Newbie!

[Netball1]

I’m about to start using Tresiba long acting insulin. If anyone has this, did you alter your short acting dose? Thanks

 

[trophywench]

Why would you change your bolus insulin when changing the type of basal insulin? They aren't even intended to do the same job.

 

[Lily123]

I use Tresiba but as @trophywench said bolus and basal aren’t doing the same job so the bolus ratios shouldn’t need to be changed.Tresiba is an awkward one because if you make any changes to the dose then it takes 2-3 days to make a difference so if you do a lot of exercise and need less basal insulin then your stuck because of the Tresiba

 

[Proud to be erratic]

I asked to move to Tresiba from Levermir, because I wanted 1 less injection per day. After 5 months I'm happy I did this. Perhaps of interest: I was on 16-18 units of Levermir, split am and pm. I was started on 12 units of Tresiba and reduced this, on advice from my DSN, within a couple of weeks to 11 units daily, now on 10 units daily. Currently this is proving to be fine.

My bolus has changed a bit: in hindsight I realise that because Tresiba is very inflexible, I am using my bolus as one means of further improvements in control. I don't see this as either bad or good, just a change in what I do.

Regarding exercise or moderate continuous activity, I don't see a need to adjust my basal for that (and never have). I now regularly reduce my breakfst bolus by 50% when I know I'm going to be active. In general this works, not always, but usually. I then make a judgement on whether to add a correction to subsequent meal boluses - depending on how my day has been so far and what level of activity is still to come. I do find that I often need to eat a few more carbs after dinner than I took a bolus for, to keep myself from potential hypos; this is "work in progress" as I discover what sort of activity is affecting my BG and by how much. Probably I shall reduce my evening bolus by a percentage after a very active day: what % is still an unknown for me, but think I'll start at 20% reduction and see how that goes.

 

[rebrascora]

Hi and welcome.

Can I ask which basal you are changing from and why Tresiba has been suggested/recommended?

Tresiba is a very long acting basal insulin. If you have a very regular lifestyle it may suit you but it has a very flat profile in that it releases a very steady amount of basal insulin day and night at the same rate. Unfortunately human bodies are not generally very uniform in their basal needs or indeed in most other functions. Many people need more basal insulin during the day and less at night, particularly between 2am and 5am. People also usually need less basal insulin after exercise. If you exercise occasionally rather than regularly you may need to eat more carbs with Tresiba rather than reduce your basal insulin to accommodate it.
Tresiba wouldn't be my choice of basal insulin because I have very active days and other less active ones and I personally need much more basal insulin during the day than at night, so a split dose shorter acting basal like Levemir suits my flexible lifestyle more.

You may find that you need to adjust your bolus ratios a bit as a result of the change because the Tresiba will probably release basal insulin at a different rate to your current one at different times of day, depending upon what you use now and your body's basal needs..... but then those change over time anyway. Diabetes is always a case of monitoring levels, looking for patterns and tweaking doses or ratios as needed. The goal posts rarely stay in the same place for long.

Can I ask, are you relatively newly diagnosed and have you been offered or done an intensive education course like DAFNE (Dose Adjustment For Normal Eating).... DAFNE is so much ore than the name suggests.... ie a lot more than just carb counting. If you haven't done such a course (your local equivalent may have another name) then do ask about being referred onto one as they can be incredibly helpful, not just in terms of what you learn but just spending a week with other Type 1 diabetics is incredibly illuminating and you learn so much from each other.

 

[Proud to be erratic]

Why would you change your bolus insulin when changing the type of basal insulin? They aren't even intended to do the same job.

Well, for me, knowing that Tresiba is relatively inflexible there is no point in even tinkering with that basal unless there is clear evidence that it is too strong or too little; then adjust as part of a longer term strategy. So, when something is wrong, my default is to adjust my bolus. This might seem strange to you, with your decades of experience, but to me I don't see what the alternative is!

Shortly after moving to Tresiba I had an infection. Previously I'd altered my Levermir, but my DSN said don't and I increased my bolus accordingly. It seemed to work well enough.

As already explained I'm becoming increasingly more active and need to do something to maintain modest BG control - hence adjusting my bolus.

So, if I'm truthful, I don't understand your question. Basal is relatively fixed - what else do you suggest?

 

[trophywench]

I do not assume someone who only joined yesterday knows practically anything - just because you or I might know more than enough about our own D and insulin regime, does not mean anyone else ever does!

 

[Proud to be erratic]

Accepted- that is a 'given'.

So what was the intention of your question? I still don't understand? As best I understand matters one's body sees insulin as insulin - something to facilitate the transfer of glucose out of the blood and into cells, muscles organs et al. Whatever the type of insulin, my understanding is that the body doesn't know that it is long life or otherwise, or indeed any of the artificial characteristics that each type of insulin has - it's just there and lasts as long as it lasts .... so if the basal is inflexible then the bolus is the variable? If I'm wrong please guide me (preferably courteously).

I'm still learning and in the last 2 years I've met my former DSN once and an Endo once; so not much verbal guidance other than reading: books, Google searches and this forum. I'm not unduly resentful about that; Covid has got in the way of so many things. But for me so has cancer, surgery, chemo and DM. I'm grateful to be alive and grateful I'm able to be able to wrestle with all of that - albeit with a lot of trial and error, along with considerable commitment.

 

[Netball1]

Thank you everyone for your replies. I completely understand that the basal and bolus have very separate jobs. I’m changing from Lantus to Tresiba, on the suggestion by my consultant. He thought it may help the high but brief peaks in bs. The unknown to me is what the profile will be. I’ve been told to begin on 12 units, having taken 8/8 units of Lantus.
A large part of my life is Masters Athletics. I’m a track and field heptathlete. Lots of adjusting of insulin! I train 5 days a week and compete in the UK and internationally.
So I’m wondering if having a more consistent amount of insulin on board, in the way of Tresiba, might be helpful and I could perhaps just inject less bolus insulin…. I use Fiasp, fast and lively!
I just need to give the Tresiba a go, obviously when I’m not competing!!!
Many thanks

 

[rebrascora]

Hope it works well for you. It sounds like it might be a good move in your circumstances.

 

[Proud to be erratic]

Thank you everyone for your replies. I completely understand that the basal and bolus have very separate jobs. I’m changing from Lantus to Tresiba, on the suggestion by my consultant. He thought it may help the high but brief peaks in bs. The unknown to me is what the profile will be. I’ve been told to begin on 12 units, having taken 8/8 units of Lantus.
A large part of my life is Masters Athletics. I’m a track and field heptathlete. Lots of adjusting of insulin! I train 5 days a week and compete in the UK and internationally.

Thank you @Netball1 for clarifying the 'why and what'. How long have you been insulin dependent?

So I’m wondering if having a more consistent amount of insulin on board, in the way of Tresiba, might be helpful and I could perhaps just inject less bolus insulin…. I use Fiasp, fast and lively!
I just need to give the Tresiba a go, obviously when I’m not competing!!!
Many thanks

From my inexperienced perspective reducing the variables by having a fixed and relatively inflexible basal makes sense. Adjusting your bosul for each day, in response to your training routines, also makes sense. So if the regular basal release isn't completely in harmony with your body's hourly needs then adjusting your bolus in 4-5 hr segments of the day seems appropriate. I haven't changed my ratios; I just apply a % reduction according to what I'm intending to do and then readjusting afterwards as appropriate.

I'm curious about the timing of your basal change, ie your reference to "when not competing". I assume once you've changed to Tresiba you will stick with that for months rather than weeks to see how things go. But do you envisage that, as you approach a competition, you will change back? How many times a year do you compete?

I'm also interested in knowing how long you have been on Fiasp, if I may ask. My Endo has suggested that I move from NovoRapid to Fiasp as part of his recommendations to give me better control of my very erratic BG. I'm undecided about this, but have a Face to Face with him next Wednesday when his rationale for the change might become clearer.

I'm the wrong side of 70 and trying to return to activity levels from 2019 and pre-cancer, but definitely not training in any formal sense. So my activity is unstructured and my plan for each day changes with the weather along with anything else that comes along! May I ask do you have a particular strategy for managing your Insulin on Board (IOB)? Perhaps because of your training regime you don't have much IOB and can just take it in your stride (literally? !).

Good luck with it all.

 

[trophywench]

In my experience as a normal T1, once you get your basal dose as right as you possibly can to fulfil your body's need for insulin without the influences of exercise or food, then you adjust your bolus insulin to deal with the exercise and food. If you can't get the balance of these correct - then you constantly need to firefight. Most people do not wish to constantly firefight every hour of every day for the rest of their lives.

Most of us are not T3s, most of us do not engage in competitive athletics.

I'm certainly not going to apologise for being a normal ordinary T1 person!

 

[Netball1]

Hi informative people! Thank you!
I was diagnosed type 1 at the age of 30, still called ‘juvenile’ diabetes. The gene is in my family and my mum was diagnosed at 30 also .
I’m now 61 but started Masters Athletics at 50. It’s fabulous and keeps me healthy but I’m always searching for better ways of using insulin whilst competing.
So during a full day of athletics I need enough IOB to be able to access glucose for muscles but not too much so the BG drops too low. Also I don’t want to eat too much but then I need enough to have the energy from food.
My regime is to leave the basal, Lantus, as normal, then I ‘microcarb’ all day, so little food and little insulin as appropriate. It works pretty well and fortunately I have Libre 2!! EG 2 x Rich Tea biscuits and 1 unit of Fiasp. Medium banana and 3 units of Fiasp, that kind of thing.
I use Fiasp to microcarb and I use Fiasp to correct high BGs. Fiasp works within 3-10 minutes for me and corrects really well.
I used to use Humalog but it’s sluggish!
Much better control with Fiasp.
So Tresiba….. when I’ve worked out the correct dose, I’ll be starting at 12 once per day, then I hope to feel I have more, steady level, IOB and I may not need so much Fiasp. Fiasp can react rather lively when exercising so I’m thinking Tresiba may be less lively?
And yes when I’ve sussed it I shall stay on it and stop the Lantus. I hope to start the trial soon as in June I shall be competing at the World Championship in Finland and going for gold
Think that’s about me.

 

[Proud to be erratic]

Thank you @Netball1, sounds fascinating particularly the concept of microcarb. On that basis you should be keeping your IOB relatively low and so not triggering the strange consequence whereby higher levels of IOB can cause a rapid downward rush towards hypo.

Again, good luck with your preparations for Finland.

 

[Netball1]

Thank you for the vote of confidence. Out of interest, how many units of Tresiba are people taking.

 

[Proud to be erratic]

As I said previously, I was started on 12 then 11 at my DSN's recommendation. I reduced myself to 10, and my overnight drops stopped.

My Endo suggested I return to 11, with a view to going up to 12, partly because he felt I had a imbalance between basal and bolus. In principle he felt it was better if they were closer to 50:50. I sustained his recommended 11 for 4 weeks, with regular overnight drops and alarms! So I unilaterally put myself back to 10 and sleep interruption is much improved! The few night interruptions I now get are from "compression lows", ie lying on or pressing on my sensor while asleep. I see my Endo next week and discussing my basal is on my list of questions for him.
His name appears in a couple of recent tech papers on DM and exercise.

Are you familiar with Gary Scheiner's book "Think Like A Pancreas"? He's a sports clinician in the US, diagnosed T1 at age 18/19 and draws on his personal experience to unashamedly focus on insulin dependent people.

 

[helli]

@Proud to be erratic we are all different (as is often said). For me, the need to adjust basal when exercising is important because the effect of exercise on my insulin sensitivity can last up to 48 hours. I am unable to do anything with my bolus overnight so I need an alternative method to reduce the amount of insulin in my body which is only basal.
If your method of adjusting your bolus is working for you, that is great.

As a woman, I have another reason for wanting a flexible basal - my insulin resistance increases once a month for a couple of days. Having to wait 3 days for an increase in Tresiba to take affect would not suit this situation so I favour a shorter acting basal. I am now on a pump but, if I reverted to MDI, I would prefer the additional injection of Levemir than the inflexibility of Tresiba. As it is, at the moment, my back up basal (in case my pump fails) is Lantus.

But as I said at the start, we are all different and the best insulin regime for you is the one that works for you.

 

[Netball1]

Wow I like the sound of the book, will check that out, thank you.
Insulin resistance is a pain. I get that in the morning

 

[Proud to be erratic]

@Proud to be erratic we are all different (as is often said). For me, the need to adjust basal when exercising is important because the effect of exercise on my insulin sensitivity can last up to 48 hours. I am unable to do anything with my bolus overnight so I need an alternative method to reduce the amount of insulin in my body which is only basal.
If your method of adjusting your bolus is working for you, that is great.

As a woman, I have another reason for wanting a flexible basal - my insulin resistance increases once a month for a couple of days. Having to wait 3 days for an increase in Tresiba to take affect would not suit this situation so I favour a shorter acting basal. I am now on a pump but, if I reverted to MDI, I would prefer the additional injection of Levemir than the inflexibility of Tresiba. As it is, at the moment, my back up basal (in case my pump fails) is Lantus.

But as I said at the start, we are all different and the best insulin regime for you is the one that works for you.

Thank you @helli, I completely understand most of this.

One tiny question, solely to help my understanding, why can't you do something about your bolus for overnight? Currently my basal is such that I am broadly stable through the night - albeit I'm sometimes higher than I would wish as I go to bed and I then finger prick and correct to that reading regardless of what my Libre or CGM are saying; my target is to be at 6.0 and I correct to that target. If I've been active that day and think I will be unstable later I reduce my evening bolus accordingly; I'm still wrestling with this aspect, but gradually learning what does and doesn't work for me. When I'm ill, which is still more frequent than I would wish, I just increase my bolus.

I'm stepping over the business of your being on a pump and just asking this should you be reverting to MDI. All that said I do understand the debate about inflexible Tresiba vs flexible Levermir or Lantus; it just seems to me there are usable ways of compensating by bolus just as much as by basal and from something that @rebrascora said a while ago she inferred that she needed a great deal of guesswork and winging it to get it right by adjusting basal. Perhaps I just misunderstood.

 

[helli]

One tiny question, solely to help my understanding, why can't you do something about your bolus for overnight?

Because I am not taking any bolus at night and can't reduce zero any further.
My last bolus is taken with my evening meal and I go to bed more than 4 hours later so have no/little bolus insulin on board. I could take less insulin with my evening meal or eat a pre-sleep snack without a bolus and go to bed with a higher blood sugar level giving me scope for my levels to drop based on my basal dose but would rather aim to keep my levels stable rather than plan for a fall. Plus I seem to react to high levels (for me this is anything over 8 or 9 mmol/l) by having a restless mind making it difficult to get to sleep.

Like everything else diabetes related, there is some trial and error working out how much to reduce basal by after exercise but I have this sussed now find it more predictable than carb absorption rates.
I think rebrascora also eats a low carb diet so she will have to manage insulin to protein ratios which, for me, vary hugely and need to be taken later than insulin for carbs. I am not sure if this impacts her basal.