Query advice from diabetic nurses

[Morgan444]

Hi
I confess that I’m a bit of a control freak when it comes to my T1D management. I have a Libre 2 CGM and was taking 45 units of Levemir a day basal split into 2 doses. However, I found that my glucose was drifting up to around 12 by 9pm even if I hadn’t eaten carbs. This felt to me like the Levemir was running out so I switched to 3 doses a day so I have a steadier stream on slow release (8am, 4pm and 11pm) but still 45 units per day. This has sorted it out and I am largely avoiding unexplained highs. However, I have now been told by the diabetic nurse that I shouldn’t be doing this as Levemir is “not licenced” to be taken 3 times a day. I explained that this had helped me manage my glucose but she was still adamant that I should only take it 2 times a day and suggested that my issue might have been my fast-acting insulin ratio instead. I don’t want to increase ratios as, even with a 1:1 ratio I am having to split the dose in 3 (once before the meal, once at the end and a 3rd two hours later) otherwise the insulin kicks in before the carbs and I have a hypo that I have to take glucose tablets to address. It feels like every time I think I have my regime sorted out I get advice from a health professional that plunges me back into confusion. I have only been diagnosed for a year and a half and am just coming out of the honeymoon phase. Not sure what I want from the forum re: this but would be good to hear if anyone else has been having similar experiences?

 

[Tdm]

If it works for you, i'd want a very persuasive explanation on why you shouldn't do it

 

[Inka]

Did you do a basal test to disprove her comment about your ratio being wrong @Morgan444 ? How are you splitting your Levemir (how much for each dose)? I’ve taken basal 3 times a day when I’ve had a pump break. Like you, I found it was running out in the evening, but if I had it earlier in the evening it then didn’t last till the morning. My consultant didn’t mind my three doses, but I’ve had Type 1 for decades and am well out of the honeymoon period.

What bolus insulin do you take? It’s worrying you’re hypoing if you take it all up front. Are you really on 1 unit to 1g carb?

 

[Morgan444]

Did you do a basal test to disprove her comment about your ratio being wrong @Morgan444 ? How are you splitting your Levemir (how much for each dose)? I’ve taken basal 3 times a day when I’ve had a pump break. Like you, I found it was running out in the evening, but if I had it earlier in the evening it then didn’t last till the morning. My consultant didn’t mind my three doses, but I’ve had Type 1 for decades and am well out of the honeymoon period.

What bolus insulin do you take? It’s worrying you’re hypoing if you take it all up front. Are you really on 1 unit to 1g carb?

Thanks Inka. Going to do a carb-free day tomorrow to get a basal test on 3 times a day. Going to speak to consultant about the QA hypos, really want to get a pump. It’s 1 unit for each carb unit which is 10g of carbs

 

[Lucyr]

Thanks Inka. Going to do a carb-free day tomorrow to get a basal test on 3 times a day. Going to speak to consultant about the QA hypos, really want to get a pump. It’s 1 unit for each carb unit which is 10g of carbs

You’re not supposed to do a basal test for the whole day at once, or to eat carb free meals during basal testing. Just supposed to miss one meal and test that time frame then a few days later miss a different meal and test that time period. Worth reading more about basal testing before you do it to make sure results are useful.

 

[Inka]

Thanks Inka. Going to do a carb-free day tomorrow to get a basal test on 3 times a day. Going to speak to consultant about the QA hypos, really want to get a pump. It’s 1 unit for each carb unit which is 10g of carbs

Ok, best to say 1:10 then, which is a perfectly normal ratio 🙂 If that’s not working for you, then you could try 1:12 (1 unit for every 12g carbs) or whatever works for you.

A basal test means no food and as @Lucyr says, it’s best to do it in segments over a period of days. I asked about basal testing because I wondered if it’s actually your basal contributing to the lows. What bolus/meal insulin are you using?

 

[rebrascora]

I am wondering if you are perhaps following a low carb way of eating some of the time and the rise you are seeing is protein release, which usually happens about 2 hours after a meal and continues for many hours after that. I need to inject bolus insulin for it, sometimes 2 or even 3 small corrections over a few hours to deal with glucose release from protein in the absence of enough carbs in a meal.
Larger doses of Levemir generally last longer whereas small doses run out quicker. I am not sure how the doses you take equate to your body weight but there is a 3 dimensional graph which shows the profile of Levemir for your unit/kg bodyweight.

As @Lucyr says, doing a carb free day long test will not give you reliable basal testing as the protein and fat you eat will release glucose and compromise the test. Similarly, if you fast all day, your liver will likely release more glucose than normal because there is no food, so that will also make any results less helpful.

Personally I don't follow "the rules" anymore and use insulin as my body tells me I need it, but I do have a good understanding of how food and insulin affect my BG levels and from what you have said, you seem to be unaware that protein can contribute quite considerably to increase your BG levels in the absence of enough carbs and fat to a lesser extent....about 40-50% of protein breaks down and about 10% of fat. If you are having a carb free day then your protein and fat intake will significantly impact your levels. For example I need 2 units of bolus insulin for a 2 egg omelette but it needs to be injected 2 hours after the meal. Those 2 units are the equivalent of my levels rising by 6mmols which is surprisingly significant. So if you had a low carb meal at lunchtime, this could well be what you are seeing in the evening.