Am I taking NovoRapid too close to eating?

[Rae]

Hi all

I have a lot of questions, so apologies. I'll put my diagnostic journey in footer...

My first question, because it's the one causing me most immediate grief, is whether I'm timing my NR right. Nurse told me to take it right at the start of my meal. The forum seems to advocate for 15-60 minutes before eating so it starts to work at same time as digestion.

I seem to having the opposite problem to most as I'm taking it before my first bite and my sugars go up as is expected, level out at about 2hrs (again as you'd hope), but then start to climb again 2-4hrs. 4-6hrs it starts to go back down.

It's almost like I'm burning through it in the first 2hrs but I'm still processing the food up to the 4hr mark. Then 4-6hrs, my background kicks in.

First, has anyone else had that? Second, if I'm still high at 2hrs (knowing it will then start going up again as well) would a correction bolus be appropriate? Can you inject smaller but more regular doses (more like a non-diabetic would produce) rather than hit it all at once? Third, does anyone take their rapid after they eat, because that seems like a sensible first step to me but I am a bit maverick that way.

Read more: Bonus ramble, click to read

Side note/bonus question - One of the most peculiar things happening at the moment is the more insulin I inject (and I'm up to 30 basal and 20-26 bolus per meal, total of about 100u per day) the worse my sugars are getting. 10 units 4 weeks ago saw me in 10s, 24 and I'm around 14. I am carb counting and recording the good, bad and occasional ugly in a food diary so I'm not just slipping in sneak carbs.

I do have a wild theory that after having gone without producing much insulin for a while as LADA kicked in, my body got used to high sugars and packing everything up as fat. Now there's insulin in my system again, it's dumping out all that fat as glycogen and the more I inject the more it's trying to get rid of it. Theoretically that should slow down as my liver calms its boots. My other thought is that as my hba1c has been +80 for 5 years, my body has got used to sugar loitering around. The insulin is treating this but my body is trying to get back to what had been normal for it. Again, my sadly fatty and enlarged liver is going into overdrive but hopefully temporarily as it starts to renew.

For anyone who got to the end of that, thank you! Does any of the above make sense? Has anyone had similar in the early days of treatment?

Thanks in advance!

Rae

---

Nov 2016, hba1c 42
April 2017, hba1c 82, T2 diagnosis (other causes not investigated)
April 2017 - Feb 2022 hba1c 67-95 (various therapies)
April 2022 - DKA, hba1c 102, ?LADA suspected
May 2022 - began insulin, NovoRapid (4U with food) & Lantus (10u AM) ave pre-meal BG 10.5mmol
June 2022 - NR (20-26u with food), Triceba (30u AM), ave pre-meal BG 13.4mmol

 

[Lucyr]

What kind of food are you eating, are you eating high fat foods? If so then reducing the fat content f your meals may help reduce the later spike, but you should also do a basal test in case the late rise is unrelated to your food. The other thing to check is whether you have any other digestive symptoms that could point towards gastroparesis.

If the late rise genuinely is related to your food, then splitting bolus in two, some 15 mins or so before you eat and some a couple hours later may help. I take insulin after i eat sometimes but not often - only when hypo before eating or when eating something that i dont know if i will like.

 

[Rae]

What kind of food are you eating, are you eating high fat foods? If so then reducing the fat content f your meals may help reduce the later spike, but you should also do a basal test in case the late rise is unrelated to your food. The other thing to check is whether you have any other digestive symptoms that could point towards gastroparesis.

If the late rise genuinely is related to your food, then splitting bolus in two, some 15 mins or so before you eat and some a couple hours later may help. I take insulin after i eat sometimes but not often - only when hypo before eating or when eating something that i dont know if i will like.

Hi @Lucyr

My carb intake is 20-50g carb per meal (so a moderate but not low carb intake) which means my fat is a higher percentage of the meal than average. I do know that higher fat can slow digestion and release of food sugars but it seemed like the lesser of the evils, and is also the recommendation for managing my inflammatory bowel disease. If anything I assumed IBD would encourage early digestion as stomach emptying is more rapid, but I suppose emptying doesn't mean digestion. It's all quite confusing and convoluted, especially as I have concurrent conditions and some of the meds I take are known to mess up glucose control. As for checking my basal, I assume that's the same as the fast test on BERTIE? Where you monitor BG over a 10-12hr fasting period and see what happens? I have been doing those once per week and am still seeing increases overnight, even at 30u triceba. I think I could do with changing to night time as my premeal BG drops during the day by up to 4mmol, but during the day I can more readily monitor myself anyway.

Thank you for answering. It is all quite new to me, although my dad was insulin dependent. He was weird too. Every 3 or 4 months he would stop needing any insulin and 2 units would send him hypo, and then a month later he'd go back to needing 48:16,24,30!

Best

Rae

 

[Lucyr]

For the basal test, you need to do this during the day, covering the time where your bg is rising after the meal, but yes its the test where you dont eat and test bg to see if its stable.

 

[Rae]

For the basal test, you need to do this during the day, covering the time where your bg is rising after the meal, but yes its the test where you dont eat and test bg to see if its stable.

Ah okay, I have been just doing a 7pm - 7am fast on a Saturday, because I stay up late. Testing premeal, 2hr post, 4hr post, 6hr post (usually 1am ish), then testing the following morning on waking and then before breakfast. If I get up for a loo break, as sadly my age has begun to warrant, I have tested then as well which is why I know that half 3 to 4am I can see a 4 or 5mmol jump that has to be dawn phenomenon, and could absolutely be messing with results. I will do a daytime one this weekend and see. At the moment I'm feeling embarrassed that I'm testing too much (and buying extra strips is expensive!) But I really want to understand what my body is doing.

Again, many thanks for explaining. Rae

 

[Proud to be erratic]

Hi, I'm T3c, so can't help on those aspects you're discussing with @Lucyr .

But with Tresiba, because it has a long profile for release, perhaps as much as 40 hrs, the time of taking it is not so critical. One of its advantages is that you can take your daily dose at, say, 8am +/- a couple of hours or even more, without detriment. Also, when you take the next day's dose that is accumulating onto residual Tresiba from the previous day, perhaps 40-24, net 16 hrs worth and the release profile is fairly even; so the last hour or two might tail off a bit but you've basically got a half day of basal residual from the previous day. Consequently changing your basal time from am to pm shouldn't have much effect on your day/night behaviour. So when you take it is best to be when a daily repeat is most convenient for you. That said anything is possible with DM .... so if you do decide to try pm basal instead of am basal, you'll just need to make the transition gradually through a succession of days.

Regarding test strips: since you are insulin dependent you should not be 'rationed' in how many you need by your GP. You need to test as often as you need! Even without DVLA requirements if you drive. You can't 'forecast' when you might be hyper or hypo, so you can't forecast your test frequency. If your average over a few weeks is 10x daily, then that becomes your requirement. If that average increases because of DM behaviour changes, then so be it. Don't let your GP restrict you; you are entitled to test and the cost of that is cheap in relation to the potential cost of hospitalisation etc, etc; never mind your personal reassurance and stress reduction (in itself v bad for DM). I was initially rationed; but a polite but robust rationale of why I needed more test strips, overtook my GP's rationing! There can be an outdated perception by GPs that you only need to test as little as 4x daily. Rebuff that if you need more.

 

[Inka]

Hi @Rae Were you actually confirmed as LADA rather than Type 2 on insulin? And are you on any other meds apart from the insulin eg Metformin? You do seem to have some insulin resistance which will probably be making things harder for you.

A basal test is the first step, as said above. Your later rise after your meal suggests a basal problem. Until you get that right, it will be hard to get control. Once you’re ok-ish with your basal, then the NR should be injected enough in advance of your meal to control any spike. This time might vary for each meal eg breakfast might need 25 mins, evening meal 15 or whatever. Taking NR after a meal is only really appropriate for low GI meals or in certain circumstances.

No, I don’t think you should correct at 2hrs. Hopefully once you get your basal right and your NR timing right, you won’t need to.

 

[Rae]

Hi @Rae Were you actually confirmed as LADA rather than Type 2 on insulin? And are you on any other meds apart from the insulin eg Metformin? You do seem to have some insulin resistance which will probably be making things harder for you.

A basal test is the first step, as said above. Your later rise after your meal suggests a basal problem. Until you get that right, it will be hard to get control. Once you’re ok-ish with your basal, then the NR should be injected enough in advance of your meal to control any spike. This time might vary for each meal eg breakfast might need 25 mins, evening meal 15 or whatever. Taking NR after a meal is only really appropriate for low GI meals or in certain circumstances.

No, I don’t think you should correct at 2hrs. Hopefully once you get your basal right and your NR timing right, you won’t need to.

Hi @Inka. Still waiting on LADA results but everyone involved with my secondary care find my disease progress unusual so they have said they're treating it as T1/LADA, especially as I went into DKA and apparently this is super rare in T2. Of course, nothing is impossible and there's definitely some measure of insulin resistance there. I think that is more to do with weight and fat distribution though (almost completely abdominal fat, arms and legs fit size 14 clothes, belly needs a 24). It's on my hit list and I don't expect to be putting in the volume I am now forever. But as things go hand in hand, I need to get my sugars normal and stable to have the energy to really tackle the bulge.

Unfortunately I don't tolerate metformin: I stuck to it for 4 months, then tried the XR version for 6. It triggered IBD and I had a lot of trouble with intestinal bleeding so we stopped it. Over that time though my hba1c never got lower than 73 and I was doing it alongside Atkins, so it wasn't really doing what it needed anyway. Possibly due to poor absorption due to the gut issues. They've taken me off everything else, as apparently the bloods I had in hospital indicated I wasn't producing my own insulin. I was on sitagliptin and dulaglutide to encourage my pancreas to do its thing, but I assume once you stop making your own, for whatever reason, insulin is the primary recourse.

I have an appointment with DSN on Friday and will ask about increasing basal again, 30 was as far as she was comfortable with when I last spoke to her. Think a basal test needs to happen before I do, so am going to do it tomorrow, eat breakfast at 8am then fast through 8pm. Should give me something to show her at least.

It really is a journey, isn't it?