A good meeting with DSN today....

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Robster65

Robster65

Senior Member
Relationship to Diabetes
Type 1
We finally got to see our local DSN this afternoon who was very helpful and seems to know what she's talking about (hurrah!).

Nothing is happening until after the 15th, but then it's all change, one step at a time.

My basal (lantus) is way too low compared to everyone else's. I'm down to 12 units compared to total humalog of about 40 units/day. She's going to start by moving my lantus from evening to morning to isolate it's effect from the humalog.

Then we go see her again and she will start playign with doses. We also have her phone number for any queries.

She mentioned pumping as an option if we can't sort things out. She also suggested maybe splitting the lantus, which I winced at, but whatever it takes.

I asked about CGM and she said they hadn't had very good results with it but they have one, which is good to know.

The biggest surprise was with injection sites. I was taught back in the stone age that your thighs were slower to release insulin than arms, and the abdomen was quicker still. A few years ago, I was told this was no longer relevant, so I ignored it.
She told me that thighs and buttocks should be reserved for basal because they are too slow releasing for the bolus. ie. if you inject bolus into thighs, it will take maybe 30-40 minutes to build up in the bloodstream, so I need to inject humalog in arms and abdomen only.

If I think of any more factoids we discussed, I'll post up but that was about it I think. But good to be back into the world of knowledgeable DSNs. 🙂

Rob
 
hey robster that is great news its always good to hear of good DSN what a releif for you and now for the fine tweeking eh ...and a suggested pump ! good luck to you I know how hard you and your partner have been working on this X🙂🙂
 
Glad it all went well great news good luck for the 15th.
 
Glad you had a good meeting with your DN, always helps! I'm lucky in that I have a good DN too, the hospital clinic/consultant is appalling so DN indispensible!

Like you, I'm only on 16 units of Levemir compared with roughly 52 units of Novorapid, trying to sort that out at the moment - probably going to need to split the levemir into 2 doses, tried to avoid it but am having to do extra injections anyway so might as well if it helps!
 
Hi Rob, glad to hear that things went well. I'm a bit confused as to why the lantus is thought to be wrong though. I'm currently on 3 lantus and about 30 novorapid a day, so my 'split' is nowhere near the 40/60 split they often suggest - in fact I'm taking even less than you as a proportion of my total daily dose!

If I had more lantus I'd be hypoing left right and centre - what I have works, so I wouldn't consider altering it to suit some general formula. Of course, if yours isn't working for you then it may need changing, but just wanted to say that it's far from unusual to have such a disproportionate split and to be a little wary of being compared to 'most other people'.
 
Robster65 said:
We finally got to see our local DSN this afternoon who was very helpful and seems to know what she's talking about (hurrah!).

Nothing is happening until after the 15th, but then it's all change, one step at a time.

My basal (lantus) is way too low compared to everyone else's. I'm down to 12 units compared to total humalog of about 40 units/day. She's going to start by moving my lantus from evening to morning to isolate it's effect from the humalog.

Why is she getting you to do some fasting tests, to see if your Lantus is correctly set, there isn't any need really to separate the effects of humalog from Lantus

Then we go see her again and she will start playign with doses. We also have her phone number for any queries.

Why is she playing with them, fasting test will show if your dose needs changing, and give a dam good indication what adjustments to make

She mentioned pumping as an option if we can't sort things out. She also suggested maybe splitting the lantus, which I winced at, but whatever it takes.

Again a fasting tests will show whether or not you are likely to benefit from spliting your lanuts.. Two reasons for splitting, the lantus isn't lasting 24 hours, or you have totally different needs of lantus for morning and afternoon, the split will the enable separte adjustments to cover each period


I asked about CGM and she said they hadn't had very good results with it but they have one, which is good to know.

The biggest surprise was with injection sites. I was taught back in the stone age that your thighs were slower to release insulin than arms, and the abdomen was quicker still. A few years ago, I was told this was no longer relevant, so I ignored it.
She told me that thighs and buttocks should be reserved for basal because they are too slow releasing for the bolus. ie. if you inject bolus into thighs, it will take maybe 30-40 minutes to build up in the bloodstream, so I need to inject humalog in arms and abdomen only.

Not strictly true, much depends on the exercise you'll doing, intensive thigh usage will bang around the insulin very quickly, hence why people can struggle injecting basal insulin into thighs, as to where you inject humalog, well anywhere you need to find where all suits you

If I think of any more factoids we discussed, I'll post up but that was about it I think. But good to be back into the world of knowledgeable DSNs. 🙂

Rob
Click to expand...

I would ask your DSN to send you on a carb counting course, so you learn how to adjust your own insulin for foods you eat, exercise and also when and how to adjust basal insulin etc from you BG data you collect..

Sorry to disagree...
 
Thanks all. Sarah has worked harder on it than I have and is the reason I'm pushing forward.

She did acknowledge that some people are on the sorts of ratios we are on and that it may end up suiting me, but she wants to make sure we consider everything from scratch, and that it would be a bumpy ride ! 🙂

She wants the lantus isolated so she can see how that's operating, then we'll review the doses if it isn't working right. The suggestions and possibilities she made were largely in line with speculations I've made myself over the weeks from things posted on here, so I'm confident she knows her stuff.

What we're doing at the moment isn't working well unless we adjust frequently (lots of lows in evening), so we're just happy someone is paying attention tbh ! 🙄

Rob
 
Hi Ellie.

No prob with questioning. I did query some of what she said and I'm reserving judgement on some of it.

It's been a long, long time since I made any reasoned changes so a lot of what I 'know' may well have been disproved since then, as has been borne out by some of the posts on here.

She did say that splitting the lantus would only be if it wasn't lasting. A fasting test may well be on the cards, although I hate doing them and her nearest clinic (she covers 2 or 3 hospitals/clinics) is about 30 minutes drive away.

One thing that did make us smile was, if the GP's argues about giving us a lot of test strips, she'll speak to them and back us up. Whether they will argue and wether they'll take any notice of her remains to be seen.

But things are very much open to all options and suggestions at the mo, so until we've tried what she suggests, I'm happy to give her a fair crack of the whip.

Rob
 
Assuming that you are injecting Lantus in the evening, it's likely that your lantus is making the distance.. a split dose might be helpful still, so that you could lower the basal for the evening, but keep a increase for the morning period, so you would effectly take a larger dose at night, and the smaller dose in the morning...

If you are having hypo's, to me this would suggest that your carb-insulin ratio's as you are swiming in insulin.. Assuming that your basal is correct, and the only way to find this information is the good old fashioned fasting test..
 
I think the lantus is lasting more or less.

post meal rise is about 5ish as an average after a couple of hours, which we're happy with, but then an hour or two later the BS is crashing, which may be the humalog over reaching. I suspect that I'm having to give a large bolus to bring down the meal spike, but it's too much for the next couple of hours. so is extending the effect. Sort of.

This is why she wants to isolate the effect of the lantus by injecting it in the morning which will show up in the morning BG. She wants to aim for ratios of about 1 unit to 10g from what I remember, which may not happen but she sees a lot of patients and I trust her methods so far. I will, however bear in mind all that Ive learnt from here and the past 32 years. When she stops making sense, I won't make changes until I'm happy with the methods and aims.

Rob
 
Hope you get things sorted out. I just calculated my insulin out and I'm on 17u total levemir and 18 total humalog so yet another variation. We are all different so what works for one wont be any good for someone else. Don't know if I've already mentioned it to you but I've just changed from once a day lantus to a split dose of Levemir. Works brilliantly for me, another possible option maybe.
 
Cheers Flutterby. Splitting doses was mentioned as a future possible, but not switching to Levemir.
My last insulin change was when I went onto lantus and humalog sometime before the last ice age. I wish I could remember when I switched, but it must have been late 90s sometime. I had to stay overnight in hopsital if I remember just while the doses were adjusted.
Novopen 1ml silver but I can't remember what pen I had for the lantus.

Ah happy days.

ROb
 
Me too! I'd still be on Lantus but I got admitted due to a stroke and the diabetic team came visiting! They asked whether I was happy with control and I said "no" so basically they got me all the stuff and said split it 50/50 to start with and left me to it! Bit different from years ago - as you say a hospital stay was involved. They told me my local team would be in touch but so far nothing! I'm not bothered, can sort it myself anyway but it's a lot more stable than the lantus. I'm amazed by it to be honest. Good luck anyway with whatever changes you make.
 
Thanks flutterby, and all others.

It'll be interesting if nothing else. 🙄

Rob
 
Glad to hear you had a good first visit. To me it sounds like there could be a timing issue with the evening meal dose. I don't know if you have considered this, to try to get the insulin peak and food peak to match better
 
Hi nikki.

It's something we can consider as we go along. I want to try one thing at a time and see what effect they all have. I'll throw it into the mix when we next see the DSN.

Rob
 
They don't do one in this authority's region. They do in a neighbouring one but I would need a referral to it and there's a waiting list longer than Santa's present list.

The other DSN in the area has done a DAFNE type course and would be able to take us through the necessaries as and when but I guess it will be a wait for that once we're up and running properly.

Rob
 
Crashing out swimming insulin....

The profile for humalog is about 10-15 minutes to start working, peaking at about 2 hours mark, by this time you've used about 80% of the dose given, the remain 20% will have some effect tailing as it tails off over the next 2-5 hours...

1 unit of insulin - 10g of carbs is only a starting point, it may well change throughout the day..

How much difference does what time you eat make to your control.. Say if you eat tea at 5pm you crash out, but if you eat tea at 6,30pm then BG remains much more stable??

As it could be that you have quite a difference in the basal profile, between the top of the highs, and the bottum of the troughs.. So you end up at one point being at the botttom of the top of a high, the quick isn't enough to keep BG stable, then when you start going into the trough the background insulin starts working with your quick and you'll swimming insulin.. Hence the crash..

Must admit it be interesting to see how it does work out..
 
Hi Ellie

We hear what you are saying :D The time we eat our evening meal seems to make diddly squat diffrence to evening levels, can start at same level before a 6:30pm evening meal as at a 5pm and still by 10:45 levels are crashing into the 3's.

There's even an odd fantastic night where all's looking great only for me to get woken by a need to test. I don't enoy seeing the "LO" come up on the meter anymore than Rob enjoys being that lo :(

Rob has got an exam coming up which I know will send levels rising and so at least we'll get a bit of sleep till then (sarcastically said as I know highs are as bad as lows) Once the exam is over we can start the testing and work with the DSN, it may turn out she's c**p and we go back and try other methods but as we live in the middle of nowhere where even a bin lorry can not get too I would rather and I think Rob will agree that for now it's best to go with what they are saying. If we start messing and things go wrong it may well need Prince William to come help us out 😱


Again Many thanks for everyones thoughts and ideas.

Sarah x
 
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