Fast Acting At Meals Or With Top Ups Between?

[LostBoyNZ]

Hi everyone. I've had Type 1 for 18 years, and always had good control (often around 8 mmol/L) and always happy figuring out the dosage myself etc. This year I started using the FreeStyle Libre and have now brought it down to 37% which looks like around 6.5 mmol/L. But I'm now aiming for a bit higher because I want to avoid hypos. According to my Libre, in the last 7 days 63% of the time I'm between 5 and 9 mmol/L, 29% above that, and 8% below.

I have long acting insulin at dinner, and novorapid with meals, but I also have novorapid when my blood sugar goes high. He really did not like that, and firmly suggested I stick to that at mealtimes only and don't worry if my sugar level goes high in between, because it's only the people who always hit a bit high that suffer long term complications.

One risk with topping up between meals is getting the fatty bits under the skin if I jab the same spot too often. But I'm pretty good with changing needles and varying the spots, so while I can't avoid that issue, I can ideally help reduce the risk.

The other risk is having too many hypos, and eventually losing the ability to detect them. That scares me. Although technology is reaching the point where something will alert you when that happens anyways, I'd still rather not lose that ability.

From my point of view, I really hate the idea of seeing my blood sugar is high and not doing anything about it. It makes me feel tired, and if it stays high during a night for example, my legs will get very stiff and uncomfortable (not a good sign to begin with I imagine).

Sorry, my long winded question is that I wonder what everyone else does? If you know your blood sugar has gone high, do you top up or wait for the next meal? (being careful with stacking of course).

Thanks for your thoughts!

 

[LooperCat]

Morning, welcome to the forum! Tagging @daisy1 for some welcome blurb

In answer to your poll question (I answered that too), I’ll take a small dose whenever needed to bring my levels down, regardless of if I’m eating or not. But I feel I do this extremely safely, for two main reasons:

1) I eat very low carb, so only take very small doses, 2u as a maximum.

2) I record all my doses meticulously in two seperate apps, so I am hyper aware of exactly how much insulin I have on board at any time, and it’s predicted effect.

So yes, I stack doses, but I make sure I don’t have enough sloshing around in my system to make me hypo. I’m on a pump now (only been six weeks) but when I was injecting, I took a similar approach, injecting half a unit here or there to nudge my levels before they get out of hand. I use a method called “Sugar Surfing”, based on a book written by a doctor who is himself T1. Microdoses of insulin and tiny amounts of dextrose to keep yourself in range, as the further away you get from where you need to be, the harder it is to correct.

What long acting insulin do you use? And what sort of inbetween-meal highs are you getting?

 

[daisy1]

@LostBoyNZ

Hello and welcome to the Forum Here is the Basic Information we give to new members and I hope you will find it useful. Ask as many questions as you need to and someone will be able to help.

BASIC INFORMATION FOR NEW MEMBERS

Diabetes is the general term to describe people who have blood that is sweeter than normal. A number of different types of diabetes exist.

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On the forum we have found that with the number of new people being diagnosed with diabetes each day, sometimes the NHS is not being able to give all the advice it would perhaps like to deliver - particularly with regards to people with type 2 diabetes.

The role of carbohydrate

Carbohydrates are a factor in diabetes because they ultimately break down into sugar (glucose) within our blood. We then need enough insulin to either convert the blood sugar into energy for our body, or to store the blood sugar as body fat.

If the amount of carbohydrate we take in is more than our body’s own (or injected) insulin can cope with, then our blood sugar will rise.

The bad news

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The good news

People on the forum here have shown that there is plenty of opportunity to keep blood sugar levels from going too high. It’s a daily task but it’s within our reach and it’s well worth the effort.

Controlling your carbs

The info below is primarily aimed at people with type 2 diabetes, however, it may also be of benefit for other types of diabetes as well.

There are two approaches to controlling your carbs:

• Reduce your carbohydrate intake
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Reduce your carbohydrates

A large number of people on this forum have chosen to reduce the amount of carbohydrates they eat as they have found this to be an effective way of improving (lowering) their blood sugar levels.

The carbohydrates which tend to have the most pronounced effect on blood sugar levels tend to be starchy carbohydrates such as rice, pasta, bread, potatoes and similar root vegetables, flour based products (pastry, cakes, biscuits, battered food etc) and certain fruits.

Choosing better carbohydrates

The low glycaemic index diet is often favoured by healthcare professionals but some people with diabetes find that low GI does not help their blood sugar enough and may wish to cut out these foods altogether.

Read more on carbohydrates and diabetes.

Over 145,000 people have taken part in the Low Carb Program - a 10 week structured education course that is helping people lose weight and reduce medication dependency by explaining the science behind carbs, insulin and GI.

Eating what works for you

Different people respond differently to different types of food. What works for one person may not work so well for another. The best way to see which foods are working for you is to test your blood sugar with a glucose meter.

To be able to see what effect a particular type of food or meal has on your blood sugar is to do a test before the meal and then test after the meal. A test 2 hours after the meal gives a good idea of how your body has reacted to the meal.

The blood sugar ranges recommended by NICE are as follows:

Blood glucose ranges for type 2 diabetes

• Before meals: 4 to 7 mmol/l
• 2 hours after meals: under 8.5 mmol/l

Blood glucose ranges for type 1 diabetes (adults)

• Before meals: 4 to 7 mmol/l
• 2 hours after meals: under 9 mmol/l

Blood glucose ranges for type 1 diabetes (children)

• Before meals: 4 to 8 mmol/l
• 2 hours after meals: under 10 mmol/l

However, those that are able to, may wish to keep blood sugar levels below the NICE after meal targets.

Access to blood glucose test strips

The NICE guidelines suggest that people newly diagnosed with type 2 diabetes should be offered:

• structured education to every person and/or their carer at and around the time of diagnosis, with annual reinforcement and review
• self-monitoring of plasma glucose to a person newly diagnosed with type 2 diabetes only as an integral part of his or her self-management education

Therefore both structured education and self-monitoring of blood glucose should be offered to people with type 2 diabetes. Read more on getting access to blood glucose testing supplies.

You may also be interested to read questions to ask at a diabetic clinic.

Note: This post has been edited from Sue/Ken's post to include up to date information.
Take part in Diabetes.co.uk digital education programs and improve your understanding. Most of these are free.

• Low Carb Program - it's made front-page news of the New Scientist and The Times. Developed with 20,000 people with type 2 diabetes; 96% of people who take part recommend it... find out why
  
  
• Hypo Program - improve your understanding of hypos. There's a version for people with diabetes, parents/guardians of children with type 1, children with type 1 diabetes, teachers and HCPs.
  

 

[Deleted Account]

I often correct between meals.
This is partially due to my body not always responding as I expect it and partially due to not always being able to accurately carb count as I eat out a lot due to work.
This may result in insulin stacking but as I keep a close eye on what I take when, I believe there is very little risk and very rarely experience hypos due to stacking.

 

[LostBoyNZ]

Thanks for the replies and the poll votes, very interesting to see

That sounds like the way to take the extra doses, and the reason too. I sometimes eat out and couldn't possibly carb count, but also even at home I eat such a wide variety of foods for dinner.

I'm using glargine, although if I increase that dose I start to get lows in the night. I could switch to day and night insulin but then with a higher dose of that, I need more predictable meal times than I have.

For lunch today I ate a bit too much at work and it went up to 17 mmol/L and was still going up. I was certainly trying to give 3 doses a day a go, but just couldn't when it was like that. I quickly corrected it and all was well again.

When I get between highs, they're usually because I didn't give myself enough novorapid, or I just had a snack. Especially with having a 5 hour gap between breakfast and lunch usually, I get hungry

I don't want to just discard my doctors advice, because he's a **** good doctor, the best I've ever had and he immediately knew what was wrong at times when other doctors couldn't figure it out. So I'll certainly give this a solid try, but I just cannot picture it working out. In a perfect world where someone eats the same meals (or can carb count everything) at roughly the same time and has the same physical activity, stress etc, I imagine it does work. But in the real world I don't want to choose between being hungry and having high blood sugar. But I certainly do agree, without a doubt, that I want to avoid hypos as much as possible.

Maybe an insulin pump is the way to go for me too, although it's really expensive here and the Libre is quite expensive already.

Just aside from that, I have to admit I truly love the FreeStyle Libre system. Back in the very early 2000's I was one of the first people to trial the Dexcom CGM, back when they had to surgically implant a jellybean sized sensor into me. So I knew this technology was coming, but it's amazing to have it here now.

Sugar Surfing looks very interesting, I'll have to give that a read for sure.

 

[Rokaab]

My answer it: it depends
Often my Novosluggish seems to take forever to kick in (especially in the morning, but not always), so I know if I correct 2-3 hours after breakfast when my libre shows that the Novorapid hasn't kicked in I know I'll hypo some time around lunch (dependent on the sluggishness of said Novorapid at that particular point in time), so I just have to wait it out and hope that I didn't need a correction - of course this sometimes does mean that I find out at lunchtime that I shoulda had a correction some hours earlier (am changing to Fiasp tomorrow (hopefully - dependent on chemist) to try and combat this).

However if I can see that the Novorapid has actually kicked in but not gone far enough then I will take a correction unless it's very close to the next meal, where I'll just add a correction dose to the amount for the meal.

 

[Engineer88]

Thanks for the replies and the poll votes, very interesting to see

That sounds like the way to take the extra doses, and the reason too. I sometimes eat out and couldn't possibly carb count, but also even at home I eat such a wide variety of foods for dinner.

I'm using glargine, although if I increase that dose I start to get lows in the night. I could switch to day and night insulin but then with a higher dose of that, I need more predictable meal times than I have.

For lunch today I ate a bit too much at work and it went up to 17 mmol/L and was still going up. I was certainly trying to give 3 doses a day a go, but just couldn't when it was like that. I quickly corrected it and all was well again.

When I get between highs, they're usually because I didn't give myself enough novorapid, or I just had a snack. Especially with having a 5 hour gap between breakfast and lunch usually, I get hungry

I don't want to just discard my doctors advice, because he's a **** good doctor, the best I've ever had and he immediately knew what was wrong at times when other doctors couldn't figure it out. So I'll certainly give this a solid try, but I just cannot picture it working out. In a perfect world where someone eats the same meals (or can carb count everything) at roughly the same time and has the same physical activity, stress etc, I imagine it does work. But in the real world I don't want to choose between being hungry and having high blood sugar. But I certainly do agree, without a doubt, that I want to avoid hypos as much as possible.

Maybe an insulin pump is the way to go for me too, although it's really expensive here and the Libre is quite expensive already.

Just aside from that, I have to admit I truly love the FreeStyle Libre system. Back in the very early 2000's I was one of the first people to trial the Dexcom CGM, back when they had to surgically implant a jellybean sized sensor into me. So I knew this technology was coming, but it's amazing to have it here now.

Sugar Surfing looks very interesting, I'll have to give that a read for sure.

Can I just confirm you are having 4 injections a day? novorapid 3 times and a long acting injection?

How long does the novorapid take to act for you? do you inject before eating and if so how long?

 

[Dixon1995]

Im personally on Abasaglar twice daily and take Novo Rapid for meals. Recently I have been eating less carbs to help with blood sugar managment and so I use less insulin. Anyway, I follow a plan for unwanted blood sugars higher than normal like this. It is different for everyone so you would need to work yours around yourself. If my blood sugar is between 4-7 fasting, I will wait until my next meal. I would definitely take NovoRapid corrections 2-3 hours after eating a meal if you are higher than you want to be, say above 8-9mmol. Don't forget to check your ketones if your sugars go higher than 14 as if they are present you may need more insulin, drink plenty of fluids. Good luck

If you go low during the night it might be because you eat too late and take your Novorapid and take too much, have a night were you don't eat anything from 6pm onwards, take your glargine, test before bed, then test in the morning, if it has lowered too much, youre taking too much glargine, so lower by one unit each night until your blood sugar remains nice and stable, not going up too much, nor down too much, as the point of glargine is to balance your blood sugar at a steady rate when fasting.

 

[LostBoyNZ]

Rokaab that's interesting the novorapid takes longer to kick in than other times. I don't suppose it's when it's injected to similar areas that it's slower to take effect?

Agreed if it's close to the next meal I'd just wait too. Fiasp? Hopefully that goes well, it's not something we have in New Zealand yet but if it works well I hope we do get it soon.

Engineer88, that's what the doctor said to do yes, 4 injections a day (3 novorapid; breakfast, lunch, dinner) and one glargine (dinner). But in reality I'd say it's not unusual that I have 2 or 3 more a day of novorapid, when I have a snack in mid-morning / mid-afternoon or evening. Mostly it's the evening, because I want to get it as right as possible before sleep. If I wake up from high blood sugar in the night, I'll correct then, but that's rare thanks to my small evening dose. It's rare I go low during the night too thankfully.

The novorapid reaction time, that's a good question. I do inject before eating (usually only a few minutes before), unless it's around 5 or so, then I want until after (otherwise I find it just goes low). If my blood sugar is like 9 or so, I'll inject earlier before eating. Overall I'd say my blood sugar rises in the first hour, then goes down.

 

[LostBoyNZ]

Dixon1995, completely agree, if mine is between 4 and 7 that's where I want it to be too, so I happily leave it. But above 8 or 9 sounds like it needs a top up. That's where the Libre comes in handy, because I can see if it's 8 or 9 and going up fast (whereas without the Libre it might be 8 or 9 going up or down, I won't know).

Good idea regarding the nights. And that's good to know it's not unusual to have 2 or 3 more a day of novorapid. When I got back home from the doctors actually I happened to have an appointment letter for our diabetes center, so it'll be interesting to get their thoughts also.

Keytones, yeah I vaguely remember about those when I was first diagnosed, but haven't had any tests since. I'll check on that. When they go higher than 14 though, I really try to get them down quickly (and safely) because they seem to effect me quite quickly. Like before when it was 11, I already had quite a dry mouth (and I drink probably 2 litres of water a day on average) and I can feel it in my legs.

 

[LooperCat]

@LostBoyNZ - the long acting glargine (we have that here, but called Lantus) doesn’t always last the full 24 hours. It has quite a peak 4-6 hours after injecting, and then tails off, often at around the 20 hour mark. This is why a lot of people injecting at bedtime found they were going hypo at night and then higher in the late afternoon and evening. The solution to this is either to switch to a much longer acting insulin like Degludec/Tresiba or splitting the Lantus dose and taking it morning and night. Or if you only want the one jab, move it to the morning, so that it’s peak coincides with when your body needs more insulin anyway. That’s almost certainly why you’re having hypos if you increase your nighttime dose. I used it for over ten years, and it worked much better when I split it.

I also find the action time of Novosluggish to vary through the day - it takes half an hour in the morning but only ten minutes in the evening before I see my levels start to drop. A unit has less effect earlier in the day that later too.