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Some advice needed...

F

freesia

Well-Known Member
Relationship to Diabetes
Type 1
Since being off work then finishing, my levels have been all over the place. Mostly, through the morning to mid afternoon, things are ok but then just before dinner levels start to spike and despite corrections often don't come down until overnight, then the same thing happens the next day.

I've been on Tresiba for a few years now and can usually adjust it when needed (eg school holidays when less activity or depending on season) however i've tried this lately (giving time for it to show what happens) and i just seem to swing between hypos and high spikes. My TIR is a real mess atm.

I thought i might need to do a basal check and started this today with the morning 6am-12pm. Levels held between 6.8/8.4. I need to try again at other times but i'm also wondering something else....

Could this not be related to the basal but actually needing a change in meal ratios? I'm confused because my lunch ratio seems fine but spikes 4-5 hours after and my dinner ratio just does nothing. Also as Tresiba is so long lasting, i shouldn't be getting dips in the day when its not working should i?

I haven't got a DSN to ask as i was discharged back to GP care during Covid and have never had a consultant.

Any ideas or advice?
 
Our basal needs fluctuate across a single 24 hr period and my perspective is that no basal can provide appropriate (ie pretty well right) basal cover for each of those hours from a single daily dose.

Also, the basal test where you fast and have no bolus on board for 8 or even 12 hour periods is not particularly relevant to anyone on a single basal dose. It can tell you a fair bit more about what your basal is doing during those fasting periods but that information is not really relevant if those periods are not actually times when you would normally be fasting and with no bolus on board.

So, I know that during late evenings and then the night, my early evening NovoRapid has become effectively nil and I'm fasting with minimal activity. Thus from such nights I can do no more than look at my CGM graphs and see whether my Tresiba is holding me steady and level. If it is, my basal is right; if my BG repeatedly and steadily drops through the night I know my basal needs reducing a little; conversely if my BG is rising steadily my basal needs increasing a little. One night alone is not good enough evidence for me; I like to see at least 3 similar graphs, having discounted (ignored) those nights where obvious circumstances have changed my fasting parameters.

If the steady graph is higher than I want to be at, I'll take corrective action - including a late bolus as I go to bed and would normally see from the graph that bolus correcting me to where I want to be, then the Tresiba holding me steady for the rest of the night. Likewise if I'm a little low a very modest snack nudges me up and again I will invariably see that lift then a nice flat line thereafter.

Now, knowing my Tresiba is keeping me steady by night, once awake I have bolus, food and activity to use as my daytime BG management tools. The important thing is that whatever effects my Tresiba is having during the day is what it is. I can't alter it and actually I don't want to alter it. I don't even need to consider it because my night time graphs have confirmed that Tresiba is releasing steadily for long periods and so is doing what it should be doing - providing a background insulin. This leaves me to review / question / interrogate what bit of the bolus/ activity/ timing/ carb count have I got wrong. There is enough in those tools to make that a challenging puzzle, without adding confusion about whether my Tresiba can somehow also be changing the rules!

For reference or comparison, for what that might be worth, my Tresiba doses are 7.5 units daily in the summer months from up to 9 last winter. During a period of illness a couple of months ago I noticed my night time graphs were consistently rising and my day time BG was all over the place. Once I'd temporarily increased my Tresiba to 9 units, in half units every 2nd day, my daytime management noticeably improved. That needed over 3 weeks at the higher doses before I reduced back to 7.5 units with daily half unit reductions.
 
Thanks for replying @Proud to be erratic. Before finishing work i had no issues with my basal at all, using the graphs as you do to determine whether i need more or less. Its been since i finished it has become more erratic.

Everything i read said about getting the basal right before anything else. Now, usually it is ok but since i'm spiking into the low teens, needing sometimes 2-3u correction at bedtime, its been hard to know what the Tresiba is doing as the corrections are bringing me down overnight. The graph shows a steady drop rather than a sudden one.

Yesterday, i suddenly thought, what if its not my basal but the ratios/timing. Maybe i need to check these first.
 
Why are T1s getting prescribed Tresiba? It's for T2s.
 
nimberry said:
Why are T1s getting prescribed Tresiba? It's for T2s.
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Where did you hear that? There are quite a few Type 1s on it, on here, as I recall, and I’ve never been told that at clinics, when discussing which basal would be best.
I wonder if you’re thinking of the double strength version, which may be more suited to some people with Type 2 who are on larger doses.
 
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Sorry your diabetes has been throwing you curve-balls @freesia

If your levels are rising steeply after your evening meal abd then stubbornly not coming down, it may be a combination of not quite enough of a meal ratio, but also insulin timing. I find my levels really stubborn once they get over 11mmol/L.

Taking insulin and then waiting a while to eat (pre-bolus) can help make my doses more effective, and if I can stop the rise getting so high, they seem more able to cope with the carbs involved.

Perhaps a little cautious experimentation with dose timing and a fractionally stronger ratio might help?
 
I don't think people realise just how different their routine can be when they retire, I found it very difficult to adjust from working anything up to 12 hours a day to there still being things to do but not that same pressure. I dropped from doing what could amount to 20,000 steps just walking about doing my job to struggling to do anything like that, even going for a walk could only clock up 10,000 steps. And a different eating routine, which I think almost certainly pushed me over that threshold into the diabetic zone.
I know that aspect will be different for you but just the change in routine will take some time to adjust.
 
everydayupsanddowns said:
Sorry your diabetes has been throwing you curve-balls @freesia

If your levels are rising steeply after your evening meal abd then stubbornly not coming down, it may be a combination of not quite enough of a meal ratio, but also insulin timing. I find my levels really stubborn once they get over 11mmol/L.

Taking insulin and then waiting a while to eat (pre-bolus) can help make my doses more effective, and if I can stop the rise getting so high, they seem more able to cope with the carbs involved.

Perhaps a little cautious experimentation with dose timing and a fractionally stronger ratio might help?
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Thanks @everydayupsanddowns. Tonight i'm having a meal i've had before so i know the exact carbs, pre bolussing a bit earlier than usual and changing my ratio slightly. All experimentation. Its very frustrating though. When working, things seemed to be mostly on an even keel and only needed correcting if i misjudged. Since i've finished everything has messed up and i'm floundering.
 
nimberry said:
Why are T1s getting prescribed Tresiba? It's for T2s.
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For your possible interest @nimberry, Tresiba is widely used in America, seemingly a major part of the basal market for T1s. I asked to get onto a single basal dose daily, was offered Tresiba and since then it has been brilliant for my needs.
 
Last night, i kept the basal the same, bolussed for dinner earlier than i usually do and changed my ratio. It worked! I did have a very short drop after dinner so maybe bring the bolus slightly forward but i stayed in target all evening, went to bed on 8 (although as soon as i got into bed the alarm went off at 10.2) and had a gentle drop overnight. Also had a decent nights sleep.
 
Good to hear!
 
Very promising outcome, @freesia. Presumably you didn't take any bolus correction and the gentle overnight drop was therefore the consequence of the Tresiba. If this becomes a trend then tweak your Tresiba down slightly to get the level graph.

If the jump from 8 to 10+ becomes a trend then your bolus might need further tweaking. It's worth considering what time did you take your first mouthful? Could the Apidra have timed out before you'd finished metabolising that meal? Or even just a little exercise between your meal and bedtime to nudge your Apidra to get going a bit more.

Your evening activity could easily be one of the subliminal changes in your routine that you might barely notice, but affecting your BG management. Sometimes after a busy day I do extremely little after eating my evening meal - just too tired to make any effort for anything. Whereas I'm the sort of person happy to clear a couple of small outstanding things. These aren't "jobs" in my normal sense of that word, but frequently do require me to go around the house finding the "thing" in the first place and then whatever was needed to fix that thing; 30 mins later I've been on my feet or constantly bobbing up and down. Consequently active in comparison to a sleepy slouch, struggling to see a TV screen.
 
Proud to be erratic said:
Very promising outcome, @freesia. Presumably you didn't take any bolus correction and the gentle overnight drop was therefore the consequence of the Tresiba. If this becomes a trend then tweak your Tresiba down slightly to get the level graph.

If the jump from 8 to 10+ becomes a trend then your bolus might need further tweaking. It's worth considering what time did you take your first mouthful? Could the Apidra have timed out before you'd finished metabolising that meal? Or even just a little exercise between your meal and bedtime to nudge your Apidra to get going a bit more.

Your evening activity could easily be one of the subliminal changes in your routine that you might barely notice, but affecting your BG management. Sometimes after a busy day I do extremely little after eating my evening meal - just too tired to make any effort for anything. Whereas I'm the sort of person happy to clear a couple of small outstanding things. These aren't "jobs" in my normal sense of that word, but frequently do require me to go around the house finding the "thing" in the first place and then whatever was needed to fix that thing; 30 mins later I've been on my feet or constantly bobbing up and down. Consequently active in comparison to a sleepy slouch, struggling to see a TV screen.
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No, bolus correction when it went up. It often does that then settles. I'll still keep an eye on it.
Its a good idea a bit of movement after dinner. We go out for a walk in the summer but i'll have to find something to do this time of year.
Thanks for the support.
 
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