How to lower high levels

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Caroline1967

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Type 2
Hi
I have been using tresiba and trurapi for just over a week now. Things seemed to be going well until today and now I am not sure.
I had 42 units of tresiba at 7 am this morning when my glucose tested 17. By breakfast everything had come down and looked fine.
I have lunch at 2pm I had 35 grams of carbs and used 4 units of trurapi. By 3pm glucose had risen from 9.5 to 14 I presume because I had eaten. It has just steadily risen more and is now 17.2 I have not had anything to eat since 2pm. I am now hungry but to be honest I am a bit anxious about eating anything if my glucose is not going to come down afterwards. The nurse I spoke to at the surgery told me to use trurapi 1 unit to 10 g of carbs and to use 42 units of Tresiba but to increase this if it is not enough. Is the raised glucose today mean that I am not having enough Tresiba? Or did I not have enough Trurapi? I am going to Spain on Sunday so can't ring the nurse for any advice. I know no-one can give medical advice and I am not really asking for it. I just wondered if anyone has been in the same position and can reassure me that my glucose will settle down!!
 
Have you done a basal test @Caroline1967 ? That should show if your Tresiba dose is right.

You were on Humulin M3 before? What were your doses on that?
 
I haven’t done a Basel test …. Not sure what that is! I will
Investigate!
 
Inka said:
I edited my post above @Caroline1967 How much Humulin M3 did you take?

Here’s basal testing:

www.mysugr.com

How To Successfully Test Your Basal Rate

Are you looking for basal rate information and testing instructions? Perfect! You're in the right place!
www.mysugr.com www.mysugr.com
Click to expand...
I took 36u in the morning and 30 at night. I thought 42 units of Tresiba seemed a lot less but I don’t really understand it all to be honest!
I will have a look at the basal testing site you have linked. I did Google it before your reply and it only mentioned type 1. Does it work the same way for type 2?
Thank you
 
Humulin M3 is 70% slow insulin, 30% fast. It’s possible that you were started on slightly less Tresiba than you need (for safety reasons). It’s not uncommon to do this. I’d try a basal test and then consider cautiously adjusting your Tresiba if necessary.
 
What level did you go to bed on on Thursday night for your levels to be at 17 on Friday morning? And what time did you eat on Thursday evening and what did you have? If it was early and nothing too fatty or fibrous like lentils, beans or wholemeal pasta etc and your bedtime level was in range then that would suggest that your Tresiba dose is not holding you steady.

Because Tresiba is a very long acting basal insulin, I believe it acts over about 36hrs, you need to adjust it so that it is keeping you steady overnight. If you are consistently rising overnight then your Tresiba dose is too small. I don't think basal testing for Tresiba through the day is all that helpful and this close to your holiday, you are going to struggle to complete it anyway, so I would look at your results for the last few nights and if you are consistently rising overnight, then that indicates you need to increase Tresiba. If the Tresiba has been holding you pretty steady overnight ie not rising or falling by more than about 2-3mmols, then you probably need to adjust your Trurapi ratios for your meals.
 
Hello @Caroline1967,

Barbara @rebrascora is right on the money here. Tresiba is a very long lasting basal and it's performance criteria make it a very different basal to any others. With an endurance of up to 40 hrs at a very steady and even profile, today's dose is topping up yesterday's dose. Since our body's requirement for background insulin is never a perfectly level or even requirement it is best to strive for the nominal 8+ hrs while asleep and thus optimise that daily dose to keep you safe and hypo free during that long fasting and relatively inactive period. Hence a basal test for Tresiba when done in conjunction with CGM is remarkably simple. If over 3 or 4 nights there is a steady trend of even, rise or fall then the evenness tells you it's good and the rise or fall that it's too low or high respectively.

But, getting that clear level performance ALSO needs you to adjust food, activity and bolus to bring you to an optimum starting BG level. I, as a T3c and with absolutely no pancreas whatsoever strive be be between 6 and 7 mmol/L as I go to bed in the expectation that I will wake up with a matching BG. All of this is easy to write but of course deceptively difficult to achieve. So if you start at 12 and end at 12 with a noticeable flat graph in between the Tresiba is good.

Getting that 12 back to 6 or 7 needs a sound appreciation of your correction (from your bolus) ratio for an evening correction; along with a realistic assessment of the fat content of that last meal before going to bed and thus how quickly or slowly that last meal will digest and thus match (or not) whatever bolus you've taken to accompany that meal; and of course for you to have a keen awareness of exercise and activity you have experienced in the last 24 (perhaps 48) hours- which can have such a big influence on how your metabolism will manage the food being digested and the relative resistance by your body to all of the insulin being taken.

This is not easy and takes time for you to get the measure of these mixed variables. These variables exist whatever basal insulin is being taken. So don't feel that this is all too much to wrestle with or that Tewsiba makes this more difficult (it doesn't!). But do accept that you might take a while to bring your starting BG level to where you want it and similarly some trial and learning from the variable responses before you can feel happy with various tweaks: not just tweaks to insulin but also to food quantities and types of meals (eg a full on pizza vs a simple piece of fish, with new potatoes and peas); along with decisions on types and timings of exercise.

Personally I'd start as soon as possible on adjusting Tresiba doses (if relevant) and accept that your coming holiday won't necessarily provide you with consistent lifestyle patterns over the holiday duration but gracefully accept more BG variation will occur for a while as you get the hang of all of this. Do your best, particularly to avoid hypos; reach for acceptable targets but do not beat yourself up if those targets aren't always achieved. If today didn't work as planned, look to see if there are lessons that can be learnt and if there aren't just park today, move on with a fresh start tomorrow.

Incidentally you asked does basal testing work the same way for T2 as T1. I am not medically qualified and with slight hesitation say YES. The principle with Multiple Daily Injections (MDI) to treat insulin dependency has to be to get the basal right then the faster bolus isn't trying to underpin an inadequate basal. There must be a certain amount of potential difference for T2s with their unusual high natural insulin resistance; one obvious marker that struck me from your post was my daily Tresiba doses range from 7.5 units in summer to 9 in winter - whereas you are quoting 42 units. However, even though the quantities are very different between you and I (and I presume my natural insulin resistance is very low) this shouldn't affect how a fasting period test is scrutinised to assess its effectiveness in holding anyone steady. I also don't think there is any sort of precise relationship between quantities of basal vs bolus insulin; there are people on just basal to help them manage their BG and conversely some T1s who started on both basal/bolus regimes but who have over time reduced their basal dose to zero. [Strangely (and originally this led me into one of several misleading rabbit holes) my very first Consult with an Endocrinologist by phone, during Covid lockdown included a comment in his written report about total basal should normally be roughly the same as bolus quantities; since I knew no different and was being told by a DSN what alterations I should be making to all my insulin doses as fixed quantities, without any reference to carb counting (!) I couldn't make any sense about my 2x daily Levermir basal dose totals being remotely near my 3x daily bolus doses - never mind any extra bolus corrections. That written remark along with other things from him led me to manipulating a change of Consultant from a different Hospital in the County.]

Sorry this is so lengthy. Enjoy your holiday; even if your BG levels are not as ideal as you might wish at this very early transition onto an insulin regime. Plenty of trial and learning ahead!
 
Thank you so much for everyone’s replies. I am waking up quite a bit higher than I went to bed. I am starting to adjust my Tresiba so hopefully that will help. I didn’t realise that different foods would make me react in different ways. I had a bar of chocolate ( which I haven’t had for a looong time!). I gave some Trurapi to account for it but I ended up using twice as much as I thought I would need before it started to come down again. I think I shall avoid chocolate! I have woken up this morning at 7.5 which is nice! I am off on my cruise at 12.15 today and hopefully I will manage to keep things under control! Thanks again for your help!
 
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