Question about insulin dosing

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MarinaDE

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Newbie here. I got my first insulin vials yesterday - Tresiba once a day, and Fiasp at meal times.

I injected the Fiasp at lunch, but my blood sugar skyrocketed. Can I vary the dose, or inject a second time? What's more important, sticking to the prescribed schedule, or keeping the sugar levels in the green zone?
 
@MarinaDE At the moment, stick to the schedule you’ve been given. You’ll have been started on less than you need for safety reasons. Gather information about how these amounts work for you (ie record meal time, carb content, insulin dose, blood sugar before). Always err on the side of caution.
 
Also, it’s normal for your blood sugar to rise after eating. What you’re looking for is if it comes down at the time of your next meal. How high did you go?

It’s likely your doses will need adjusting, but this will be done carefully and gradually - not just your Fiasp but the Tresiba too. Getting the basal insulin dose right (Tresiba in your case) is the foundation of good control. You then build on that by getting your mealtime doses as right as you can.

Have you been given a mealtime ratio, ie 1 unit of Fiasp for every 15g carbs or whatever? Areyou on fixed dose of the Fiasp, ie take X units at lunch, etc? If so, were you given a rough estimate of how many carbs that fixed dose would cover, eg take X units of Fiasp and eat Y grams of carbs?
 
So it in the early days of starting on insulin, the doses should be less than you actually need and you should not be aiming to come straight down into the green zone as that will put a significant strain on your blood vessels, particularly the fine ones in your eyes. The idea is to bring your levels down gently and gradually over a period of weeks, so yes, stick with the doses you have been given and do not be too impatient. Slow and steady progress is what you are looking for but yes, your levels will spike after food and then the insulin will kick in and start to bring them down. Hopefully you will see them slightly lower than they were before the previous meal when you inject for the next meal. The doctor/nurse needs to see how you respond to these doses in order to figure out how much you actually need and slowly work towards the doses which balance your levels.
 
@Inka types faster than I do!
 
rebrascora said:
So it in the early days of starting on insulin, the doses should be less than you actually need and you should not be aiming to come straight down into the green zone as that will put a significant strain on your blood vessels, particularly the fine ones in your eyes. The idea is to bring your levels down gently and gradually over a period of weeks, so yes, stick with the doses you have been given and do not be too impatient. Slow and steady progress is what you are looking for but yes, your levels will spike after food and then the insulin will kick in and start to bring them down. Hopefully you will see them slightly lower than they were before the previous meal when you inject for the next meal. The doctor/nurse needs to see how you respond to these doses in order to figure out how much you actually need and slowly work towards the doses which balance your levels.
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Thank you so much for telling me about the blood vessel strain, as I was tempted to inject more. I will do anything to protect my eyes.
 
210mg/dl is only about 12mmols I think which is not desperately high and nothing to worry about at this early stage.
 
MarinaDE said:
I went to 210 mg/dL. I have no idea what these numbers mean!! But it's in the orange zone.
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That’s fine @MarinaDE That’s not desperately high at all. I wouldn’t worry about that. it’s 11.7 in U.K. measurements.

It’s not just the worry about your eyes though. The main worry is having a nasty hypo. Insulin is a miracle drug but it’s powerful and having too much can have very unpleasant effects at a minimum.
 
I would expect you to be mostly in the orange zone for the first week or two, so don't worry too much.

It is also possible that once your pancreas gets used to having some injected insulin, the strain on it will be relieved and you may then find that it recovers a bit and starts producing a bit extra itself which could very easily drop you low, so it is really important to bring levels down slowly for lots of reasons.

Insulin is an incredibly powerful medication and it doesn't work instantaneously, so you have to be patient and give it time..... usually about 4-5hours for mealtime insulin.
If you want to help it a little, go for a gentle walk but make sure to always have hypo treatments with you as exercise, even quite gentle exercise can make that Fiasp much more effective and drop your levels faster than you expect, so important to always be prepared. I always carry Jelly Babies and Glucotabs. The standard hypo treatment is 15g carbs which is 3 JBs or 4-5 Glucotabs or most of a small carton of juice or a small can of full sugar cola. Hopefully you will not need any of those for now but always be prepared and keep them everywhere including by the bed and even in the bathroom as a hot bath can drop levels.
 
I'm reading about insulin and weight gain. Is this inevitable? I eat a pretty good diet and am fairly active, so there's not much room for me to cut calories and increase movement. The endocrinologist said the insulins are weight neutral, but everything I'm reading says they're not.
 
Insulin doesn't cause weight gain. It just enables the body to access the glucose from the food you eat the same as previously your own home produced insulin did.

With people who eat more than they need then yes, insulin will help them to store that excess glucose as fat as oppose to it sloshing around in their blood stream and sticking to their red blood cells and potentially clogging up their fine blood vessels. With Type 1 or Type 3c where you are unable to produce enough insulin of your own, unless your doses are too high and you are having to constantly eat more to prevent hypos, then insulin will not cause weight gain, unless you were putting on weight with your diet before you were diagnosed. We should gradually learn to adjust our doses to what we need to balance the food/diet that keeps our weight stable.

My weight was quite stable for a few years after diagnosis but just recently I have been putting on weight and it is simply because I am eating too much and not doing enough exercise. Yes I am also injecting more insulin but that is because it has to match the food I am eating to keep my BG levels in range, but if I didn't have diabetes my pancreas would be doing that. It is the food which is putting the weight on me and I simply need to be more disciplined with my diet and exercise..... just like I did before I was diagnosed and obviously before I was injecting insulin. The insulin isn't making me fat, the food and not enough exercise is.

If your weight was stable before and you don't change your diet and exercise from that which was keeping it stable, then the insulin won't change that because it is just replacing what your own pancreas is no longer producing.

There are people here who have been on insulin for 50 years and not put weight on, other than perhaps a bit of middle age spread as comes with age, so NO, insulin does not cause weight gain. It can only facilitate it if you eat too much as I have been doing recently.
 
Apologies if the above post is rather repetitive. This issue is a very sensitive one because many people with Type 1 believe this and develop mental health issues and start to not take their insulin because they worry it will make them fat or they stop eating and stop injecting. It can lead to very serious eating disorders as well as uncontrolled diabetes and the potential complications that that risks to sight, feet and kidneys particularly and it simply is not true that insulin causes weight gain.
 
MarinaDE said:
I'm reading about insulin and weight gain. Is this inevitable?
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No.
if you are injecting insulin with Type 3c you are replacing the insulin your pancreas would produce if it was able.
To my understanding, excess insulin can cause weight gain if you have insulin resistance (type 2).

I will write as someone with Type 1 but I believe the same is true for Type 3c.
I have been injecting insulin for 20 years. I eat the same as my non-diabetic partner. I weigh the same now as I did 30 years or more ago. Insulin has not caused me to gain weight and others I know personally with Type 1 are not overweight.

Actually, it makes me angry when I read about this myth. Many people are worried enough about taking insulin without the internet perpetuating this falsehood.
 
Insulin doesn't cause wight gain. I'm thinner now i am on insulin than i was before
 
MarinaDE said:
I'm reading about insulin and weight gain. Is this inevitable? I eat a pretty good diet and am fairly active, so there's not much room for me to cut calories and increase movement. The endocrinologist said the insulins are weight neutral, but everything I'm reading says they're not.
Click to expand...

I’ve been taking insulin for almost 30 years. My BMI is around 19. Insulin does not make you fat. That’s a very pervasive myth that annoys me a lot. If you lost weight prior to diagnosis, the insulin will help you get back to a normal weight but you won’t get fat. All you’re doing is replacing the insulin you can no longer make. People without diabetes make plenty of insulin. Everybody in the world would be fat if insulin made you fat!

Nick Jonas has Type 1 - is he fat? Theresa May has Type 1 - she’s not fat either! Ooh, what I’d do to the idiots who spread myths like that! 😡
 
I'd say t1 are more likley to be thin as
1/ if they weren't they be misdiagnosed as t2!
2/ weight lose is a symptom of t1 so most of us will start off on our diagnosis journey skinnier than normal for us
3/ makes you think twice about snacking if you have to jab yourself with a needle, or if it sends your bs off whackbasically, t1 have to think more about eating
 
OK so this hit a nerve! But I'm incredibly relieved to hear this.

I forgot to take my Tresiba today and I skipped lunch. When I finally had dinner my blood sugar skyrocketed into the red zone. My consultant emailed me! It feels very weird being monitored.
 
Wow! Absolutely amazed that your consultant is monitoring your Libre and emailed you when you went high!! That would not happen on the NHS and especially on a Saturday! Did they give you advice bout what to do?

You can take Tresiba several hours late and it doesn't make too much difference, whereas some other basal insulins it makes more of a difference when you are late because it impacts the next dose.
Gradually you just get into a routine of injecting and it becomes automatic. I always inject before i get out of bed on a morning so my routine is wake up, inject insulin and then get up. Hopefully you will find a routine that works for you soon, but you will make mistakes and forget stuff until it becomes more automatic.... and then when it becomes automatic you question whether you actually injected because you can't remember doing it. I can jab some insulin and then 5 mins later, not recall whether I actually did inject it or just logged it in the notes on my Libre. Thankfully I have a pen that records the last dose so I can check but it is surprising how you can do stuff like that subconsciously, so that you have no recollection of it shortly afterwards.
 
@MarinaDE, Tresiba happens to be the basal insulin with the longest profile, in that each daily dose is expected to last 40 hours. Today's dose is topping up yesterday's dose. That means it is very forgiving in timing, its not a basal that must be injected exactly every 24 hours. But this weekend you haven't really built up a residual backlog of Tresiba for that benefit to be particularly effective, yet. Once that accumulative effect is in place Tresiba is usually regarded as a very inflexible and stable basal insulin. Changes in Tresiba dosing can need 3 x full 24 hrs to properly take effect and so Tresiba is not a basal that we change frequently.

At this very early stage your Consultancy will be using their experience to estimate what you're basal (and bolus) doses will need to be. They take account of things like your age, weight general fitness etc and start you off. But they will be cautious and be trying to keep you away from going hypo; ALSO the nature of diabetes is that we all respond quite differently to an insulin type and have surprisingly different insulin needs. So it's an extremely lucky guess to get the start doses right straightaway (never mind that you have been in DKA and your body needs to find it's new equilibrium).

The other most important aspect is that you should try to behave normally in terms of showing your team your likely eating routine. They may be very good, but not that good! If you think your normal routine will invariably lead to you skipping a daily meal - fine. But if you skipped lunch because you were nervous about needing to take a meal bolus (or had unfortunately heard the nonsense about insulin can make you fat!) then you are doing yourself a disservice and making the task of your remote monitoring team nigh impossible. They can only see outcomes after the day and only then evaluate what changes in both basal and bolus doses might help you steadily restore your BG to a sensible level AND keep you in roughly the right place.

To help you manage your expectations: this will take time, will not be immediately steadied and normality will not be instantly restored. Neither you nor the Consultants will have an accurate understanding, yet, of how much your panc'y today will behave this coming week, nor in a fortnight, nor when your panc'y will finally stop producing any natural insulin. That alone could change this month , or in 12 months or in 10 years. More tests and monitoring is needed and as you have already told us that must now wait a bit. Today's CGM tech is wonderful - in comparison to what was available even 4 or 5 years ago. But this medical science behind Endocrinology is still as much an estimating art (guesswork) as it is a science. There are so many variables, no computer can calculate all the permutations and definitively state the exactly correct answer. I'm a retired civil and structural engineer, used to analysing situations and crunching numbers; but I know when the calculations need extra safety factors that don't allow the most refined answers. I know when the time and budget needed does not exist for perfect solutions.

But to also help manage your expectations: you have survived DKA, you are receiving initial superb first response, with brilliant monitoring and you are in a great place - even though the remote monitoring feels weird. Give yourself a break and your team a fighting chance and somehow try to do the sorts of eating and activity patterns that you might normally do, 7 days a week. That does not mean eat identical meals at identical times, etc. Variety is fine, just not too varied for a fortnight or more; let some patterns emerge.

Insulin adjustments will be needed - don't try to become the instant expert and let your team do their monitoring and adjusting. But by all means ask questions - ask them, ask us. We'll try to explain what we can and try not to give medical advice, we're not medical professionals.

Sincere apologies if I've just lectured you! I'm far from perfect at this D management malarkey. I'm awake at 2am because last night's meal out didn't work out how I was expecting it to. I didn't get my insulin before dinner to match the carbs I'd counted, so my BG dropped lower than I'd anticipated while I was eating and then gently climbed far higher than it should have done. A modest correction insulin dose as I went to bed turned out to be too much and my CGM alert an hour ago has transitioned from alert to an alarm and I'm monitoring - eating cautious snacks (got too much insulin in my body), trying to resist over-reacting and knowing this sleep broken night will hurt me tomorrow! These things happen, I'll live; when I know what I did wrong I'll try to learn the lesson. Right now I don't know why this has occurred and unless I get a flash of inspiration I shall have to accept matters, take note and try my best to move into another day - without beating myself up or letting it niggle me. But I'm far from perfect at that also ....
 
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