Toying with an experiment....

rebrascora

rebrascora

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As many of you know I love my Levemir and adjust it regularly to try to match my body's needs and usually I can achieve low 90s% TIR. As a result of this, I do not think a pump would suit me and whilst I could probably make a case for it as I often have nocturnal hypos even with no evening Levemir dose, although sometimes I do need evening Levemir, hence all the adjusting. Obviously this conclusion about a pump is based on never having used one and since I dislike technology and change my decision is probably biased. That said I had a situation last night which set me thinking today....

I stayed overnight at Ian's last night on the spur of the moment, so I didn't have my Levemir with me. The last few days I have needed 2.5 units overnight because I haven't been doing nearly enough physical activity. Anyway I managed my overnight levels with Fiasp. Granted it needed a correction at 3.11am when I woke up on 7.4, having risen from 4.1 when I went to sleep (I know that is low, but I knew it would rise because of the lack of Levemir), so I jabbed 2 units Fiasp and went straight back to sleep within minutes and woke up at 7am on 7.2 so that was a pretty good call and probably the best overnight graph I have had for a while and probably no more disruption to sleep than most nights when I need a JB or a correction, so no big deal..... I am very adept at calculating and injecting a correction, semi conscious in the dark and being back to sleep in minutes.

What I am getting at is that I am toying with the idea of going 24 hours without my Levemir and just using Fiasp to see how I get on and also to see if I need less overall units per day than I normally would using Levemir. I suspect I will need more, but I know that people who go onto pumps usually find a reduction in total daily insulin requirement.

Obviously I am not going to be injecting a tiny dose every few minutes, but just wondering if, with perhaps hourly daytime jabs and one per night, I can keep a lid on it and keep in range. I think being low carb may make this easier than it would be for someone following a normal diet as I already correct between meals for protein release, so I am used to jabbing more frequently and stacking insulin according to my Libre data and with my Fiasp only lasting about 3 hours for me, the overlap should be reasonably easy to assess, and I will be relying very heavily on my Libre to keep me between the lines and envisage I may need a few JBs here and there to stave off daytime hypos.

I am not doing it today as I have a few things to do that would mean I couldn't give it my full attention and clearly it would need that, but just wondered if anyone could see any pitfalls that I haven't considered before I decide to undertake it.

I would add that I have good hypo awareness and will not be doing it on a day that I will be driving and will be keeping a very close eye on my Libre which is really reliable for me to help guide me and I will pull out of the experiment if I find it too challenging at any point and just jab a percentage of my Levemir dose that I think appropriate at that time. Basically I will be injecting Fiasp to keep me below 10 and have the JBs ready to keep me above 4 and I will be logging each insulin dose, so that I can keep tabs on active insulin on board.

I suspect many will see this as fool hardy, but I like experiments and challenging myself both in terms of what I can achieve but also my thought processes and I want to know if I am right in my unwavering loyalty to Levemir or could a pump perhaps offer me something I haven't considered, although this is obviously a very crude imitation of a pump and I am not likely to have nearly enough experience for a 24 hour experiment to yield particularly good results!
I will update here if I attempt it. Maybe I should break it down into 6 hour trial periods, rather than go for the whole 23 hours straight away.

I know we have at least a couple of members who get by on just bolus insulin but I definitely need a significant amount of basal..... currently 26.5 units, so that isn't exactly comparable.

I would be curious to know if there are any members pumping whose basal needs are similar and if so, what sort of hourly rate they need to cover that just to give me a ball park figure.
 
I think you’d need to leave sufficient time for the Levemir to fully leave your body @rebrascora Once it had, I think you’d find you’d be injecting Fiasp often/lots to keep down the rise. A reasonable experiment would need a few days, but I don’t recommend that.

A better idea - well, to me, at least - is to swap to a regular bolus insulin. Because of the longer duration of action, this can be used as a kind of basal over the day (if you’re eating and bolusing for meals). That’s what we did in the old days - basal at night only as the regular insulin on MDI covered the daytime.
 
Hello Barbara [rebrascora].
What you have described is exactly what my Pump + G6 sensor combo does. It only uses Fast acting insulin but in 2 ways.
1/ I do a carb count per meal and tell the pump how many units it needs to pump into me.
2/ My pump supplies constant monitoring and a background supply of Fast insulin to keep me on the straight and level and gives me a reading every 5mins.
No Long acting insulin is required anymore.
My control has greatly improved, I'm constantly in the 80% to 90% range for my target goals set by my diabetic nurse, previously I would be around the 50% to 60% range when doing the "double tap" of self inject Fast and Long acting insulins.
Regards
 
Why not just keep your Levemir with your Fiasp so you always have it with you?
When I was on MDI, I rarely went out without both types of insulin in case I was out for longer than planned and it makes sense to me to keep all my diabetes "in use kit" together. That covered me for a night on the tiles, a night round my friends or, heaven forbid, a night in hospital.
I am with @Inka that your experiment needs to be more than a day to make sure you have no Levemir and can be a real pain. When I had a tubed pump, I disconnected it when I went to a spa for a day and reconnected every hour for a "basal top up" which was far from convenient and I wouldn't do just for an experiment.
 
As regards Levemir fully leaving my system, it is generally gone in about 16-18hours, 20 hours tops, so if I started the experiment on an evening, I might have to extend the period to include the first night where there would still be some Levemir active, but I should be well clear of it by the next morning to start the 24 hours in earnest and then go all day and the following night before returning to Levemir the next morning, unless of course I pull the plug on the experiment early.

I really don't know anything about "regular insulin" or how I would approach getting that. I certainly do not want to swap from Levemir as I am just talking about a very short term experiment and I am looking to more mimic a pump than specifically replace the Levemir in the experiment, so just use the Fiasp as someone on a pump would do to cover the basal needs, but just as and when levels were heading for the top threshold (10) rather than at any particular set interval. It may be that I might need to top up every half an hour in the morning but every 1.5-2 hours in the afternoon/ evening and then perhaps just once or twice through the night. That is what my current Levemir dosing might suggest but as I said, I would be guided by Libre as I am already to a large extent for my protein corrections and indeed corrections in general. If I hit 9.2 (my high alarm) I know I need 2 units to bring me back down. Obviously this is with Levemir, so without it I envisage probably 4 units possibly more, so 2 to cover protein and 2 to cover basal needs. I would err on the side of caution at least until I saw how it was panning out.

In reality this is probably no different to forgetting to inject your basal one day and having to correct regularly to keep a lid on things but obviously a deliberate and hopefully reasonably well considered decision rather than an unplanned accident.
 
Regular insulin is the original bolus insulin before analogues were introduced. It’s sometimes called short-acting or neutral. You can just get it on prescription. There are various brands, mainly human, but an animal one too. They negate the need for daytime basal, so, in theory, if you didn’t need any basal at all at night, you could just use regular as a bolus, which would also cover your daytime basal needs.
 
helli said:
Why not just keep your Levemir with your Fiasp so you always have it with you?
When I was on MDI, I rarely went out without both types of insulin in case I was out for longer than planned and it makes sense to me to keep all my diabetes "in use kit" together. That covered me for a night on the tiles, a night round my friends or, heaven forbid, a night in hospital.
I am with @Inka that your experiment needs to be more than a day to make sure you have no Levemir and can be a real pain. When I had a tubed pump, I disconnected it when I went to a spa for a day and reconnected every hour for a "basal top up" which was far from convenient and I wouldn't do just for an experiment.
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I used to carry my Levemir with me all the time but I have recently started using an over the shoulder pouch to carry my gear instead of by larger backpack and space in it is more limited so I have been leaving the Levemir at home more recently. Not having it was not an issue at all for me as I knew I would manage fine overnight with just Fiasp. It is just the circumstances which set me thinking that I would like to know how I would respond to a pump like situation and cope without my "beloved" Levemir, as maybe my faith in it is an illusion I have created. I am also curious to know if my nighttime basal needs are actually as low as they appear from my Levemir doses and if I really need so much more during the day and so little at night or if the day dose is significantly propping up the nighttime dose, when I have one. I have heard others say that they thought from their basal doses, that they needed significantly less at night, but when they moved to a pump it turned out not to be the case. It may be that my large morning dose is significantly more active during the night than I believe. I am not sure if there are any conclusions I could draw from that if it is the case, like maybe I could reduce my morning dose and increase my nighttime one so that I have more wriggle room with reducing the nighttime dose after exercise.... Once I am down to zero and still dropping into hypo, it suggests that would be a benefit. To a large extent we take the information we get about the profile and activity time of our insulins as being correct for us as individuals and we all know that diabetes and human bodies and how they respond, covers a very broad range of "normality".

What I am saying is that maybe I could get away with taking 15u in the morning and 10 at night and still get the same results as I do now, but means I can reduce the night time dose more than I can now, which is usually only 2-3 units before I hit 0, to prevent nocturnal hypos after exercise. Maybe my doses gradually got more and more skewed to a high morning dose and low evening dose but I could perhaps manage better if they were more even. Or maybe the experiment will show that actually I might be better off with a pump after all or at least make me reconsider it.

I appreciate that most people would not want to do this experiment and I am certainly not recommending anyone else does, but I think my unique circumstances allow for me to do this relatively safely with a view to getting some useful info from it.
 
Inka said:
Regular insulin is the original bolus insulin before analogues were introduced. It’s sometimes called short-acting or neutral. You can just get it on prescription. There are various brands, mainly human, but an animal one too. They negate the need for daytime basal, so, in theory, if you didn’t need any basal at all at night, you could just use regular as a bolus, which would also cover your daytime basal needs.
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A longer acting bolus insulin would not suit me I don't think. I like that Fiasp is gone in 3 hours. It is probably one of it's most attractive features.

What I meant about obtaining regular insulin was that I would not be able to get a prescription for it particularly easily and I am not sure how I would sell it to my consultant if and when I get my next appointment. My annual December tel appointment has just been cancelled and no new one scheduled yet.... not that I am concerned about that as I manage fine. Unfortunately you have not yet convinced me that regular insulin would benefit me, so I am not sure that I could explain to a consultant why I wanted to try it. Perhaps I am not explaining my situation clearly enough. I am happy where I am with Levemir and Fiasp, and if I was offered a pump today I would almost certainly decline it, and part of that is because I love and trust Levemir so much when perhaps that is an illusion that I have created.
I also found the change to Fiasp incredibly challenging but now that I have developed strategies to make it work for me, I would be extremely loath to change again without being really confident of a significant benefit and Fiasp is definitely growing on me, now that my 2 x 3 month trials of pretty well daily frustration are becoming a more distant memory and it would be hard to break the "habits" I have learned work for me with Fiasp let alone develop new ones with a slower acting insulin. To me that just seems like a step backwards and I am not sure I want to try to manage my diabetes with 3 insulins if that was an option although I believe there are some people particularly abroad who do.

Anyway, those are just my thoughts as to why this experiment appeals. I appreciate that it may be hard for many people to comprehend, as I guess most people would jump at the chance of a pump, but I have very unconventional ways of managing my diabetes with the insulins I have, so a pump might create more frustrations for me, in that I rarely carb count these days but need to bolus for protein 2 hours after a meal but I don't calculate that either, I just do it from experience and intuition and stack doses even half an hour apart if I need to. A pump might not cope well with this regime and perhaps even not achieve the results I currently get, which are generally very good.
 
You sound like you know what you’re doing with your diabetes, so why not give it a go, as long as you’re careful and do it on days when you can monitor your blood sugars really carefully. The thing about making sure all your long acting is gone from your system is a good point. Pumps deliver basal in extremely tiny doses every few minutes (e.g. 1 unit per hour split into 20 doses every 3 mins) which you couldn’t do with pens, but if you did one injection every hour I suppose it would work similarly (assuming you can inject a unit or two at intervals which work for you). I can’t imagine how it would work if you’re a busy person though, having to remember to inject that often! Do let us know how you get on though if you do try it 🙂
 
Thanks @Sally71
Yes, I am not looking at doing it long term, as it would fast become very tedious and easy to take your eye off the ball I imagine, but as I am retired and spend most of my days on my own, pottering on, I think I could easily pick a day that it wouldn't be too onerous a task to keep my focus and if it is reasonably successful and I get some interesting data, I might do it again a week or so later, just to see if it was a fluke or if I get similar results. Diabetes being what it is and not being able to draw any conclusions from a single set of results. 🙄 Of course I accept that I may have a bit of a disaster and find it untenable and knock the whole thing on the head within a few hours! Might try it tonight/tomorrow as I don't have much on.
 
I would keep a levemir pen at anyone’s house that you may stay overnight at, I do this and just swap the pen out for a different spare before it expires. DKA can set in very fast so going 24 hrs without basal isn’t sensible, regardless of how on top of things you feel you are.
 
Maybe I misunderstood @rebrascora I thought you were trying to reduce/omit some of the Levemir (because you need very little overnight). So, my suggestion was made with that in mind, ie regular would mean your daytime basal was covered by your bolus, and your nighttime basal could be nothing (you said you didn’t need Levemir some nights) or a few units of Levemir as needed. So, 3 bolus injections a day and zero/one basal. Hope that makes sense and apologies if I misunderstood what you were saying re your experiment purpose.

For some reason, regular insulin is often prescribed to Type 2s. I remember the nurse at my GP surgery telling me that. I think they largely use Humulin S (?).

I don’t think there’s any problem with you not wanting a pump. If you’re happy as you are and everything’s working to your satisfaction, then it makes total sense.
 
Thanks @Inka. I understand what you were getting at a lot better now. That was certainly one of the motivators for my experiment but I often eat late on an evening and generally don't have a steady enough routine for that to work for me. I ate at 10pm the other night for instance and that is not uncommon and can be later although usually nearer 8-9pm, sometimes 7pm ish and sometimes not at all, so not sure that would work well for me.

Anyway, my experiment begins.....

I started last night and clearly got it wrong! No Levemir and 1 unit of Fiasp at 11pm before I went to sleep, when I was on 5.7 and climbing slowly. I woke at 12.40am and scanned a 5.6 so that looked to have worked reasonable well, but at 3.17am the alarm went off and I was down to 4.3. Had one JB because there was no significant insulin in my system, just the very tail end of previous morning dose of Levemir. Unfortunately that tail end must have gobbled up the JB before I did 🙄because I didn't come up above the low alarm threshold and I woke at 5.01am on 3.8. I woke lying on my sensor side so assumed it was a compression low and went straight back to sleep (I know I should have double checked but I like my sleep) and woke up again at 7am with Libre showing 3.2 (Libre usually reads low for me so I am not overly concerned about this but think I was probably very mildly hypo) but again I didn't double check it but just ate another JB lay a bit longer until it was up to 4.8, since I knew I needed to inject before I got out of bed and couldn't inject when hypo.
At that time and level (4.8) I would normally have my 24 units of Levemir and 5 units of Fiasp then get out of bed (really important that I inject before I get up) and need to wait 30-40 mins before breakfast. Since I have a very strong FOTF and there should be no or negligible residual Levemir in my system, I decided to inject 10u of Fiasp. (definitely overkill and not well enough thought out.) Lets just say, I got to eat breakfast rather more quickly this morning and 2 JBs with it and a few roasted peanuts afterwards to stabilize things. I didn't get a downward arrow (not even diagonal) but low alarm at 4.5 went off within 5mins of getting up and Libre dipped into the red slightly whilst I was eating hence the 2 JBs. Now sitting at 5.6 with an horizontal arrow, so looks like the 10 units wasn't too far out and maybe 8 units would have been about right. It was really nice not to have to sit around looking at my breakfast for 40 mins before I can eat it though, but would have been goosed if I had had needed to drive somewhere this morning.

Apologies for all the detail here but I am using this thread to record my data and thoughts as I go along so that I can learn from it and hopefully improve on it if/when I do a second experiment. Anyway, so far not too bad and it is nearly lunchtime and only the 1 big jab of Fiasp and Libre showing levels steady in the mid 5s, so that is pretty surprising as I half expected to be feeling like a pin cushion by now!!
 
Wow! Still 5.4 and level on Libre and 5.5 finger prick and no more insulin since that 10units of Fiasp before I got up. Starting to feel anxious as this is not at all what I expected and wondering if levels are suddenly going to take off into orbit! I am tempted to add another unit of Fiasp now even though things are so stable. I will surely be finished with my morning dose now and be pretty much "run out" of any insulin in my system as it is 27 hours since my last Levemir. Not done any exercise today yet or any activity at all because I was concerned that 10 units would be too much and drop me fast.

Not feeling like I need any lunch just yet but I have decided that i am going to inject that 1 unit of Fiasp.... just to put some insulin in my system. I can always have a couple of JBs if it drops me, but at least it is something in my system.
 
Not sure if it is relevant but I am currently waiting for surgery (second attempt to fix my arm). I have been NBM since 6:15am when I chose to have yoghurt instead of my usual fruit because the carb count and, hence my insulin dose would be more accurate.
To avoid a hypo which would have to be treated and thus affecting my NBM, I was conservative with my carb count thinking I could top it up later.
Although I do not have full HCL, my pump auto suspends my basal when my BG heads towards hypo.
Since breakfast, my BG has not risen above 5.5 and my basal has been suspended for 3 hours.
I am doing no exercise to reduce my BG and slightly anxious about the surgery which I would expect to cause a liver dump.
It’s as if my liver has switched off but all I have had to drink is small sips of water so I can’t blame alcohol.

I guess my point is that bodies are weird and unpredictable.
 
Down to 4.9, so still no significant impact from my missing Levemir and starting to wonder if I need it at all!! Going to have another cup of coffee which should stop the slight drop.
24 units is a decent dose of Levemir and 6 hours in, an extra 6 units of Fiasp (5+1) have been too much by the look of it and morning is the time of day when I suspected my needs were significantly greater. I am finding this experiment really much more interesting than I expected!
So pleased I went ahead with it so far. I might even end up extending it if things continue like this but I half expect things to go badly haywire the longer time goes on.
Wondering if maintaining levels in the 4s and 5s significantly improves insulin sensitivity for me. I know that if I go above 8 I can sometimes feel it in that exercise become harder and I sleep poorly and above 10 it takes hours to bring me down. Going to lower my high alarm from 9.2 down to 8mmols so that I get more time to react if levels do suddenly start to take off....

@helli. Best of luck with your surgery. Hope it all goes smoothly and is successful this time. Thanks for your input. It is interesting.
So far my morning routine has not been too dissimilar to other days other than that big jab of insulin this moring but I have jabbed that much on a morning before on the odd occasion when I have woken on 10mmols in fact I have a rough guide for my morning dose that if I wake on 5 I inject 5u Fiasp, if I wake on 6, I inject 6, 7 I inject 7, 8 I inject 8 etc with my standard breakfast and this seems to work really well for me, but always with my 20+ units of Levemir. It almost seems now that my Levemir is doing nothing, but fully expecting that thought to be blown out of the water at any moment.

Now down to 4.6mmols and this has taken me 15 mins to type as I have had a phone call and a text to deal with whilst composing it and my coffee although that hasn't really had time to register on Libre yet. .
 
Well it is on the up at last! Might just be the milky coffee, but 6.6 now, so I have jabbed 1.5units of Fiasp and if I need to eat something to keep in the 5s I am good with that, but still not hungry so not bothering with lunch.
Heading out now that the torrential rain has eased a bit, so will add a little exercise into the mix which again would be fairly normal for me, although generally I would have gone earlier this morning. Will have JBs (and insulin) at the ready but 1.5u now plus the previous 1unit which is now 2 hours old, can't drop me far!
 
Out of interest @rebrascora , what’s your Correction Factor? You say 1.5 units (plus the end of the 1 unit) won’t drop you far, but I wouldn’t correct a 6.6 and 1.5 units would drop me 6mmol at this time of day. I’m imagining your CF is very different to mine?
 
Yes, of course, normally, I would not even consider correcting at his level, but I am factoring in that I have no basal insulin in my system, so this injection is my clumsy interpretation of your pump giving you tiny doses of bolus insulin every few minutes.
The way I look at it is that 2JBs raise my BG by 3mmols, which is equivalent to what 1 unit of insulin would drop me, so if I have jabbed this 1.5u and it isn't required to cover my liver output, I will simply eat 3 JBs to counteract it. It is not a big deal when I am monitoring things closely.

My CF is generally 1 drops me 3mmols at this level ie below 8. Between 8 and 12 it is about 1 drops me 2mmols. So when my high alarm goes off, I usually inject 2 units and that might be enough or it might need another unit but that is usually dealing with protein release, so the protein is trying to push me upwards as the correction is trying to bring me down. Above 12 and I just keep stacking small corrections until it comes down as that seems to work best for me with Fiasp and more effective but less frustrating and dramatic than hitting it with one large correction.

The Fiasp is slowly bringing me down, currently 5.8, so looks like I may need my JBs after all but holding fire on that at the moment. My low alarm is set at 4.5. Perhaps I have some beta cells left that have stepped in to cover that missing basal or my liver has gone to sleep. And I haven't even been out to "swing my legs" yet!
This experiment really is throwing up some very surprising results, but still plenty of time to go....
Staring to wonder what happens to all that Levemir that I jab in my backside every morning!
 
Haven't needed the JBs so far, just a handful or roasted peanuts when I dropped below 5. Currently very level on 4.9 (was 4.8 5 mins ago, so may be drifting upwards slightly) and it is now very nearly 2 hours since I jabbed that 1.5 units so that seems to have been a really good guestimate, as Fiasp usually lasts about 3 hours for me, so not much of it left.

Really starting to wonder if I could actually manage my diabetes like this long term without the Levemir. Levels are really remarkably stable and with very little overlapping of Fiasp doses so far. Ok, I haven't had lunch (which is not uncommon for me) and I haven't yet done much activity, as the rain came back before I got out but I expected to be doing jabs every hour and that clearly hasn't been necessary and I also expected a lot of up and down between 4 and 10, but hitting it preemptively before it has a chance to get that high, seems to be saving insulin as well as keeping my levels so much more stable.

Really enjoying this experiment! Thanks @Sally71 for the encouragement as I think I just needed that bit of support to give it a go.
 
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