Few questions on insulin pls.

[Clueso]

Hi Everyone,

Firstly, I hope everyone is well and managing the best you can.
My brief summary is as follows. Domiciled in Australia and at age 29 diagnosed with LADA with positive GAD Antibody result and elevated blood sugars.

Similar to most on the forum, followed Dr. Bernstein’s counsel and on a very low card diet for the last ten years and exercise and managed to keep HBA1C to around 42 to 46. Most recent antibody result was 13 IU/ML and HBA1C of 46.

But as most would understand, it’s pretty draining and mentally it does get to you. Whilst my sugars are under control, I do like to have just two carb meals per week and when I do its hours of guilt as my readings are close to 10 for about 4 hours. Its starting to impact my mental sate of mind on a daily basis.

Therefore, I am looking at using Bolus Insulin purely for a couple of Carb meals per week so that I have something to look forward to without worrying how much I am damaging my organs. What I would like to know from the knowledgeable group here is as follows.

1. Is there any fast acting insulin you would recommend in terms of brand? There are so many varieties and I am looking for what seems to work for the majority.
2. I realise its different for every body composition, however if you were going to have a 60G carb meal, how much insulin would you inject and how many hours before having your meal?
3. Once you do this, what would you expect your B.S readings to be after two hours?
4. My only vice is I do like a glass of wine and Whiskey before a meal and I know with insulin this can be dangerous. At the moment I use it as a pseudo insulin before a carb meal as it does bring my sugar down! Anyway for those who consume some alcohol, how would this change how much insulin you take and what time would you take the insulin before the carb meal?

Many thanks and your feedback is much appreciated.

 

[EllieM]

Hi @Clueso and welcome to the forums (edited to add, welcome again, I see your first post was 2 years ago )

52 years of T1 here, 17 of those in Australia, currently in NZ.

Is there any fast acting insulin you would recommend in terms of brand? There are so many varieties and I am looking for what seems to work for the majority.

This is really a question for your endocrinologist. I'm boggled that you aren't on any fast insulin yet. When I was in Australia my endo put in on humalog, and I've no complaints, though there are fancier fast acting insulins out there (not sure how available in Australia).

I realise its different for every body composition, however if you were going to have a 60G carb meal, how much insulin would you inject and how many hours before having your meal?

Not really possible for me to answer this, as it depends so much on the person's metabolism and the meal. Certainly bolus ratios of insulin to carbs can vary from 1unit to 1g or 20g (or an even wider range), and they make special x5 strength insulins for folk (often but not always T2) who are heavily insulin resistant. And of course, it also depends on how much of your own insulin you still have.

Once you do this, what would you expect your B.S readings to be after two hours?

Again, that depends on the person and what you ate (eg pizzas are notorious for delaying the action of the carbs).I work on the principal that I try to maximise my time in range (4-10mmol/L) but others have different range values and I only very rarely get a 100% day.

My only vice is I do like a glass of wine and Whiskey before a meal and I know with insulin this can be dangerous. At the moment I use it as a pseudo insulin before a carb meal as it does bring my sugar down! Anyway for those who consume some alcohol, how would this change how much insulin you take and what time would you take the insulin before the carb meal?

Again, a very personal thing, just be careful of hypos when drunk. Do you have a cgm with alarms?

I may not be the best person to advise here because as a long term T1 I had a childhood without glucometers, and have never aimed for the tight control that you seem to be currently achieving. But I would point out that I still don't have any significant diabetic complications and diabetes doesn't rule my life, though I do pay attention to my levels and inject accordingly.

Similar to most on the forum, followed Dr. Bernstein’s counsel and on a very low card diet for the last ten years and exercise and managed to keep HBA1C to around 42 to 46. Most recent antibody result was 13 IU/ML and HBA1C of 46.

The WOEs (ways of eating) employed by the T1s here are very varied, and you don't have to follow Dr B to get good results.
The advent of cgms and pumps has led to drastic improvements. eg @Marie 2 has outstanding hba1cs and she's on a relatively high carb vegan WOE (my apologies if I've got that wrong Marie). And I'll tag in @RoughcutAU because I know he's in Australia.

Hopefully some more T1/LADA folk will chime in as the time zones change.

Good luck.

 

[Clueso]

Hi @Clueso and welcome to the forums (edited to add, welcome again, I see your first post was 2 years ago )

52 years of T1 here, 17 of those in Australia, currently in NZ.


This is really a question for your endocrinologist. I'm boggled that you aren't on any fast insulin yet. When I was in Australia my endo put in on humalog, and I've no complaints, though there are fancier fast acting insulins out there (not sure how available in Australia).


Not really possible for me to answer this, as it depends so much on the person's metabolism and the meal. Certainly bolus ratios of insulin to carbs can vary from 1unit to 1g or 20g (or an even wider range), and they make special x5 strength insulins for folk (often but not always T2) who are heavily insulin resistant. And of course, it also depends on how much of your own insulin you still have.


Again, that depends on the person and what you ate (eg pizzas are notorious for delaying the action of the carbs).I work on the principal that I try to maximise my time in range (4-10mmol/L) but others have different range values and I only very rarely get a 100% day.


Again, a very personal thing, just be careful of hypos when drunk. Do you have a cgm with alarms?

I may not be the best person to advise here because as a long term T1 I had a childhood without glucometers, and have never aimed for the tight control that you seem to be currently achieving. But I would point out that I still don't have any significant diabetic complications and diabetes doesn't rule my life, though I do pay attention to my levels and inject accordingly.




The WOEs (ways of eating) employed by the T1s here are very varied, and you don't have to follow Dr B to get good results.
The advent of cgms and pumps has led to drastic improvements. eg @Marie 2 has outstanding hba1cs and she's on a relatively high carb vegan WOE (my apologies if I've got that wrong Marie). And I'll tag in @RoughcutAU because I know he's in Australia.

Hopefully some more T1/LADA folk will chime in as the time zones change.

Good luck.

Hi and thanks for your response @EllieM. I actually didnt want them initially to put me on any insulin as I was managing with a very low carb diet and I simply didnt want to have the fear of hypos. That's the only good thing about managing without Insulin but as mentioned not being able to have any carbs is starting to get to me. I currently dont have a CGM but I think I will get one once I go on Insulin just to take the guess work out of it and monitor whats going on.

Could I ask roughly how much carbs you eat a day, how many times do you take insulin and roughly whats your HBA1C levels are at?

lastly, given you have lived large portion of your life with this, for you personally do you now know the signs of hypos and are they pretty easy to identify? This is my main worry with Insulin usage especially in the first few months of usage.

 

[EllieM]

Could I ask roughly how much carbs you eat a day, how many times do you take insulin and roughly whats your HBA1C levels are at?

lastly, given you have lived large portion of your life with this, for you personally do you now know the signs of hypos and are they pretty easy to identify? This is my main worry with Insulin usage especially in the first few months of usage.

I'm at about 50mmol/mol. on lowish carb (usually under 100g a day) but I can dose for more if I want. I take insulin before I eat plus a few correction doses if I'm higher than I like.I'm on lantus as a basal which is supposed to be a 24 hour insulin but I split it because I find it slightly more predictable when I do. (I'd love to try levemir but its' not available in NZ).

As for hypos, precgm, whenever my levels went much below 50 (eg pregnancy) I used to have less hypo awareness and started to not always respond to hypos. Now with a dexcom I get warned at 4.4 so I only rarely go below 4.0. It also makes a massive difference to night times, because I get woken from sleep.
,
Honestly, I don't think you need to worry about hypos if your hypo awareness is good, which I would hope/expect that it would be for a newish diabetic. The symptoms are very obvious and as long as you carry sugar with you and test before you drive you should be fine. An issue would be if you had too many hypos and lost awareness, but with a cgm that is avoidable. Yes, T1s get hypos and it's very annoying, It's not normally more than that though. Probably be easier to understand and less frightening once you've had your first one.

Good luck.

 

[becca59]

Hi @Clueso I’m on a basal bolus regime. My daily carb intake is Mainly 80 or under, but I do relax more at weekends. Also drink wine at weekends. I don’t worry too much about 2 hours after I have eaten. Basal insulins are in your system still working 4-5 hours after taking, so will still keep levels coming down. I have been living like this 8+ years now after a diagnosis at 54. Weight has stayed pretty stable and a good stone less then I had been all my life. Latest HBA1C 41.
The game changer for me has been Libre 2. In the last 3 months hypos have been virtually non existent and even then not drastic. Time in range about 93%. (4.2-8.5)I have alarms set to react with HALF A jelly baby the minute I reach a certain level. It just nudges me back and keeps me level. This would be your answer to hypo fears. Guilt about eating carbs sounds a slippery slope to all sorts of mental problems. Plus using alcohol to keep levels down sounds a lot less healthy than eating a few carbs. There are many healthy, long lived type 1s who just eat what they want and inject accordingly. Sounds like it is time to add in a bolus insulin, wear a Libre and just relax and enjoy food a little. Good luck.

 

[In Response]

Similar to most on the forum, followed Dr. Bernstein’s counsel and on a very low card diet for the last ten years

I think you will find most people with Type 1 (even on this forum) do not follow the regime of a doctor who can't manage women - he proposes all women go on the pill because their hormones cause too many problems!
Despite this not being an issue for me, I chose not to restrict my diet but to learn to use the tools I have available - insulin and CGM - to maintain a similar HBA1c to yourself for the last 20 years whilst living a full and adventurous life without letting diabetes take over.
Dosing insulin takes some practice because different carbs are converted to blood sugars at different rates - correct dosing is not just about quantity, it is also about timing.
Yes, I have hypos but I am hypo aware, carry fast acting glucose with me wherever I go and recover quickly.

 

[Marie 2]

Hi @Clueso

A book
Insulin brands

I would push for a fast acting insulin. You won't have a choice eventually about using it and you might as well start to learn for some dosing now. In the US they do the same thing, they like to start you on a slow acting first, but it really limits you on what you can eat if you don't have a fast acting one.

Novolog or it's called Novorapid in some countries and Humalog are fairly similar, but they do have different chemical make ups, so sometimes it's a preference of what someone likes. Some don't care at all which one. I think you have to just go ahead and try one and see. I like Humalog better, but plenty like Novolog better.

Fiasp is by the same manufacturer as Novolog, it has an added ingredient to make it work faster. But a few people like me, it seems to not work at all. Lyumjev is by the same manufacturer as Humalog it has an added ingredient to make it work faster. Lyumjev has some people that love it and say it is very fast. It is newer and not always offered as an alternative in some countries. Afrezza is very fast and I love it, but anyone in Australia that uses it has to self fund I'm pretty sure, and it's not cheap.

Carb eating
I am a vegan

I eat about 120 carbs as an average, I'm retired and just generally don't eat a lot. But I don't care whether I have 150 carbs in a pizza or whether it's 20 carbs in a bowl of veggies. I eat what I feel like and just dose for it. You have to learn how much 1 unit covers per carb. The best thing to stop spiking for me is the timing of a prebolus. I like to dose about half for my normal meals about 30 minutes before I eat. That way I can take the second dose for what I actually ate. But some might dose a third 10 minutes before. You have to find what works best for you. That's using Humalog and Novolog, of course Fiasp, Lyumjev and Afrezza require different timing.

It seems you are still making some insulin, so your ratio is likely to change over time. I guess at a lot of food I eat, I have never been the exact measurement type person. So if I start trending in going too low, I just eat some fresh pineapple or something else I love that I would probably eat later anyways.

I have a pump and I "sugar surf" I do mini doses throughout the day when needed. I get on my exercise bike as needed too.
Sugar Surfing by Steven Ponder is a great book and he has a lot of information on his website too.
https://www.sugarsurfing.com/

 

[Clueso]

Hi @Clueso I’m on a basal bolus regime. My daily carb intake is Mainly 80 or under, but I do relax more at weekends. Also drink wine at weekends. I don’t worry too much about 2 hours after I have eaten. Basal insulins are in your system still working 4-5 hours after taking, so will still keep levels coming down. I have been living like this 8+ years now after a diagnosis at 54. Weight has stayed pretty stable and a good stone less then I had been all my life. Latest HBA1C 41.
The game changer for me has been Libre 2. In the last 3 months hypos have been virtually non existent and even then not drastic. Time in range about 93%. (4.2-8.5)I have alarms set to react with HALF A jelly baby the minute I reach a certain level. It just nudges me back and keeps me level. This would be your answer to hypo fears. Guilt about eating carbs sounds a slippery slope to all sorts of mental problems. Plus using alcohol to keep levels down sounds a lot less healthy than eating a few carbs. There are many healthy, long lived type 1s who just eat what they want and inject accordingly. Sounds like it is time to add in a bolus insulin, wear a Libre and just relax and enjoy food a little. Good luck.

Hi @becca59 Thank you for your response and you make quite a few salient points. I do this its got to a point that I need to use a Bolus as what I am doing now is not feasible in the long run.

When you do have a high carb meal, what insulin do you use and how long before meal consumption?

 

[Clueso]

@Marie 2 Thank you for your detailed response and you have given me alot to work with and even more to think about. I will read up the material you have provided.

Given your carb intake, your HBA1C is quite phenomenal. I can only hope to acheieve those sorts of levels. One last questions if I may.

When you have a large carb meal say pizza, and you dose appropirately, two hours after the meal, roughly what do you expect your bloody sugar to be? and after how many hours does it go back to your normal range and what is that normal range.

I realise it depends but I am just trying to get a feel as to how long you spike after a large carb meal even after taking insulin?

Many thanks

 

[Daibell]

Hi. One of the most popular Bolus insulins in the UK is NovoRapid. I use the Libre 2 and rely on the alarms feature particularly during the night to warn of hypos. I'm hypo aware so start to get spaced-out and hot and sweaty when I go too low.

 

[Marie 2]

Pizza is a huge trick for everyone. I am a vegan and the pizza I usually eat has some fat, but not like regular pizza. So it wasn’t hard. I do a third 30 minutes before, a third when I ate, and a third 30 minutes after.

Then a pizzeria here started making a vegan pizza with sofrito sauce and vegan cheese, very high fat and high carb. I learned about what everyone was complaining about. I still dose about 20% 30 minutes before, 40% when I eat, 20% about 30 minutes after and another 20% 60 minutes after I eat. And I bet on needing some more later. It’s still a learning process and one of the problems is guessing at carbs in the pizza in the first place. And for now they have dropped the vegan cheese, so it is less fat than they used to pile on. So now it's different again lol, I've only had it once since then and it was easier.

 

[becca59]

Hi @Clueso my basal insulin is Tresiba. Bolus is Fiasp.

 

[david4503]

Just wanted to emphasize, especially for someone new to taking insulin and its effects, that dosing is not as simple as following a fixed formula based on carbs. Many factors can affect what’s going on with your blood sugar besides how many carbs you’ve eaten recently or plan to eat. If it was as simple as launching a calculator app and plugging in some numbers, we would have had a working artificial pancreas long ago. Definitely consult the professionals when it comes to dosing advice. People here can be helpful but doctors and such can teach you how to help yourself.

 

[ert]

Hi Everyone,

Firstly, I hope everyone is well and managing the best you can.
My brief summary is as follows. Domiciled in Australia and at age 29 diagnosed with LADA with positive GAD Antibody result and elevated blood sugars.

Similar to most on the forum, followed Dr. Bernstein’s counsel and on a very low card diet for the last ten years and exercise and managed to keep HBA1C to around 42 to 46. Most recent antibody result was 13 IU/ML and HBA1C of 46.

But as most would understand, it’s pretty draining and mentally it does get to you. Whilst my sugars are under control, I do like to have just two carb meals per week and when I do its hours of guilt as my readings are close to 10 for about 4 hours. Its starting to impact my mental sate of mind on a daily basis.

Therefore, I am looking at using Bolus Insulin purely for a couple of Carb meals per week so that I have something to look forward to without worrying how much I am damaging my organs. What I would like to know from the knowledgeable group here is as follows.

1. Is there any fast acting insulin you would recommend in terms of brand? There are so many varieties and I am looking for what seems to work for the majority.
2. I realise its different for every body composition, however if you were going to have a 60G carb meal, how much insulin would you inject and how many hours before having your meal?
3. Once you do this, what would you expect your B.S readings to be after two hours?
4. My only vice is I do like a glass of wine and Whiskey before a meal and I know with insulin this can be dangerous. At the moment I use it as a pseudo insulin before a carb meal as it does bring my sugar down! Anyway for those who consume some alcohol, how would this change how much insulin you take and what time would you take the insulin before the carb meal?

Many thanks and your feedback is much appreciated.

You should ask your specialist team to consider an alternative diagnosis was you have managed to stay off insulin for 10 years. Have you had a recent c-peptide test or been tested for MODY? GAD antibodies exist in the general population in people without diabetes so it is the c-peptide test which is used. It is rapid deterioration only insulin that would support type 1/LADA. Below are the clinical notes the Exeter University team used to reclassify type 1 diabetics. Also the news article on c-peptide test.

https://www.exeterlaboratory.com/test/c-peptide-plasma/
https://www.exeter.ac.uk/news/research/title_707155_en.html

 

[Clueso]

Hi Everyone,

I finally started taking Novorapid purely to be able to enjoy a few carb meals and I must say the results are depressing. I simply cant work out how to balance it out. I am just going on this depressing merry go round of going down to hypo levels and then taking a few Jelly Beans and overshooting the other way and cycle continues. If you could advise me on how you handle the following I would greatly appreciate it.

1. Once you go down to 3, how do you treat your hypo and how much do you take? For example yesterday I had a bowl of pasta and injected 3 units and within one hour I was at 3, thus took only two Jelly beans and I have been over 12 for the last 12 hours which is never the norm for myself.

2. I am also trying to figure out how long before my meal should I take insulin? I have tried 15 mins before and yesterday one hour before food and I still went down to 3. Logically I know I should probably take 2 or 1 units and see how I go, but I still need to know how I manage hypos without overshooting on the high end.

3. Lastly, I dont seem to have any hypo symptoms at all when my sugar is at 3 which is concerning. Is this quite normal?

Something that was supposed to give me a bit more flexibility and mental relief is causing the exact opposite. Any counsel on how to get the dosage right will be much appreciated.

Thank you

 

[EllieM]

3. Lastly, I dont seem to have any hypo symptoms at all when my sugar is at 3 which is concerning. Is this quite normal?

Hmm, is this 3 measured by a libre or by a glucometer? I'd expect you to have hypo symptoms if you are truly at that level .

 

[Clueso]

Hmm, is this 3 measured by a libre or by a glucometer? I'd expect you to have hypo symptoms if you are truly at that level .

Hi Ellie, its by a glucometer and finger prick.

 

[EllieM]

Hi Ellie, its by a glucometer and finger prick.

Ouch. Some glucometers are more accurate than others, I guess.
In your position, I would probably have a chat with your diabetic team. Is that possible?

 

[Clueso]

Ouch. Some glucometers are more accurate than others, I guess.
In your position, I would probably have a chat with your diabetic team. Is that possible?

Yes thats my next step but generally I seem to get better input from forum members than my medical team! If I may ask, what do you take to treat hypos and whats your general process in terms of how long before you recheck etc.

 

[Marie 2]

It comes down to the right timing and dosing of the particular food you ate. Not always the easiest to figure out.

I am going to hazard a guess that something you ate with the pasta had some fat content. Given that you have said you dropped to a 3 after an hour then shot up to a 12 later. The jelly bean at 2 carbs each/4 carbs is usually a good amount to treat a hypo. But it can depend on how much insulin is hitting etc.

This is a guess, since I don't know what you ate and we can all be different in how we react. In this case I would guess your prebolus timing and then dosing were off.

Since you had eaten, the jelly beans negated some of the insulin you took. Let's go with the assumption your insulin hit faster than your food. You dropped, ate the jelly beans, and then proceeded to climb as your food digested. But at that point you didn't have enough insulin. Some went to the jelly beans originally, but it sort of sounds like you might not have had enough insulin for your meal too. 2 jelly beans commonly would not make you go from 3-12. Some of the food did that, meaning at that point you hadn't had enough insulin.

Fat content slows down the absorption of the carbs. So you prebolused for that particular meal too soon for the food you ate to hit. So you dropped. If something has a higher fat content, I don't necessarily prebolus. In this case I would say you needed the jelly beans because you dropped, but you needed more insulin for your food. With a higher fat meal, I commonly do my insulin in stages. I don't always prebolus for it either. There are variables of course for all of us in digestion time, insulin need and timing.

Example for me, a vegan taro donut. High carb with fat content because it is deep fried. I dose a third when I eat it, a third a half hour later and another third an hour after........ and adjust with some later if needed.

Higher protein can also hit later. But even if it wasn't high fat.......... your insulin dose hit too early for your food. In that case you could be really insulin sensitive. Your insulin hit before your food. But you went too high, doubtful the jelly beans caused that increase. So then it comes down to... not prebolusing so early for that meal, and potentially needing more later because it wasn't enough.

And always keep in mind things can vary, we have usuals. But usuals can be influenced by say heavy exercise earlier or even the day before.

It's very unfortunate you don't feel hypo's. Some people just don't. Most of us can reset at what level we feel them by making sure we don't have any so you become sensitive to them again. If people drop too much all the time, they stop feeling them or don't feel them until they are really low. When I first started using insulin I felt anything under 100. Now they don't bother me until I am somewhere between 3.3-3.9 (60-70). It is unlikely since you just started insulin that you have had a lot of lows? Although I do remember a few people said they experience hypo's when they first were having issues with BG levels.

Hope this helps, just keep in mind we really can all vary in our response and our needs.