Struggling with consistent control

[Levy]

Hi,
I've been using the Libre sensor since May to finally try and get on top of my control (I've never been great at it on finger pricks).

However, I've noticed in the last few months that I'm really struggling to get consistent control. Some days I feel like it's a breeze, my boluses and corrections work really fast, there's no huge spikes and I manage to stay within target without much effort at all.

Then other days it's like I'm injecting water and my levels just do not want to be within the green zone! My corrections aren't even touching the highs (I have to correct two or three times before it even starts to come down) and every time I finally seem to get it back down it'll go straight back up and just hover around 15.

I've been keeping track and it's nothing to do with dodgy insulin vials, my carb and correction ratios are correct, I'm not eating anything different or exercising more or less. It's nothing to do with my time of the month either (it happens quite frequently, I'd say maybe once or twice a week on average but not on similar days)

I literally have no idea why some days I can't bring and keep my levels down, and I was wondering if anyone else experiences the same? It's getting extremely frustrating!

 

[x Carol x]

Hi Levy, yes I get this too. I don't know what causes it but when my blood sugar goes up after injecting my usual bolus, I know it's time to inject more basal eg. instead of the usual 4 units in the morning, I inject 7. It's rather scary though injecting a larger basal dose because it will suddenly drop again at some point, resulting in a hypo. I've often wondered if it's my thyroid that causes the fluctuation (I have hashimotos).

 

[himtoo]

hey there @Levy
have you shown these results to your DSN ?
even though there is a variation -- there does appear to be a couple of patterns in the timings of your results -- looking at 2am and around 10am
for the spike changes

it sounds as though you are working hard on your control !!
I see you are not on a pump
a strong word with your DSN about how a pump could benefit you !!!

all the best !

 

[Levy]

hey there @Levy
have you shown these results to your DSN ?
even though there is a variation -- there does appear to be a couple of patterns in the timings of your results -- looking at 2am and around 10am
for the spike changes

it sounds as though you are working hard on your control !!
I see you are not on a pump
a strong word with your DSN about how a pump could benefit you !!!

all the best !

Hi, I haven't had the chance yet. I've just changed clinics so not been able to go through these in too much detail.

As for a pump, I used to have one years ago but didn't get on with it. I exercise a lot and can't do that with Novorapid active because it just makes me drop like a rock. I found I could only do it with a hugely reduced temp basal two hours beforehand which just make it very inflexible and a huge hassle with MDI, I can go whenever I want and remain perfectly stable on Levemir alone.

 

[Levy]

Hi Levy, yes I get this too. I don't know what causes it but when my blood sugar goes up after injecting my usual bolus, I know it's time to inject more basal eg. instead of the usual 4 units in the morning, I inject 7. It's rather scary though injecting a larger basal dose because it will suddenly drop again at some point, resulting in a hypo. I've often wondered if it's my thyroid that causes the fluctuation (I have hashimotos).

Thank you for the response! I just changed clinics and had a blood test done, and I think they might have actually tested my thyroid on that one. I'll phone for the results tomorrow, that might shed some light on things! If not, I'll ask about it at my next clinic.

 

[Omnipod]

Try this:

 

[Levy]

Try this:

Thanks, but I've already ruled these causes out (and already do most of these anyway). This isn't about mealtime spikes or incorrect ratios, it's about consistent high levels (even when fasting) that just won't come down despite several corrections.

 

[tim2000s]

it's about consistent high levels (even when fasting) that just won't come down despite several corrections.

Which begs the question, "When was the last time you undertook a basal test?". When fasting, are you seeing a steady increase, or remaining flat when high?

Also, how many shots of Levemir do you take a day? NICE recommends two shots daily rather than a single shot as it is much more effective like that, and I would have to concur. In small doses (0.2u/kg) I find it lasts less than 12 hours, and that could easily be driving issues, as you'd be having to use Novorapid to cover the gaps.

Just some food for thought.

 

[Levy]

Which begs the question, "When was the last time you undertook a basal test?". When fasting, are you seeing a steady increase, or remaining flat when high?

Also, how many shots of Levemir do you take a day? NICE recommends two shots daily rather than a single shot as it is much more effective like that, and I would have to concur. In small doses (0.2u/kg) I find it lasts less than 12 hours, and that could easily be driving issues, as you'd be having to use Novorapid to cover the gaps.

Just some food for thought.

I take Levemir twice a day and have done for years. It's not a steady increase, but as you said it always remains flat(ish) at that high level, somewhere around 12-15.

I don't see how it can be a basal issue when most days everything is good, and then on seemingly random other days this happens (only for it to be good again the next day).

I tried to draw a correlation with exercise, as in seeing if it could be that I need more basal on non exercise days, but that also doesn't seem to be related.

 

[becca59]

I feel your pain. Your post could have come from me. I know everybody mentions the basal dose. I too have upped doses after big highs only to find persistent hypos result. One thing the Libre has shown me is a lovely flat fasting line in the night. So on balance my Toujeo is correct. The injecting water scenario happened to me yesterday, it is very frustrating. For me my rotational sights do include thighs and buttocks. Along with stomach I can then have a 5 week rotation. Perhaps for me that may help. My favourite comment from my consultant this year, “it’s like herding cats!” Just about sums it up. Good luck!

 

[tim2000s]

@becca59 has a good point. Absorption can vary depending on site. It may be worth, the next time you see your DSN/Consultant, asking them to check your injection sites for lipohypertrophy. How much do you rotate injections sites?

 

[Levy]

@becca59 has a good point. Absorption can vary depending on site. It may be worth, the next time you see your DSN/Consultant, asking them to check your injection sites for lipohypertrophy. How much do you rotate injections sites?

I had an appointment last week and she checked them all. They're all fine and being rotated every single time I inject (different side of my body, different part of the tummy every time, sometimes back of arm)

 

[tim2000s]

If we look at those graphs, can you walk us through what happened on Monday? It looks like you had a massive hypo rebound, after which your glucose levels stayed high for some time. How low did you go? Also, do you have many hypos? After a hypo, the liver tends to keep dropping glucose into the system for quite a long time after the hypo (around 24 hours) so it can make bringing down a post hypo high particularly difficult, and can result in needing a lot more insulin for a period of time afterwards.

In addition, I'm guessing by your Avatar that the sport you do is martial arts related. That tends to be an anaerobic form of exercise, which can result in the body releasing glucose to power the muscles, then trying to reabsorb it, which can cause post exercise highs, then an associated hypo event.

Then there are also hormonal issues that may affect you, such as Thyroid. Have you been tested for thyroid activity?

 

[Levy]

If we look at those graphs, can you walk us through what happened on Monday? It looks like you had a massive hypo rebound, after which your glucose levels stayed high for some time. How low did you go? Also, do you have many hypos? After a hypo, the liver tends to keep dropping glucose into the system for quite a long time after the hypo (around 24 hours) so it can make bringing down a post hypo high particularly difficult, and can result in needing a lot more insulin for a period of time afterwards.

In addition, I'm guessing by your Avatar that the sport you do is martial arts related. That tends to be an anaerobic form of exercise, which can result in the body releasing glucose to power the muscles, then trying to reabsorb it, which can cause post exercise highs, then an associated hypo event.

Then there are also hormonal issues that may affect you, such as Thyroid. Have you been tested for thyroid activity?

I don't think I've been tested for thyroid issues but will bring that up.

As for exercise, I've been doing it for over 5 years and manage to keep my levels perfectly stable throughout training as long as I have no Novorapid active (I always train before dinner). Then for dinner I take the same ratio and have never noticed anything off with that either. The only time it doesn't work out - as you can see that Monday - is when I've had to snack or correct beforehand. On Monday evening I had a corrective dose of Novorapid active when I started and that together with my training brought it down and made it dip to 3.6 post-exercise. I had a little swig of orange juice (not even 100ml) which made it jump straight back up into the 12s. I hear what you're saying about the effect of exercise, but I can assure you with the experience I've had over the years, I know this isn't how my body normally reacts, even after training.

I did have quite a bad hypo the night before. My levels had started staying high since 6pm on the Sunday, and the hypo was a result of two corrective doses (one taken at 6pm and one again at 9pm when the first one had not brought it down whatsoever and the libre was showing a -> arrow). The hypo then lasted two hours (being 1.5 at its lowest) and was treated by taking 2 gluco tabs and finger pricking every 20 minutes before taking further action.

I'd like to add that I've also experienced the same thing happening even when I haven't had any hypos, so although I understand on this day the hypo will have probably contributed, I can't pinpoint it as the sole culprit as it isn't consistent with the rest of the times.

 

[ickihun]

Hi Levy, yes I get this too. I don't know what causes it but when my blood sugar goes up after injecting my usual bolus, I know it's time to inject more basal eg. instead of the usual 4 units in the morning, I inject 7. It's rather scary though injecting a larger basal dose because it will suddenly drop again at some point, resulting in a hypo. I've often wondered if it's my thyroid that causes the fluctuation (I have hashimotos).

I'm exactly the same but higher bgs give me additional insulin resistance which takes even longer to get insulin levels back down. A very very slow procedure.

 

[Levy]

Just come off the phone with one of the DSNs at my clinic. They tested my thyroid function in my blood test last week and they say it's fine, so that doesn't explain it either.

 

[tim2000s]

I'm exactly the same but higher bgs give me additional insulin resistance which takes even longer to get insulin levels back down. A very very slow procedure.

Just to be clear though Ickihun, you're not a type 1, but a type 2, so the physiological mechanisms and insulin dosing models are slightly different.

 

[TheBigNewt]

You've only had the Libre 5 months, so it's hard to get a pattern out of it. Take me for example: I finger prick before meals, bedtime, in the AM. No looking for spikes after meals, no seeing it on the way up and down, just before I'm due to take more insulin. So I think it'll take you awhile to see "the good with the bad". Even on your "bad" graph there were only a few high readings that were at the absolute BOTTOM of the downward swings. We all have those.

 

[x Carol x]

@Levy Could it be something you're eating? I've just realised that eating raw eggs causes insulin resistance in me. I'm currently injecting over double my usual basal dose so I've now cut out the raw eggs! I also have a problem with cod liver oil which does the same thing. My bad blood sugar days last at least 4 days and then I'm back to normal so I can change the basal to match but if you're only getting it for one day it's a bit different. For me it's like the time of the month increased need for insulin but it happens at any time of the month. I can only suggest doing a diary and plotting your insulin resistant days. I think that's a good idea for me too to spot if there's a pattern.

 

[ickihun]

Just to be clear though Ickihun, you're not a type 1, but a type 2, so the physiological mechanisms and insulin dosing models are slightly different.

Nice reminder @tim2000s . I do advertise im type2 all over my label on every post and in my signature. Hopefully not too long a medical history for some to read. I know I get bored repeating myself. Thankgod for labels?