Tresiba, Dawn Phenomenon, Split Dosing

Applenerd81

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Hi All,

It's been a long time since I've posted/ been active on the forum! Am in need of some advise regarding Tresiba & dawn phenomenon.

I have always understood Tresiba to be an ultra long acting insulin - and to date I have found its action to be as such, especially at larger doses. However, having revisited Dr Bernsteins Diabetes Solution, I have concerns with regards to bolusing large volumes of insulin at one site.

I am trying to figure out a suitable split dosing pattern for Tresiba, it's not been the most successful yet, especially with dawn phenomenon - my BGs appear to be be rising up from 3am from 4/5mmolL up to 12+ mmol by 6am. This rise wasn't so pronounced with my previous dosing regime and I could get away with 1-4 iu of Humalog upon rising to cover my rise up til I get to work at the office.

I've searched the forums but there is very little on splitting basals (specifically Tresiba) - does anyone else on here use this method? Any advise greatly appreciated. I am using the Libre.

Previous regime: Single shot of 20 units at 6 pm, 1-4iu Humalog upon rising.
Current regime: 2x7iu @ 6pm, 7iu upon waking + correction dose!

Teleseminar on basal splitting:
 

Fairygodmother

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Hi @Applenerd, I don’t know if I can be much help; I haven’t taken Tresiba but I understand it lasts up to 36 hours so you probably wouldn’t gain anything by splitting. In fact splitting may complicate its action, but maybe someone who’s had experience with Tresiba might be able to give more advice.
I also understand, from reading others’ experiences on this forum, that it takes about three days for any alterations in Tresiba doses to bed in. How long is it since you began the new regime?
 
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Applenerd81

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Hi @Applenerd, I don’t know if I can be much help; I haven’t taken Tresiba but I understand it lasts up to 36 hours so you probably wouldn’t gain anything by splitting. In fact splitting may complicate its action, but maybe someone who’s had experience with Tresiba might be able to give more advice.
I also understand, from reading others’ experiences on this forum, that it takes about three days for any alterations in Tresiba doses to bed in. How long is it since you began the new regime?

Have only just started splitting doses this weekend (yesterday), so I am perhaps a little keen! Tresiba is stated to last up to 36 hrs however, that number is based on dosing of 0.4-0.6iu per KG bodyweight - which for me equates to around 32iu - 48iu per day, my basal needs are around 18-24 per day - so I'd doubt it would ever last thta long, plus im not keen on injecting so much insulin in one site.
 

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donnellysdogs

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I was after pump puton tresiba. Dose I think about 16 units.. dreadful for me with DP and waking phenomem.

Now i do 10 or 11 units of insulatard at 3.30am, 4 or 5 units at 7 or 8am plus 1 unit of bolus and just 1 unit oof tresiba every other day atthe moment. It was every day but was too lowwith 1 unit daily, 1/2 unit ddidnt work at all. So starting today I am trying 1 unit every other day as it does for me last at least 42 hours.

Still playing around witth tresiba...
 
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kitedoc

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I moved to a pump before Tresiba and Fiasp were a twinkle in the eye of researchers.
But Levemir served me well. I could vary the morning and night doses and timings a little so that the pm dose could sorta have a very mild peak around the 4 am mark.
It was not perfect but better than anything else.
I admit that at the time I did not consider Isophane say at 11 pm allowing its peak to co-incide with the 4 am Dawn. Levemir say 10 am??
The pump was better in the end but the above could be food for thought !
 

donnellysdogs

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By splitting tresiba, it makes no real difference to it being aninsulin that cannot manage DP or waking... so to me, there was nothing else to try but to find an insulin that could be given when I needed the peaks and be out of my body when I needed next to nothing. By switching to insulatard at 3.30 (stupu hour and I do not like doing this, but needs must).... the insulin would be working as and when I needed it but it was too much if I took it all at that time. My consuktant and educator did not want me to split timing of insulatard but they had tried for 2 years and regimes that were standard and awful for me so I ignored them. I split it to 7 or 8am as a 1/3rd because I needed more earlier... by having 2nd dose in morning it too is working when I need it but its actions are less later when I need less.

I need some small background dose overnight but not a lot. Taking in to account that the insulatard was pretty much my always dose... around 17 units.. then I thought, try 2 units but that acted too severely so I have been cutting it down and down by 1/2 units gradually. Then I was down to 1/2 unit. Well for me 1/2 unit by itself does nothing... so I went 3 days clear of tresiba to see if I deginitely need tresiba, and yes, I do. If I dont I wake up high and levels that much higher during day too. So now I'm trying tresiba 1 unit every other day as if it is a flat insukin and stays in my body for 42 hours it should every other day be the dose that is better. Or at least thats my way of thinking...

Tresiba is a flat line insulin. I foubd DP and waking horrendoys with it, increasing dose caused lows other times of day. And still didnt manage the DP.

I dont know anybody else doing this regime but my consultant has now told me that only I can tweak as he has no other alternatives of any other regimes and as I am happy to do so and determined... then he okay with that. I'm still in the top 5% of hba1cs from patients at the hospital despite finding my own way with everything.

I too had tried the levemirs, lantus etc and their actions and peaks didnt suit my body over night...
 
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Applenerd81

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IMG_1528109988.073701.jpg


Been much better today. Tresiba split dosing: 16iu(7iu+7iu+2iu) at 6pm and 5iu at 7am.

Also, didn’t eat after 7pm, bed for 11pm.

Didn’t need my usual Humalog correction bolus this morning.

Still some tweaks to be done but looking much better than days 1 and 2.
 
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Applenerd81

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By splitting tresiba, it makes no real difference to it being aninsulin that cannot manage DP or waking... so to me, there was nothing else to try but to find an insulin that could be given when I needed the peaks and be out of my body when I needed next to nothing. By switching to insulatard at 3.30 (stupu hour and I do not like doing this, but needs must).... the insulin would be working as and when I needed it but it was too much if I took it all at that time. My consuktant and educator did not want me to split timing of insulatard but they had tried for 2 years and regimes that were standard and awful for me so I ignored them. I split it to 7 or 8am as a 1/3rd because I needed more earlier... by having 2nd dose in morning it too is working when I need it but its actions are less later when I need less.

I need some small background dose overnight but not a lot. Taking in to account that the insulatard was pretty much my always dose... around 17 units.. then I thought, try 2 units but that acted too severely so I have been cutting it down and down by 1/2 units gradually. Then I was down to 1/2 unit. Well for me 1/2 unit by itself does nothing... so I went 3 days clear of tresiba to see if I deginitely need tresiba, and yes, I do. If I dont I wake up high and levels that much higher during day too. So now I'm trying tresiba 1 unit every other day as if it is a flat insukin and stays in my body for 42 hours it should every other day be the dose that is better. Or at least thats my way of thinking...

Tresiba is a flat line insulin. I foubd DP and waking horrendoys with it, increasing dose caused lows other times of day. And still didnt manage the DP.

I dont know anybody else doing this regime but my consultant has now told me that only I can tweak as he has no other alternatives of any other regimes and as I am happy to do so and determined... then he okay with that. I'm still in the top 5% of hba1cs from patients at the hospital despite finding my own way with everything.

I too had tried the levemirs, lantus etc and their actions and peaks didnt suit my body over night...

I found large doses of Tresiba don’t help - they just make the insulin last longer and result in hypos at other times of the day (when basal needs are lower).
 

donnellysdogs

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I found large doses of Tresiba don’t help - they just make the insulin last longer and result in hypos at other times of the day (when basal needs are lower).

Ditto..
 
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LooperCat

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I found large doses of Tresiba don’t help - they just make the insulin last longer and result in hypos at other times of the day (when basal needs are lower).

This is really interesting. I take a single dose of 17u Tresiba at 8am, which keeps me flat level during the night. However, I do get a dawn rise between 4-7am and then a slump at around 6-7pm. At the moment I’m dealing with these by waking up at stupid o’clock to head off the rise with a unit or two of Novorapid, and a good dollop of protein at around 2pm. However, I’d rather not have to do either of these things, the first because I’m not a morning person, and the second because it’s not always convenient.

So if I were to split my 17u dose to try and get around this, how would I split it? 50:50? Or slightly more at one and of the day to the other? I’d be grateful for any input
 
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kitedoc

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This is really interesting. I take a single dose of 17u Tresiba at 8am, which keeps me flat level during the night. However, I do get a dawn rise between 4-7am and then a slump at around 6-7pm. At the moment I’m dealing with these by waking up at stupid o’clock to head off the rise with a unit or two of Novorapid, and a good dollop of protein at around 2pm. However, I’d rather not have to do either of these things, the first because I’m not a morning person, and the second because it’s not always convenient.

So if I were to split my 17u dose to try and get around this, how would I split it? 50:50? Or slightly more at one and of the day to the other? I’d be grateful for any input
I cannot speak for Tresiba dosing etc but with Levemir I used to split it 2/3 total dose for am and 1/3 total dose pm and adjust further from there. Because it was of 12 to 14 hour duration I would take the am dose about 8 am and pm dose about 10 pm. The slight peak of the 10 pm Levemir seemed to help deal with the Dawn phenomenon without over duly causing a low BSL near breakfast. Of course that may vary between individuals.
The problem I foresee with Tresiba is the overlaps. In theory, if the first two doses were taken say 12 hours apart, the level of Tresiba's action might almost double at the 12 hour mark and at regular further dosing this effect would keep stacking up.
The other thing is that Tresiba action is flat and pretty reliable in its absorption but a body's basal insulin need varies over the day and night, as the Dawn phenomenon exemplifies. Yes, an insulin pump with programmed basal profile can deal with this.
I assume you take the Novorapid at 2 am along with the protein meal. Have you tried the Novorapid taken a bit earlier, say start with 11 pm one time, 12 mn another and see if that works any better and whether a protein meal is still needed? Would a slight reduction in Trsiba by say 1 unit help as well. Just suggestions for you and your doctor !
Best Wishes and fingers crossed !!
 

LooperCat

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I cannot speak for Tresiba dosing etc but with Levemir I used to split it 2/3 total dose for am and 1/3 total dose pm and adjust further from there. Because it was of 12 to 14 hour duration I would take the am dose about 8 am and pm dose about 10 pm. The slight peak of the 10 pm Levemir seemed to help deal with the Dawn phenomenon without over duly causing a low BSL near breakfast. Of course that may vary between individuals.
The problem I foresee with Tresiba is the overlaps. In theory, if the first two doses were taken say 12 hours apart, the level of Tresiba's action might almost double at the 12 hour mark and at regular further dosing this effect would keep stacking up.
The other thing is that Tresiba action is flat and pretty reliable in its absorption but a body's basal insulin need varies over the day and night, as the Dawn phenomenon exemplifies. Yes, an insulin pump with programmed basal profile can deal with this.
I assume you take the Novorapid at 2 am along with the protein meal. Have you tried the Novorapid taken a bit earlier, say start with 11 pm one time, 12 mn another and see if that works any better and whether a protein meal is still needed? Would a slight reduction in Trsiba by say 1 unit help as well. Just suggestions for you and your doctor !
Best Wishes and fingers crossed !!
Thank you :)

I think we’ve got the am and pm a little mixed up - I have the protein meal around 1400 (2pm), and don’t inject for it, so by the time the protein is kicking in, it stops the later afternoon drop. But I don’t always want to stop what I’m doing to eat then, it’s right in the middle of my afternoon work.

The Novorapid dose I’m talking about to head off the dawn phenomenon is at some point between 4 and 7am, I wake up with a bit of a jolt (a dump of cortisol, I think), scan my Libre and see it’s just about to soar after a flat level line. No point setting an alarm for it, as the time seems to vary, but 9/10 times it wakes me in time to deal with it. I’ve worked out a sort of sliding scale for a dose that depends on what the BG is when I wake, and have printed it off and pinned it to my bedside table, so I can just read it and inject accordingly in my groggy half awake state!

I am quite concerned about the overlaps of splitting Tresiba, like you say. I’ve just started a steroid inhaler for newly diagnosed asthma, so I’m watching closely to see what effect that has at the moment, to see if any changes are needed to it. I’ll probably just put up with the hepatic alarm clock and the unwanted meal for now until that settles in. I have tried dropping the Tresiba by a unit as you suggest, but ended up horribly high through the night. Sigh.
 

kitedoc

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Thank you :)

I think we’ve got the am and pm a little mixed up - I have the protein meal around 1400 (2pm), and don’t inject for it, so by the time the protein is kicking in, it stops the later afternoon drop. But I don’t always want to stop what I’m doing to eat then, it’s right in the middle of my afternoon work.

The Novorapid dose I’m talking about to head off the dawn phenomenon is at some point between 4 and 7am, I wake up with a bit of a jolt (a dump of cortisol, I think), scan my Libre and see it’s just about to soar after a flat level line. No point setting an alarm for it, as the time seems to vary, but 9/10 times it wakes me in time to deal with it. I’ve worked out a sort of sliding scale for a dose that depends on what the BG is when I wake, and have printed it off and pinned it to my bedside table, so I can just read it and inject accordingly in my groggy half awake state!

I am quite concerned about the overlaps of splitting Tresiba, like you say. I’ve just started a steroid inhaler for newly diagnosed asthma, so I’m watching closely to see what effect that has at the moment, to see if any changes are needed to it. I’ll probably just put up with the hepatic alarm clock and the unwanted meal for now until that settles in. I have tried dropping the Tresiba by a unit as you suggest, but ended up horribly high through the night. Sigh.
OK, Apologies for my confusion ! Your GP should have some info on how many steroid inhaler puffs reaches the equivalent of a low dose steroid tablet ( i.e. the amount that is likely to affect BSLS) (I did know once, but the inhaler strengths and steroid types have changed over time). There may be drug info by the company that does give the answer.
My understanding of the Dawn phenomenon is that it begins about 4 am and might last an hour or 2. How does taking Novorapid at between 4 am and 7 am deal with the 4 am beginning of the event? Yes, Novorapid has a variable peak timing, say 1 to 3 hours, which may things tricky ++! For me, it was nearer 3 hours so I needed to actually take it 1 hour before meals to be sure of best controlling BSLS. So a 4am shot might cover you from say 5am to 7 am or so. But may not if your peak Novorapid effect is 3 hours from injection. Your readings would help you sort this out, no doubt.
The idea of the 12 mn Novorapid dose depends on the peak timing being nearer the 3 hour mark. Another tweak I have tried with some success is to utilise the difference in absorption time between insulin injected in the abdomen vs in the leg, say outer thigh.
With no exercise of the leg to be injected say for an hour up to and following injection (exercise increases rate of absorption I believe,) an injection of a small amount of Novorapid say 12am to 12.30 am into outer thigh subcut tissue ( not muscle!! I have made that mistake to my cost !!) might, MIGHT, just peak say 3.30 pm in anticipation of the Dawn event. The Novorapid would be through by ? 6 am. If it works for your BSLS it saves you precious sleep ! Just a suggestion to think about with your doc. Fingers and toes crossed !!! To put it politely and carefully, the exercise restriction does however influence the timing of any 'nocturnal activity occasioning exercise'.
 

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Thank you for such an informative and well thought through suggestion, @kitedoc - it’s all so complicated, isn’t it? I think my body is very uncooperative, because it doesn’t seem to follow the rules on DP.

If I am a little higher than I want to be at bedtime (around 2200), I’ll take a small correction dose. This works at my usual evening ratio of 1u:3mmol - a correction would be around half a unit, never more than 1u. I’ll then sleep solidly until I get woken with a start at some point between 3am and 8am (I usually get up at 8, that’s when I take my Tresiba, the joys of being self employed and running my business from home means I can run my hours to suit!). It’s not like when you wake with a hypo, there’s no sweating, shakes or any of the usual symptoms of that. I just wake up. From fast asleep to wide awake in an instant. So I scan the Libre, and can see that (usually) the trace is even, steady and constant in my range - after basal testing I’m happy I’ve got the dose right for overnight stability - with a slight tip up that seems to have happened in the last half hour or so, usually an increase of 0.5-1mmol above my bedtime reading. The pic of my scanner shows a typical example. The arrow marks where I was awoken just after it had started to rise. So I took however many units I’ve calculated is right (quite a bit of trial, error and dextrose went into working it all out), and it bottomed out at around 4.5mmol, which I’m happy with before climbing slightly to the 5.4 on the screen. It’ll climb slowly through to about mid morning, so I sometimes have to take a unit correction to keep it under control.

So I don’t know how it deals with it, but it certainly seems to - I can bore you rigid with all the scanner shots I’ve collected showing that it really does ;) After I’ve done the jab, I just read my kindle until I fall back to sleep.

3575E13F-BA7D-4CF3-979F-5394BAC602A7.jpeg


On the rare occasion I manage to sleep through the hepatic alarm clock, I’ll end up with something like this one, and it’ll take me all morning to get it back into range, because I’m quite insulin resistant in the morning.

F3568D1D-F0EE-4543-810D-2C7AC029E3AB.jpeg


I do inject into muscle when I want faster corrections in the daytime, usually a deltoid, and then work it to make it speed up. But if/when I can nip that dawn rise in the bud before it really gets going, I have a nice, steady BG day. If I can’t, I tend to be a bit all over the place. So as inconvenient as all this is, if I were to try a midnight jab, I’d still have to set an alarm and wake up, because I’m asleep well before then! I suspect I’d hypo if I tried that, to be honest. Especially if it all kicked off later rather than earlier - for the same reason, I don’t think a pump would be the answer, as the timing is really variable and unpredictable. I even recorded and charted the time it happens agains sunrise, outside and room temperature, my basal waking temperature and bedtime BG, but there was no correlation.

Today has been lovely so far. Woke at 5 with a 6.1 that was just showing signs of rising (went to bed on a 6.5), so I took 1.5u Novorapid, and it’s been running in the mid fives and low sixes all day so far. I’ve just had a protein shake, so I’m hoping that’ll stop the slump later. I’ll let you know! But thank you for putting so much though into it all, I really appreciate it x
 

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Ooh those results look like my morning rise. ANNOYING!
 

kitedoc

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Thank you for such an informative and well thought through suggestion, @kitedoc - it’s all so complicated, isn’t it? I think my body is very uncooperative, because it doesn’t seem to follow the rules on DP.

If I am a little higher than I want to be at bedtime (around 2200), I’ll take a small correction dose. This works at my usual evening ratio of 1u:3mmol - a correction would be around half a unit, never more than 1u. I’ll then sleep solidly until I get woken with a start at some point between 3am and 8am (I usually get up at 8, that’s when I take my Tresiba, the joys of being self employed and running my business from home means I can run my hours to suit!). It’s not like when you wake with a hypo, there’s no sweating, shakes or any of the usual symptoms of that. I just wake up. From fast asleep to wide awake in an instant. So I scan the Libre, and can see that (usually) the trace is even, steady and constant in my range - after basal testing I’m happy I’ve got the dose right for overnight stability - with a slight tip up that seems to have happened in the last half hour or so, usually an increase of 0.5-1mmol above my bedtime reading. The pic of my scanner shows a typical example. The arrow marks where I was awoken just after it had started to rise. So I took however many units I’ve calculated is right (quite a bit of trial, error and dextrose went into working it all out), and it bottomed out at around 4.5mmol, which I’m happy with before climbing slightly to the 5.4 on the screen. It’ll climb slowly through to about mid morning, so I sometimes have to take a unit correction to keep it under control.

So I don’t know how it deals with it, but it certainly seems to - I can bore you rigid with all the scanner shots I’ve collected showing that it really does ;) After I’ve done the jab, I just read my kindle until I fall back to sleep.

View attachment 26888

On the rare occasion I manage to sleep through the hepatic alarm clock, I’ll end up with something like this one, and it’ll take me all morning to get it back into range, because I’m quite insulin resistant in the morning.

View attachment 26889

I do inject into muscle when I want faster corrections in the daytime, usually a deltoid, and then work it to make it speed up. But if/when I can nip that dawn rise in the bud before it really gets going, I have a nice, steady BG day. If I can’t, I tend to be a bit all over the place. So as inconvenient as all this is, if I were to try a midnight jab, I’d still have to set an alarm and wake up, because I’m asleep well before then! I suspect I’d hypo if I tried that, to be honest. Especially if it all kicked off later rather than earlier - for the same reason, I don’t think a pump would be the answer, as the timing is really variable and unpredictable. I even recorded and charted the time it happens agains sunrise, outside and room temperature, my basal waking temperature and bedtime BG, but there was no correlation.

Today has been lovely so far. Woke at 5 with a 6.1 that was just showing signs of rising (went to bed on a 6.5), so I took 1.5u Novorapid, and it’s been running in the mid fives and low sixes all day so far. I’ve just had a protein shake, so I’m hoping that’ll stop the slump later. I’ll let you know! But thank you for putting so much though into it all, I really appreciate it x
Wow Mel. That is awesome control ! I wonder whether on the not so good occasions your BSL just dips a tad too low, as in the second BSL graph example and the response includes a larger cortisol response at 4 am which might explain the increased BSL and perceived resistance compared to the 'better' days along with the lack of that small correction dose. ? But yes, the tyranny of the 4 am or so dose cannot be fun. The waking up may be the effect of the cortisol rise. But waking up itself is a stress of sorts too.
With an insulin pump it may be possible to 'sculpt' the basal rates to deal with the 4 am rise and stabilise that time of the day saving you having to wake up to give the correction dose. Only a trial would tell, I think. So much of these up and downs are like being in a boat. If nothing rocks the boat too much things stay even and steady but a little bit too much rocking sets up a momentum which takes a long time to dampen. But staying exactly in the middle of the boat has its limitations too. Making the most of it and continually learning the ropes to pull and tweak to settle the momentum is the trick. Repeat times 3 miliion and more !! Best Wishes. If the boat metaphor sounds ideal, the kite one is a potential nightmare. That is me after 51 years and on a pump !!
 
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LooperCat

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Thank you @kitedoc , I’m happy to take a compliment from someone who’s been dealing with it as long as you have :)

You could be right re dropping a little lower and resistance, but with a sample size of one and the impossibility of two days being identical, I’ll probably never know for sure. The 4am-ish wake up isn’t really any worse than other folk who have to get up in the night for the toilet, I suppose - at least I can do my jab without getting out of bed! I’m usually asleep again in half an hour. And if I can’t, it’s a nice quiet time to read without anyone bothering me!

I’m really reluctant to use a pump, if I’m being honest. I know there is a tubeless Omnipod, but the thought of having a machine attached to me and tubing 24/7, even if it’s doing an essential job, freaks me out rather. I can just about handle having a Libre, mostly because I can’t see or feel it. It’s totally irrational, I know. I suspect it’s partly due to my Asperger’s, I’m a bit weird when it comes to things being in contact with my body. I’ve just ordered a transmitter to go with my Libre, so I can set alarms to wake me if I’m going low - or beginning to rise quickly. So that’s another step towards going full cyborg, I suppose! However, I don’t think I’d qualify for a pump under our funding guidelines, as my diabetes is now regarded as being under excellent control, and they are prioritised for patients who aren’t managing. I don’t mind MDI, to be honest.
 
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kitedoc

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Fair enough. I avoided considering the pump for more than 30 years, stubborn independence was the diagnosis, but once in 'half incomplete cyborg' mode with the insulin pump on board I am much happier. I learnt that it was a matter of swapping certain inconveniences for others. I cannot afford the Dexcon continually to go with my pump and am on the sidelines watching re the Libre which has just arrived here in Oz with the app.
And use of the super-dupa closed loop pumps are still confined to USA ( I think) at least for general usage by TIDs who can afford them. A closed looper would be a complete cyborg !
A last thought for the darned Dawn effect is to think about a tiny dose of Levemir at 10 pm with no Novorapid at 4 amish and maybe, 1/2 unit less of Tresiba in the morning as opposed to your current regime.
In the end the KISS (Keep It Sweet and Simple) principle is usually the best strategy.
 
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Applenerd81

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This is really interesting. I take a single dose of 17u Tresiba at 8am, which keeps me flat level during the night. However, I do get a dawn rise between 4-7am and then a slump at around 6-7pm. At the moment I’m dealing with these by waking up at stupid o’clock to head off the rise with a unit or two of Novorapid, and a good dollop of protein at around 2pm. However, I’d rather not have to do either of these things, the first because I’m not a morning person, and the second because it’s not always convenient.

So if I were to split my 17u dose to try and get around this, how would I split it? 50:50? Or slightly more at one and of the day to the other? I’d be grateful for any input

If I was taking 17iu per day I would try 12iu (6iu + 6iu) at around 6/7pm. Then the remaining 5iu as soon as you wake up. Monitor closely as less insulin may be required (basal test). I find injecting this way makes it easier to adjust for different times of the day.

2/3:1/3 is the approximate ratio I use.