advice please

[bridge]

Hi everyone
Could I have advice please. Anyone else use Tresiba and humalog? Can't get my readings down sometimes and everytime I am advised to increase Tresiba by one unit, I go hypo around 2am. I am so sensitive to small amounts and only take 10 units of tresiba in the morning. I should be an expert now after 30 years but no...!!

 

[Inka]

Hi @bridge 🙂 Have you done a basal test to check it’s the Tresiba? And have you tried swapping to a more flexible twice daily insulin?

Is there any particular times you’re going high?

 

[rebrascora]

If you only use relatively small doses, a half unit pen might be helpful for the Tresiba but personally I would be asking for a more flexible (shorter acting) basal Like Levemir which can be taken twice a day and adjusted to match your body's basal needs more closely. For instance I need a lot of basal during the day but very little at night, sometimes none if I have been very physically very active for 2-3 days, so I currently take about 20 units of Levemir in the morning, usually an hour before I get up (I set an alarm, inject and go back to sleep without getting out of bed) and anywhere between 0 and 7 units on an evening, usually at bedtime. Sometimes I get spells where my levels start to rise in the evening so I take it at 7pm instead of bedtime (11pm ish) to deal with that. Being able to adjust the timing and the doses independently for day and night and get real time results rather than wait 3 days to see the full effect of any changes is also a big bonus and means that I can dial my evening dose back if I have had a very active day or done a lot of exercise and notch it back up the next day if I have been more sedentary or if I am ill or injured.
I love Levemir for providing that flexibility and cannot imagine how I would cope on Tresiba with such a disparity between day and night time basal needs.

 

[Proud to be erratic]

Hi everyone
Could I have advice please. Anyone else use Tresiba and humalog? Can't get my readings down sometimes and everytime I am advised to increase Tresiba by one unit, I go hypo around 2am. I am so sensitive to small amounts and only take 10 units of tresiba in the morning. I should be an expert now after 30 years but no...!!

Tresiba, was 10 units; recently went to 9 and nudged back to 9.5 daily at 8am with the shift into summer weather. But my bolus is Novarapid.

Changed from Levermir 2x daily, several months ago, when I had no identifiable stability. I'm finding the Tresiba way better, it's optimised to give me steady nights and I use my bolus to adjust as necessary by day.

 

[bridge]

Hi @bridge 🙂 Have you done a basal test to check it’s the Tresiba? And have you tried swapping to a more flexible twice daily insulin?

Is there any particular times you’re going high?

Hi Inka thanks for your reply. Yes it seems that it is the Tresiba as I dropped from glucose of 10 to 4 at
2 am the other night and I had no fast acting insulin on board, had not done exercise that day and had not had any wine!
The highs are particularly after meals (usually breakfast). I try to inject 20-30 minutes in the morning before I eat and that sometimes helps. Sometimes I just tend to run in double figures (although I am talking 10-11's) not massively high. This was why my DSN suggested increasing Tresiba but due to the drop in the night (although it didnt happen last night??) I always end up going back from 10 units to 9. I am frustrated. Also, going through menopause which doesnt help!!

 

[bridge]

If you only use relatively small doses, a half unit pen might be helpful for the Tresiba but personally I would be asking for a more flexible (shorter acting) basal Like Levemir which can be taken twice a day and adjusted to match your body's basal needs more closely. For instance I need a lot of basal during the day but very little at night, sometimes none if I have been very physically very active for 2-3 days, so I currently take about 20 units of Levemir in the morning, usually an hour before I get up (I set an alarm, inject and go back to sleep without getting out of bed) and anywhere between 0 and 7 units on an evening, usually at bedtime. Sometimes I get spells where my levels start to rise in the evening so I take it at 7pm instead of bedtime (11pm ish) to deal with that. Being able to adjust the timing and the doses independently for day and night and get real time results rather than wait 3 days to see the full effect of any changes is also a big bonus and means that I can dial my evening dose back if I have had a very active day or done a lot of exercise and notch it back up the next day if I have been more sedentary or if I am ill or injured.
I love Levemir for providing that flexibility and cannot imagine how I would cope on Tresiba with such a disparity between day and night time basal needs.

Hi Barbara thank you so much for your reply! I agree that a half dose might help but Tresiba does not come in a half unit pen. I have been thinking about the possiblity that Tresiba is not the best for me but I think I originally went on to it to help with the high number of hypos I was experiencing but I can't remember the details. I think I have actually used Levemir in the past and agree it may be an option. I do a lot of exercise - pilates, yoga and some running.
Thank you again x

 

[bridge]

Tresiba, was 10 units; re tcently went to 9 and nudged back to 9.5 daily at 8am with the shift into summer weather. But my bolus is Novarapid.

Changed from Levermir 2x daily, several months ago, when I had no identifiable stability. I'm finding the Tresiba way better, it's optimised to give me steady nights and I use my bolus to adjust as necessary by day.

Hi thank you for your reply! Are you able to get Tresiba in half units? I was told it is not available. Thankyou

 

[Inka]

Hi Inka thanks for your reply. Yes it seems that it is the Tresiba as I dropped from glucose of 10 to 4 at
2 am the other night and I had no fast acting insulin on board, had not done exercise that day and had not had any wine!
The highs are particularly after meals (usually breakfast). I try to inject 20-30 minutes in the morning before I eat and that sometimes helps. Sometimes I just tend to run in double figures (although I am talking 10-11's) not massively high. This was why my DSN suggested increasing Tresiba but due to the drop in the night (although it didnt happen last night??) I always end up going back from 10 units to 9. I am frustrated. Also, going through menopause which doesnt help!!

Apparently the menopause can cause erratic sugars so that could be a factor too. I have a pump but when I take a pump break and use injections, I use a twice daily basal. Like @rebrascora i need significantly less basal at night. Also, I’m scared of nocturnal hypos so like the close control of a shorter acting basal.

If I was you, I’d experiment with another basal or else stay on the lower dose of Tresiba and use the Humalog to deal with any highs. 10 or 11 is pretty good for a high so it might also be you need to accept a few of those, especially with fluctuating hormones.

I use Humalog and I inject 30 mins in advance of breakfast if my blood sugar is normal. I also make sure to eat breakfast soon after getting up as I find my blood sugar goes up else. So, focussing on advance bolusing would be something I’d do too.

 

[Inka]

Hi thank you for your reply! Are you able to get Tresiba in half units? I was told it is not available. Thankyou

I’ve never used Tresiba but there are videos demonstrating that the Tresiba cartridge fits in, for example, a Luxura half-dose pen. That is, you snap out the Tresiba cartridge and simply use it in a half unit pen like the Luxura or other types it fits in.

Alternatively, you could get an appropriately marked syringe.

 

[helli]

I’ve never used Tresiba but there are videos demonstrating that the Tresiba cartridge fits in, for example, a Luxura half-dose pen. That is, you snap out the Tresiba cartridge and simply use it in a half unit pen like the Luxura or other types it fits in.

Alternatively, you could get an appropriately marked syringe.

Tresiba is manufactured by NovoNordisk. All of their insulin cartridges are the same and can be used in the NovoPen Echo which comes in half units.
I do not know if Tresiba prefilled pens are available in half units but the reusable ones are much better for many reasons so would always recommend the more robust and economically friendly option (unless you lack the dexterity to change cartridges).

 

[Proud to be erratic]

Yes, I have the NovoEcho pens and the disposable cartridges. I can confirm that pre-filled Tresiba pens do not come in 1/2 units. If you change to a disposable pens make sure you get 2 from the outset; might sound silly (or excessive) but although these pens have longevity, if one should fail and you have no reserve you're in trouble until you get a replacement!

I now have both basal and bolus in cartridges with different coloured NovoEcho pens; huge choice of colurs - blue and red, for me basal and rapid respectively. The space saved in the fridge is really useful and the pen records in the end of the barrel the value of your most recent dose plus an indication of how long ago. So when I have that little moment of uncertainty - did I take that planned dose? - I can check. The pen is also a nice weight and balance, it just feels right! I liked the Tresiba 'soft touch' pre-filled pen, but I prefer the NovoEcho package overall.

I'm still a relative Newbie to all of this. However, I can't get my mind around the concept of close control by flexible daily changing basal. It seems to me that depending on what one's been doing, the weather or any other BG factor, that as well as applying an adjustment to one's bolus (which is more of a guess than a precise science anyway) one also has to estimate (guess) what adjustment or change is needed for basal. I appreciate that @rebrascora has her ultra low carb diet which suits her body, so there is very little bolus for her to adjust anyway. But I have c.230-250 gms of carbs daily, spread across 2 or 3 main meals, plus snacks when I want (or need). So by day I'm already regulating my BG with bosul (in as much as any of us can regulate ....) and I appreciate having my inflexible basal optimised for no night hypos, on a target of 6 overnight. Perhaps this perspective will change in another year.

I do recognise that I'm fully retired and choose my daily agenda without an employer or clients tugging at me and our 4 grandchildren are not close geographically, so we also choose when and where we can be involved with them. This probably does make it easier to daily manage my DM and to decide whether to correct a high with a one-off bolus or change my activity level. It also means that lows and hypos inconvenience me but rarely anyone else; so I can treat those gradually and reduce the chance of getting back on that roller coaster that I got bored with!! I have noticed when we stay for a night or 2 with our daughter, son-in -law and grandson my 'freedom' is noticeably reduced. I'm totally at home there - but it's not the same.

 

[rebrascora]

I too recommend the Novopen Echo for half unit adjustment, recording the last dose (such a help for those "did I or didn't I" moments) and being more environmentally friendly.... much less plastic waste. Economically I think they work out about the same over the lifetime of the pen so there should at least be no negative aspect to the NHS and a positive benefit to you. As mentioned, make sure to get a spare pen in case of loss or damage but they are really robust and feel like a quality product.

As regards the spikes, particularly at breakfast, the key for me is to get my breakfast bolus into me ASAP because I get Foot on the Floor syndrome (Dawn Phenomenon's more sociable sister 🙄 ) as soon as I get out of bed, so my BG starts rising as soon as I get up and then my breakfast bolus is fighting a rising tide. If I inject my bolus before I get out of bed it at least has a fighting chance to counteract that rise as it is happening rather than chasing to catch up. I need about 45 mins prebolus time on a morning to prevent spiking, so if I inject before I get out of bed I can then get washed and dressed and a cup of coffee and make breakfast before I eat to take up that time. I usually make my breakfast first so that if my levels start to drop, I can eat sooner and I use Libre to show me when the insulin is starting to "win" and I eat then. Timing is different for everyone and many people would hypo long before 45 mins so you have to gently increase the timing from what you do now until you find the right timing for you and your insulin. I now use Fiasp which is a bit quicker.... Novo(not so)Rapid used to take 75 mins (yes, an hour and a quarter prebolus! 😱 ) on a morning for me which led to me getting distracted and then ending up hypo when I tried to fit too much into the time or just plain forgot to eat, but if I inject before I get out of bed with Fiasp, 45mins is manageable and I don't peak above 8 most mornings.

I think with diabetes management your body will change over the years and obviously your lifestyle/routine will change so it is about finding what works for you at any set point in your life. I also think that Libre allows much closer understanding of BG levels that we didn't have before and enables us to devise new strategies to deal with the issues it highlights.

If you are mostly managing with Tresiba at 9 units at the moment, then a half unit pen and some careful experimentation with longer prebolusing at breakfast (particularly) might make a big difference and injecting before you get out of bed really is something that can make quite a big difference. Certainly worth experimenting with before changing basal.... and if you did end up changing to Levemir afterwards, the Levemir cartridges also fit the Novopen Echo so you would still have the half unit option.

 

[everydayupsanddowns]

Sorry to hear you are having a tricky time wrestling your doses into shape.

It could well be that the hormonal shenanigans of the menopause is adding quite a lot of extra complexity to your dose adjustment.

I wonder if a little more experimentation with pre-bolus delay timing might be worth cautiously undertaking. We have members who have needed to leave 40 minutes or even up to an hour before eating. But this needs to be approached with extreme caution, as food doesn’t digest immediately, and leaving it too long risks a mistiming hypo - which is very frustrating, as well as dangerous.

Perhaps try an extra 5 minutes wait to see if that might keep you nearer 9 at 2hrs after eating?