BG dropping throughout morning

[MarkGeordie]

Hey everyone, it’s been a while, I was poorly and then dealing with a foot ulcer that healed and then came back.

I’ve made lots of changes and I’m eating better, better BG control and starting to lose some weight I needed to.

I seem to be having the issue whereby my BG is dropping throughout the morning, without insulin been injected.

Example -

Last night I went to bed with BG of 8.2.

This morning I woke and was 6.6.

1.5 hr later at 7.50am I was 5.4.

30 min later I was 4.5.

No food or insulin taken. Before this.

At this point I had a small snack as did not want breakfast, it was a banana. I took no insulin as I was quite low.

1hr 20 min later I’ve risen slightly to 5.6.

I think I did the right thing not injecting with the banana because if I had I might have gone further down.

Am I having too much night time insulin for me to keep dropping in the morning when I wake up?

I don’t always fancy breakfast, so if I hadn’t of had the banana I’d imagine I may have went into a hypo.

I don’t want to be forced to always eat breakfast but obviously sometimes I do.

 

[pawprint91]

Am I having too much night time insulin for me to keep dropping in the morning when I wake up?

Sorry to hear you've been poorly and about your foot, hope you're on the mend now. To answer your question above - I would say yes. I don't know much about Tresiba as I am on Levemir, but if you inject it once a day and continue to drop without having any other insulin on board then I would say this is where the problem lies. Could you knock a half unit or unit off your next dose? You may end up slightly higher but could be worth it to stop a drop and be able to go without breakfast if you don't fancy it. If the problem persists could you move to an insulin like Levemir that has a split dose option of am and pm ? That way if you are naturally lower in the morning/day, it's easier to have to adjust one dose rather than try and do one to think about the following 24 hours maybe?

 

[MarkGeordie]

Thank you that does make sense.

Just checked again and just over an hour later it’s gone down again to 4.8 and that’s with the banana and no insulin with it.

I think what I could do as you suggest is lower the night time long acting insulin and keep monitoring.

I will just need to be careful throughout the day and make sure this long acting insulin that seems to now be too much for me doesn’t impact all day.

Once Tuesday comes I will try and get hold of a DSN.

 

[Tdm]

Wondr if the weight loss has reduced your basal needs? There will be less of you, after all.
If i were you i would just reduce my basal (unless you can't as you are on a low dose and only have a whole unit pen). After all, if thats too low you can always top up after a couple of hours.

 

[MarkGeordie]

I was thinking it could be the weight loss.

I take 44 units at the moment, I aim for 10pm each evening and my pen only goes up in full units.

Is it recommended to only lower by 1 unit at a time or could I try a few?

 

[pawprint91]

I was thinking it could be the weight loss.

I take 44 units at the moment, I aim for 10pm each evening and my pen only goes up in full units.

Is it recommended to only lower by 1 unit at a time or could I try a few?

Probably best to lower one at a time until you hit the numbers you want, but you could try 2 if you don't mind being a bit higher for a couple of days and understanding the reason why. I would say 1 to be on the safe side, but if being low is affecting your day to day life and well being then 2 wouldn't hurt, far better to be on the higher side for a day or so (under 10) than constantly having to ward off hypos in my opinion, others may say different.

 

[helli]

If your levels are dropping in the absence of bolus, I would agree with @Tdm to take a look at your basal. The recommendation I have seen is that you could reduce it by up to 10%. Put it this way, my basal is around 15, I would reduce it by 1 or 2 units a night if I exercised or drank a few glasses of wine.However, it could take a few days for your body to notice. Therefore, give it a few days to settle after reducing.

 

[Spathiphyllum]

If your levels are dropping in the absence of bolus, I would agree with @Tdm to take a look at your basal. The recommendation I have seen is that you could reduce it by up to 10%. Put it this way, my basal is around 15, I would reduce it by 1 or 2 units a night if I exercised or drank a few glasses of wine.However, it could take a few days for your body to notice. Therefore, give it a few days to settle after reducing.

Agree with Helli and Pawprint and Tdm-- your basal seems clearly too high. 44 units of basal is a *lot*; you may have needed that much in the past, but the results you describe in your first post indicate you don't need that much now.

Given that you're currently using so much basal, it seems sensible to start by reducing by 2 units. Because you're using Tresiba (I do too) and it has an 'ultra-long profile', Helli's right: "give it a few days to settle after reducing" and see what's going on after a few days.

So you could start with injecting 42 units this evening, and Sunday evening and Monday evening. Then, by Tuesday morning, you'll have a reasonable idea of whether this has helped, and if so how much it has helped. And if it hasn't helped at all, or not as much as you'd like, you can have a chat with your DSN. Fingers crossed!

 

[Proud to be erratic]

Everything you've said screams at me that your basal is too high @MarkGeordie. Possibly weight loss, possibly the change to warmer weather or probably you've never really got your Tresiba optimised for you and nights.I am a big fan of Tresiba and it sometimes seems that people using this long lasting basal haven't had sufficient explanation from their HCPs about its characteristics.

Because it has a 40+ hr profile, it should be taken only once daily, but there is no need to be precise about when you take Tresiba. Indeed a bonus side effect of Tresiba is that its particularly useful for people regularly flying long-haul. The core thing to keep in sight is that today's dose is "topping up" yesterday's dose. One consequence is that changes with Tresiba dosing need time to take effect - typically 3 days; so in real terms allow at least 4 days and don't make a change until you are pretty sure that is really needed. In this case I, in my non-medical opinion, think that is so. There is an excellent analogy that dosing with Tresiba is akin to being the Captain of a super-tanker crossing the ocean. Because of winds and currents course adjustments are needed, but they need time to take effect. Super-tanker Captains have the benefit of complex computer programmes to work it all out, in advance, from predicted met data - which is where the analogy collapses! We have to make our own judgement and do that after the evidence is available.

I would be happy to change by 10%. A DSN some 2 yrs ago recommended a decrease of up to 20%. One rationale for such %s is because generally our body's basal needs are not evenly spread across any 24 hr period. So Tresiba can only be optimised to cover part of the day - for most of us that will be nights. With that partial optimisation we can aspire to have safe, hypo free nights and without major excursions towards hypo. Consequently one MUST anticipate a combination of bolus and exercise/activity to regulate our BG by day. So if a Tresiba reduction is too big, that's fine - night readings will drift up over that period and bolus correction needed the next morning. I would be more conservative if I were making a Tresiba increase.

To help build a fuller picture of your circumstances, but don't worry if you are not keen to share:

How long ago were you switched to Tresiba?
Have you done a DAFNE, or equivalent, course?
Are you confident that your bolus ratios are correct for you?
Do you have Libre or any other CGM?

In my opinion it's essential to get one's basal correct first, otherwise one's bolus is always chasing an out of kilter basal. But it follows, that once the basal is optimised (particularly for Tresiba), you need to be happy that bolus ratios and understanding how exercise/activity affects tour BG are key to keeping things steady during the day. But really that is core to all of us on MDI and I find the exercise/ activity bit really frustrating.

 

[trophywench]

The other thing that struck me is that you had an ulcer on your foot, which has subsequently healed. So your BG would have been affected (increased) by the inflammation caused by the ulcer - but now no ulcer so nothing to increase your BG - hence it makes perfect sense to me that you'd now need less insulin.

 

[MarkGeordie]

Thanks to you all. Everything that has been said makes sense.

I think I would rather adjust slowly, than too much at a time, but yes I will make sure I give it enough time since the adjustment to assess it.

I will of course seek DSN help too.

I never thought about the ulcer impacting previously so that’s a good point, thanks.

To answer the questions, I was asked. Here you go -

How long ago were you switched to Tresiba? - I have been on it a few years now, admittedly my BG has not always been in the best control, so I would prefer to give it a chance and stick to 1 injection daily.

Have you done a DAFNE, or equivalent, course? - No, I was on a list, then Covid hit, still on a list, however they are “re-designing” the course at my hospital, so got to wait. I am about 50% through the online BERTIE course on the recommendation of my GP.

Are you confident that your bolus ratios are correct for you? - Again, they were never perfect, but I now have this under control to the extent that I understand my ratio.

Do you have Libre or any other CGM? - Yes, Libre 2 and this is how I have managed to do more monitoring to see what’s going on.

 

[MarkGeordie]

Update - I decreased my evening Tresiba by 2 units and it will be night 3 tonight since. I’ve noticed it is better but I do think I need to maybe drop by a further unit, I am hoping to speak with a DSN from the team tomorrow.

Since I am trying to be better with everything, I am going back to basics in my mind. What do people say is acceptable in terms of BG after a meal? So what I mean is, when you test 2 hours after, what is acceptable in terms of changes? Should it go up or down and by how much? Or is both ways acceptable as long as it’s not going low or high by too much?

Weighed myself Sunday again, lost 2.2ibs.

 

[pawprint91]

Update - I decreased my evening Tresiba by 2 units and it will be night 3 tonight since. I’ve noticed it is better but I do think I need to maybe drop by a further unit, I am hoping to speak with a DSN from the team tomorrow.

Since I am trying to be better with everything, I am going back to basics in my mind. What do people say is acceptable in terms of BG after a meal? So what I mean is, when you test 2 hours after, what is acceptable in terms of changes? Should it go up or down and by how much? Or is both ways acceptable as long as it’s not going low or high by too much?

Weighed myself Sunday again, lost 2.2ibs.

There are people on here with far more knowledge than me about diabetes, but I would say 2 hours after eating (depending on what you have eaten) if things have gone well, you probably want to see a number under 10? But that depends on what your BG was when you started to eat too, as well as lots of other things! This is where I, and many others, find a Libre or similar device so helpful - it shows you which direction your blood sugars are going. For example earlier I was 8.7 (probably less than an hour after eating, I'm a bit of an obsessive scanner) but I could see that was slowly rising so headed out to walk the dog - obviously when pricking your finger you don't know which side of the 'peak' your number is on.