New Insulin Regimen…. Advice needed!

[Jhp86]

Hi,

So following on from my previous post, I’ve been put on a new Basal/Bolus Regimen.

Looking to pick it up from the pharmacy today, so will be beginning the Basal tonight. I’ve been advised to do it in the evening before bed (around 1hr before)
But what I want to know is does it need to be taken with food? Or do i take it and then in the morning take my Bolus before breakfast?

Also for Bolus, I know its a little more flexible than mixed for timings, but I just want to know if the timings are ok, so I don’t overlap to much.
Breakfast is around 6:45am
Lunch around 1pm at the earliest, 2pm latest
Dinner around 7-7:30pm
That’s weekdays, weekends can vary, in the sense I usually have a later breakfast, sometimes don’t have lunch and then dinner around 6ish.
What do I do in that case?

Lastly, I don’t tend to snack during the day, but sometimes I will do. Do I need to correct for snacks? I.E If I have my breakfast early, lunch at 2pm, but have a snack at 11am, would I need to correct for it?

Sorry for all the questions! And thanks in advance

 

[Inka]

Hi @Jhp86 No, you don’t need to take your basal with food. It’s a slow insulin that works away in the background over many hours.

You can have your meals when you like, or even skip meals. Although they often say to leave 4hrs between meals, that’s not crucial, eg one day last week, I had breakfast at 9.30am and lunch at 12.15pm. What they call ‘stacking insulin’ only really applies to correction doses. However, the advice they give re 4hrs is general and aimed at people who might get confused. The bolus insulin is not like antibiotics where you carefully have to space out the dose. For example, you can bolus for your main meal at 6pm, then bolus again at 6.30pm for dessert. That’s fine.

A basal/bolus regime is far more flexible. There’s no schedule apart from taking your basal at the right time(s). You can have your meals when you want.

If you need a snack at 11am, say because you’ve been out shopping and your blood sugar is a bit lower than you’d want (not hypo, just lower) then just eat around 10-20g carbs without a bolus. If your blood sugar is fine at 11am but you’re just feeling peckish, you can either have a no carb snack (often you’ll find you don’t have to bolus for snacks under 10g carbs, but it varies) or you can have a carby snack and bolus for it.

NB - injecting for a snack is not a correction dose. A correction dose is extra bolus insulin given without food to bring down a high blood sugar.

Please bear in mind that the meal ratios they’ve started you on for your boluses are just estimates. You might need more, you might need less, so just go along carefully and don’t expect perfection. Not that perfection is possible anyway, but at the start of a new regime, it’s normal for blood sugar to be a bit wonky while you fine tune things.

 

[Proud to be erratic]

Hello @Jhp86, please don't be sorry for asking very valid questions. Reading back into your posts since 5 Aug you've been in trouble for a while; so I think, I'm not medically qualified, that your Basal/Bolus regime should be much better for you.

I'm not familiar with your 2 insulins of Lantus and Humalog rapid so won't try to answer your specific questions. But I'm sure someone will be along very soon to help. Good luck with your Multiple Daily Injections (MDI) and your opportunity to manage YOUR Diabetes in a more helpful way.

I must be a prophet .... @Inka has just replied!

 

[Jhp86]

Hi @Jhp86 No, you don’t need to take your basal with food. It’s a slow insulin that works away in the background over many hours.

You can have your meals when you like, or even skip meals. Although they often say to leave 4hrs between meals, that’s not crucial, eg one day last week, I had breakfast at 9.30am and lunch at 12.15pm. What they call ‘stacking insulin’ only really applies to correction doses. However, the advice they give re 4hrs is general and aimed at people who might get confused. The bolus insulin is not like antibiotics where you carefully have to space out the dose. For example, you can bolus for your main meal at 6pm, then bolus again at 6.30pm for dessert. That’s fine.

A basal/bolus regime is far more flexible. There’s no schedule apart from taking your basal at the right time(s). You can have your meals when you want.

If you need a snack at 11am, say because you’ve been out shopping and your blood sugar is a bit lower than you’d want (not hypo, just lower) then just eat around 10-20g carbs without a bolus. If your blood sugar is fine at 11am but you’re just feeling peckish, you can either have a no carb snack (often you’ll find you don’t have to bolus for snacks under 10g carbs, but it varies) or you can have a carby snack and bolus for it.

NB - injecting for a snack is not a correction dose. A correction dose is extra bolus insulin given without food to bring down a high blood sugar.

Please bear in mind that the meal ratios they’ve started you on for your boluses are just estimates. You might need more, you might need less, so just go along carefully and don’t expect perfection. Not that perfection is possible anyway, but at the start of a new regime, it’s normal for blood sugar to be a bit wonky while you fine tune things.

Thank you so much for this, it’s super helpful!

 

[Jhp86]

Hello @Jhp86, please don't be sorry for asking very valid questions. Reading back into your posts since 5 Aug you've been in trouble for a while; so I think, I'm not medically qualified, that your Basal/Bolus regime should be much better for you.

I'm not familiar with your 2 insulins of Lantus and Humalog rapid so won't try to answer your specific questions. But I'm sure someone will be along very soon to help. Good luck with your Multiple Daily Injections (MDI) and your opportunity to manage YOUR Diabetes in a more helpful way.

I must be a prophet .... @Inka has just replied!

Thank you!

Yeah it’s been a rough couple of months, and although I know it’ll take time, I’m semi confident this will help.

It’s really helpful having advice from people who properly ‘get it’. Not to disrespect my drs and nurses, but like with many things, when you live with it, and all the symptoms and issues, you have a greater understanding in some ways. Like I said to him yesterday, it’s MY body and MY lifestyle as well. I know I’ll always be diabetic, and I know I’ll always be on insulin and meds, but I want to live my life as normal as possible, which hasn’t been possible lately, and I know that by making adjustments to insulin isn’t miraculously going to solve everything, it may help me get back onto the path of normality

 

[Tdm]

What i'd say is, you may find you have different ratios for bolus insulin at different times. For example, during a working day, i have different ratios for breakfast, dinner and tea. For weekends i have the same ratio for all meals ( i skip breakfast) but need 1 unit to correct for the rise due to dawn effect. I vary from 1: 8 to 1:22 this week!
My basal wobbles between zero and 4...whatever is needed to keep me level overnight (am on a 24 hr basal)

So it may be worth breaking down your ratios as one size does not fit all

 

[helli]

What i'd say is, you may find you have different ratios for bolus insulin at different times. For example, during a working day, i have different ratios for breakfast, dinner and tea. For weekends i have the same ratio for all meals ( i skip breakfast) but need 1 unit to correct for the rise due to dawn effect. I vary from 1: 8 to 1:22 this week!
My basal wobbles between zero and 4...whatever is needed to keep me level overnight (am on a 24 hr basal)

So it may be worth breaking down your ratios as one size does not fit all

Is this advice appropriate for someone with type 2?
I ask out of curiosity not as a criticism.

 

[Proud to be erratic]

Perhaps @Tdm could be right, but perhaps not.

In my earlier days of D management I thought carb counting had to be done precisely; after 3 years I got a DAFNE course and was advised that certain previously counted foods could be ignored. There is even a pocket sized version of the Carbs and Cals book reinforcing that many foods should be ignored.

In those earlier days I also had different precise ratios for different times of the day. They worked - sometimes. Most of the time I was deluding myself.

In those earlier days I had no idea how much influence daily exercise or activity could have on the relationship of food, insulin and BG. I was even advised to regularly consider applying a 50% reduction of bolus if I was planning to be active that day and carry that 50% forward the next day - perhaps!! Today I can reduce my bolus by as much as 80% SOMETIMES and have larger snacks with no bolus at all IF the circumstances are appropriate.

How do I know they are appropriate? My CGM gives me so much more visibility of action and consequence; previously with just finger pricks I really had no idea what my BG was doing. Plus some hard earned experience from trial and learning; this needs time.

So what I'm suggesting @Jhp86 is stay grounded and for now keep things simple. Start with the simple ratio of 1u for 10gms carbs - for all meals. Certainly experiment as you settle down into this new regime of MDI, but give it time (certainly weeks not hours) so you can learn what is best for you. Be particularly aware that exercise and activity CAN need major adjustments to your bolus doses, if so then that invalidates fiddling around with accurate and complicated arithmetic. But how much adjustment will depend on what your normal exercise/activity level already is - and how sedentary or full on a normal day is for YOU. Yesterday, today and tomorrow. You are starting MDI with a T2 background and from your earlier posts they read as though you have a naturally high resistance to your own natural insulin. So I can't guess what doses you might need nor by how much you will need to adjust those doses. I just know that trial and learning is going to be a big part of your life for a while AND I think you will sort this out gradually.

 

[Proud to be erratic]

PS @Jhp86: right now my wonderful and essential CGM is harassing me, trying to panic me, as my BG is steadily climbing. I'm still in bed, I was trying to have a leisurely start to this damp day. I woke close to 10, now 12.5 and have done nothing and changed nothing that could explain to me why this is happening. So however well I think I'm doing on the surface, below the surface things just have their own agenda and for now their own momentum. My solution? Just do what I know I can do with the insulin and knowledge I've acquired and refuse to let this get to me!

 

[rebrascora]

I think it is really important to keep it as simple as possible in the early days of starting MDI.

Yes, as others have said, basal is not taken with food, just whatever time you need to take it. Personally I find bedtime is easiest rather than an hour before, because I keep it by the bed and it is part of my bedtime routine which makes it easier to remember and an hour later than suggested is not going to make any real difference to it's action and in fact you may find some benefit in taking it later.

The 1:10 ratio for meals is just a starting point but use it for several weeks until your clinic appointment so that they can see how it is working out. It will be helpful if you can keep things straightforward with 3 meals a day so that they can look back and see how that meal time ratio is working out, so if you need a snack between meals because you are hungry, a low carb snack like a few nuts or a boiled egg or a chicken drumstick or a chunk of cheese will not skew your results or need extra insulin, but of course, if your levels are droppng low, then have a small carby snack like a digestive biscuit or a piece of dried fruit like a date or a couple of prunes/apricots to nudge it up. Keeping good records on your Libre app of insulin doses and carbs will help the nurses figure out if your ratios need tweaking when you get your clinic appointment. Eventually you will be able to snack on whatever you fancy between meals and just inject an appropriate amount of insulin for it once your ratios have been worked out but in this early stage, the simpler you can keep your insulin needs the easier it will be for the DSNs to figure out your ratios and with you being Type 2 I suspect that your ratios may be quite different to the range of ratios that Type 1s typically use, so there may be quite a bit of adjusting before you find what works and even then it is always a case of watching for patterns and adjusting as your body/diabetes changes, but learning to carefully experiment to see what works for you is the most important part of successful diabetes management.

 

[helli]

Personally I find bedtime is easiest rather than an hour before, because I keep it by the bed and it is part of my bedtime routine which makes it easier to remember and an hour later than suggested is not going to make any real difference to it's action and in fact you may find some benefit in taking it later.

This may be true for the Levemir that you take. However. the reason for suggesting that Lantus us taken slightly earlier is that the profile is not as flat as other long lasting insulins and has a spike soon after taking so taking it just before going to sleep may not be ideal as it could result in a hypo whilst asleep.
I used to take mine with my evening meal to ensure I was awake for the spike.
As you say, it just needs to be taken approximately the same time every day.

 

[Jhp86]

Is this advice appropriate for someone with type 2?
I ask out of curiosity not as a criticism.

What i'd say is, you may find you have different ratios for bolus insulin at different times. For example, during a working day, i have different ratios for breakfast, dinner and tea. For weekends i have the same ratio for all meals ( i skip breakfast) but need 1 unit to correct for the rise due to dawn effect. I vary from 1: 8 to 1:22 this week!
My basal wobbles between zero and 4...whatever is needed to keep me level overnight (am on a 24 hr basal)

So it may be worth breaking down your ratios as one size does not fit all

Hi,

I was going to ask, as my nurse/dr said it’s not overly nessercsry to use a calculator or do ratios as although I’m not producing a lot of insulin; I am producing some,
Is that normal? As in not doing ratios etc?

 

[rebrascora]

This may be true for the Levemir that you take. However. the reason for suggesting that Lantus us taken slightly earlier is that the profile is not as flat as other long lasting insulins and has a spike soon after taking so taking it just before going to sleep may not be ideal as it could result in a hypo whilst asleep.
I used to take mine with my evening meal to ensure I was awake for the spike.
As you say, it just needs to be taken approximately the same time every day.

I appreciate that and as I understand it, it has it's peak about 5 hours after injecting which means that taking it an hour before bed will give you the peak during the depths of the night/sleep, so to me taking it slightly later might be preferable to that or better to take it earlier, so I can understand taking it at the same time as your evening meal or in the morning when you wake up, but to me taking it an hour before bed just seems like it may be challenging to remember to take it then, as hard to attach it to any other activity/routine and still gives you a peak of activity whilst you sleep.

 

[helli]

I can understand taking it at the same time as your evening meal or in the morning when you wake up,

Taking it in the morning is not a good idea as Lantus often does not last a full 24 hours so it will be running out at the same time as DP.
I think it is best not to confuse @Jhp86 from what he has been recommended by his DSN.

 

[Inka]

Hi,

I was going to ask, as my nurse/dr said it’s not overly nessercsry to use a calculator or do ratios as although I’m not producing a lot of insulin; I am producing some,
Is that normal? As in not doing ratios etc?

It doesn’t matter so much as to what’s normal, just what works for you @Jhp86 It might well be you don’t need to be so precise about ratios. I’d just go along slowly, steadily and cautiously and see what works best for you.

 

[Jhp86]

Thank you all so much.

Everyone’s been so helpful and really understanding! It’s gonna be a lot of trial and error and learning.

I think for the time being I’ll stick to a 1:10 ratio, the main thing I want to aim for at the moment is bringing my levels down, I know this won’t happen overnight, but getting into the mid teens right now would be a bonus, and then go from there.

I certainly will benefit from the flexibility also, my days sometimes are pretty standard and others a bit more hectic! But I’ll get there.

I really am so thankful for everyone’s help, support and advice so far, I’m sure I’ll have even more questions along the way, but I feel a bit more positive now which is nice!

 

[mashedupmatt]

Unfortunately when you begin a basal/bolus regime, it is very much trial and error, and absolutely everyone is different - we all have different insulin sensitivity (honeymoon period was a complete rollercoaster!) and require less/more depending on the situation/food/exercise/which shoelace you tied first! That said, if you can get the right Basal Insulin that is a very good start - try skipping meals and monitoring your levels - if they are steady you're just about right - and keep an eye on overnight levels - if you are high or low, you need to consider adjusting - you will learn what foods spike you more, and in time, will be confident enough to adjust your ratios accordingly - it's taken me🙂 2 years but I'm beginning to feel more in control - you will get there, but there will be a few bumps in the road - good luck

 

[Dragon queen]

Good evening I think you will find your new mix of insulins will help. I had a rough year bloods all over the place. Started first insulin Lantus then 4 weeks later Novo rapid. Lantus I usually do about 9pm it does sting a bit as it’s the acid baseline but quickly settles. I started on 14 units but now at 22 which gives me waking at 6.9-7.5. My Novo fast acting I take about 5 min before I eat 4 unit breakfast then depending on what eating 6 lunch same tea. I do adjust if having few more carbs mines 1 unit to 10g carbs. After 7 weeks my levels stay about 7 before meal and back to this four hours after food. So it’s stable for me. But everyone’s different. I’m sure this will settle for you

 

[Jhp86]

Unfortunately when you begin a basal/bolus regime, it is very much trial and error, and absolutely everyone is different - we all have different insulin sensitivity (honeymoon period was a complete rollercoaster!) and require less/more depending on the situation/food/exercise/which shoelace you tied first! That said, if you can get the right Basal Insulin that is a very good start - try skipping meals and monitoring your levels - if they are steady you're just about right - and keep an eye on overnight levels - if you are high or low, you need to consider adjusting - you will learn what foods spike you more, and in time, will be confident enough to adjust your ratios accordingly - it's taken me🙂 2 years but I'm beginning to feel more in control - you will get there, but there will be a few bumps in the road - good luck

Yeah I guess with this new insulin it’s a case of trial and error as you say.

Food wise I’m reasonably able to tell what I can and can’t tolerate, but guess that changes all the time as well! I think for me it’ll be getting used to adjusting per meal, I’ve been so used to mixed where it’s set doses all the time. But I’ll get there!

I see your type 2 as well, may I ask if you use a bolus calculator? Initially, my nurse told me it’s not really necessary because of being type 2, but I wonder if it could be helpful?

I’m gonna start using my sensor tomorrow, so fingers crossed it’ll help me see what’s what.

 

[Jhp86]

Good evening I think you will find your new mix of insulins will help. I had a rough year bloods all over the place. Started first insulin Lantus then 4 weeks later Novo rapid. Lantus I usually do about 9pm it does sting a bit as it’s the acid baseline but quickly settles. I started on 14 units but now at 22 which gives me waking at 6.9-7.5. My Novo fast acting I take about 5 min before I eat 4 unit breakfast then depending on what eating 6 lunch same tea. I do adjust if having few more carbs mines 1 unit to 10g carbs. After 7 weeks my levels stay about 7 before meal and back to this four hours after food. So it’s stable for me. But everyone’s different. I’m sure this will settle for you

Thank you, this is really reassuring

My levels have shot up for no reason in the past couple of months (before I was averaging between 8 at the lowest and 11/12 highest) and all of a sudden with no warning and no real reason I was getting 11/12 lowest and 17/18 highest, and now it’s no lower than 17 and highest is close to 30! So hoping that this helps!