Recently diagnosed type 1 - clarification on the role of basal and bolus insulin

[rebrascora]

I'm sorry Roland - having T1 diabetes is nob all like having T3c. The SOLE bit of our pancreas that has ceased to function are our Beta cells. I can't comment whether DP is one to be dealt with by bolus insulin with T3c, except to seriously wonder how you can successfully do that when you're asleep? Like I said, as a T1 as long as DP isn't a huge increase (and it actually starts rising at least 2 hours previously to when it's at its height, anyway) it is normally treated by adjusting basal insulin. But anyway - it's very very early days for the lad and his parents to be juggling imponderables on their own. Far more sensible to take things more slowly in my view.

Let's concentrate on education.

I used to use my bolus insulin to tackle Foot on the Floor which is essentially DP but just a bit more sociable and easy to manage. I would inject 1.5-2 units every morning the moment I woke up to counteract it. Now I wake up an hour early and inject my Levemir to cover it and then go back to sleep. On Tresiba that wouldn't work because you don't get any peaks of activity with it so you have to adjust the dose to keep you out of the red through the night and then adjust with bolus during the day to make up for any daytime shortfall. I don't think being Type 1 or Type 3c makes any difference in that respect. I see it as a limitation of Tresiba that it is inflexible, but Roland prefers that situation and I can respect that. I guess it is just what you get used too and find a way to work with to cover your needs.

 

[Proud to be erratic]

Thank you @trophywench.

I did say I joined this thread with some trepidation. But I did so because I felt and still do, perhaps completely incorrectly, that a suggestion to test daytime basal was inappropriate for Tresiba. My comments lie solely in the Tresiba area of the discussion and I make no comments on more specific T1 aspects.

I'm sorry Roland - having T1 diabetes is nob all like having T3c.

Unhelpful comment. For the record I was discharged in Feb 2020 as a T1 - clearly, blatantly, wrong - and various Consultants use that record to show me as T1 in their reports. It's an uphill struggle to get 2 (now previous) Endos or a previous DSN to appreciate that T3c is complex; I have complete insulin dependency, with many T1 characteristics and several more D challenges in addition. That struggle is not helped by a GP who thinks I only need to test 4 times daily protected by Receptionists that can be more like guard dogs than support staff.

The SOLE bit of our pancreas that has ceased to function are our Beta cells. I can't comment whether DP is one to be dealt with by bolus insulin with T3c, except to seriously wonder how you can successfully do that when you're asleep?

I'm flattered that you imagine I have some of Superman's powers - able to give a correction bolus while asleep. Alas, that bar is just too high for me.

Like I said, as a T1 as long as DP isn't a huge increase (and it actually starts rising at least 2 hours previously to when it's at its height, anyway) it is normally treated by adjusting basal insulin.

I have far too little experience to state categorically that Tresiba adjustments definitely won't work. But I don't believe they will work for me, because of its 40hr profile and inflexibility.
That inflexibility is, for me, the strength of Tresiba. I'm optimised for the nighttime stability and don't (won't) alter my basal Tresiba on an ad-hoc basis. That said I have just reduced my basal because of this very hot weather here in the South.
So my solution is to use my bolus (or extra carbs) for managing my D against whatever the day throws at me.

But anyway - it's very very early days for the lad and his parents to be juggling imponderables on their own. Far more sensible to take things more slowly in my view.

Agreed

Let's concentrate on education.

I thought I was informing, rather than educating and sorry that I have not conveyed that satisfactorily to you.
If you have a further response please PM me and take further dialogue out of this thread.

 

[Bruce Stephens]

But I did so because I felt and still do, perhaps completely incorrectly, that a suggestion to test daytime basal was inappropriate for Tresiba.

I'd have thought the same, yes. Given that it also works overnight I'd have thought you should get it right for night time and then fix things up in the day as necessary. And if it's sufficiently annoying to do that, change to something like Levemir. (But I haven't actually tried anything longer acting than Levemir.)

 

[trophywench]

@Proud to be erratic especially - I apologise - I freely confess that the whole idea of treating T1 diabetes to me is to try and replicate what a normal body does as close as I possibly can - ie @everydayupsanddowns phrase of 'impersonating my pancreas' and since the body absolutely NEVER chucks out a regular amount of insulin 24/24 - whyever would, however could, Tresiba - which apparently does that very thing - be a truly viable longterm solution?

We've moved forward A Lot in recent years with T1, with pumps and CGM with closed loop 'Control IQ' and similar whether it's a matched thing some pump and CGM systems enable hand in hand, or a more DIY system of the same thing which people have adopted off their own bats for umm, at least the last 10 if not 15 years, by now.

I merely wish to encourage the latter thing as I see it being far, far more natural and healthier solution enabling T1 folk far and wide to live long and (hopefully) prosper.

This is all getting too technical for someone newly diagnosed - it's far beyond the A level diabetes course for a kid who's only just taken his 11+.

 

[Proud to be erratic]

@Proud to be erratic especially - I apologise

Thank you, apology not particularly needed. Unluckily you caught me post surgery, with hospital won Covid and generally not feeling great.

- I freely confess that the whole idea of treating T1 diabetes to me is to try and replicate what a normal body does as close as I possibly can - ie @everydayupsanddowns phrase of 'impersonating my pancreas' and since the body absolutely NEVER chucks out a regular amount of insulin 24/24 - whyever would, however could, Tresiba - which apparently does that very thing - be a truly viable longterm solution?

I guess, as a relatively new insulin, Tresiba provides a different approach. I stumbled into it by accident; I just wanted to reduce my daily Injections.
Whether because of Covid and lack of face to face or just plain laziness no D Specialist had told me that my Levermir basal was one of the weapons available to me to use in different quantities as part of the D management process. It was just a fixed dose thing twice daily. And, I hadn't read anything to guide me differently. Meanwhile I roller-coasted for almost a year from hypo to hyper and back again with no external help and being told I could only finger prick 4x daily. I felt horrible and felt imprisoned at home, unable to go out for fear of going hypo while out. Even a 10 minute stroll into our village would need JBs before I could get home. In truth I'm pretty bitter about how little medical help and support I got. Being a T3c with no panc'y was challenging.
Anyway, I set about learning and teaching myself.
Only time will reveal if Tresiba will be a viable long term insulin; meanwhile it, aided and abetted by Libre 2 has brought me a stability I didn't previously know was possible. It has reduced, almost removed, the night time 'imponderables'.
I have 6 night low glucose events in the last 90 days, 5 are false Libre low readings (2 last night); not compression lows, just Libre displaying readings 2+ pts below actual; one might have been a real drift just below 4.0. 4 days in and I'm today going to have to fit and bed in a new sensor; not the end of the world, but yet another D interruption to my daily living.

We've moved forward A Lot in recent years with T1, with pumps and CGM with closed loop 'Control IQ' and similar whether it's a matched thing some pump and CGM systems enable hand in hand, or a more DIY system of the same thing which people have adopted off their own bats for umm, at least the last 10 if not 15 years, by now.

Yes, you have remarked elsewhere that if you're going to join this insulin dependency club, no better time than 2022 - rather than even 2012, never mind 1972.

I merely wish to encourage the latter thing as I see it being far, far more natural and healthier solution enabling T1 folk far and wide to live long and (hopefully) prosper.

This is all getting too technical for someone newly diagnosed - it's far beyond the A level diabetes course for a kid who's only just taken his 11+.

Yes. I taught at post-grad level for 4 years and while I know my brain has slowed down, I find the complexity of D almost overwhelming.
I try to "eat the elephant" one bite at a time, but regularly trip over 2 or 3 different things happening simultaneously; right now post op medical stress along with wonderful but overbearing hot weather are 2 contra factors that I'm trying to pilot my super-tanker between!
I sometimes wonder if it is almost unhelpful to know so much about D's complexity; could be better to just manage each day - but I think I'd make poorer daily decisions.
My late brother ignored it all until it was too late and he became a T2 double amputee. So his precedent stimulates me - I won't be following in his footsteps!

 

[TheClockworkDodo]

My understanding is that the Tresiba basal insulin which he injects at night keeps the fasting glucose levels static at night/between meals and the rapid acting Novorapid is used as meal times to correct for carbs eaten or reduce glucose levels when he's high. His graph overnight is a nice flat line which suggests to me his basal insulin is correct but when he eats a meal he never comes back to where he started suggesting his insulin to carb ratio is set too high as we're weighing everything.

Contacting our diabetic team/consultant is a bit his and miss and the last time they just advised he ups his basal dose without any explanation of why basal and not meal bolus. If he ups his basal dose and that's already flat won't he start going down ? Should we be looking more at his insulin to carbs ratio so he comes down to a nice level after his meals ?

@Higgy65 hello and welcome to the forum 🙂

Just to say that I agree with the advice you've been given by @Thebearcametoo and @rebrascora - particularly because I too am on Novorapid and Tresiba, and I too was told by my DSN that I should raise my basal to prevent spikes after meals even though I have fairly level readings overnight (she also told me to lower my bolus doses to reduce daytime hypos). I was extremely dubious about this advice, but wanted to be able to say I'd given it a shot, so I have now tried it three times. Each time it was a complete disaster - raising my Tresiba and lowering my Novorapid means I have huge spikes after meals, I still have just as many hypos during the day, and I also have hypos overnight, which never usually happens.

I'm pretty sure for me the post-meal spikes are almost entirely a timing issue, so I've started experimenting with pre-bolusing a bit more, and this is helping. I've also found there are one or two carb-heavy foods I used to be able to eat without any problems and now don't seem to be able to eat without a huge spike, unless I reduce the quantity of the foods (tried increasing the Novorapid, that didn't work).

But if I were you/your son I should be very wary of increasing his Tresiba, as hypos in the night are not a good idea.

 

[TheClockworkDodo]

PS meant to say, I shouldn't try anything other than correction doses/hypo treatments (as appropriate) at the moment as the ridiculously hot weather is likely to mean the results of any experimenting now will be meaningless. I'd wait until it has cooled down a bit!