Levemir Dosing: Not Always Clear Cut

Levemir FlexPenI asked about trying Levemir back in December, 2007. My PCP gave me some sample pens and said to take it twice a day. Later I saw another doctor who tried to tell me that it was a once a day insulin. Although in the beginning I did better on Levemir than I had on Lantus, I found that it just didn’t last long enough and I would run high before my 12 hours was up.

The following spring, there was a discussion on a message board and several of us felt that Levemir was not lasting for 12 hours. I brought up trying it three times a day and I decided to give it a try. I actually found that worked a lot better for me. Right around when I tried that was when I also learned about doing basal testing. By doing basal testing, I know that my rates are set correctly and I can go 24 hours and have my blood sugar stay fairly stable.

Another person on that message started taking Levemir three times a day also after I started. There is a third person on TuDiabetes that also takes her Levemir that way. I know that there are at least three of us taking Levemir three times a day successfully.

A couple weeks ago, there was a discussion on TuDiabetes about Levemir. Someone has having trouble with it and I told her what I did. Every time I suggest that to someone, I also suggest doing basal testing and state that I know it works for me because of doing basal testing. Someone else immediately piped up and told her that she couldn’t do that. My response was why not. I have been doing it for 3 ½ years less the 8 months that I was on the pump. I get pretty good results from it.

If you read the prescribing information for Levemir, under Pharmacodynamics, it states “The mean duration of action of insulin detemir ranged from 5.7 hours at the lowest dose to 23.2 hours at the highest dose (sampling period 24 hours).” You can read the prescribing information on the Levemir website here, or I scanned the first page and have it below if you threw yours away. If you are someone getting the 5.7 hours out of Levemir, then taking it twice a day is not exactly going to work for you. If you are someone getting 23 hours out of it, you don’t want to be taking it three times a day – that won’t work either. The best way to know what works for you is to do basal testing.

If you read the line above, it says “5.7 hours at the lowest dose to 23.2 hours at the highest dose.” Note the lowest to highest. If you add more Levemir to your dose, then you will be able to extend the duration. However, if adding more Levemir causes you to go low, then that isn’t good either.

I take my Levemir at 7 AM, 3 PM and 11 PM. There are some drawbacks. If you stay up late and want to sleep in, you have to get up or your blood sugar will be high. If you are tired and want to go to bed early, that can be a pain. I have dual alarm clock so I have alarms set for 7 AM and 11 PM. If I want to go to bed early, my alarm wakes me up to take the Levemir.

My view on everything is that even if something works for 99.99% of people, if you are in that 0.01%, you need to find something that works for you. I grew up left handed in a right handed world, so I am used to doing everything differently – even telling time. Figure out what works for you and don’t worry about what everyone else is doing.

Levemir prescribing information

Comments

  1. We are on the pump now, but when we were doing injections we were using Levemir. We started out with one shot per day. Then we cut the dosage in half and moved to two shots per day. We had better numbers that way. I think three shots would have been tougher to manage for us, but I can see how it could benefit your numbers.

  2. Kristen says:

    Hi Kelly,

    I stumbled upon your blog after Googling “Levemir three times a day,” and I am wondering if you could offer me any advice or insight regarding my recent issues. My mom astutely noticed that we’re both redheads – she’s of the belief that redheads’ bodies are just special and react differently, as mine has my whole life :). I apologize that this will be a long explanation, but you are so far the only person I’ve found who needs to give 3 shots of Levemir a day!

    Issue: I have been on the Minimed Paradigm pump for 12 years and over the past year, I have switched between 3 types of sites (Silhouettes, Mios, Quicksets), all of which have randomly failed more than once on the 1st or 2nd day and given me ketones (including 20 minutes before my scheduled MCAT exam!). Before this year, I had been using the Silserter automatic injector with 17mm Silhouettes with no ketone problems at all for 11 years (I had to switch away from the injector because it only seemed to insert correctly if I was using my stomach, a relatively flat surface, and not on my back or around curves.) I got so frustrated that I started using shots 4 days ago. All I had was Levemir at the time, so I started with that and my regular Humalog. At first I tried giving a 24hr dose, and that certainly didn’t work – then I tried 2 12hr doses, and I went from a consistent 100-110 for ~7 hours to 170 then 220 with ketones on the 8th hour after injection. I decided to try splitting my Levemir into 3 8hr dosages, but even that hasn’t seemed to work: I gave 4units at 12AM and stayed at 130 all night. Then I gave 15units at 9AM, was in the very low 100s all day, and then went up to 155 with large ketones and nausea at 3PM. I gave 12 units of Levemir, was at 140 at 4PM, and am crossing my fingers that my blood sugars and ketone levels will behave until my next dose at 12AM.

    Plan for tomorrow: I went down a little (from 130 at 9AM to 100 at 11AM) after my 9AM dose, so I was thinking about pushing my 9AM dose to 10AM and also increasing the dose from 15units to 17units. It seems like my 12AM 4unit shot somehow lasts a little longer than 9hrs, but that my 9AM shot lasts somewhere around 5 hours. I completely understand that 155 (and even 220) are nowhere near awful numbers and that I’m in pretty good control, but I feel ketones extremely intensely and get sick very easily from them. Additionally, I’ve already needed cataract surgery because of diabetes, so I feel that perhaps compared to the average person, I need to be in even tighter control to help prevent long-term complications.

    Normally, my basals total to 22units, so I am shocked that I would need 30+ units of Levemir! The only additional thing complicating this is that I haven’t been eating carbohydrates for a few days (to monitor the long-acting insulin), so that may be contributing to the higher levels of ketones, since my body is breaking down more fat.

    Any ideas about what to do or try? I need to re-schedule my MCAT exam (a little over 5 hours) soon, and I want to make sure I have my diabetic health under control. Two fellow Type 1 friends have suggested I try Lantus, as it lasts longer. Have you ever tried it? If so, what was your experience?

    Thank you so much!
    Kristen

  3. Hi Kristen,

    Although I never heard that redheads bodies react differently, I agree with your mother! It seems that everything is different for me. At least one of the people that that I know that does Levemir 3 times a day is also a redhead. I actually do know a few other people that do it.

    If you give more Levemir, then you can make it last longer. But the problem with doing that is you end up going low. If you do basal testing, you shouldn’t go up for down by more than 30 points and if you take too much Levmir, that wouldn’t happen. It sounds like you are getting about 6 hours out of it during the day.

    There are a couple things that you could try. One would be to shift your times, if that is possible. I am sure that you know from pumping that your basals aren’t even all day. Last fall I started having a problem going low in the afternoons with my Levemir – mornings were fine but for some reason, I started going low. I didn’t want to switch my times so I decided to cut back the Levemir so I didn’t go low in the afternoon, but added some fast acting to help with the mornings.

    I do my afternoon shot at 3 PM and I need the least amount then (3 units). That is out of my system by about 9 PM so I take some Apidra when it starts wearing off to cover me until I take more Levemir at 11. I use the most in the mornings – 11 units and I take 5 units overnight.

    If you know that your Levemir runs out at 6 hours, you might try adding some fast acting at the 6th hour so you don’t go high. Cell phone alarms are what help remind me to do this stuff!

    I did use Lantus before trying Levemir but hated it. In fairness to Lantus though, no one ever told me to split it and I was doing that once a day. I had to take a lot to get it to last 24 hours and had a lot of bad lows. I had never heard of basal testing until I switched to Levemir. I remember someone on TuDiabetes that had trouble with Levemir too and felt that they were having to take too much of it to get it to work.

    If you can’t get Levemir to work, it wouldn’t hurt to try the Lantus – it might work better for you. You can always decide which is the better of the two.

    I pumped for about 8 months and could never get sites to last a 2 full days. Maybe it is the hair color!

  4. Kristen says:

    Thank you so much for your reply, Kelly! Thankfully, the rest of today went great (I was between 95-115 all evening up until now… we’ll see what happens when I add carbs back into my diet). That’s interesting that you, and most others, seem to find that giving more Levemir helps it last longer – for some reason, it seems to be the opposite in my case! The 15 unit dose lasted 5-6 hours, but my 12 unit dose has lasted from 3:30PM until now (8.5+ hours). Even more strangely, my 12AM 4 unit dose lasts me 9+ hours. I blame the hair color!

  5. Kristen says:

    Oh, and I’m so sorry to hear that you’ve never been able to get pump sites to work! I have to admit, there were definitely huge perks to being on the pump. That said, I am really enjoying being off of it for now. What types of sites did you try and in what areas on your body?

    • Hopefully the rest of your night went OK Kristen! Your experience is the classic YMMV! My eye doctor likes to say that something can work for a million people but if you are that one person it doesn’t work for …. That is funny the 12 AM dose lasts 9 hours.

      I had the Animas Ping and apparently have a Teflon allergy so had to use the metal sets. Their only metal set was Contact Detach, which I hated because the needle was so thick. I mostly used Orbit Micros and they did last longer for me. I only used the left side of my stomach- I apparently already had a lot of scar tissue on the right side because I could never get a site to work (I have been diabetic for over 28 years now). I also used my love handles – I had good flow from those but they still fizzled out after a day. I think some of my problem could have been allergies because I am having all kinds of weird allergies now.

      • Kristen says:

        Hi again Kelly,

        Just wanted to send you a brief update since you’d been helpful:

        After getting ketones 2x/day with Levemir, needing to take it 3x/day, and needing to take about 150% of my normal basal dosage, I switched to Lantus. So far, it seems to work much better for me! I seem to need an extra 2 units of Humalog right around 1PM (I get an afternoon peak rather than a dawn peak), but other than that, pretty steady! My only concern is that I’ve heard it’s common to gain weight (in some cases, 10+ lbs). Maybe if you ever get tired of dosing Levemir 3x/day, you could give Lantus a shot – no pun intended.

        I’m not sure if you’ve ever tried Sure-T’s (although they are used with the Medtronic pump, and it sounds like you probably aren’t even interested in any type of pump now), but I’ve heard several success stories and had them recommended to me today.

        Fingers crossed that Lantus will keep working, and that eventually I can get that darn pump to cooperate again! Hope you are doing well!

  6. Kristen, I am glad that Lantus is working for you. I have talked to a couple people that Levemir just didn’t work for them – I am sure if they tried 3x/day or not. At least you found something that will work. I hope that you don’t gain weight with it. When I was using it, I didn’t gain weight until I had to stop exercising. Hopefully you won’t!

    A couple friends did suggest the Sure-T’s for me. A pump isn’t 100% out of my future. Unfortunately, MM doesn’t have a trade-in program – you have to go thru the pump purchase process and my insurance won’t cover another new pump until after the warranty period.

    I will keep my fingers crossed for you!

  7. For those interested, I read the Lantus pharmacodynamics. Their study showed Lantus can last between 10.8 hours to > 24 hours. So it seems Lantus does last longer. I use Levemir. I recently started taking 3 shots of Levemir/day. I probably need 4 as I still have a gap I need to fill with Humalog. All insulins last the shortest duration for me. Humalog lasts about 1.5 hours, Regular lasts about 3 hours and it seems Levemir lasts about 6 to 7 hours. 3 shots of Levemir is working for me as long as I fill in the gap. It works much better than 2 shots/day. I used to use Lantus (I did for many years) but changed to Levemir. Lantus definitely has more of a peak than Levemir. I like the near peakless action of Levemir.

  8. Sorry that it took me so long to get this approved & responded to Tony! That is interesting that you are on the short side of all those insulins. My Levemir also lasts about 7 so two shots a day did not cut it for me either. I figure as long as it is flat, I will continue the three a day and fill in as needed.

  9. Hey Kelly – I’ve been consulting with you know who – about the 3X a day Levemir regime for our basals (a friend of mine who has gone onto a pump gave me her Levemir to try out). I have to admit – going into day 4 – I’m starting to have 2nd thoughts about continuing with it – but going to tough it out for at least a week. The good thing – this time around – no allergic reaction like I did back in 2009 ( http://www.diabetes1.org/blogs/Annas_Blog/Allergic_reaction_to_Levemir_is_this_a_common_occurrence )

    I do know that my BG’s are not as good (level) as they are with my 2X Lantus shots (which I’d noticed last time as well – but figured that was due to allergic reaction). I know too, that tonight’s shot before bed – I was VERY tempted to lower the amount by 1/2 unit – as the last few days I’ve been waking up to lower numbers than I am happy with (e.g. 3.5 mmol/l or 63). Thinking it may have been a fluke that the lower BG’s occurred – so giving at least another day before I tweak the dose. I’ve learned though with your blog post and others who have commented – that Levemir has a shorter time span than Lantus – so that explains the gap time where I seem to be dealing with higher BG’s than normal. This was something that hadn’t been explained to me by “you know who”.

    The other thing I’m really not liking – having to live by an alarm – for those shots – not used to that at all. With Lantus – it seemed far more simple – especially for adjusting – but again – this is a new regime – I’m trying to adjust to a “new kid on the block”.

    Off to test my #BGnow before hitting the hay – and getting up at 0600 for that 1st of 3 Levemir shots for the day (oh – did I mention – I’m losing sleep with this regime ???? I’m such a lazy cow aern’t I!!!).

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