Time to split or change basal?

[TashT1]

I’ve been struggling for sometime with higher than normal levels. I keep quite a strict target range of 5.3-8mmol but I’m finding I’m rarely within this boundary at the moment & I’m injecting much more basal & bolus. Looking back at my Libra data & it’s been 12 days since I’ve had 24hrs I’m happy with & 21 days since things seem to have begun to change significantly.

Background info - using a Libra 2 consistently, basal is Lantus, bolus is Novarapid, carb ratios used to be 1:5 morning, 1:7 lunch, 1:8 tea. Eating low carb (ish) frequently less than 80g with some cheat days. 11 months post diagnosis & in honeymoon period.

I usually find I need to up my basal by 2u for my period but this month when I returned to a lower dose everything went out of control so I increased it back to 24u, still not working & I wondered if the pen was off so I changed to the new prescription, no joy. So in the last week I’ve increased it by 2 every 3 days, it’s a little better but not much.

I’m seeing a rise at 3am (basal usually taken at 6.30am), then a further rise on waking/ getting out of bed which I assume is DP. So now when I’m taking my morning basal a finger prick confirms I’m 10+. So I take a correction dose of 2u:1 mmol and don’t have any carbs for breakfast. This only drops me to 7s, even after the morning walk to school.

I’m used to being in 5/6s for lunch but since I’m now in 7s it seems like even a low carb lunch 15g with bolus will go up to 9s & eventually back to 7s after another walk to school. Tea time comes & I have most of my carb intake but the 1:8 ratio isn’t working anymore & I can go back up over 10. I’ve dropped it to 1:5 and it’s still not great.

So I’m thinking maybe I’ve lost more insulin production & this is one of those unpredictable times I was warned about or Lantus has stopped working as it should. I’m not sure splitting the dose will help much but maybe worth considering.

I’m not seeing my consultant until September with a new c-peptide but will call the nurse on Tuesday. Just wondering what springs to mind as possible causes/ solutions from everyone’s experiences?

 

[Jaylee]

I’ve been struggling for sometime with higher than normal levels. I keep quite a strict target range of 5.3-8mmol but I’m finding I’m rarely within this boundary at the moment & I’m injecting much more basal & bolus. Looking back at my Libra data & it’s been 12 days since I’ve had 24hrs I’m happy with & 21 days since things seem to have begun to change significantly.

Background info - using a Libra 2 consistently, basal is Lantus, bolus is Novarapid, carb ratios used to be 1:5 morning, 1:7 lunch, 1:8 tea. Eating low carb (ish) frequently less than 80g with some cheat days. 11 months post diagnosis & in honeymoon period.

I usually find I need to up my basal by 2u for my period but this month when I returned to a lower dose everything went out of control so I increased it back to 24u, still not working & I wondered if the pen was off so I changed to the new prescription, no joy. So in the last week I’ve increased it by 2 every 3 days, it’s a little better but not much.

I’m seeing a rise at 3am (basal usually taken at 6.30am), then a further rise on waking/ getting out of bed which I assume is DP. So now when I’m taking my morning basal a finger prick confirms I’m 10+. So I take a correction dose of 2u:1 mmol and don’t have any carbs for breakfast. This only drops me to 7s, even after the morning walk to school.

I’m used to being in 5/6s for lunch but since I’m now in 7s it seems like even a low carb lunch 15g with bolus will go up to 9s & eventually back to 7s after another walk to school. Tea time comes & I have most of my carb intake but the 1:8 ratio isn’t working anymore & I can go back up over 10. I’ve dropped it to 1:5 and it’s still not great.

So I’m thinking maybe I’ve lost more insulin production & this is one of those unpredictable times I was warned about or Lantus has stopped working as it should. I’m not sure splitting the dose will help much but maybe worth considering.

I’m not seeing my consultant until September with a new c-peptide but will call the nurse on Tuesday. Just wondering what springs to mind as possible causes/ solutions from everyone’s experiences?

Hi,

If this is a recent "thing?" Maybe worth monitoring the trend a little,longer to make sure. Certainly liaise with your health team about it.
I use Lantus myself. From your post you are seing a rise at 3am but inject at 6.30am?
Now I'm thinking it could be liver dump, or the Lantus could be tailing off in the early hours at the end of its working profile..?
I inject before bed. It is said Lantus only lasts 20 hours. However my evening activity levels along with the last dose wearing off & increased sensitivity. Can hold me around 4.8/5.2?

It's wothwhile basal testing first before considering any timing change or split on the shot prior to even looking at what your fast acting insulin is doing on the meals?

 

[TashT1]

Hi,

From your post you are seing a rise at 3am but inject at 6.30am?

Yeh it’s something I’ve noticed before but wasn’t too concerned because I was rising from about 6 to 8, I’d take my morning basal and I’d drop back down again. The rise was very easy to spot because overnight levels would be a flat line until 3am, now it’s all over the place.

I’ve thought about basal testing, did some reading on it this week but always come unstuck at the “eat a predictable meal” part. Right now no meal is predictable. I was also wondering if the time of day mattered. Most basal testing seems to be in the evening but also most instructions seem to assume you take basal at night. So if I usually take it in the morning is a morning basal test the place to start?

 

[searley]

For me lantus/levemir only lasted about 18 to 20 hours

So that rise could be liver dump could be lantus running out

I was always told by my nurse to take mine at night. As it would be running out by my evening meal and I could deal with that at the meal time with rapid

But I hear lots of people being told to take in the morning or split

In my first 3 years I went from 15 units to 28 units a day.. and found for my that even though I occasionally upped and downed a little I sort of fell back to the 28 units a day

Talk to the nurse see what they say

Possible reason bad injection site.. try alternatives see if that helps.. repeated use of the same sites makes them less effective.

Next reason as you say would be you need more insulin.. basal testing 7 to 11 hours after lantus will help with checking this.. 7-10 to get past the peak of the lantus.

Another reason.. slight illness ? Maybe you’ve not noticed a slight cold or something? Even hay fever can affect things?

 

[In Response]

@TashT1 have you had your Covid jab recently?
Quite a few people are finding it has upset their insulin resistance/sensitivity.
Three weeks after my second jab and my basal dose is still different to usual

Like @searley I took my Lantus in the evening so I was awake to manage it running out. You could try moving the timing rather than splitting.

 

[Jaylee]

Yeh it’s something I’ve noticed before but wasn’t too concerned because I was rising from about 6 to 8, I’d take my morning basal and I’d drop back down again. The rise was very easy to spot because overnight levels would be a flat line until 3am, now it’s all over the place.

I’ve thought about basal testing, did some reading on it this week but always come unstuck at the “eat a predictable meal” part. Right now no meal is predictable. I was also wondering if the time of day mattered. Most basal testing seems to be in the evening but also most instructions seem to assume you take basal at night. So if I usually take it in the morning is a morning basal test the place to start?

Well? I dose at night & don't do breakfast. So naturally it's easy for me to come from that angle. (Pretty much every day.)
Using a Libre is also a game changer in this respect. So, your already on a roll.

If the timing of your basal suits your lifestyle? It's worth getting some performance data & tweak it from there.
What could be happening, is a "dead spot" with your basal somewhere it's tailed off & the new dose kicks in?
But that is a discussion between you & your HCPs.

 

[EllieM]

Like @searley and @Jaylee I dose my lantus at night, mainly because I have issues with dawn phenomena so don't want it running out then. (I don't care if it runs out in the evening because I've got my evening meal bolus to help out). So changing your lantus timing (split or do it at night) could be something to discuss with your team.

Also, if your honeymoon is ending then it's likely that both your insulin needs will go up and you'll have to live with a higher spike after meals.... (What's your carb intake like? Low carbing might reduce your spikes but you don't have to live like that. Non diabetics can get brief spikes after meals.) Unfortunately injected insulin just doesn't work as well as internally produced insulin. Of course, if you're prepared to put the work in, you might get better results with a pump..

Good luck.

 

[TashT1]

Thanks for your thoughts, I’ve got a call in to the nurse but it might take a couple of days to get back to me.

I did have the 2nd covid jab on 5th May, didn’t really notice an impact but maybe it’s knocked things just a bit out of whack.

I’ll ask the nurse about maybe moving my basal to the evening, I was given a choice of morning or evening on diagnosis & at the time I just thought morning was easiest, plus I don’t like injecting after I’ve had a drink but I guess that evening dose could be 6 or 7pm.

@EllieM I cut a lot of carbs straight away, I was about 50g a day but I’ve relaxed a bit to 80g & have the odd take away. Yesterday I had 55g, over injected by a couple of units & I still went up to 9 post meals, didn’t get lower than 7 & had a pretty active day.

Ideally I need to stay below 9 otherwise I feel really tired & out of it. I’ve lost too many hours of work this past fortnight because I’m falling asleep after lunch, fortunately I WFH bad mostly control my own schedule. Plus I lost an entire day on Saturday when I was over 10 for 24hrs, just couldn’t stay awake. Anyway I’m just a bit exhausted with it all, it’s been a long 11 months with a lot more in front of me.

 

[EGeraldo]

Diagnosed 5 moths ago and struggling with similar issues. During the last couple weeks my insulin (Fiasp & Tresiba) needs increased a lot and have spikes in the 11s - 13s and stabilizes in the 8s (starting in the 4s or 5s ); had pretty nice ratios e.g., 1:18 at lunch that is now around 1:7/1:6. Every meal has a different outcome rendering me unable to fix my ratios, it's quite frustrating xD. As of lately i also have sudden BS linear increases after lunch (liver dump?). The basal remains untouched (16U).

It all started after my first jab (Pfizer, no side effects except for a sore arm), but it could be a coincidence, had a lot going on at the time.

 

[TashT1]

I had the Pfizer jab too, if I went far back enough in my libra data it might show a similar pattern after 1st & 2nd jab.

My nurse hasn’t called me back yet, so here I am at 4am after the high alarm woke me up. Went to bed on 7, alarm at 12 & a finger prick confirms 11 so correction administered.

Hopefully you can contact your team & get a quicker response to help adjust your basal.

 

[EGeraldo]

Sorry to hear about it, that's quite annoying.

Before Tresiba, i was on Lantus dosed at night, and just like others mentioned above, towards the end of the evening it seemed to run out. If left alone, my BS would reach 10s to 12s.

I haven't touched the basal because i didn't need to. Strangely enough, the reaction to the basal didn't change; stable with a slight tendency to decrease (except when sleeping, usually have to wake up at 4/5am to eat a cookie but during the day is perfect xD)

 

[TashT1]

Still no call from my DN, so chased it up yesterday. But I did manage to get a good stable day in & decided to basal test in the evening.

Woke on 9.4 but a 4u:1 correction brought me back down in range. Used a 1:3g ratio all day & stayed in the 6/7s.

Started a basal test at 10pm on 6.3 and saw a slow rise around 3am from about 5.8 - 8.1 by 5.30am. Usually gets a bit higher by the time I inject at 6.30 but 8.8 wasn’t too disappointing.

My question is, in the absence of a call back from the DN, how many times would you repeat the basal test to confirm that a split or a swap to evening is the right move?

If she’s not going to get back to me for a few more days I’m wondering if the best thing to do is basal test in the evening & present a clear data set.