Off premix, On to basal/bolus, Help!

[acron^]

Hi folks,

I've had a good read of the current topics regarding Levemir and I feel like I need some clarification

I recently came off Novomix where I was on around 8u in the morning and 8-12u in the evening. My control was pretty good but not perfect and so I asked to come off premix and go onto a basal/bolus regime. The diabetic nurse I saw at Warwick Hospital put me on 4u Levemir before bed and then try a 1u:10g carb ratio.

Firstly, it's only been a week but my levels are all over the place. Reading other posts, even though I'm low-carbing (average 40g a day), 4u seems pretty low compared to a lot of others and I am contemplating upping it and maybe splitting it? I'm still feeling a bit fragile and I need a bit of validation.

Secondly, a 1:10 ratio for bolus seems well out too but it's hard to tell until I'm happy with my basal. What are other people's ratios?

Thirdly, "correcting". What is it and how do I do it safely?

Thanks in advance because I know your answers will be smashing 8)

 

[iHs]

Hi Acron

The only real way to find out what your exact insulin to carb ratios are going to be is to do bg tests approx every 2 to 2.5hrs from breakfast until you go to bed. You are looking to try and get your target bg levels to be somewhere between 4 - 6 before you eat a main meal and no higher than 8, 2 to 2.5hrs after you eat. By using trial and error, log all your bg results, how much carb you eat, your insulin dose and then see how high or low you are mid way. By increasing/decreasing your insulin or eating more/less carb you should be able to work out what your insulin to carb ratios are to reach the above targets. Most people do need more bolus insulin in the morning than they do at lunchtime though. The 1:10 ratio is only a rough starting point.

If you look at the BDEC website,( google - BDEC diabetes) you will see how correction doses of insulin work. The correction dose is how much bolus insulin you need in order to make your bg levels drop back to your target. Unfortunately though for the time being, until you are able to work out what your total daily dose of insulin is with MDI, you won't be able to use correction doses that accurately.

Its difficult to say whether you should increase your basal or bolus as you dont say what you are eating for your meals or what your bg levels are 2hrs after eating.

 

[LittleSue]

Hi Acron

Everyone's different so we can't tell you how many units you need, but I wouldn't expect 4 units of Levemir to last 24 hours. With Levemir, smaller doses don't last as long as bigger ones, so you may need a second dose, maybe at breakfast. Low carbing shouldn't affect your Levemir dose much because your mealtime bolus should be dealing with the carbs. The Levemir should be holding your bs stable day and night assuming you didn't eat.

A ratio of 1u for 10 carbs is a starting point from which to adjust. You're right that you need to get your basal sorted first, otherwise you could end up constantly compensating for insufficient Levemir with artificially big bolus doses.

Correcting means knowing how far 1 unit of bolus will reduce your bs and thereby how much extra you need to reduce your bs to the desired level without going hypo. (The correction dose is on top of anything you're injecting to cover food.) Generally corrections are done with meals and at bedtime, although once you know your own ratios inside out you may be able to correct sooner. If you jump in and correct too soon after a meal, the doses can overlap too much and cause hypos. You could start by assuming 1u reduces by 3mmol and see if that works, though you may need more units for the same reduction if bs is very high (about 14 or more) to start with. The beauty of this is that you can correct an unexpected high bs and still know what your bs would have been if you hadn't corrected it. Therefore you can see trends without tolerating high bs for days before making a change.

Similarly if you know 10 carbs raises you by 3mmol, then you know how many extra carbs to eat to adjust a low bs up to where you want it.

Can you adjust your doses by half-units? If not, ask your nurse about half-unit pens. At low doses, these make a fantastic difference, especially with the Levemir. The usual increase/decrease step is about 10% of the dose - whereas to adjust your Levemir from 4 units without a half-unit pen you'd have to increase or decrease by 25%. Things tend to be more stable overall if the basal is just right and a half-unit pen gives you more scope to tweak it.

Sorry there's no quick answer, it really is a case of trial and error.

 

[acron^]

I understand that it's very specific to me, I mainly just want to know what indications I should be looking out for that perhaps my basal needs to go up? It just feels a bit too low...

At the moment I'm waking at anything between 7 and 16. Today, for example...

Woke up with 11.2mmol.
Breakfast: 11.4g carbs, and 5u Novorapid.
Pre-lunch (1pm) was 6.8mmol.
Lunch: 3.9g carbs, and 4u Novorapid.
2hrs after lunch was 7.7mmol.
Pre-dinner (8pm-ish) was 9.9mmol <- an increase?
Dinner: 22.7g carbs, and 6u Novorapid.
10pm - 4u Levemir.
Before bed (11pm): 8.2mmol.

I feel like i'm getting really frustrated with it because I'm used to having much better control than this...sorry.

 

[gbtyke]

I think the health proffesionals will always start you low and build up to avoid hypos. I have recently switched and since mixed is 70% long acting I expected to be put on 70% of my mixed dose but it was lower than this. I have recently upped the starting dose but have introduced it in the morning instead of upping the evening dose. Still some tweaking to do yet. 4 does seem low but it is based on so many things particularly body weight that it is hard to say what is small.

 

[acron^]

10.9 this morning... Man, I want to punch something.

 

[NickW]

It does sound like your basal amount is too low from the figures you've posted, particularly if you were low-carbing while you were on the mix. That implies you used to need 20 units per day and now you're being advised to use 8. I suspect that you may end up needing double-figures of your basal insulin and only a handful of quick acting. But this is just my gut feeling, obviously I could be completely wrong!

In my opinion the best way to find your basal dose is to fast for a day and see what happens to your blood. The way I would approach this is, on your chosen day, test when you wake up - if your blood is high take a small corrective bolus to bring it down a bit. Continue to test every hour, and don't eat anything all day (unless you go hypo, in which case you should of course treat it). I fasted for the entire day and ate a small very-low-carb meal at about 7pm, just so that I didn't end up going 36+ hours without any food - I don't think that's strictly necessary, but I was worried I'd chew my wife's arm off in my sleep if I didn't eat something!

If you find that your blood tends to climb all the time, and you have to take corrective boluses to keep it down, it means your basal amount is too low. If you tend to go hypo your basal rate is too high (or you got too enthusiastic with a correction). Your ideal outcome for this test is that your blood stays stable all day.

This is the approach I took to find my basal rate (I repeated it 3 times or so, tweaking the amounts as I went), and it's something I repeat every few months to check that I'm still correct.

Once you know your basal rate is correct, working out your ratios and corrections is MUCH easier.

 

[dipsticky]

Jeez NickW. You are good ! Haven't I met you somewhere else on the net ? Paleo diet and all that ?
It'll come to me eventually ?

D.

 

[acron^]

Nick, that's fantastic, thank you.

I'm going to wait for a morning that I wake up with a decent BG level and then do a fast, in exactly the way you've described. I am also convinced that my basal is too low, considering several examples already where I'm experiencing unexplained rises during the day.

 

[SophiaW]

We recently put my daughter onto Levemir/Novorapid combination having been using a Novomix combination. My daughter is 8 so the amounts she takes will vary from you. She has 4.5 units Levemir at night and 6 units in the morning. I worked out her basal dose by doing the fasting thing that Nick talks about, but we did it in half days. So first day she woke with a good reading and we skipped breakfast but injected the Levemir, I tested her every hour to see what happened. We didn't have lunch until about 2pm, she was starving by then! It took a few days of tweaking to get this right. We did the fasting test thing over a period so that she didn't go for consecutive days fasting. It's also good not to make adjustments too quickly, give it a few days on the new dose before you make further changes. To check the afternoon we did the same fasting thing but had breakfast and then skipped lunch, testing throughout the afternoon until her evening meal. When her readings held steady throughtout the day we knew the morning dose was right. For the evening dose I woke every hour to test and that way we got a good picture of how the insulin was working and how much she needed. Once the basal was worked out then we could get to grips with the bolus carb:insulin ratio. For my daughter it varies during the day with the morning needing a 1:8 ratio and the rest of the day needing a 1:13 ratio. I plan to do a fasting test every so often just to make sure the doses don't need changing as she's a growing child.

 

[phoenix]

Even as an adult most people don't fast for a day to basal test. Its easier to do it in bits.
This short article describes the way that many people do it
http://www.diabetesdaily.com/forum/articles/16675-basal-testing-multiple-daily-injections

 

[NickW]

Good points, you can break the testing down into periods; the link phoenix posted looks like a good explanation of how to do it. I personally found day-long fasts to be more accurate, but plenty of people do it by breaking into chunks so that can obviously work well too. I don't mind long fasts (particualrly after reading the research on the potential benefits of Intermittent Fasting), but if it's easier to fit in smaller fasts then go for that.

dipsticky, you've got me blushing I dunno if you've bumped into me before - I don't post on that many forums to be honest. Not sure if you read Robb Wolf's blog, or know what CF or the PMenu are...?

acron^, do let us know how you get on. It takes a little bit of tinkering to get it right usually, but I reckon you'll be fine - you've got an amazing A1C already so you're obviously taking good care of yourself!

 

[dipsticky]

dipsticky, you've got me blushing I dunno if you've bumped into me before - I don't post on that many forums to be honest. Not sure if you read Robb Wolf's blog, or know what CF or the PMenu are...?

Hey Man. Yes. Must have been that blog then, although I am sure I saw you elsewhere ? Mate of mine was into real weird stuff. Palio diets and stuff, boy was he one fit dude. California guy, you know what those beach bums are like ? I'm not sure about the CF ? I think it something to do with training or crossfit. Like I said, he was seriously weird and was always going on about this Wolf man and somebody called lamonde or something like that. I wouldnt have liked to cross him, he looked a bit like the missing link. Made two of me. :lol:
Keep kickin !
D.

 

[acron^]

Argh, just took 6u for 3.6g carbs and now I'm at 7.9. Terrible :/ That's less than 1:0.6! My basal must definitely be wrong. I'm going to try increasing my Levemir to 5u tonight and then i'll give it another week (already been one week on 4u). Alternatively, it seems like splitting is pretty popular. If I get up to 6u and still no good results then I'll try splitting. Does the morning injection have to be 'at the same time every day' like the evening one? I can forsee an issue on some weekends :wink:

 

[iHs]

Argh, just took 6u for 3.6g carbs and now I'm at 7.9. Terrible :/ That's less than 1:0.6! My basal must definitely be wrong. I'm going to try increasing my Levemir to 5u tonight and then i'll give it another week (already been one week on 4u). Alternatively, it seems like splitting is pretty popular. If I get up to 6u and still no good results then I'll try splitting. Does the morning injection have to be 'at the same time every day' like the evening one? I can forsee an issue on some weekends :wink:

Acron

Get yr fasting bg levels overnight sorted first by increasing the levemir up to whatever dose it takes in order that you get up in the morning with an ok target bg level. Then start to give yourself about 3 units of levemir in the morning and see how you go on this. As a general rule of thumb - the more basal you inject, the less bolus you will need.

Some people on the forum inject basal every 12hrs but both Fergus and myself (along with loads of other peeps) inject it before going to bed and first thing in the morning before breakfast. By doing this we gradually increase the morning dose and decrease the evening dose to cover the amount of hours that we want the basal to cover. What you decide to do is entirely up to you

 

[acron^]

Cheers iHs. It really helps just to hear what other people do and what options are available to me. Now I have a plan and I feel a lot more confident because of it.

 

[lilibet]

Acron

I feel your pain!! :roll:
i swapped exact regime for regime today. I know its very very early days and my levemir am dose seemed fine (skipped lunch for ages today by default). However, my ratio to carb seems SO not working and my pre dinner bg was HORRIBLE. So cant tell if levemir tailing off too early after 12 hours or if Novo to little for lunch time
My concern is that ifyou have a rubbish pre dinner, then you then end up going to bed higher ifyour ratio is not set right, and then its hard to tell if your setting 'levemir' at a stable setting, when that bg is HORRIBLE.

I know setting the basal is the holy grail of MDI but I wonder how I will be ablen to assess the true profile if my FBG has the hyper hangover from the night before. Then with a rubbish starting fbg the whole bloody things starts again!

Aaaagh!!!

 

[acron^]

Sounds like we're having the same kind of woes lilibet I think it's just a case of thinking differently to how we did with premix. It's like, a totally different game.

This ratio stuff is baffling me though. Woke up @ 8.0mmol, injected 6u to cope with a 5g carb breakfast and an hour later I'm 8.0mmol still. So, on the assumption that my basal is all dried up by morning, is my ratio 1:0.8? Surely not...

 

[lilibet]

Not a clue petal!

Overnight seems to be ok - am waking up within 1mmol so far (though granted its only been 2 days :lol: ). Have been trying to make sure 4 hours between all meals to let novo out my system and check. Yesterday a bit unfathomable - rose and then dropped all through the day - after skipping breakfast to check day time basal. I mean, it went from 6.8 to 8.2 to 5.1 to 7.8 NOT your typical levemir pattern so I am STUMPED

My ratios are out too though I bet DNS says they are fine. I always thought it would work on the basis that your bg should come back to what it was when you injected/before you ate so your rise is just at one hour, starts dropping and then returns to what it was. Im finding Novo drops it to its lowest after about 2 or so hours and then it doesnt move much after that. Not sure if basal needs adjusted, but likely ratios I think.

Its horrible seeing higher numbers after a year of as good control as I can (and 3 x 5% A1c's) but im working on the basis that with premix we didnt always check after eating (unless feeling funny) and the one and two hour readings are probably similar to when on premix. I think its probably we just expected so much more from taking a bolus short acting - but of course, it is still early days and we will get there. ITs just that its not quick enough for us!

Still if anyone has any ideas why the no food = wavy bg readings I would be most intrigued to find out!. I was told not to test too much (aye, right) and Im sure when I hit DSN with my squillions of readings, I'll get a bit of a frown. Still, Its my pancreas, and I'll cry if I want to!

 

[NickW]

acron,

If you need 6u for 5g carbs in the morning, I'd suggest finding out what you need for 0g carbs - i.e. just eat a couple of slices of cooked meat or something (do still eat something though, as food signals the body to release / stop releasing various hormones).

It sounds very much like you either get dawn phenomenon (where your blood rises all by itself in the morning); that you're very insulin resistant in the morning (which is quite common); that your basal is still too low (quite likely as we discussed above); or all of those things apply.

However, you really need to get your basal dose sorted out before you can get all this right; concentrate on that first, then work on the ratios. The morning one is often tricky and you might actually need a specific injection for dawn phenomenon (e.g. I take 2 units when I wake up to account for it, rather than changing my morning ratio). This all takes a bit of tinkering, but it all starts with getting your basal dose right.

If you're struggling to get your BG right in the morning and that's stopping you doing a decent fasting test, I'd consider cautiously increasing the basal dose (e.g. by 1u per day) until it's more stable. Obviously you need to be alert for hypos, but given that you're now injecting much less than before, you're not having unexplained hypos, and your BG is tending to rise, I'd say this is relatively safe; it looks like your current basal is way lower than it needs to be.

Good luck!