Looking for advice and/or opinions Type 1

[Platty1953]

Hi All

I am T1 but usually well controlled with latest HbA1C 54 and diabetic consultant happy with all reviews. Have other health issues but medication for them hasn’t changed in a long time.

However, recently I have had real issues with steady control of blood sugar levels often running from hyperglaecemic to hypoglaecemic and getting quite frustrated, and to be honest worried, about why this is happening.

I don’t do things like low carb as quite honestly I enjoy all sorts of food and think my diet is wide, varied and pretty healthy.

For example, yesterday I had breakfast which contained about 90 grams of carb and on my normal ratio of 1 unit of Humalog to 5 grams of carb, I took 18 units of insulin. within an hour my reading was up to 16+ and rising quickly. I took 4 units correction dose but level continued to rise. About an hour later I was dropping like a stone, down to 8.6 and soon down to 4.3 and experiencing hypo symptoms. Had to then start popping glucose tabs to try to correct this quickly.

This morning I have had breakfast containing 50 gms of carb and took 12 units of Humalog (1:5 ratio plus a bit extra because my pre meal reading was slightly high at 8.3). Just had warning from monitor that level was high and rising at 12.1. Have done nothing to address this but waiting to see what happens as I don’t want to take a small correction dose and risk provoking another hypo like yesterday.

Must admit I am worried about this latest change and don’t know what else to do. Have tried to contact diabetic team and dieticians but have to wait 6-8 weeks to get appointment.

Only other change I have made in last three to six months is to take vitamin supplements (VitB complex, VitC, VitD and zinc) to help with other health issues. Can’t see any evidence that these would affect BG levels but again your views would be welcomed.

Look forward to your comments.

 

[rebrascora]

Hi and welcome.

Sorry to hear that you are finding things frustrating at the moment. I think most of us can relate to having spells when our levels become erratic. I go through regular bouts of it and usually it indicates that my basal insulin dose is not right and needs some adjustment. Have you done a basal test to see if it is holding you steady in the absence of food?

You mention a "monitor".... Are you using a Freestyle Libre or similar CGM or do you mean a BG meter? If it is Libre or other CGM, do you double check those high levels before you do a correction because they are not generally accurate enough above and below range to use to calculate corrections.

Having said all that above, it sounds like it is the timing of your breakfast bolus which may be the problem rather than the dose. Doing a correction one hour after breakfast is probably jumping the gun, especially with 18 bolus units of Humalog in your system. How far in advance of breakfast did you prebolus? I usually need 45 mins prebolus time with Fiasp at breakfast to prevent my levels spiking and it was 75mins with Novo(not so)Rapid before that, but it will also depend on my waking reading and the time of year and maybe how well I have slept and/or if I had a drink or two the night before. 45 mins would likely be too long for most people who would hypo before then but that is what my body needs and everyone is different. There are certainly others like me who need a really long time for our breakfast insulin to get to work but many people find they need to prebolus longer than the recommended 10-20 mins, particularly at breakfast time when we are most insulin resistant.
I appreciate that this situation may be new for you but our bodies change for all sorts of reasons.... hormones, the seasons, how well we slept, how much exercise we did the day before.... so you have to identify a pattern and then develop a strategy to fix it. For me I inject my bolus insulin as soon as I wake up and before I get out of bed to deal with this morning insulin resistance and surge of glucose released by the liver.... referred to here on the forum as Foot On The Floor Syndrome. Then I get up and potter about getting washed and dressed and making myself breakfast and a coffee before I check my Libre to see if my bolus insulin is kicking in and the direction arrow is starting to angle downwards and then I eat. From injecting to eating is a fairly consistent 45mins for me most days following this method of watching and eating to my Libre arrows and I almost never get a spike above 10 doing this, usually no spike at all. Timing is the real art with preventing spikes if your standard dose is eventually bringing you back down.... or in this case premature corrections are bringing you down too low.

Hope some of that is some help. Out of interest, if you are using Libre, how long have you had it and is it possible that this was happening before you got it but you were just unaware of the height of the spikes because you were not finger prick testing at the 1 hour mark to see that spike..... A case of "What the eye didn't see, the heart didn't grieve over"?

 

[helli]

It looks as if your body is digesting the carbs quicker than your insulin is working. Therefore, you go high before the insulin starts working.
How much earlier than eating do you pre-bolus?
It may be worth trying to pre-bolus earlier - start 5 minutes earlier and then move it by 5 minutes until you hit the sweet spot.

I don't know why this has recently started happening (assuming it was not happening previously) but I too have noticed something similar since I recovered from covid and wondered if my digestion is working at a different speed.

 

[trophywench]

Hi @Platty1953 - seemingly weird first questions from me - how long has it been since you did a full 24hr basal test, and what basal insulin do you use, plus, who on earth told you to test after 1 hour and correct immediately if too high for your liking?

 

[littlevoice359]

I think that Vitamin B can cause BG to rise? I only mention this as the original post mentions VitB complex…

 

[Platty1953]

Hi and welcome.

Sorry to hear that you are finding things frustrating at the moment. I think most of us can relate to having spells when our levels become erratic. I go through regular bouts of it and usually it indicates that my basal insulin dose is not right and needs some adjustment. Have you done a basal test to see if it is holding you steady in the absence of food?

You mention a "monitor".... Are you using a Freestyle Libre or similar CGM or do you mean a BG meter? If it is Libre or other CGM, do you double check those high levels before you do a correction because they are not generally accurate enough above and below range to use to calculate corrections.

Having said all that above, it sounds like it is the timing of your breakfast bolus which may be the problem rather than the dose. Doing a correction one hour after breakfast is probably jumping the gun, especially with 18 bolus units of Humalog in your system. How far in advance of breakfast did you prebolus? I usually need 45 mins prebolus time with Fiasp at breakfast to prevent my levels spiking and it was 75mins with Novo(not so)Rapid before that, but it will also depend on my waking reading and the time of year and maybe how well I have slept and/or if I had a drink or two the night before. 45 mins would likely be too long for most people who would hypo before then but that is what my body needs and everyone is different. There are certainly others like me who need a really long time for our breakfast insulin to get to work but many people find they need to prebolus longer than the recommended 10-20 mins, particularly at breakfast time when we are most insulin resistant.
I appreciate that this situation may be new for you but our bodies change for all sorts of reasons.... hormones, the seasons, how well we slept, how much exercise we did the day before.... so you have to identify a pattern and then develop a strategy to fix it. For me I inject my bolus insulin as soon as I wake up and before I get out of bed to deal with this morning insulin resistance and surge of glucose released by the liver.... referred to here on the forum as Foot On The Floor Syndrome. Then I get up and potter about getting washed and dressed and making myself breakfast and a coffee before I check my Libre to see if my bolus insulin is kicking in and the direction arrow is starting to angle downwards and then I eat. From injecting to eating is a fairly consistent 45mins for me most days following this method of watching and eating to my Libre arrows and I almost never get a spike above 10 doing this, usually no spike at all. Timing is the real art with preventing spikes if your standard dose is eventually bringing you back down.... or in this case premature corrections are bringing you down too low.

Hope some of that is some help. Out of interest, if you are using Libre, how long have you had it and is it possible that this was happening before you got it but you were just unaware of the height of the spikes because you were not finger prick testing at the 1 hour mark to see that spike..... A case of "What the eye didn't see, the heart didn't grieve over"?

Thanks for taking the time to respond so fully, much appreciated.

I haven’t done a test on basal dose but will do so and see if that reveals anything.

I use a Freestyle Libre 2 monitor which has been pretty reliable since I started using it about 4 years ago, but again I will try double checking when levels are high.

I don’t “pre bolus“ as I don’t take a standard amount with every meal. I did a WIDAC course which allows me to assess carb intake at each meal and calculate the amount of Humalog required which I take with or just after the meal. Might discuss with diabetic specialist nurses if this needs to be reassessed and start taking insulin a little before meals or adjust the ratio. Humalog is supposed to be the fastest acting insulin available which makes it so attractive in my case, but will look at all options.

As I said in my post I haven’t taken a correction dose today to avoid provoking a hypo, and also not jumping the gun. Not eaten anything since breakfast and reading only just come down below 10, about four hours post breakfast.

Really appreciate your input.

 

[Platty1953]

It looks as if your body is digesting the carbs quicker than your insulin is working. Therefore, you go high before the insulin starts working.
How much earlier than eating do you pre-bolus?
It may be worth trying to pre-bolus earlier - start 5 minutes earlier and then move it by 5 minutes until you hit the sweet spot.

I don't know why this has recently started happening (assuming it was not happening previously) but I too have noticed something similar since I recovered from covid and wondered if my digestion is working at a different speed.

Seems like it could be absorption of carbs and just spoken to diabetic specialist nurse (DSN) who thinks it could be related to injection sites being resistant so now changing them as well, although I do rotate sites regularly as expected.

Covid angle is also interesting as I did have it quite badly in January. DSN thinks it could be a possibility but that it is less likely so long after….

Thanks for your input, really appreciated.

 

[Platty1953]

Hi @Platty1953 - seemingly weird first questions from me - how long has it been since you did a full 24hr basal test, and what basal insulin do you use, plus, who on earth told you to test after 1 hour and correct immediately if too high for your liking?

Not done a basal test for some time but plan to do so after my latest episode. I use Lantus as basal insulin and always been ok with it. Nobody has told me to test after an hour but on a Libre 2 monitor I get high glucose alarms at 11.5 and over so it is always going off and I guess I panicked yesterday when it went up to 16.7, which I have never been, so took correction dose as I thought I had drastically undercooked my bolus injection. I haven’t taken any correction dose after breakfast today, but let it ride, when it peaked at 12.2 and took just over four hours to come back to 9.9.

 

[Platty1953]

I think that Vitamin B can cause BG to rise? I only mention this as the original post mentions VitB complex…

I guess that is one I have to accept as I take it for spinal nerve issues. I’d rather have slightly higher BG than the constant back and leg pain. Isn’t getting old fun?? ‍♂️

 

[Bruce Stephens]

Humalog is supposed to be the fastest acting insulin available which makes it so attractive in my case, but will look at all options.

I've no experience with Humalog (or Fiasp), but judging by https://onedrop.today/blogs/blog/fiasp-insulin-why-its-different-how-it-works (which doesn't give graphs, admittedly) it looks like Humalog's probably not much faster than NovoRapid (which I do use). (As I understand it NovoLog and NovoRapid are the same thing, with NovoRapid being used outside the US.)

That suggests to me that pre-bolus is a reasonable thing to try. Many of us find NovoRapid to work well injecting 15-60 minutes before eating (varies between people and between times of day).

 

[helli]

Humalog is supposed to be the fastest acting insulin available which makes it so attractive in my case, but will look at all options.

This may have been the case some time ago but there are faster acting insulins available today such as Fiasp and Lyumjev.
I believe the official profile of Humalog is similar to NovoRapid but as they are different, some people find one faster than the other - I found Humalog very slow for me.

 

[rebrascora]

You can of course test the speed of your Humalog by injecting some and watching your Libre to see when it starts to kick in and then eating when you see it taking effect, which is what I advocated in my first post and in fact what I do every morning..... And yes I too carb count and adjust my doses according to what I eat but I know what I am having for breakfast before I get out of bed. Maybe you are less of a creature of habit and rarely have the same breakfast. I have a standard breakfast that I have most mornings but I have other options that I know the carb count for, so I can make that decision when I wake up if I fancy a change and still inject before I get out of bed.

 

[DaveB]

Hi. For most of us it is necessary to pre-bolus for each meal for up to 30 minutes. Bolusing after a meal will result in mis-matched timing. I have to say that high level of carb intake would rapidly send me off the scale. It is often said that T1s can have nay level of carbs and just bolus to match. For some of us that just isn't true. I aim for around 150/gm per day total. Much more than that and I'm in trouble and no amount of Bolus will bring the BS down for hours. Yes, do check your Basal.

 

[Inka]

I don’t “pre bolus“ as I don’t take a standard amount with every meal. I did a WIDAC course which allows me to assess carb intake at each meal and calculate the amount of Humalog required which I take with or just after the meal.

I don’t know what WIDAC is but pre-bolusing simply means bolusing in advance of eating. You don’t have to have a set amount. I use Humalog, and although it is fast I still need to bolus 30 mins in advance of breakfast and anywhere from 10-20 mins in advance of other meals. This greatly reduces any spike.

As your blood sugar does eventually drop, I’d say moving your bolus more in advance would be wise. Your digestion might be mucking your about too, but it would be rare to be able to inject and eat immediately unless your meal was low GI or something.

 

[Platty1953]

I don’t “pre bolus“ as I don’t take a standard amount with every meal. I did a WIDAC course which allows me to assess carb intake at each meal and calculate the amount of Humalog required which I take with or just after the meal.

I don’t know what WIDAC is but pre-bolusing simply means bolusing in advance of eating. You don’t have to have a set amount. I use Humalog, and although it is fast I still need to bolus 30 mins in advance of breakfast and anywhere from 10-20 mins in advance of other meals. This greatly reduces any spike.

As your blood sugar does eventually drop, I’d say moving your bolus more in advance would be wise. Your digestion might be mucking your about too, but it would be rare to be able to inject and eat immediately unless your meal was low GI or something.

This seems to be the general view from others. I will be trying out taking bolus 10-15 minutes before meals over the next week or so to see if that has any effect. Lots of other things to try as well, but I guess it is one step at a time.

For info for all those who have read this thread I have just uploaded my data into Libreview and my 90 day GMI is now 49 so can't be doing everything wrong.

 

[rebrascora]

Great result although do be aware that Libre usually predicts quite a few points lower than actual HbA1c for most of us. I think my last Libre prediction was 45 and my actual result was 51. I'm very happy with that.
Let us know how you get on with prebolusing. It works for most of us, but different meals need different prebolus times. Moast of us find breakfast needs the longest and you have to be careful with pizza or creamy pasta dishes or fish and chips etc ie meals with carbs and quite a lot of fat as if you prebolus too early for those you end up hypo before the end of the meal and then high all night. A split bolus for such meals is the best strategy, so injecting some just before the meal and the rest an hour or 2 later.

 

[nonethewiser]

Has to be prebolus 99% of time, luckily mine doesn't vary that much through day so 15 to 20mins works fine using fiasp insulin, even in morning.