Correction Doses

[Merryterry]

I see on this forum that some people take 'correction doses;. I take this to mean taking some insulin between meals to correct a wayward BG reading?

My Diabeic nurse told me never take doses in between meals but just adjust the dose at the next meal and the next meal after that if neccessary. I will admit that was many years ago.

Surelly by taking 'correcting doses' you can end up chasing your levels all over the place?

 

[helli]

There is a fear of "stacking" if you take fast acting insulin before your last bolus insulin has "run out" which is often the reason provided for not taking corrections. If you forget about insulin on board when taking a correction, you could go too low which I guess it what you are referring to about chasing levels.

I am a regular corrector as I am unwilling to stay above 10 whilst I wait for my next meal. Likewise, I wait for my levels to fall below 10 before eating which requires correction doses. That said, my meals are more than 4 hours apart and I prebolus to avoid spiking too high but still get it wrong sometimes or see a rise due to stress.

In other words, if you are aware of insulin on board, you should not end up chasing your levels.

 

[rebrascora]

There are good reasons for not correcting between meals, but I think some of them were based on the fact that people were only finger pricking before meals and you were unable to clearly see what your levels were doing in between whereas now we have Libre, we have a much clearer picture of what is going on.

For me, like @helli, I am not prepared to leave my levels in double figures for hours on end. I feel like I have lead weights around my ankles and wrists when my levels go above 9-10 and I sleep very restlessly at that level through the night, so I prefer to keep tighter control.

Secondly, I follow a low carb way of eating which means that the protein I eat releases glucose approx 2 hours after my meal, so I need to correct for that and this will sometimes involve stacking small corrections, because the amount I need can vary.

Thirdly, I use Fiasp as my bolus insulin and if my levels get above 10 it turns into water. This often means that I need to stack small corrections to bring my levels down from double figures... Like @helli I don't eat if my levels are above 8 because otherwise I am fighting a losing battle. For me keeping my levels below 10 as much as possible makes my diabetes much less frustrating and I need less insulin, so being proactive about it is important to me for that reason.

Fourthly, I no longer carb count or weigh or measure stuff, even when I am not eating low carb. I inject an amount of insulin in advance of my meal and then I correct later. This takes an enormous amount of work and mental effort out of my diabetes but it is really only with Libre (or other CGM), that this is an option. I do have to be aware of roughly how much active insulin is still left in my system (thankfully Fiasp is pretty well finished after 3 hours for me and not much activity after 2 hours to be honest, so that makes it easier. With small doses for low carb eating, I can't go too far wrong and if I get it wrong I can treat myself to an occasion date, prune or fig and if I get it very wrong, a jelly baby or two. I rather like it when I get it wrong 😉! Not saying hypo level but 4.5 with a vertical arrow means I get a JB treat and 5 or above with a vertical downwards arrow gets me a date or dried fig etc. What is not to love!

From experimenting with these situations, I have learned how my body responds and how I can comfortably and safely break "the rules", but I stress this would not be possible without Libre and perhaps my slightly more unusual circumstances of following a low carb way of eating also help but it was through trying to find a way to make FIasp work for me, that has led me into it. I had a 2x very frustrating 3month spells trying to figure out how to get on with Fiasp.
Yes, I need more injections but to me that is no big deal. I have good hypo awareness so I am not totally reliant on the Libre but it helps me judge when I need the corrections. I would not for instance inject a correction if my levels spiked above 10 after a carb rich meal, but if my levels were still above 10 2hours later I would be hitting it with more Fiasp. Similarly, if I have a low carb meal and the spike remains below 10 but I can see my levels slowly drifting upwards towards 10 a couple of hours later (my upper alarm is set at 9.1) then I will inject 1.5-2 units depending upon the arrow) and thereafter keep a close eye on things and have a 5g carb snack to hand or indeed my insulin if it continues to rise. I have injected stacked corrections as close together as 20mins because levels continued to go up after the first correction but that can be the nature of protein release on a low carb diet.

 

[Proud to be erratic]

I see on this forum that some people take 'correction doses;. I take this to mean taking some insulin between meals to correct a wayward BG reading?

Correction can mean taking insulin between meals, @Merryterry. But it also can simply be a component of the bolus taken at or just before a meal time. So some of the bolus would be for the forthcoming food and some for correcting because for any one of some 40 other reasons your BG can be above your personal target.

My Diabeic nurse told me never take doses in between meals but just adjust the dose at the next meal and the next meal after that if neccessary. I will admit that was many years ago.

That advice was being quite strenuously advised during my DAFNE course last November.

Surelly by taking 'correcting doses' you can end up chasing your levels all over the place?

You certainly can end up chasing levels. Again my recent DAFNE course was preceded by a pre-course meeting some 3 weeks earlier. We each provided a brief introduction of our treatments and targets. At that pre-course meet the DSN very informally observed that probably 7 out of the 9 of us were "chasing" levels, over-correcting and most of us were accordingly taking more insulin than we really needed. During the 5 day actual course we kept DAFNE daily logs (or diaries) and collectively analysed each others diaries, being encouraged to make suggestions about what dosing changes might help or be appropriate for each other. By the end of the course most attendees had reduced their overall total insulin usage and were each looking potentially likely to have a net reduction in glycaemic variability - principally by stopping the instinctive tendency to take too many corrections.

What you remember from years ago @Merryterry still makes great sense and seems still wholly relevant today. Libre 2, or other CGM does give us a much improved picture of our BG movement over any 24 hr period. This does mean we can "tweak" more, either with snacks producing quite visible outcomes or small intermediate insulin "corrections". But the evidence from my DAFNE course was that people were still over- interfering and consequently using more insulin than they needed, day by day.

This applied to the 2 attendees who were not using CGM as well as most of the rest who were more routinely using CGM. One attendee had been T1 for only 3 months and had Libre 2; I was the next 'newbie' at nearly 3 years. The oldest and longest with T1 had well over 50 yrs experience and was adamant that CGM was not for her, but her T1 adult children either had Libre or were about to start using it.

Incidentally, I was the only person on my DAFNE course who felt that my body had increased insulin resistance when I am above 8 (better 7) and so needed to wait for my BG to drop, before eating. None of the others even seemed to recognise that situation and the lead DSN said she didn't understand why I did the waiting. I took the opportunity to question my Consultant when I had a face to face meeting last week; I do wait - but there is no question that it is an example of how my personal D management interferes with my daily living and affects my wife's best intentions of meal planning, etc. My Consultant confirmed that he thought I shouldn't wait for my BG to start dropping; that I should increase my total bolus for food and any correction by a percentage, perhaps 10% or even more [trial and learning needed]; that there wasn't really any medical evidence of my presumption of increased insulin resistance and the whole process of getting the balance 'right' was rather more complex. So I am experimenting with his suggestion to apply an increase to the calculated bolus. So far I have no conclusion; but I'm away from home, doing entirely different things including a lot of walking up and around the Rock of Gibraltar, enjoying 3 young granddaughter's time and antics and have no 'normal' right now. But I am eating family meals when they are served and not being anti-social and waiting; pre-bolus is also unrealistic just now for family meals (the indicated time frame is seldom met). Recent TIR is poor with lows (so far no hypos) after exceptional walks and a lot of highs.

 

[everydayupsanddowns]

Yes, I’m pretty sure it’s one of the major principles on DAFNE, which aims to simplify thungs and reduce variables and ‘tail chasing’.

Only take insulin (and any required correction) at mealtimes, thereby keeping doses pretty much independent of each other. And I think DAFNE attendees are encouraged to resist the temptation to check between meals because the dose that is dealing with that meal is still active and hasn’t finished yet.

Certainly this makes a lot of sense, and helps avoid the unpredictability some experience where two doses with onset / peak / fade act over the top of each other (eg peak can combine with peak and give more effect than you intended).

And DAFNE and it’s principles work. They have some of the best outcome data of any structured education programme for intensive diabetes management.

@Proud to be erratic ’s observations about over correcting, tail chasing and actually making glucose variability worse rather than better by fiddling too much are compelling!

If in doubt - simplify.

But interestingly, I was having this conversation via PM with a member recently. What about snacks? If you have something carby between meals it’s not practical to dose for that up front with your previous meal. The insulin could act too early, and you may not know you will be fancying to stop at that coffee shop mid-morning at breakfast time because you weren’t planning to go out.

And if DAFNE is about being able to ‘eat normally’ then an occasional snack ought to be part of the picture?

Plus I suspect it may partly have to do with

Like @helli I do correct between meals (and occasionally snack too). I’ve developed some rough rules of thumb and strategies to try to reduce errors. So as an example, if I was mid-range befor a meal and halfway between meals I’m flatlining at 10.5 I’d only consider giving sufficient insulin to reduce BG to 9.0, which is theoretically where the meal should have peaked, then I’ll let the earlier dose mop up the remaining meal carbs and get me back into range. Hopefully!

Part of my problem is I’m more of a guesstimator than a scrupulous measurer, so some of my med-point corrections are just adjusting the meal dose for the one it should have been 😉