All very interesting stuff. What i could really use is a piece of software that accurately (?!) depicts insulin and carb/dinner potency with the ability to change the times and doses of each. I had a quick stab in Excel and it would appear to suggest (assuming i eat a typical fatty dinner at c. 21hr that gives me a quick spike followed by a slow rise together with Dawn effect) shifting my bolus forward half an hour and my Levemir c. 4hrs forward (from middnight to 20hr) should show a decent improvement. Not sure why it seemed to have no effect when i tried for a few days.
Before:
After:
This would also explain my extreme sensitivity to insulin at breakfast time (when the Levemir is ‘peaking’, assuming middnight injection).
But the trouble is, the outcome is so sensitive to the various inputs that it effectively serves little purpose, given the absence of certainty/variability around insulin action time/potency/etc, except to show a ‘concept’ here.
Anyhow, will try this shift and be rigorous about a 30min pre-bolus.
Interestingly, timing insulin in advance like this might result in an improvement of outcome, but it certainly ties your hands for the evening and arguably reduces one’s flexibility. For if i’ve injected my Levemir at 20hr (and pre-bolussed!) i better make sure i have that dinner i planned, and at the right time… else things get messy. I guess the counterfactual is that they are messy now, but i guess you see my point?
I think you would be a good candidate for an insulin pump. Especially now that closed loop pumps are available (i.e. the Tandem Control IQ or a do-it-yourself solution), it sounds like you are interested in the data and would benefit from this. I like Levemir because it’s somewhat flexible and, most importantly, it works most of the time for me. It’s nowhere near as flexible as a pump though, and with your schedule I think it would make your life way easier.
Hi John, I’m sorry that you are going through all of this. Sounds very frustrating. I remember speaking with you when you were switched to Levemir which is not my favorite basal insulin. Your calculated TDD of insulin would be 31u based on 0.5u/kg/d so your prior dose of 16-18u of Tresiba was accurate for your weight. I would not expect your basal insulin requirement to double. I have also found that Levemir is NOT a good basal insulin that does NOT have good 24 hr coverage also having peaks and valleys. My first suggestion would be to really determine your correct basal dose by doing a mini fast for 12 hours and see your BG trend overnight. If there is a steady state with no more than 2.2 mmol/L variation (40mg/dL) then the basal dose is correct. You want to limit any other variables during this time so keep all your other ratios the same and try to avoid bolusing during this time.
As for the dawn phenomena, this is caused by the secretion of daily hormones (cortisol, growth hormone, and catecholamines) which promote the liver to release large amounts of glucose into the bloodstream preparing for waking up. This secretion lasts for a few hours and then things return to “normal,” I was taking my usual Tresiba dose at bedtime finding a rise of as much as 8 mmol/L (150 mg/dL) starting at 3 AM and then drop dramatically after 7AM. Try to avoid bolusing for this rise because you will crash once these hormones are done being secreted for the day. I simple change of the timing of your basal insulin may help. I started taking Tresiba at dinner which resolved the issue.
Just remember not to make multiple changes at once so you can see cause and effect of only 1 change. Once you have a correct basal dose, you can see if your other ratios are correct doing mini experiments. Levemir may not be a good insulin for you and I would see if Tresiba could be restarted if that can be approved.
It is a great basal insulin, it just might not be the right basal insulin for you. The problem with fasting is that, while it may give an indication of what true basal requirements are, digesting meals have to be accounted for, especially on MDI where there is no way to set temporary basal increases or extend boluses. My basal needs can be several units higher depending on what I eat for dinner or if I eat late at night, for example. Tresiba was awful for me because it can never be adjusted for the short term. You can argue this isn’t really basal needs increasing, but it requires more insulin over several hours, regardless of how you classify it. On MDI Levemir is a great basal to deal with these situations because it can be taken at different amounts every night without affecting the next day.
A lot of people (most people?!?) apply it that way. I don’t.
I mean, basal covers me while not eating, but I also factor in how much I ate to adjust my basal. Because eating is part of my basal requirement.
I think the problem is in the application of the idea that basal has nothing to do with food and bolus is only for food.
Everything works together. All of the parts are linked. How much we eat, how much exercise, how much insulin, basal, bolus, sleep, stress, etc. Trying to distinguish them as distinct and unrelated components is where we miss things.
Yeah I understand what you’re saying, but I really prefer conceptually to keep basal distinct. The way I conceptualize it, basal needs change over months and years and bolus needs change depending on what you ate for dinner and whether or not you exercised or had a stressful day… I acknowledge it may be a little more complicated for women’s cycles…
But at the end of the day everyone can call it whatever they like… the way my mind works it’s advantageous to completely separate and not intermingle the concepts…
Basal insulins were not designed for prandial glucose excursions nor your meal composition. When you dose basal insulin to cover your meals then you run the risk of having too much basal insulin on board and likely will have lows when you are not eating. I agree that meal composition can pose a dilemma with MDI but you can easily solve that issue by watching your CGM and taking an additional bolus of short acting insulin. There are many different formulas to account for protein and fat in your meals all requiring a second mealtime bolus 3-4 hours after your meal. The CGM is your friend in this case because it allows you to see trends and react to them. Determining the correct basal dose allows you to fine tune your ICR and ISF. Again, basal insulin should not be used to cover mealtime glucose excursions.
In a perfect world yes, but it’s not that simple. I can’t take additional boluses while I’m sleeping unless I want to wake up every 3-4 hours. The whole point of AP/loop systems is that they increase basal (or extend boluses for hours, or whatever you want to call it) to deal with excursions. This is what the pancreas does, it gives insulin when it’s needed. Some meals can digest for 8 hours or more, so an additional shot of bolus before going to sleep isn’t going to cut it. There is also stress and other variables that change insulin needs. I don’t believe in rules like this, I believe in doing what works. For you maybe having a flat 24-hour basal rate that never changes works, and that’s great. For me I would be running an A1C in the 9s if I followed specific rules. I agree about watching CGM though, which is why I don’t even believe in ICR or ISF anymore. There are too many variables, including quality of sleep, absorption at the injection site, how quickly food digests at a given moment, activity level, stress level, etc. I used to spend hours trying to fine tune these ratios only to get different results every single time.
Completely disagree, this might be the case for you but stress, activity level, and other variables can absolutely affect basal needs. This is why I can’t use Tresiba. If I have a stressful day at work I need significantly more basal - taking bolus corrections do almost nothing unless the basal is jacked up. I might as well be injecting water! Weekend basal is also completely different than during the week as well.
But those aren’t “basal needs”… by definition they’re bolus needs if they’re affected by short term variables… like I mentioned we can all call it whatever we want but that Is in disagreement with the basal/ bolus concept
That’s fair, I’m not sure the classification matters much then. I think AP/loop systems are doing away with it, it’s just about delivering insulin in bolus bursts or over time as determined by the system in combination with the user. Unfortunately on MDI the options are more limited, but I don’t see any issue with using a long-acting insulin such as Levemir to cover not only what would be considered classic basal needs, but needs foreseeable for the next several hours as well, be they caused by liver excursions, insulin resistance, fatty/high-protein meals that digest for hours, or whatever.
Yeah the concept definitely becomes less meaningful with pumps and loop systems…And I think a lot of the discussions over the years about pumps have kind of disintegrated the concept of what is basal and what is bolus really… at least in the traditional sense
It’s kind of interesting because the conventional treatments blurred the lines - using NPH/R covered bolus and basal needs, or so I’ve heard in the 60s people would take a shot of Lente to cover everything and probably just feed it all day. The distinction was a big advance and now it seems like you’re right, we’re blurring the lines again with the new pumps.
Basal needs when fasting aren’t the same as basal needs when eating, even if your basal insulin is not at all covering your meals, because your basal covers liver glycogenesis, which will be very different under conditions of fasting than not. So fasting might be fine to get a ballpark, but you shouldn’t assume that will translate to the ideal basal for regular days, so not good for fine-tuning. I’ve never understood why people seem to think it would be.
Oh and yes, 100% basal needs are affected by exercise, stress etc. It’s absurd to say otherwise, ignores the biological systems that cause the need for basal insulin, which are also affected directly by those factors. Perhaps for some, a basal regimen happens to be flexible enough to not need adjustment for their own variability in activity levels, but that is likely the exception, rather than the norm (and I would wonder if it represents some residual insulin production or other reason for that increased flexibility).
I take Tresiba, and it is very inadequate for responding to changes in activity. It works for me, because my activity levels are mostly pretty much the same. The exception is when I travel and am usually walking constantly (vs tons of time at the computer), and inevitably, I end up with an extra day or so of adjustment on Tresiba where I’m going low constantly, but I also usually am ok with that because I just eat delicious local foods to cope until the dose change kicks in.
Oh and finally, for most people, exercise (and stress, illness, even sometimes hot weather) is a basal effect, because it isn’t short-term. I remember being in diabetes camp, where we are suddenly super active, and my whole cabin getting low at different points every night. It was rare that someone wouldn’t go low overnight, ha. Some of us, as kids some of whom were still honeymooning, would get to the point where they were taking only half a unit and still going low, and they would refuse to give them no insulin, so yeah. Significant exercise has effects on basal needs long after the exercise itself, I believe because your glycogen stores are getting depleted and/or going to your muscles, rather than raising your blood sugar, but @Eric can speak to that better than I can.
That’s the one thing i’m really loath to try. It’s just too invasive for me, and my skin is sensitive…i imagine nightmarish infusion site problems. Just having the Libre in my arm is bad enough, with skin reactions and sometimes aches throughout my arm for the full 14d, if i unluckily placed it somewhere near a ‘nerve cluster’ or something (i’ve no idea why this sometimes happens).
My endo says the same, but i thought he was just lazy/sick of my emails. Perhaps he’s right. He doesn’t seem to want to prescribe NPH or Humulin I, which I feel might be all i need as a third tool in the toolkit, injected once per night to stop these highs. Daytime volatilty i’ll just have to deal with. I think he fears hypos, which used to be a nighttime problem for me…less so now i have my CGM. in fact, i haven’t had a ‘out-of-it-until-11am’ morning once since i had my CGM, whereas i was having them every fortnight without it. So i’m not sure i understand the reticence to NPH.
I really don’t know what to do re. basal, I really like the idea of the flexibility of Levemir given my lifestyle but something has gone wrong since 23 July when i started it. My TDD chart is below, showing an almost-doubling, since Apr/May/Jun. I have lost weight (down to 61 from 65) so that puts me at (on some days) 1u /kg bodyweight. That sounds a lot for someone who exercises every day (30-40mi/wk run + 50-100mi/wk ride + 1/2 resistance sessions).
I have gone back to Tresiba as of yesterday (18u) to see if i can reverse some of this, and perhaps see if it was my body disagreeing with Levemir (or a bad batch? does that ever happen?)
If i don’t bolus, i will rise to the mountains. I’ll be at 20mmol/l on waking, as i sometimes was before my CGM. I can’t afford that. If i bolus at 3 or 4am, it’s likely out of my system by breakfast.
Although interestingly, my CIR is typically much higher in the morning (c. 15) versus afternoon/evening, although i put that down to a ‘peak’ in the evening basal shot.
I tried shifting to both 6p and 8pm (from 11pm) - made no difference for me. Up i went.
