30/70 to modern regime

[pshawfocus]

Hi all. I'm a 45yo guy who has been T1 for 32 years. A couple of months ago I switched from the regime I had been on throughout that period of twice daily novomix 30 / 70 across to novorapid and lanctus. Historically my diabetic control has always been excellent, I have great sensitivity to my levels, no other (known) complications, my HBA1C has always been <6 (more recently it's been <5), I'm office based but lead an active life and exercise regularly (cycling - though less so at the moment due to the weather), consume a generally low carb moderately high fat diet, I carb count reasonably well, early riser / early to bed, minimal alcohol, no smoking.... essentially I am very fit and healthy. I switched because I had been reading about the extra flexibility the newer regimes offer and because the few T1s I know have all moved across to it. A lunch with a customer who is T1 cemented my thoughts that I should look into it further, as he enjoyed a small amount of rice with his curry Having made the move, I have a couple of questions, I'm hoping you can all assist with.

Quick acting insulin? I get the sense that the novorapid operates over a 3-4 hour period? I find that in the evenings I have had my meal, tried to closely match the insulin intake vs the carbs but I am still somewhat low when I go to sleep 3-4 hours later.

Dawn phenomenon? I've never felt I've had this before now but on the new regime I consistently wake with a 10+ glucose. Is this occurring to the type of food (fat / protein etc) I'm consuming around dinner (I'm no expert on this element of diabetes management). Is there a solution? I was wondering if I could switch to taking my long term dose in the evening, so it is still working overnight - i get the sense it is running out of steam in the early hours or is that a red herring?

Evening? During the day (10am-3pm) I don't tend to consume that many carbs. Previously I would eat a low carb (<10gr) salad occasionally at lunch time but can happily go through the day on coffee and the occasional piece of chocolate if I've cycled hard, am stressed or had a smaller breakfast etc. I have been experimenting a little with the new regime and eating the occasional croissant or having some carbs at lunch and taking a dose of novorapid to match that. I find that most evenings (4-6pm) I am going low which is unnerving as previously (under 30 / 70) my bg would be starting to climb as the insulin wore off. I have been eating small amounts of carbs to counter this until I have my dinner but often these smaller amounts don't lift the bg significantly and 30mins later I'm still heading low (<4).

I'd really welcome some insight from T1s on the three points above. I'm hoping a couple of small adjustments / awareness will return my bg management to a more normal curve, because at the moment I'm a bit all over the place and the morning highs are driving me insane!

Happy to answer any questions if I've not explained anything properly. Thanks in advance.

 

[catapillar]

Quick acting insulin? I get the sense that the novorapid operates over a 3-4 hour period? I find that in the evenings I have had my meal, tried to closely match the insulin intake vs the carbs but I am still somewhat low when I go to sleep 3-4 hours later.

Novorapid starts acting about 15-30 minutes after injecting and lasts for about 5 hours.

You say you are carb counting, but if your going low after meals that suggests your insulin to carb ratio isn't correct and you need less insulin with dinner.

You can do the free NHS online carb counting course here - https://www.bertieonline.org.uk - you need to remember that carb counting isn't just counting carbs, it matching your insulin to the carbs you eat. If your insulin to carb ratio isn't correct then you aren't going to be able to do that. What insulin to carb ratio are you using for dinner time?

Dawn phenomenon? I've never felt I've had this before now but on the new regime I consistently wake with a 10+ glucose. Is this occurring to the type of food (fat / protein etc) I'm consuming around dinner (I'm no expert on this element of diabetes management). Is there a solution? I was wondering if I could switch to taking my long term dose in the evening, so it is still working overnight - i get the sense it is running out of steam in the early hours or is that a red herring?

Lantus lasts around 18 hours. So if you are taking it in the morning it could well be running out by the time you wake. Many people split their lantus and take a shot in the morning and a shot at night. You could also look at basal testing to see if your basal dosage is correct - https://mysugr.com/basal-rate-testing/

Evening? During the day (10am-3pm) I don't tend to consume that many carbs. Previously I would eat a low carb (<10gr) salad occasionally at lunch time but can happily go through the day on coffee and the occasional piece of chocolate if I've cycled hard, am stressed or had a smaller breakfast etc. I have been experimenting a little with the new regime and eating the occasional croissant or having some carbs at lunch and taking a dose of novorapid to match that. I find that most evenings (4-6pm) I am going low which is unnerving as previously (under 30 / 70) my bg would be starting to climb as the insulin wore off. I have been eating small amounts of carbs to counter this until I have my dinner but often these smaller amounts don't lift the bg significantly and 30mins later I'm still heading low (<4).

That really suggests your basal dose needs looking at and you need to do some basal testing. The job of your basal insulin is to keep you flat when you aren't eating or bolusing. If your dropping without bolus on board that suggests your basal dose is too high.

 

[pshawfocus]

Thanks. I've split my basal as suggested and that's resulted in morning levels being reduced to c. 9BG. I'm going to increase the evening dose a little to get it down a bit further. It has certainly resulted in a more consistent through the day level so I think that change was the key. When I was talking about switching to this regime the doctor has suggested I could do 2 doses but the diabetic nurse said go with 1 to start with. I think when Xmas is over and a few less carbs are being consumed plus I'm back to cycling to the office, I'll have to adjust the basal doses down a little to compensate. Many thanks for the guidance - it's had the desired effect.

you need to remember that carb counting isn't just counting carbs, it matching your insulin to the carbs you eat.

Well...obviously...you don't do it for fun. I go to the cinema for that!

 

[darrenh04]

Hi. I find the majority of Novorapid's action happens in the first 2 hours but there is a tail that lasts. With Lantus, while it last 18 hours (ish) I found it tends to have more impact in the first few hours then tail of over the remaining period. I found the amount of Novorapid to used changed depending on the time of day in relation to my Lantus injection. Having been on this regime for 4 years I have just moved to Tresiba as it is much flatter and my Novorapid injections are more consistent. I can also directly relate exercise level to food and adjust Novorapid accordingly. Splitting the Lantus dose may help as it will get you away from one daily peak.

 

[Daibell]

Hi and welcome. Note that Novo Nordisk have recently introduced a new rapid insulin called Fiasp which acts much faster than NovoRapid. It may not be right for you but some people may prefer an insulin that starts working very fast and acts over a shorter period of time. It's available now on the NHS.

 

[Tabzmcfc]

Hi and welcome. Note that Novo Nordisk have recently introduced a new rapid insulin called Fiasp which acts much faster than NovoRapid. It may not be right for you but some people may prefer an insulin that starts working very fast and acts over a shorter period of time. It's available now on the NHS.

Hi
I split my Lantus too but weirdly find that I need to adjust the morning dose to affect the overnight levels

 

[O_DP_T1]

Hey pshawfocus

I'm in my 40's been a T1 for about 40 odd years and been on the 30/70 most my life i lead an active life exercise regularly and HBA1c has always been around 5-6.8ish. Any way long story short I switched to the MDI NovoRapid and Lantus over the weekend and TBH it's a nightmare.

Even counting carbs correctly and dosing correctly I still get a spike and it stays around 8-9 for the whole day. On the 30/70 insulin i would get a spike to about 10 2 hours after and then within an hour or 2 after that it would be in normal range again.

Currently on the standard ratio of 1 unit on NovoRapid to 10g carbs I might up that to 2 units of NovoRapid to 10g of carbs and see if that helps.

Also tomorrow is a heavy legs day so not sure if upping the insulin is a good idea but lets see.

I will give this a chance for a few weeks but if all else fails I want to go back to my old routine, does anyone know if that is allowed?

Anyway good luck mate.....

 

[himtoo]

with a total of 45 years experience as a type 1 ( started on 1 injection per day and the regime was very strict back in 1972 )

to now..... and been pumping for just over 2 years and the flexibility is enormous ( seriously !! )

my advice is to remember that living with T1d is a lifelong condition once diagnosed and everything involves a learning curve that takes time , as we are actually learning in real time - no faster.

( and that is without all the curves that our D can throw at us )

so to me , measuring success in changing regimes , patterns ,anything to do with the balance of our bodies, the medicines we take , and our lifestyles -- all need time when we make major changes

 

[SueJB]

with a total of 45 years experience as a type 1 ( started on 1 injection per day and the regime was very strict back in 1972 )

to now..... and been pumping for just over 2 years and the flexibility is enormous ( seriously !! )

my advice is to remember that living with T1d is a lifelong condition once diagnosed and everything involves a learning curve that takes time , as we are actually learning in real time - no faster.

( and that is without all the curves that our D can throw at us )

so to me , measuring success in changing regimes , patterns ,anything to do with the balance of our bodies, the medicines we take , and our lifestyles -- all need time when we make major changes

Hard to change though when you're not sure of what you're doing and the uncertainty of changing to something new again is scary

 

[catapillar]

Even counting carbs correctly and dosing correctly I still get a spike and it stays around 8-9 for the whole day. On the 30/70 insulin i would get a spike to about 10 2 hours after and then within an hour or 2 after that it would be in normal range again.

Currently on the standard ratio of 1 unit on NovoRapid to 10g carbs I might up that to 2 units of NovoRapid to 10g of carbs and see if that helps.

That would be a 100% increase in your I:C ratio. DAFNE recommends trying only 20% alterations and seeing how they go. You don't need to change from 1:10 straight to 2:10. Especially if your high is only "staying around 8-9 for the whole day" doubling the insulin you take with meals is asking for a hypo. I would suggest trying a 1:8 ratio before diving in with 1:5.

As you've only been on basal bolus since the weekend and its only Tuesday now (so 2 days?) you should really give it a few days to settle and then consider basal testing (see the link in post #2) to check if you are on the correct basal dose.

To consider whether your I:C ratio is correct you should then have a look at the BERTIE course (see the link in post #2). You might also want to consider the timing of your bolus, when are you bolusing for meals? Pre- bolusing can help in avoiding spikes.

You should also ask your DSN on the DAFNE course, or whatever the local version of it is. It's a course in a room of other type 1s on basal/bolus running through carb counting and the insulin regiem.

Of course if you want to go back to mixed insulin that's your choice and all you have to do is ask.

 

[TheBigNewt]

I've always taken my Lantus (25U, 70kg body weight) in the morning. I've done that since Lantus was released. My BS might drift downward a tad during sleep so I have a sustained release carbs bar I use at bedtime more often than not, maybe 70 calories. You may have to adjust your Lantus total dose until you get an even glucose level for the most part. The bolus you'll figure out pretty fast. I think you'll do fine on this if you did that well on the mix (I never used that only NPH for a few months in the beginning). Good luck (not that you'll need much!).

 

[pshawfocus]

Still finding my feet a little with the new regime and I can totally understand the frustration of O_DP_T1 (and others I suspect). I have dipped in and out of this forum for a while as I get slightly frustrated by the preachiness of some of the contributors on here when all people are doing is asking for a bit of guidance...Having managed my T1 for 30 years VERY well, clearly I'm familiar with carb counting and acutely aware of how I feel with my BG and the impact changes of dose, timing, exercise, food, emotions etc could all have. Having people tell me I need to match carbs to insulin...***, you don't say. I hope those who are newly diagnosed and come here for help are cut a little more slack and sympathy... There appears to be a bit of an assumption that 'well I do it this way, so obviously you should to'...forgetting that we're all unique and managing T1 is, as a result, a bit of art as well as science.

Anyway...rant over.

When I switched over I got told by the dietician to do 1 unit of Novorapid per 10g of carbs. That seemed quite low to me and after only a couple of days with BG consistently >12 I too doubled the dose. So a typical day (no cycling) I take 6-8 with breakfast (2 slides of wholegrain toast with butter) and if I have lunch or snacks (morning or afternoon; quite rare to be honest - I tend to live on coffee) I count carbs and inject. I'll need to reassess that when the weather improved and I cycle to work again (1 hour / 16 miles, plus I also cycle another 5 miles in the evening to/from the station).

Following advice above I have switched and split my Lunctus 50/50 to a morning and evening dose, taking 12 units on each occasion. I am still finding myself a little high in the mornings (12BG today) and looking at my libre history I can see that it rises quickly 3-4 hours after bed and then the climb rate levels off. Should I look to adjust the 50/50 split to a 40/60 as I am more active during the day?

Not sure if others experienced this when first switching over, but I am probably having a touch too much carbs to correct a slightly lower BG level. For example, whereas on 30/70 I'd have a couple of biscuits before bed if my BG were heading lower than planned I think on the new regime, I only need 1 or even half a biscuit or smaller glass of orange juice. The fear (after 30+ years on the previous regime) remains of a night time hypo but this needs to be revisited, because the effects of the new regime are different. I'm going to see how that impacts things over the next few days, if there is any low(er) BG as I head to bed. And if someone says I shouldn't be going low as I head to bed if I'm carb counting....

 

[MargiK]

I'm still juggling after 30ish yrs on both insulin. I thought the dawn phenomenon was a liver dump shortly after waking. I need more novorapid in a morning even without food. If I'm over 10mm when I wake I can have 2 unit's no food and go for a run for 40mins to keep on an even keel. Whereas after lunch I have a serious dip at 4-5 hr mark. I can go for a run at 15+mm 4hr after lunch and be 3mm 30-40min later. In the evening I require less insulin per carbs. Whether my sensitivity, liver dump or viruses, I'm in a constant juggle of control.

 

[Cobia]

I shouldnt even comment.

For the op. No one has suggested check your basle. If the basle is not right nothing else will too.

Its worth the teuble.

 

[iHs]

I didn't do any basal rate testing myself but got round the MDI regime by testing bg levels every 2hrs, logging down the grams of carb eaten, the bolus dose and then tried to adjust the carb ratio and try to get the same bg levels according to the NICE bg guidance. For me I decided to pick 6mmol before a main meal and then allow for a rise of 2.5mmol mid morning and mid afternoon. On levemir twice per day, I used 1u to 7g carb novorapid as the bolus and used trial and error to see if my bg levels were 2.5mmol higher mid morning. So a bg level of about 5 to 6mmol pre meal would be 8.5mmol mid way. If I was lower than 8.5mmol, I would eat a small snack so that the bolus wouldn't cause to go hypo before the next meal. To work out a correction dose if I was high I looked at the 100 Rule which is on Google and adjusted my bolus using that.

 

[Shiba Park]

Having people tell me I need to match carbs to insulin...***, you don't say. I hope those who are newly diagnosed and come here for help are cut a little more slack and sympathy...

I think you completely missed the point being made in that post, it's not an easy task which you really should know.
If only there was a formula that accounted for time of day, type of food being eaten, recent and imminent exercise, timing etc. Getting a workable ICR is just the start...

So, in what way is advising someone new to MDI to match insulin to carbs bad or unsympathetic advice?

 

[pshawfocus]

So, in what way is advising someone new to MDI to match insulin to carbs bad or unsympathetic advice?

Don't all T1's do this irrespective of the regime they are on???

 

[O_DP_T1]

Thanks for all the advice here guys. I have another quick question here:

So this morning I took my bolus at 9:30 had porridge etc and then went to gym at 10:30 for an hour and a half all good
THEN back at 12:30 ready to eat and levels around 4, question is is it ok to take a second bolus jab within 3 hours with food? I don't want to wait more then a hour and miss that 'golden hour' after training to take carbs and protein.

With the old 30/70 after training I just ate and based the carbs around the BG level after training didn't think twice about it, boom bang shabam all good!!!

 

[himtoo]

Don't all T1's do this irrespective of the regime they are on???

sadly not..........I know a few T1D's in real life that have been diagnosed for at least 7 or 8 years and have not been on carb counting courses, and don't really know about I:C ratios , pre-bolusing , etc.

 

[iHs]

Don't all T1's do this irrespective of the regime they are on???

Match insulin to carb is another way of saying get the correct insulin to carb ratio sorted for different times of the day which is easier to achieve through bg testing and using bg targets to calculate the dose needed. You don't need to do a DAFNE course for that but getting advice regarding exercise, drinking alcohol, eating pizzas etc is all discussed on these courses.