Bolus/ Basal question

[Speedbird]

Hi,

l have just been recently introduced to bolus and was looking forward to more stable blood glucose readings, which, for most of the time I am having.
But my DN just advised me to take just 1 unit of Novorapid before my evening meal and reduce my Lantus by 1 unit.
My question is, would be better to gauge the bolus on the meal to be eaten rather than just take 1 unit as she advised.
And why just evening meal and why reduce the Basal by the amount of units used for Bolus?
Also, does one base the amount of Bolus by the blood sugar reading just before eating the meal?

I should have been more proactive in questioning my DN but was hoping for a bit more input from her.
As it is, I have an appointment with her in a few weeks and will raise those question.

Meanwhile if anybody has any words of wisdom, they will be gratefully received.
Thank you.

 

[In Response]

It is common to start bolus on a fixed dose.
Why only your evening meal? Whilst I could speculate, that is a qu based on your blood sugar levels throughout the day. Assuming you are based in the UK, you should have a Libre (if not, this is something to raise asap) so you can see this information clearly.
I wonder if you DSN chose the evening meal because your basal was not lasting the full 24 hours.

 

[Speedbird]

It is common to start bolus on a fixed dose.
Why only your evening meal? Whilst I could speculate, that is a qu based on your blood sugar levels throughout the day. Assuming you are based in the UK, you should have a Libre (if not, this is something to raise asap) so you can see this information clearly.
I wonder if you DSN chose the evening meal because your basal was not lasting the full 24 hours.

Thank you. Yes I’m in the UK and have the Libre2
I am in my target range 4.00-9.00 mmol/L for 89% for the last 30 days. But I am now bolusing 1 to 2 units for each meal to stay in target.
Curious to know if one should adjust bolus according to the amount of carbs in the meal or what the blood sugar reading are before the meal or take both into consideration..

 

[EllieM]

Curious to know if one should adjust bolus according to the amount of carbs in the meal or what the blood sugar reading are before the meal or take both into consideration..

In the long run you'll probably carb count and have an insulin ratio and a correction factor to aid you in dosing for meals.

1) Insulin ratio (often started at 1 unit for 10g but can vary massively eg 1 unit for 1g or 1 unit for 20g) So if your insulin ratio was 1 unit for 10g you'd take 4 units for a 40g meal.

2) correction factor. Also varies massively, but if your correction ratio was that 1 unit of insulin brought you down by 3 mmol/L then you'd add in a correction dose to your meal if your starting bg was too high eg if you were 6mmol/L too high you'd add in 2 units.

3) It's almost impossible to get the above right if your basal is wrong so the basal dose is the first thing to address.

Having said all that, the fact that you are new to insulin and probably still producing some of your own means that there's no hurry to do the above calculations, though in your position I'd probably ask the DN what she's assuming about how much carb you are having in your meals.

And just to make things more complicated, insulin ratios can vary by time of day and activity level....


Good luck.

 

[Matt2023]

Hi Speedbird,

Thank you for this post, it is something that I am going to watch, as I am in a similar situation as in trying to adjust my Lantus and Aprida at the moment.

I started taking (5 Years ago) one dose of Lantus, but found that it would not last the full 24 hours.

So about a year ago I started having 2 separate Lantus injections per day so that it would cover the whole 24 hours, but again recently I have discovered that my dosing was not correct. I was taken 28 units of Lantus in the morning and 6 units in the evening, where I've now realized I should have been taken 2 equal doses at the same time, 8:30 AM and 8:30 PM each day for example.

These past days I have been adjusting my dosages by one unit per day. For example two days ago I had 14 units of Lantus in the morning and 14 units of Lantus in the evening, this straight away had a positive effect and stabilized my bloods throughout the day. Over the next few days I had to increase the dosage by one unit each day for both morning and evening, and at the same time I was able to reduce my Apidra so I'm not injecting so much as I was before, a goal I have been trying to achieve for some time. So Yes for me it seems the slightly more Lantus I take, the less Aprida I need to have, I was regularly injecting just one unit several times a day.

I look at each day as a blank canvas and I learn something new today and I will apply it tomorrow and I am confident in the next week or two I will have my dosage correct after many years and I have to say that thanks to this forum in part.

I will be keeping watch on this post and hopefully learn myself to improve my management of the diabetes even better.

Big thank you for asking and I wish you luck.

 

[Speedbird]

In the long run you'll probably carb count and have an insulin ratio and a correction factor to aid you in dosing for meals.

1) Insulin ratio (often started at 1 unit for 10g but can vary massively eg 1 unit for 1g or 1 unit for 20g) So if your insulin ratio was 1 unit for 10g you'd take 4 units for a 40g meal.

2) correction factor. Also varies massively, but if your correction ratio was that 1 unit of insulin brought you down by 3 mmol/L then you'd add in a correction dose to your meal if your starting bg was too high eg if you were 6mmol/L too high you'd add in 2 units.

3) It's almost impossible to get the above right if your basal is wrong so the basal dose is the first thing to address.

Having said all that, the fact that you are new to insulin and probably still producing some of your own means that there's no hurry to do the above calculations, though in your position I'd probably ask the DN what she's assuming about how much carb you are having in your meals.

And just to make things more complicated, insulin ratios can vary by time of day and activity level....


Good luck

Ah, thank you @EllieM.

Yesterday I fasted until 1300 and then had half a low carb roll with sardines and half a home made low carb scone with butter and sugar free jam. The whole lot came to about 8gm carbs. Before that lunch I was 6.6 so I took 1 unit of Novorapid. It took 2 hours to come down to 6.5!
My supper was steak, broccoli and mushrooms. I didn’t even bother to count the carbs in that meal but my bs was 6.9 before it. I took 2 units of Novorapid and it came down to 4.3. I then had a coffee and a handful of almonds. 3 hours later the bs started to climb to 8.4.
I took 9 units of Lantus last night as recommended by DSN, and by this morning it was 11.1. So I took 1unit of Novorapid.
I wonder , was it the protein in last nights supper? I did not eat anything today and after my walk the bs has stayed stubbornly at 7.0.
I’m not sure where I am going wrong. Maybe I’m still in Type 2 mindset and a bit reluctant to up my dosage or have suddenly become insulant resistance?

 

[Speedbird]

@Matt2023
Thank you for your post. It’s interesting to know that you can split Lantus, and in your case it seems to have benefitted you.
When you did it originally, how long did it take for you to realise it was a better outcome?
I am never sure whether it is better to take more bolus as you eat or a bigger dose of basal for long term stability? And how the difference works.
Being on 9 units of Lantus, would I take 5 in the evening and 4 in the morning? Then the bolus before meals as routine? In my case, it’s not just the carbs I have to calculate but protein too. Is this the same for you?

 

[Rokaab]

In my case, it’s not just the carbs I have to calculate but protein too. Is this the same for you?

Bolus'ing for protein mostly only tends to be needed for those on a very low carb diet as far as I can tell (basing this on what I've read), and given your diet looks to be very low carb that may be why you have to.
Personally I've never had to be then I've never done a very low carb diet

 

[Daibell]

Hi. Its sounds like your DN is not being very helpful or being over-careful. It's perfectly normal to use the Bolus for all main meals not just one. The NHS often starts you on a fixed dose which I think is not very helpful. Fortunately my great DN started me on carb-counting from the first day. It's up to you what you do; just don't take too much insulin without regular checking if you do change any dosage.

 

[Matt2023]

Hi Speedbird,

When I explain to someone about diabetes I say it's like a person walking on a tightrope and you have to balance your blood throughout the day. What I found is that after taking two equal doses of Lantus that the balancing act slowed down, that my blood sugars were coming down slower and going up slower and are able to control it easier. That happened within a few days of starting the new regime.

Now that the balancing act has slowed down I am now more able to keep my levels within the “time in range” which for me is currently between 4.5 mmol/L and 10 mmol/L, So it is easier at the moment to manage than it was before.

I did become unwell about 10 days ago (Timing was unbelievable) which hampered my experiment of this new insulin regime but once I got over the illness my levels stabled out again.

This past week, what I have been doing is adjusting my Lantus by one unit either up or down per day and then working out how much more or less quick acting insulin I need throughout the day. I think with slight adjustments over the next week I will be able to calculated to a much more finer point.

I've noticed for example since moving over to these two equal amounts per day I do not need to be injecting one unit of quick acting for just two cups of tea which has about 4 grams of carbs each (Milk).

My sugars do not go wildly up or down for just a small amount of carbs these days so again I'm finding it easier to manage.

Don't get me wrong there are days like yesterday though were I just still could not understand what I was doing wrong, As my sugars were going up and down very rapidly. But I start each day as a new day and try again. Today is a new day.

I have only changed over to this regime in the last 14 days, the previous five years I was taking one large dose of Lantus in the morning (28 Units) and one very small dose (6 Units) in the evening because I thought that is the way to take it. I was taking the smaller dose in the evening because I found the Lantus just never worked the entire 24 hours so I took it to help with the morning/dawn phenomenon. Again something that has come under control since taking two equal doses throughout the day.

As for dosing I find that I need to take 16 units in the morning and 16 units again at night (At the Moment, still experimenting) so in total I am taking 32 units of Lantus throughout the entire day. I am however not injecting as much quick acting during the day, I am down to about 8 injections of quick acting, down from 12 to 14 a day. I have been diabetic for many of years, so expect to take much more insulin.

I do not calculate my protein only my carbs when counting.

Sorry I can type quickly and do not realize the length of my messages sometimes so I shall leave it here.

If you have any further questions do you feel free to ask and I will answer them to the best of my ability.

And please do let us know how you get on, it's very informative for me personally as you are in a similar boat as me, and even though I am currently experimenting, the more information I can glean from other forum members, the better that is for me.

Thank you and have a great day/evening/night ahead,

 

[markpj31]

I was on 28 units of Lantus and 8 breakfast, 8 lunch and 10 nova rapid for dinner. This was what I was discharged with originally with the DSN's back in 2022.

My Hba1c for that period was 48. 49, and 45.

I had an extreme Hypo following a few hypos before (Blood went to 1, was in A&E Resuss unconscious in a pubic area (and subsequently robbed while unconscious - somebody stole my wallet and spent £180 in the local supermarket).

My doses were reduced to 18 Lantus and 3, 3, 3 Novarapid but now my bloods are all over the place with 13 before lunch yesterday and 12 before dinner today (10.2 waking). So, now I'm doing my own thing again and stepped up to 24 Lantus and 8, 8, 8 but still seeing highs.

This is really frustrating.

 

[Matt2023]

markpj31,

Sorry to hear you got robbed, but I want to say I know the frustration you are feeling, there are days I think I have got it, only for the next day to be completely different. What I say to myself is that tomorrow is another day, and if like today my sugars are high (another story), even though I am trying to get my sugars down, I wont stress and know that tomorrow morning that providing my sugars a relatively OK, we start a fresh.

I do what you are doing and micro adjusting my long acting each day to find that sweet spot where I am not struggling to get my sugars above 5 mmol/L but not struggling to get them below 10 mmol/L either.

Perseverance and patients I tell myself and I will get there.

Good Luck

 

[markpj31]

markpj31,

Sorry to hear you got robbed, but I want to say I know the frustration you are feeling, there are days I think I have got it, only for the next day to be completely different. What I say to myself is that tomorrow is another day, and if like today my sugars are high (another story), even though I am trying to get my sugars down, I wont stress and know that tomorrow morning that providing my sugars a relatively OK, we start a fresh.

I do what you are doing and micro adjusting my long acting each day to find that sweet spot where I am not struggling to get my sugars above 5 mmol/L but not struggling to get them below 10 mmol/L either.

Perseverance and patients I tell myself and I will get there.

Good Luck

Try not to stress because that will also have an impact on your blood sugars (easy to say I know).

The body is a complex machine and blood sugar can be affected by many different variables (stress, exercise, lack of sleep, illness etc.). It doesn't make any sense to say just do this dose or that dose with breakfast/lunch/dinner as it's much more complex than that.

I know they probably don't give people free reign to do what they want for a reason, but it's all about finding what is right for you and adjusting accordingly. To be 3 nova rapid with each meal doesn't make sense as there are just too many other factors to consider.

 

[Old’un]

I have been on Lantus and Novorapid for many years now and in my experience there are just far too many factors that influence blood sugar levels to be able to control it precisely. Some diabetes clinicians seem to think that a mathematical approach should work but it will only ever be partially successful. I find that there are too many variables that cannot be quantified for an accurate dosage level to be calculated and it has to be largely down to experience and guesswork.

Some days when I am particularly active I need no Novorapid at all and still have to snack several times between meals. Other days when less active I need insulin and no snacks. Stress can push the blood sugar sky high as can illness. Some medication can also elevate sugar levels or cause hypoglycaemia. I even find that the weather affects it a bit and in the summer I generally have four units less Lantus than in the winter. I find that when I am tired the blood sugar tends to run higher even if I am forcing myself to be active.

The choice of food also has a profound effect as refined carbohydrates are absorbed far quicker than unrefined ones and a fibre rich meal will take longer to digest. The fat content of the food will also have an impact on the blood sugar levels and if you have very large amounts of protein then some of that will be broken down by the liver and also raise the blood sugar level.

For me as well there is another issue that can play havoc with my blood sugar levels as I have a degree of autonomic neuropathy and as a consequence the passage of food through my digestive system is somewhat variable. Sometimes with all other factors the same as far as I can judge, a meal can be digested fairly quickly but another day an identical meal could still be in my stomach sixteen hours or more later. I have also found that I never regained the control I once had since having covid last year.

 

[ert]

Hi,

l have just been recently introduced to bolus and was looking forward to more stable blood glucose readings, which, for most of the time I am having.
But my DN just advised me to take just 1 unit of Novorapid before my evening meal and reduce my Lantus by 1 unit.
My question is, would be better to gauge the bolus on the meal to be eaten rather than just take 1 unit as she advised.
And why just evening meal and why reduce the Basal by the amount of units used for Bolus?
Also, does one base the amount of Bolus by the blood sugar reading just before eating the meal?

I should have been more proactive in questioning my DN but was hoping for a bit more input from her.
As it is, I have an appointment with her in a few weeks and will raise those question.

Meanwhile if anybody has any words of wisdom, they will be gratefully received.
Thank you.

I would wait for your next appointment before making any changes. Blood sugar control is a marathon rather than a sprint. Ask to be enrolled in the DAFNE course. Complete the BERTIE Online type 1 diabetes course created by the Royal Bournemouth Hospital, in the meantime, to learn how to carb count and dose with MDI.

 

[Daibell]

I was on 28 units of Lantus and 8 breakfast, 8 lunch and 10 nova rapid for dinner. This was what I was discharged with originally with the DSN's back in 2022.

My Hba1c for that period was 48. 49, and 45.

I had an extreme Hypo following a few hypos before (Blood went to 1, was in A&E Resuss unconscious in a pubic area (and subsequently robbed while unconscious - somebody stole my wallet and spent £180 in the local supermarket).

My doses were reduced to 18 Lantus and 3, 3, 3 Novarapid but now my bloods are all over the place with 13 before lunch yesterday and 12 before dinner today (10.2 waking). So, now I'm doing my own thing again and stepped up to 24 Lantus and 8, 8, 8 but still seeing highs.

This is really frustrating.

Hi. Having the same Bolus amount at each meal isn't a good idea which is why being taught carb-counting is important. It's dead simple but not for me to explain but the job of your nurse. You need to insist it's explained and not wait for a training course. That's NHS nonsense.

 

[Deleted member 571965]

Hi Speedbird,

Thank you for this post, it is something that I am going to watch, as I am in a similar situation as in trying to adjust my Lantus and Aprida at the moment.

I started taking (5 Years ago) one dose of Lantus, but found that it would not last the full 24 hours.

So about a year ago I started having 2 separate Lantus injections per day so that it would cover the whole 24 hours, but again recently I have discovered that my dosing was not correct. I was taken 28 units of Lantus in the morning and 6 units in the evening, where I've now realized I should have been taken 2 equal doses at the same time, 8:30 AM and 8:30 PM each day for example.

These past days I have been adjusting my dosages by one unit per day. For example two days ago I had 14 units of Lantus in the morning and 14 units of Lantus in the evening, this straight away had a positive effect and stabilized my bloods throughout the day. Over the next few days I had to increase the dosage by one unit each day for both morning and evening, and at the same time I was able to reduce my Apidra so I'm not injecting so much as I was before, a goal I have been trying to achieve for some time. So Yes for me it seems the slightly more Lantus I take, the less Aprida I need to have, I was regularly injecting just one unit several times a day.

I look at each day as a blank canvas and I learn something new today and I will apply it tomorrow and I am confident in the next week or two I will have my dosage correct after many years and I have to say that thanks to this forum in part.

I will be keeping watch on this post and hopefully learn myself to improve my management of the diabetes even better.

Big thank you for asking and I wish you luck.

Couldn't your healthcare professional look at switching you to Toujeo/Tresiba?