs (3 dextro-energy tablets) and sail smoothly into the night.

Ultimately, the Levemir day ends up on a 102 mg/dL average, compared to the Lantus 101 mg/dL average but we had 2.5x less highs, and 8x less lows. The SD of 26 is outstanding for a "tennis" day.

We'll stick with Levemir for the next few months and see how the story unfolds.

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