Yoyoing bolus ratio and basal

[gillrogers]

They don't use basal insulin at all in pumps. The pump only uses fast acting (bolus) insulin and it delivers tiny amounts of it throughout the day and night to balance the glucose from your liver. You (or your nurse) set up a profile for every hour of the day and night for your basal needs and then you tell it when and how much to deliver for meals. It means that when you are dropping fast you can suspend your basal profile so there isn't all the basal insulin you inject on a morning or evening or both, releasing it throughout the day and night, but just a tiny trickle of fast acting insulin every few minutes providing that basal cover. So if you are going to exercise, you can suspend the basal an hour or so before hand and that should prevent you having a hypo during the exercise. You can have more for however many hours in the morning you need to cover DP/FOTF but less or none after lunch if you have problems dropping low in the afternoon. You can set up different basal profiles for work days and weekends or different times of the month. This makes it sound really good and it is, but it is also more complicated because you can adjust so many more things. The closed loop systems do a lot of this adjusting for you, but you have to know how to use it in manual mode because technology can fail and will usually do so at the least convenient time.

Ooh barbera, im.confused. how can you suspend basal if its not coming from the pump?

 

[silentsquirrel]

Ooh barbera, im.confused. how can you suspend basal if its not coming from the pump?

Basal and bolus come from the pump, but a short acting insulin eg Novorapid or Fiasp is used for both.

 

[helli]

Ooh barbera, im.confused. how can you suspend basal if its not coming from the pump?

Basal IS coming from the pump
Basal is not long acting insulin. It is background insulin.
When on the pump, you do not need long acting insulin because the pump provides background insulin by "pumping" fast acting insulin 24 x 7.
Therefore, you can suspend the basal by stopping the pumping of the fast acting insulin from your pump.
I find it is brilliant. However, it gives you much much more to tinker with and get frustrated by
If you are going to have a pump, you must get used to understanding your body and when to adjust your basal based on longer term trends at different times of the day. Adjusting your basal profile (how much fast acting insulin to pump in 30 minute intervals) is something you can do but if you change it as often as you change your Levemir dose, you will be frustrated and the mental cost of diabetes will be even higher than today.

 

[Inka]

Ooh barbera, im.confused. how can you suspend basal if its not coming from the pump?

Your pancreas, before you got diabetes, only made fast-acting insulin. It released tiny quantities of insulin many times a day to control your blood sugar. That’s what the pump is replicating. The only reason basal/slow insulin was invented was so people didn’t have to have numerous injections every day. Nobody’s body makes basal/slow insulin.

Pumps constantly release tiny amounts of fast insulin to control your blood sugar in the absence of food (like a basal). You then tell the pump to give you a larger amount of that same fast insulin as a bolus when you eat.

 

[helli]

@gillrogers I just looked back at your previous posts and wondered how much your hypo anxiety is affecting your diabetes management.
Your range lower level seems to be 6 which is a good average target level but as you get concerned when you near it, your average is much higher.
Eating glucose when your levels are falling when you are nowhere near hypo (4 mmol/l) and have undigested food, will mean that your levels will bounce a lot.
The stress of your anxiety will cause your liver to dump extra glucose which will push your levels up higher.

Have you requested therapy to help with this anxiety?
I think this is a psychological thing which needs to be address and without doing so, your diabetes management is gong to be much harder.

 

[Proud to be erratic]

I guessed it would be. They’re obsessed with Tresiba being ‘easier’ but for many people it’s not. They’re also obsessed with long-lasting basals. Think about that new basal recently that they said would last a week. To me, that sounds hideous not an improvement. Newer isn’t always better. Many of these new insulins aren’t actually step forwards. They’re just a chance to advertise longer/quicker/whatever and keep on making money.

Don’t be pushed into changing @gillrogers if you don’t want to. Often their suggestions are generic not aimed at the individual.

@gillrogers,
I definitely agree "don't be pushed into changing if you don't want to". As you say yourself getting a response from DSNs can take a long time while in the meantime you have to live with the problem as you wait for that help. You must do what you feel you can work with.

But, with huge respect to @Inka I simply don't agree with the generic statement or implication that Tresiba is more difficult. My experience is very much the reverse. I set my Tresiba to keep me steady and safe through the fasting hours of late evening and the night - THEN I simply do what my pancreas would be doing if I had one and use my shorter acting bolus to manage my D while I'm awake in conjunction with food and/or activity. I don't have the confusion of "is it my basal or bolus that needs adjusting?" Managing is just SIMPLER. Going low = too much insulin on board, so a snack is needed. Going high needs a correction = a modest bolus correction or some activity; going high is NOT an Urgent matter, just something that needs managing in due course.

I have a CGM to help me, both from visual graphs either for past days or recent hours PLUS alarms (which I call alerts) to tell me when change is happening. So managing D is definitely helped by the early alerting from my phone or Reader; I no longer have to finger prick frequently to check if I'm safe to go to the shops or into the garden, etc. NOR wait for hypo symptoms and then panic into speedy glucose hypo treatment. When I had the unreliable (for me) Libre 2 I had to fp before every meal just to reassure myself about how much bolus for each meal. But the trend arrows from L2 did seem reliable in telling me if my BG was static, going up or going down.

As for the proposal to have a basal that lasts a week BRING IT ON. I don't change my once daily Tresiba dose frequently - perhaps 4 times a year. So why would I need to change my future weekly basal dose? Basal = background insulin; why constantly change this background medication? Why make the D management more complicated?

This is all about keeping my D management simpler, less stressful and just dealing with what I know and understand - going low or high needs timely alerting (thanks to CGM) then appropriate response according to what I'm doing at that time.

That appropriate response has had to be learnt by trial and learning and can vary a bit on any one day - but is broadly consistently across any one week. And when that appropriate response isn't perfect - so what? It hasn't killed me. I might have needed even more extra snacks or had to be mildly more active - but daily life isn't a series of perfect moments either. [The Met Office has the single most expensive Gov't funded computer in UK, but still frequently get the weather forecast wrong]. I might misjudge my appropriate response, or my BG may be affected by any of the 42 factors currently identified as BG changing things. Or the 43rd factor of choosing the wrong colour socks today (= the unknown unknown!) is just playing today.

I hope your appointment goes well this afternoon.

 

[trophywench]

7 day basal brilliant idea providing it also completely stops all the effects of the body's 'fight or flight' reactions and it's response to stress, and of course it would need to do that with usual hormones - it couldn't cope with anyone eg giving birth, having a period, the best orgasm of their life or half a ton of bricks falling on them from scaffolding, could it? So the insulin would need to 100% guarantee that no surprises - good or bad - naturally caused or not - ever happen to you again.

Stupid idea, sorry.

 

[gillrogers]

@gillrogers I just looked back at your previous posts and wondered how much your hypo anxiety is affecting your diabetes management.
Your range lower level seems to be 6 which is a good average target level but as you get concerned when you near it, your average is much higher.
Eating glucose when your levels are falling when you are nowhere near hypo (4 mmol/l) and have undigested food, will mean that your levels will bounce a lot.
The stress of your anxiety will cause your liver to dump extra glucose which will push your levels up higher.

Have you requested therapy to help with this anxiety?
I think this is a psychological thing which needs to be address and without doing so, your diabetes management is gong to be much harder.

Yes i have, its a form of cbt. Im realky hoping it works. Id rather do hypnotherapy as i know it will work but i cant afford it

 

[gillrogers]

Didnt get my talk from dbn until this morning. They would rather i didnt do tresiba. But want me to have a joint meeting with the dietitian and my consultant to formulate a plan of action. Well decide for sure then wether or not to move to tresiba. So just waiting now for a date.

 

[Proud to be erratic]

7 day basal brilliant idea providing it also completely stops all the effects of the body's 'fight or flight' reactions and it's response to stress, and of course it would need to do that with usual hormones - it couldn't cope with anyone eg giving birth, having a period, the best orgasm of their life or half a ton of bricks falling on them from scaffolding, could it? So the insulin would need to 100% guarantee that no surprises - good or bad - naturally caused or not - ever happen to you again.

Stupid idea, sorry.

Not stupid - just needs you to pause and think.

All those things you consider might be resolved by constantly changing your basal can just as easily be done by adjusting bolus; eg fight or flight responses and responses to stress. How do you think I manage those today with my apparently inflexible Tresiba? Those things can also be managed by bolus, regardless of whether a basal dose is once daily or weekly.

It's what a nondiabetic person's pancreas does all the time. It's what a pump releasing fast acting insulin is doing every hour or part of an hour. That does NOT mean taking a bolus by MDI every hour or even every 2 hours. For that exceptional half a ton of bricks or giving birth will need an equally exceptional response treatment.

If major illness returns to me I expect to need a fresh insulin strategy - and that might well include self-funding a pump or further tech IF that is a possible solution. OR a return to a shorter lasting basal if that is what is needed. But my D still could not be sensibly managed by faffing around with frequently changing my basal.

You, Jenny, amongst many others, regularly talk about getting your basal right before getting the bolus sorted; I agree with that principle. So why do you think constantly adjusting basal is a stable way to proceed? You have more than once talked about not changing 2 variables at the same time; I agree also with that principle. So why be so alarmed by the idea of having a once a week basal?

I can see that change is frightening, yet we progress by trialling change. I can see that there are minor challenges, such as forgetting the once-weekly basal dose - but there are possible tech solutions to that.

Diabetes treatment has moved forward hugely in your lifetime. Improving MDI routines should not be neglected just because we are concerned about change.

What does bug me is how little change has occurred with CGM apps, how their mediocrity is tolerated and their constant failures are just allowed to happen with no apparent concern by the NHS procurement department. But that's for a different thread.

 

[Inka]

I’m not Jenny but I too wouldn’t like a once a week basal. It’s not to do with change - there have been many changes through my 30 years of Type 1 - it’s because a once weekly basal is a blunt tool. You mention pumps. The beauty of a pump is the ability to fine-tune basal. My pump gives me more than 3000 injections of basal every week! That’s a lot of flexibility and means it pretty much does what my pancreas should do. It also means my basal profile can closely match my needs.

So, my dislike of the idea of a once daily basal isn’t change, it’s the inflexibility (apologies - I was going to elaborate on this more, but children are calling so can’t at the moment) Levemir (twice daily) is often seen as a step towards a pump. I can’t see how one weekly basal injection would be an improvement. I see what you’re saying about using your bolus insulin or carbs, but to me that’s more complicated. When my basal’s wrong, nothing works as well. I can ameliorate things with bolus and carbs but it’s harder and not so good IMO. When I take a pump break, I actually have three basal injections a day because that’s what works best for me. If I could get the same results with bolus and carbs, I would, but, although I do use those as tweaks, I don’t want to be doing that too often to compensate for ‘wrong’ basal. I’m extremely busy and getting my basal as right as possible simplifies things and makes the whole ‘fun’ experience less stressful.

Perhaps Type 3c is different? I don’t know. My experience is of Type 1 only so there may be some differences that are relevant.

 

[helli]

I read an article which suggested the 7 day insulin is targeted at people with type 2 diabetes who produce some of their own insulin and elderly/sedentary people with Type 1 who need less flexibility.
Like @Inka I would find it too inflexible but I am not in either of these groups.

 

[Inka]

Interesting @helli That makes sense. I know that for me, my lifestyle just wouldn’t work with a weekly basal. There’s so much change, so much unpredictability. I remember twice daily insulin and the inflexibility of that. However, I know some older people are happy with twice daily because the routine works with their predictable lifestyle.

 

[trophywench]

It's simply because with 50+ years under my belt I most certainly know about all the sodding things that can affect my own BG and have each individually almost driven me nuts trying to handle them. I'm sorry cos this sounds a bit rude which I don't want to be since I certainly appreciate the different and difficult challenges that you've had but comparatively (and only that) you've had D for about 5 minutes.

But - of course I'm certainly not an expert in diabetes if anything at all - and maybe I am wrong and you're right on this occasion, who knows?

So as far as I'm concerned I'm perfectly happy to agree to differ on this one.

 

[rebrascora]

Perhaps Type 3c is different? I don’t know. My experience is of Type 1 only so there may be some differences that are relevant.

Yes, I was wondering if @Proud to be erratic not having a pancreas at all, made a difference in this situation. And @gillrogers still being in her honeymoon period, so producing some insulin (possibly quite a significant amount of her own since her doses are so small) may mean that she needs more flexibility rather than less.

I wondered if a once weekly insulin may also be helpful for people who are quite insulin resistant and so have less wobble in their basal needs.

 

[Inka]

@rebrascora The insulin resistant bit would fit with Type 2s as @helli mentioned so that could be true. I also agree that it might be relevant how much insulin a person uses. I’m not sure if I’m remembering correctly @gillrogers but did you say you were trying to put on weight or am I getting muddled? Is it you who sometimes feels reluctant to eat much because of the worry about going high or low?

I think people just need different amounts of insulin. Obviously weight/size must play a part but it can’t just be that. I take roughly 6 or 7 units of basal a day and my correction factor is 1 unit to 8+ mmols in the evening and 1 unit to 4+ mmol during the day. I’m well out of my honeymoon period. I’ve always used small doses. It’s been so long that I can’t remember the exact details but once my honeymoon ended (it lasted some years) my basal went up gradually and has then stayed around the same amount.

I think that’s another reason I’d dislike a whack of basal every 7 days.if something went wrong, like Lantus does sometimes, then any extra units I absorbed could have a dangerous effect due to my insulin sensitivity.

 

[gillrogers]

This is crazy! Similar problem.as last week anf monday. Thought at lunchtime i was dropping to much with no bolus on board. Same thing was happrning at tea time and had some blueberries while cooking tea that got dealt with by the basal within 30 minutes. Dbn wanted me to up my bolus ratio for dinner and raise my daytime basal by another half.Decided not to raise my bolus tonight and was very right not too as ive already munched an extra units worth of insulin in carbs. And im.sat down doing nothing. Done no more today than usual .

 

[gillrogers]

@rebrascora The insulin resistant bit would fit with Type 2s as @helli mentioned so that could be true. I also agree that it might be relevant how much insulin a person uses. I’m not sure if I’m remembering correctly @gillrogers but did you say you were trying to put on weight or am I getting muddled? Is it you who sometimes feels reluctant to eat much because of the worry about going high or low?

I think people just need different amounts of insulin. Obviously weight/size must play a part but it can’t just be that. I take roughly 6 or 7 units of basal a day and my correction factor is 1 unit to 8+ mmols in the evening and 1 unit to 4+ mmol during the day. I’m well out of my honeymoon period. I’ve always used small doses. It’s been so long that I can’t remember the exact details but once my honeymoon ended (it lasted some years) my basal went up gradually and has then stayed around the same amount.

I think that’s another reason I’d dislike a whack of basal every 7 days.if something went wrong, like Lantus does sometimes, then any extra units I absorbed could have a dangerous effect due to my insulin sensitivity.

Sorry Inka, yes im trying tp put pn weight. But i think the problem there is me actually with not going over 60g carbs in a meal as that throws my bolus ratios somewhat and im trying to sort other stuff out without having to work that out as well. Im maintaining though.

 

[Proud to be erratic]

Hello again @trophywench, @Inka, @helli, @rebrascora,

I feel that I have poked a hornet's nest and that was not my intention! My observation on my desire for a 7 day basal, with an unstated by me (but clear in my mind) wish to have a reduced activity for managing my D strongly remains. I'm not convinced by your arguments; with 3 of you using pumps and those pumps using a shorter acting insulin for both basal and bolus this simply reinforces the fundamental point that our bodies don't "know" that the insulin it encounters is engineered for different purposes (basal or bolus) - it is just insulin. If its there it will be used (and our individual insulin sensitivity characteristics will play a part in that) and if its not there each of us has trouble ahead!

My T3c from having no pancreatic functions whatsoever will be a factor: I have no expectations of getting any pancreatic help (so one uncertainty is removed) and I'm pretty sure I have no linkage with autoimmune considerations. I have some post surgery issues still bubbling up periodically, which almost certainly introduces daily variability in digestion of food eaten - leading to bolus guesswork. But I don't think the T3c factor is a major player: I'm still comprehensively insulin dependent. I'm lucky enough to manage my D sufficiently well that my HbA1c is reasonable and TIR is better than 70%. That "luck" means that I can't start a dialogue with the NHS about getting a pump; I don't meet NICE Guidelines. My fear from that is as I get older my mental capacity to take on that change will become impractical; if I'm honest with myself I'm pretty resentful of that scenario.

Since the proposed 7day insulin of icodec is still under trial in USA and not yet approved by the FDA nor yet in UK I think I should agree to differ, in a completely amicable way, on this. I intend to immediately step back from any further comment in this thread on 7 day basal insulin. I am distracting focus on @gillrogers needs.

Sincere apologies to you @gillrogers for disrupting your thread. I wonder how you got on with your potential 7 day freeze / pause from an earlier thread?

 

[gillrogers]

Sincere apologies to you @gillrogers for disrupting your thread. I wonder how you got on with your potential 7 day freeze / pause from an earlier thread?

Hi @Proud to be erratic , i think ive forgotten something? I dont remeber anything about a 7 day pause ‍♀️. Either way if i was it didnt gappen. I had a repeat performance last night of monday night. Then my basal did the same 2.5 mmol dip that it did bwfore lunch and just before tea at 12.30 am so got woken at 3 by my alarm. The probkem its giving me is with me sat down doing nothing. No exercise. I had a feeling at lunch time and at tea time it was going to happen. Now i got told yesyerday to up my bolus dose at lunchtime and tea time and my basal today. I clearky didnt need to do either and I didnt do either and i still ended up eating glucose all it and i reduced the basal back down again. Air pressure has dropped again too incidentally! Problem.is being on such a low dose of basal i cant to 10% changes. Its either going to be too much or too little.