Advice

[LittleSunflower]

You want to bed at 12.4 and dropped almost 7mmol to 5.5 : /
You’ve only just been started on insulin (you should have had it earlier) and the amounts chosen are not ‘magic’ amounts that you need - they’re guesses You’ve already had one of your twice daily injections reduced by 25%....

I’d feel bad if I didn’t repeat what I’d do from above - I’d reduce your evening Levemir. Having had serious nocturnal hypos myself, it simply isn’t worth the risk.

I am beginning to think the same. I’m sorry you’ve had to go through them, they sound scary,
I’mthinking of reducing it by the same as this morning. So 6 to 4 tonight, check levels, still 6 in the morning as today then to discuss with the nurse tomorrow?

 

[Inka]

That’s what I’d do if I was in your situation @LittleSunflower Its far preferable to be a little bit high in the morning than to risk a hypo. Indeed, you might not even be high in the morning after 4 units.

If it was me, I’d also set an alarm to test during the night maybe around 1-2am and eat a little then if my blood sugar was too low or looked like it was heading down too much. Keep hypo treatments by your bed along with longer-acting carby snacks like plain digestives. You can then nibble at them if needed. Even though I’ve had Type 1 almost 30 years, I still have part of a biscuit if I wake and test in the night and have any concern about dropping.

 

[rebrascora]

This may sound stupid but I will sleep more soundly knowing you have reduced it.

If you think about it logically, if you hadn't been started on insulin, your BG would have been high in the morning just as it has been for weeks and nobody worried too much. The insulin will bring you down even only at 4 units, so you may not be as low as 5 in the morning but you will still be a lot lower that you were 2 mornings ago which is actually what they should be looking to achieve with insulin. A slow steady reduction in levels, not a near hypo the first dayl
Not following the dosage you have been given and risking the nurses wrath and being 6 or 7 or even 10 in the morning is much less of a worry than dropping into a hypo overnight, although it is still possible that might happen, so do please set an alarm and check.

 

[LittleSunflower]

Thank you @Inka & @rebrascora for your concern and your help. I have had 4 units this evening and an update from my nurse saying to reduce both doses to 5 from tomorrow. As you said, I’d rather be a bit higher tomorrow morning than to risk the hypo. (Even though it still may happen, I will keep a check in the night as advised).
My BG level beforehand was 12.2.

 

[rebrascora]

As regards your question about the Levemir doses being 12 hours apart, apologies as I don't think we answered that. It is advised to take them 12 hours apart but personally I have always taken it at bedtime which is about 11pm normally and 7am and that works fine for me but at the moment I need all my basal insulin through the day and none at night otherwise I hypo, so just one injection of Levemir in the morning for me just now. Stick with the advice you have for now or a couple of hours either way shouldn't make too much difference. It helps the nurses figure out your dose adjustments better if you are following their guidance on such things. Do confess that you only took 4 units tonight instead of 5 (or 6) because you had a near hypo earlier and were frightened of having a night time hypo. It is important that they know so that they can see what effect it had and adjust your dose again for tomorrow if necessary. Probably best not to mention us keyboard warriors advising you though, as that tends to get up medical professional's noses.
Hope you have a restful night and your levels are nice and stable.

 

[trophywench]

I've never used my arms, mainly to begin with because I wasn't dexterous enough to do it one handed and especially with a heavy glass syringe that I wasn't used to and again, you were supposed to 'draw up' slightly in case you'd accidentally hit a vein - was that long ago I'd forgotten that palaver until literally just that second. And honestly, cack handed though I was and still am - I have never to my knowledge hit a blood vessel - and you'd know alright cos you'd bleed and have to staunch it.

I found my midriff bulge - even when I was size 10 I had a nice little bit of padding above the waistband under my ribs - and certainly do now - a prime spot to easily jab into.

And no - Levemir does not absolutely have to be jabbed 12 hours apart - and it's amazing how much eg half an hour sooner or later, can make - but that's for your Advanced driving course, not for a new driver with the L plates on!

 

[trophywench]

🙂 A number of us typing at the same time.

 

[Inka]

How did things go @LittleSunflower ? I hope you had an ok night.

 

[LittleSunflower]

I did wake up in the night but I felt absolutely fine and must have fallen back to sleep pretty quick because I didn’t test. (Thankful to have had a good nights sleep since the start of the week!) taking the 4 units instead of 6 definitely relaxed my anxiety about a nocturnal hypo. I still had 2 digestive biscuits and a small cup of milk before bed.
I tested when I woke up and was 5.8 (even with the 4 units) so had breakfast again before my 5 units this morning. I was 5.3 at lunch time and felt myself going a bit shaky. All ok after a good meal.
I also spoke with the nurse today and she understood completely why I took 4 units instead of 6 last night. I was also given a guideline of what I should be before bed as @rebrascora asked about yesterday - this is no lower than 7-9 to be on the safe side. I was also told that I can experience a hypo at levels just above 4 as I’ve been running high for so long. If I were to have another hypo in the afternoon like yesterday, I am to test again as advised 10-15 minutes afterwards and then think about reducing my insulin the following morning by 10% or 1-2 units to stop that from happening; not the evening dose?
My nurse is very understanding and reassuring. She explained that the reason they said stomach only for injection is due to them not knowing how much muscle mass I have in my thighs due to recent weight loss and my needles being quite short. I could inject in my thighs when I start on the Novorapid.

I feel a lot better and like I have a bit of control over things. I’ve also been told it’s very good I am aware of my body signs that tell me I am too low and can act fast to treat this.
They are now trying to get me an appointment at the hospital for a confirmation of Type 1 from a consultant (as the nurses cannot give me a full diagnosis but they believe it and are treating it as that).
I am set to stick with the 5 units of Levemir in the morning and 5 in the evening until my check in next week.
I would be in such a state if it wasn’t for you all on here, so thank you, really.

 

[Ljc]

What length needles have they prescribed you , thought some of us may prefer longer needles , no matter how thick or thin the fat layer is coz we shouldn’t inject insulin into muscle, we really only need 4mm needles.

I’m glad you slept well and easier las night

 

[rebrascora]

Thanks for the update and pleased to hear you had a safe night. So pleased you had that milk and biscuits as I dread to think how low you might have dropped.
I am concerned that she has left you on 5 units tonight still. Your reading was 12.2 before bed and you had 2 digestives and a cup of milk which will have effectively bumped you up by another 6-7 mmols.... so effectively nearing a BG of 18-20 and you woke on 5.8 this morning, so you effectively dropped 13-14 mmols during the night and she wants you to take an extra unit tonight??? Did you tell her your evening reading and that you had the biscuits and milk after that. I wonder if she thought the milk and biscuits took you up to 12.2I Still think they are not being conservative enough with your doses. Bringing your levels straight down into the 5 and 4s from mid teens on the first day is too drastic and risky in my opinion.

The other thing is that the extra insulin you are injecting can take the strain off your flagging remaining beta cells in the pancreas. If they get a bit of a breather, they can fire back up again with renewed vigour so that can also add unpredictably to the insulin in your system.

Hypoes don't feel the same at night as through the day. I have had a few recently where I woke up but didn't know why and in my groggy half sleepy state I rolled over and went back off to sleep without testing. It wasn't until the third time that I woke up that it clicked that I should test and I was 3.3 and had been in the red for over an hour according to my Libre sensor, which samples my levels every few mins. So don't assume if you feel OK when you wake up through the night that you are not hypo. Always best to test. The more you test, the more you will learn about how your body works.

Personally I would have liked to have been encouraged to test a lot more and experiment in the early days. I felt quite naughty testing more often than they suggested and bought extra pots of test strips myself so that I didn't feel guilty about using more NHS test strips than I was authorized to do, but my understanding and control improved so much with that increased testing. I appreciate that you are still only on basal insulin so there is not a lot you can do with any info you get but my suggestion of testing when you inject the Levemir at 9.30pm and then again at bedtime, so that you have an idea if it is going up or coming down as you approach bedtime is useful knowledge for deciding how many biscuits to eat before bed to keep you safe.

My advice would be to stick with the 4 units tonight again, but do whatever you feel comfortable with, but please do test through the night if you wake up, even if you feel fine, particularly in these early days when they are still trying to find the correct dose for you and you are clearly very sensitive to it. I know it is a pain as it disturbs your sleep but really important to stay safe.

 

[Inka]

I totally agree with @rebrascora Stick with the 4 units tonight (or even reduce it to 3 units) and basically try to repeat what you did last night blood sugar-wise and snack-wise.

In my opinion, you’ve been started on too much basal. You need less and possibly the Novorapid introduced with a pen that does half units. You can see that food is putting your blood sugar up and the Novorapid would stop that.

So if it was me, I’d want less basal insulin and tiny amounts of Novorapid to cover meals. Rather than have the 14 units of Levemir you were initially told to take, your regime might look something like 4 and 2 units for the Lev, and 2/1/1.5 for the Novorapid. Those are just example figures not recommendations. I still think your nurse is hoping to just keep you on the Lev only. That’s not how it works. You need both insulins because they do different jobs. Even if someone is only on tiny amounts of insulin, they still take both kinds. When I was diagnosed, I initially started on 1 unit of basal (yes, one). Nobody thought I could do without bolus/meal insulin just because I had a tiny amount of basal insulin. In fact my bolus insulin was more than my basal.

Sorry to ramble on, but I feel you might need to stick to your guns here. I have found GP diabetes ‘expert’ nurses not very expert at all, and lacking in knowledge, particularly about Type 1 and Type 1 regimes. Don’t be afraid to be polite but firm. It’s something many of us have had to do a number of times throughout our diabetic careers.

 

[rebrascora]

I think a half unit pen for both Levemir and NovoRapid is going to be important and I totally agree with you @Inka in what you say about doses. I know you are more sceptical than me about their intentions as regards just using Levemir. I am confident that the NR will be incorporated into the regime once they get the LR somewhere near. I hope I am not wrong in that! I just think they have started far too heavy handed with the Levemir and I am surprised that they don't seem to be doing enough about reducing it. We are all encouraged to err on the side of caution and yet these doses are clearly too high to be bringing levels down into the 4s and 5s straight away considering that the insulin is also being used to cover food at the moment as well.

If it helps you to understand the potency of insulin @LittleSunflower most of us would need a unit of insulin for each digestive biscuit. So without those 2 digestive biscuits at bedtime you would potentially have had 2 extra units of insulin in your system which are capable of dropping you about 3mmols each. You woke on 5.8 which is less than 6 so without those 2 digestive biscuits you would without doubt have been hypo through the night. and possibly quite a nasty one.

 

[LittleSunflower]

I wish I had you both around to talk with my nurse about all of this! (Although you’re dealing with it all yourself so you wouldn’t need my stress too).
It’s all still very new to me and it can be difficult to take all of the information in so quickly.
I do agree it’s concerning that my levels have gone from double figures to near hypo figures in a couple of days. I’m not sure if there was miscommunication with the BG reading when I spoke to the nurse earlier.
I will repeat with the 2 digestives and milk tonight, along with the 4 units of Levemir, testing BG before. If I do wake, I will make sure to check levels instead of just feeling that I’m ok.
Were you started on both insulin’s together or just the one at the beginning like myself? I will make sure to mention about the Novorapid with the nurse next week, to see when this will start etc.
Do you think it’s still best I stick with the 5 in the morning and 4 in the evening from now on? As the 5 will take me through the day, I know Levemir doesn’t work with food as the Novorapid does
I feel kind of rebellious changing the dose myself but I really do not want to drop into hypo figures, especially when I can even feel shaky in the 5s having been high for however long.
My levels today have been
Waking 5.8, lunch 5.5 and before dinner 10.9.

 

[Inka]

Yes @LittleSunflower I was started on both insulins at exactly the same time. My dose was determined by the sliding scale I’d been on (an insulin drip used in hospital) but even that only gave a rough estimate. My doses were adjusted a few times but those were slight tweaks rather than massive changes.

Your daytime Levemir doesn’t look too wrong from those figures but because it’s the only insulin and is working without it’s counterpart, Novorapid, it’s hard to say whether it’s ultimately the right dose or not. It’s possible it might need reducing slightly once you get the Novorapid in there to deal with your meals.

If you’re happy with the morning 5 units of Levemir at the moment, then it’s not such an issue to stick with that because you can test and will be awake to catch hypos before they happen. But the nighttime dose concerns me, which was why I, and no doubt @rebrascora too, replied at length last night. Nocturnal hypos are something to be avoided at all costs.

As a comparison, last night my blood sugar was 6.0 when I went to bed (I have an insulin pump so can run slightly lower than I do on injections for reasons I won’t bore you with) and I woke up at 5.6. That was my basal insulin doing it’s job - keeping my blood sugar steady overnight. Your Levemir is dropping you a lot overnight. That’s not right.

I agree that your starting doses were too high with the Levemir. Usually doses are started low (below what they think someone will need) then gradually increased as necessary (if necessary at all). So I would have expected you to be started on say 2 units of Lev a.m and 2 at night. I don’t know why you were started on bigger doses. If it was to cover your food, as suggested by the nurse’s comments, that’s not right and potentially risky as far as hypos are concerned. It could also be that the nurse has Type 2s in mind. They have a resistance to insulin so generally have larger doses. But even saying that, I’ve seen Type 2s started on lower doses than you sometimes.

Don’t feel bad about adjusting your doses downwards. The only result of that could be that you’re slightly high. As you’ve been left all this time without insulin, that’s not an issue really.

If it was me, I’d either stick with the 4 units and big snack tonight, or reduce it to 3 units, still have a big snack and see how it goes. Do test if you wake up in the night. It will give useful information whatever your blood sugar.

 

[rebrascora]

Yes, looking back through my records (my memory is a bit of a blur around that time so really can't actually recall) I was started on them both but the Levemir was just once a day at night and they started me on 6 units and then upped it to 8. I didn't split my Levemir into 2 doses until the October, so 6 months later, just before I started my DAFNE course and by then I was up to 14 units of Levemir and split it into 7 morning and 7 night which worked OK for a little while and then I had to start reducing the night time dose and increasing the morning one.

Looks like I was carb counting within a couple of weeks of starting on insulin and adjusting my NovoRapid doses, but i think we had an agreement that 4 was a max. per meal initially. I was mostly just using 1 or 2 units though.

I would be curious to know what you had for breakfast lunch and dinner. It surprises me that your lunchtime reading was in the 5s still but then it headed up after that.

I would just like to say that once again @Inka and I are in total agreement as regards the strategy for tonight and her thoughts in general. Good luck and I hope you have another good night.

 

[LittleSunflower]

What length needles have they prescribed you , thought some of us may prefer longer needles , no matter how thick or thin the fat layer is coz we shouldn’t inject insulin into muscle, we really only need 4mm needles.

I’m glad you slept well and easier las night

I have been prescribed 4mm needles

 

[rebrascora]

As another comparison, I went to bed on 8.2 and dropped to 3.4 by 5.15 am and needed 2 Lift tablets to bring me back up (Technically it should have been 3x Lift tablets for 15g carbs to treat a hypo but I go too high very easily) and I had no evening insulin on board, so my body used up what was in my blood stream and for some reason my liver produces very little glucose during the night and lots during the day, so the tiny amount of residual insulin from my morning dose of Levemir was enough to drop me into the red ie a hypo at 5am. Woke up on a very nice 5.3 but without those 2x Lift tablets I might have needed an ambulance!

 

[LittleSunflower]

Goodness me, that is frightening to read, let alone experience first hand! I’m so glad you had the tablets @rebrascora.
Breakfast - two slices of wholemeal marmite toast with a cup of decaf tea
Lunch - southern fried chicken and a very small portion of chips
Afternoon snack - a piece of milk chocolate, a matchbox size of cheese and a packet of crisps (not the best choice I know)
Dinner - lasagne

so a ‘carby’ type day

I personally don’t have a good feeling about tonight, I don’t feel very well within myself. Bed time reading before insulin is only 9.5 tonight. I took 4 units of Levemir and have had half a sandwich and an apple just to try and boost my levels a bit. I am yet to have the biscuits and milk but I am full of anxiety and have become so overwhelmed it’s resulted in tears. I don’t know how I’m going to cope with all of this, it’s just a huge life change and shock to try and come to terms with, especially with my levels still fluctuating all over the place. I’m really worried about a lower than 4 hypo happening if I already feel bad in the 5s

 

[Inka]

It is a big life change but I promise it does get easier @LittleSunflower You’ll gradually get the hang of the practical things, but importantly you’ll also process the emotional upset and stress. I know it might not seem like it now, but you will. We’re not special. We’re just ordinary people like you. If we can do it, you can 🙂

If you’re anxious about tonight, then remember you can set an alarm to test during the night. It helps peace of mind as well as being useful.

I would lower your evening Levemir tomorrow. You can always increase it if needed. It would be worth it so you had less anxiety, and your ‘numbers’ suggest it would be sensible.