Split basal insulin question

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gillrogers

gillrogers

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Type 1.5 LADA
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Just looking for help in thinking this through.

So im.pretty sure need to up my daytime basal by half a unit from 3 to 3.5 units. My evening is 2.5 units. Im.confident my evening dose doesnt need changing. If i up my daytime dose it will influence my evening dose anyway which i think would be too much. So do i up by bolus ratios instead? Stumped! ‍♀️
 
There is no one answer to your question as it depends how long the slow acting insulin works for you.
Despite the advertised insulin profiles, these are only guidance and insulin works differently for all of us
But why do you think you need to tweak your insulin dose again? What has changed in your life?
 
helli said:
There is no one answer to your question as it depends how long the slow acting insulin works for you.
Despite the advertised insulin profiles, these are only guidance and insulin works differently for all of us
But why do you think you need to tweak your insulin dose again? What has changed in your life?
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Because im not coming back past 10 after my meals. My basal never sits still for long. It gradually moves up or down. Im.too sensitive to stress, weather changes , lack of sleep which is all going on at the moment.Ive no idea how long my basal lasts. Have no idea how to tell but im.pretty sure my bolus is lasting me 5 hours.
 
gillrogers said:
Because im not coming back past 10 after my meals. My basal never sits still for long. It gradually moves up or down. Im.too sensitive to stress, weather changes , lack of sleep which is all going on at the moment.Ive no idea how long my basal lasts. Have no idea how to tell but im.pretty sure my bolus is lasting me 5 hours.
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Can you post a graph? Do you mean you stay at 10 until the next meal?
 
Inka said:
Can you post a graph? Do you mean you stay at 10 until the next meal?
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No , i dont return past 10 corrections, get ignored. PostingIMG_1929.jpeg wednesdays graph as thursday and friday went wrong for other reasons. Those dots that look like they are in the green are false readings ‍♀️
 
@gillrogers I remember you’re worried about hypos and get concerned when your blood sugar drops. Your graph looks fairly average, except for the fact your ‘base level’ is a little high. I presumed that was because you don’t want to go below 9ish? If that’s not the case now, then yes, it looks like you need a little more basal.

If you’re worried about it affecting your evening dose (I don’t think it will very much, if at all), then you could up your morning dose to 3.5 and temporarily drop your evening dose to 2 units just until you see how it’s going. If all’s well after, say, three days, you could put your evening dose back to 2.5.
 
Haha says me and i am actually back in the green ! 1mmol from where I started. So dbn nurse says thats ok.
 
Inka said:
it looks like you need a little more basal.
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I don’t want to confuse @gillrogers but that is not my interpretation of her graph.
The purpose of basal is to keep BG stable in the absence of anything else (like food, exercise, stress, bolus insulin, …). And, it looks stable with peaks for food, always returning to around 10mmol/l.
If more basal was needed, there would be an upward trend.
Likewise, I am not convinced there is a problem with the bolus ratio for food … because the graph returns to 10ish.
If that was my graph, I would give myself a single correction bolus to bring down the baseline level but keep everything else as it is.

The other thing worth bearing in mind is insulin resistance at higher BG. I would need more insulin for the highs so, if I made that correction bolus, I may then need less basal to maintain the stability. Hence, I would be very reluctant to increase either basal or the insulin to carb ratio.

Sorry, Gill, I think we are saying that, as you are seeing, it is not simple.
 
Perhaps we’re thinking the same thing but looking at it in a different way @helli ? Yes, I agree the basal is to keep us steady in the absence of food. For me, if I saw a graph like that showing my own readings, I’d think that my basal distribution was right (right hourly rates, etc) but that I simply didn’t have enough basal (ie I’d probably increase my rates across the board). If I lowered all my hourly basals by 50%, I’d still have a nice flat line if I didn’t eat, but that line would be at too high a level. So, I’d increase my basal.

I appreciate Gill’s not on a pump but I do similar when I take a pump break (within the limits of my basal insulin, of course) and fiddle with my basal doses until I get a reasonably flat line at a reasonable level.
 
But surely the job of the basal is to keep everything level. Not to bring levels down.
If the general level is too high, you need a correction dose of bolus insulin, perhaps to bring the general level down from 10, to, say 6.
And that is actually, i think, the only issue with gills curve. Its not especially peaky. Its just generally too high.
So I agree with helli. If the bottom of the line were shifted down to between 5 and 6, the above graph would be more like 60-70% in range, perhaps better.
And i think that would be very do-able. Gillrogers, i really don't think you're far off some big improvements of time in range here!
 
@Tdm To keep everything level and within range. If somebody is having to correct a lot, then that might be a sign their basal is too low. Ideally, someone should be able to not eat for 24hrs and have their blood sugar remain steady and in range. If that hypothetical person’s blood sugar does remain steady, but is steady at 15mmol say, then they need more basal so that their blood sugar not only remains steady but does that at a reasonable number, eg 6 or 7, or whatever is appropriate for the individual.
 
Your peaks go 9- 15, ie 6 m/mols.

So if the bottom of your valleys were about 5, then your peaks would be 11.

And if you went for a short walk after meals, you may find you can cut off the peaks to under 10.

Possibly 2 steps away from acheiving big improvements here?
(of couse, diabetes is never plays by the rules, but i think you are nearer better tir than you think)
 
Inka said:
@Tdm To keep everything level and within range. If somebody is having to correct a lot, then that might be a sign their basal is too low. Ideally, someone should be able to not eat for 24hrs and have their blood sugar remain steady and in range. If that hypothetical person’s blood sugar does remain steady, but is steady at 15mmol say, then they need more basal so that their blood sugar not only remains steady but does that at a reasonable number, eg 6 or 7.
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I think we will have to agree to disagree here.
Whilst you would use a temporary increase in basal to bring down levels, i would prefer to do it by bolus, get it over with WHILST awake, then continue at the correct level.
Gillrogers basal keeps them level overnight, so its going its job, at the right dose, at least overnight.
Their bolus is returning them to the level, and is therefore right.
They just need to establish the general overall lower level with a correction dose of bolus
 
No, I think we’re talking at cross purposes @Tdm 🙂 Yes, if I had a random high, I’d correct with my bolus insulin, but if I was wondering if my basal was right and so did a basal test, saw it was holding me steady at 15mmols, I’d increase my basal amount slightly - because it’s supposed to hold me steady, yes, but steady in range, not steady at 3mmol or steady at 16mmol. Not a temporary basal increase, a longterm basal increase (until I need to tweak it again).

During my pregnancies when basal testing isn’t advised (because you’re supposed to eat regularly), I often saw a needed basal increase by noting what my blood sugar reverted to (I called it base level). If it generally hung around 10 like Gill’s, I’d increase my basal.
 
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I think that technically @helli and @Tdm are right however Gill states that she has been doing corrections with her boluses and that hasn't been bringing her down, which if those corrections are at each meal may mean that the correction is propping up the basal..... or the correction factor or ratios are wrong. I think most of us find that when levels are above 10 we need a bigger correction factor (more insulin) to correct than if we were below 10.

Knowing that Gill is anxious about levels dropping, I think @Inka's suggestion is probably one that would be more comfortable to her rather than giving a larger correction dose and most likely seeing levels drop more sharply than an extra half a unit of basal is going to cause over the course of 12 hours. I think adjusting the evening basal down half a unit for a few days will also provide Gill with some reassurance and then reassess once you see how that works out. I certainly see a bit of overlap of action between my daytime and night time doses so I can understand Gill's anxiety of it potentially causing her night time levels to drop although there is a lot of wriggle room if she is mostly around 10mmols through the night.
As you say, the graph is great other than the baseline needing to be lowered and my feeling is that a half a unit of basal more will perhaps do that more gently, which may suit Gill better to give her more confidence. It might only drop the baseline 1 or 2 mmols over the day and maybe if she ran at that for a few weeks that would give her some improvement over the day without making her anxious.
 
Haha my coreectiaon doses get ignored. That says my basal is not high enough. I was actually thinking on doing what @Inka suggested. Across the board. My peaks are high because my bolus timing has gone back up and it seems to rise/lower an mmol a day depending which way one is going at a time so i cant just go back to where i was at the start of my bolus timing lowering a few weeks ago. Tried that and was just short of a disaster.
So i could lower my evening tonight and raise daytime to 3.5 and see how that goes.
 
rebrascora said:
I think that technically @helli and @Tdm are right however Gill states that she has been doing corrections with her boluses and that hasn't been bringing her down, which if those corrections are at each meal may mean that the correction is propping up the basal..... or the correction factor or ratios are wrong. I think most of us find that when levels are above 10 we need a bigger correction factor (more insulin) to correct than if we were below 10.

Knowing that Gill is anxious about levels dropping, I think @Inka's suggestion is probably one that would be more comfortable to her rather than giving a larger correction dose and most likely seeing levels drop more sharply than an extra half a unit of basal is going to cause over the course of 12 hours. I think adjusting the evening basal down half a unit for a few days will also provide Gill with some reassurance and then reassess once you see how that works out. I certainly see a bit of overlap of action between my daytime and night time doses so I can understand Gill's anxiety of it potentially causing her night time levels to drop although there is a lot of wriggle room if she is mostly around 10mmols through the night.
As you say, the graph is great other than the baseline needing to be lowered and my feeling is that a half a unit of basal more will perhaps do that more gently, which may suit Gill better to give her more confidence. It might only drop the baseline 1 or 2 mmols over the day and maybe if she ran at that for a few weeks that would give her some improvement over the day without making her anxious.
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Yup thanks @rebrascora
 
I would keep your night time dose the same tonight and then add the extra half unit in the morning and then reduce your night time dose tomorrow night.
 
I keep editing my post above because I think I’m explaining badly! Let me have another try: if I’m persistently seeing that my ‘base level’ is 10 or 12 or whatever, I’d look to increase my basal insulin because that shows I’m not having enough basal. I don’t mean I’d increase it temporarily for a few hours, I mean I’d try increasing it longterm, then monitor how that went. Hopefully, I’d then find that my basal was holding me steady now at 6 or 7 rather than the 10 or 12.

If someone doesn’t eat for 24hrs and is having to correct with bolus to stay in range during those 24hrs, then their basal clearly isn’t enough.
 
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Thats how i undrrstood you @Inka
 
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