Background insulin change advice please

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JohnBont

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Type 1
Hello, hope someone can help. I’m a type 1 diabetic. I’ve been advised to increase my Toujeo long acting insulin from 38 units to 40 which I administer at 7.30 am. On doing this I found I was having some hypos particularly about 10.30 am and at other random times of day. Today on waking my BG was 10.3, I took my 40 units of toujeo but did not inject any of my NovoRapid nor did I eat anything. At 11.30 I was 6.2, at 12.15 I was 5.5, at 12.45 4.9 and at 13.10 I was 4.1. I had not eaten anything not injected any fast acting insulin. Is this enough to conclude 40 units of Toujeo is too much please?
Any advice would be appreciated.
Thank you
 
I would say yes, it has dropped you about 6mmols over that period which is too much. What are your overnight levels like? Did you do more exercise/activity yesterday than usual as that can drop you for up to 48 hours afterwards?

What problems were you having that the Toujeo was increased?
 
I would agree with @rebrascora

If you have been having difficulty with you basal, you could talk to the DSN about using Levemir, which is a basal which is usually split. Some in the morning and another injection at night. It enables you to make changes to the daytime dose 9r the evening dose without changing the other. The action time is shorter and I found it gave me a lot more flexibility when I did that switch.
 
rebrascora said:
I would say yes, it has dropped you about 6mmols over that period which is too much. What are your overnight levels like? Did you do more exercise/activity yesterday than usual as that can drop you for up to 48 hours afterwards?

What problems were you having that the Toujeo was increased?
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Thanks for your reply. Since upping to 40 units I sometimes have hypos in my sleep. I didn’t exercise more yesterday. I purposely did nothing much knowing I was going to inject the toujeo as normal today but no food nor NovoRapid. I saw a new nurse a few weeks ago and I was averaging about 7.4 on all my Hba1c results for years so she suggested the increase. All other doctors and nurses I’ve seen seemed happy with the 7.4.
 
Was she a Diabetes Specialist nurse or just a practice nurse at your GP surgery who has had a bit of training in diabetes and manages the diabetics within the practice?

What is your Time in Range like? These days that is generally considered a better assessment of your diabetes management than HbA1c or average BG.
As regards the nocturnal hypos, are they genuine ones or could they be "compression lows", where you lie on the arm with the sensor on it and the reading dips into the red, showing a false low and then comes up again when you roll over and take the weight off it?
 
rebrascora said:
Was she a Diabetes Specialist nurse or just a practice nurse at your GP surgery who has had a bit of training in diabetes and manages the diabetics within the practice?

What is your Time in Range like? These days that is generally considered a better assessment of your diabetes management than HbA1c or average BG.
As regards the nocturnal hypos, are they genuine ones or could they be "compression lows", where you lie on the arm with the sensor on it and the reading dips into the red, showing a false low and then comes up again when you roll over and take the weight off it?
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Apparently she’s a nurse who has just started looking after diabetics. She’s only been doing so for a matter of weeks. My time in range was prior to the increase in toujeo about 65% over 90 days. I’m now about 59% due I think to the number of hypos and the subsequent shovelling of glucose into me in panic! The nocturnals are genuine, I finger prick and my blood confirmes the reading.
 
Looks like it wasn't very good advice from someone who is probably not yet experienced enough.

Personally I decide what my basal doses need to be and I would not thank a nurse for suggesting a change unless he/she wants to come and live with me for a fortnight and make those decisions on a near daily basis. I am on Levemir and I adjust it very regularly, to balance my levels, usually several times a week, particularly my evening dose as my nocturnal levels are very sensitive following exercise. I really love Levemir for it's flexibility.
 
Er, why not try 39 units? Literally just so you can assess what if any difference that makes. The original Lantus pen could only be adjusted in units of 2 at a time but good grief! - that was last century!!!

Because it doesn't start working for 6 hours and then can last for the following 36 hours - I don't believe trying any dose change of it (up or down) for just a couple of days can possibly give you or anyone else whether medically qualified or not a proper picture of whether it's OK or not.
 
I was offered Toujeo instead of my Levemir but refused it as I like the flexibility of twice a day Levemir. I Think Toujeo is fine if your BS is reasonably predictable but otherwise I would go for Levemir
 
I would suggest that you get a Abbott Libre or similar continuous BG monitoring system. You will be able to see, minute by minute, hour by hour, how you Blood Glucose (BG) is being raised or lowered all the time. If you can bring it to a level curve (a straight horizontal line), perhaps by not eating before you sleep. That will give you idea of you basal requirements.
My DSN had me on 58 units a day of Toujeo and with my Libre now take some 24 units a day. They just guess with no real data. Libre has been the best way to take control of my diabetes.
 
Sounds like your basal was better where it was @JohnBont Nocturnal hypos are a nightmare, and best avoided at all costs. After a while the T1 brain just gets used to them and stops firing warning signs to wake you up, so they can last for hours and really mangle your warning signs in the daytime 😱

Personally I’d be pretty happy with your average BG. And 65% TIR is not to be sniffed at!

Are you seeing big rises after meals that take a long time to come back down into range? Have you experimented much with prebolusing? That is - leaving a bit of a gap after injecting your dose before eating the meal. I found that very helpful in reducing rises after meals and increasing my time in range. Certainly at lunch and breakfast.
 
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