Insulin sensitivity

[Lily123]

Hi,
I’m finding that the last few days my numbers are around 5 when I do my BG test and injection for dinner but then in the 5 minutes in between doing my injection and eating dinner I’m going hypo. I also scan the Libre just before I do my injection and it says stable! Does anyone have any ideas what’s happening in those 5 minutes to make my BG react to the insulin that quickly?

 

[Pumper_Sue]

Hi,
I’m finding that the last few days my numbers are around 5 when I do my BG test and injection for dinner but then in the 5 minutes in between doing my injection and eating dinner I’m going hypo. I also scan the Libre just before I do my injection and it says stable! Does anyone have any ideas what’s happening in those 5 minutes to make my BG react to the insulin that quickly?

Hello Lily, the easiest way to find out is don't inject at your usual time and just monitor your blood sugars for 15 mins. Ask your Mum nicely to delay your meal by 15 mins so you can see what is happening🙂 This way you will soon find out if it's your basal doing the big dipper. 🙂

 

[Lily123]

Hello Lily, the easiest way to find out is don't inject at your usual time and just monitor your blood sugars for 15 mins. Ask your Mum nicely to delay your meal by 15 mins so you can see what is happening🙂 This way you will soon find out if it's your basal doing the big dipper. 🙂

Yes that’s an idea! I’ll do that tomorrow. dinner normally varies from 5:30 to 5:45 each day so it might be the basal. If it is the basal that will help my case in getting a pump. The basal is Tresiba, I was thinking about asking about Levemir as it may help to be able to have better control but I wouldn’t remember to do both injections

 

[Proud to be erratic]

Hello Lily, I have way less experience than yourself in this DM world but I did start on Novarapid and 2x daily Levermir, before moving to Tresiba mid 2021.

I had no problem with forgetting my 2x daily; I did one as soon as I got out of bed and the second at the same time as my bolus for dinner. The routine was sufficient to keep me on track. When I had the odd lie-in, I would either take the basal late or jab at 7am and go back to sleep.

However I asked to move to 1x daily basal and was put on Levermir - which seems to be working for me. Until that change I only had experience of the basic, single unit, disposable pens. I knew nothing else so accepted them for what they were - with the occasional frustration of jamming mid injection and then the angst of not knowing how much insulin had reached me. The Tresiba "soft" pen was a revelation to me: somehow so much more pleasant to use (yes, I know that sounds silly - injecting really isn't pleasant). A short while later I was changed onto the Nova Echo pen with replaceable cartridges to allow me to bolus in 1/2 units. That was a second revelation - another pen which was so much nicer to use.

Regarding your going hypo just before dinner: as a male this is not my field of expertise, but I have a daughter and 3 grand-daughters, one in your age group. This could be hormones in reverse. It would be normal at your age to have growth spurts, your growth hormone is very active in your teens and if there has been a spurt, there must inevitably be a pause (or the spurt isn't a spurt, just a constant!). Also estrogen, cortisol and adrenaline are hormones that trigger the liver to release glucose. So you'd found a general formula for bolus ratios etc based on what your body used to be doing, but now (perhaps just sometimes) isn't doing, ie not creating glucose because the hormone routinely triggering your liver to release glucose wasn't playing!

Also, for me and my particularly brittle form of DM as a T3c, 5 is too low for me to take pre-bolus. The insulin arrives before there are carbs to work with and of course if the dinner has a relatively low GI then those carbs take longer to metabolise and get into the bloodstream; so a hypo is inevitable. At 5, I either take just one JB to give my BG a tiny boost or take my bolus immediately before eating. That one JB seems to arrive remarkably quickly.

My other thought on this is that as we get older things change, including one's metabolic processes and that is probably more pronounced in your age group than mine, on the wrong side of 70. I have no doubt that you and your parents have adjusted your formulas as you got older; this could be another moment when adjustment is a "normal" task.

I hope you can move forward on getting a pump; that is also my aspiration. Have you coupled your Libre to a CGM app? I found the Diabox app earlier this year and now struggle to imagine how others cope without CGM! When I'm 5 or lower I switch from 5 minute monitoring intervals to 1 minute intervals and watch what is going on minute by minute, responding accordingly. I'm on an android phone; there are currently some problems with ios and Diabox.

 

[PattiEvans]

When I was on Levermir which I took twice a day, in the morning around 8 am and again before bed, I constantly had hypos around 5:30 - 5:45pm. I tried every way to stop these hypos, but it appears that I need very little insulin in the period from about 2pm to 6pm. Those hypos were the main reason I got a pump. I now have my pump set with just 0.05u per hour during those hours. Obviously I am a lot older than you @Lily123 but it's worth you writing these hypos down along with the other reasons you think you would benefit from a pump.

 

[Lily123]

Hello Lily, I have way less experience than yourself in this DM world but I did start on Novarapid and 2x daily Levermir, before moving to Tresiba mid 2021.

I had no problem with forgetting my 2x daily; I did one as soon as I got out of bed and the second at the same time as my bolus for dinner. The routine was sufficient to keep me on track. When I had the odd lie-in, I would either take the basal late or jab at 7am and go back to sleep.

However I asked to move to 1x daily basal and was put on Levermir - which seems to be working for me. Until that change I only had experience of the basic, single unit, disposable pens. I knew nothing else so accepted them for what they were - with the occasional frustration of jamming mid injection and then the angst of not knowing how much insulin had reached me. The Tresiba "soft" pen was a revelation to me: somehow so much more pleasant to use (yes, I know that sounds silly - injecting really isn't pleasant). A short while later I was changed onto the Nova Echo pen with replaceable cartridges to allow me to bolus in 1/2 units. That was a second revelation - another pen which was so much nicer to use.

Regarding your going hypo just before dinner: as a male this is not my field of expertise, but I have a daughter and 3 grand-daughters, one in your age group. This could be hormones in reverse. It would be normal at your age to have growth spurts, your growth hormone is very active in your teens and if there has been a spurt, there must inevitably be a pause (or the spurt isn't a spurt, just a constant!). Also estrogen, cortisol and adrenaline are hormones that trigger the liver to release glucose. So you'd found a general formula for bolus ratios etc based on what your body used to be doing, but now (perhaps just sometimes) isn't doing, ie not creating glucose because the hormone routinely triggering your liver to release glucose wasn't playing!

Also, for me and my particularly brittle form of DM as a T3c, 5 is too low for me to take pre-bolus. The insulin arrives before there are carbs to work with and of course if the dinner has a relatively low GI then those carbs take longer to metabolise and get into the bloodstream; so a hypo is inevitable. At 5, I either take just one JB to give my BG a tiny boost or take my bolus immediately before eating. That one JB seems to arrive remarkably quickly.

My other thought on this is that as we get older things change, including one's metabolic processes and that is probably more pronounced in your age group than mine, on the wrong side of 70. I have no doubt that you and your parents have adjusted your formulas as you got older; this could be another moment when adjustment is a "normal" task.

I hope you can move forward on getting a pump; that is also my aspiration. Have you coupled your Libre to a CGM app? I found the Diabox app earlier this year and now struggle to imagine how others cope without CGM! When I'm 5 or lower I switch from 5 minute monitoring intervals to 1 minute intervals and watch what is going on minute by minute, responding accordingly. I'm on an android phone; there are currently some problems with ios and Diabox.

Hi,I use Tresiba in a NovoPen Echo (both pens are the same colour so that’s an issue) I have the Libre 2 and use it with the LibreLink app. It could be hormones like you say but insulin usually take 15-20 minutes to work for me (NovoRapid) and bolusing on 5 is normally okay for me and I’ve bolused on 4.1 waited 10 minutes for dinner and haven’t gone hypo

 

[Lily123]

When I was on Levermir which I took twice a day, in the morning around 8 am and again before bed, I constantly had hypos around 5:30 - 5:45pm. I tried every way to stop these hypos, but it appears that I need very little insulin in the period from about 2pm to 6pm. Those hypos were the main reason I got a pump. I now have my pump set with just 0.05u per hour during those hours. Obviously I am a lot older than you @Lily123 but it's worth you writing these hypos down along with the other reasons you think you would benefit from a pump.

The hypos before and during dinner, I start to feel hypo just before eating and just ignore it until I’ve eaten (I couldn’t drink a glucose drink straight before dinner and the dinner normally solves the hypo) I do think that Levemir may help (I was originally on Lantus before Tresiba) but I’m unsure if it would help because it’s in such a certain timeframe that the hypos are happening

 

[Lily123]

That is curious @Lily123, perhaps you could do a finger prick test while you are 'feeling' the hypo at dinner time. The Libre could be giving shaky readings. Does the Libre graph show the hypo as a brief dip?

I normally pick up on the hypo before the Libre does,which confuses me even more
The hypo was at roughly 17:55 and this is what the Libre said after dinner

 

[Proud to be erratic]

Hi,I use Tresiba in a NovoPen Echo (both pens are the same colour so that’s an issue) I have the Libre 2 and use it with the LibreLink app. It could be hormones like you say but insulin usually take 15-20 minutes to work for me (NovoRapid) and bolusing on 5 is normally okay for me and I’ve bolused on 4.1 waited 10 minutes for dinner and haven’t gone hypo

Hi again, interesting.

My DSN told me I could ask for an extra pen of a different colour and since I was seen as a T1 such a request would not cause any difficulty; and so it shouldn't - it's just plain sensible. My local pharmacy confirmed they stock different colours, just needed a prescription (or my wallet). I was given 2 pens from the outset, on the presumption that if, unlikely but .., if the pen failed I wasn't immediately in trouble. You really should have at least 3 Nova Echo pens, preferably 4.

Yes I have Libre 2 and LibreLink and I'm sending my data to LibreView which I share with the Endocrinology team. The Diabox app is free and written by people who are themselves diabetic, so have a good sense of what we need to know. It takes readings from a variety of sensors (just have to tell it to use Libre 2 in settings) but uses its own "algorithm" to convert the sensor output into a reading which it displays; not too surprisingly Abbott don't want to share their technology and indeed it could affect their insurance if something went wrong because Diabox was using the Abbott calculations .. Diabox then uses Bluetooth to get the Libre 2 sensor reading to the Diabox app, which duly appears on the Diabox screen along with other info, continuously.

So when you say you've successfully bolused on 4.1 and waited 10 mins that 4.1 could be on a rising BG and your 5 on a falling BG. Also are you confident that you didn't have some residual insulin and so unwittingly "stacked". No criticism inferred here, just one of the many things I'm learning to be careful about. I had a very disrupted night last night because something was wrong - just don't know what! Low Glucose Event for 90 mins, from midnight to 1.30am, fortunately not too low, but progressively took 10 or 15 gm snacks, got recovery then a full yo-yo rebound to over 14.

Although Librelink tells you something about the possible rate of change with your reading it is still only a snapshot from that moment of scanning. CGM tells you more and Diabox does update literally every minute, along with a numerical value for any rate of change; if I'm changing at 0.1, I pay little attention, but at 0.3 going down I react and my alarm is set for that threshold. Anyway Diabox and CGM is a bit of a digression for now.

From your logbook detail picture there is a strong recovery from 8-9pm, suggesting the digestion of that meal was a bit delayed so perhaps a relatively low GI meal. Did you take any extra food, such as JBs, because you were hypo? Is that sort of picture normal for you?

 

[Lily123]

Hi again, interesting.

My DSN told me I could ask for an extra pen of a different colour and since I was seen as a T1 such a request would not cause any difficulty; and so it shouldn't - it's just plain sensible. My local pharmacy confirmed they stock different colours, just needed a prescription (or my wallet). I was given 2 pens from the outset, on the presumption that if, unlikely but .., if the pen failed I wasn't immediately in trouble. You really should have at least 3 Nova Echo pens, preferably 4.

Yes I have Libre 2 and LibreLink and I'm sending my data to LibreView which I share with the Endocrinology team. The Diabox app is free and written by people who are themselves diabetic, so have a good sense of what we need to know. It takes readings from a variety of sensors (just have to tell it to use Libre 2 in settings) but uses its own "algorithm" to convert the sensor output into a reading which it displays; not too surprisingly Abbott don't want to share their technology and indeed it could affect their insurance if something went wrong because Diabox was using the Abbott calculations .. Diabox then uses Bluetooth to get the Libre 2 sensor reading to the Diabox app, which duly appears on the Diabox screen along with other info, continuously.

So when you say you've successfully bolused on 4.1 and waited 10 mins that 4.1 could be on a rising BG and your 5 on a falling BG. Also are you confident that you didn't have some residual insulin and so unwittingly "stacked". No criticism inferred here, just one of the many things I'm learning to be careful about. I had a very disrupted night last night because something was wrong - just don't know what! Low Glucose Event for 90 mins, from midnight to 1.30am, fortunately not too low, but progressively took 10 or 15 gm snacks, got recovery then a full yo-yo rebound to over 14.

Although Librelink tells you something about the possible rate of change with your reading it is still only a snapshot from that moment of scanning. CGM tells you more and Diabox does update literally every minute, along with a numerical value for any rate of change; if I'm changing at 0.1, I pay little attention, but at 0.3 going down I react and my alarm is set for that threshold. Anyway Diabox and CGM is a bit of a digression for now.

From your logbook detail picture there is a strong recovery from 8-9pm, suggesting the digestion of that meal was a bit delayed so perhaps a relatively low GI meal. Did you take any extra food, such as JBs, because you were hypo? Is that sort of picture normal for you?

I have looked through the basket with all my diabetes stuff in and discovered a spare Novopen Echo (same colour as the two I’m using) and another pen which wasn’t an Echo as it wasn’t in half units (which I’ve never used and don’t remember getting that!) and an old Sanofi pen (when I used Lantus). The Sanofi pen is black but is too small to hold Tresiba cartridges. I’ll ask about a different pen at my next appointment in February ,the pens are in different cases but you can’t be too careful.The rise is numbers at about 8 o’clock happens most days and is a basal issue I think.With the BG being able to bolus on 4.1 no issue the Libre will read that as stable just before I do my BG test and with the 5 yesterday it said stable.The BG meter that I use which in an accu-chek aviva expert tells you how much insulin there is active and it said 0.0 units active. I’ll have a look at Diabox. With the hypo I know I was hypo as I felt it although it would have probably been 3.8 and not 3.6 like the Libre said I didn’t have anything extra because I knew if the number dropping used some of the insulin the insulin then wouldn’t covered all the carbs therefore the hypo fixed itself.

 

[rebrascora]

Hi Lily Just because you get an horizontal line with your Libre reading doesn't actually mean that your levels are not moving up or down. I can't remember the actual rate of change for an horizontal arrow, but at 4.1 it would be very easy to drift into the red on the Libre between injecting and eating due to your basal even if you only wait 5-10 mins.

 

[Lily123]

Hi Lily Just because you get an horizontal line with your Libre reading doesn't actually mean that your levels are not moving up or down. I can't remember the actual rate of change for an horizontal arrow, but at 4.1 it would be very easy to drift into the red on the Libre between injecting and eating due to your basal even if you only wait 5-10 mins.

The few times I’ve been 4%1 and bolused I haven’t gone low but yesterday I was 5 and it’s both the trend on the Libre and the arrow that I look at. This is Tuesdays graph.

Looking at the time I dropped both Tuesday and yesterday I think it could be either bolus or basal but it’s past that time now and I haven’t felt hypo or been hypo

 

[Pumper_Sue]

The hypos before and during dinner, I start to feel hypo just before eating and just ignore it until I’ve eaten (I couldn’t drink a glucose drink straight before dinner and the dinner normally solves the hypo) I do think that Levemir may help (I was originally on Lantus before Tresiba) but I’m unsure if it would help because it’s in such a certain timeframe that the hypos are happening

From what I can make of the graph I would suspect most of your problem is the bolus. Your bolus has for many people a kick in it between 4 and 4 .5 hours after injecting. I use Fiasp and it does have the kick for me as well.

The reason you detect the los before your Libre is because the Libre is about 15 mins behind a finger poke. This is why people set their CGM's to alarm at 5 so that any potential low is caught before hypo land is visited.

 

[Lily123]

From what I can make of the graph I would suspect most of your problem is the bolus. Your bolus has for many people a kick in it between 4 and 4 .5 hours after injecting. I use Fiasp and it does have the kick for me as well.

The reason you detect the los before your Libre is because the Libre is about 15 mins behind a finger poke. This is why people set their CGM's to alarm at 5 so that any potential low is caught before hypo land is visited.

I’ve just eaten dinner and it hasn’t happened,but as I have eaten dinner later today could it be at roughly 17:55 when I usually eat it’s a mixture of bolus and basal causing the hypos?

 

[Lily123]

Hi Lily, your graph shows that maybe your level starts to dip and you have something to eat at approximately 4pm, your level goes up briefly to 9 then rapidly drops back to 4 and creeps into hypo again as you start to eat your meal.

Do you take take any bolus for the food at 4pm? Or is that a snack to plug a hypo?

That was a snack to stop a hypo - kind of I actually had a glucose drink as it was on 4.0 and falling

 

[Lily123]

I thought so, which brings us full circle. The hypo you headed off earlier with the glucose drink had not finished, it came back and tried again at dinner time.

I would suggest there are at least 3 confounding factors:

• A little too much bolus at lunch time (the long tail)
• Too much basal
• Unexpected Exercise; running, walking back from school, or doing chores at home

I think the easiest alteration is less bolus at lunchtime. Experiment half a unit reduction at a time.

I think you’re right. I didn’t hypo at dinner today but it may be because I ate later and there wasn’t a mixture of the lunch and dinner bolus and too much basal at once?