Puzzled

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JJay

JJay

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Relationship to Diabetes
Type 1
Even after 27 years some things still puzzle me!

I've been having trouble with my basal, to the extent that I've recently switched from Lantus to Levemir. Only 3 days in so basal testing has just been overnight so far. But my question is more general:

If accepted wisdom is that you don't go to bed on less than 8, but NICE guidelines say you should be between 5 and 7 on waking, then your BG would probably have to drop by more than the 1.5 "trigger" for adjusting basal. So how is it possible to conduct a meaningful basal test in those circumstances?
 
Are you sure the guidelines for being between 5 and 7 on waking aren’t just for type 2s? Because it’s pretty hard to wake up in that range every morning if you’re type 1! Do a basal test for a start and see what it tells you. I understood that you shouldn’t rise or fall by more than about 2, 1.5 seems a bit strict. If you’re staying fairly level then your basal is about right. If it drops just enough to keep you within the guidelines then maybe that will work for you.
 
@JJay how are you doing your basal test? Are you just looking at the level you go to bed at and the level you wake at? Or are you looking at your levles in between (this is easier with a CGM or LIbre)?

My understanding is that the "go to bed at 8" is required if you find your levels fall during the night. Personally, I struggle to get to sleep if my levels are that high and aim to be in the 6s with no bolus on board.

If you are only looking at two readings (before bed and on waking), it ignores whether you experience Dawn Phenomenon.
or example, I could go to bed at 8, have too much basal so drop during the night to 4 and then DP kicks in and I wake at 7.

Sorry, I have raised more questions than answer the one you posed.
 
JJay said:
So how is it possible to conduct a meaningful basal test in those circumstances?
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There was nothing meaningful about my overnight basal tests until I got a Libre, and could see the full picture. Even if I set an alarm for the middle of the night, I still often didn’t catch the dip I usually have around 3 or 4 am. The guidelines tend to assume a flat line overnight, and many people have anything but.
 
Only on pump can you get anyway near tight bg levels using different basal rates, even then there's no quatantee.

On injections would be happy with bg drop of 2 as usually went to bed on bg level of 7 anyway.
 
I ignore the 1.5 trigger as it’s not appropriate for every situation. If you don’t have a pump, levels can vary more overnight, and on injections I’d go to bed around 8. Better safe than sorry as far as nocturnal hypos are concerned. So, I’d personally be looking at 2 or 3 not 1.5 on injections. I don’t even use 1.5 on a pump. Sleep quality, daylight, disturbed sleep, what i ate, if I exercised - they all have an effect on my blood sugar overnight. So the fiction of such amazing control that you wake up perfectly in that 1.5 range is just that - a fiction.
 
helli said:
@JJay how are you doing your basal test? Are you just looking at the level you go to bed at and the level you wake at? Or are you looking at your levles in between (this is easier with a CGM or LIbre)?

My understanding is that the "go to bed at 8" is required if you find your levels fall during the night. Personally, I struggle to get to sleep if my levels are that high and aim to be in the 6s with no bolus on board.

If you are only looking at two readings (before bed and on waking), it ignores whether you experience Dawn Phenomenon.
or example, I could go to bed at 8, have too much basal so drop during the night to 4 and then DP kicks in and I wake at 7.

Sorry, I have raised more questions than answer the one you posed.
Click to expand...
Yes, I have Libre 2 so checking the graphs (thank goodness, I hate having my sleep disturbed!)

Don't apologise, it's so useful to have other approaches to ponder!
 
Thank you all so much for your responses. I'm now seeing there's a bigger picture and I can be more flexible in my approach.

I think part of the problem is that I've been cursed by a succession of DSNs (I love 'em really!) who are obsessed by hypos and pounce on any overnight drop saying "too much basal"!
 
JJay said:
Thank you all so much for your responses. I'm now seeing there's a bigger picture and I can be more flexible in my approach.

I think part of the problem is that I've been cursed by a succession of DSNs (I love 'em really!) who are obsessed by hypos and pounce on any overnight drop saying "too much basal"!
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I'm with them on that: hypos are bad. But now we've got the Libre we can track much better what's happening overnight so we can do much better than used to be possible. And the occasional hypo overnight's not that bad: good chance the alarm will wake us up anyway.
 
I think a lot of the guidance is based on dated diabetes management.
Now that we have Libre which gives us a much better idea of overnight patterns we don't necessarily need to be over 8 to go to bed and I often do a correction these days if my levels are above 8 at bedtime but that is because I can adjust my evening Levemir dose to what my body needs rather than a longer acting basal which might end up giving me more insulin overnight than I need in order to meet my daytime requirements. I think more flexible basal insulins like Levemir or pumps of course, allow you to go to bed in range and wake up in range rather than bumping levels at bedtime with a carb snack in order to prevent the risk of over night hypos from too much basal.
 
rebrascora said:
I think a lot of the guidance is based on dated diabetes management.
Now that we have Libre which gives us a much better idea of overnight patterns we don't necessarily need to be over 8 to go to bed and I often do a correction these days if my levels are above 8 at bedtime but that is because I can adjust my evening Levemir dose to what my body needs rather than a longer acting basal which might end up giving me more insulin overnight than I need in order to meet my daytime requirements. I think more flexible basal insulins like Levemir or pumps of course, allow you to go to bed in range and wake up in range rather than bumping levels at bedtime with a carb snack in order to prevent the risk of over night hypos from too much basal.
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Good point. After 18 (?maybe) years - I honestly can't remember when I changed from twice-daily Humulin I to basal/bolus - I think I'm trying to use Levemir with a Lantus mindset!
 
JJay said:
I think I'm trying to use Levemir with a Lantus mindset!
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I think this is the problems with many DSNs too. The old training and thought processes are deeply ingrained so it must be difficult for them to rethink it all, especially if they are not challenged/confronted with a different way of looking at it from a patient's point of view. To be fair, the changes have taken place over so many years that probably no one stopped to think about any changes needed to such basic guidance. I also think that the one size fits all approach can now be safely challenged because individuals have the technology (and information sharing thanks to the likes of this forum) to become the expert in their own personal diabetes and show clinicians that what they do is working for them even if it conflicts with the standard guidance. I think there is an element of needing a role reversal with some clinicians in that they could do with learning from some of their patients, but that will sit more easily with some than others.....

A prime example is the advice that you only prebolus a maximum of 20 mins before eating.
My consultant was absolutely horrified that I needed 75 mins with Novo(not so)Rapid at breakfast time and 45mins now with Fiasp but he can't knock it as my Libre shows that it works for me and I would hope that he might use that knowledge to encourage other diabetics to carefully experiment with their prebolus timing.
 
Yes, lots in this thread that fits my relatively limited experience. CGM provides hard evidence that many of us have different DM behaviour; that some DSNs and Endos need to refresh their understanding; that with CGM you can experiment more to find what works for you. The result (better control) is probably more important than how you got that result.
 
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