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In My Opinion: There is No 24-Hour Basal Insulin
The views expressed by this author are his own and are not necessarily the views of this publication. Consult with your diabetes care medical team before making any changes to your insulin regimen.
You can make any insulin last longer by injecting a large enough shot. (See Scott King's column, "Why Smaller Shots of Insulin Get Absorbed Faster, Peak Sooner, and Are Out of Your System Quicker", for the math on this.) 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 proper basal dose for a 154-pound, non-obese, non-pregnant person with type 1 diabetes (without a history of insulin resistance from PCOS, iron overload, low testosterone in males, etc.) is usually about 12.5 to 15 units daily. If you have high muscle mass, it may be lower.
Lantus is the only basal insulin I use for my patients because, in my opinion, it lasts slightly longer than Levemir. So a 154-pound person would take approximately 7 units of Lantus in the morning and 7 units at night. If you are a type 1, you can check this by correcting the dose for your body weight and then injecting half the dose upon rising and half at bed time. If you fast for 24 hours, this amount of Lantus insulin should keep your blood sugar close to level. That is the purpose of basal insulin, which should be used solely to prevent blood sugar increases while fasting.
By performing their clinical trials using doses that are larger than true basal amounts, insulin makers have persuaded the FDA that one shot lasts 24 hours. Now, with the blessing of the FDA, they are forcing people who follow their dosing guidelines to eat through the day, in order to prevent hypoglycemia by covering the excess basal insulin with food - just as Dr. Galloway covered the unneeded insulin with a glucose drip.
I teach my patients to use basal insulin correctly so that its sole function is to prevent blood sugar increases while fasting. I show them how to use the faster insulins to cover their food. I've been studying the action of insulin closely in my patients for more than 25 years. In my experience, and in that of all but two of my insulin - using patients, no long-acting insulin lasts a full 24 hours when administered in proper basal doses.
Unfortunately, there are now only two basal insulins available in the U.S. I find that even when Lantus is split into two doses, the bedtime dose barely lasts nine hours overnight.* As a result, my patients who wish to sleep late on weekends must arise after 8-1/2 hours of sleep, take their morning shot of long-acting insulin, and then go back to sleep. Many must also take a small dose of rapid-acting insulin as a stopgap while the long-acting insulin gets started.
The large "basal" doses needed to make "long-acting" insulins last 24 hours have the potential for a number of undesirable consequences. These include hypoglycemic episodes, weight gain, and possible vascular effects. The weight gain results both from overeating to cover the hunger caused by low blood sugar and from the anabolic (tissue building) effect of insulin. While small physiologic amounts of insulin foster a healthy vascular system independent of blood sugar effects (endothelial flexibility, reduced vascular leakage, etc.), excessive insulin levels adversely affect the vasculature.
* This is due in part to the "dawn phenomenon," described on pages 93 and 94 of my book, 'Diabetes Solution'.
Dr. Bernstein is the author of 'Diabetes Solution' and 'The Diabetes Diet', published by Little Brown in 2007. He has had type 1 diabetes for 61 years and practices medicine in Mamaroneck, New York.
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Comments
Dr. Bernstein ... thank you, yet again.
I have been counseling peers who have gotten themselves into "pickles" of overprescribed insulin.
Their symptoms are: huge weight gain, even worse insulin insulin resistance, DKA, very, very high blood sugar and A1Cs.
Those who listen have reduced insulin use by 60-75%, decreased average their blood sugar by equal amounts AND increased their insulin sensitivity (decreased their correction and carb to insulin ratios).
Most of all - they're not constantly sick anymore and just plain feel better.
Thank you for publishing WHY correctly using insulin in direct opposition to the pharma's and endo's instructions works.
These are the same problems that made NPH, Lente, and Ultra Lente "inferior" to the newer experimental insulins. If you use an insulin in inappropriate ways, it is going to have undesirable consequences. Doctors are not taught the true personality characteristics of the different basal insulins. Right or wrong, doctors will only follow the status quo in prescribing medicines.
Dr. Bernstein is correct. Lantus and Levemir require at least two shots per day. Patients will present with "dead-zone" time periods in the hours leading up to the next '24-hour' shot if the standard once a day protocol is utilized. Doctors will only increase the dose of basal insulin to cover the 'dead-zone' time period. This leads to too much basal insulin earlier in the day. Using any basal insulin in ways that do not cover basal needs appropriately creates a frustrating life of rollercoastering blood sugars. This is no fun for the diabetic or their families.
Thank you Diabetes Health for getting this very important information out there. Make sure this article make it into hard print in the magazine.
Thank you, once again, Dr. B. for trying to open the eyes of those with diabetes and those who treat diabetes.
Dr. Gordon
Interesting! Another reason to be glad that I'm using an insulin pump.
Dear Dr. Bernstein,
Thank you so much for your book, The Diabetes Solution! I was diagnosed with type 2 diabetes 2-3 years ago. Fortunately, I read your book and was able to get my diabetes under control very quicky with diet and exercise. You mentioned that for type 1 diabetics, the purpose of basal insulin, is to prevent blood sugar increases while fasting. As a type 2 diabetic, I probably have too much insulin because my blood sugar tends to drop during fasting. You mention that your "patients who wish to sleep late on weekends must arise after 8-1/2 hours of sleep, take their morning shot of long-acting insulin, and then go back to sleep. This is due in part to the "dawn phenomenon." I seem to be affected by the dawn phenomenon because because my blood sugar is higher in the morning than the night before and contiunues rise, until a sudden drop by mid-morning or noon (during fasting). What causes this sudden drop? If I sleep in late, my blood sugar is lower upon waking than it was on earlier mornings. If I continue to fast, my blood sugar drops into the 60's, possibly even lower, but my body apparently compensates because it fluctuates up and down between the 60's and 80's. If I fast intermittently for several days, all my blood sugars improve drastically, even my postpranial sugars. My glucose tolerance seems to improve, because I am able to tolerate more carbohydrates after fasting than I was before. How do you explain this phenomonen?
I have had type 1 diabetes for 40 years since childhood. I've used Lantus for 1 1/2 years and have found out exactly what Dr. Bernstein recommends, that two small basal injections a day provide better coverage than one larger injection. The same week that I visited my specialist with a HgbA1C of 6.1 and told him I had was now splitting my 24-hr Lantus dose to two 12-hr doses (like when I was on NPH), he stated that I was the sixth patient that week to have made this change.
I was a pump user for 12 years and find that I can provide myself with the same excellent control using both Lantus with a rapid-acting insulin for meals at a much lower cost. Thank you for another good article. Cherie
Dr. Bernstein,
Thank you for your personal observations and anecdotal opinions regarding basal analog insulins. Unfortunately numerous well designed clinical studies fly in the face of said observations. If you have a concern that basal insulins such as Glargine are not lasting a full 24 hour period as claimed, you may want to examine your dosing and titration methodology. Many physicians that report good morning fasting sugars followed by elevated evening sugars somehow neglect to understand that the basal insulin continues to work throughout the day, but the patients' eating habits are not adequately controlled with their prandial insulin injections. If there is any clinical evidence that Glargine does not last a full 24hr period, we all could benefit by examining these data. In the meantime, I recommend your readers look into studies by Bolli, Yki Jarvenin, Rosenstock and Janka to gain a better, and more widely accepted view of the PK/PD effects of Insulin Glargine. Thank You.
I've been taking insulin for nearly 30 years. The past 3 or 4 years I've been wearing a CGMS. I've taken NPH twice daily, Lantus once and twice daily, and Levemir at first twice daily and now once daily. I found that if you take short acting insulin you really need your basal to last 16 or 18 hours. In fact all the better, I can be more aggressive with my short acting insulin at dinner. Usually dinner is my largest meal and it is very hard to take a largest enough dose to cover the carb load of the meal. Not splitting my basal makes this much easier to do.
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