Adjusting insulin

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Hi

So I had a recent appointment and saw a consultant(always someone different) They basically said I need to reduce my insulin because I've been having around 2 to 3 hypos per day. There wasn't much info aside from that, I have a problem of going into appointments and spacing out unfortunately. When I try to contact to clarify what they said I never hear back from anyone until my next appointment which I know is soon going to be much less frequent soon.

I think my basal dose is okay but running out in the evening as I've been going high while sleeping . I asked about splitting the basal dose again but they told me no don't do that. I was exercising in the evening after dinner which brought levels down a bit overnight but they told me to start exercising before dinner instead which means I'm having dinner even later.

Throughout the day with the exception of the odd spike at 15 once a week my post meal levels are okay but tend to come down very fast after 2 hours, then I have to eat a bit or hypo. I'm concerned about reducing the bolus because when I do I get those spikes of 15 which I hate. I do carb count with a ratio but generally have similar amounts at each meal.

Goes like this:

Morning 645am around 7 to 8 bg. Have 4 units to 70g will hit about 10 at peak but 2 hours later drop to hypo or if I can snack in time I'll dodge it . Levels stay steady then until lunch

Lunch 1pm bg between 4.5 and 5.5 have 6 units to 70g . Usually most unpredictable , can get as high as 7 or 13 after. Though I'm seeing trends with certain foods now. 2 hours later same as breakfast , will have snack to keep me going

By the time I get home at 7pm or 8pm depending on traffic I might need a top up before exercise with a snack.

Dinner at 9pm usually 5 units to 90g I've been told to knock off around half the insulin because of exercise. Will peak about 8 bg and drop before bed to 5. Then start to rise soon after. I'm in bed at 11pm

Sorry that was very long winded. I have a number of theories for the evening problem but the day time is a battle. Maybe I'm complaining for no reason but if anyone has any examples of how they went about dealing with steadying their glucose I'd love to hear it. Thanks again for all the support I've got on this since joining !
 
The peaks and then hypos suggest to me that you are using too much bolus insulin but not injecting it long enough before you eat.
Which bolus insulin do you use and when do you inject it? As an example, They generally recommend 15-20 mins prebolus time for NovoRapid I believe but at breakfast time I experimented by increasing that by a few mins each day and found that I needed to inject it over an hour before eating breakfast inorder to avoid spiking up to 15 and then crashing back down later which really isn't a nice feeling. Do you have Libre? If so, it makes it easier to see when the insulin is starting to kick in and then start eating, but try increasing that pre-bolus time by 5 mins each day and see if that starts to improve it.
I should say that I only needed to prebolus 20 mins in advance of other meals but breakfast took a ridiculous amount of time due to working against Dawn Phenomenon/Foot on the Floor syndrome. I now use Fiasp which is slightly quicker but I still need 40-45 mins pre bolus time at breakfast and 15 mins the rest of the day. This is unusual but there are other people who need a similarly long prebolus time and some who would hypo after 15 mins, so you need to carefully adjust it and see what works for you. You might be best to reduce your bolus first for a few days to stop the mid meal hypo and then slowly experiment with reducing the spike once you find the right dose that stops you from hypoing and brings you back into range by the next meal..... So adjust the dose first and then work on eliminating the spike by adjusting the prebolus time.

Which basal insulin do you take and when do you take it and how many units?
 
Yes, how far in advance of your meals are you injecting @jazzchicken ? I found if I injected earlier, I not only reduced any spike but could also have less insulin (which helped stop me going low later).

For appointments, don’t be afraid to take in pen and a notepad and write things down. They should wait for you to jot down notes if you need to. Your consultant letter will also briefly cover the points made.
 
@rebrascora using Nova rapid , I inject between 20 to 25 minutes in the morning, between 15 to 20 minutes at lunch and 10 to 15 minutes at dinner. The later in the day it is , the quicker I seem to hypo. That's been the issue with timings, I have the libre and keep an eye when levels begin to drop after taking insulin. Especially when I wake when I want my levels to drop a bit before eating. It definitely seems as though I'm using too much bolus but it's also difficult to increase the timing. I take it you would recommend concentrating on one meal at a time then move to the next ?

I take levermir for basal, once every night around similar time which is before bed. It's 6 units at the minute. Started at 12 but they recommended reducing over time due to hypos and overnight lows, but I'm convinced it's the bolus causing the issues. Last two consultants spoke about another type to try but always say we'll wait and see.Not sure if I have to come out and say I want to change to another now.

Thanks
 
@jazzchicken Never be afraid to advocate for yourself eg if you want to try a different insulin. If I’d just let them do their thing I probably wouldn’t have a pump and would be a lot worse off. I’ve found you really have to be a bit ‘pushy’.

‘They’ can’t stop you splitting your Levemir as long as you know what you’re doing. When I was on injections, no-one told me to split my basal but it was obvious it needed doing, so I did it, always erring on the side of caution and starting off with less than I thought I’d need.

I remember ‘talking’ to you before, but I can’t remember if I recommended books about Type 1. There are a couple of good ones if you’re interested and if they’ve not been mentioned.
 
The thing about levemir, is that it really doesn’t last 24 hours, and the smaller the dose, the less long it lasts.So I suspect it it’s running out long before bedtime, and you’re relying solely on bolus to keep control during the afternoons and evenings, which is why you are finding it so hard. Have you tried basal testing? If not, have a look at how you do it (I’ll look up a link in a mo) and see if it’s holding you at all steady.
Edit. There’s a pdf of basal testing on post #4 of this thread.
 
@Inka I did take notes at the beginning but noticed I was spending an awful long time there. Could tell they wanted to get to other patients which is understandable. I'm quite an anxious person which doesn't help. I have access to a patient portal but they don't seem to put up notes until they send the letter out, so just waiting.

As mentioned above the timings change throughout the day
 
I’d start with one meal at a time and experiment with gradually moving your bolus forward 5 mins at a time @jazzchicken I found it takes a few days to experiment with each time move - ie 5 mins earlier for 3 days and then make a judgement whether to move forward again.

FWIW, as you’re probably in the honeymoon period still, I don’t think your numbers are bad. The honeymoon does give ups and downs in blood sugar.

Edited to add that if you had some Levemir in the morning too that might help with your spikes.
 
jazzchicken said:
I take levermir for basal, once every night around similar time which is before bed. It's 6 units at the minute. Started at 12 but they recommended reducing over time due to hypos and overnight lows, but I'm convinced it's the bolus causing the issues. Last two consultants spoke about another type to try but always say we'll wait and see.Not sure if I have to come out and say I want to change to another now.
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You are on a very low dose of Levemir and it's known that the lower the dose per kilo of body weight the sooner it will run out. However, the highs at night are unlikely to be caused by your Levemir dose as you are taking it directly before bed. Have you ever done a basal test to see what exactly your Levemir is doing and whether it's holding you steady all day? If your basal is wrong then it's virtually impossible to get your boluses right. I attach instructions of how to do a basal test. Hope this helps 🙂
 

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@jazzchicken regarding taking notes and the like, you could ask if you can record the appointment on your phone to play back later. They should be happy with you doing so.
If there wasn't a pandemic, I would suggest bringing a friend/partner with you to take notes and listen on your behalf but I think they are reluctant to have extra people in the room at the moment.
 
@Inka think I've just been frustrated from them telling me oh we could try this at some point but not now. I would have thought between two appointments if nothing has changed then something has to change. I think you might have suggested some books, I can't remember sorry. I was in a book shop not long ago just out of curiosity and found most are aimed at type 2 or preventing diabetes. Though I'm sure there are plenty for type 1. I get lost a bit reading online , alot of info out there.

I'll give the adjustments a go, just bit weary of it. I might say to them again anyway that I'd like to try splitting my basal dose. Consultant was just pretty firm on now changing anything yet.
 
@Robin yes I've been told this a few times now and when I told two different consultants they said no it lasts 24 hours, although they admitted sometimes it can be split.

I tried a one off basal test for the morning time to find a rise around 1.5 and then dropping 1 before lunch. But I know I have to do this several times to confirm. I'll check out the link you provided, thanks !
 
@Pattidevans I thought maybe the levermir was just taking a while to kick in. What I'm seeing is an initial rise an hour into sleeping and then it stays roughly that level through the night which makes me think the levermir is kicking in then to stop any further rise. Could be the initial rise is from my meal earlier ? Not sure. Thanks for the pdf!
 
@helli I had thought about recording audio but nervous to ask. Is this something you have done or known others to do ? My partner was going to tag along for the last one but she thinks I need to figure this out myself and she is right about that I don't disagree. She says she will go to the next one.
 
jazzchicken said:
@helli I had thought about recording audio but nervous to ask. Is this something you have done or known others to do ?
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It is definitely something I have seen advised to others. There is no reason why you should feel nervous to ask ... but out of courtesy, I would ask rather than just doing it.
 
Anyone else able to try download that basal testing pdf? Not working for some reason
 
Must be something wrong with my phone. Thanks for the screenshot 🙂
 
jazzchicken said:
@Inka think I've just been frustrated from them telling me oh we could try this at some point but not now. I would have thought between two appointments if nothing has changed then something has to change. I think you might have suggested some books, I can't remember sorry. I was in a book shop not long ago just out of curiosity and found most are aimed at type 2 or preventing diabetes. Though I'm sure there are plenty for type 1. I get lost a bit reading online , alot of info out there.

I'll give the adjustments a go, just bit weary of it. I might say to them again anyway that I'd like to try splitting my basal dose. Consultant was just pretty firm on now changing anything yet.
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Here are two two great books about Type 1

Think Like a Pancreas’ by Gary Scheiner.

And Type 1 Diabetes in Children Adolescents and Young People by Ragnar Hanas (ignore the title - it’s great for adults too)

Browse, dip in - I find it’s helpful to have books on the shelf to refer to.

When I have a break from my pump, I use basal insulin in small doses and find it noticeably runs out at around 11 hours, so in my opinion one daily Levemir at such a small dose isn’t going to last you 24 hrs.
 
They didn't change me to split dose until the weekend before my DAFNE course and that was deliberately timed presumably so that they can help you find the correct doses and split on the course.
 
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