Help Requested with Novorapid Ratio

[Bluemarine Josephine]

Good morning my beautiful friends, I hope that you are all very well today!
Please, would you be so kind to help me with my quick acting insulin ratio because, weirdly enough things have changed…

My morning ratio is the same and likewise is my evening ratio.
However, for lunchtime, my ratio is incorrect and I cannot quite figure out what it is
My morning and evening Levemir is the same as it has been.

Two days ago, pre-lunch was 9.5 mmols.
30 grams carbs, 3 units (on a 1:1 ratio) Novorapid +1 unit correction.
14:30 : 5.3 mmols (15 grams)
14:45 : 5.7 mmols
15:30 : 5.9 mmols
17:00 : 5.0 mmols
18:00 (pre-supper) : 5.4 mmols

This is the second incident during this week, something similar happened last Monday.

I run a basal test yesterday:
Pre-lunch : 8.5 mmols
Lettuce salad and 70 grams lean steak
15:00 : 9.8 mmols
17:00 : 9.5 mmols
18:00 (pre-supper) : 8.9 mmols.
Therefore, the Levemir dosage seems correct.

I have added a bit of exercise in the morning after breakfast to minimize the morning spike from the dawn phenomenon (I quite enjoy exercise and I would prefer to continue exercising) and I suspect that the effect of the exercise makes me more sensitive to insulin during lunchtime (considering the overlap from my two Levemir injections plus the Novorapid). I generally see an effect from exercise some 5-8 hours after exercise (this is not a surprise for me to be honest).

Please may I have your suggestions as to how should I handle my lunchtime ratio? Does it look more like 1.5:1?

Thank you so much
Regards
Josephine

 

[tim2000s]

Hi @Bluemarine Josephine you need to tell us your insulin sensitivity factor as well, before we can comment.

 

[Bluemarine Josephine]

Hi @Bluemarine Josephine you need to tell us your insulin sensitivity factor as well, before we can comment.

Hello Tim!! (to the rescue!!)
I do not know exactly to be honest...
Basis calculation that my doctor did, 1 unit should bring me lower by 3.5 mmols.
Up until now, on the basis of experience, I believe that 1 unit dropped my bg my 3mmols (unless my bg was high to the teens... where in such a case it equals 1.5-2 mmols).

 

[tim2000s]

I wonder if you may have a basal level that is slightly too high.The roughly 20-25g of protein in that steak that you ate yesterday for lunch would cause my glucose levels to be rising roughly an hour after eating, but it doesn't seem to have affected you, which is usually a sign that it is being mopped up by the basal insulin. This may be interacting with your lunchtime insulin occasionally, depending on what has gone on during the day.

I wonder what would have happened to your bg levels without the lunch?

 

[himtoo]

Hi Josephine
my first potential change would be to move from a 1:10 ratio at lunch out to a 1:12 ratio
and trying to repeat the same meal and timings.
this would mean a dose of 2.5 units instead of 3 plus any correction if required depending on pre lunch BG
( I think you have a 1/2 unit bolus pen )

these exercises can only be done in real time so patience in taking a few days to find the ratio is important.

 

[Bluemarine Josephine]

I wonder if you may have a basal level that is slightly too high.The roughly 20-25g of protein in that steak that you ate yesterday for lunch would cause my glucose levels to be rising roughly an hour after eating, but it doesn't seem to have affected you, which is usually a sign that it is being mopped up by the basal insulin. This may be interacting with your lunchtime insulin occasionally, depending on what has gone on during the day.

I wonder what would have happened to your bg levels without the lunch?

Tim, thank you so much for your suggestion.
My diabetes nurse suggested that I should reduce my evening Levemir by 1 unit.
I will, also, test your suggestion by fasting to see the outcome.

However, here is my concern:
Looking at the way that the numbers move, the trend of a lower glucose level takes place when the two Levemir injections overlap in between 13:00 and 15:00 (obviously, they overlap earlier than 13:00 but, 13:00-15:00 is my period of concern). When the evening Levemir abandons at around 15:00, the bg levels are fairly stable and consistent up until supper.

This makes me believe that if the problem is with the Levemir, then it should be the evening Levemir that is pushing lower.
I I drop my evening Levemir by a unit, I understand that I will have to adjust the breakfast ratio, which is okay.
What worries me though is the possibility of nocturnal hyperglycemia.

Up until now, the 6 units of my evening Levemir (injected every evening at 21:00) keep me fairly stable with a slight morning drop which is however, within the acceptable 3 mmols of difference. I do have an occasional incident where at midnight I will be at a 9.3 and I wake up at a 5.3 in the morning but, it is not a consistent pattern.

This is why I feel reluctant to change my evening Levemir dosage.
I am wondering if I can work around this issue my altering the lunchtime Novorapid ratio instead…

My basal insulin needs change during 24hours and I know that, ideally, I need a pump to address this issue however, I am still waiting for my doctor to invite me to apply… so, for the time being, I can only work with what I have available…

Thank you!
Josephine

 

[tim2000s]

My basal insulin needs change during 24hours and I know that, ideally, I need a pump to address this issue however, I am still waiting for my doctor to invite me to apply… so, for the time being, I can only work with what I have available…

Don't wait to be invited to apply. That way madness lies. Go into your next meeting with all the data you have showed to us and explain where your issues are and why you are struggling to manage on MDI as you are now. Explain that what you want to get out of the conversation is their agreement that they will put you forward for a pump.

 

[Bluemarine Josephine]

Hi @Bluemarine, you just described exactly the issues that I have experienced with split Levemir.
Like yourself when basal testing everything was fine. Mornings and evening meal ratios were fine on the whole, but lunchtime ratios were such a headache. They would change massively to the extent it really started to impact my life. It was just so unpredictable. Tried every combination of Levemir timing, exact same foods but to no avail.
In the end I concluded that activity/exercise was the culprit, even the smallest amount. Without it, and fasting everything was fine. I concluded the crossover of morning and night, no matter when it occurred would be the time I would get problems if eating and taking fast acting after any activity. I tried reducing doses but just led to lack of basal and rise in levels. Because of the such huge variations I had to rethink split Levemir, and currently still working out what to do next.
All the best and hope you can manage to find a workable solution.

Oh my God, JPTS, you are reading my mind!! (and thank you for your kind words)

When during DAFNE course, I was suggested to switch to a split Levemir dosage, I was told that this scheme of 2 injections of basal insulin would give me more flexibility in adjusting meals and also exercise. I was told that I could exercise and be active and just adjust either of the dosages. I wouldn’t have to inject once a day and then keep “feeding” my insulin, in the case that the dosage was too much.

Allow me to say that this split dosage scheme is a massive headache!!

I always, always have to consider the time of Levemir’s injection, the fact that it kicks in 2-3 hours later, the peak 6 to 8 to 10 hours later, the overlap with the 2nd Levemir injection, the Novorapid ratio during the period that the two Levemir injections overlap…

I mean, I just want to look at my diabetes nurse and ask her “when you were suggesting this during DAFNE course back in December, where you actually serious????” This is a massive headache… During the whole of the day (and night) I have to plan and consider what the 2 Levemirs are doing, if/when they overlap, if and when they peak, if the overlap and the peak coincides with the Novorapid peak, if my blood sugar will rise when one Levemir abandons and the Novorapid starts to fade, if I will have to be active during the overlaping Levemirs and the Novorapid peak…

And when I have to figure out which one of the two creates a problem, then I feel like trying to solve a riddle…

Bloody hell….

I honestly do not know if I like this scheme anymore. I got into this with high expectations of a better and more flexible control and I am starting to regret it…

There are days when I really miss my one morning injection (and that was it)
And particularly, I am missing Tresiba to be honest… (not Lantus…oh no, no, no)

Thank you!
Josephine

 

[Bluemarine Josephine]

Hi Josephine
my first potential change would be to move from a 1:10 ratio at lunch out to a 1:12 ratio
and trying to repeat the same meal and timings.
this would mean a dose of 2.5 units instead of 3 plus any correction if required depending on pre lunch BG
( I think you have a 1/2 unit bolus pen )

these exercises can only be done in real time so patience in taking a few days to find the ratio is important.

Hi Himtoo!! Thank you so much for the guidance.
I had 30 grams carbs and injected 2.5 units. Monitoring closely to see what happens.

Thanks so much always
I trust you are very well!!
Josephine

 

[Bluemarine Josephine]

Don't wait to be invited to apply. That way madness lies. Go into your next meeting with all the data you have showed to us and explain where your issues are and why you are struggling to manage on MDI as you are now. Explain that what you want to get out of the conversation is their agreement that they will put you forward for a pump.

Oh Tim, you are ever so right...
Last time I saw them was in December when we finished with the DAFNE course.
Haven't seen them since and I am waiting patiently to be invited for a review of my condition in order to address the issue and request for a pump.

I was hoping that they would have called/sent me a letter/texted me by now... Seems that they are either very busy or understaffed at the local hospital here.

 

[Daibell]

Oh my God, JPTS, you are reading my mind!! (and thank you for your kind words)

When during DAFNE course, I was suggested to switch to a split Levemir dosage, I was told that this scheme of 2 injections of basal insulin would give me more flexibility in adjusting meals and also exercise. I was told that I could exercise and be active and just adjust either of the dosages. I wouldn’t have to inject once a day and then keep “feeding” my insulin, in the case that the dosage was too much.

Allow me to say that this split dosage scheme is a massive headache!!

I always, always have to consider the time of Levemir’s injection, the fact that it kicks in 2-3 hours later, the peak 6 to 8 to 10 hours later, the overlap with the 2nd Levemir injection, the Novorapid ratio during the period that the two Levemir injections overlap…

I mean, I just want to look at my diabetes nurse and ask her “when you were suggesting this during DAFNE course back in December, where you actually serious????” This is a massive headache… During the whole of the day (and night) I have to plan and consider what the 2 Levemirs are doing, if/when they overlap, if and when they peak, if the overlap and the peak coincides with the Novorapid peak, if my blood sugar will rise when one Levemir abandons and the Novorapid starts to fade, if I will have to be active during the overlaping Levemirs and the Novorapid peak…

And when I have to figure out which one of the two creates a problem, then I feel like trying to solve a riddle…

Bloody hell….

I honestly do not know if I like this scheme anymore. I got into this with high expectations of a better and more flexible control and I am starting to regret it…

There are days when I really miss my one morning injection (and that was it)
And particularly, I am missing Tresiba to be honest… (not Lantus…oh no, no, no)

Thank you!
Josephine

Hi. I know most people split their Levemir as it doesn't last the 24 hrs but my nice DN said not to split it (she believed Novo's 24 hr claim and showed me their flat 24 hr graph!). However, I'm pleased I don't split. I have my injection at night and in the evening when it has run out I use an appropriate Bolus ratio for dinner to compensate. Now, I still have some of my own insulin production so this may not work for everyone. The benefit is one less injection and it makes Basal balancing easier.

 

[Bluemarine Josephine]

Hi @Bluemarine, well every single thing you just said is exactly the thought process I have on a day to day basis.
It became too much of a headache and at present I am on one dose at night of Levemir. It is not a solution, only short term until I decide my next move, but with the one dose my correction ratios, and carb to insulin ratios are absolutely spot on. The down side is without regular meals it doesn't cover fasting throughout the day and into the evening so it isn't really a solution.
I see a lot of people get on fine with split doses but for me as you say I find myself having to have it exactly the same time each dose, working out the start of action, the peak of action, the start and peak of the second dose, where they meet, if a bolus is going to be given during those times, especially peak times, what activity I've had leading up to a bolus, insulin already onboard. God it's such a headache, hardly just split the dose for consistent basal and get on with your life! And with all that trying to keep your levels in range, I simply found impossible unless I tested and tested to keep track of variations, of which there were a lot! so just wasn't practical.
I've recently been offered Tresiba to try. Read a great deal about it, and trying to decide if it will work for me. I noticed you've also been on it, and for the same reasons as yourself the thing that slightly puts me off is the fact it can't be adjusted on a day to day basis but I guess I won't know until I give it a try.
If you don't mind me asking as you moved away from Tresiba do you think despite the current issues overall control on Levemir still has the edge over Tresiba.
Many thanks.

Hello JPTS,
When I was on Tresiba, I had the following difficulties:
1. It is an insulin which, I found, is sensitive to activity. So, eventhough my basal rate was correct, Tresiba would push lower during and after activity (maybe more than Lantus which I was using prior to Tresiba)
2. My diabetes changes from day to day. This thing that they say during DAFNE course ‘wait for a 2-3 day pattern” is impossible for me, I have no pattern! During most days, my insulin intake is a guessing game.

When I used Tresiba, and I had to drop or raise the dosage I had to chase after hypoglycemias/hyperglycemias for 3 days up until the new dosage gave a steady state (which is in about 3-4 days).

Keeping these in mind, Tresiba is not an easy insulin to handle.

But!

1. It is so flat and smooth, you don’t even know its there. You inject it and completely forget about it. No peaks, no overlaps, to temperament, nothing. It’s beautiful.
2. In comparison to this twice-a-day stabbing and the overlapping/peaking madness with Levemir, I think I would choose Tresiba instead despite the drawbacks…

Between the two evils, I would prefer to go back to Tresiba to be honest,
But… the local hospital does not prescribe it anymore in an effort to minimize the costs…

 

[tim2000s]

The other question to ask now is whether you potentially can use Toujeo. It's a similar insulin to Lantus, kind of halfway between Lantus and Tresiba, but by all accounts provides a flat profile over 24-36 hours. It's apparently cheaper than Tresiba.

May be worth a try.