Season/Insulin changes

[SBee]

Hi all,
It’s that time of year again, where I’m heading into the warmer months and I have to muck about with my insulin doses because otherwise I’m completely out of whack.
Last night for example, I was 8.9mmol/L before my night time dose of Levemir and as you can see from the line I went up and stayed there.

I’m never a fan about talking to a DE about this issue, because they always tell me to have more NovoRapid with my dinner, which I don’t feel is the right choice because of the timing. I know there’s extended bolus for those of you on pumps, but I’m MDI.

Should I do an extra dose? I did have some basmati rice in my dinner, but the rise of my levels was 4 hours after that. I did go to bed straight after my Levemir.

I really do get frustrated with having to adjust so much depending on the time of year. I totally understand how people get diabetes burnout!

Would really appreciate some ideas!

[MarkP]

Disclaimer…I don’t claim to be any sort of expert on any of this…

However, I was MDI for a long time before switching to pump and my favorite approach was to take a moderate or borderline substantial bolus dose 4-4.5 hours before bed. This enabled me to eat as I wanted and make sure that only basal was in the system as I was going to bed at a blood sugar I liked. It also seemed fairly easy to raise the number in the event of too much insulin rather than contemplate a dose to lower things right as I was going to bed.

I was never big on taking doses right before bed but sometimes it seemed necessary because staying up a little later than usual would lead to some cortisol being released by my body.

[bostrav59]

I don’t know about Levimir (sp), but my 2 c on this has to do with exercise. I find that if I can do a little exercise between my last meal and bed, my glucose levels stay pretty steady and low. And by little exercise I mean maybe a 15 min walk or something like that.

My theory, based on very little evidence, is that somehow exercise turbocharges the effectiveness of the insulin.

Also, as @eric has mentioned I believe, try not to eat too late / too close to bedtime.

fwiw

[bkh]

@SBee

Should I do an extra dose?

Are you certain that your CGM will wake you if you are going low while asleep?

Mine does, so if my BG were that high and not coming down, I would take the NovoRapid correction. If my CGM wasn’t quite that dependable, I’d still take the insulin but I’d stay up late to watch the BG; I’d rather lose the sleep than tolerate the high BG overnight, but that’s just my personality quirk, definitely not a recommendation in general.

The seasonal change in basal requirement is a nuisance, and somehow I never seem to recognize it until after several days of having to take extra corrections overnight. During the past week my insulin requirement during the night hours has risen from 0.8u/hr to 1.05u/hr. That’s what happens to me as we enter the deep autumn around here.

[SBee]

Thanks @bkh , @bostrav59 & @MarkP for your replies.

I should have mentioned that I’ve had previous issues with my long acting insulin dramatically reducing my levels overnight.

It seems to be a very fine line between too much and too little, which is why I never know whether I should have more NovoRapid.

Yes, my CGM does wake me if I go low, but the low usually comes between 4-6am, which is when I get my most restful sleep, and if I’m woken, then I’m a write off for the day. Yes, my body is frustrating!

I have just been adjusting daily (winging it), and have been managing it reasonably well. Some days I have more NovoRapid and others I don’t, and so far I haven’t had too many hypos or have been waking up too high.

It would be nice to get through a season change without this mucking about!

[bostrav59]

@SBee

It seems to be a very fine line between too much and too little, which is why I never know whether I should have more NovoRapid.

A couple of weeks ago I was sitting on a bench on a beautiful fall day, next to a couple in their mid-60s. The husband noticed my tubing and asked about my pump (this happens very rarely - I suspect that people notice the tubing but don’t say anything). It turns out that his wife, sitting next to him, was also a T1 Diabetic, and was on a Lantus / Novolog regimen, but had a problem of going low too often. Her husband wanted her to go on a pump - her doctor (at Joslin Clinic) didn’t think it was necessary and she wasn’t too eager.
Before I knew it, I was in the middle of a discussion about whether the wife should go on a pump! I told them this was their argument and I didn’t need to be in the middle of it, but I had to find another bench.

All of which is to say … have you considered a pump? Because you don’t have the long-acting insulin with the pump and so you can get better control.

[SBee]

@bostrav59, I cannot afford a pump. I’m on a disability pension and in Australia, the government subsidises a lot of things for T1D 's, but sadly, pumps are only subsidised for children.

Diabetes Australia is advocating for all T1’ s, but I don’t think that will happen any time soon. I’ve asked my DE’s to let me know if any of the manufacturers (specifically Dexcom) think they could provide me with a free one. But I’m not holding my breath on that one either.

Pumps are included under the top hospital covers with private health insurance providers, but again, that is not something that is within my budget as it was around $200AUD a fortnight last time I checked. We have universal healthcare here, so it would only be for that, so if I could afford that amount, I could afford to buy the pump outright!

So, unfortunately I am MDI for the foreseeable future.

[bostrav59]

@SBee

let me know if any of the manufacturers (specifically Dexcom)

Dexcom doesn’t make pumps. They make CGMs that are linked to pumps. Are CGMs covered in Australia’s health plan?

[SBee]

Sorry, I meant the Tandem tslim that works with Dexcom. Yes, CGM’s are subsidised here and because I am a concession card holder, my Dexcom CGM is fully subsidised.

We have an organisation called the National Diabetes Subsidy Scheme. All supplies are available to order through this organisation and collectable from almost all chemist/pharmacies.

Our government negotiates what prices can be charged for medications (all, not just diabetes medications - a different scheme called the Pharmaceutical Benefits Scheme) and then they pay a majority of it when we order things or put in a prescription.

So for example, when I put in my prescription for NovoRapid, the actual cost is $211, but with my concession, I pay $6.80, whereas someone without a concession pays $42.50.

We also have what’s called a safety net threshold. So if your annual prescriptions go over the amount of $495, you don’t pay for any more prescriptions for the rest of the calendar year.

[Trying]

@SBee

also have what’s called a safety net threshold. So if your annual prescriptions go over the amount of $495, you don’t pay for any more prescriptions for the rest of the calendar year.

Wow, that is impressive! I imagine Dr appt and hospitalizations have similar thresholds?? That sure reduces some of the stress from being sick, not having to worry about medical bills, that is!

[SBee]

@Trying, hospitals are free nationwide. There are private hospitals that you can pay for, or use your private health insurance for. The public system is great, certainly in an emergency, but the waiting lists can be quite long for some things and you get in on the level of urgency that an initial consultation decides, whether that be with your GP or a specialist via GP referral.

For example, my dad has cataracts and requires surgery, however the priority system has him at a level 2, and I believe the wait time is currently 18 months, but that is also due to covid when they cut back on a lot of surgeries like that and now there is a backlog.

I have presented to hospital, via ambulance and in DKA. I was in ICU for 9 days and I didn’t have to pay a cent.

Ambulance services are state based in Australia, so depending on where you live, depends on whether you need insurance to cover your ambulance journey or not.
Fortunately, I live in a state where we pay a levy via our electricity (state owned power supplier), and therefore the state government will cover all ambulance costs, regardless of where I am in the country.

Seeing a Dr, is currently a little more complicated.

There are medical centres everywhere. Some are even open 7 days. Basically the government has set a price that medical practices can claim directly, what we call bulk billing and there isn’t meant to be anything for the patient to pay. But over the years, the amount of the rebate hasn’t increased in line with costs. So, some practices charge fees and then the patient has to claim the rebate, which does not cover the entire cost anymore.
Claiming the rebate is pretty easy (online/app), but it’s the increasing gap that is becoming an issue. The other problem is that many practices, aren’t taking on new patients and the level of burnout in medical staff is pretty much everywhere, primarily due to covid workloads, so there’s a GP shortage, especially in rural areas.

However, as a concession holder, and the fact that my GP is one of the few that continue to bulk bill their concession holders, going to see my GP costs me nothing. And he’s a nice guy and even makes sure that I don’t pay the fee for things like nurses giving me an iron transfusion, which is usually charged regardless of concession.

So no, no medical bills to worry about, unless you’re taking a medication that isn’t on the PBS, which does happen sometimes.

[Trying]

@SBee

I believe the wait time is currently 18 months

@SBee

The other problem is that many practices, aren’t taking on new patients and the level of burnout in medical staff is pretty much everywhere, primarily due to covid workloads, so there’s a GP shortage, especially in rural areas.

Oh, wow, that could be disastrous if wait time is that long. Although wait times here have gotten much worse here, too, in recent years. It can take a few months to get an appt with a new Dr.

Emergency here, is extremely expensive. My sister was hit by a car in the pedestrian walkway and an ambulance was called just to take her one block to the hospital. It cost $1000+!! Insurance wouldn’t pay for it.

It sounds like AU (you are in AU, right??!!) has a great system despite some long waits. I’m glad for you!! Thank you for explaining all of this. It is good to know what the US needs to aspire to!!

[SBee]

@trying, yes I’m Australian, and you’re welcome