Increasing insulin

[JellyBaby21]

Recently diagnosed T1d. I'm still trying to find the right level of long acting insulin. Started on 6 units twice a day and am now on 9 units twice a day. Fast acting ratio is 1:10 but I eat very low carb so have not used it much - just 2 units with breakfast and 1 at lunch if I have an apple with it.

Today I finally got a row of good readings: 4.7 before breakfast, 5.0 before lunch. Then 2 hours after lunch I got 11.5 so I decided to correct with 1 unit of rapid insulin. It worked and an hour later I had 6.1. Then before evening meal was 6.5.

So my question is, should I correct using rapid insulin or is it more likely that I still need to up my slow acting still? How do you know which you need more of? The pattern for me so far has been lowest first thing and then creeping up in the afternoon. Highest at evening meal/before bed.

 

[rebrascora]

Hi

Just to clarify..... Are we talking about your basal insulin being Levemir?

If you are finding morning readings are lowish then it is going higher as the day goes on, then it suggests that you may need more daytime basal and perhaps a little less at night. What I find with Levemir is that I need a lot more during the day (currently 22 units) but very little (only 4) at night. Health care professionals start you off on an even split but very few people's bodies need the same amount of basal day and night and the beauty of Levemir is that it allows you to adjust thm separately although there is a bit of overlap, which is why I suggest that a bit less for the evening dose may be wise.

However, a one off situation is not something to warrant a change of basal dose. Usually you are looking for a pattern of 3 days before you make a change in basal and that is the guideline recommended on the DAFNE (Dose Adjustment For Normal Eating) course which is the "gold standard" for patient education in MDI insulin usage..... So if this is just something that has happened today, then the advice would probably be to use your bolus insulin to do corrections and if it is a repeated problem that isn't related to miscalculation of carbs over a few days (not necessarily consecutive but enough to see a pattern) then a basal adjustment would be recommended and I would suggest that it is only your morning dose that needs increasing, but perhaps a slight evening reduction might be wise as the extra overlap of the increase daytime dose could be enough to drop you low overnight and waking on 4.7 is a bit low anyway.

Do you have freestyle Libre so that you can see what your levels are doing overnight?

 

[JellyBaby21]

Hi. Yes Basal insulin and it is Levemir. Novorapid is my bolus insulin.

 

[JellyBaby21]

Thank you, your reply is hugely helpful. Lots I didn't know there. So you only really correct with bolus if you got meal count carbs wrong - it's not to be relied on daily, have I understood that correctly?

For the last week my readings have been creeping up from early afternoon to bedtime so a definite pattern there. But I have only been on 9 units am and pm for 2 days so I will see what happens tomorrow (without bolus correction unless I make a mistake with carb count) and then increase morning basal by another unit (I will check with DSN to confirm) . Still so much to learn but it's fascinating and I'm just so relieved my levels are coming down and I am beginning to have some understanding finally. Thank you!

 

[JellyBaby21]

No I don't have the Freestyle Libre unfortunately as they have still not officially confirmed T1d. I have no idea how long that will take as I keep getting different answers.

 

[rebrascora]

Sorry, I may not have been totally clear..... No problem using a corrective dose if your levels are creeping up after a meal instead of coming down as long as you take into consideration that you may still have active insulin on board from the meal, which could drop those levels within the 5 hour period of activity, so probably better to add a correction to your next meal time dose at this stage if you need it rather than injecting corrections between meals..... especially when you don't have Libre to be able to see what is happening between finger pricks. If you had a low carb lunch with no NovoRapid, then it is reasonable to use a corrective dose mid afternoon if levels are rising, but do not be tempted to add a further correction to your next meal time dose if it is within the 5 hr activity period of the NR.

If you don't have Libre yet and therefore can't see what is happening overnight, I would be quite concerned about you waking up under 5, so I would encourage you to reduce that evening Levemir dose a bit and that will be more important if you decide to increase your daytime dose, so if for example you were to increase your daytime dose by 1 unit, I might be inclined to reduce the evening one by 2 and see how that goes. BUT.... you should really run any changes past your DSN particularly if they have not authorized you to make adjustments to your basal insulin. I find basal insulin can be much more powerful than bolus insulin...... By that I mean.... I might need 2 or 3 corrections totaling 7 or 8 units of bolus insulin to keep my levels in range, but an increase of 2 units of Levemir the next day will mean that I don't need any corrections..... so those 7-8 units of bolus insulin were effectively replaced by 2 units of Levemir and I get a lovely steady graph again and none of the frustration because I am not having to fight my rising levels or making myself into a pincushion with corrective doses. Conversely, Levemir will drop me like a stone if the dose is too high and that is particularly true after exercise. The way it works for me is that I need to dial my evening dose back by 2 units if I have had a very active day or done prolonged exercise. If I have 2 consecutive days of activity/exercise, I need to reduce my evening dose by another 2 units and so on. Once I get to a zero evening dose (gotta love one less injection a day ) I have to start reducing my daytime dose otherwise I will have persistent nocturnal hypos. This maybe specific to me and my diabetes/body, but don't kid yourself that your basal dose can't cause some really nasty hypos if you get it wrong and nocturnal ones can be dangerous, so always err on the side of caution with it, at least until you get Libre and can keep a better eye on things.

 

[JellyBaby21]

OK I understand. Very clear thanks. I will not do anything without running it past my DSN I promise. I just like to be informed and get ahead in my understanding. What you have said has cleared up a lot of questions for me. Thank you so much for sharing how things work for you x

 

[rebrascora]

Something else to know, if you intend to continue with a low carb diet and may be having an impact here with what you are experiencing.... "Protein release".... In the absence of enough carbohydrate, your body will break down protein and fats into glucose for fuel. Approx. 40% of protein and 10% of fat will produce glucose, so to all intents and purposes, unless you are eating huge amounts of fat, you don't have to worry too much about that, but the protein can have an impact and cause levels to rise about 2 hours after a low carb meal. Protein release is slow and steady.... more of an upward drift rather than a sudden spike like carbs produce, so it is quite east to catch it before it goes too high and bring it down with some fast acting insulin.
So for example, for me (and once again we are all different) if I had a 2/3 egg omelette for brunch with a side salad and coleslaw, I probably would not need any bolus insulin in advance of the meal, unless my levels were above range to start with and I needed a correction, but I would probably need a couple of units 2 hours later as the protein started to break down and release glucose into my blood stream. This has been very much trial and error for me and I don't try to calculate it, I just watch my levels (so easy with Libre ) and when I start to see them steadily rise, usually about 2 hours after the meal, I bung in a small dose of fast acting insulin (a correction if you like) to deal with it.
Many people will tell you that this makes low carb really complicated but actually with Libre, I find it really easy because most of the time I don't really have to do any weighing or calculations, I just respond to the trend arrow on my Libre. Some meals will nees a unit or two up front for a few carbs in the meal and then another jab 2 hours later with a couple of units or so for the protein but for me that is so much easier than weighing and calculating carbs and insulin doses on a regular basis. Can't remember the last time I weighed anything I ate and even if I go off piste with my diet and eat carbs, I just guess and correct later depending upon what my Libre arrows show is happening..... either a small carb boost like a dried apricot or a unit or 2 after the meal just to nudge my levels in the right direction and keep them in range. Admittedly I need to keep an eye on my Libre to do it but it takes a lot of the mental strain out of my diabetes and I see it more as a game where I use a small dose of insulin or a little few carbs to gently keep my levels from dropping below or above my range threshold of 3.9 and 10. Not sure that that will make much sense to you now when you don't have Libre but hopefully it will when you do.
Talking of which, have you considered applying for the free 2 week Libre trial ie a free sensor, if you have a compatible phone to scan it and not used Libre before. If you go to the Abbott Laboratories website you will find details of how to apply for it. You don't have to be Type 1 for the free trial, just be diabetic.

 

[JellyBaby21]

Hi. Yes this does make sense to me. I think I agree with you that low carb and adjust for proteins 2 hours later is easier than including lots of carbs. And I have eaten low carb for the last 3 or 4 years so am very used to it anyway. I saw the free trial for the Freestyle Libre 2 and have ordered one thanks. Really stable results today all ranging from 5.1-5.5 until this evening about 1 hour after eating when I got 8.1. Will see what bedtime reading is. This is with basal still at 9 units am and pm. 2 units of bolus with breakfast only (I introduce a small bowl - 15.5g carb - of porridge for breakfast earlier in the year to introduce oats into my diet as a healthy complex carb). The protein thing I have heard a few times - was hoping the porridge and high amount of non-starchy vegetables might help prevent this. My DSN said we'll see what happens but I agree it's something to keep an eye on. I don't eat huge amounts of fat no.