Correction Doses

[IainB]

Hi all,
I am taking Lantus and Novorapid insulin and over the last week my BG (Dexcom 1+) has been unusually high for long periods 13-17mmol and the Novorapid seems to be having very little effect.
Yesterday I spoke to one of the diabetic nurses in the hope of the Novorapid being changed to one of the faster acting ones. I was told that I shouldn’t give correction doses until it went above 17mmols and they wouldn’t consider changing the Novorapid until I was needing 60-70 units a day.
Any opinions would be gratefully received, thanks

 

[helli]

I have not been discouraged from taking corrections when my BG is greater than 10 mmol/l about 3 hours after my last bolus and would certainly do so earlier if my BG was higher than 15.
I changed to use Fiasp about 3 years ago. My TDD (bolus and basal) is less than half of the dose your DSN is suggesting.

I have a few thoughts about your situation
- are you checking those Dexcom highs with a finger prick? CGMs have a tendency to over-egg highs so you may not be as high as you think.
- in my experience corrections to a BG over 15mmol/l can be very resistant. I need twice my usual dose and it takes longer to start working. This affect is even greater with Fiasp (it can take 90 minutes to start working when my BG is high) which is one reason why I work hard to minimise these kind of highs.
- have you tried changing your injection sites? Is it possible you have built up some resistance in your usual sites? I appreciate you have been doing this "diabetesing" longer than I so I apologise if I am treating you to suck eggs.
- there is a greater fear of hypos from HCPs as we get older. And even though I am younger than you, I have noticed our age is often treated as a number rather than looking at the fitness of the person. I wonder if your age is the reason for your DSN''s comments and reluctance to change to Fiasp or "the other one" as they can appear "unstable" until you understand their quirks.

 

[rebrascora]

I have had to increase my basal insulin since the weather got colder and I am into my winter daytime doses already!
I correct at 9.2 which is where my high alarm is set. That is partly because I follow a low carb way of eating where protein is releasing once I get to that level and like @helli I use Fiasp which I find is unresponsive once my levels get above 10, so I too proactively work to keep it below that level. At 15 I need much bigger correction doses and generally I stack them, sometimes within an hour of each other to bring levels down. I am very careful to log all the insulin I inject on my Libre so I can check back to see how much is left active when my levels get down to 5 or 6mmols and then if they are still dropping fast I will have a jelly baby or two to level it out.

I don't know about Lyumjev, but Fiasp can be quirky and I had two very frustrating 3 month trials of it, before I managed to figure out a way to make it work for me and that included ignoring those guidelines about only correcting at mealtimes and when levels are over 10 and not stacking corrections. I get on well with it now and I like the fact it is quite short lived for me and is generally finished working in about 3 hours, but it has taken a lot of time and effort to develop these strategies. No one has called me out on them, but I don't have a DSN and just have a telephone appointment with the consultant once a year. As far as I am concerned, I live with my diabetes and this insulin and my lifestyle 24/7 so it is up to me to find the best way to make this insulin work for me and as long as I get good results and don't need assistance, then I am not doing anything "wrong" and I would challenge anyone who suggested otherwise.

We are all different and my approach would likely not work, or even be dangerous, for others, partly because this approach has been developed to cope with my low carb way of eating, but I would not be happy with a DSN telling me I am not "allowed" to correct under 17 and how would she stop me anyway! It is my life and I use my medication to the best of my ability, to get good results. If my results are consistently bad, then they can criticize the decisions I make.

I also think that having CGM means that we can keep ourselves a lot safer when doing corrections at lower doses these days, so perhaps part of your nurse's reticence is that she is following old school thinking and sticking to "the rules" rather considering the benefits of modern technology and giving individualised advice, taking into consideration your experience and fitness and mental awareness.

Just my thoughts. I should say that I am generally a very compliant sort of person but I found that all these "rules" about corrections were hindering me in managing my diabetes well and that frustrated me, so I make my own "rules" now.

 

[trophywench]

Nah that's not an old rule - cos I've never heard of it! We were told to only ever have corrections when bolusing for the next meal, not between meals or at other times and not to do one if your BG was less than 13ish.

Probably a daft question @IainB - but as well as trying a 'virgin' site, are you 1,000 per cent positive that Novorapid is OK and if you're not 1,000 per cent sure, have you got any other cartridges you could try instead? I've certainly, more than once in the last 25 years of using it - had cartridges out of the same box - or vials with the same date and serial number - that just don't work right cos the contents have 'gorn orf' for no apparent reason so my judgement tells me that summat or another must have happened to it, like being unfridged for too long, before it actually got to me and into my fridge.

 

[IainB]

I have not been discouraged from taking corrections when my BG is greater than 10 mmol/l about 3 hours after my last bolus and would certainly do so earlier if my BG was higher than 15.
I changed to use Fiasp about 3 years ago. My TDD (bolus and basal) is less than half of the dose your DSN is suggesting.

I have a few thoughts about your situation
- are you checking those Dexcom highs with a finger prick? CGMs have a tendency to over-egg highs so you may not be as high as you think.
- in my experience corrections to a BG over 15mmol/l can be very resistant. I need twice my usual dose and it takes longer to start working. This affect is even greater with Fiasp (it can take 90 minutes to start working when my BG is high) which is one reason why I work hard to minimise these kind of highs.
- have you tried changing your injection sites? Is it possible you have built up some resistance in your usual sites? I appreciate you have been doing this "diabetesing" longer than I so I apologise if I am treating you to suck eggs.
- there is a greater fear of hypos from HCPs as we get older. And even though I am younger than you, I have noticed our age is often treated as a number rather than looking at the fitness of the person. I wonder if your age is the reason for your DSN''s comments and reluctance to change to Fiasp or "the other one" as they can appear "unstable" until you understand their quirks.

Thanks helli, I have been checking my Dexcom with finger pricks and have been very surprised at how accurate it is
I think I’ll ignore the 17mmol for correction doses and try a bit harder to work with my current insulin and my old age.

 

[IainB]

Nah that's not an old rule - cos I've never heard of it! We were told to only ever have corrections when bolusing for the next meal, not between meals or at other times and not to do one if your BG was less than 13ish.

Probably a daft question @IainB - but as well as trying a 'virgin' site, are you 1,000 per cent positive that Novorapid is OK and if you're not 1,000 per cent sure, have you got any other cartridges you could try instead? I've certainly, more than once in the last 25 years of using it - had cartridges out of the same box - or vials with the same date and serial number - that just don't work right cos the contents have 'gorn orf' for no apparent reason so my judgement tells me that summat or another must have happened to it, like being unfridged for too long, before it actually got to me and into my fridge.

I did think of that so I changed the cartridge to be sure both for my Novo and Lantus.
I have lived with urine testing, finger pricks and now sensors and in the past would only correct when bolusing for next meal but with the advent of CGM I now think if alarms are properly set we can safely bolts between

 

[nonethewiser]

Thanks helli, I have been checking my Dexcom with finger pricks and have been very surprised at how accurate it is.

Although using different Dex device I find same thing, that they are very accurate at higher levels as before with Libre they could be way off.