Switched Bolus and Having Issues

[Michele01]

Basal test is done for the night as you can use your Libre (no sleepless night) 🙂
Morning test take basal as normal
Skip breakfast as long as you are in range (not hypo or need a correction dose as out of range)

Next day have Breakfast as normal.

Skip lunch and have evening meal as normal.
Following day skip evening meal and see how it goes.
This way you should get a reasonable idea as to what is going on.
There are loads of peeps on here who can help out and see things you can't. (those pesky trees are a pain) 🙂

It's a slow frustrating process but it can be done and at the end of the day less hypos and you will feel a lot happier and healthier. 🙂

Thank you so much - this makes sense to my confused brain!

Now I have a few questions on this please. I never eat breakfast. Normally when I open my eyes in the morning if I'm in range (which is most of the time), I either don't take any bolus OR I take a correction dose to get me in range but of course I inject with basal. IF however I wake up with a hypo and have to correct I need to abandon the test for that day OR would it be okay to do the test at lunchtime (which would be approx 6 hours later)?

So because I never eat breakfast, I'm guessing I will have to try to calculate by skipping lunch. From what you've written, I wouldn't take any bolus and hopefully if the basal is right, my levels should be holding without too much dipping or rising? If basal is wrong I'll see swings and this will be when I need to rethink the amount. Do I correct at that point? So for example, if I see it going from 6-10 do I take a few extra units of basal to correct OR do I wait for the evening basal? I'm assuming I correct but carefully and then the following day see if a slightly higher (or lower) amount keeps me stable?

So second question (just thought of this one) .......... I take my 2nd basal at the same time as I have dinner so I'm guessing I would take the basal but just not eat (until morning or if I get a hypo and need to correct). Is that right please?

I'm so sorry to ask so many questions but I feel that you've all been of enormous help and I've learned more today than in the past 7 years or however long it's been!

Thank you from the bottom of my heart x

 

[rebrascora]

So pleased you managed better tonight and are feeling happier about managing things going forward. We all totally understand the frustration when levels are unstable and nothing seems to work as it should. It happens quite regularly to most of us but the more experienced you get, the quicker you spot it and figure out a strategy to fix it. Sometimes when life is chaotic you are so busy doing every day stuff that you don't stop to really think about what is going wrong with your diabetes management and you end up just fire fighting it as best you can, but you soon learn that a bit of time spent sorting your diabetes out, makes the rest of life so much easier. Experimenting and becoming the expert in your own diabetes is key, rather than relying on general guidance from HCPs which may or may not apply to you and your body.

I don't think it is an exaggeration to say that I find it is "bliss" when my basal insulin dose is correct. It is like a great weight is taken off my shoulders because everything suddenly needs less micromanaging and my diabetes behaves reasonably predictably and I don't have to keep my eye on things every 5 mins or get caught out with a hypo when I take my eye off the ball and need to drive somewhere for an appointment or come out of the supermarket and get stranded in the car park for an hour waiting until I can legally drive home with my dairy produce cooking in a hot car.
It is very easy to underestimate the mental toll that diabetes takes on you because of the relentless nature of it and not just in relation to food, but all manner of other aspects of life where we need to take it into consideration when we want to do something or go somewhere.

Now I have a few questions on this please. I never eat breakfast. Normally when I open my eyes in the morning if I'm in range (which is most of the time), I either don't take any bolus OR I take a correction dose to get me in range but of course I inject with basal.

Not sure if this is a typo but you would only ever correct with bolus insulin. ie your NR or Fiasp not basal insulin, ie your Levemir

So for example, if I see it going from 6-10 do I take a few extra units of basal to correct OR do I wait for the evening basal?

Again, you seem to be suggesting that you would use basal insulin to correct when you would actually use bolus insulin (NR or Fiasp) to bring you down not Levemir. Obviously that correction would suggest that your basal insulin which covers that period may need increasing the following day but that would be a dose adjustment not a correction which is achieved using Quick Acting (QA) insulin to have a relatively immediate effect.
If you have been using basal insulin for corrections then that could be another reason why your levels don't make sense.

 

[Pumper_Sue]

Thank you so much - this makes sense to my confused brain!

Now I have a few questions on this please. I never eat breakfast. Normally when I open my eyes in the morning if I'm in range (which is most of the time), I either don't take any bolus OR I take a correction dose to get me in range but of course I inject with basal. IF however I wake up with a hypo and have to correct I need to abandon the test for that day OR would it be okay to do the test at lunchtime (which would be approx 6 hours later)?

So because I never eat breakfast, I'm guessing I will have to try to calculate by skipping lunch. From what you've written, I wouldn't take any bolus and hopefully if the basal is right, my levels should be holding without too much dipping or rising? If basal is wrong I'll see swings and this will be when I need to rethink the amount. Do I correct at that point? So for example, if I see it going from 6-10 do I take a few extra units of basal to correct OR do I wait for the evening basal? I'm assuming I correct but carefully and then the following day see if a slightly higher (or lower) amount keeps me stable?

The idea of basal testing (levemir) is you inject that as normal. This way you know it is holding you steady when you decide not to eat.

So inject your Basal as you normally do.
If you are hypo abandon the test. Basically you know your basal is wrong if you are hypo.
So skip it until the following day. After reducing your basal at bedtime do the test again the next day.
Same again if to high but you must use NR to correct not your Levemir.

Any basal testing needs to be done at least 5 hours after your last injection of NR so it is out of your system and doesn't then interfere with the results.

I don't eat breakfast either so I just skip lunch when I need to test lunch time basal.

So second question (just thought of this one) .......... I take my 2nd basal at the same time as I have dinner so I'm guessing I would take the basal but just not eat (until morning or if I get a hypo and need to correct). Is that right please?
Most people take their basal at bedtime, so something else to think about so things are smoother for you.
I'm so sorry to ask so many questions but I feel that you've all been of enormous help and I've learned more today than in the past 7 years or however long it's been! How do you learn if you don't ask, the info we are giving you is passed on learnt from other forum members. This then enables you to do the same in the future 🙂

Thank you from the bottom of my heart x

 

[everydayupsanddowns]

IF however I wake up with a hypo and have to correct I need to abandon the test for that day

Yes hypos are frustrating, because their capacity for mangling results later and/or the liver getting all twitchy means that any hypos in the previous 6 hrs mean you should abandon the test.

This from the mySugr basal test instructions:

Preparation​

As you prepare, there are a few things you’ll want to keep in mind:

• The starting sugar should be between 90mg/dl - 180mg/dl (5-10 mmol/l).
• The test should only be performed when glucose levels are stable. (for CGM and FlashGM carriers: horizontal trend arrow)
• No meal and insulin administration
  → in the last four hours when using a short-acting analog insulin.
  → in the last six hours when using a normal insulin.
• Last meal before the test should be low in protein and fat.
• No values below 70 mg/dl (4 mmol/l) at least six hours before
• No unusual sporting activity 12 hours before
• No alcohol 12 hours before
• Ensure physical well-being (no strong stress, no infections, fever...)
• If your blood glucose levels fluctuate before menstruation, it is better to perform the basal rate test after menstruation.

 

[Michele01]

@rebrascora and @Pumper_Sue can I just say thank you thank you thank you to you both for hanging in there with me yesterday. You REALLY helped me and I feel so much better and in control now.

Just to reassure you both, I never correct with Basal (Levemir). I'm afraid that my dyslexia often mixes up words that are similar and frustratingly bolus and basal are similar words! Grrrrrrr!

So things I've learned overnight:

1. My evening basal of Levemir needs a bit of tweaking. I had a hypo at 4am (actually the Libre2 said 3.8 but the finger prick was 4.2 but I could see the trend was heading downwards). So I took 4 glucose tablets and remained stable for the rest of the night. I had taken 12u Levemir just after my evening meal (bear in mind I used to take 24u when I went to bed a month ago!) but it is wearing off by the time I get up (which makes sense because it's around 12-13 hours which means I open my eyes, my level is ok but then within half an hour of getting up it's starting to rise sharply. So what I'm going to do is reduce the dose to 11u tonight but take it a little later in the evening - so between my evening meal and bed time. Hopefully that will sort out the hypo and be ok when I'm waking. II'll rinse and repeat every night until I find my sweet spot and keep an eye on it!

2. Fumbling around in the dark, finger pricking was an experience! lol Let's hope I don't have to do too many of those!

3. Today I am going to do my basal test omitting lunch. I think I'll be ok because if lunch is normally at 1-2 o'clock, I'll fit into all the parameters posted by @everydayupsanddowns (thank you). Until I free myself of night time hypos, falling into the category for daytime basal testing is a bit more challening but as I eat a late lunch I'm hoping I'll get a fairly accurate picture. Late afternoon is when I can get a hypo (if I'm going to get one) so I've reduced my basal this morning by 1u (from 19u to 18u) and will see where that takes me! I've had to correct my early morning high with some bolus but that should be out of my system and in the parameters mentioned above!

Wish me luck and thank you all again for sticking with me!

 

[rebrascora]

Sounds like a great plan and you really seem to have grasped the issues very well. I want to give your post multiple "likes" because I am so happy for you!

Sometimes that morning rise in BG caused by Dawn Phenomenon or Foot on the Floor syndrome, when the liver pumps out extra glucose to give you energy to start your day, is just too much for your Levemir to cope with and you may still need to inject a bit of NR or Fiasp when you first wake up to counteract it, but shifting the timing of your evening Levemir back a bit may well help to mitigate it, so that is a sensible first step. It is not so much that your Levemir is running out then, although it does tail off a little, but that your body's need for more insulin at that time of day increases. It is similar with the 3-4am dip. It is natural that you need less insulin in the deepest part of your sleep where the brain is at it's quietest and your body is resting. The key is to find the Levemir dose which keeps you at a safe level at that time of night and then if necessary tweak your levels with Bolus insulin to cope with highs at other times, like in the morning when you wake.

Once or twice daily basal insulin injections are only ever a crude tool to get a "near enough" fit compared to the body balancing levels when you have a fully functioning pancreas which secretes tiny amounts of insulin all the time in response to BG levels. I love my Levemir for the flexibility it provides compared to some of the longer acting, once daily basal insulins, but I still need to use quick acting insulin to help it out here and there because it can't provide the perfect profile of insulin release for my body's needs, but with the help of Libre it enables me to get 90+% time in range most of the time with a little help from Fiasp.

I am sure you will find a "best fit" with your Levemir doses now that you have the information and knowledge that you need but please push for a DAFNE (or local equivalent) course as it really will help you. I believe they are starting up again in person here in the North East... not sure about other areas.... so get your name down for one. Not only is the course input really helpful but just spending a whole week with other diabetics and exchanging thoughts and experiences and frustrations and learning from each other is invaluable. It gives you a huge insight into just how variable diabetes can be and it can also provide a peer support network for after the course ends.

Good luck and keep us updated with how your experiments go.

 

[SB2015]

Hi @Michele01

So glad you have been safely in the hands of @rebrascora and @Pumper_Sue to make sense of all that has been going on. Although you say you have not Had access to an education course, you certainly have got your head round things. Having done that it is so frustrating when our diabetes just doesnt behave.

As @rebrascora has said the Dawn Phenomonon is pretty common. I know that once I am up my leveks just start to rise and can go up by as much as 4 In a short space of time. To counter this I Add in a bit extra at breakfast, and bolus before I get out of bed, shower then breakfast so the the anarchic has got going before the rise. This takes a bit of trial and improvement to work out what works for you, as with so many things related to D.

I tried Fiasp for six months and it did mean I could shorten my pre-meal bolus time, but for me I ended up with issues around the sites. Eventually the benefits were not enough to outweigh skanky sites.

Keep in touch and let us know how you get on.

 

[Michele01]

UPDATE!

@rebrascora @Pumper_Sue and @SB2015 thank you again for your responses. I thought I'd give you a really positive update!!!

So I spoke with my Endo team on Monday and they looked at my Libre2 graph and agreed that I needed to go back to Novorapid! So I'm now back on it and soooooooo happy!

I have actually managed to reduce the spikes before meals CONSIDERABLY by injecting 30 minutes before eating. This is something I've never done before and the difference is phenomenal. I'm hardly spiking at all - even with a dinner that beforehand would have given me a large spike! I barely get above 9 or 10 now which from where I was (18 or thereabouts) is nothing short of amazing! Thank you to you for suggesting I do that.

I did a basal lunchtime test yesterday (had to abandon it after I went hypo at 4pm) but am in the middle of doing it again today after reducing my basal by 1u this morning. It's looking really good and stable so I'm pretty sure my daytime Levemir is right now. Also, I reduced my evening Levemir by 1u last night and no hypo and reasonably straight line (a few minor bumps). It does seem to be wearing off earlier than I get out of bed so I am having the early morning highs that I need to correct with bolus but now I know that's pretty common I am not quite so worried about it.

Lastly I asked my Endo about the DAPHNE course but they are not doing them in my area at the moment (I'm assuming because of Covid) but they mentioned BERTIE which is an online course so I'm going to do that later in the week.

So all in all, I'm much much much more positive and with your help I've got things firmly back in control again now. I can't tell you how much I appreciate it. Thank you.

 

[rebrascora]

Absolutely delighted we were able to help you make a few little tweaks to sort things out. It's funny how something so simple can make such a massive difference both physically and mentally.
Please don't forget to come back and ask for help if you get into difficulties again. The combined knowledge of people here on the forum means that there are literally centuries of lived experience and shared best practice. Most of the difficulties you will come across have already challenged other people here and strategies figured out to deal with them.

Pleased you are going back to NR. I am at last settled with my Fiasp now but it has taken me about 7 months to get to grips with it and this is my second attempt. Not sure I would want to go back to NR now but not sure the benefit of Fiasp has been worth the upheaval of getting used to it. For me it just isn't significantly faster, it's just not quite as slow as NR! I am learning to be less impatient!.....Maybe that is what has taken me 7 months!!

Anyway, good luck from here on in. Hope you get some smooth sailing with your diabetes now.

 

[Pumper_Sue]

It does seem to be wearing off earlier than I get out of bed so I am having the early morning highs that I need to correct with bolus but now I know that's pretty common I am not quite so worried about it.

I'm so pleased you are feeling more positive and your numbers are so much better.

Just a suggestion regarding your basal wearing off have you actually moved it forward by an hour or two to see if that makes any difference?

 

[SB2015]

Thank you so much for the update, with such a positive outcome.
Keep in touch and let us know how you get on.

 

[Inka]

I have actually managed to reduce the spikes before meals CONSIDERABLY by injecting 30 minutes before eating. This is something I've never done before and the difference is phenomenal. I'm hardly spiking at all - even with a dinner that beforehand would have given me a large spike! I barely get above 9 or 10 now which from where I was (18 or thereabouts) is nothing short of amazing! Thank you to you for suggesting I do that.

Yep, the difference is amazing, isn’t it? What I don’t understand is why your team didn’t suggest that to you rather than switching you to FiAsp. I’m glad you got it sorted. Sometimes the best answer is actually something rather simple 🙂

 

[helli]

Yep, the difference is amazing, isn’t it? What I don’t understand is why your team didn’t suggest that to you rather than switching you to FiAsp. I’m glad you got it sorted. Sometimes the best answer is actually something rather simple 🙂

Probably because they don't live with Type 1 diabetes 24 hours a day, 7 days a week, 52 weeks of the year.
They see the results months after making a suggestion so I guess they don't always realise what works ... or what is worthwhile trying.
That's the value of fora like this 🙂

 

[trophywench]

Tee Hee! - they are all too young to know that pre-bolusing was an absolute requirement with older insulins. You ALWAYS injected your 'main meal' bolus approx. when you lit the gas under the spuds ! - so approx 20-30 mins before you plated the meal.

@Michele01 - The BERTIE online course, once you've registered on the site to do it, you don't have to do all of it in one go - just do it a bit at a time and take as long or as short a time as you want!