Advice on rapid-acting insulin.

Amy2993 said:

... Could I not inject with my evening meal at all? I can’t use any lower than 1, but I don’t want to eat every night to account for my insulin.

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When going low between meals, basal usually needs to be reduced. Reducing mealtime insulin will cause a bigger spike after the meal. Basal testing by skipping dinner and testing until breakfast would deciding on changing the evening Levemir. Sounds like you are making most of your insulin. It won't last forever, and glucose toxicity shortens this period.

MarkMunday said:

When going low between meals, basal usually needs to be reduced. Reducing mealtime insulin will cause a bigger spike after the meal. Basal testing by skipping dinner and testing until breakfast would deciding on changing the evening Levemir. Sounds like you are making most of your insulin. It won't last forever, and glucose toxicity shortens this period.

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Glucose toxicity?

rarity88 said:

Glucose toxicity?

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This not well known, but high glucose kills beta cells. This is why T2s often end up having to inject insulin. High blood glucose also shortens the honeymoon period for T1s. People with LADA can extend endogenous insulin production indefinitely by using small amounts of insulin where it is needed and keeping blood glucose close to normal. At which level glucose toxicity starts is not clear, but it is thought to be at 140mg/dl (7.8 mmol/l).

Here is an excerpt from a paper on the subject.

... Glucose toxicity means a decrease in insulin secretion and an increase in insulin resistance due to chronic hyperglycemia. It is now generally accepted that glucose toxicity is involved in the worsening of diabetes by affecting the secretion of β-cells. Several mechanisms have been proposed to explain the adverse effects of hyperglycemia. It was found that persistent hyperglycemia caused the functional decline of neutrophils. Infection is thus the main problem resulting from glucose toxicity in the acute phase. ...
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2738809/#:~:text=Glucose toxicity means a decrease,the secretion of β-cells.

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Hi Amy,

Something to keep in mind is that a normal glucose level is actually 4.8. If you're newly diagnosed, your pancreas is still producing insulin. As Mark said, high blood sugar levels are toxic to insulin producing cells and will speed up their destruction, leading to the need to inject more insulin. This hasn't been studied a huge amount, but Dr Richard Bernstein believes that the body's autoimmune response rarely destroys all of the body's insulin producing ability; instead, it's the resulting high blood sugars that get rid of the rest.

He advocates a low carbohydrate diet to manage type 1 (and 2) diabetes. He's been managing his own diabetes in this way since his 30s (and is now in his 80s). Troy Stapleton, a doctor in Australia, also manages his type 1 diabetes with a low carbohydrate diet. I think he was diagnosed in adulthood around 2012. He quickly switched to the low carbohydrate way of eating, and in a lot of his videos he's mentioned that he only needed to take long-acting insulin to maintain normal blood sugar levels. I'm not sure if this has changed at this point, but at the very least he has managed to maintain his honeymoon phase for a number of years.

With this in mind, it's obviously very important to avoid hypos; if you're interested in the possibility of a low carbohydrate diet, some research will be required to do this safely. This video is a good starting point if you'd like to know more:
All the best, and I hope things get more straightforward for you soon.

You could ask your DSN for a half unit pen. That might help with dinner. Lots of people have different ratios for different meals.

rarity88 said:

Glucose toxicity?

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I do not think you have to worry about "Glucose Toxicity" with your control and levels. It mainly occurs in those that have sustained high BG levels and are yet to be diagnosed or those that are diagnosed and fail to properly maintain their BG levels causing sustained Hypers.

Amy2993 said:

Was wondering if anyone can offer advice. So I take 7units in morning and 8units in evening of levemir. I take 1unit of novorapid for pretty much anything I eat. At lunch this seems to raise my levels from 4.5-5 to around 6-6.5. This is with a small lunch.

For my evening meal I take 1 unit and no matter what I eat my levels are never over 5.5 before bed. I can have snacks, crisps, chocolate, toast, fruit and it doesn’t raise my levels in the evening. Could I not inject with my evening meal at all? I can’t use any lower than 1, but I don’t want to eat every night to account for my insulin.

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Hi,
Sounds like you're doing great with the numbers. Are you snacking in the evening to avoid night time lows?

Talk to your HCP. Personally, I would be looking at doing a basal test. Especially with the overnight stuff..

Amy2993 said:

thank you will email my nurse tomorrow about doing a basal test. Yes snack quite a lot at night, il inject 1 unit at 6 o'clock for dinner. Then eat snacks up until about 1am. I have a libre now and can see that I go very low at night and it comes back up without waking is that normal?

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Hi,

It is a concern.
You are either dropping BG wise, or.. what can happen is a "compression low" a false low reading from literally sleeping on the sensor?
I have a bluetooth CGM style set up with my Libre. Which means i can calibrate the data to my BG meter & alarms can be set if out of ideal range?
There is a way to find out.
A set up that alarms when you go low, so you can wake & check with a meter. (But it is advised to check anything errant with a Libre against the meter anyway.)
I also site my sensor inside the arm, so i tend not to lie on it..

If this is a regular occurance you recently spotted with the libre? & have no BT set up. you could set a normal alarm at the times these anomalies are happening. Scan, then check against the meter..

Amy2993 said:

... I have a libre now and can see that I go very low at night and it comes back up without waking is that normal?

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Yes, it is normal. The body tries to prevent blood glucose dropping too low. During the night liver glycogen is converted to glucose and released into the bloodstream to satisfy glucose requirements while we sleep. This increases blood glucose, but it can be overwhelmed by too much insulin. Waking up with high blood glucose because of going low at night is called the 'Somogyi Effect'. Insulin requirements also increase in the early hours of the morning (part of the circadian rhythm), increasing blood glucose.

MarkMunday said:

Yes, it is normal. The body tries to prevent blood glucose dropping too low. During the night liver glycogen is converted to glucose and released into the bloodstream to satisfy glucose requirements while we sleep. This increases blood glucose, but it can be overwhelmed by too much insulin. Waking up with high blood glucose because of going low at night is called the 'Somogyi Effect'. Insulin requirements also increase in the early hours of the morning (part of the circadian rhythm), increasing blood glucose.

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Though to express caution.
If there happens to be too much insulin happening. One shouldn't rely on the liver alone to sort it out.

It is worth noting that the average liver contains about 130 grams of glycogen. A similar amount is stored in muscle but can't get into the bloodstream, so no use during a hypo. Eating very low carb is thought to reduce liver glycogen by up to 50%, but because of reduced insulin dosage this is generally not a problem. Exercise depletes muscle glycogen, leaving liver glycogen intact. So in the absence of other complicating factors, there will be automatic recovery from moderate hypos. But there are no guarantees. The best way to reduce risk is to minimise insulin action, especially at night.

MarkMunday said:

It is worth noting that the average liver contains about 130 grams of glycogen. A similar amount is stored in muscle but can't get into the bloodstream, so no use during a hypo. Eating very low carb is thought to reduce liver glycogen by up to 50%, but because of reduced insulin dosage this is generally not a problem. Exercise depletes muscle glycogen, leaving liver glycogen intact. So in the absence of other complicating factors, there will be automatic recovery from moderate hypos. But there are no guarantees. The best way to reduce risk is to minimise insulin action, especially at night.

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Appreciated. you LC i LC. let's not muddy the water for for the OP in early days, Eh?

Amy2993 said:

Thank you very much! Love how quick you guys reply, very interesting learning about it all.

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Hey, you will learn at your own pace. On your own terms..

Just keep asking as you go along.

The Somogyi phenomenon is an unproven theory with little scientific evidence to support it.

I'm LADA and was in a trial where they measured my insulin (c-peptide) output over a few hours after a measured amount of glucose.

My pancreas is still producing some insulin but it has a VERY delayed response. For my body that means by the time I have my evening meal my pancreas has decided to kick out some natural insulin.

So for chilli, 60g of rice, some strawberries and dark chocolate this evening I've only needed 2 units of lantus. If i had that meal at midday I'd have to take about 6 units.

Now I know I have a 1/2 unit pen so if dinner is low carb I can take a really low dose.

I did a basel test and was fairly flat all day and night. Pancreas only seems to want to help out if I have a carby lunch!!