Insulin stacking

[Teapot99]

Hi everybody,

I was hoping to find out more about insulin stacking if possible? My DSN has ran over bits of it with me but I don't fully understand it still. I used to have meals and then an hour/two after, if I was hungry, I'd inject a bit more as a correction so I could have a snack.
I had an issue a few months ago where I was did a correction, not long after I went to the gym and then I had a complex carb meal and did all of the insulin that was needed and didn't split it. I sent myself into a frenzy and since then have had issues worrying about having snacks between meals.
I was just wondering what everybody's understanding on it is please? I keep thinking that I can't correct between meals for a snack and therefore making myself hungry, or having the snack and my blood sugars staying higher. I have tried to read up on it but I still don't fully understand, hoping to speak to my DSN on Thursday to ask more but I thought I'd see what everybody thought first, thank you!

 

[Robin]

I think it works better if you don’t think of it as a 'correction' if you inject for a snack between meals.
I take a reading, and note that I've got insulin left on board from the previous meal, but I don’t take the reading into account*. I just allow that insulin to go on working on the carbs I ate at that previous meal. So I start with a 'clean slate' and just inject the amount of insulin I actually need for the carbs I'm having in the snack, if that makes sense?

*I'd only take the reading into account if it was lower than expected, and I thought I might have overestimated the insulin for the carbs earlier. In which case I'd inject a reduced amount for the snack.

 

[Teapot99]

I think it works better if you don’t think of it as a 'correction' if you inject for a snack between meals.
I take a reading, and note that I've got insulin left on board from the previous meal, but I don’t take the reading into account. I just allow that insulin to go on working on the carbs I ate at that previous meal. So I start with a 'clean slate' and just inject the amount of insulin I actually need for the carbs I'm having in the snack, if that makes sense?

@Robin thank you for your reply! Yes that does make sense. My DSN said something about taking the amount of insulin off that I had used in my correction, off of my meal dose of it’s fairly close to my next meal.

E.g. So if I injected 2 units as a correction for my snack and I needed 7 units for dinner, then inject 5. I think that’s what she was meaning, I’m not sure whether I got what she was trying to say which is why I will call her on Thursday anyway just to verify sure

 

[helli]

Like @Robin, I do not think of insulin for snack as a correction. It is just another (small) meal.
The only difference is if I have bolused in the last 4 hours I will have active insulin on board so I need to take this into consideration if I am also doing a correction because my BG is too high.
If I did not need a correction and was only calculating the insulin for the snack, I would just calculate that as usual.
I would not reduce my insulin for my next meal because the insulin for the snack is "used' by the snack.

Simply, I bolus for the carbs I eat at the time I eat them (unless I do a split bolus but that is another ball game).

 

[rebrascora]

My DSN said something about taking the amount of insulin off that I had used in my correction,

What do you mean by correction in the sentence above?
I think you are confusing the issue by using the term correction when perhaps you mean bolus?

A bolus is an amount of insulin injected to cover food, be it a meal or a snack. A correction is an amount of insulin used to bring your levels down into range when there is no active insulin in your system and you are above range.
Typically you would do a correction before a meal when there is no active insulin in your system and your levels are high and often you would add that correction to your meal time bolus insulin.
So for example, if you wake up on 12mmols which is higher than you want, then you would calculate how much correction would bring you down to a nice "in range" number like 6mmols and then calculate how much insulin you need for whatever breakfast you are going to eat, add the 2 together and inject it as one. So if your correction factor is 3 ie 1unit of insulin drops your levels by 3mmols then 2 units would drop you by 6 mmols, so 2 correction units would theoretically bring your levels down to (12-6) = 6mmols and then perhaps you are going to eat a breakfast that needs 6 units of insulin, then you would inject (2+6) = 8 units of insulin before breakfast..... 6 for the food and 2 for the correction and that should mean that by lunchtime 4-5 hours later when the NovoRapid has stopped working, you should have come down to about 6mmols.
If you decided that you wanted a snack mid morning, then unless your levels were low at that time, you would just inject enough insulin for your snack and eat it even if your levels are a bit high at that time, BUT if your levels were a bit high at lunchtime you would not calculate another correction like you did before breakfast because the insulin for the snack would still be active and likely to bring your levels down into range. Basically each injection is active for 4-5 hours and will continue to work during that time, so it isn't advisable to do a correction if you have active insulin in your system unless you are very experienced and can calculate how much that remaining insulin will bring you down, which I think is probably too much for you to deal with at the moment.

In your situation with you just starting to carb count, I would avoid snacks until you get your carb counting and meal time ratios sorted, because otherwise it is going to confuse things. Do make sure to log everything so that your nurse can see what you have eaten when and how much insulin you have injected and when as that is all really useful information whcih will help to work out your meal ratios.

 

[Lucyr]

I sent myself into a frenzy and since then have had issues worrying about having snacks between meals.

What actual blood sugar is a frenzy?

 

[Inka]

I almost always snack between meals at least once, if not twice a day @Teapot99 Just bolus for your snack, but think about when you last ate/bolused and when you’re next going to bolus. If you want to snack an hour or so after lunch just bolus for the snack like normal unless you’re low or eating it to top up your blood sugar for exercise or whatever. The only thing not to do if you eat a snack an hour after lunch is to correct your blood sugar - because you know it will be coming down from your lunch bolus.

Like others, I think you’re being confused about ‘correcting’ for a snack. You don’t correct for a snack, you bolus for a snack (or don’t bolus at all if low/exercising). Correcting is just for high sugars. More than that, my consultant told me insulin stacking was only really a worry for corrections. As an example, your blood sugar is 15 so you correct. An hour later it’s still 15 so you whack some more insulin in - but you shouldn’t have done that because the first correction hasn’t had a chance to work. That is insulin stacking!

 

[SB2015]

Good morning @Teapot99
I eat when I want to and deliver the bolus for whatever I choose to eat. If this is within four hours of my previous meal there will be some active insulin so that will be dealing with my levels if they are a bit above target and I let it get on with that job and enjoy my snack.
Like @Robin if my levels are lower than I would expect with insulin active I would guess that I had overestimated my carbs at the previous meal and might take a bit off the bolus.

 

[PhoebeC]

I agree with everyone else.

• Snacks = bolus
• High = corrections

Please remind me have you had DAFNE recently? I do think that would help you if you haven't already had it.

The key with corrections for highs is not loading too much insulin in if its not had time to work yet, it is waiting for it to come back down and sitting on your hands and not having more insulin.

I find the HCL works with this, as I will go to give another corrective dose and it will tell me its not needed, or do the maths on the amount I should have, it can be overidden by me. I don't override unless I know say I had a leaky pod, it doesn't know I've not had all that insulin, thinks I had the full amount, I will be cautious with amount I give to not overload. Otherwise I trust it based on my experience and leave it to do what it thinks best.

Also on correcting highs. I don't correct all levels outside of range, I have outside of range and high (take action), and it depends what I am doing next - eating, exercising etc.
Over 13.5 I take action ideally around a meal time, but if not then I will consider what I am doing next. For over 10 out of range but under 13.5 I take no action and only monitor. I know others are different but that works for me and I am working on bringing this high number down, as one of my personal goals in next 6 months.

 

[martindt1606]

@Teapot99 Within your original scenario you mentioned going to the Gym. Are you factoring this in to any of your bolus calculations? For example if i had a snack and knew I was going to the Gym an hour or two later I wouldn't bolus for the snack (unless blood glucose was high...........but then i probably wouldn't have the snack). I would also consider the impact of the Gym session when calculating the post activity meal bolus.

 

[SimonP]

Having an app that keeps track of your IoB and CoB is very useful in cases like this. XDrip+ works, there are probably others available. I find it very useful to be able to see both how much insulin is yet to be used up as well as how much is currently active and an indication of how many carbs have yet to be digested (this is the least accurate part, but you get a feeling for what's happening.)

I correct if needed, I take bolus for snacks if needed. If I'm going to exercise I either reduce bolus in advance, or wait until I've not got too much IoB (depending on how long the exercise will be)

 

[Teapot99]

What actual blood sugar is a frenzy?

Hi @Lucyr, that day I had done a correction (no food) and then been to the gym and then did my full meal insulin dose, when I should have split it. So in an hour my blood sugar dropped from around 18 to 6 with my Libre 2+ arrow pointing straight down

 

[Teapot99]

I almost always snack between meals at least once, if not twice a day @Teapot99 Just bolus for your snack, but think about when you last ate/bolused and when you’re next going to bolus. If you want to snack an hour or so after lunch just bolus for the snack like normal unless you’re low or eating it to top up your blood sugar for exercise or whatever. The only thing not to do if you eat a snack an hour after lunch is to correct your blood sugar - because you know it will be coming down from your lunch bolus.

Like others, I think you’re being confused about ‘correcting’ for a snack. You don’t correct for a snack, you bolus for a snack (or don’t bolus at all if low/exercising). Correcting is just for high sugars. More than that, my consultant told me insulin stacking was only really a worry for corrections. As an example, your blood sugar is 15 so you correct. An hour later it’s still 15 so you whack some more insulin in - but you shouldn’t have done that because the first correction hasn’t had a chance to work. That is insulin stacking!

Hey @Inka,

Yes I have muddled my wording, I did mean bolus for food and correcting for high blood sugar. I think, how your consultant explained it is exactly what my DSN has said if I remember correctly! That makes a lot more sense, I had in my head that I shouldn't be bolusing for a snack if I am eating lunch/dinner in 2 or so hours. This makes me feel a lot better about it all, I bolused for a snack today as I was hungry and after a while my blood sugar did come down 🙂

 

[Inka]

I wouldn’t correct at all if I was going to the gym @Teapot99 (unless I was super-high and then I’d correct and delay exercising). Perhaps it was the tail end of that correction working that caused your blood sugar to fall quickly after your meal?

As with most diabetic things, I tend to have a snack routine - ie most of the time I eat one of a few favourite snacks at a similar time. This way, I know how it will affect me and any subsequent meal.

It sounds like you’re doing ok 🙂 Remember, attempting to be your own pancreas is hard. Nobody gets perfect results all the time. It’s like trying to steer a wonky supermarket trolley!

 

[Teapot99]

I agree with everyone else.

• Snacks = bolus
• High = corrections

Please remind me have you had DAFNE recently? I do think that would help you if you haven't already had it.

The key with corrections for highs is not loading too much insulin in if its not had time to work yet, it is waiting for it to come back down and sitting on your hands and not having more insulin.

I find the HCL works with this, as I will go to give another corrective dose and it will tell me its not needed, or do the maths on the amount I should have, it can be overidden by me. I don't override unless I know say I had a leaky pod, it doesn't know I've not had all that insulin, thinks I had the full amount, I will be cautious with amount I give to not overload. Otherwise I trust it based on my experience and leave it to do what it thinks best.

Also on correcting highs. I don't correct all levels outside of range, I have outside of range and high (take action), and it depends what I am doing next - eating, exercising etc.
Over 13.5 I take action ideally around a meal time, but if not then I will consider what I am doing next. For over 10 out of range but under 13.5 I take no action and only monitor. I know others are different but that works for me and I am working on bringing this high number down, as one of my personal goals in next 6 months.

Hey @PhoebeC,

Yeah I realised I said the wrong thing haha, I was meaning insulin stacking for corrections but also talking about bits to do with bolusing as where I have been hungry, I don't want to starve myself. I feel a lot more comfortable about it all now though so thank you (and everybody else!)

It's great to hear that the HCL will tell you not to over correct. I'm looking forward to knowing that it knows what it is doing and will autocorrect for me. I've been told to look at the Medronic 780 and the Ypsomed pump to see which I think would be best for me. I'm not looking at starting a family for another 5 years+ but my DSN said that as I am not great with change, maybe I should go straight on the Ypsomed pump so I won't have to change later on down the line. She has also said that she would not be surprised if the Medtronic 780 becomes suitable for pregnancy in the next few years too. I need to work out which would be best for me but I have been told that they are all like phones, they do the same thing but look different!

That's really interesting as I thought everybody would correct when they're blood sugars are as you have suggested but that sounds more like how I correct. Hopefully you reach your personal goal!

EDIT: Sorry I forgot to say, yes I have been on the DAFNE course but I am looking through all of my DAFNE stuff and randomly at BERTIE to look through bits 🙂

 

[Teapot99]

@Teapot99 Within your original scenario you mentioned going to the Gym. Are you factoring this in to any of your bolus calculations? For example if i had a snack and knew I was going to the Gym an hour or two later I wouldn't bolus for the snack (unless blood glucose was high...........but then i probably wouldn't have the snack). I would also consider the impact of the Gym session when calculating the post activity meal bolus.

Hey @martindt1606,

At the time I don't believe I did. I thought I was doing well with carb counting (I had only officially started it a few days prior) and I usually struggle with change and thought I was doing well. I don't think I should have done the correction looking back, and maybe considered splitting and lowering my overall insulin dose for dinner.

I have definitely learned from my mistake but I am slowly getting back to the gym and trying not to worry. I always have snacks on me now, I sort of look like a walking lunch box haha. In relation to the post gym meal bolus, that is something that I am trying to work out at the moment, sometimes the gym effects my BG more than others. I think my DSN suggested splitting my post gym bolus doses or just doing half of the dose to see how it goes. It turns out that most of my meals seem to be complex carbs, so I split my dose for most meals anyway 🙂

 

[Teapot99]

Having an app that keeps track of your IoB and CoB is very useful in cases like this. XDrip+ works, there are probably others available. I find it very useful to be able to see both how much insulin is yet to be used up as well as how much is currently active and an indication of how many carbs have yet to be digested (this is the least accurate part, but you get a feeling for what's happening.)

I correct if needed, I take bolus for snacks if needed. If I'm going to exercise I either reduce bolus in advance, or wait until I've not got too much IoB (depending on how long the exercise will be)

Hey @SimonP ,

Thank you so much for talking about this, I think this is something I will look into as I know the pumps show similar stuff to this and I am hoping to get a pump September/November time. I think my DSN may have mentioned it before, along with other things that may have got lost in my brain, so thank you for reminding me!

That is something that I have been considering too! Currently if my blood sugars are high around lunchtime, I do my suggested dose without a correction if I know I am going to the gym in hope that the slightly higher blood sugar will hold for the gym. I am still working on it but slowly getting there! Thank you for your advise 🙂

 

[Teapot99]

I wouldn’t correct at all if I was going to the gym @Teapot99 (unless I was super-high and then I’d correct and delay exercising). Perhaps it was the tail end of that correction working that caused your blood sugar to fall quickly after your meal?

As with most diabetic things, I tend to have a snack routine - ie most of the time I eat one of a few favourite snacks at a similar time. This way, I know how it will affect me and any subsequent meal.

It sounds like you’re doing ok 🙂 Remember, attempting to be your own pancreas is hard. Nobody gets perfect results all the time. It’s like trying to steer a wonky supermarket trolley!

@Inka that is also what I was thinking too, and the fact that I should have split my dinner bolus as the mash I had was homemade and had butter, milk and cheese in, so all very fatty!

That's a good bit of advice so thank you! I am starting to do similar now that I am back to work after a week off! I am getting more into fruit as snacks too and seeing how that effects me. I'm also have a shake in the mornings for breakfast (Oats, banana, milk, strawberries and a small bit of honey) rather than granola as that was running my BG high and then dropping quite quickly.

Thank you! I am doing better than I was! Still trying to get my BG down in the day but I had a great evening/morning this morning. I had dinner and split my dose and after a while my blood sugars dropped to 12 with Libre2+ arrow going straight down so I had a milk chocolate digestive, then half an hour later they were 6 arrow straight down so I had two jelly babies and a milk chocolate digestive (I didn't panic at all!) and then went to bed with blood sugar at 9.3. I then woke up this morning on 9.8! The best my blood sugar has been overnight in years! I'm not sure what I had done but it had worked! I am just battling the blood sugar in the day now 🙂 I agree with your metaphor! Sometimes steering in the rain too haha

 

[Inka]

That’s great @Teapot99 I know how hard it is with hypo anxiety. Doing things gradually and cautiously is definitely the best way.

 

[Lucyr]

Hi @Lucyr, that day I had done a correction (no food) and then been to the gym and then did my full meal insulin dose, when I should have split it. So in an hour my blood sugar dropped from around 18 to 6 with my Libre 2+ arrow pointing straight down

6 is fine though, especially when you’ve just eaten so it will be going up soon