Yoyoing bolus ratio and basal

[Proud to be erratic]

Hi again @gillrogers,

So we last exchanged a few messages around 30 Oct and I suggested you take a pause, no more experimenting for 6 or 7 days and take stock of what effect changes made by then were having. When I asked about this earlier today I had not looked back at that conversation and was just working from my memory of our dialogue plus my perception from that dialogue that you were keen on a pause in experimenting.

I still haven't thoroughly looked back; and if my perception was incorrect or that events have just overtaken the suggestion - no matter. I have considerable sympathy for your predicament because I still remember how confused I became during the 9 months after my pancreatectomy. My circumstances were pretty different: no CGM and thus no decent visibility of what was going on for my first 12 months; Covid and lockdown meant my contact with my nominated DSN was by email and I thought she knew what she was doing, then it became clear that she thought that despite my having no panc'y I didn't need to test much and only begrudgingly conceded that testing was needed before I drove. So I was actually medically adrift and meanwhile racing from hypo to hyper and back - only knowing from serious and deep hypos confirmed by the odd test. Oh, and I only found this forum after 9 months.

Now, apart from having empathy for you I'm reluctant to say much more. You are getting loads of suggestions and don't really need even more. I think if I were in your position I'd just cling to one responder and follow up on just one set of suggestions. But only you can judge how much you should rigorously cling to what a DSN is recommending, albeit intermittently when someone from the Forum might be suggesting something a little different. I had minimal help or understanding in my first 9 months - you potentially could have an excess of help that might increase your confusion and anxiety. My one observation and thus comment is that managing D is complicated and needs time to assess the benefit or otherwise of any single change. This could mean, other than for real hypo response, days rather than hours to find out if there is true progress. I wish you well and will continue to observe how you progress.

 

[Inka]

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!

@Proud to be erratic I kind of see what you’re saying but I think you misunderstand pumps. Although the pump uses exactly the same type of insulin for basal and bolus, they’re very carefully differentiated in the programming. Figures rounded for simplicity: I had a total of 15 units of insulin yesterday. All of it was fast insulin. However, 6 units of it was basal, 9 units bolus. I can’t just ‘swap that round’ as long as it all totals 15 units. Having too much or too little basal would be bad and would affect my control, possibly put me at risk of hypos or ketones, and reduce my flexibility. On a pump, as on MDI, it’s important basal and bolus are differentiated. Importantly, getting them right makes my life easier as well as my blood sugar better. If I’d had 9 units of basal and 6 of bolus, I’d have spent a lot of the day hypo, being stuck treating lows and unable to drive or exercise. I know you’re thinking that the other insulin will make up for it, but it doesn’t. Having the ‘wrong’ basal makes things hard as does having the wrong amount of bolus. Maybe you’re unusual in that you can work with this.

I don’t agree that pumps ‘reinforce the idea the insulins people on MDI take are ‘the same’ to the body’. They have different jobs. A slow-releasing basal replicates the background insulin our pancreas should make, a fast-acting replicates the bolus on eating carbs.

While a 7 day basal is pie in the sky at the moment, we do have longer-acting basals like Tresiba, which has been suggested for @gillrogers Although that’s easier in that it’s one injection of basal rather than two, it isn’t easier overall as it reduces flexibility and means that the basal might not match the body’s needs as closely.

@gillrogers I honestly think that a lot of this stems from your anxiety. It’s normal for things to vary day to day. That doesn’t mean your basal or bolus is necessarily wrong. It’s more likely to be one of the 42 things that affect our blood sugar. This is how the D acts. It’s a pain in the bum because we can do exactly the same thing each day and get different results. Sometimes I’m high and take a small correction, sometimes I’m low and have a carb top-up. This isn’t because anything is wrong with my insulin doses. It’s just how the D rolls.

 

[Proud to be erratic]

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!

@Proud to be erratic I kind of see what you’re saying but I think you misunderstand pumps. Although the pump uses exactly the same type of insulin for basal and bolus, they’re very carefully differentiated in the programming. Figures rounded for simplicity: I had a total of 15 units of insulin yesterday. All of it was fast insulin. However, 6 units of it was basal, 9 units bolus. I can’t just ‘swap that round’ as long as it all totals 15 units. Having too much or too little basal would be bad and would affect my control, possibly put me at risk of hypos or ketones, and reduce my flexibility. On a pump, as on MDI, it’s important basal and bolus are differentiated. Importantly, getting them right makes my life easier as well as my blood sugar better. If I’d had 9 units of basal and 6 of bolus, I’d have spent a lot of the day hypo, being stuck treating lows and unable to drive or exercise. I know you’re thinking that the other insulin will make up for it, but it doesn’t. Having the ‘wrong’ basal makes things hard as does having the wrong amount of bolus. Maybe you’re unusual in that you can work with this.

I don’t agree that pumps ‘reinforce the idea the insulins people on MDI take are ‘the same’ to the body’. They have different jobs. A slow-releasing basal replicates the background insulin our pancreas should make, a fast-acting replicates the bolus on eating carbs.

While a 7 day basal is pie in the sky at the moment, we do have longer-acting basals like Tresiba, which has been suggested for @gillrogers Although that’s easier in that it’s one injection of basal rather than two, it isn’t easier overall as it reduces flexibility and means that the basal might not match the body’s needs as closely.

I need to start a new thread, not particularly for the Icodec and 7 day basal discussion, but I think I do understand broadly what a pump is trying to do - in terms of fine tuning to get insulin on board and active at the right time. I'll come to that new thread when I can - it should help me politely challenge why I ought to have a pump.

@gillrogers I honestly think that a lot of this stems from your anxiety. It’s normal for things to vary day to day. That doesn’t mean your basal or bolus is necessarily wrong. It’s more likely to be one of the 42 things that affect our blood sugar. This is how the D acts. It’s a pain in the bum because we can do exactly the same thing each day and get different results. Sometimes I’m high and take a small correction, sometimes I’m low and have a carb top-up. This isn’t because anything is wrong with my insulin doses. It’s just how the D rolls.

I do support your interpretation of @gillrogers circumstances. Anything that helps ease her anxiety seems a great comment to my mind and reinforcing this aspect that D creates variations in responses day to day should be singularly helpful. This is
akin to choosing the wrong colour socks - we don't know why and life is too short to get bogged down in that question. [BUT if this is not an isolated variation but part of a repeating trend, then of course we must look further].

I also think some slowing down might help IN CONJUNCTION with recognition that being low needs fairly prompt attention and being hypo must receive prompt response; but going high is more of a nuisance that doesn't always need a fast response. Yes, sometimes being high can make me feel under par - but mainly I would be oblivious if my G7 wasn't telling me that I'm high.

Trial and learning takes months if not years, unfortunately!

 

[gillrogers]

Hi again @gillrogers,

So we last exchanged a few messages around 30 Oct and I suggested you take a pause, no more experimenting for 6 or 7 days and take stock of what effect changes made by then were having. When I asked about this earlier today I had not looked back at that conversation and was just working from my memory of our dialogue plus my perception from that dialogue that you were keen on a pause in experimenting.

I still haven't thoroughly looked back; and if my perception was incorrect or that events have just overtaken the suggestion - no matter. I have considerable sympathy for your predicament because I still remember how confused I became during the 9 months after my pancreatectomy. My circumstances were pretty different: no CGM and thus no decent visibility of what was going on for my first 12 months; Covid and lockdown meant my contact with my nominated DSN was by email and I thought she knew what she was doing, then it became clear that she thought that despite my having no panc'y I didn't need to test much and only begrudgingly conceded that testing was needed before I drove. So I was actually medically adrift and meanwhile racing from hypo to hyper and back - only knowing from serious and deep hypos confirmed by the odd test. Oh, and I only found this forum after 9 months.

Now, apart from having empathy for you I'm reluctant to say much more. You are getting loads of suggestions and don't really need even more. I think if I were in your position I'd just cling to one responder and follow up on just one set of suggestions. But only you can judge how much you should rigorously cling to what a DSN is recommending, albeit intermittently when someone from the Forum might be suggesting something a little different. I had minimal help or understanding in my first 9 months - you potentially could have an excess of help that might increase your confusion and anxiety. My one observation and thus comment is that managing D is complicated and needs time to assess the benefit or otherwise of any single change. This could mean, other than for real hypo response, days rather than hours to find out if there is true progress. I wish you well and will continue to observe how you progress.

Oh yes thats right. It worked for lunchtime showed i need an adjustment there but thinfs kept going heywire at tea time. With barely a rise and goung downhill. I new i had to make bolus adjustments and prebolus adjustments and was gwtting know where. Then come monday i endedup eating glucose all night until hakf midnight. Then an hour after my am basal i started dropping before my breakfast abd had to have a glucose tab. Breakfast i didnt prebolus and dropped a unit on it. Breakfast was cleared up without a unit of basal. nighttime basal had dropped.
Had a very simular event last night too. Thinknis when tjis happens im not doing any activity so if im not to over correct on glucose and carbs i take it slowly. When ilook back i see that im dtoping before lunch time, and before dinnertime after my bolus has worn off. From what ive learnt that means my basal is too high. Because im on such a liw dose what would be a small drop for most is abig one to me.

 

[rebrascora]

How low are you going on these occasions Gill. Could it be that your own insulin production is trying to bring you down to a nice level of 5 but you are fighting it by eating glucose and what you are interpreting as too much basal is actually just your own pancreas trying to balance your levels?

 

[Proud to be erratic]

Oh yes thats right. It worked for lunchtime showed i need an adjustment there but thinfs kept going heywire at tea time. With barely a rise and goung downhill. I new i had to make bolus adjustments and prebolus adjustments and was gwtting know where. Then come monday i endedup eating glucose all night until hakf midnight. Then an hour after my am basal i started dropping before my breakfast abd had to have a glucose tab. Breakfast i didnt prebolus and dropped a unit on it. Breakfast was cleared up without a unit of basal. nighttime basal had dropped.
Had a very simular event last night too. Thinknis when tjis happens im not doing any activity so if im not to over correct on glucose and carbs i take it slowly. When ilook back i see that im dtoping before lunch time, and before dinnertime after my bolus has worn off. From what ive learnt that means my basal is too high. Because im on such a liw dose what would be a small drop for most is abig one to me.

Well I think that is really useful for 2 general reasons:

Firstly you are starting to see patterns for yourself and that knowledge alone should lead to a greater confidence in you finding out how you are responding which in turn should help ease your own anxiety. You are also getting the opportunity to recognise when your BG is changing and gaining experience (trial and learning) in what responses work best.

Secondly you are starting to see this confusing variability from one day to the next which is probably just because variability is an inevitable fact - sometimes.

I would want to see slightly more accurate time intervals before concluding that your basal is too big in case your bolus is lasting a bit longer than you imagine. If bolus is still present and still "playing" but it has already helped the movement of surplus glucose from your blood into body cells and muscles etc - THEN I might conclude that your bolus ratios are a bit too strong for the carbs actually being eaten and this is less of a basal matter than a bolus matter. So I would change very little straightaway and see what repetition occurs but NOTING down accurate timings for when the bolus was injected, when my CGM started to tell me that the injected bolus had physically reached my blood and when the movement of glucose into individual cells seemed to end.

We are all different and while the manufacturer indicates how long each insulin might last in our bodies - that will vary for each one of us.

Also our natural insulin sensitivity, ie how much resistance each person has to any one type of insulin will also vary. That variation could occur because of:

the weather (eg a cold morning but warming up as the day progresses),
the time of day (my natural resistance is greater at breakfast time than in the evening - so any bolus takes longer to get going and can run out of steam too soon),
how quickly or slowly that particular meal gets digested and thus possibly the glucose from that meal arrives late but the insulin available has dissipated,
how high or low my BG is when I take my bolus - if I'm pretty low my insulin resistance is always low and if I'm highish my insulin resistance is invariably greater so the effect of that insulin gets slowed down by that resistance,
and even modest exercise or activity always plays a big part for me.

All for now - got a job I need to finish while everyone else is out.

 

[gillrogers]

Well I think that is really useful for 2 general reasons:

Firstly you are starting to see patterns for yourself and that knowledge alone should lead to a greater confidence in you finding out how you are responding which in turn should help ease your own anxiety. You are also getting the opportunity to recognise when your BG is changing and gaining experience (trial and learning) in what responses work best.

Secondly you are starting to see this confusing variability from one day to the next which is probably just because variability is an inevitable fact - sometimes.

I would want to see slightly more accurate time intervals before concluding that your basal is too big in case your bolus is lasting a bit longer than you imagine. If bolus is still present and still "playing" but it has already helped the movement of surplus glucose from your blood into body cells and muscles etc - THEN I might conclude that your bolus ratios are a bit too strong for the carbs actually being eaten and this is less of a basal matter than a bolus matter. So I would change very little straightaway and see what repetition occurs but NOTING down accurate timings for when the bolus was injected, when my CGM started to tell me that the injected bolus had physically reached my blood and when the movement of glucose into individual cells seemed to end.

We are all different and while the manufacturer indicates how long each insulin might last in our bodies - that will vary for each one of us.

Also our natural insulin sensitivity, ie how much resistance each person has to any one type of insulin will also vary. That variation could occur because of:

the weather (eg a cold morning but warming up as the day progresses),
the time of day (my natural resistance is greater at breakfast time than in the evening - so any bolus takes longer to get going and can run out of steam too soon),
how quickly or slowly that particular meal gets digested and thus possibly the glucose from that meal arrives late but the insulin available has dissipated,
how high or low my BG is when I take my bolus - if I'm pretty low my insulin resistance is always low and if I'm highish my insulin resistance is invariably greater so the effect of that insulin gets slowed down by that resistance,
and even modest exercise or activity always plays a big part for me.

All for now - got a job I need to finish while everyone else is out.

Thank you to your insight to your experiences. Very interesting ad some of it is similar. I have higher resistance in tge mirning than i do a lunch and in the evening. Infact its almost double. My evening resistance seems to be moving towards the same as my lunchtime. Now today has gone pretty darn well with my me landing back where i expected to be and my dinner time almost a tad too good. (Hardly a rise and hovering for an hour before starting a really slow decline.) To me its worked because i lowered my morning basal by half a unit, lowered my evening bolus by half a unit lowering my evening basal by half a unit. No fastish drop before lunch and dinner after breakfast bolus and lunch bolus had worn off. My instincts from seeing these patterns over the last few weeks especially with these evening meals was telling me its basal plus bolus.

Tomorrow ill be on the same basal today as its worked, i will raise my lunch basal by half and touch wood i wont need to change my evening bolus anymore.

I realised earlier what i was doing with these hiccups in the evening. Prior to me firing out the lyumjev when this happened i knew darn well it was bolus with the occasional basal change needed. But wjen the drops happened because of the rocket in the lyumjev the drop was much faster so i was mnching on alot more glucose to stop it consequently i would nine times out of ten end up needing a bed time correction dose. However when that didnt happen and i would start dropping off again after a rise back up i found it was basal needing a drop too.

So did the change the next day and it would work. This tended to happen in the hot weather we had last summer. If i remeber rightly hapoened for two or three days in a row.

Now its a much slower slide down and ive sat on my hands and not shoved so much glucose in so not to go high again. But because it was basal as well as bolus needing a change i could have given me a bit more glucose so i wouldnt have been needing another tablet 45 mins to an hoir later.

If i had realised what i was doing at the time this all staryed a few weeks back i dont think id have been so confused driving you all bonkers

Thanks all for being there.

 

[gillrogers]

How low are you going on these occasions Gill. Could it be that your own insulin production is trying to bring you down to a nice level of 5 but you are fighting it by eating glucose and what you are interpreting as too much basal is actually just your own pancreas trying to balance your levels?

Hi Barbera, I’m not going low as I’m stopping it but I’m not going high either. If I’ve eaten twenty grams of carbs on top of my meal carbs that the equivalent of 2 units worth of insulin. If i left it and didn’t stop it ie it was acting as a correction it’s equivalent to 6mmol, or 8mmol if my basal is too high.

 

[rebrascora]

Hi Barbera, I’m not going low as I’m stopping it but I’m not going high either. If I’ve eaten twenty grams of carbs on top of my meal carbs that the equivalent of 2 units worth of insulin. If i left it and didn’t stop it ie it was acting as a correction it’s equivalent to 6mmol, or 8mmol if my basal is too high.

That is kind of my point. You are not letting your levels get down to a good normal level like 5 or 6 then perhaps it is your own insulin production which is trying to bring you down to that level, rather than the tiny amount of insulin you inject, because it seems to me you are almost eating more hypo preventative glucose than the insulin you have injected, which suggests it is your own insulin which is dropping you because it is trying to balance your levels to where they should be, but you keep eating glucose to try to prevent that which means your body releases more insulin and you then eat more glucose. I wonder if you might be better not injecting any bolus with your evening meal and see if your body can bring it down on it's own.
How much insulin did you inject tonight for your evening meal?

We have just had a post from another member saying that they have had to stop their bolus insulin because they don't need it anymore, when they had been needing it for several months, so it is not uncommon for this to happen.