Need advice

[ray30]

Hello

For the last 5 years, I have been advised to decrease the amount of Levemir I take to increase my HbA1c. It was really low but it's now at an ideal level. The amount of Levemir I was on 5 years ago was 24 units, now I'm taking (what seems like an insignificant) 6 units.

The last report sent to my GP from the endo stated I take a very small amount of long acting insulin compared to the rapid acting insulin which is unusual. I usually take 1u of NovoRapid for 5g of carbs except in mornings - I take more to lower very high BG (dawn phenomenon??) so I'm take approx. 26u per day and have been suggested to take much less insulin (1:10) as this is "normal". I did try this but I was getting really high levels of over 20mmol/l so I went back to 1:5 which is better but still getting highs and lows.

I've recently been using the Freestyle Libre system and found that my BG is all over the place! I've had T1 diabetes for 25 years and when fingerprick testing (approx. 5 times/day) my BG was not too bad but now I'm able to see what my glucose levels are like throughout the entire day and it's causing concern.

Having read a bit on basal testing I thought I might do a fast to see if I'm taking the right amount of insulin but I'm really not sure what to do about this result:

I take 6u Levemir at 11pm and do notice a drop in BG often overnight but always rise waking sometimes to a ridiculous level and other times they're quite high and rise higher when waking.

I just don't know what to do! Any help would be appreciated.

 

[dancer]

It looks like you may need to eat a snack before bed to prevent you going hypo during the night, leading to a liver dump. When I was on MDI, I found it necessary to have a bedtime snack. My consultant agreed with this but said that other consultants disagreed.

On the other hand, perhaps you just need to reduce your Levemir again. You could try that first, doing another basal test after a couple of days to see what's happening.

 

[Type1Bri]

Have you tried a different basal? That drop looks as if Levemir is work like a fast acting insulins would act

 

[noblehead]

Having read a bit on basal testing I thought I might do a fast to see if I'm taking the right amount of insulin

That's always a good idea, once you get the basal dose right your half-way there, you need to be sure that your bolus doses are not making up for a lack of basal insulin

The over-night hypo does look like your levemir needs to be decreased again, however you could move the timing of your basal back to early evening to see if that helps, I use to take my basal before bed but moved it back to early evening after speaking with my DSN.

 

[catapillar]

The all night hypo suggests you need less night time levemir.

Levemir lasts about 12 hours and is usually taken in an am and pm dose. So if your only taking levemir at 11pm then 11am-11pm you've got not basal insulin. Which could explain the double figures through the day. You might need to consider splitting your dose of levemir - have a chat with your DSN about timings.

It also looks like youre having dawn phenomenon, from the duration and depth of the hypo the rise doesn't look like a hypo related live dump to me. If it's dawn phenomenon/waking rise you might need to consider a correction bolus in the morning to manage that or looking into a pump where you can bespoke the basal rate so it's not too much sending you hypo early evening but is more at "dawn" to combat the DP. But I'd make dealing with night time hypos the first priority - you need to stop those.

 

[donnellysdogs]

I would be doing a split dose if it was me....

Basal testing is a must.. To do it though you got to get your night levels sorted first.As this should really mean no food from 5pm then you need to make sure you can test hourly really from 5pm to bed. Libre gives a good pattern if not... I would personally wake and do tests during the night every two hours... just for one night to see how it does actually compare to the libre scan readings too...

If it dips low you probably need to split insulin.

At the moment until the night levels are sorted you cannot be sure if the rises are DP/Symogi affect or just liver dumping from low levels..

I had endless night hypos on levemir but tresiba is fantastic, albeit I have to wake at 4am for my first correction bolus I can cope with that as, at least I'm not going low before that....it will keep me really flat until 4am...

 

[ray30]

Thank you all for your help. I have an appointment with my DSN soon so will speak about splitting Levemir and timing. Til then I'll try to stop them overnight hypos and do some more basal tests.
Thanks again.

 

[tigger]

Try a snack before bed with some protein added like peanut butter or hard cheese to try and make the carbs hit around 2am in the meantime.

 

[Scott-C]

Your paragraph just before the photo talks about a basal test so I'm assuming it's a bssal test photo and you didn't have any carbs/bolus during that time.

The rise from 7am to 10am looks kinda like "foot on floor" to me. I can wake up quite happily at 5 or 6 and then it can double just by getting up and moving around so I usually take 2 to 3u to pin it. It's a noticeably rapid spike on the libre and will carry on so that I would easily be around 10 at lunch if I hadn't pinned it.

Your graph does indeed show you hovering around 10 from 10am till 6pm. It's remarkably stable throughout that period. Although much higher than you'd like it to be, oddly, it does suggest that your basal is correct: if you've had no food/bolus that's the point of basal: holds you where you are. It's the bolus which teases you into the right place before the holding pattern occurs. Personally, I'd have abandoned a basal test if it had been preceded by a hypo and foot on floor.

That leaves the 1am to 7am hypo. No information about what you'd done in the previous 5 hours: could it have been a bolus miscalculation after effect, was it a Friday night with a pub involved? Know nada about levemir as I'm on lantus (has it's problems but I'm generally ok with it) but lantus does have a small peak effect after 2 hours even though it's meant to be flat: maybe levemir does too?

Your comment about docs advising 1:10 and your experience if that is fascinating. After almost three decades of making educated guesses about dosing, mostly correct after lots of trial and error in the early years, and having literally no idea of what ratios were, I went on a DAFNE course. Sure, learned a lot of fine tuning tips, am grateful to them for that, and would recommend it to people without hesitation, but we went out to buy lunch from prepacked stuff in the hospital cafe which had carb count on the packet, I looked at mine, said I'll need X units for this, nurse says, no, remember it's 1:10, I say , are you effing crazy, that'd put me through the roof, nurse says, no, no trust me. Guess what happens. Rest of the day I'm through the roof, up at 19 for an extended period, first time that's happened since dx. She then offered some views on correction doses: I declined, not politely. Stick to your guns on ratios. Even endos seem to think 1:10 is writ in stone. I've been messing around a lot with daily charts in libre, looking for good post-prandial results. Overwhelmingly, it works out at about 1.5:10. I can show this to docs on a graph, and they still say, you were on the course, why aren't you doing 1:10. Aaargh! Sorry, rant over....

 

[Jake2701]

Your paragraph just before the photo talks about a basal test so I'm assuming it's a bssal test photo and you didn't have any carbs/bolus during that time.

The rise from 7am to 10am looks kinda like "foot on floor" to me. I can wake up quite happily at 5 or 6 and then it can double just by getting up and moving around so I usually take 2 to 3u to pin it. It's a noticeably rapid spike on the libre and will carry on so that I would easily be around 10 at lunch if I hadn't pinned it.

Your graph does indeed show you hovering around 10 from 10am till 6pm. It's remarkably stable throughout that period. Although much higher than you'd like it to be, oddly, it does suggest that your basal is correct: if you've had no food/bolus that's the point of basal: holds you where you are. It's the bolus which teases you into the right place before the holding pattern occurs. Personally, I'd have abandoned a basal test if it had been preceded by a hypo and foot on floor.

That leaves the 1am to 7am hypo. No information about what you'd done in the previous 5 hours: could it have been a bolus miscalculation after effect, was it a Friday night with a pub involved? Know nada about levemir as I'm on lantus (has it's problems but I'm generally ok with it) but lantus does have a small peak effect after 2 hours even though it's meant to be flat: maybe levemir does too?

Your comment about docs advising 1:10 and your experience if that is fascinating. After almost three decades of making educated guesses about dosing, mostly correct after lots of trial and error in the early years, and having literally no idea of what ratios were, I went on a DAFNE course. Sure, learned a lot of fine tuning tips, am grateful to them for that, and would recommend it to people without hesitation, but we went out to buy lunch from prepacked stuff in the hospital cafe which had carb count on the packet, I looked at mine, said I'll need X units for this, nurse says, no, remember it's 1:10, I say , are you effing crazy, that'd put me through the roof, nurse says, no, no trust me. Guess what happens. Rest of the day I'm through the roof, up at 19 for an extended period, first time that's happened since dx. She then offered some views on correction doses: I declined, not politely. Stick to your guns on ratios. Even endos seem to think 1:10 is writ in stone. I've been messing around a lot with daily charts in libre, looking for good post-prandial results. Overwhelmingly, it works out at about 1.5:10. I can show this to docs on a graph, and they still say, you were on the course, why aren't you doing 1:10. Aaargh! Sorry, rant over....

Well, my wife, after getting Libre last year, and bit of experimenting with her doctor, has worked out morning ratio 1:3 (till 9:00), then all day 1:7.

Edited to,remove link

 

[ray30]

Your paragraph just before the photo talks about a basal test so I'm assuming it's a bssal test photo and you didn't have any carbs/bolus during that time.

The rise from 7am to 10am looks kinda like "foot on floor" to me. I can wake up quite happily at 5 or 6 and then it can double just by getting up and moving around so I usually take 2 to 3u to pin it. It's a noticeably rapid spike on the libre and will carry on so that I would easily be around 10 at lunch if I hadn't pinned it.

Your graph does indeed show you hovering around 10 from 10am till 6pm. It's remarkably stable throughout that period. Although much higher than you'd like it to be, oddly, it does suggest that your basal is correct: if you've had no food/bolus that's the point of basal: holds you where you are. It's the bolus which teases you into the right place before the holding pattern occurs. Personally, I'd have abandoned a basal test if it had been preceded by a hypo and foot on floor.

That leaves the 1am to 7am hypo. No information about what you'd done in the previous 5 hours: could it have been a bolus miscalculation after effect, was it a Friday night with a pub involved? Know nada about levemir as I'm on lantus (has it's problems but I'm generally ok with it) but lantus does have a small peak effect after 2 hours even though it's meant to be flat: maybe levemir does too?

Your comment about docs advising 1:10 and your experience if that is fascinating. After almost three decades of making educated guesses about dosing, mostly correct after lots of trial and error in the early years, and having literally no idea of what ratios were, I went on a DAFNE course. Sure, learned a lot of fine tuning tips, am grateful to them for that, and would recommend it to people without hesitation, but we went out to buy lunch from prepacked stuff in the hospital cafe which had carb count on the packet, I looked at mine, said I'll need X units for this, nurse says, no, remember it's 1:10, I say , are you effing crazy, that'd put me through the roof, nurse says, no, no trust me. Guess what happens. Rest of the day I'm through the roof, up at 19 for an extended period, first time that's happened since dx. She then offered some views on correction doses: I declined, not politely. Stick to your guns on ratios. Even endos seem to think 1:10 is writ in stone. I've been messing around a lot with daily charts in libre, looking for good post-prandial results. Overwhelmingly, it works out at about 1.5:10. I can show this to docs on a graph, and they still say, you were on the course, why aren't you doing 1:10. Aaargh! Sorry, rant over....

Yes it is a basal test graph. You're spot on about the bolus miscalculation.. I remember over correcting but did have something to raise my bg four hours previous to the test.

Trying not to go hypo or hyper so I can do another one of these tests!