Splitting Tresiba dose?

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duck said:
I'm splitting my Tresiba to 2/3 in the morning and 1/3 in the evening prior to sleeping and it worked fine for me after some time dealing with the dawn phenomenon (DB) and having to correct it with short-acting insulin.
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Hello @duck,
As a user (and liker) of Tresiba I'm interested in your decision to do this. When, please, did you start splitting Tresiba and when did you start with Tresiba originally?

The thread you've attached to goes back to 2019 - nothing wrong with that. The original poster @Flutterby hasn't posted here for over a year. Although one of the replies talks about a 25 hr profile, the manufacturer claim 40 hrs and that seems to fit with my experience. Certainly I can wake and take my Tresiba at 6am or midday and don't seem to see any variation. It is also used by people who are regular long haul fliers and is claimed to suit their lifestyle because of its long profile.

What I have found is that regardless of what time of day for taking Tresiba, am or pm, once its established and as close to correct as one can reasonably expect, I can get steady nights (ie my longest fasting periods) and MUST deal with BG fluctuations during daytime SOLELY by bolus or exercise measures. I don't mind that, indeed it seems to me almost more intuitive - if my BG is out of kilter I'm turning to a method (bolus, exercise or extra carbs) that brings a result moderately quickly (usually 4 hrs rather than a half day of one of the shorter basals) and I'm not having to wrestle with shall I change my basal or bolus.

I do find there is far more turbulence with my BG from all sorts of other things, such as my level of activity not matching what I'd assumed (or hoped) when I planned my bolus and meals; or a carry over from the previous day's activity; or ambiguity about the carb count (did I really receive 150 gms of pasta as asked?) or the GI of the meal on the plate and so speed of digestion; or many other factors that seem to descend on my daily living! I am fully retired and have no regular pattern of daily activities.

For my battle with DP over the last 2+ months I have been fairly fastidiously taking carb free snacks to bed with me, typically a small piece of cheese and 2 or 3 low carb nuts. I eat this if I wake and need to go to the bathroom and I eat this immediately I wake before getting up. So far this has proved very successful in deflecting and defeating DP. The most increase I've had is c.0.5mmol/L, usually only if there is a further lengthy delay between waking and starting breakfast. Taking the snacks upstairs is a faff and I sometimes wonder if its worth the effort. But I was finding DP to be variable - perhaps no DP 2 mornings in 7 - and could be 1.0 or >3.0 mmol/L on different mornings and that was proving challenging in trying to finish breakfast at a sensible level. The good (or at least helpful) news was the usefulness of my CGM, taking away so much uncertainty, never mind the inevitable finger prick to get reassurance.
 
Proud to be erratic said:
For my battle with DP over the last 2+ months I have been fairly fastidiously taking carb free snacks to bed with me, typically a small piece of cheese and 2 or 3 low carb nuts. I eat this if I wake and need to go to the bathroom and I eat this immediately I wake before getting up. So far this has proved very successful in deflecting and defeating DP.
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Very interesting @Proud to be erratic
 
I find injecting my breakfast bolus as soon as I wake up and before I get out of bed, deals with my DP/FOTF. I add 1.5-2 units to my breakfast bolus to cover the liver dump rather than change my breakfast ratio because some mornings I might not want or have time for breakfast, but I still need that bit extra insulin to balance my liver output. If my liver isn't as enthusiastic some mornings then Libre will alert me and I can eat a date or a couple of prunes to soak up that extra insulin, but it is rare that I don't need that 1.5-2 units to cover DP/FOTF.
 
rebrascora said:
I find injecting my breakfast bolus as soon as I wake up and before I get out of bed, deals with my DP/FOTF. I add 1.5-2 units to my breakfast bolus to cover the liver dump rather than change my breakfast ratio because some mornings I might not want or have time for breakfast, but I still need that bit extra insulin to balance my liver output. If my liver isn't as enthusiastic some mornings then Libre will alert me and I can eat a date or a couple of prunes to soak up that extra insulin, but it is rare that I don't need that 1.5-2 units to cover DP/FOTF.
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My challenge is that DP is just plain inconsistent. Not every day and not to a reasonably similar effect when it does happen.

I don't have a regular routine. Being fully retired I don't have the remit to meet work schedules, nor house pets or livestock that need my attention. So, while I've not super diligently tried to get the "measure" of when DP occurs nor to what extent, I've slightly lazily decided I don't have the desire or energy to get that degree of understanding and thus start semi-automatically managing the DP component. But I don't think I can arbitrarily take "a stab" at this and just assume a certain level of DP response automatically.

I already usually need 45 mins of breakfast pre-bolus and will normally aspire to take that pre-bolus very shortly after waking. Even after I've eaten my relatively standard breakfast I find my body doesn't habitually let me eat, briefly digest, then start doing whatever I planned. If, during eating, I drop towards 4.0+, then I might get a normal recovery or equally I might not. This is my most frustrating part of being insulin dependent: with a normal recovery, then I can drive away or start jobs. But frequently, enough to count 2 or 3 times every week, I sit with my BG determinedly very close to 4.0 for at least 2 hrs and just walking calmly to the bathroom can topple me below 4. Then the "bolus rage" becomes really hard to resist; @everydayupsanddowns has referred to bolus rage in the 'forgot to take insulin' post that's very active this weekend. It certainly is hard to not take a snack and then get the inevitable swing to hyper.

While sitting very close to 4 I might get short periods just below, say 3.8 and definitely not feel hypoish. So those lows don't bother me at all; I definitely do feel hypo symptoms around 3.5 and that is fine with me. It's the knowledge that I shouldn't drive along with knowing that I'm super sensitive close to 4 and can topple myself really quickly. I waste hours in a week waiting to be sure I can get active. I try to start at 6.0 and this helps reduce the incidence of this sticking too low problem.

This is a bit of a digression, discussing DP or my persistent lows, rather than splitting Tresiba. But these things are of course inextricably interwoven. It is at these frustrating and wasteful times that I sometimes wonder if the root of my frustration is Tresiba as a basal (too stable .... ?). Yet, when it's all working as planned .... I am far from frustrated, able to push my activity boundary, I know how I'm getting on hourly and generally have a confidence in my BG management that allows me to forget the frustrating times and be happy with what I know. I suspect many, if not most, of us are blessed with this quirk. Also, I'm somewhat reluctant to change what I know and return to a shorter profile basal and need to learn new techniques. But in contradiction of that comment, if my Consultant will support me for a pump I will absolutely change what I know. I'm confused, so I would understand if anyone reading this is even more confused.

Meanwhile this morning, a standard start, taken my basal as usual, normal pre-bolus, 5gms lower carb intake than allowed for, start eating in a good place ..... and BG races to 11 and showing no hint of my bolus recovering the situation. So now, I just have to wait. Insulin on board, no justification for a premature correction, yet a likelihood of ending this morning still somewhere above 10. This doesn't feel like a fair game today.
 
duck said:
I'm splitting my Tresiba to 2/3 in the morning and 1/3 in the evening prior to sleeping and it worked fine for me after some time dealing with the dawn phenomenon (DB) and having to correct it with short-acting insulin.
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This thread is 4 years old @duck, and I’m afraid the original poster is no longer a regular poster on the forum so is unlikely to see your reply.
 
Proud to be erratic said:
Meanwhile this morning, a standard start, taken my basal as usual, normal pre-bolus, 5gms lower carb intake than allowed for, start eating in a good place ..... and BG races to 11 and showing no hint of my bolus recovering the situation. So now, I just have to wait. Insulin on board, no justification for a premature correction, yet a likelihood of ending this morning still somewhere above 10. This doesn't feel like a fair game today.
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I had a similar morning but when my levels got to 8.6, 3hrs after my bolus was injected and 2 and a quarter hours after my breakfast, I injected a 1 unit correction. because I know for a fact that there is not enough Fiasp left from my 5.5u breakfast bolus/FOTF correction to bring me down from 8 after 3 hours.

I understand your situation with Tresiba and in many respects it works well for you most of the time which is all most of us can hope for without a pump. There is no perfect 1 or 2 injection basal fit. My FOTF correction (in advance) is my compromise with Levemir. Thankfully my morning liver dump is more predictable than yours by the sound of it and if it isn't, I get to eat a treat so there is no frustration for me and actually rather the opposite.

I think to a certain extent the basal that suits you depends on how your body performs/reacts overnight. If your body is pretty stable overnight with your basal needs and fairly balanced with your daytime needs then Tresiba is a good choice. If your overnight needs vary a lot and or there is a significant disparity between day and nighttime basal needs, then Levemir is probably a better choice.
As you are aware, in many respects Levemir is more of a step towards the action of a pump albeit a small step in that you are adjusting to fit with your body for 2 long time periods as oppose to 24 or whatever shorter basal periods with a pump, but the important thing with MDI is that you find something that works most of the time for you and your body and I think it is important to experiment with whatever tools/insulins you have to see if there is a way to make what you have work for you, possibly disregarding "the rules" in the process, but be prepared to try something else if you can't make it work consistently. My gut feeling is that Levemir would probably work for most people (especially now with the benefit of CGM) providing you understand how to adjust it, but it takes time and trial and error, much like a pump does in the early stages of setting up your basal profiles, although the modern closed loop is clearly taking some of the need for subsequent adjustment out of the equation.

Changing insulin should not be taken lightly in my opinion as it can take months to unlearn and then relearn new strategies, so I can entirely understand your thought process. Changing from NR to FIasp did my head in, despite them being relatively similar and it took 2 X 3month trials to get to grips with it, but 3 years down the line and I can almost say I like Fiasp and I am no longer interested in looking for the "greener grass"..... but not in the same way as I love my Levemir! 🙄 :D
 
Yes, thanks for wading through that!

Of the many different aspects of background issues, it's hard to quantify some of the decisions we make let alone explain them to a DSN or a Consultant - then consequently convey a message that this could (or at least might) all be less stressful if a pump was agreed to. But I'm outside the NICE criteria so any reasoning is already a tough call.

Superficially there was (is) an argument to have taken (or now take) a modest correction this morning. But my G7 is telling me I have a horizontal trend, while it's gently drifted down to 8.8 and I'm probably now no longer iob. I won't do anything now because I'm now busy in the garden (the only one!), hoping someone in the rest of the family will offer to make coffee, v warm in the sun and generally now anticipating a possible further drop. I know why I've made this morning's decisions, but they don't leap out to random external scrutiny. So each time the alternative suggestions most gently and courteously emerge from my Consultant, to help me get even more stability, I'm internally screaming "Do you think I haven't considered that ... " or "At the time the actions felt right .... " and externally sounding as though I'm just resisting professional help, help within the boundaries of the tools we do have.

One thing that is clear to me is that there are not specific ways we should deal with our D management. We need to find what works for us and, I fully agree with you, settle for what works, disregard the rules [ONCE you are comfortable and confident about your body responses and signals - NOT advice for newcomers to insulin] and certainly be happy to chase glucose with insulin or chase insulin with carbs. Whatever works generally. No specific right or wrong way. Settle for reasonable success don't strive for perfection. Don't overanalyse those things that didn't work. Oh, and keep smiling - we're still alive. Enough for today! Roland 😎
 
duck said:
@Proud to be erratic I just came back to let u know what motivated me to split my Tresiba was starting with this forum I think it might be useful.
https://forum.tudiabetes.org/t/dose-once-or-two-times-a-day-with-tresiba/55974
I tried to register to it but it hangs on the processing page then nothing happens.
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Thank you @duck. I've been in France for a few days with no roaming mobile signal and surprisingly poor hotel WiFi.

I did manage to look at that site and for the most part found little convincing evidence. However Sam19 in Feb' 19 provided an excellent schematic graph explaining how over multiple days the overlapping profiles produced a very constant level output from single dosing. That effect is achieved regardless of whether that single dose is taken am or pm and also achieved even when that single am or pm dose is early or late.

Various people quoted Dr Bernstein as their proof and in the same sentence tell you that it's contradictory and confusing. I read the first half of one of Bernstein's books and I was initially being lulled into thinking there might be a solution from what he was saying. However the more I read the more I realised that his claims were unreliable and his ideas were not for me.

No contributors to that forum provided anything that convinced me that splitting Tresiba made sense and when something doesn't make sense I'm inclined to notice that really it is nonsense. Without proper trials using different large groups under laboratory conditions that clearly demonstrate there is a benefit of splitting Tresiba I still believe that 2 half doses is creating one injection that is unnecessary. For Tresiba to meet the various regulatory bodies that approve such medications they have done those trials and the 40 hour profile was accepted. Even if there was a 10% +/- error in that figure of 40, ie between 36 to 44 hrs the outcome would still prove to be a sufficiently long period to achieve a consistent insulin release from a single daily dose.

The problem is that in the real world - rather than the laboratory - we have a multitude of other factors that influence how our body needs to respond; some 42 of them apparently of which food ingested and insulin injected are just 2 of those factors. So how or why we get glucose internally released into our bloodstream, apart from the food we eat, can be very varied across the 24 hr day. Thus no basal provides an even cover of insulin release in those 24 hours; nor does 2 shorter basals. The basal that I have found that works for me is Tresiba, taken once daily and optimised in dose size by me after monitoring (thanks to CGM) during fasting periods to keep me stable through the night.

Not every 24 hr period is identical for me, but most nights are pretty similar. As a 74 yr old male I'm not subject to monthly hormonal changes; but I can have really active days labouring in my garden through the hottest day of the year and consequently create a very non-standard night which I must allow for in my bolus or carb responses that evening and probably for the next day or even 2 days. But I know this and accept that I can't nudge my Tresiba to get an instant basal response, or even a basal response within 24 hrs. I know that I must regulate my daily needs solely through my bolus, exercise or activity responses. I do know that basals with shorter profiles have greater flexibility which can accommodate changes in dose sizes from one day to the next. Personally I don't see the benefit in adding one more decision [adjust my basal or my bolus this morning / evening] to my 300+ daily decisions I already need to make as someone on MDI.

Taking split basals to their logical conclusion you could presumably get even better performance by having 4 basal doses daily, or 8 , or better still why not inject a little every single hour ...... ie be on a pump. Meanwhile, until I can get that otherwise unaffordable pump through the NHS, I must do what I can with what is available. I stumbled into Tresiba and I appreciate its degree of rigidity from fixing one period of my 24 hr day from just one daily stab. I'm clear that splitting Tresiba is nonsense for me and find I can work well enough with then managing my varied days from one basal dose along with bolus, carbs and activity.

There is no absolute right answer for MDI as a whole. We just manage what we can with what's available, trying to learn as we go along and trying not to repeat yesterday's mistakes - if we can deduce that we did make a mistake yesterday. Or was it yesterday when we chose the wrong colour socks?
 
That is precisely why I wanted to try 2x Levemir rather than 1x Lantus! Already having to test multiple times a day and make shedloads more decisions than just about diabetes, working full time in a job I loved so having to find answers to some very strange queries most normal folk wouldn't get asked and yes OK there was run of the mill stuff as well, but the interesting query clients certainly made up for the boring ones, a lot of the time. Usually I got these sort of Qs at 5 to 5 on a Friday obviously .... cos that's Sod's Law. So one extra jab of Basal insulin per day? Pfft, utterly insignificant if it meant better stability in BG, and it did - eventually. Same as having an insulin pump - not instant success BUT just makes some aspects easier - eventually once you've personally worked out its different little idiosyncracies.

Same as people - you're introduced to people as they're Mr Bloggs and you're Mrs Smith and before too long as you get to know each other, you'll be on first name terms and asking them if their wife/child's recovered from having their accident.
 
trophywench said:
That is precisely why I wanted to try 2x Levemir rather than 1x Lantus! Already having to test multiple times a day and make shedloads more decisions than just about diabetes, working full time in a job I loved so having to find answers to some very strange queries most normal folk wouldn't get asked and yes OK there was run of the mill stuff as well, but the interesting query clients certainly made up for the boring ones, a lot of the time. Usually I got these sort of Qs at 5 to 5 on a Friday obviously .... cos that's Sod's Law. So one extra jab of Basal insulin per day? Pfft, utterly insignificant
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I take your point @trophywench about the one extra jab.
trophywench said:
if it meant better stability in BG, and it did - eventually. Same as having an insulin pump - not instant success BUT just makes some aspects easier - eventually once you've personally worked out its different little idiosyncracies.

Same as people - you're introduced to people as they're Mr Bloggs and you're Mrs Smith and before too long as you get to know each other, you'll be on first name terms and asking them if their wife/child's recovered from having their accident.
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But since nowadays most of us have CGM the decision making is "a bit different" and also nowadays most newbies get negligible support from DSNs or equivalent. So that understanding of when to alter bolus (ratios) or basal is just not apparent despite the hugely improved visbility of daily graphs from CGM. I certainly was told for my first 12 months when to alter what were effectively fixed doses with absolutely zero explanation of why the change was appropriate and I didn't have Libre for those first 12 months. For me, one less jab is still a noticeable improvement n my quality of life - since I can see when intervention is needed and possibly intervene with activity rather than yet one more bolus.
 
Well Roland - you are exceedingly lucky having a CGM that actually works like it says on the tin. Unfortunately this is absolutely NOT the case for some of us. Libre 1 wasn't very accurate for me and though it is sometimes very OK - neither is Libre 2, for me. Hence I don't trust it to tell me as much as I either need or want to know whenever it comes to bolusing for food or giving correction doses. Plus since the bolus wizard for my pump is contained within the matching BG meter/remote control for the pump - this means I still need to use the meter even if the cannula's 'gorn orf' so I need a manual, pen bolus, rather than via the pump - and I'm frankly, bloody fed up with that scenario. (Not likely to change unless I can have a full body transplant - or at the very least all my skin and interstitial fluid - and get rid of all the things that are flipping wrong with it that mar absorption of insulin. ie impossible, so I'm just stuck with it.)

You're also fortunate that your brand of diabetes responds well to exercise and of course that you're in a position to physically take that when needed.

I'm pretty horrified at the difficulties Karen (aka Flutterby) obviously had as a child - but I do personally know very well that some of the staff at the very same hospital in the early 1970s could still be bloody horrible to patients there and also know my big sis had an awful time herself in another hospital when she was little, in the 1950s too. Which she never mentioned to me whatsoever until we were both 50+. One always hopes such things are better throughout these days - BUT. At times like this I get to wonder how K is these days but never got to know her really well to have remained in touch with her. It was more a jokey thing between us for starters where we both said we'd have to get together one day and write a book about about our different experiences of the place.
 
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