Type 1 high BG readings in the evening

[John Johnston]

Hi, haven't been on here for years but I'm very worried, I've been told I have signs of retinopathy and have started experiencing symptoms of neuropathy. Well my Hba1c is 60+ so my GP has told me that's not good enough! My control is reasonable during the day, I count single figures as reasonable now. In the evening if I test 2 hours after meal is it generally around 10mmol ish. However when I then test another 2 hours later I am generally around 18mmol. Cant get my head round it and I have been waiting for a call back from the diabetic nurse for 2 days. Thought I would throw it out there to see if anyone has had similar. It is very frustrating. I may also mention if my reading is high 2 hours after a meal and I take a few units of fiasp insulin it will still generally be higher again another 2 hours later, insulin does not seem to correct it.

 

[danielmg]

Hi John, welcome back to the forum.

What time(s) do you typically take background (basal) insulin? In regards to evening meals as well, do you keep the same insulin to carbohydrate ratio, or adjust for the increases toward the end of the day?

I struggled with having the correct basal insulin dose (that I would take each night before bed), as it has a life of approx. 18hrs for me and the effect of this would gradually wear off toward the end of the day. This means I needed to account for this by increasing my insulin:carbohydrate ratio for evening meals. This is just my personal experience, but I know everyone reacts differently.

 

[John Johnston]

Hi John, welcome back to the forum.

What time(s) do you typically take background (basal) insulin? In regards to evening meals as well, do you keep the same insulin to carbohydrate ratio, or adjust for the increases toward the end of the day?

I struggled with having the correct basal insulin dose (that I would take each night before bed), as it has a life of approx. 18hrs for me and the effect of this would gradually wear off toward the end of the day. This means I needed to account for this by increasing my insulin:carbohydrate ratio for evening meals. This is just my personal experience, but I know everyone reacts differently.

Hi Daniel,
Thanks for the reply, I have tried adjusting my ratio for the evening, I can't seem to get it right though, I went to 2x ratio and an hour after dinner almost passed out with a reading of 2.1! Other nights 2x has worked OK. I agree it may be to do with background insulin. What really confuses me is if I have a reading of say 18, take a correction dose of say 4 - 5 units i may have a reading of 22 two hours later!

 

[rebrascora]

Hi John

Sorry to hear you are having such problems. It must be making you feel rotten as well as complications being a concern.

Which basal insulin do you use and when do you take it and can you give us an idea of how much basal insulin you use? If it is that tailing off then 4-5 units of Fiasp may not be enough and correction units tend to be less effective the higher your BG is, so that might be why the correction units of Fiasp are not keeping pace with it.
It may be that changing the time you take your basal could help or splitting your basal dose if it is an appropriate basal insulin to do that or a change of basal insulin because the one you currently using may no longer have a suitable profile of activity to meet your current needs.
.
I would agree with @danielmg that it is likely a basal issue. I think increasing your evening bolus by 100% (x2) might be a bit extreme depending upon how many units we are talking about. Do you have a Freestyle Libre as that would be helpful in seeing what is happening between finger prick BG tests?

When you say you are waiting for a call back from the diabetic nurse, is this the nurse at your GP surgery who oversees the diabetics at the practice or a Diabetes Specialist Nurse based in a clinic at the hospital, who will have a significantly greater knowledge of Type 1 diabetes and treatment than the practice nurse whose main focus if to manage the Type 2 diabetics.

How long have you been using Fiasp? Personally I find correction doses much less effective than I would like and they seem to be getting less effective with time and I may be asking to go back to NovoRapid at my next review, so just curious if you may be finding the same.

 

[trophywench]

Well if your basal's not **** on, you're fighting a losing battle fiddling with boluses.

Have you done a basal insulin test - and been on a DAFNE or similar education course?

 

[John Johnston]

Hi John

Sorry to hear you are having such problems. It must be making you feel rotten as well as complications being a concern.

Which basal insulin do you use and when do you take it and can you give us an idea of how much basal insulin you use? If it is that tailing off then 4-5 units of Fiasp may not be enough and correction units tend to be less effective the higher your BG is, so that might be why the correction units of Fiasp are not keeping pace with it.
It may be that changing the time you take your basal could help or splitting your basal dose if it is an appropriate basal insulin to do that or a change of basal insulin because the one you currently using may no longer have a suitable profile of activity to meet your current needs.
.
I would agree with @danielmg that it is likely a basal issue. I think increasing your evening bolus by 100% (x2) might be a bit extreme depending upon how many units we are talking about. Do you have a Freestyle Libre as that would be helpful in seeing what is happening between finger prick BG tests?

When you say you are waiting for a call back from the diabetic nurse, is this the nurse at your GP surgery who oversees the diabetics at the practice or a Diabetes Specialist Nurse based in a clinic at the hospital, who will have a significantly greater knowledge of Type 1 diabetes and treatment than the practice nurse whose main focus if to manage the Type 2 diabetics.

How long have you been using Fiasp? Personally I find correction doses much less effective than I would like and they seem to be getting less effective with time and I may be asking to go back to NovoRapid at my next review, so just curious if you may be finding the same.

Hi Barbara,

Thanks for the reply, so firstly, I use Toujeo and 22 units, this usually causes me to be around 4mmol when I wake up, low I know! I take it between 10pm and 11pm generally. I agree with you about the correction doses of Fiasp having little or no effect, I have been using Fiasp for about 3 years. I have contacted the diabetes specialist nurse at my local hospital and await a call back.
It appears that Toujeo can be taken as split doses but I will maybe wait and chat to the nurse first, hopefully they will call on Monday, I will also request a Libre system as I only have a finger prick kit.
Thanks everyone for taking the time to reply and offer suggestions.
John

 

[John Johnston]

Well if your basal's not **** on, you're fighting a losing battle fiddling with boluses.

Have you done a basal insulin test - and been on a DAFNE or similar education course?

Hi, yes I was on a course a few years ago but can't see anything about doing a basal insulin test? Tell me more

 

[danielmg]

Hi Daniel,
Thanks for the reply, I have tried adjusting my ratio for the evening, I can't seem to get it right though, I went to 2x ratio and an hour after dinner almost passed out with a reading of 2.1! Other nights 2x has worked OK. I agree it may be to do with background insulin. What really confuses me is if I have a reading of say 18, take a correction dose of say 4 - 5 units i may have a reading of 22 two hours later!

Best of luck with contacting the DSN. Hope you find a solution, and please let us know how you get on here.

 

[rebrascora]

How long have you been on the Toujeo? There are a few people here on the forum who seem to find it difficult/unpredictable. My feeling is that it may be better suited to Type 2 diabetics who are on larger doses and don't have so much sensitivity. I didn't know you could split it as I believe it is a very long acting basal. I am pleased you have access to a DSN to get help. Hope they are able to make useful suggestions.

With the Fiasp, I find a large dose (for me) like 5 units seems to hit me hard but since I eat low carb I usually use small doses of 2-3 units which seem to do very little. If I am up at 10 and I use 2 correction units, it doesn't even drop me to 8 but if I use 3 correction units I go hypo and 2.5 is unpredictable... it seems to be all or nothing but exercise definitely helps it get going... just not always convenient. I have tried Fiasp before for a short period and didn't find a benefit but wanted to give it another proper longer term trial now that I am more experienced. I keep saying that I will give it a full year but I am ready to throw the towel in now at 4 months and go back to Novo(not so)Rapid.

 

[Ljc]

You should find this helpful.Basal testing
You break it up into sections of the day and it can take quite a few days to complete a whole day and quite often for one reason or another you have to repeat that section, tbh it is a pain but well worth it.
Before I started to use the Libre I used to start with night time Basal testing, my alarm became my enemy lol.

 

[trophywench]

Hi, yes I was on a course a few years ago but can't see anything about doing a basal insulin test? Tell me more

Basal insulins « Diabetes Support Information Exchange (diabetes-support.org.uk)

I did a local course(CARBS 4 1), based on BERTIE and this was the result between myself and the chap who set the website up who'd done DAFNE, both coming at it with 60+ years of T1 between us. My clinic use a printed A4 landscape spreadsheet they issue to all their T1s to record our meter results on, but the bit of paper isn't important - only the meter results and times.

 

[trophywench]

Lin got there before me!

 

[Ljc]

Lin got there before me!

 

[everydayupsanddowns]

Sorry to hear you are having such a runaround with your BG levels @John Johnston

I’d agree that doubling your dose ratios was probably too extreme. I think a DSN once suggested to me that changes were best done in increments of 10 or 20% up or down rather than 100% 🙂

Maybe it would be worth doing a bit of a refresher of the education course you went on while you are waiting for an appointment with your DSN?

Two of the most respected courses in the UK, DAFNE and BERTIE are available online if that helps

DAFNE - (dose adjustment for normal eating):
https://dafne.nhs.uk

BERTIE Online carb-counting course:
www.bertieonline.org.uk

 

[John Johnston]

Thanks again everyone, lots of good advice, I'm glad I came back here now! Will update once I hopefully have things in control again.