Question re basal should “keep you steady”

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TwilightMidna

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Type 1.5 LADA
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Hi everyone, I wanted to pick your brains about this. I understand the purpose of basal insulin is to match the liver output, that it should have nothing to do with food, and that it should keep you steady in the absence of food.

I’m wondering what this looks like in practical terms? Should it keep you steady at roughly the same level, regardless of food/bolus? Or should it keep you steady at wherever your last meal/bolus left you (after both have left the system, for want of a better way of saying that)?

I’m asking because it seems that no matter what level I go to bed at, I always seem to start to gradually drop sometime between 12am and 12:30am, and always end up eventually steady at mid 4s/5s throughout the night. Does that sound like my basal is doing its job, or should I be staying at whatever level I go to bed at?

In case it’s helpful - I inject my Lantus at ~8:45am and my last NovoRapid bolus of the day is almost never later than 6:30pm (so presumably my bolus should be all used up by 11:30pm?).

Thanks for any insights anyone may have!
 
Basal is supposed to keep you steady, BUT, and it’s a big but….
Basal assumes your liver produces the same amount of Glucose 24/7, and it's not necessarily so. Also, you may be producing dribs and drabs of your own insulin, and your body may chuck some into the mix at night until it’s lowered you to a level that it thinks is appropriate. I always plummet the moment I get into bed, however long it is since I had my last meal and bolus, then I rise from 4am as my liver output starts up again for the new day.
 
@Robin, thank you for sharing! Interesting to hear that you have a similar thing going on at night. Do you ever have lows at night because of this? I’ve had 2 lows at night (3 total) since starting on insulin in August, which makes me think the basal is actually okay... I’m planning on asking my doctor about split dose basals and also I read here the other day that Lantus can be given in half units with a cartridge and reusable pen, which might be another option for me. Thanks again for sharing - much appreciated!!
 
The other thing worth considering is the "Lantus affect".
Lantus is one of the older longer acting insulin - it did me well for 12 years and is still pretty common.
However, the "activity profile" of Lantus is not as flat as the new longer acting insulins such as Tresiba and Levemir. Lantus has a bit of a "kick" around the 5 hours mark (although the profile will be different for each of us) which could explain the 12:30 drop.

It also doesn't last a full 24 hours for many of us which means you may find your BG starting to rise around the 4pm mark.
 
Thanks @helli! I didn’t know Lantus had a kick in it at 5 hours. That’s very interesting to know. I think maybe I wrote the wrong times in my post but my Lantus is given in the morning at 8:45am but the drop is at midnight/half 12 at night. Maybe that could still be an issue though, just later on in the day? I can’t do the maths of how many hours are between 8:45am and midnight :rofl:
 
TwilightMidna said:
Do you ever have lows at night because of this
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Only when I took my Lantus at night, and occasionally crashed round about 1am. Taking it in the morning, I found it ran out just when I was needing something to counteract the dawn rise. Splitting it, its profile went even more lumpy at smaller doses. So in the end, I switched to Levemir, and take 6 units in the morning, and 3 at night. Because it’s flexible, if I have a couple of glasses of wine, which I find lowers me overnight (while the liver is breaking down the alcohol, it stops putting out glucose, it’s a poor multitasker), I can reduce it to 2 or 2.5 for that night.
 
Hi @TwilightMidna
Interestingthat you are going to look at a split basal. I was switched to Levemir prior to moving onto a pump as they felt it most closely matched the variations to basal that are possible in a pump. I did a basal am and pm and found that this gave me the flexibility to reduce my night time dose without changing my day time one, or vice versa. This helped me to more closely match what my body needs, as like others I found I dipped during the night. I also get a dump of glucose when I get up, whatever happens overnight.

Let us know how you get on.
 
@Robin @SB2015 it definitely sounds like the twice daily basals have much more flexibility. I was reading that the current recommendation is to start people on the twice daily basals, so not sure why my GP went for Lantus. Maybe he thought I wouldn’t want to do an extra injection… Anyway, I shall certainly keep you all updated. Thanks so much for sharing - it’s always so useful to hear others’ thoughts and personal experiences!
 
It is the fact that you are human that causes the 'early hours' drop in blood glucose - knob all to do with the fact you have diabetes or use injected insulin. It's when people working nights get the munchies and (sorry about the next bit) more suicides in the past occurred.
 
TwilightMidna said:
@Robin @SB2015 it definitely sounds like the twice daily basals have much more flexibility. I was reading that the current recommendation is to start people on the twice daily basals, so not sure why my GP went for Lantus. Maybe he thought I wouldn’t want to do an extra injection… Anyway, I shall certainly keep you all updated. Thanks so much for sharing - it’s always so useful to hear others’ thoughts and personal experiences!
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Some HCPs have this obsession with “OMG, that will mean another injection!”. It’s patent nonsense. The injections are way down the list of Type 1 annoyances. Once daily basals suit a few people but most people do better on twice daily basals due to the flexibility they give and the ability to adjust the day and night segments separately.

If you’re dropping significantly overnight, I’d say your Lantus was too high. But mainly, I’d say ditch the Lantus and go for Levemir or an isophane basal.
 
trophywench said:
It is the fact that you are human that causes the 'early hours' drop in blood glucose - knob all to do with the fact you have diabetes or use injected insulin. It's when people working nights get the munchies and (sorry about the next bit) more suicides in the past occurred.
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I love your turn of phrase 🙂
 
Levemir doesn't have a flat profile either, it rises to a peak of activity between 5-8 hours and then slowly tails off and depending upon the dose will last from about 1about 16 hours to 22ish.
I need a lot of basal insulin during the day but almost none at night. Currently 22units in the morning and just 1.5 at night but can drop to zero at night if I have done a lot of exercise on consecutive days, or if I have been sedentary for a few days it might go up to 4 or 5 units at night. I used to find that alcohol made no appreciable difference to my evening dose whereas exercise the previous day/s makes a big difference. Oddly my daytime basal needs change very little proportionally between 20 and 22u.
The great thing about Levemir is that you can also tweak the times you take the individual doses so that the peak of activity happens when you need it most. Usually I take mine, the moment I wake up on a morning and always before I set foot out of bed, so that it can start dealing with the surge of glucose from my liver ASAP and I also jab 1.5-2 units of bolus insulin to help it as I have a very strong Foot on the Floor syndrome. I did start setting my alarm for an hour before I wanted to get up to inject my Levemir but I soon got tired of that idea, so as soon as I wake up plus some bolus insulin works for me. On an evening I usually take it at bedtime but occasionally I start to get a rise in levels around 7pm, so at those times, I bring my evening dose forward and perhaps increase it by a unit to help deal with that issue. I love how Flexible Levemir is and that I can change my evening dose consecutive evenings and get the results I want then and there without really impacting my daytime levels. There is a slight overlap of day and nighttime Levemir, more so with may large morning dose overlapping my small evening dose and you do still have to be mindful of that and ideally not change day and night time doses in the same 24hr period and it does take more thinking about because there are a few factors to consider when adjusting your basal insulin, but I personally love Levemir and cannot imagine how I would manage with another basal insulin except maybe an isophane because of my daytime and nighttime disparity. My main problem is still nocturnal hypos even on tiny or no evening dose but they would be far far worse if I had a very long acting or once a day basal.
 
Inka said:
If you’re dropping significantly overnight, I’d say your Lantus was too high. But mainly, I’d say ditch the Lantus and go for Levemir or an isophane basal.
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This is part of what confuses me a bit - if I go to bed at 6 and drop to 4.8, that doesn’t seem particularly significant (to me). But equally I can go to bed at 10 and drop to 5, which seems more significant, but either way, I always drop to the same, steady level. It’s weird (or seems weird to me haha)
 
@rebrascora it’s good to ready how happy you are with Levemir. Did you ever use a once a day insulin at the start? One thing that does concern me is dealing with two peaks of basal a day. I could probably do with a bit of a peak at breakfast, but I’m not sure another would suit me. Something to ask my doctor about I suppose!
 
TwilightMidna said:
This is part of what confuses me a bit - if I go to bed at 6 and drop to 4.8, that doesn’t seem particularly significant (to me). But equally I can go to bed at 10 and drop to 5, which seems more significant, but either way, I always drop to the same, steady level. It’s weird (or seems weird to me haha)
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It may well be that your own body is contributing to bring you down to that 5mmol level then. I find that I sleep best (deepest and soundest) between 4 and 5 so it may be that the body tried to achieve that level for the most restorative sleep but it is a fine line balancing that with insulin, especially for me as my night time levels are very erratic. I sleep very poorly when my levels are above 8.
 
TwilightMidna said:
@rebrascora it’s good to ready how happy you are with Levemir. Did you ever use a once a day insulin at the start? One thing that does concern me is dealing with two peaks of basal a day. I could probably do with a bit of a peak at breakfast, but I’m not sure another would suit me. Something to ask my doctor about I suppose!
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I started Levemir on once a day and split it just before my DAFNE course, when I was on 7 morning and 7 evening, but after my course it became clear that it needed changing particularly when I started exercising more. I was obviously still producing some of my own insulin at that time whereas now I am pretty sure I have run dry. My evening dose is so small, I don't worry much about a peak of activity, it is more about bringing it forwards sometimes to overlap more with my morning dose to get a bit of a kick in the evening when I occasionally get spells of needing that. It has become very intuitive with me now and I mostly get a gut feeling for what my evening dose needs to be and when I need it. I adjust it on an almost daily basis and last night was the first night when I can genuinely say I was stuck for what to inject because I had swung from Friday night where I had 2.5 units and my high alarm went off and I injected 4 units of Fiasp at 5am to bring it down which I thought was heavy handed but the lowest I got was in the 4s and then it started going up again, to 1.5 units Levemir the next night and needed 5 JBs throughout the night and still hypoed. So my intuition to reduce the dose was right even though I hadn't had much exercise but I didn't reduce it enough. Last night I really wasn't sure but I plumped for 2.5 because my levels had been high all day yesterday and I had needed loads of corrections and it was just a bit too much and I needed 3JBs so I.5u would probably have been right. I have upped my morning dose this morning though by 2 units which is balancing my daytime levels a lot better, so I need to consider the tail end of that when I decide on tonight's dose. It all probably sounds very complicated but Libre really helps me to get a good picture of what is going on and enables me to gradually become more intuitive with my doses.
 
@rebrascora sorry to hear about the hypos. I absolutely hate being woken up at night so I feel for you! It does sound complicated but yes the Libre is so helpful and it certainly sounds like you know what you’re doing and what your body needs. Hopefully it’ll become more second nature to me too as time goes on x
 
No great worries about the nocturnal hypos for me. I wake up eat a JB or 2 and will be back to sleep in less than 2 minutes. Sometimes I wake up, scan the reader and fall back off to sleep before I eat the JBs and then wake up an hour later with naughty red on my graph but still eat a couple of JBs then and go straight back to sleep in minutes. I know I should stay awake for 15 mins and retest with a finger prick but I love my sleep too much and I wake up again later if I need more JBs. I am not recommending anyone else do this as it is bad practice, but if I put the light on and warm my meter up enough to test, or go into the other room to test if I am at my partners house or he is at mine, it really interrupts my sleep and that affects quality of life, so I try to stay awake long enough to treat before I drop back off but I don't feel unwell at the level my alarm goes off (4.5) to really prompt me or stop me from dropping back off. It is one of the reasons I don't set my alarm higher, because I would simply ignore it and I get my best, deepest sleep at that 4-5 level.
 
TwilightMidna said:
This is part of what confuses me a bit - if I go to bed at 6 and drop to 4.8, that doesn’t seem particularly significant (to me). But equally I can go to bed at 10 and drop to 5, which seems more significant, but either way, I always drop to the same, steady level. It’s weird (or seems weird to me haha)
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Possibly the Lantus is running out and then your own insulin is bringing you down. When I was first diagnosed, I only needed a tiny amount of basal. Overnight I think my body could have brought my blood sugar down itself.

I wouldn’t worry too much about the two peaks of a twice daily basal. They’re not massive peaks and it’s possible your evening basal dose will be tiny anyway. The two doses don’t have to be exactly 12hrs apart. You can time them to suit (within reason, obviously).
 
I'm another one that switched to livermer I was put Trisbria(super long acting insulin I believe it lasts up to 42 hours). But whenever I had busier day of even a busier Evening I would find that I kept dropping thought the night and couldn't do anything about that expect eat.

I was unsure at first but now I like the fact I can just reduce it if I've been partially busy that day. Also I can take different amounts for morning dose and evening dose. Actually at the moment by some odd occurrence that happens In the diabetics world Im taking less in the morning than I do in the evening and thinking about reduceing my morning futher
 
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