Lows

[Woodywoodpecker]

Hi looking for some advice. Every early morning this week have had low alarm, couple off days been twice have finger pricked and it is low. Should I put my levimer down only take 6 units at 7pm, alarm been going off between 1 and 3am. Last nova rapid taken is usually 7.50pm for supper

 

[mashedupmatt]

You certainly could look to lower your evenng dose by 10% and see if this helps, or maybe look at your mealtime ratio for the Novorapid in the evening as that may still be working at 1am depening on exactly when you took it (I take a fair bit less quick acting insulin for evening meal, as compared to breakfast and lunch)

 

[rebrascora]

Do you take Levemir in the morning as well or only at night?

 

[Woodywoodpecker]

You certainly could look to lower your evenng dose by 10% and see if this helps, or maybe look at your mealtime ratio for the Novorapid in the evening as that may still be working at 1am depening on exactly when you took it (I take a fair bit less quick acting insulin for evening meal, as compared to breakfast and lunch)

You certainly could look to lower your evenng dose by 10% and see if this helps, or maybe look at your mealtime ratio for the Novorapid in the evening as that may still be working at 1am depening on exactly when you took it (I take a fair bit less quick acting insulin for evening meal, as compared to breakfast and lunch)

My meal time is early 4.30, it’s a snack I have before bed usually about 23 carbs 2 units off nova rapid, have only been taking 1 unit but been sitting bit higher so taken the 2 units

 

[Woodywoodpecker]

Do you take Levemir in the morning as well or only at night?

Yes 6 units both times

 

[helli]

Do you have a half unit pen?
Reducing from 6 to 5 is, proportionally, a large jump whereas, if you had a half unit pen, you could try reducing it to 5.5 units.
To be honest, if you do not have a half unit pen, I would strongly recommend requesting one as it is so valuable.
My daily basal dose varies daily based on things like the amount of exercise I do (exercise can increase my insulin sensitivity for up to 48 hours) so having that additional flexibility of half units is great.
These half unit pens are reusable ones. Again this is far better than the single use ones - they are more robust, better for the environment, the cartridges take up much less space in your fridge than the pens and you get a reminder of your last dose.

 

[rebrascora]

I think your late snack could certainly be clouding the issue. Have you considered a low carb snack if you feel the need to have something then, so that you know that your bedtime level is pretty well free of bolus insulin.

That said, I can't see there being any real draw back in experimenting with your evening Levemir dose a little if you feel confident and competent to do so. You can always increase it again if you need to or decrease it a little more if the problem persists. You might find that as you decrease the evening dose, you need a little more in the morning as there will be some overlap of the two and indeed this is how my doses ended up being 20u in the morning and anywhere from 0-4 at night depending upon how active I have been over the past few days.

 

[helli]

I think your late snack could certainly be clouding the issue. Have you considered a low carb snack if you feel the need to have something then, so that you know that your bedtime level is pretty well free of bolus insulin.

Given this is eaten at 7:50, I would not think it is the problem - NovoRapid should be completely gone by 1am. Given @Woodywoodpecker eats her evening meal at 4:30, I can see why she needs something later.
My advice is not to let diabetes dictate lifestyle/diet (unless you want to) but to determine how to get your insulin regime work for the lifestyle/diet you want.
FWIW My evening meal is eaten around 8pm and it does not cause early morning lows.

 

[Woodywoodpecker]

Do you have a half unit pen?
Reducing from 6 to 5 is, proportionally, a large jump whereas, if you had a half unit pen, you could try reducing it to 5.5 units.
To be honest, if you do not have a half unit pen, I would strongly recommend requesting one as it is so valuable.
My daily basal dose varies daily based on things like the amount of exercise I do (exercise can increase my insulin sensitivity for up to 48 hours) so having that additional flexibility of half units is great.
These half unit pens are reusable ones. Again this is far better than the single use ones - they are more robust, better for the environment, the cartridges take up much less space in your fridge than the pens and you get a reminder of your last dose.

Waiting on half pens coming through from hospital, have just phoned them letter not been sent to my doctors yet

 

[Woodywoodpecker]

I think your late snack could certainly be clouding the issue. Have you considered a low carb snack if you feel the need to have something then, so that you know that your bedtime level is pretty well free of bolus insulin.

That said, I can't see there being any real draw back in experimenting with your evening Levemir dose a little if you feel confident and competent to do so. You can always increase it again if you need to or decrease it a little more if the problem persists. You might find that as you decrease the evening dose, you need a little more in the morning as there will be some overlap of the two and indeed this is how my doses ended up being 20u in the morning and anywhere from 0-4 at night depending upon how active I have been over the past few days.

Thank you have always had later snack, never affected it before, but mibi worth looking at. Have just been on to hospital about half unit pen, someone is going to phone me back, will mention lows to them

 

[Woodywoodpecker]

Given this is eaten at 7:50, I would not think it is the problem - NovoRapid should be completely gone by 1am. Given @Woodywoodpecker eats her evening meal at 4:30, I can see why she needs something later.
My advice is not to let diabetes dictate lifestyle/diet (unless you want to) but to determine how to get your insulin regime work for the lifestyle/diet you want.
FWIW My evening meal is eaten around 8pm and it does not cause early morning lows.

Thank you I didn’t think nova would be affecting me that late

 

[rebrascora]

I often eat late too, sometimes as late as 10pm, but I am more confident of adjusting my evening Levemir and I have Fiasp which is much shorter acting than NR which helps.

I think in the early months of diagnosis, they like you to go to bed more or less clear of bolus insulin so that your bedtime reading can be above a certain level, like 8, and therefore be reasonably sure you are safe from nocturnal hypos. Once you are confident in your diabetes management and adjusting your doses, these guidelines are no longer so much of a concern but if you are experiencing nocturnal hypos or having to prevent them then it might be worth doing some basal testing or assessment before adjusting it.

 

[Woodywoodpecker]

Had phone call from hospital told to put alarm down to 3.9

 

[rebrascora]

I am a little shocked at that advice! What is your low alarm currently set at?

 

[Woodywoodpecker]

I am a little shocked at that advice! What is your low alarm currently set at?

So am I 4.4, also told them struggling to get strips for keyton said should only test if over 15 and not well, was told before to always test over 15

 

[rebrascora]

I have never "deliberately" tested for ketones since diagnosis 6 years ago and would only do so if levels were persistently mid teens and refusing to come down, not a one off reading that needed a correction to bring it down or perhaps needed a second "stacked" correction to bring it down. I am a bit "gung ho" about stacking corrections though, since I started using Fiasp as it is much less effective at lowering levels above 10, so I often end up stacking them.

I say "deliberately" as I have tested for ketones to see if I was in dietary ketosis, when test strips, either for urine or blood, were going or had gone out of date, just out of curiosity, because I follow a low carb way of eating.

The odd time I have been ill, I have stacked corrections if necessary in order to keep in range and/or increased basal doses, so never felt the need to test for ketones. I think CGM allows us to do this reasonably safely, provide we monitor things closely when we have taken such action.
I didn't actually manage to get blood ketone strips on prescription until 5 years after diagnosis, but I did have urine strips.... but as said, I never felt the need to use them.

 

[helli]

So am I 4.4, also told them struggling to get strips for keyton said should only test if over 15 and not well, was told before to always test over 15

Like @rebrascora, I have only tested ketones for a persistent high BG. I con't consciously think about whether I feel unwell but it is rare for me to be persistently that high and not feel unwell.
The reason for the ketone testing is the risk of DKA. As I understand it (but I am not medically trained), this is not a risk for a short high spike.

Regarding low BG alarm, there are two trains of thoughts
- have low alarm high enough to get an advanced warning to avoid hypos - you can treat before they happen
- have low alarm low enough to avoid alarm fatigue.

Obviously, these can contradict each other and are personal approaches.
As with many things diabetes related, there is no one answer - you need to work out what is best for you.
Personally, I favour the lower level (but still not hypo) because I have suffered from alarm fatigue and started to just ignore it which isn't good.
So, do not feel you need to set it at 5.0 because some on the forum does this or set it at 3.9 because your DSN tells you to. Try different levels and see what works for you.
My only caveat is that a hypo is anything under 4.0 so I would set it no lower than that - you don't want your body to get used to being hypo and lose hypo awareness.

 

[Inka]

My meal time is early 4.30, it’s a snack I have before bed usually about 23 carbs 2 units off nova rapid, have only been taking 1 unit but been sitting bit higher so taken the 2 units

That’s probably a big part of the problem then @Woodywoodpecker Some Type 1s need a bedtime snack but they have that without insulin. If you have insulin with it,you’re undoing its purpose of making sure you don’t drop too low overnight.

Why are you needing to eat so early at 4.30pm? Is this because of work?

 

[Woodywoodpecker]

Like @rebrascora, I have only tested ketones for a persistent high BG. I con't consciously think about whether I feel unwell but it is rare for me to be persistently that high and not feel unwell.
The reason for the ketone testing is the risk of DKA. As I understand it (but I am not medically trained), this is not a risk for a short high spike.

Regarding low BG alarm, there are two trains of thoughts
- have low alarm high enough to get an advanced warning to avoid hypos - you can treat before they happen
- have low alarm low enough to avoid alarm fatigue.

Obviously, these can contradict each other and are personal approaches.
As with many things diabetes related, there is no one answer - you need to work out what is best for you.
Personally, I favour the lower level (but still not hypo) because I have suffered from alarm fatigue and started to just ignore it which isn't good.
So, do not feel you need to set it at 5.0 because some on the forum does this or set it at 3.9 because your DSN tells you to. Try different levels and see what works for you.
My only caveat is that a hypo is anything under 4.0 so I would set it no lower than that - you don't want your body to get used to being hypo and lose hypo awareness.

Thank you just thought wud have spare pack to test, don’t test if just peeks up and down. My alarm is 4.4 think 5 would be going off all the time. Don’t usually get to many lows early hours, so don’t know what’s happened this week

 

[helli]

That’s probably a big part of the problem then @Woodywoodpecker Some Type 1s need a bedtime snack but they have that without insulin. If you have insulin with it,you’re undoing its purpose of making sure you don’t drop too low overnight.

Why are you needing to eat so early at 4.30pm? Is this because of work?

I disagree.
A snack at 7:50 is unlikely to be bedtime snack - it is supper when tea is at 4:30 (and the reason for her eating times is irrelevant - diabetes needs to work around her day not the other way around).
I interpret Woody's comment that it is what she does regardless of diabetes not something to maintain BG throughout the night.
(Apologies @Woodywoodpecker if I have misunderstood)

Plus even a "slow" NovoRapid is unlikely to be the cause of a low more than 5 to 7 hours later.