Moving from Pre-mixed to MDI help please

Hi @O_DP_T1, I'll give this a go for you.

• Do I need to take insulin every time I eat something that is 10g or carbs and over? - Most of us do, but the best way to find out is to test when you do it and see what effect eating ten grams of carbs has. You may not need to.
• Is the insulin taken before or after meals? Always take it before if you can, unless you have gastroparesis. You may find that fast acting insulin needs to be taken up to 45 minutes before eating, but you should start at around ten minutes and test at tw hours to see what your post-prandial spikes look like.
• What happens if my levels are high after a meal do I have to take another injection post meal or just wait and see it it the levels drop? With fast acting insulin, the idea is that an injection of the correct amount of insulin will drop you to the same blood glucose level as before you started eating after about four hours. THis is how you find out whether your insulin dose is correct. You may also want to test at two hours to see if your post prandial level remains low enough, or if you need to move the dats acting injection earlier before eating.
• Do I need to take insulin for protein only foods? This can be a bit tricky and really depends on your metabolism. Some do have to and some don't, so you will need to test to confirm whether you do. I, for example, need to take roughly 50% of the amount of insulin for protein that I do for carbs.
• How do you work out the bolus dosage for foods where you can’t accurately calculate the carbs? It's basically an educated guess. You should ask to go on DAFNE which is a course that will help you with this.You can also look at http://www.bertieonline.org.uk which will help.
• How would it work with exercise, currently insulin doses stay static but carbs are cycled high and low dependent on if I'm exercising or not, each meal has about 40g carbs if not exercising and 80g+ carbs if exercising ? Would I need to adjust insulin intake on days I train? Normally that's what is recommended. The suggestion is that you reduce your bolus for a meal before you exercise. Again, it comes down to testing to see what works best.
• U usually train 4 days a week, my exercise usually consists of about 10 mins cardio and then about 1hr -1.5hrs of heavy weight lifting both of which lower my levels I like to start excise with a level of between 10-12
• I either exercise first thing in the morning after breakfast or in the evening after dinner, both meals contain carbs, I will either have a meal (40g carbs 50g protein) after the morning training session or a protein shake after exercise at night usually about (10g carbs 40g protein) do I need to take insulin after these? If so how much and how do we prevent lows later that day/night without constantly feeding the insulin? This is where you will have to test and find out the right levels that work for you. For example, when I was on MDI and doing weight training, I used Levemir as my basal insulin. I used to reduce my amount of insulin on nights after weight training otherwise I went low.
• Is it OK to use good fats rather then carbs for fuel if lowering the insulin in take, to support it? That's fine, as long as you are aware of adjusting your insulin appropriately.
• Will the way my body handles carbs change on the new insulin type? At the moment things that have a high GI load are a nightmare but lower GI foods such as porridge, brown rice, sweet potatoes etc rise the glucose levels slowly but no major spikes, will the different insulin have different results or will my body still handle them the same way? Nobody can really tell. In theory you shouldn't see a difference as to how your body handles different types of carbs, but its something that you'll have to test.
• Is this administered through a vial and syringe or pre-filled pen? Usually a pre-filled pen for each insulin type.
• How does it work on a night out with alcohol, if levels are high after a night of drinking do I need to take insulin before bed? what if I eat food after a night out would I need to take insulin to cover it? Each person arrives at their own strategy. It's often recommended to use less insulin if eating after drinking, and many clinics will tell you not to give insulin if you are high before bed after drinking alcohol. It will come back to you testing and seeing how things work for you.

Sorry those might not seem like categorical answers, but much of MDI is about understanding how you interact with it, and in the early stages, this means that you need to do quite a lot of testing to get familiar with how you react with it. Once you are good though, the flexibility is much greater than that of Twice daily mixed insulins.

O_DP_T1 said:

Hi all,

This is a my first time posting here so please take it easy on me; I’ve been reading the forum for a good couple of years and have found some pretty good advice and a wealth of knowledge here.

I have been a Type-1 diabetic for over 35 years and have been on the pre-mixed twice a day daily (currently Human M3) regime most my life, anyway my results are pretty good on it (HBA1c of around 6 to7ish) and I’m happy with that.

However over the last 12-15 months my insulin sensitivity has gone through the roof to the point where I have had to reduce my evening dosage by around 20 units in order to prevent night time lows and some days it’s like I’m attached to a glucose drip just constantly drinking fruit juices to keep levels in range. Thing is if I lower the evening dosage too much to prevent the lows I get a huge spike in the morning and wake up with anything from a 7- 12mmol/lm getting that happy medium I used to have seems to have disappeared without any reasoning that I can think of, is it a case that my body is changing and I need a different type of insulin to work efficiently?

Anyway I have been advised that changing from the pre-mixed insulin to the current MDI Basel/Bolus system would give me better control overall and should prevent the regular lows; so before I commit to making the change I have a few questions that I’ve listed below answered if possible, and I’d like to find out more from anyone that has swapped from premixed to MDI.

• Do I need to take insulin every time I eat something that is 10g or carbs and over?
• Is the insulin taken before or after meals?
• What happens if my levels are high after a meal do I have to take another injection post meal or just wait and see it it the levels drop?
• Do I need to take insulin for protein only foods?
• How do you work out the bolus dosage for foods where you can’t accurately calculate the carbs?
• How would it work with exercise, currently insulin doses stay static but carbs are cycled high and low dependent on if I'm exercising or not, each meal has about 40g carbs if not exercising and 80g+ carbs if exercising ? Would I need to adjust insulin intake on days I train?
• U usually train 4 days a week, my exercise usually consists of about 10 mins cardio and then about 1hr -1.5hrs of heavy weight lifting both of which lower my levels I like to start excise with a level of between 10-12
• I either exercise first thing in the morning after breakfast or in the evening after dinner, both meals contain carbs, I will either have a meal (40g carbs 50g protein) after the morning training session or a protein shake after exercise at night usually about (10g carbs 40g protein) do I need to take insulin after these? If so how much and how do we prevent lows later that day/night without constantly feeding the insulin?
• Is it OK to use good fats rather then carbs for fuel if lowering the insulin in take, to support it?
• Will the way my body handles carbs change on the new insulin type? At the moment things that have a high GI load are a nightmare but lower GI foods such as porridge, brown rice, sweet potatoes etc rise the glucose levels slowly but no major spikes, will the different insulin have different results or will my body still handle them the same way?
• Is this administered through a vial and syringe or pre-filled pen?
• How does it work on a night out with alcohol, if levels are high after a night of drinking do I need to take insulin before bed? what if I eat food after a night out would I need to take insulin to cover it?

Sorry about all the questions I just wanted some feedback from actual users of the regime to help me decide, I’m just concerned that switching to this new insulin may not actually fix the sensitivity issue.


Thanks in advance

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Hello and welcome to the forum To keep this short I'll try and answer your questions in brief bullet point format in line with what you've written.

-Yes, but bolus doses can be affected by exercise, illness and alcohol consumption.

-Usually before, but high fat meals (lasagne, macaroni cheese, etc) sometimes after or two doses split in half.

-You can take a correction dose applicable to your personal needs (calculated by trial and error) somewhere between 3-5 hours after eating, but no sooner.

-Some, but not all T1D's need to bolus for protein when the protein is eaten without carbs. I'm one of them. Protein with carbs, I don't need to bolus for. It's to do with how the body fuels itself.

-Carb counting estimation. It gets better over time. Carbs & Cals is a good mobile app which uses pictures to assist you.

-You'll probably find that you need both less bolus and less basal insulin on training days. High intensity exercise usually results in a spike followed by a gradual lowering of BG if prolonged enough. Whereas moderate/low intensity exercise results in a gradual lowering of BG without the spike.

-You'll find varying opinions regarding keto diets. It's all dependant on your personal preference, lifestyle and opinion on whether ketosis is healthy or not.

-Your body will react the same way to carbs wrt whether they are high/low GI. You'll likely find a difference in how quickly the insulin starts to work though. So worth bearing in mind for the lower GI stuff. With high GI foods, you can take your insulin a bit early to minimise/eliminate the spike, it's a good technique.

-Typically an Insulin pen. Novorapid (for example) offer disposable pens or the metal pens with changeable cartridges. The latter is better and has less of an environmental impact IMO.

-Regarding alcohol. Best idea at the start of your new insulin regime, take NO bolus insulin and eat a fair amount of carbs before bed. It's common to see a huge drop in BG overnight after a good scoop. You can always correct when high (once you know your own reaction to drink and insulin) but when you're severely low - well we both know the potential outcome...

I hope this at least partly helps

tim2000s said:

Hi @O_DP_T1, I'll give this a go for you.

• Do I need to take insulin every time I eat something that is 10g or carbs and over? - Most of us do, but the best way to find out is to test when you do it and see what effect eating ten grams of carbs has. You may not need to.
• Is the insulin taken before or after meals? Always take it before if you can, unless you have gastroparesis. You may find that fast acting insulin needs to be taken up to 45 minutes before eating, but you should start at around ten minutes and test at tw hours to see what your post-prandial spikes look like.
• What happens if my levels are high after a meal do I have to take another injection post meal or just wait and see it it the levels drop? With fast acting insulin, the idea is that an injection of the correct amount of insulin will drop you to the same blood glucose level as before you started eating after about four hours. THis is how you find out whether your insulin dose is correct. You may also want to test at two hours to see if your post prandial level remains low enough, or if you need to move the dats acting injection earlier before eating.
• Do I need to take insulin for protein only foods? This can be a bit tricky and really depends on your metabolism. Some do have to and some don't, so you will need to test to confirm whether you do. I, for example, need to take roughly 50% of the amount of insulin for protein that I do for carbs.
• How do you work out the bolus dosage for foods where you can’t accurately calculate the carbs? It's basically an educated guess. You should ask to go on DAFNE which is a course that will help you with this.You can also look at http://www.bertieonline.org.uk which will help.
• How would it work with exercise, currently insulin doses stay static but carbs are cycled high and low dependent on if I'm exercising or not, each meal has about 40g carbs if not exercising and 80g+ carbs if exercising ? Would I need to adjust insulin intake on days I train? Normally that's what is recommended. The suggestion is that you reduce your bolus for a meal before you exercise. Again, it comes down to testing to see what works best.
• U usually train 4 days a week, my exercise usually consists of about 10 mins cardio and then about 1hr -1.5hrs of heavy weight lifting both of which lower my levels I like to start excise with a level of between 10-12
• I either exercise first thing in the morning after breakfast or in the evening after dinner, both meals contain carbs, I will either have a meal (40g carbs 50g protein) after the morning training session or a protein shake after exercise at night usually about (10g carbs 40g protein) do I need to take insulin after these? If so how much and how do we prevent lows later that day/night without constantly feeding the insulin? This is where you will have to test and find out the right levels that work for you. For example, when I was on MDI and doing weight training, I used Levemir as my basal insulin. I used to reduce my amount of insulin on nights after weight training otherwise I went low.
• Is it OK to use good fats rather then carbs for fuel if lowering the insulin in take, to support it? That's fine, as long as you are aware of adjusting your insulin appropriately.
• Will the way my body handles carbs change on the new insulin type? At the moment things that have a high GI load are a nightmare but lower GI foods such as porridge, brown rice, sweet potatoes etc rise the glucose levels slowly but no major spikes, will the different insulin have different results or will my body still handle them the same way? Nobody can really tell. In theory you shouldn't see a difference as to how your body handles different types of carbs, but its something that you'll have to test.
• Is this administered through a vial and syringe or pre-filled pen? Usually a pre-filled pen for each insulin type.
• How does it work on a night out with alcohol, if levels are high after a night of drinking do I need to take insulin before bed? what if I eat food after a night out would I need to take insulin to cover it? Each person arrives at their own strategy. It's often recommended to use less insulin if eating after drinking, and many clinics will tell you not to give insulin if you are high before bed after drinking alcohol. It will come back to you testing and seeing how things work for you.

Sorry those might not seem like categorical answers, but much of MDI is about understanding how you interact with it, and in the early stages, this means that you need to do quite a lot of testing to get familiar with how you react with it. Once you are good though, the flexibility is much greater than that of Twice daily mixed insulins.

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HOW DID YOU DO THAT SO QUICK!?

O_DP_T1 said:

• Do I need to take insulin every time I eat something that is 10g or carbs and over?

• Is the insulin taken before or after meals?

Click to expand...

To your first question, yes. Your ratio might be different (I started at 1 unit per 15g carbs, but it can vary wildly per person) but that's the general idea to go for. Keep adjusting your ratio in small steps if it's not correct until you hit your sweet spot, and make sure to err on the side of caution to avoid issues. Planning meals in advance and sticking to home-cooked meals so you have all the control for a while at first will help you settle into the regime, after that you'll probably have a good grasp of your insulin needs to eat out.

Rapid acting insulin takes anywhere from 10-30 minutes to kick in. This is also individual based, but typically people start with injecting 15 minutes in advance and then move the timing around to find their sweet spot. Keep in mind that protein and fat heavy meals delay carb absorption, so if you inject early and have a greasy meal, your bloodsugar will drop before the food kicks in. (For example, if I eat pizza, I don't inject until I start eating and I do a split bolus - half now, half in 3-4 hours, because it takes longer for the carbs to kick in and my bloodsugar starts rising after 4 hours when the insulin has worn off.) This is something you'll have to trial and error for a bit until you know what your body does, but it's perfectly normal.

O_DP_T1 said:

• What happens if my levels are high after a meal do I have to take another injection post meal or just wait and see it it the levels drop?

• Do I need to take insulin for protein only foods?

Click to expand...

Depends on how long ago you ate and what you are. Once you figure out your ratio, you need to be careful with stacking insulin. NovoRapid lasts between 3-5 hours, so if you're still high at around 4 hours, it's a good idea to take a correction. If you take more insulin while your first injection is still active, you can drop dramatically. I recommend using something like a bolus calculator in the MySugr app, it helps immensely for my control and injections. It keeps all these factors in mind - if I'm at 11 due to poor timing of my injection but still have enough insulin in my system, it tells me NOT to take more insulin to get me back down to the correct level. It's super super useful.

Protein is something some people need to bolus for. I typically don't, I eat a moderate to high carb diet so protein is not converted to glucose in my body. If you low carb you may need to. Another thing you can just test for!

O_DP_T1 said:

• How would it work with exercise, currently insulin doses stay static but carbs are cycled high and low dependent on if I'm exercising or not, each meal has about 40g carbs if not exercising and 80g+ carbs if exercising ? Would I need to adjust insulin intake on days I train?

• U usually train 4 days a week, my exercise usually consists of about 10 mins cardio and then about 1hr -1.5hrs of heavy weight lifting both of which lower my levels I like to start excise with a level of between 10-12

• I either exercise first thing in the morning after breakfast or in the evening after dinner, both meals contain carbs, I will either have a meal (40g carbs 50g protein) after the morning training session or a protein shake after exercise at night usually about (10g carbs 40g protein) do I need to take insulin after these? If so how much and how do we prevent lows later that day/night without constantly feeding the insulin?

Click to expand...

I cycle everywhere I go, typically if I'm around 7-8mmol/L I don't inject insulin because it would crash me during exercise. It can help to reduce your insulin for a pre-workout meal by around 50% so you don't crash and work from there. If you stay stable with that, great! If you stay high, go up to 75% etc.

Basal insulin also matters a lot in exercise. I got mine stable to the point where 30 minutes of biking typically doesn't make a dent in my levels, which helps to keep me level a lot. If you can nail your basal then you'll probably have better control all around with exercise.

I admittedly have no experience with strength workouts and insulin so I can't comment on that, but I'm sure others can chime in.

O_DP_T1 said:

• Is it OK to use good fats rather then carbs for fuel if lowering the insulin in take, to support it?

• Will the way my body handles carbs change on the new insulin type? At the moment things that have a high GI load are a nightmare but lower GI foods such as porridge, brown rice, sweet potatoes etc rise the glucose levels slowly but no major spikes, will the different insulin have different results or will my body still handle them the same way?

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Sure! Low carb is something a lot of people do, but I think for full effectiveness you'd need to be in ketosis (the good kind) which means you have to stick to anywhere between 20-60g a day of carbs total for a while. If you eat low carb only a handful of days in a week your body won't make full use of the fat resources.

Different insulin types can affect the way the body behaves, so that is a possibility, but the only way to figure it out is to give it a shot and test often.

O_DP_T1 said:

• Is this administered through a vial and syringe or pre-filled pen?
• How does it work on a night out with alcohol, if levels are high after a night of drinking do I need to take insulin before bed? what if I eat food after a night out would I need to take insulin to cover it?

Click to expand...

Depends on what you're prescribed/where you live, I think! In Europe the pens are the most common for insulin dependent diabetics, in the US vials and syringes are still extremely common.

Alcohol can be safely consumed and depending on what you're drinking, you may not need to bolus. I typically don't bolus for my 1-2 glasses of wine or beer, as the carb load is small and the liver stops producing glucose to deal with the alcohol so it balances out for me. For sugary cocktails and mixes, you may need to bolus to catch the sugar load, but you have to be very mindful during the night. You can go low because of the liver's lack of glucose output. If you go out drinking, drink in moderation and opt for drinks that aren't mixed with sugar if possible. Before you collapse in your bed at the end of the night, test, have a snack like a biscuit or two, or a whole wheat sandwich, to keep your levels steady throughout resting.

I know I'm type2 but I love my basal/bolus regime compared to humulin m3.
Specialist had me taking it 3 times a day to prepare me for seperate injections.
I take toujeo300 for insulin resistance and novarapid for food. Far less insulin for me as I am opposite to your sensitivity.
You can move your units to suit which is too rigid on humulin mixed m3.
Ok no half units but maybe ask for an insulin which allows half units?
I love my seperate insulins.

Ps. I have less water retention due to huge amounts of insulin serum.
A big plus for me as I'm trying to lose 8 more stones.

Hi. You've had some excellent replies so far. I would just add that T1s should generally be on Basal/Bolus rather than mixed as the control is much better and the extra injections are no big deal; I don't split the Basal as I don't really see the need and that makes 4 injections rather than 5.

O_DP_T1 said:

Hi folks,

So I've spent the last few days reading as much as I can on the MDI stuff and it's been really useful stuff.

Another thing I wanted to know is that do you have to take your Basal dosage every day at the same time? At the moment I usually take my morning dose between 7-8:30am depending on when I get up; however there are days that I do take my morning dose at a different time for example the other day I went to Goodwood and took my dosage at 5:30am and about an hour and half earlier in the evening and this has no effect on my levels, is it the same with MDI?

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Toujeo300 gives a 3hr window but best if you can set an alarm and stick to nearly same time.

Hi. I'm just reading "Think like a pancreas " , an excellent book that was recommended on this forum. It literally answers all the questions you have asked, with the reasons behind it. I strongly urge you to read a copy. For starters the reason why you need less insulin could be age related. As you get older you make less growth hormone and other types of hormones that work against insulin
Cheers
Leeannea

I'll tag @catapillar . Different for me as a type2.
Hoping plenty of type1s will be along shortly with their experience.
Wish you good luck, I'm sure you don't need it thou!

O_DP_T1 said:

Quick question for the bolus side of things do I need to reduce the dosage taken pre-meal on exercise days?

If I train after breakfast and before lunch my level is around 4ish when I return and I usually eat a carby/protein based lunch, BUT insulin sensitivity goes through the roof and I usually keep it topped up through the day with good carbs, I'm a bit worried about taking insulin with that too.

I've been advised 1u of insulin for every 10g of carbs should I reduce this?

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See the previous response on exercise:

tim2000s said:

• How would it work with exercise, currently insulin doses stay static but carbs are cycled high and low dependent on if I'm exercising or not, each meal has about 40g carbs if not exercising and 80g+ carbs if exercising ? Would I need to adjust insulin intake on days I train? Normally that's what is recommended. The suggestion is that you reduce your bolus for a meal before you exercise. Again, it comes down to testing to see what works best.
• U usually train 4 days a week, my exercise usually consists of about 10 mins cardio and then about 1hr -1.5hrs of heavy weight lifting both of which lower my levels I like to start excise with a level of between 10-12
• I either exercise first thing in the morning after breakfast or in the evening after dinner, both meals contain carbs, I will either have a meal (40g carbs 50g protein) after the morning training session or a protein shake after exercise at night usually about (10g carbs 40g protein) do I need to take insulin after these? If so how much and how do we prevent lows later that day/night without constantly feeding the insulin? This is where you will have to test and find out the right levels that work for you. For example, when I was on MDI and doing weight training, I used Levemir as my basal insulin. I used to reduce my amount of insulin on nights after weight training otherwise I went low.

Click to expand...

You will just have to figure out what works for you. That might be avoiding exercise with insulin on board, considering a reduced insulin:carb ratio for meals before and after exercise, or taking on more carbs, uncovered. Check out www.runsweet.com for tips on exercise and mdi.

A 1:10 ratio is the default starting point. You'll figure out if 1:10 is an appropriate ratio that actually works for you once you start using it and testing to see how it works.