Basal tweaking issue (Levemir)

[Levy]

Hi guys, I'm on 2x Levemir and I've been tweaking my doses over the past few weeks with the help of my Libre but I've run into a bit of an issue.

Before tweaking, I used to take 16u at 9am and 16u around 8pm. The Libre was showing me a consistent drop of around 3/4mmol overnight, so I decided to drop my evening dose. After a couple of weeks, I am now down to 10u at 8pm. The great thing is that I'm now MUCH more stable overnight (although still dropping 1/2mmol).

HOWEVER, my mornings have started to become incredibly spikey which they never used to be. Before, I used to take 2u of Novorapid on waking to stop DP. This kept me perfectly stable until breakfast, for which I followed a 1:8 ratio, which then again kept me almost perfectly stable until lunch time.

Since dropping to 10u, when I take 2u on waking my body acts like I haven't taken any insulin whatsoever and my BG keeps going straight up to 11/12. By the time I have breakfast 2 hours later, it still hasn't started to come down and when I eat it spikes even more on top of that, usually up to around 15. By around 11am I'll have had enough of it all, take another correction, and it'll finally start coming back down and then acts 'normal' for the rest of the day.

I'm really confused. Does this mean I need a higher basal rate throughout the morning (between 7am and 12pm) than during the night and the 16u I took before was covering that even though it was making me drop during the night? If so, could I fix that by changing the timing of my injections?

Or could it mean I needed a higher correction factor/ratio all along, and the higher basal rate I took before was masking that issue by giving me too much?

 

[JoeT1]

Please take others opinion ahead of mine. Would it mean your nighttime basal is now actually wearing off a little before your morning basal kicks in? Therefore leaving a gap with no basal? It might mean rather than 12 hours between basal's, it might be you need it to be 11 hours? If you take at 8pm at night, maybe it's 7am it needs to be taken the next morning?

Obviously if 7am isn't possible, try and take the night time one later, therefore taking the morning at 8am.

 

[scotteric]

Hi guys, I'm on 2x Levemir and I've been tweaking my doses over the past few weeks with the help of my Libre but I've run into a bit of an issue.

Before tweaking, I used to take 16u at 9am and 16u around 8pm. The Libre was showing me a consistent drop of around 3/4mmol overnight, so I decided to drop my evening dose. After a couple of weeks, I am now down to 10u at 8pm. The great thing is that I'm now MUCH more stable overnight (although still dropping 1/2mmol).

HOWEVER, my mornings have started to become incredibly spikey which they never used to be. Before, I used to take 2u of Novorapid on waking to stop DP. This kept me perfectly stable until breakfast, for which I followed a 1:8 ratio, which then again kept me almost perfectly stable until lunch time.

Since dropping to 10u, when I take 2u on waking my body acts like I haven't taken any insulin whatsoever and my BG keeps going straight up to 11/12. By the time I have breakfast 2 hours later, it still hasn't started to come down and when I eat it spikes even more on top of that, usually up to around 15. By around 11am I'll have had enough of it all, take another correction, and it'll finally start coming back down and then acts 'normal' for the rest of the day.

I'm really confused. Does this mean I need a higher basal rate throughout the morning (between 7am and 12pm) than during the night and the 16u I took before was covering that even though it was making me drop during the night? If so, could I fix that by changing the timing of my injections?

Or could it mean I needed a higher correction factor/ratio all along, and the higher basal rate I took before was masking that issue by giving me too much?

The problem with Levemir is lowering the dose not only lowers the strength of it while it is active, but the duration. So likely it is not lasting as long and wearing off when you are waking causing your problem. I tried and tried and could never get it where I wanted it. Eventually I switched to Tresiba but couldn't find a dose that worked for me with it either. Went back on my pump and nothing else compares with it!

 

[Levy]

The problem with Levemir is lowering the dose not only lowers the strength of it while it is active, but the duration. So likely it is not lasting as long and wearing off when you are waking causing your problem. I tried and tried and could never get it where I wanted it. Eventually I switched to Tresiba but couldn't find a dose that worked for me with it either. Went back on my pump and nothing else compares with it!

Does it? I seriously had no idea, but it does seem to make sense with what I'm experiencing. I will firstly try and see if taking it later helps at all, maybe at 10 or 11pm.

If not, I did try Tresiba for a little while a couple of months ago and but kept having inexplicable spikes at bedtime (11pm to 1am) instead! This is why I went back to Levemir after a bit and the spikes disappeared. I'm sure it's a great basal for lots of people but if I've got such a difference between my two doses I'm not sure if one static dose a day would suit me.

I get what you mean about the pump. I had one years ago and had my basal tweaked to perfection on that. Unfortunately it didn't work out for me with exercise, so I'm really hoping I can somehow fix my Levemir issue rather than having to consider a pump again! Glad it works for you though and thanks for the reply!

 

[Levy]

Please take others opinion ahead of mine. Would it mean your nighttime basal is now actually wearing off a little before your morning basal kicks in? Therefore leaving a gap with no basal? It might mean rather than 12 hours between basal's, it might be you need it to be 11 hours? If you take at 8pm at night, maybe it's 7am it needs to be taken the next morning?

Obviously if 7am isn't possible, try and take the night time one later, therefore taking the morning at 8am.

That would make sense with what I'm experiencing. I'll play around with the timing a bit, thanks!

 

[karen8967]

hi levy are you still doing fingerpricks as well as the libre as sometimes the libre says im very low (2.6)and i do a fingerprick test im not that low and vice versa with the the high readings too

 

[Levy]

hi levy are you still doing fingerpricks as well as the libre as sometimes the libre says im very low (2.6)and i do a fingerprick test im not that low and vice versa with the the high readings too

Yes, definitely. The readings are 100% correct!

 

[scotteric]

Unfortunately it didn't work out for me with exercise, so I'm really hoping I can somehow fix my Levemir issue rather than having to consider a pump again!

I know what you mean, I've never been able to get temporary basal rates to prevent exercise lows and still have to eat before sports/exercise. I had evening spikes with Tresiba too, as well as severe lows in the morning. I found it to be too strong within the first 9-12 hours after injecting and then it would wean off as the day went on. I was never able to get 24-hour flat coverage like it is supposed to work.

 

[donnellysdogs]

I tried everything from lantus, levemir and tresiba.

Now on tresiba at 4pm - just 1 unit.

Insulatard at 3.30 if need a correction too but 99% of time not needed.

Another insulatard and bolus at 8am

8.30 another 2 unit bolus (trialling this time rather than 9am as I was fed up of waiting an hour before getting out of bed..

Thats without eating anything....

Not perfect but better than results on the other insulins...

 

[Levy]

I tried everything from lantus, levemir and tresiba.

Now on tresiba at 4pm - just 1 unit.

Insulatard at 3.30 if need a correction too but 99% of time not needed.

Another insulatard and bolus at 8am

8.30 another 2 unit bolus (trialling this time rather than 9am as I was fed up of waiting an hour before getting out of bed..

Thats without eating anything....

Not perfect but better than results on the other insulins...

How did you end up on that regime? Did your consultant suggest it or did you research it and request it from them?

 

[donnellysdogs]

How did you end up on that regime? Did your consultant suggest it or did you research it and request it from them?

I researched it.

I got my peaks snd troughs from
my pump hourly basal rates and adjusted them for it jyst being novorapid with a peak time of 2.5 hours as an average. Then looked at how insulin profiles matched my needs..

Had tried everything consultants said. Adding in insulatard to the larger dose of tresiba, just tresiba and a bolus etc.. tried so many I have lost count...

Insulatard peaks and troughs with its workings different to most of the others. The educator didnt like me splitting morning dose but their methods werent working.

Its been and still is tough. I would love to get up straight awayy after my morning bolus but I cant at the moment. I've not found a way around this at the moment.

My levels for my basal went up almost up to triple from 6am to 11am.. and then dropped. Another smaller rise at 4-6pm and another small rise from 10-12midnight...and then a big drop till 6am. The insulatard by splitting gives me a better peak acting when I need it but I still need the bolus. Then it drops when I need it to as the 3.30am dose is out of me. The insulatard at 4pm gives me just a small add on then for around tea time. And is small enough from midnight to 3.30am to stop me dropping. Consuktant had me on around 10-12 units tresiba at one time... can you imagine that working from midnight to 3am?? When 1 unit keeps me level when I need it?? Insulatard I tjink from what I remember kicks in quite quickly really but peaks at 4-8 hours laterbwhen I need it.. 8am one I'm still playing around with as I now have a big dog to exercise in afternoons.
The 10-midnight now doesnt seem to be that bad but dont know why...

I still have figures I'm working on but my life is also difficult from my stomach and colon, so that affects me as well.

 

[Levy]

Update: I took my Levemir at 11pm last night instead of 8pm and this morning looked a LOT better. Hopefully this will keep up! Thanks for the advice everyone!

 

[Levy]

And just like that, I see my consultant this afternoon and he's changing me to Tresiba now I can start the whole process over again

 

[HS13]

I've been having similar issues. About a month and half ago I was on 6 units of levemir at 8am and 6 units at 10:30pm - taken later to cover a pronounced dawn phenomenon, in which my blood sugars would regularly spike to around 15mmol/L after breakfast.
I then trialed the freestyle libre, did some fasting (no carb) breakfasts to test morning levemir dose, and ended up raising it to 11 units in the morning. Kept the night time one at 6 units. But, I started to have more hypos at night which I was sleeping through. Really scary to see this, that I'd be hypo for a number of hours over night without waking up. I don't know if this is because the daytime levemir was increased by so much so quickly - could that be part of it? Or if these nightime hypos have been happening for longer, but with the libre I could now see it!
In any case, I've reduced my night time levemir dose to 5 units, and tonight am doing a carb-free dinner to test this. I've also reduced my morning levemir dose to 9 units, as after starting my period (and becoming much more insulin sensitive) I was basically having non-stop hypos on the 11 unit dose. I've also started taking my nighttime levemir dose at 8pm, so that they are evenly split 12 hours apart - to try and stave off those daytime hypos with levemir doses overlapping. But now that my period has stopped, the morning spikes have come back! When I eat a carb-free or very carb-lite breakfast (just some yoghurt) and do certain types of exercise like cycling to work, then I can avoid these spikes - but without the exercise, and/or with more carbs for breakfast the spikes seem to happen. It's confusing! And I think because I've changed both the morning and evening doses at the same time it's hard to see what is doing what.. Could the reduced night time levemir (and taking it earlier) contribute to the return of the morning highs?
Any thoughts much appreciated!

 

[HS13]

So I woke up at 7:45 this morning at 3.5mmol/L. No longer have the libre so don't know how long I was low, apart from that I woke and tested at 1:45am and was at 7.5mmol/L. Ate two jelly babies and then waited 30 minutes until 8:15am to take 9 units of levermir and 4.5 units of novorapid with my blood sugars at 6.1mmol/L. About 30 minutes later, had a very low carb breakfast of yoghurt, nuts and half an apple, followed by a slice of bacon and some tomatoes. Settled in to work from home, but feeling foggy and finding it difficult to focus on the reading I need to do, and by 11:30 my blood sugars have spiked to 13.9mmol/L. I'm wondering if this could be a rebound from the nighttime hypo?
I have taken a correction, even though the DSN has told me not to inject between meals (as per DAFNE), but I'm really struggling to do my work with these blood sugar levels and can't put it off until my sugars fall again.. Otherwise, I'm feeling pretty fed up to be honest, because I don't understand why such a low-carb breakfast with plenty of insulin on board would cause my sugars to go up so high. It wouldn't be so bad if it wasn't accompanied by feeling so rubbish, and unable to do my work. Sorry for such a downbeat post, just feeling a bit lost with what to do!

 

[scotteric]

So I woke up at 7:45 this morning at 3.5mmol/L. No longer have the libre so don't know how long I was low, apart from that I woke and tested at 1:45am and was at 7.5mmol/L. Ate two jelly babies and then waited 30 minutes until 8:15am to take 9 units of levermir and 4.5 units of novorapid with my blood sugars at 6.1mmol/L. About 30 minutes later, had a very low carb breakfast of yoghurt, nuts and half an apple, followed by a slice of bacon and some tomatoes. Settled in to work from home, but feeling foggy and finding it difficult to focus on the reading I need to do, and by 11:30 my blood sugars have spiked to 13.9mmol/L. I'm wondering if this could be a rebound from the nighttime hypo?
I have taken a correction, even though the DSN has told me not to inject between meals (as per DAFNE), but I'm really struggling to do my work with these blood sugar levels and can't put it off until my sugars fall again.. Otherwise, I'm feeling pretty fed up to be honest, because I don't understand why such a low-carb breakfast with plenty of insulin on board would cause my sugars to go up so high. It wouldn't be so bad if it wasn't accompanied by feeling so rubbish, and unable to do my work. Sorry for such a downbeat post, just feeling a bit lost with what to do!

It's more likely your dawn phenomenon coming at a time when your basal insulin is at its lowest. 5 units isn't very much and it's likely your Levemir is fading out as you wake (and at the worst possible time since this is during DP). The problem with Levemir is lowering the dose lowers the strength and duration of action. I found when I used it at the dose I needed I could get about 8 hours of it overnight but not much more. If I slept in past 6am I was screwed! Also, and dose only at the advice of your doctor of course, but there shouldn't be any reason to delay your Levemir dose, even if you're low. It takes 2-3 hours to kick in so all you're doing is widening your gap in basal coverage well past the time you've treated your hypo causing problems later.

 

[scotteric]

yoghurt, nuts and half an apple

Also remember that nuts can hit you hours later causing a spike, past the time your of your bolus. I usually extend a bolus on my pump for a couple hours or so if I eat nuts. Fruit and yogurt can cause spikes in the morning and I tend to avoid them. Lastly your liver was probably dumping glucose due to the DP when you woke up, so treating the hypo may have made things worse since the DP might've taken care of it and then some...! You'd probably be amazed to see how much your BG rises in the first couple hours after waking due to DP. The process accelerates when you get out of bed. I can skyrocket from 5 to 12 in no time, even if my basal is set right if I don't take any insulin or increase my basal upon waking. The fading Levemir probably makes it so much worse!

 

[donnellysdogs]

Have you tried basal testing for a few mornings?

 

[HS13]

It's more likely your dawn phenomenon coming at a time when your basal insulin is at its lowest. 5 units isn't very much and it's likely your Levemir is fading out as you wake (and at the worst possible time since this is during DP). The problem with Levemir is lowering the dose lowers the strength and duration of action. I found when I used it at the dose I needed I could get about 8 hours of it overnight but not much more. If I slept in past 6am I was screwed! Also, and dose only at the advice of your doctor of course, but there shouldn't be any reason to delay your Levemir dose, even if you're low. It takes 2-3 hours to kick in so all you're doing is widening your gap in basal coverage well past the time you've treated your hypo causing problems later.

This is really helpful, thank you, makes loads of sense of that post-breakfast spike. I've only really recently realised that Levemir doesn't start working immediately! It's amazing what understanding the processes can do - instead of looking at that spike feeling really frustrated I now know a bit better how to prevent it next time.
Though I'm unsure what to do with the night time Levemir because reducing it seems sensible to try and stop the overnight hypos, but then reducing it is potentially also worsening the morning dawn phenomenon. And I'm not so keen on having to get up at 6am every morning...!

 

[HS13]

Have you tried basal testing for a few mornings?

Heya, yeah I'm doing that this weekend - having a few carb-free breakfasts to see if the morning Levemir is set at the right dose.