It’s not a children’s pen. The problem is not enough attention is paid to MDI. I agree that a pump offers many advancements, and that with looping it is becoming even more advanced. However, I still think a CGM is the most important tool you can use (even if it is Libre with MiaoMiao, which works better than Dexcom for me). You can absolutely obtain a low A1C and SD on MDI. The trick is using a CGM, using a NovoPen Echo or other half-unit dosing pen, injecting as many times as necessary, just like someone on the pump would, and using/adjusting the right basal insulin on a twice-daily basis. Levemir is newer than Lantus. Studies have shown it to be more consistent from injection to injection, less likely to cause nighttime hypos or weight gain, and unlike Lantus it has no ability to cause a massive hypo if accidently injected into blood. You mentioned injecting 5x day, this is the bare minimum on MDI with 2 basal injections and 3 meal-time doses. There are days I might inject 10-12 x or more, depending on how often I eat, how many corrections I need, etc. I don’t find this burdensome, I would do the same thing if using a pump and can inject just as quickly, maybe quicker, with a pen. The beauty of Levemir is that it can be adjusted every 12 hours for exercise, anticipated stress, active days, if you ate a big meal loaded with fat/protein that will digest for hours. I don’t get the hype about Tresiba. I’m sure it works well for some people, but to me it is a step backwards since there is no ability to adjust the basal for 42+ hours. This is further away from closed-loop pumping, not closer to it.
@john_coburg
I’ve been T1D for 41 years and use MDI with Lantus and Humalog. I got a Dexcom G6 CGM less than a year ago and it has made a huge difference. My A1C is now 6.4, and it continues to go down. My TIR and SD have improved greatly. All this to say that I’m not interested in a pump either, but I am still improving my BG control. One of the major tools that I learned on this forum is prebolusing. I take Humalog approx 20 min before eating and that technique along with the CGM are the tools that have made the biggest difference. When done correctly, I don’t spike after a meal any more (some foods and/or combinations of foods affect this of course).
It doesn’t sound like you are doing anything “completely wrong” and actually sounds like your control is fairly decent. Like you, I have also never been able to achieve ultra-tight control in my nearly 29 years of diabetes. One thing to remember is that these forums tend to be skewed heavily towards people with very tight control. You and I have similar control, and even though it seems poor compared to many others who post, it’s actually quite decent compared to the average level of control many people with Type 1 have.
I will say, a pump and CGM made an enormous difference for me (I used a pump for many years before getting a CGM). I use features such as temporary basal rates (up or down) and partial-unit boluses on an almost daily basis, which just wouldn’t be possible with injections. Before going on the pump, I could not get an A1c below about 7.5%. Getting a pump finally allowed me to stay in the low 7% range, but I was not able to often get below 7.0%. Having the pump and CGM, and using the pumps’ features to respond to the CGM graph, have finally allowed me to keep my A1c at around 6.5%. My average blood sugar and standard deviation are about the same as yours, so our control is probably pretty similar.
I think t’s likely that if you got some additional tools, whether that be a pump or just more flexible MDI tools, you could probably improve your control. (For me, I really think it will take a closed-loop system to hit the ultra-tight range.)
Thanks for the reply, Jon.
Well, I just mean ‘low’ rather than ‘zero’. For example, for lunch i might have a salad (leaves, toms, olives, etc…but no rice or pasta or beans…) and for dinner some meat or fish with veg and perhaps just 20-30g (dried) pasta/potato/rice/beans, rather than a more typical 50-75g portion. i call that low carb, rather than zero carb. just means the margin of error when dosing is reduced… if i eat 100g of rice and i inject 10, there’s a chance my ratio was in fact 1u/12g (in which case i’ll hypo) or 1u/8g (in which case i’ll go high). If i’m just having 20g, injecting 2u feels like a safer bet, and less likely to result in a mistake.
I do too, which is why i am low-carb. but it’s not a hugely impressive improvement. in fact, since moving lower carb, it’s almost as if the body became conditioned to the ‘new norm’, and when i dare to have a big carb portion (e.g. before a long ride, or if i just fancy it), my body just can’t deal with the shock, and management becomes almost impossible. Hence, perhaps the low-carbing idea is in fact a false economy, and doesn’t help at all.
Agree it sounds great…not approved in the UK, so a non-runner for me. Novorapid my only option.
much as i detest the idea of a pump, it seems to be my only hope. i can’t spend all day every day staring at my CGM and injecting, correcting, injecting, correcting. that’s no life.
i think this is precisely what i’m trying, just not quite as low as 30g…but maybe close to that some days. But doesn’t the liver need a store of glycogen, even if just for emergencies, when low? the most violent hypos of my life have always been after a few days of very low carbs, and a bout of heavy exercise, where the body seemingly has no stores left in the liver (regardless of functioning of alpha cells) and hence completely collapses. i chipped my tooth and covered myself in bruises a couple of months ago after losing conciousness at 4pm in the afternoon after a hypo sneaked up on me from nowhere. i was out on the floor for 3-4hrs until i came round, shaking violently for an hour or so before i worked out what was going on. i can’t be going through that again… and i think the violence was correlated with my liver being out of glycogen, and hence not able to dump glucose for me.
as i’ve alluded earlier, moving A1C from 7 to 6 is a lot easier than moving it from 6 to 5, so there is a non-linear relationship between effort and outcome…i haven’t worked out where the optimum point on this curve is, but i suspect i’m not on it.
could you explain the sugar surfing concept to me? from what i have read, it is simply close management with plenty of bolus and corrections where trends are identified, trying to get ahead of the curve rather than reacting from behind…but that’s what i’m trying to do anyway, so i must be missing something in the approach.
This makes for a thoroughly depressing read. But congratulations on such impressive control. 1%/98%/1% - you couldn’t hope for better. Mine, i’m ashamed to say after much hard work, is more like 30/60/10. So very depressing.
John - Don’t fret. I read a few of your other posts on the forum, and I can assure you that you’re doing far better than I was after 16 years of T1D. I was a 21 yr old who thought I was indestructible, blood glucose meters hadn’t become available, and the A1C test hadn’t become mainstream.
I would be more than happy to share with you how I manage my TIR and SD. From what I can see, much of the difference has to do with dietary habits and corrections of low blood sugars. Getting a better handle on your morning BG would also make your day easier.
I can help you … If you’re interested, lets see what we can do 
Greetings @eric, @bkh, @chris, @Katers87,
Hope all is well. My Levemir arrived today. So having had my usual shot 16u of Tresiba last night, should i try 8u of Levemir tonight and 8u in the morning? I’m not sure if this is the best ‘starting point’, but it intuitively feels like it.
Not sure what i should be ‘looking for’ to adjust it…but guess that will become more obvious in time.
What is your range actually? It seems approximately 3.0 - 8.5 mmol/l (54-153 mg/dl)?
You will still have some Tresiba in your system. In theory, it will be over almost half still floating around in there!
So you should probably ease into the Levemir a little bit. Maybe 4u tonight, 4u the next morning, and then 8u starting the next night and then 8u the next morning.
If you multiply your normal dose of 16u of Tresiba by 24/40 (24 hours per day / 40 hour duration), basically each day you are getting about 60% of your Tresiba dose. If that makes sense.
So going with the half Levemir doses the first day is closer than doing a full Levemir dose. And you can always increment it up after the first one, if needed.
EDIT:
I am stating the above under the assumption 16 units of Tresiba is your normal daily dose. If you are already dialing it back in preparation for the switch to Levemir, than my math is wrong and I’d need to adjust all of the stuff I wrote. 
16u is currently the norm - so maths makes complete sense. Thank you.
That sounds dangerous. The Tresiba lasts a long time, doesn’t it? Like 42 hours? So if you were to take Levemir this soon, you would be getting a double dose because you would only be 24 hours into your 42-hour span of active tresiba. Perhaps someone who has experience moving off of tresiba will post with their experience, or perhaps you can search out some posts on “stopping tresiba” or “switching from tresiba to”
I’m doubly concerned because of this:
In addition, the graph you showed earlier in this thread shows dropping BG all night long, which would indicate too high an overnight basal rate for that particular night.
If the miao-miao with sensor has been working reliably for you that will help keep you safe. But for the first night I’d add the protection of setting an alarm to wake up in the middle of the night for a fingerstick measurement.
Here in the USA we would have to say that your medical staff is the only right and legal place to obtain medical advice, and so it would be best to continue your tresiba as instructed until you can obtain proper medical instruction on making the transition. So what I am going to say below is not advice, it is merely a story about what I might be thinking if I were stuck in your situation with proper medical advice completely unobtainable. This is just a story for you to think about, and only a fool would actually do what it says.
If I were switching from 16u lantus to levemir, with your overnight graph I would start with not 8u, but perhaps 7u for the overnight period. But the tresiba still in your system surely makes that too much for this first night. If I were making your transition, I think I would entirely skip a basal insulin dose for this night, and set one or more alarms to wake up and measure every few hours to stay safe, and if the BG is starting to rise overnight use Novolog/Humalog corrections until morning. I would start the levemir the next morning (i.e. 36 hours after the last tresiba) with a smaller than expected dose (like 3u or 4u) so that if it is too much the recurring hypo can be managed, and keep a good watch on BG during the day. That evening I’d plan for a smaller than expected dose (maybe 5u or 6u) anticipating a rising BG as the last of the tresiba wears off, on the theory that a minor deficit of insulin while asleep is safer than too much insulin. The next morning, after 2 nights of disturbed sleep, I would try a “normal” dose of levemir, like 8u or 9u, (and the same for overnight, like 6u or 7u to start) and depending on what happens I would make small adjustments each subsequent day until a good basal rate is zero’d in. This would best be done as a normal “basal testing” process, which is a useful search term if you aren’t well-versed in setting a good basal rate.
Good luck, and keep a close eye on the actual BG for the next few days, and have plenty of fast carbs and fast insulin on hand so that you can stay safe.
A few caveats before I reply to your reply:
- I am early-stage LADA, so I still produce some insulin. Therefore, my experience will be different than yours. However, I think I can take that into account when applying my thoughts to your situation.
- I’ve only had this condition for a bit over a year, so things that may seem more straight-forward to me may not actually be so straight-forward after several or 10s of years of management.
With those out of the way (!), some thoughts:
- I am in no way a “Bernstein stan”, but a consistently truly low-carb diet (20-30 net carbs/day, no exceptions) has given me (with some notable exceptions!) incredible consistency in my glucose levels.
- In the few times I’ve made exceptions to my 20-30 net carb/day routine, I see a “long tail” of unpredictable glucose patterns that I find maddening. As a self-identified control freak, this does not work for me at all. SO… I stick to my diet plan. But I have to say, with some ingenuity, my diet plan doesn’t really feel like I’m compromising all that much. I plan on launching a website about my low carb lifestyle soon - stay tuned!
- As I look at the dynamics from my POV, here’s what I see: Insulin, exercise, and alcohol all bring glucose down, while carbohydrates (and too much protein), caffeine (for me) and liver glucose releases will bring glucose levels up. So, for me, it’s a “glucose economy” that needs to be managed. So, that’s what I do - with the help of my CGM, I look at how much each activity/dynamic adds/reduces to my net-zero-glucose ideal and manage appropriately.
- In the morning, I know coffee brings my #s up (as does a shower - don’t ask), so I match those activities with a morning treadmill walk to mitigate that dynamic. In the afternoon or evening, I might want a glass of wine or some scotch - this will bring my #s down, so I need to compensate with some raspberries, low-carb jelly with some peanut butter, or other low GI fruit or food. At this point, 1 year in, I’ve made this “matching strategy” part of my regular thinking process. It’s not even a chore - it’s just a routine and a pattern that I’m quite happy to follow in exchange for glucose equilibrium. Yes, it’s a shame I can’t do this automatically anymore, but it’s wonderful that I have a mind that can compensate for the lack of organ-managed automation.
- To this point, if you decide to go truly low-carb like I have, there will be no more “pasta moments” that your body overreacts to. You will instead move to edamame pasta, pasta zero, miracle noodles, etc. and really just never carb load again. This may sound distasteful, but I’ve found it to be liberating and wonderful - and I’ve been able to eat more and keep the weight off as well, which is a super-added bonus for a chronically overweight person my whole life (until now).
- I will be provocative and suggest that you may be able to avoid the dreaded pump if you buckle up and try to tighten controls of your inputs and outputs to manage glucose equilibrium.
- To your question about the liver, the good news is that the simple answer is “no” - your liver doesn’t need carbs to have its store of glycogen. Evolution has served us well! We can extract and store energy from a variety of inputs. And thanks to a stage of metabolism called ketosis, people on the keto diet (which I think is beyond what I do) simply change what they convert into glycogen - switching from converting carbs to converting fat. Yes, this is kind of a backup system but it also seems robust enough to act as a primary system. It could be quite healthy to go back and forth from traditional to ketosis…just something we humans haven’t had to do since the advent of modern agriculture! My guess is that my diet isn’t extreme enough for me to be in ketosis most of the time, but probably goes in and out which helps keep the weight off while never feeling hungry.
- Your hypo events from low-carb + exercise make perfect sense in the context of the above equilibrium POV. It would be the same if you exercised and then drank 2 shots of vodka. You’re engaging in two glucose lowering activities and not mitigating with any glucose-raising activities! If you go truly low-carb and exercise a lot, you will probably need to significantly reduce your exogenous insulin to compensate. Which… I’d humbly suggest…is the ideal outcome!
- I don’t think moving from 7-6 is technically any different from moving from 6-5. It’s linear, right? I think it’s about the management techniques we use, and how effective they are. As a for instance, with my management plan (now, again, I’m still producing insulin so it’s not a fair comparison!), I went from 6.5 to 4.1 A1c in a year. But 4.1 w/some insulin is probably close to 5.1 w/o insulin. Maybe. Hard to say. But what’s not hard to say is that by looking at glucose equilibrium as a system dynamics challenge, it becomes super clear to me, at least, how to manage it effectively. There is no boogie-man in diabetes. It’s just that our automation sub-system has failed and requires a manual override, and our brain can handle that override just fine if we know what problem we’re trying to solve.
If I come off as too Pollyanna here, I deeply apologize - not at all my intent. This is NOT easy to do. It’s just easy - and for me, interesting - to talk about. Especially when my “grand plan” goes awry when, suddenly, something changes inside of me, and I don’t know what it is, and my whole system goes haywire and I have no idea what’s going on. These episodes are incredibly frustrating to me, and I get upset right quick because what used to work stopped working. But I am convinced that when things stop working the way they did, it’s because something tangible happened in the system. It’s then really incumbent on me to develop hypotheses and develop tests to figure out the source of the change, and compensate and adjust to suit.
As someone who has a “problem solving” type mind, this kind of stuff challenges me more in a positive way than in a negative way. I can totally understand that for other types of minds, this is just friggin annoying and barely worth the effort. I hope that my orientation toward this condition can help others at least see another way into the system dynamics so that they can get some control back.
That story is a wonderful reminder that YDMV. JonDeutsch has an approach that he finds really satisfactory, and it would drive me out of my mind. I like carbs and eat lots of them, and take lots of insulin to go along with them. And I actively steer the BG in a good direction, some manual control and lots of automated control from LOOP. The result is sufficient joy, plus an A1C in the high 5s and a “time in range” in the high 90s.
It’s good to hear stories of “this works for me”, as it helps each of us learn alternative approaches. Yet the vast differences in our bodies, circumstances, goals, lifestyles, and personalities means that there will be a huge variety of preferred approaches to manage our diabetes. Low carb and extreme low carb approaches work really well for their adherents. And are simply intolerable for people like me. YDMV.
I like carbs too! They are extremely useful for me!
Switching insulins is messy, and there is no perfect method because everyone is different. Tresiba lasted a really, really long time for me - more so than it does for others based on what I’ve read on this forum. When I switched from Tresiba to Lantus, I waited until I noticed an upward trend before I gave any Lantus. That wasn’t until around 36 hours after my last Tresiba dose. I only gave half of what I expected my Lantus dose to be at that time (which was 25% of my total 1x/day Tresiba dose).
If I remember correctly, Levemir tends to kick in very quickly. If I were in your position, I would wait until seeing an upward trend. I would not start a new basal insulin right before going to bed at night. I would err on the side of going high during the night and set an alarm so that I could give a Novorapid correction dose if needed.
I would base my morning dose on what the trends were during the night. If I agressively trended upward during the night, then I’d give close to what I expected my Lantus dose to be at that time. If the upward trend was minimal, then I’d stick to 50% of what I expected my Lantus dose to be at that time. Since I would be awake to give myself glucose if it ends up being too much, I would be less concerned about being aggressive with my morning dose.
Completely agree!
@Boerenkool - exactly (I use 3.0-8.5 on Sugarmate, on my Dexcom alerts are set for 3.6 - 7.5).
Are you using a Dexcom or Libre?
@bkh - Love this post. And I have an admission to make 
… I abandoned my low carb / keto ways for quite a while during the quarantine (which was a strictly followed way of life for the majority of the citizens in my small part of 
). EDIT: The self-isolation / quarantine was strictly followed in Canada, Not the Keto lifestyle 
I have been consuming large quantities of the 3 P’s: Pasta, Pizza and Potatoes, and let me tell you they are delicious! Far more challenging to bolus for, but for the most part quite doable.
I’m back to lower carbs most days now, as I’m recovering from a broken hip and I’m still a month from getting back to regular exercise.
I use a Libre and my target range is 4.0-8.0 mmol/l (72-144 mg/dl).
I suspect that if/when I need to go on insulin, I may ease up a bit on my diet restrictions - at least from time to time. But for now, I am doing what I can to avoid needing exogenous insulin so I’m happy to manage the other levers of control that I have at my disposal.
My endo said that there are “literally hundreds of phenotypes” of diabetes, so, “YDMV” is accurate. YDDV (does vary) may even be more accurate!