Tresiba question

[Tom1982]

Hello all.
Recently swapped our daughters basal insulin from Levemir to Tresiba. No real feedback from nurse as to what dose we should start on. So we tried it as 1 unit less than levemir (so a seven dose)
Coincidentally at the same time she’s got a stomach bug from school. Now she seems to be going low a lot more often and quickly too. Should we change the dose?

 

[Proud to be erratic]

When I switched from Levernir to Tresiba I was told to move from mid 20s of Levermir to 16 units Tresiba. This didn't make sense then, but in hindsight definitely should have done.

Tresiba has a nominal 40 hr profile, ie is very long lasting. So after 24hrs the next dose is actually topping up the previous days dose. Within a few days my 16 units was reduced to 14, then 12. Today, having taken full responsibility for my own dosing, I'm on 9 units and I tweak it from time to time but, perhaps every 2 months or much longer. It is an inflexible basal, because any change can take 3 days to show an effect; but for me, that inflexibility is its strength. I have optimised my daily dose to keep me safe through the night; realistically no fixed basal dose will provide optimum cover across 24 hrs, our insulin needs (without any carb intake) vary too much.

People on Levermir regularly adjust their basal, some on a daily basis, using it to regulate their BG depending on how active they have been that day. Tresiba is not appropriate for such regulating. I use my bolus for all carb eating and for any necessary BG corrections when high (of course when low I must snack). This does mean, from time to time, I need to take a correction outside of my meal dose - eg before bedtime when my last meal carb count hasn't worked. But this does NOT mean taking corrections every time my BG starts to rise.

I am acutely aware of how much insulin I might have on board and, thanks to Libre, I can take a measured view of what is going on. My diabetes is brittle, my BG can rise or fall very quickly; or more accurately it used to - but since I moved onto Tresiba I seem to have eased that brittleness, or if not the Tresiba I'm just getting better at the D management! Still a long way from perfect, but that is not my goal or expectation.

I'm not medically qualified to answer your question "should we change the dose?" You should ask your DSN, but I would anticipate "yes". It takes time to find the right level and each change needs at least 3 days to get fully in place, then realistically another 3 days to allow the adjustment to be confirmed by results. You can't rush this process. But I appreciate the longer term stability from Tresiba.

Good luck.

 

[Tom1982]

When I switched from Levernir to Tresiba I was told to move from mid 20s of Levermir to 16 units Tresiba. This didn't make sense then, but in hindsight definitely should have done.

Tresiba has a nominal 40 hr profile, ie is very long lasting. So after 24hrs the next dose is actually topping up the previous days dose. Within a few days my 16 units was reduced to 14, then 12. Today, having taken full responsibility for my own dosing, I'm on 9 units and I tweak it from time to time but, perhaps every 2 months or much longer. It is an inflexible basal, because any change can take 3 days to show an effect; but for me, that inflexibility is its strength. I have optimised my daily dose to keep me safe through the night; realistically no fixed basal dose will provide optimum cover across 24 hrs, our insulin needs (without any carb intake) vary too much.

People on Levermir regularly adjust their basal, some on a daily basis, using it to regulate their BG depending on how active they have been that day. Tresiba is not appropriate for such regulating. I use my bolus for all carb eating and for any necessary BG corrections when high (of course when low I must snack). This does mean, from time to time, I need to take a correction outside of my meal dose - eg before bedtime when my last meal carb count hasn't worked. But this does NOT mean taking corrections every time my BG starts to rise.

I am acutely aware of how much insulin I might have on board and, thanks to Libre, I can take a measured view of what is going on. My diabetes is brittle, my BG can rise or fall very quickly; or more accurately it used to - but since I moved onto Tresiba I seem to have eased that brittleness, or if not the Tresiba I'm just getting better at the D management! Still a long way from perfect, but that is not my goal or expectation.

I'm not medically qualified to answer your question "should we change the dose?" You should ask your DSN, but I would anticipate "yes". It takes time to find the right level and each change needs at least 3 days to get fully in place, then realistically another 3 days to allow the adjustment to be confirmed by results. You can't rush this process. But I appreciate the longer term stability from Tresiba.

Good luck.

That’s brilliant. Thanks very much for the input and we’ll definitely tread carefully with the Tresiba. Very handy info.

 

[Thebearcametoo]

We did Lantus to tresiba and were told to go 10-20% lower dose to begin with because of the different profile and the length of time tresiba stays in the body. It’s hard to know where you’re at as there’s been illness too but lots of hypos suggests you need to go down a bit. When changing doses it takes 3-4 days to see the true effect so don’t keep swapping and changing more often than that.

Generally we liked tresiba (now on a pump) but it does have its quirks.

 

[helli]

@Tom1982 do you have half unit pens for your Tresiba?
I do not know if the single use pens are available in half units but the reusable NovoPens definitely have half unit options and fit the Tresiba cartridges.
Half units will help with tuning your daughters dose, especially as she will be on small doses.

 

[Tom1982]

@Tom1982 do you have half unit pens for your Tresiba?
I do not know if the single use pens are available in half units but the reusable NovoPens definitely have half unit options and fit the Tresiba cartridges.
Half units will help with tuning your daughters dose, especially as she will be on small doses.

Yeah we have the half unit pens. She had her first proper hypo the other night. It was awful. Was giving her jelly babies and glucose drink but level was still going down. She was all lethargic and falling asleep. Then after she was sick as a dog. Proper scared me that! Can’t have that too much.

 

[Tom1982]

We find that Jo seems to go high after her dinner Novorapid runs out. So 4 hours after dinner at about 11 her levels start to go up. Would this suggest we’ve under carbed with the fast acting? Or the slow release carbs (pasta, chips and so on) is being absorbed and the Basal insulin dose isn’t right? Any ideas?

 

[Thebearcametoo]

It may be the timing of the bolus dose or the ratio. Some foods have a second wind and only kick in later so there can be a mismatch between the timing of the insulin getting to work and the carbs hitting. If she isn’t going massively low in the 1-2 hours after dinner then you could up the insulin ratio if you know how but it’s also ok to send the data to her team and get their input. Or you may need to move the bolus dose later - this runs the risk of forgetting though so imperfect insulin is better than no insulin.

I wouldn’t mess with the basal at the moment given what you were going though with hypos but lowering the basal may mean she needs more bolus but you can get an idea of how good the basal dose is by what happens overnight. If she’s stable overnight then the basal is the right dose. If she’s coming down massively it may still be too high. It can be harder to see though if she’s artificially high because of late carbs kicking in after dinner. Being able to see the data over a week or so gives more of an idea of trends than one or two days.

 

[Proud to be erratic]

With Tresiba, you use the bolus to regulate food and to apply corrections; not the basal. I think this is a bolus problem.

Chips can be slow to release but not for everyone. Pasta is invariably slow release and often outlasts the NR 4 hrs. For an adult one might be suggesting the bolus is split, but I don't know if that is appropriate for a child; you should consult the Team.