I need to reduce my Tresiba (again!), and it's a pain in the proverbial. And nighttime hypos.

[Antje77]

Just a bit of a vent really, but thoughts and tips welcome of course, no matter your type of diabetes or medication. One thing I've learnt in 7+ years of having diabetes is that the best outside the box ideas sometimes come from those who aren't too familiar with it.

During the first 4 years I needed to steadily increase my doses, until I got pretty much stable at 98 units of Tresiba and a varying amount of Levemir between 0 and 25 units, plus a bolus insulin of course.

For those unfamiliar with those insulins, Tresiba is the longest acting and most stable of all long acting insulins, perfect for steady going but not if you need to adjust your basal regularly because it takes some 3 days for a dosage change to take full effect.
Levemir is the shortest acting of all long acting insulins (outside NPH), with an action time of about 16 hours, give or take a few hours depending on dose and metabolism. Perfect for constantly adjusting your basal, but very sensitive to timing.
With the combination I have the best of two worlds: the Tresiba at the dose I need on my lowest needs days to keep me steady, the Levemir to top up as needed.

During the past 6 months I've had to reduce my Tresiba to 92 units, and Levemir hasn't been over 10 units in a long time, usually less or nil.

During the past 4 days I've experienced nighttime hypos, which I never have before.
My current sensor isn't too well calibrated so no alarms until I'm in the low 3's.
I found out I don't feel hypo at those numbers until I get out of bed to pee, even if I'm half awake to cuddle dogs and the likes. Once I get out of bed, the hypo is very clear, and I treat without issue, but it is possible that I've spent a good part of my nights in the 3's. Not sure about that because of my lying sensor, but I really don't like the thought I might have been. It's unsettling to have to deal with nighttime hypos for the first time since diabetes!

I've been down to 86 units (from 92) for 2 days now, and still lows are threatening all day with a reduced amount of bolus, and it gets frustrating. Today I woke up at 3.2, treated, went to the swimming pool for aquajogging and dropped to 3.4 again afterwards. This afternoon I took way less bolus for a slice of low carb bread and two beers than I usually take, went to make a step for an elderly dog who's staying the week with me and who has trouble getting up the couch, and a 3.7 again. Very frustrating because I was working with a circular saw, so I had to take a break for safety. I did finish the project afterwards though, with a flashlight between my teeth because it had gotten dark.

I don't mind needing less insulin, but titrating down is a rather complex job with the slow Tresiba. I don't want to go too fast because I keep expecting my needs will go up again, but I don't want those lows either, especially not the nighttime ones without useful alarms!
I guess I should eat some crisps or such before bed tonight, those should keep my BG a bit higher for a long time.

 

[EllieM]

Maybe all that swimming is finally reducing your insulin resistance? Maybe extra dog cuddles are reducing stress?

I feel your frustration though, chasing lows and highs is a pain, particularly with such a slow basal....

Good luck.

 

[In Response]

Like @EllieM I wondered whether the aquajogging (something I have never heard of but like the idea of) is reducing your basal requirements.
I find when I exercise enough to raise my heart rate, I need 15 to 20% less basal for the next 24 hours. This is really easy with an insulin pump and not too bad with Lantus. I could never use Tresiba because it last for so long. \
With this in mind, I wonder if it is worth reducing your Tresiba further and increasing your Levemir to about 20% of your total which would make it easier to reduce your overall basal for the days after aquajogging. My thought is that this will give you both the stability of Tresiba but also the flexibility of Levemir.
It would not affect your ability to increase your Levemir more on days when your dogs don't fancy a cuddle.
It is not something I have ever done and I am only thinking "in theory".

But I am sorry I have no suggestion for the question you actually asked which is how to manage the transition phase.

 

[Antje77]

Maybe all that swimming is finally reducing your insulin resistance? Maybe extra dog cuddles are reducing stress?

Both are a reasonable possibility. Other possibilities:
I've lost a little weight since last year (just a little, but it might make a difference).
My back is hurting way less than it has done in the past two years (unmedicated) for unknown reasons, which may be a difference.
My depression has been doing better than it has in years during the past 3 or 4 weeks.

But you might be onto something with the extra cuddling I did last weekend, that's when it started, and it wasn't dogs. But no extra cuddles happened during the past two nights and I still had lows. So either it's an extended effect, or it's unrelated.

 

[Antje77]

Like @EllieM I wondered whether the aquajogging (something I have never heard of but like the idea of) is reducing your basal requirements.
I find when I exercise enough to raise my heart rate, I need 15 to 20% less basal for the next 24 hours. This is really easy with an insulin pump and not too bad with Lantus. I could never use Tresiba because it last for so long. \
With this in mind, I wonder if it is worth reducing your Tresiba further and increasing your Levemir to about 20% of your total which would make it easier to reduce your overall basal for the days after aquajogging. My thought is that this will give you both the stability of Tresiba but also the flexibility of Levemir.
It would not affect your ability to increase your Levemir more on days when your dogs don't fancy a cuddle.
It is not something I have ever done and I am only thinking "in theory".

But I am sorry I have no suggestion for the question you actually asked which is how to manage the transition phase.

Glad to see that your ideas match mine very closely.
It's not the aquajogging (have done that for years), but I started open water swimming last october, and the cold water has some interesting effects.
I usually do those short outside swims 2 or 3 days a week, but last week I went 6 days in a row.
It's less than 10 minutes in the water, but this actually might be the cause of the sudden drop in insulin needs.

The Levemir being 15 to 20% of my basal is indeed how I like it, it gives me room to adjust for more or less active days, and for hormonal or mysterious changes in insulin needs. I had this nailed for a pretty long time, until it didn't work.

I'm sure I'll find that sweet spot again, but it's a bit unsettling to need less insulin, I'm used to titrating up, not down!

 

[EllieM]

Well exercise and weight definitely make a difference for me, and I can well believe that back pain would be pushing your levels up.

I wonder if skipping the pain meds also makes a difference? (Probably not, my googling suggests ibuprofen may have the opposite effect in higher doses https://pubmed.ncbi.nlm.nih.gov/6624082/ )

In any case, better mental health is well worth the pain of adjusting your insulin doses IMO.

 

[In Response]

I started open water swimming last october, and the cold water has some interesting effects.
I usually do those short outside swims 2 or 3 days a week, but last week I went 6 days in a row.

6 days of outside swimming in winter? Are you mad?

To be honest, I am just jealous - I am not a great swimmer and hate the cold but love the idea of it

 

[Antje77]

In any case, better mental health is well worth the pain of adjusting your insulin doses IMO.

Excellent point!

 

[Antje77]

6 days of outside swimming in winter? Are you mad?

Just a little.
It started by accident, more or less, and then I found it made me feel very good, so I kept on doing it throughout the winter, up to the point we needed a crow bar to break the ice. (https://www.diabetes.co.uk/forum/threads/cold-water-swimming-and-diabetes.200255/)
So much better by now, with the water being a balmy 6-8 °C.
This was the day before yesterday:

To be honest, I am just jealous - I am not a great swimmer and hate the cold but love the idea of it

You can always give it a try after one of your runs when you're all hot and sweaty. No need to be a good swimmer, just choose a spot with calm waters where you can stand if you want to, and bring a friend.

 

[Zhnyaka]

Similar story . Literally in a year and a half, my basal dose dropped from 26 to 12 units, and only recently rose to 14, despite the fact that up to this point, since the end of puberty, my dose has been very stable. I have no idea why this happened. I was under a lot of stress when I couldn't eat or sleep for almost a week, and then this happened. To be honest, I expected cortisol to boost bg, but it seems the opposite has happened. ******* magic

 

[Antje77]

Similar story . Literally in a year and a half, my basal dose dropped from 26 to 12 units, and only recently rose to 14, despite the fact that up to this point, since the end of puberty, my dose has been very stable. I have no idea why this happened. I was under a lot of stress when I couldn't eat or sleep for almost a week, and then this happened. To be honest, I expected cortisol to boost bg, but it seems the opposite has happened. ******* magic

Glad to hear I'm not the only one!

Last night went better, went to sleep on 6.3, last insulin was 9 hours before so definitely no IOB. Normally, I would give a small correction for a 6.3 but not this time, which proved to be the right decision.
I also took less insulin during the day than I'd usually would.

Reduced my Tresiba by 2 more units to 84, third night of reduction so it should start to be noticable now.
Woke up at 4.1, still not what I want to see when going to bed at 6.3 without IOB, but a fine number to wake up to.

Haven't had much of a foot on the floor effect either for weeks, except one day with mysteriously stubborn BG.

 

[eventhorizon]

Diabetes is just odd. I've had days where my insulin needs just drop for no reason. It's easier now I'm on a closer loop insulin pump but looking back at the data I see some periods where my pump has not delivered any insulin for hours and my blood sugar has been hovering around 4 and I can't work out why.

I do know various factors can add up greater than the sum of their parts. A little weight loss, a bit more exercise, a little less stress, a slight change of diet, the weather........all will make a difference. Add a few together and it's very difficult to predict the outcome.

If I were you I'd make a hefty reduction in Tresiba and work upwards again. I rather deal with a few highs and corrections than repeated lows.

 

[Antje77]

If I were you I'd make a hefty reduction in Tresiba and work upwards again. I rather deal with a few highs and corrections than repeated lows.

There's a lot to say for your approach. But I really, really dislike running high more than I should...
At least it looks like I now have the calibration for my sensor correct so it should alarm if I drop below 4. And I'd rather deal with a few mild lows (not low 3's!) than with stubborn highs and an all day eternal fight of trying to keep myself from rage bolusing too soon.

 

[becca59]

@Antje77 I would be inclined to set your alarm at high 4s until you are more stable. Always have mine set at 4.9. If it goes in the night I eat one jelly baby and turn over. A nudge just keeps me level.

 

[Antje77]

@Antje77 I would be inclined to set your alarm at high 4s until you are more stable. Always have mine set at 4.9. If it goes in the night I eat one jelly baby and turn over. A nudge just keeps me level.

I think I should do this, or at least set it at mid 4's.
I have never had to deal with nighttime hypos before, so for years I've been sleeping blissfully in the 4's and 5's, and sometimes 6's (to the horror of my first diabetes practice nurse, who firmly believed in 8 for the night).
The good thing is that I don't see steep drops, just a very slow decline, so an alarm at 4.4 should warn me way below dropping below 4. No need to wake up still safely in the higher 4's.

Very curious what tonight will do. I went to my weekly gym and had a rather serious workout, followed by a pretty long cold dip (no real swimming, mostly chatting with the other swimmers), which means lower insulin needs for the rest of the evening and possibly night.
Last cold swim was on friday, so right before the nighttime lows started to happen.

 

[Antje77]

Very curious what tonight will do. I went to my weekly gym and had a rather serious workout, followed by a pretty long cold dip (no real swimming, mostly chatting with the other swimmers), which means lower insulin needs for the rest of the evening and possibly night.

Yesterday went well. I did drop again, but only to 4, at which point I got out of bed and let foot on the floor nudge me up a little.

And last night it all went wrong again, worst hypo in ages. My own fault too, it's not like I don't know to treat a hypo right away and not postpone.
Three times during the night the alarm went off, perfectly warning me when I was between 3.7 and 3.9 with a fingerprick. (Sorry @becca59 , I forgot to dial up the alarm before bed.) Three times I treated and went back to a wonderfully cozy bed shared with 5 small dogs and 1 neighbour (who hasn't even complained about the repeated alarms, I have a very nice neighbour).
The 4th time the alarm went off some 20 minutes before the normal alarm to get out of bed went off, and I stupidly thought I could snuggle up to my friend for just a little bit longer before getting out of bed.

Apparently this one wasn't one of those slow declines but a steep drop, and in no time I was dripping with sweat and in no doubt on needing to treat. I reminded my friend of the Baqsimi nosespray in my bag just in case.
I got out of bed, dropped into a chair and munched winegums while fingerpricking an alarming 2.8. I did manage to ask for a cup of coffee, but when my friend asked me to reach behind me for a mug I couldn.t work out how to open the door of the closet. Couldn't find the words to explain either, except for "can't". Which worked, and I still got a coffee while recovering.

At least it was a good wake up call, won't be making this mistake again any time soon!

Friday is swimming pool day, so I still went despite feeling rubbish. I expected to feel better quickly, I don't usually have any lingering effects after a hypo, but it was only towards the end of the aqua lesson I started to feel a bit more myself again. I tested at a safe 5.4 after swimming so I went to the supermarket. And got the next hypo when I came back to the car. I treated, waited for it to come up again and went home (no mandatory wait in the Netherlands).
Completely fed up with hypos by now, I decided to have a slice of low carb bread without insulin, usually this bread needs about 8 units, and it only raised me to 5.8. Huh?

If I were you I'd make a hefty reduction in Tresiba and work upwards again. I rather deal with a few highs and corrections than repeated lows.

I changed my mind, will do this tonight!
I still have the Levemir to top up if I start running high.

 

[EllieM]

@Antje77 I wonder if you need to consider adding some longer acting carbs to your wine gums when you have a hypo at night? If your insulin resistance is reducing and you have too much basal in your system then logically you need the longer acting carbs to keep you from repeated lows in the night.

Oh how I hate and loathe hypos, specially at night,. Lots of virtual hugs.

 

[Antje77]

@Antje77 I wonder if you need to consider adding some longer acting carbs to your wine gums when you have a hypo at night?

I thought I did, with the milk chocolate and a piece of bread...
Obviously not enough, but it feels so counter intuitive to eat more than half a winegum to treat a mild hypo (don't worry, I used significantly more than half a winegum last night, fully believing I'd shoot right up!), and it's pretty difficult to make rational decisions when half asleep and wanting to go back to bed.
The stupid thing is, even in hindsight and fully awake, I took what makes sense to me to treat or even a little more. But it obviously wasn't enough.

Nighttime/basal hypos are a whole new game for me, never got to practice this before.

I guess I'd better do some rummaging in the kitchen to see if there are any longer acting carbs about to put next to my bed. And I'll put crisps on my shopping list.
Will add some cashews to my midnight snacks, hopefully they'll do the trick.

 

[MommaE]

I thought I did, with the milk chocolate and a piece of bread...
Obviously not enough, but it feels so counter intuitive to eat more than half a winegum to treat a mild hypo (don't worry, I used significantly more than half a winegum last night, fully believing I'd shoot right up!), and it's pretty difficult to make rational decisions when half asleep and wanting to go back to bed.
The stupid thing is, even in hindsight and fully awake, I took what makes sense to me to treat or even a little more. But it obviously wasn't enough.

Nighttime/basal hypos are a whole new game for me, never got to practice this before.

I guess I'd better do some rummaging in the kitchen to see if there are any longer acting carbs about to put next to my bed. And I'll put crisps on my shopping list.
Will add some cashews to my midnight snacks, hopefully they'll do the trick.

In the past I’ve been advised to also take something like a spoon of almond butter or slice avocado at night. Not to treat the hypo obviously but to help sustain a reasonable level overnight.

 

[Antje77]

Went to bed at 6.8, woke up at 5.2, no alarms, wonderful night of sleep!

Drank a glass of kefir without insulin. Bad idea, rose to 8. But glad it looks like I need insulin with my food again, feeding the basal is no fun.
I took a small correction just now and I'm trying to convince myself to get my lazy bottom off the couch to go for a quick cold swim to kickstart the insulin before rising more.