Getting the basal units right

[digihat]

Good Evening Everyone

I'm trying to nail my rough basal amount I've been on toujeo 32 units for awhile as I thought found the right amount as my mornings were out of double figures and occasionally staying steady with not much of a rise compared to pre 30 units. My overnight levels tend to rise most nights looking back at CGM although ive not had a good run with last few CGM's being way off with lows so ended up turning off the alarms altogether now. There will be the dawn phenomenon mixed in no doubt plus I wake up alot in the night can fall asleep fine normally

I've inadvertently done a basal test a few days last week as I occasionally skip breakfast my levels gradually fall until lunch time which if ive read correctly implies I'm taking too much basal? I inject first thing in the morning about 7:00am. The two graphs are from last two days have had breakfast. None of the highlights were actually low below often mid 4's to low 5's upon finger prick

Carb ratio is 1:12 barely had any actual hypos since this change,even though my time in range below 3.9 is 13%.... Ignoring CGM aside

 

[everydayupsanddowns]

I've inadvertently done a basal test a few days last week as I occasionally skip breakfast my levels gradually fall until lunch time which if ive read correctly implies I'm taking too much basal?

Yes that would be my understanding too - if you only have basal active (no food meal insulin on board) ideally your BG should stay within +/- 1.7mmol/L

There’s a good writeup of how to carry out a full basal here, and things to bear in mind.

https://www.mysugr.com/en/blog/basal-rate-testing/

I inject first thing in the morning about 7:00am. The two graphs are from last two days have had breakfast. None of the highlights were actually low below often mid 4's to low 5's upon finger prick

I think with Toujeo, the long action of the insulin up to 36 hours, means that the timing of the injection has less impact, because each dose overlaps with doses from the previous day (or possibly even days!)

If you are changing your dose, it can also take 3-4 days for the new dose to bed in, so you may need a little extra patience if tweaking your dose 🙂

 

[Tdm]

Not sure if i am missing something here, but your levels go up overnight midnight to 6am (about 5 m/mol).
That implies to me that your basal is too low.

If you're on a 24 hour basal or more, i would say the job of your basal is to keep your levels flat overnight.

During the day, you can adjust via quick acting insulin / food, and levels of excerise will confuse matters anyway.

 

[everydayupsanddowns]

Not sure if i am missing something here, but your levels go up overnight midnight to 6am (about 5 m/mol).
That implies to me that your basal is too low.

But @digihat’s levels drop through the morning when he only has basal active, which can be interpreted that basal is too high.

I wonder whether the rise overnight is due to Dawn Phemonenon - which does make things extra tricky as it can be like having a ‘meal’ overnight.

Basal on MDI can be a bit of a ‘Hobson’s Choice’, and it seems like if @digihat set basal high enough to counteract DP, it would be far too high during the day and cause problems there.

Some members find it helps to have a shorter acting basal like Levemir where they can have higher or lower doses running daytime and overnight as needed.

It’s a tricky one for sure!

 

[digihat]

Not sure if i am missing something here, but your levels go up overnight midnight to 6am (about 5 m/mol).
That implies to me that your basal is too low.

If you're on a 24 hour basal or more, i would say the job of your basal is to keep your levels flat overnight.

During the day, you can adjust via quick acting insulin / food, and levels of excerise will confuse matters anyway.

Normally I would agree with what you've said above and increase it however I get some nights where the lines stay steady such as last night which I have put below but the previous two rose quite alot by the morning. As you can see below it is already starting to gradually fall. @everydayupsanddowns

 

[helli]

@digihat do you exercise more on some days than others?
The reason I ask is that I notice my Dawn Phenomenon is far less pronounced on the day AFTER intensive (rising heart rate) exercise.

 

[digihat]

But @digihat’s levels drop through the morning when he only has basal active, which can be interpreted that basal is too high.

I wonder whether the rise overnight is due to Dawn Phemonenon - which does make things extra tricky as it can be like having a ‘meal’ overnight.

Basal on MDI can be a bit of a ‘Hobson’s Choice’, and it seems like if @digihat set basal high enough to counteract DP, it would be far too high during the day and cause problems there.

Some members find it helps to have a shorter acting basal like Levemir where they can have higher or lower doses running daytime and overnight as needed.

It’s a tricky one for sure!

This is the mystery at the moment i believe it is dawn phenomenon that is the culprit but last night was more steady which I've put in my last reply. With looking at this morning blood sugar was 7.2 nearly at 6.2 now this after an hour which to me implies too much basal.

 

[digihat]

@digihat do you exercise more on some days than others?
The reason I ask is that I notice my Dawn Phenomenon is far less pronounced on the day AFTER intensive (rising heart rate) exercise.

I do gym with mainly weights twice a week beyond that just some light few mile walks more at a slower pace due to low blood sugars coming up have got better at timing trying to make sure its after rapid has worn off now

 

[helli]

I do gym with mainly weights twice a week beyond that just some light few mile walks more at a slower pace due to low blood sugars coming up have got better at timing trying to make sure its after rapid has worn off now

Even though the rapid insulin has warn off, the affect of exercise can last up to 48 hours.
I would recommend tracking your morning BG against the previous day's exercise (especially the weights).
I have always reduced my basal the night after exercise but this is only possible with one of the shorter lasting long acting basals (in other words, not Tresiba).

 

[everydayupsanddowns]

I have always reduced my basal the night after exercise but this is only possible with one of the shorter lasting long acting basals (in other words, not Tresiba).

Insulin manufacturers seem obsessed with longer and longer-acting basals. As if it is the physical taking of the injections that is the biggest ‘downside’ to insulin use?!

It’s always struck me as a fundemental misunderstanding of what makes diabetes hard to live with.

 

[rebrascora]

Can I just clarify those 2 graphs in your first post.... are they when you had breakfast or you didn't? Your comment suggests you had breakfast but not sure if that is a typing error....

The two graphs are from last two days have had breakfast. None of the highlights were actually low below often mid 4's to low 5's upon finger prick

If your levels are dropping steeply like that on just basal that is surprising and concerning. If however these were morning when you DID have breakfast as the quote from your post above suggests then you are having too much insulin or prebolusing too far in advance.

Like @helli my overnight levels after exercise are very susceptible to the effects of that exercise and I have to reduce my night time dose of Levemir to try to prevent hypos. My muscles suck glucose out of my blood whilst I sleep at a very significant rate and I can often be really steady at bedtime but the minute I fall asleep, my levels start to drop. I would suggest you look for a correlation between exercise and the overnight graph following it.

The BG rising when you go to bed could be pizza effect depending upon what you ate and when you ate it. Do you have a note of what the evening meals were preceeding those graphs and when you ate them.

 

[digihat]

Can I just clarify those 2 graphs in your first post.... are they when you had breakfast or you didn't? Your comment suggests you had breakfast but not sure if that is a typing error....

If your levels are dropping steeply like that on just basal that is surprising and concerning. If however these were morning when you DID have breakfast as the quote from your post above suggests then you are having too much insulin or prebolusing too far in advance.

Like @helli my overnight levels after exercise are very susceptible to the effects of that exercise and I have to reduce my night time dose of Levemir to try to prevent hypos. My muscles suck glucose out of my blood whilst I sleep at a very significant rate and I can often be really steady at bedtime but the minute I fall asleep, my levels start to drop. I would suggest you look for a correlation between exercise and the overnight graph following it.

The BG rising when you go to bed could be pizza effect depending upon what you ate and when you ate it. Do you have a note of what the evening meals were preceeding those graphs and when you ate them.

Apologies @rebrascora will clarify the graphs for you. The graphs in the last two posts are from the last two days where I did have breakfast Saturday/Sunday where I had rapid insulin. I had done one or two days during the week where I didn't have breakfast and observed the general trend heading down. Observing same affect this morning which I will show below

Yeah exercise is the main thing I'm still getting used to with adjusting everything slowly getting there a lot of experimenting.

I don't have a full note of what I eat those days but the times of the last meals were 20:15pm on the 8th and 9th about 7:00pm. I did have cheese toast on the Saturday evening which was the 7:00pm beyond that I barely eat breaded products these day's due to celiac disease.

The graph from this morning where I only have done my basal

 

[digihat]

If your levels are dropping steeply like that on just basal that is surprising and concerning. If however these were morning when you DID have breakfast as the quote from your post above suggests then you are having too much insulin or prebolusing too far in them.

Forgot to address your other comment @rebrascora apologies I often get those steep declines after a meal although I normally pre bolus about 15 mins before a meal with 1:12 ratio prior to doing that I was having alot of hypos after food when doing 1:10 haven't had many hypos recently since the switch

 

[rebrascora]

Are you treating those steep declines after meals with a few carbs or are they levelling out without any other intervention? From the sharp bounce back up on those first 2 graphs, it looks like you give it a few fast acting carbs and it goes up sharply but then comes back down again. To me if you are needing a few carbs to push it back up, that indicates that 1:12 is still too much, so maybe try 1:15 and I would suggest that 15 mins is probably too long prebolus time, so maybe try injecting just 5 mins before you eat. If you spiked after eating you would need more prebolus time but you are dropping straight away, so you need less time. Those would be my thoughts.

How many slices of cheese on toast are we talking on Sat night? I slice probably wouldn't have too much impact but 3 or 4 slices could definitely have pizza effect and cause that significant rise through the night.

 

[rebrascora]

It may also be that your day and night time basal needs are too disparate for the Toujeo to cope with and you might be better with a shorter acting basal like Levemir which you inject morning and evening and can adjust separately for your day and night time needs and also adjust for exercise. Toujeo is not very flexible in this respect.

 

[digihat]

Are you treating those steep declines after meals with a few carbs or are they levelling out without any other intervention? From the sharp bounce back up on those first 2 graphs, it looks like you give it a few fast acting carbs and it goes up sharply but then comes back down again. To me if you are needing a few carbs to push it back up, that indicates that 1:12 is still too much, so maybe try 1:15 and I would suggest that 15 mins is probably too long prebolus time, so maybe try injecting just 5 mins before you eat. If you spiked after eating you would need more prebolus time but you are dropping straight away, so you need less time. Those would be my thoughts.

How many slices of cheese on toast are we talking on Sat night? I slice probably wouldn't have too much impact but 3 or 4 slices could definitely have pizza effect and cause that significant rise through the night.

Most of the time I dont end up doing an intervention and it tends to sort itself out/level. I need to intervene once in awhile or as I have been seeing recently secondary spikes seem to happen. Should the come down be more gradual after eating compared to the sharp decline that happens to me most of the time? Something I have wondered about that. I check when libre gives me a low warning but most of the time recently I have been in range when checked. I only do finger pricks for rapid calculations now. In terms of the carb ratio I have wondered about upping the carb ratio recently might give that a try once I reduce the basal as based what people are saying need to have a look closer first. Due to the basal tests as it fell by about 3 mmol this morning no food etc.

It was about 3 slices from what I remember looked back on previous graphs does tend to rise after eating that have it once a week. I remember having been pizza not long after getting out of hospital post dka that was a rough night afterwards generally avoiding it since

 

[digihat]

It may also be that your day and night time basal needs are too disparate for the Toujeo to cope with and you might be better with a shorter acting basal like Levemir which you inject morning and evening and can adjust separately for your day and night time needs and also adjust for exercise. Toujeo is not very flexible in this respect.

Im due to see DSN in April will mention it to them sse what they think I have some stable nights comparatively to the graphs I shared. Yeah I've been getting that sense recently regarding Toujeo generally its worked for me so far in first few months since diagnosis but probably getting to the stage now tweaking things more

 

[Inka]

Insulin manufacturers seem obsessed with longer and longer-acting basals. As if it is the physical taking of the injections that is the biggest ‘downside’ to insulin use?!

It’s always struck me as a fundemental misunderstanding of what makes diabetes hard to live with.

It’s just where the money is. When MDI came in, it was all “Look, people! 4 injections a day are much better than two!” Now it’s “We’re working on a basal insulin that you’ll only have to take once a week - won’t that be a lot better?”

 

[helli]

It’s just where the money is. When MDI came in, it was all “Look, people! 4 injections a day are much better than two!” Now it’s “We’re working on a basal insulin that you’ll only have to take once a week - won’t that be a lot better?”

When I read the report about the once a week insulin, I remember that it was targeted more at people with type 2 rather than Type 1.
If you only take basal, I can see the advantage but when we are taking a bolus every time we eat, the overhead of basal is pretty small and reducing this overhead comes at a huge cost of less flexibility.