FUDiabetes

Need advice on how to go from a pump to injections

I have been on a pump for 31 years and my doctor has suggested that I take a break and use a combination of Afrezza and Tresiba. I have been testing out the Afrezza and have been quite pleased with the results. I am concerned about using Tresiba for my basal though. With a pump I reduce my basal when I exercise, which is usually 5 times a week. I can probably play around with eating something like a Clif Bar before I bike or run and make that work. However, on my exercise days I typically will go low during the night if I don’t reduce my basal. How would this work with Tresiba? I’m assuming that it would still be in my body by the evening.

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I’m sure the others will chime in and I can refine my answers later because it’s starting to get a little later over here.

-Regarding basal insulin, find one you like and maybe test a few. I started with Lantus, but then Toujeo made me gain weight and Tresiba, I just felt a little off, so then went back to Lantus (or Levemir…I liked both and found them similar)

-Regarding basal during exercise, carb requirements were generally fairly predictable depending on the routine and situation, having minimal bolus in the system made it so that things moved even less

-I know @Eric will provide additional wisdom, but for me, it seemed like MDI worked pretty well in the early evening because it takes time for the basal dose to start working and it was possible to dose less bolus during that window, restoring glycogen post exercise has also been helpful for preventing lows during the early phases of sleep, I forget my exact numbers but made some posts earlier I’ll have to look up after some advice from the previously mentioned @Eric

-I guess one solution would be to find another doctor…but I found my pre-pump time to be very valuable to develop routines and to see how the body responded to a variety of scenarios, I think that it’s possible to have a basal dose that closely matches the body’s needs but that it takes more energy to line things up

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@HippieNerdBabe,
Can you tell me what your basal profile looks like on your pump? Is it pretty much the same throughout the day, or do you have different rates for day and night?

What was the reason for your doc telling you to take a break? Is your doc just wanting you to try a different regimen to see if you like it better, or is there another reason?

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Hi Eric,
My basal profiles look pretty consistent through the day and night. There are some slight variations but nothing too significant. The decision to take a break was made after discussions of how my sugars have been unstable for a while with no discernable reason. He thought I should take a break and give my body a chance to heal from having a needle in me for 31 years. I completely agree as I have been running out of spots for quite a while. At the moment I have my CGM at the top of my breast and my Silhouette on my side near my ribs. I’m about to rip that one out as it’s hurting but I’m trying to suck it up since it seems to be working. Anyway, I digress, I’m excited about leaving the world of the pump behind for a bit. But since it’s been 31 years I really don’t know anything about taking basal doses and how that works. I like my doctor and trust his advise but I don’t think he gave me enough information so now I am searching it out on my own. I appreciate the info that Mark gave regarding the different types of insulin. Who knew that different insulin worked differently. I’ve had Novolog in my pump for as long as it’s been around. I guess I need to start educating myself :slight_smile:

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Hi Mark, thanks for the information regarding different basal insulins. I wouldn’t have known that they are different. I’ll start with the Tresiba, since it’s a sample and try another one if need be. I never knew that there were so many different kinds. I’ve only used Novolog in my pump (since it came out) so I’ll need to educate myself which is why I reached out to this group. I’m pleased with my doctor and since I’m in Nevada, it would take at least 6 months to find another one anyway because, at least in my area, there is a doctor shortage. If you are not an established patient, plan on waiting a long time for that first appointment.

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In that case, Tresiba might work okay for you. It is very flat, and if your basal rates are pretty much the same day and night, that is fine.

The problem with Tresiba is if you need more basal at night or less at night or whatever.

One challenge will be with exercise. As you said, when you exercise you reduce your basal. When you use MDI and inject your basal you can’t do that. So the only real alternative is to feed that basal during exercise.

Tell me about your exercise routine. There are some adjustments you could make to help with that. Like doing your exercise soon after a meal, and taking less insulin for the meal. Something like that might work.

Or the other thing would be to just have some rapid sugar sources available, like sports gels or Gatorade, and just take some of that while exercising.

Or taking the Clif Bar like you mentioned above right before you start, since those have some more sustained carbs and would last a while.

For this, you will probably need to eat more carbs for dinner!

If you are concerned about weight gain, you can substitute some of the other calories and make it more carb-centric. Like less calories from protein and fat, and more from carbs. That would help prevent lows at night, and you can manage weight that way.

There are a lot of things to manage and adjust, so please feel free to ask and post.

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My exercise consists of biking (3 times a week), running (2 times a week), kayaking (weekends but sporadic) and hiking (weekends but sporadic). I think I have the biking and running pretty much under control. If I stay consistent with the distance and/or intensity of the exercise then I can eat a Clif Bar about 1 hour before and be okay. There have been times when I have had to stop and eat some gel but I can deal with that. Kayaking is okay because its not as strenuous. It’s the hiking that I will have to work with. I’ve always struggled with that. I most often will reduce my basal to almost nothing and then still have to eat a bunch before (and during). Not sure why this exercise is such a problem but since we only do it about once a month I will figure something out.

I just took my first injection of Tresiba and then read the pamphlet regarding the possible side effects. Oops. Should have done that first. It says that weight gain might occur. Nope. Don’t want that. I know that Mark mentioned weight gain with a particular brand (not Tresiba). I guess I’m going to have to research what people’s experiences are with which one works best.

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Those disclaimers for things like weight gain are not extremely useful. The real explanation is this:

Without sufficient insulin, your body is unable to move glucose from your blood into the cells. Excess glucose that is not needed for energy and replenishment of muscle glycogen is converted to fat.

T2’s who do not have sufficient insulin, are not moving the glucose properly. So they end up with high blood sugar, and they end up peeing the glucose away. Certainly not very healthy, but it can reduce their weight because they are not properly using or storing glucose and fat.

So the T2 goes to the doctor, and Tresiba is prescribed. Now they are better able to move the glucose, to use it, and to store it. Their blood glucose is better, but that also means they can gain weight because they are no longer peeing it away. They are no longer wasting the carbs, they are using them and storing them.

But really, it is not the Tresiba that causes the weight gain. It is the fact that their body is able to use the food properly. Instead of peeing glucose out of their system, they can use it and store it. So really, the food is the reason for the weight gain. It’s just that they are actually using the food instead of it being wasted out of their body through their kidneys.

Another way of saying it is like this. Any insulin can cause weigh gain compared to no insulin. Imagine if you stopped using insulin altogether. I promise, you would lose a lot of weight for a week before you died. Your body would not be able to process anything you ate.

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I didn’t notice any weight gain with Tresiba (although only took it for a few weeks). It was pretty wonderful how flat the number stayed but I just felt slightly tired (don’t want to plant a bias here). My endo uses it and thinks it’s great. However, Toujeo led to weight gain so it was good to get away from that one.

Overall, I felt that the biggest challenge with daily injections is lining up the BG for sleep. I post on this topic a lot. But my general approach was to take a humalog dose around 5:30 pm (and perhaps a smaller one an hour to an hour and a half later) and let that dwindle down while having the BG find it’s range for going to bed. Other than that, I felt like the approach worked great and could be set up for things to go smoothly without too much effort.

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Just came back from a successful bike ride. Quite happy my numbers were perfect. Ate a Clif Bar 1 hour before. I’ll be interested to see how the rest of the day goes. I might be reaching out to get your advise/experience on the dose in the evening.

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My situation is similar, I was using NPH and Regular injections when I switched to pump. So I have never used Lantus, Levemir, etc (or pens) except short duration while a replacement pump was shipped. I couldn’t wait to get pump back, and like it more since recent switch to Tandem with CIQ.

Hope you post how your transition goes, some day I may give it a try.

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@HippieNerdBabe 2 cents from a type 2 DM on MDI bicyclists. When I first started MDI with a CGM I was unable to ride or do a brisk walk for more than 15 minutes. My BG would plummet and I would have night time hypos. Being type 2 I do make some insulin, but it is quite diminished after 30 years.

I take 25u Lantus and around 6u Humalog in a day. What worked for me is cutting Metformin by 50% (yeah, that probably doesn’t apply to you) and splitting the Lantus (basal) in 3 doses. 10 morning, 10 noon and 5 late afternoon, I know this sounds like a bolus schedule and those are done close to the basal injections.

If I am going to do a 1 hour or less bike ride, nothing changes. However, I do a 2+ hour group ride every week. I cut the morning Lantus by 30 to 50% depending upon BG reading at that time. The remainder at the end of the ride.

Just before the ride I will eat a Kind bar (9g carb). They give me a much smoother curve. I ate 22g carb for breakfast, basal 7u bolus 1u, BG 78, 75 minutes later, at ride start, ate 9g Kind bar with BG 89. Over the course of 2 hours 15 minutes BG rose to122, took the last 3u Lantus. BG dropped back to 105 by lunch.

I’m not suggesting this for anyone. It is what works for me. It took a lot of tinkering and watching BG trends. When I was on Lantus and Metformin only, I split the dose 2/3 at night and 1/3 in the AM. This reduced night time hypos 6 hours after dosing. They say Lantus is flat, but the curves actually show a slight peak close to 6 hours.

I had another problem after going on MDI. For two hours after lunch my BG was great then it would start ramping up. That’s when I split Lantus into 3 doses with a reduced dose at night.

Good luck with the new regime.

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After exercise I just reduce my nighttime dose of Tresiba. I give 9 units of Tresiba twice a day. Whenever I have a late soccer game, I’ll reduce my nighttime dose to 7 units and it seems to work out fine.

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Another question regarding taking Tresiba. I was given a sample by my doctor. He told me to take 13 units (basically what my total basal was with my pump). He gave me no other instructions so for the first 2 days I took all of it in the morning. I vaguely remember (from forever ago) that I took an injection in the morning. I think at that time I probably took one at night also. When I actually filled my prescription, the instructions said to take it at night. And you are saying that you give injections twice a day. I know from experience (and this being a new doctor) that I have to figure out what works best for me. So I’m curious as to what others do.

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I regularly swap from pumping with Omnipod to Lantus. When I do so I use a Lantus dose that matches my pump basal; my pump basal is 0.5IU/hour so I do, net 12IU/day of Lantus. However Lantus has a short acting time compared to Tresiba; 12-18 hours rather than 24+ (depending on how you count it). Consequently what I do is 6IU morning and 6IU evening.

I would not do a single “long acting” dose in the evening; it may be long acting but the majority of the action is still in the first few hours, so within 6-9 hours for Lantus and I’m guessing 12 hours for Tresiba. The problem with long acting insulins is that they aren’t constant release, so the basal is too high for the first half of the action period and too low for the second. This can be fixed by overlapping multiple doses, flattening out the highs and lows; taken to the limit this is how a pump does a basal despite using a “fast” acting insulin.

When I was on MDI I used Ultratard for a long time and found single morning injections worked just fine, then I had to switch to Lantus (Ultratard was discontinued and I’m in the US), that was a disaster on single injections. I should probably try Tresiba, it does seem to be available in the US, but if I do so I will still do it twice daily to avoid the peaks and troughs of injected long acting insulin.

The bottom line is that the more often you inject the closer it is to a pump - to a constant basal - and the more easy it is to control. You can’t suck the stuff out after you’ve injected it, so the second best is to inject reduced quantities at more frequent intervals.

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I’m on Lantus, vice Tresiba, so there may be a difference whether splitting dose is advised or not (Others here with more experience can advise better).

My doc prescribed taking my entire 11 unit Lantus dose in the evening before bed. I try to take about the same time, but it actually varies by up to an hour. I found I seemed to go low overnight fairly frequently. After reading about split doses, I chose to try it, taking 7 in the am and 6 at night. My perception is it took a few days to “even” out, but I still found I seemed to settle at a higher BG level than I wanted, so I tried increasing the dose 1 unit for the evening and I seem well balanced (for the most part). I’ve since discussed with my Endo, who didn’t seem to mind the relatively minor excursion on my own (I figure she’s there for expert advice but I’m the ultimate decision authority; she seems on the conservative side of treatment (accepting of higher numbers to inhibit any lows), where I want better/more control understanding I may have treat going toward a low).

Hope that’s helpful to you!

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I split my Tresiba doses. My doctors always tell me that I do not need to split it but I always felt better giving it twice a day.

First, I worry that the insulin would have absorption problems if I was giving all 18 units at once.

Second, dosing twice also helps me adjust the insulin due to life’s impacts. I can reduce the amount of insulin I take if I exercise or increase the amount if I eat too late.

Third, I still fear there being a peak for the Tresiba like there used to be for NPH (in the 70s, I have been diabetic for a long time) so I feel like this peak would be less if I divided the dosing in half.

Fourth, I also have a constant fear of forgetting my shot (I rarely actually forget it but spend a lot of my time worrying about whether or not I gave it) and feel like forgetting 9 units is less of a problem than forgetting 18 units.

The last two reasons are mainly my own paranoia but splitting the doses makes me feel better about it.

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It’s incredible seeing this post tonight. I am responding a little after 8PM EST and this evening I am removing my pump. I also have been on the pump for 30 yrs, looking for a pump break if you will. Like most of you, I stay very active as well which is a concern (5 – 6 days a week), and not having the ability to perform a temp basil will be tricky but will work through it.
I will be using Toujeo (insurance covers), so will see how things go. Through my pump I take 37u/day, so I was thinking right out of the gate I would do 20u this evening (approx. 10PM) and 17u approx. 7AM.

For a while now I have been doing all of my boluses through my inPen, which I highly recommend and only use my pump for basal. I use the inPen because when I take a shot, I know I am receiving my insulin, I tend to have several bad sites hence the change. At one point I was looping but needed to change my pump (Omnipod) every 1.5 days, just could not support the continuous site impacts if you will.

I will post here over the next few days to let you know how things are going, if you have any input please jump in, this is new territory for me for sure, long way from the NPH straight to pump transition!!

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We are here for you if you have question, you can do this! Day one may not look perfect, but it will be ok. Then you will refine what works for you.

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I’m trying to laugh at myself. I stated 11 units, then went on to say split dose of 7 morning and 6 evening…obviously 13 units at that point, eh?! I actually started out with 6 and 5, then increased from there as previously stated. Sorry for the math issues; I’ve always done fine multiplying and dividing 4 digit decimals, but simple addition/subtraction eludes me!

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