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pat593

Yup, really a Type 1.5!

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stinastina

Wow, Pat, that nurse sounds like a witch ! If she had told me to eat all those carbs or don't come back, I would have said sayonara, sister ! I hope you can find a more supportive and intelligent medical team to help you. They have dummies at Yale, too !

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pat593

I'm still looking for the perfect endo - but until then I am reading and learning and testing. 

 

I didn't know I still had to account for protein - thought it was a "free" food.  Is that because as a Type 2 it was?  I never measure my protein.  Maybe that is why Yale takes that position on carbs.  

 

Right now my instructions are only to bolus before a meal if my blood sugars are above 155. That only happens if I eat more than 10 carbs with the prior meal.  My fear is I will go low if I eat no carbs but if I go high, I have no correction bolus instructions. 

 

I am confused about what to do at bedtime since they are usually my only readings above 140.  What should I do if my before bed is high, around 250?  I take my Lantus right before bed so I can't do a correction too, especially since I worry about DP.

 

According to Think Like a Pancreas, I am supposed to increase my basal if there is more than a 30 point spread between my before bed reading and my fasting.  But every time I do, I have too many lows.  So it seems I need to do a better job of preventing the evening highs. 

 

Thanks for the responses.  Still thinking like a Type 2.

 

Still struggling for a pattern here.  Lots of trial and error.

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algarve7

Dr Bernstein suggests:

 

"when you arise in the morning, you might inject a most-rapid-acting insulin (e.g., Humalog) to bring down a slightly elevated blood sugar, then a rapid-acting insulin (regular) to cover your breakfast, then a long-acting (basal) insulin (Levemir). Take the most-rapid-acting (Humalog), then the less-rapid-acting (regular), and last the long-acting, one injection after another, all using the same syringe. Use different sites for each injection."

I try to keep my blood sugars between 80-90 mg/dl. This is achievable with the right insulins at the right time and with practice getting the dosing right.

 

I only started taking insulin at the end of last year and it was quite difficult for a couple of months because it was all new and I was using insulin that wasn't good (Novolin 30R which containes Protamine). Then I decided to only use basal insulin which wasn't enough to control blood sugars. Now I'm getting good control with Humulin Regular, Novolog Rapid and Levemir long-acting basal.

 

At the moment I'm using Novolog Rapid, mainly just in the morning, to bring down BS if they are elevated (sometimes 110, 120, 130 mg/dl). This is usually only necessary if I snack a bit late, and not doing that I can rise with a BG level of around 90-110. About 30 minutes after that I take the Humulin Regular insulin (about 7-8 units) for the morning exercise and light breakfast. This gets me through to lunch around 12:00-1:00 and I'll have a BS of about 80-90 mg/dl. I take the next Humulin Regular (about 7-8 units again) for the lunch which covers me until dinner with a BS usually around 80-90 mg/dl at 6:00pm. Then the dinner bolus of Humulin Regular again until bedtime. If I don't eat too late or snack after dinner, I can achieve my target range and just take the long-acting Levemir basal insulin to cover me at night until morning. If I eat something before bedtime or eat dinner a bit late, I'm taking 3 or 4 units Novolog Rapid in addition to the 7 units long-acting at bedtime, otherwise I'll end up with BS around 110-120 in the morning, even if my bedtime BS is perfect around 80-90. I tend to eat protein and fat, which is slow to digest.

 

I'm still looking for the perfect endo - but until then I am reading and learning and testing.

The most important thing you need an endo or doctor for is to prescribe the insulin you want. ;) Other than that, they usually have no idea. So long as you know what you need, it's ok.

 

Right now my instructions are only to bolus before a meal if my blood sugars are above 155.

Stupidest advice I've ever heard, especially from someone who is supposed to be an expert! ;) You bolus, ideally from a normal BS level of around 85 mg/dl, and you want to prevent a blood sugar rise after the meal, measured about 3 or 4 hours after for protein/fat heavy meals. If you used the right dose you should have normal BS by then, and you shouldn't experience hypoglycemia.

 

My fear is I will go low if I eat no carbs but if I go high, I have no correction bolus instructions.

You'll need to work out from trial and error (taking notes of your before and after meal BS and what you eat), how many units you need for the types of meals you're eating. I'm often sticking to similar or the same meals every day to make it easier to get predicable results.

 

Remember: small doses mean smaller errors. Until you work out what number of units you need to prevent the BS rise after meals, start low and increase checking your records to see what happened before. I like using Google Spreadsheet for recording my BG, units and what I'm eating. It can be viewed and edited on a smartphone, which is very handy.

.

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Uff Da

I'm still looking for the perfect endo - but until then I am reading and learning and testing. 

 

Wish I could refer you to my endo.  He's great!  But Olympia, WA is a little far for you!

 

I didn't know I still had to account for protein - thought it was a "free" food.  Is that because as a Type 2 it was?  I never measure my protein.  Maybe that is why Yale takes that position on carbs.  

 
I think there is some level of carb intake, perhaps the amount that's actually used for energy, beyond which one doesn't have to include protein in the calculations.  I eat a high enough carb diet that I don't normally need to.  I think you'll just have to keep good records and do an analysis of your own figures to see where the point is for you.
 

Right now my instructions are only to bolus before a meal if my blood sugars are above 155. That only happens if I eat more than 10 carbs with the prior meal.  My fear is I will go low if I eat no carbs but if I go high, I have no correction bolus instructions. 

 

I agree with algarve7 that this is a poor way to manage blood sugars.  The normal use of a fast acting insulin is to prevent postprandial highs.  I calculated my own I:C ratios and correction bolus based upon the information in Using Insulin and didn't even see my endo again for 11 months (and though I saw my PCP in the meantime, she doesn't know squat about insulin, so was of no help.)  And I'm still using the same ratios a year later that I calculated in the first two weeks, so obviously for someone whose diabetes doesn't change much, it isn't that hard to get things figured out.  All the doctor can give you is guidelines for starting ratios anyway, like the charts in the books.  Each person is going to have to work out his/her actual ratios based on what happens with their own situation.  I'd say find a doctor that will give you permission to do your own thing, then just do it.  I'll bet you could have things in control in a few weeks.  Well, maybe a month because of the extra analysis of what's happening with the protein.

 

What should I do if my before bed is high, around 250?  I take my Lantus right before bed so I can't do a correction too, especially since I worry about DP.

 

What is your TDD - total daily dose of insulin, lantus and fast-acting combined, on the average on a day when your numbers are pretty good.? The usual charts for correction dose are based on a person's weight and their TDD.  If you don't have these charts in your books, we can look it up for you.

 

If your bedtime high was 250, you could also just take a one unit correction, get up in the middle of the night, say four or five hours later and see how much your BG was reduced.  That would give you a good idea of your correction factor.  There is no way from one unit that your BG would drop below 70 from 250, a 180 point drop, and be unsafe.  If your drop was actually only 40 points, then use that as your correction factor the next time, but be conservative, so that whatever number of units you took wouldn't drop you below 100 or 120, just in case you were a bit off.  After checking several times, you'll be sure enough of your correction factor and how stable the rest of your numbers are that you might be able to safely aim for a lower ending number like 90 or even 80.  

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Uff Da

I am confused about what to do at bedtime since they are usually my only readings above 140.  What should I do if my before bed is high, around 250?  I take my Lantus right before bed so I can't do a correction too, especially since I worry about DP.

 

I should have commented about the portion of your statement that I bolded, but forgot until too late to edit.  There is no reason you can't inject a correction with your fast-acting insulin at approximately the same time as you take your Lantus.  You will be doing so in a different location and with a different needle, of course.  But your basal needs don't affect your meal and correction needs, so think of them as two entirely different things.  Each is calculated separately.  I don't understand what the correction might have to do with DP.

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algarve7

I think there is some level of carb intake, perhaps the amount that's actually used for energy, beyond which one doesn't have to include protein in the calculations.

I basically don't eat any carbs at all, and I need about 7 or 8 units Humulin Regular bolus insulin to cover the protein in the meal and I also need bolus for exercise. The meal might consist of majority meat/fish, including fat from the meat plus butter and coconut oil usually, some green vegetables, such as spinach, Maitake mushroom, Shiitake, or other mushrooms, egg plant, cabbage etc. Those might contain very small amounts of carbs, but I think insignificant compared to eating rice, wheat, potatoes, fruit, starchy vegetables, sugar etc.

 

What is your TDD - total daily dose of insulin, lantus and fast-acting combined, on the average on a day when your numbers are pretty good?

I would break Total Daily Dose up into Bolus and Basal as well, because they are quite different. The units of Bolus tells us the amount needed for our type of diet. I'm using Bolus at bedtime only to cover overnight blood sugar rises.

 

My total daily dose of insulin, TDD is:

 

25-30 units Bolus - Humulin Regular rapid, Novolog rapid for corrections

7 units Long-acting Levemir basal insulin

 

32-37 units in total daily

 

My weight is around 75 kg. Recommended dose for Humulin R is 0.5-1 unit/kg/day, which for me would be 38-75 units/day. So I'm using well below the low end of what's recommended.

 

I would switch to Levemir basal instead of Lantus because of the higher cancer risk for Lantus due to IGF-1 interaction, and also Lantus has a much lower stability. Lantus (glargine) insulin may lose a significant amount of potency 30 days after you remove the first dose, even if it's stored in the refrigerator. Levemir (detemir) insulin also has a limited shelf life, but about twice that of Lantus.

.

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Lady Imp

Yeah Pat, if I were you, I would be looking for a new endocrinology team. My personal opinions of Yale aside (I grew up in Princeton, I'm predisposed to dislike them ;)), a medical professional who doesn't listen to a patient shouldn't be in the field. They're just there because they enjoy the feeling of being belittling. To top it all off, the medical advice she gives is OMG awful. I wish I could give you my endocrinologist, I love her. She doesn't care what I do, as long as my numbers are good, and she's also very good at not being an evil little witch if I fall off the wagon.Unfortunately, I live about 1000 miles away from you so that's not gonna work. :( I'm assuming you live in the New Haven area, which thankfully is a decent size, in addition to being close enough to NYC that you could have a team there if absolutely necessary. You sound like the kind of person who isn't dependent on an endocrinologist, so I wouldn't be afraid to look outside the immediate area. heck, I'm moving 6 hours away soon and I hope to keep my doctor here, I like her that much.

 

The nice thing about it though....is that she isn't hovering over your shoulder telling you what to eat. So continue to eat low carb. When you get those awesome A1c's back, you can start singing the I Told You So Song:

 

https://www.youtube.com/watch?v=IV4sB7O97ro

 

 

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pat593

So I decided to get serious about this and trying to follow the advice above as well as my new Bible, Using Insulin.  So much to absorb!

 

I have been testing every two hours or so and to my SHOCK I tested at 319 before bed the other night.  Forced myself to test again at 2 am and I was still high at 219.  Dinner/snack was under 10 carbs from vegetables and nuts. Woke up at 236 at 6 am, didn't eat breakfast and dropped to 79 by 10 am! 

 

Once again, my gut felt that I needed more help even though my medical team thinks I have great control with an A1C of 6.3.  The highs and lows are making me crazy.

 

Conclusion - maybe my basal does not last 24 hours?  Maybe I need to split the dose or try taking it at dinner and increase my bolus for lunch if my late afternoon numbers start rising?  Maybe the Lantus pen lost efficacy after two weeks? 

 

Now I feel I have the tools I need - I need to get my basal right and work on my bolus.  I have calculated my TDD to be about 26 units of insulin. Right now my basal/bolus ratio is way off but I think I can work it out. 

 

According to everything I read, I should be taking at least 3 injections a day to help even out my blood sugars.

 

And I should shoot for my basal to be about 70% of my TDD - which means I should be increasing my bolus, especially at dinner.  Seems the less active I am, the higher my readings.  If I am out working all afternoon, my before dinner reading is fine, under 100. But if I take a catnap right after eating, late afternoon or after dinner, my numbers go very high.  Even with the same low carb meal!

 

I take 24 units of Lantus at night and 2 units of Humalog before dinner as long as my blood sugar is above 80.  This clearly isn't working since I still have high fasting and high bedtime readings.  My daytime numbers are fine but I eat very few carbs and am pretty active. 

 

I've calculated a conservative correction bolus of 75 points per one unit and a carb factor of about 21 grams per unit.  According to Using Insulin, this should be a good starting point to work for better control. Why couldn't my medical team tell me how to do this?  So I would keep coming back every two weeks?

 

I feel a little more comfortable about using bolus now to get better control and have a much better understanding of how to get there without the fear of too many lows.  The highs I saw this week have scared me.  I need to control this and will.  

 

So, thanks to all who have helped explain it. Your comments and "tricks of the trade" really help. 

 

Can anyone tell me how to go about splitting my basal dose?  Can I take half at dinner and half before bed or at breakfast?  Not sure if I need to slowly do this or can just split the dose as long as my daily totals are the same. 

 

I still want to go back on Met - especially with the comments about Lantus and cancer!  I've read that Met might help Type 1.5's use slightly less insulin.  If there is no downside, why not?  Maybe it can help me minimize any more weight gains from the insulin - so far up 12 pounds and hope it stops! 

 

 

 

 

 

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Uff Da

I have been testing every two hours or so and to my SHOCK I tested at 319 before bed the other night.  Forced myself to test again at 2 am and I was still high at 219.  Dinner/snack was under 10 carbs from vegetables and nuts. Woke up at 236 at 6 am, didn't eat breakfast and dropped to 79 by 10 am! 

 

You didn't say what your BG was before dinner, whether or not you took a before-dinner bolus, or how long after dinner and bolus your bedtime reading was.  Assuming that the bedtime reading was at least four hours after food and bolus, a drop of 100 points between bedtime and 2 AM would tell me that your basal is set too high.  Looks like you have a fair amount of DP that kicks in somewhere in that 2 to 6 AM time period.  Over time you may want to test during that period when you just happen to wake up and you'll eventually find out what time it actually kicks in, if you think that might be important to you.  (I've learned that for me if I wake up before about 5:00 or 5:30, I can eat some high-fat, high-protein food and just about shut off any DP rise, but each person is different.)  The big drop between 6 AM and 10 AM also tells me your basal is too high.  But it also might have reflected some exercise during that time period.  (I'd have to walk at a good clip for 2.5 hours to get that big a drop without injected insulin!)

 

If you get another night of dropping BG, I'd decrease the basal.

 

Once again, my gut felt that I needed more help even though my medical team thinks I have great control with an A1C of 6.3.  The highs and lows are making me crazy.

 

Patience, patience.  You are still new at this, and an A1c is a great start, especially when it seems to me your medical team gave you so little help to start with.  My endo gave me a starting I:C ratio and a starting correction factor and I didn't see him again for eleven months.  I had to change both, but at least I had some place to start.  Your team really left you in the dark.  But give it a month or so and I'll bet you'll feel you have a fair handle on it all.

 

Conclusion - maybe my basal does not last 24 hours?  Maybe I need to split the dose or try taking it at dinner and increase my bolus for lunch if my late afternoon numbers start rising?  Maybe the Lantus pen lost efficacy after two weeks? 

 

It is possible that it doesn't last a full 24 hours, and if you expect to continue needing a high proportion of basal to bolus, lasting 24 hours might be important to you.  I take my basal shortly after dinner, so if it doesn't last quite 24 hours, I have my bolus acting at the same time during those last few hours.  And besides I take such a low percent of my TDD as basal since I eat higher carb.  If it still looks like it doesn't last 24 hours after another day or so, splitting the dose may be your best bet.  I can't help you on that transition.

 

 

And I should shoot for my basal to be about 70% of my TDD - which means I should be increasing my bolus, especially at dinner.  Seems the less active I am, the higher my readings.  If I am out working all afternoon, my before dinner reading is fine, under 100. But if I take a catnap right after eating, late afternoon or after dinner, my numbers go very high.  Even with the same low carb meal!

 

I take 24 units of Lantus at night and 2 units of Humalog before dinner as long as my blood sugar is above 80.  This clearly isn't working since I still have high fasting and high bedtime readings.  My daytime numbers are fine but I eat very few carbs and am pretty active. 

 

I've calculated a conservative correction bolus of 75 points per one unit and a carb factor of about 21 grams per unit.  According to Using Insulin, this should be a good starting point to work for better control. Why couldn't my medical team tell me how to do this?  So I would keep coming back every two weeks?

 
Each person needs to use whatever amount of basal she needs to keep her approximately level through the night and able to skip or have late meals at will during the day.  Our needs can be so different!  And yes, exercise really affects BG.  I've noticed that my own BG drops about one point for every minute I walk at a good clip.  When I do heavy work in the yard like spading or going up and down the ladder pruning shrubs I have to change my i:C ratio for my meals from 1:8 to 1:10.  Just be observant of how much different exercises affect you and for how long after the exercise, and you'll be able to work out your own adjustments to your ratios or decide if an extra snack would make more sense. 

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algarve7

So I decided to get serious about this and trying to follow the advice above as well as my new Bible, Using Insulin.  So much to absorb!

 

I have been testing every two hours or so and to my SHOCK I tested at 319 before bed the other night.  Forced myself to test again at 2 am and I was still high at 219.  Dinner/snack was under 10 carbs from vegetables and nuts. Woke up at 236 at 6 am, didn't eat breakfast and dropped to 79 by 10 am! 

 

Once again, my gut felt that I needed more help even though my medical team thinks I have great control with an A1C of 6.3.  The highs and lows are making me crazy.

 

Conclusion - maybe my basal does not last 24 hours?  Maybe I need to split the dose or try taking it at dinner and increase my bolus for lunch if my late afternoon numbers start rising?  Maybe the Lantus pen lost efficacy after two weeks? 

 

Now I feel I have the tools I need - I need to get my basal right and work on my bolus.  I have calculated my TDD to be about 26 units of insulin. Right now my basal/bolus ratio is way off but I think I can work it out. 

 

According to everything I read, I should be taking at least 3 injections a day to help even out my blood sugars.

 

And I should shoot for my basal to be about 70% of my TDD - which means I should be increasing my bolus, especially at dinner.  Seems the less active I am, the higher my readings.  If I am out working all afternoon, my before dinner reading is fine, under 100. But if I take a catnap right after eating, late afternoon or after dinner, my numbers go very high.  Even with the same low carb meal!

 

I take 24 units of Lantus at night and 2 units of Humalog before dinner as long as my blood sugar is above 80.  This clearly isn't working since I still have high fasting and high bedtime readings.  My daytime numbers are fine but I eat very few carbs and am pretty active. 

 

I've calculated a conservative correction bolus of 75 points per one unit and a carb factor of about 21 grams per unit.  According to Using Insulin, this should be a good starting point to work for better control. Why couldn't my medical team tell me how to do this?  So I would keep coming back every two weeks?

 

I feel a little more comfortable about using bolus now to get better control and have a much better understanding of how to get there without the fear of too many lows.  The highs I saw this week have scared me.  I need to control this and will.  

 

So, thanks to all who have helped explain it. Your comments and "tricks of the trade" really help. 

 

Can anyone tell me how to go about splitting my basal dose?  Can I take half at dinner and half before bed or at breakfast?  Not sure if I need to slowly do this or can just split the dose as long as my daily totals are the same. 

 

I still want to go back on Met - especially with the comments about Lantus and cancer!  I've read that Met might help Type 1.5's use slightly less insulin.  If there is no downside, why not?  Maybe it can help me minimize any more weight gains from the insulin - so far up 12 pounds and hope it stops!

 

I don't think Using Insulin is a good book for you, because his approach isn't low carb at all and it's an old book now, about 2003 right? From what I've read about the book, his principles are based on an assumption of 45-65% of calories from carbs. These days, low carb, high fat is becoming understood to be better for diabetes, so why try to follow a book that still suggests we need to eat carbs.

 

I recommend the book Dr. Bernstein's Diabetes Solution. Dr. Bernstein is a type 1 diabetic so he has first hand experience with diabetes and he has developed an effective system for acheiving excellend control of BG. This is a big difference from other books which are written by people who don't have diabetes themselves. Dr. Bernstein does what many of us with diabetes do, and that is to experiment and try different things. In the book he publishes his experiences that work.

 

Humalog is very rapid insulin with a shorter duration. It might be ok, but I prefer the longer duration of Regular Human insulin to cover a meal containing only protein and fat. I like a rapid analog to lower a high BG reading. Forget about Basal insulin, because it doesn't do much. Is 2 units bolus enough insulin to cover your meal? It sounds like it's too small an amount to cover the meal. I would avoid carbohydrates competely if you are ok with it, because it's easier to use smaller doses of insulin. In my experience, nuts have a fair amount of carbs, so they will make you go high, especially if you don't bolus for them outside your other meals.

 

I would stick to eating only your main meals and get your insulin dose right and avoid eating anything like snacks after your breakfast, lunch and dinner (except to correct hypoglycemia of course). Otherwise you need to bolus for snacks too, and it's harder to bolus for small amounts of foods eaten randomly. Try to stick to a regular time of eating meals and similar meals so that you can compare the previous day's after meal BG levels, to see if you are estimating your pre-meal bolus amount correctly.

 

I would just take a smaller dose of Basal at bedtime only, rather than throughout the day as well. You shouldn't need so much basal insulin if you can get your bolus dose right that you cover your meals properly, so that after eating, your BG level is between 80-100. Once you get more experience and the right diet, you can easily achieve between 80-90 premeal. If you can't achieve this with Rapid insulin for a high fat, low carb meal, then you could try Regular human insulin. If your bedtime reading is high, say 120 mg/dl, you need to work out the amount of rapid insulin to take to lower it correctly, and also take your usual amount of Basal to prevent the blood sugar rise during the night. By injecting in the buttocks the insulin is absorbed more slowly than the arms and abdomen for the bedtime doses. I inject in the arms in the morning and abdomen for lunch and dinner meals. With my meals, and instead of breakfast, I have tea with butter and coconut oil in it so I don't get hungry between meals.

 

Don't let the A1C numbers guide you as to how well you're doing because it's the intraday values that are important, avoiding highs and achieving a normal blood sugar level 2 or 3 hours after the meal. Once you get good, you should be testing before the meal with a normal BG level around 80-90 mg/dl. If it's elevated above your target, say 110, 120 or 130 or something you'd need to add extra units to correct for the premeal high. You'll have to work out what sort of dose does that for you, in addition to what you'd normally use for a typical meal.

 

I would stay off Metformin because you'll want to get your blood sugars from protein if you avoid eating carbs. It's much easier to bolus for blood sugars from protein than to bolus for carbs, because they rise much faster. All drugs, including Metformin, do have side effects. Insulin is the most natural way to treat type 1 and LADA, so long as we choose the right mix of insulins and combine it with a high fat, moderate protein, low carb diet, which doesn't require large insulin doses.

 

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pat593

.I recommend the book Dr. Bernstein's Diabetes Solution.

I would avoid carbohydrates competely if you are ok with it, because it's easier to use smaller doses of insulin. In my experience, nuts have a fair amount of carbs, so they will make you go high, especially if you don't bolus for them outside your other meals.

 

I would stick to eating only your main meals and get your insulin dose right and avoid eating anything like snacks after your breakfast, lunch and dinner (except to correct hypoglycemia of course). Otherwise you need to bolus for snacks too, and it's harder to bolus for small amounts of foods eaten randomly. Try to stick to a regular time of eating meals and similar meals so that you can compare the previous day's after meal BG levels, to see if you are estimating your pre-meal bolus amount correctly.

 

I would just take a smaller dose of Basal at bedtime only, rather than throughout the day as well. You shouldn't need so much basal insulin if you can get your bolus dose right that you cover your meals properly, so that after eating, your BG level is between 80-100. Once you get more experience and the right diet, you can easily achieve between 80-90 premeal. If you can't achieve this with Rapid insulin for a high fat, low carb meal, then you could try Regular human insulin. If your bedtime reading is high, say 120 mg/dl, you need to work out the amount of rapid insulin to take to lower it correctly, and also take your usual amount of Basal to prevent the blood sugar rise during the night. By injecting in the buttocks the insulin is absorbed more slowly than the arms and abdomen for the bedtime doses. I inject in the arms in the morning and abdomen for lunch and dinner meals. With my meals, and instead of breakfast, I have tea with butter and coconut oil in it so I don't get hungry between meals.

 

Don't let the A1C numbers guide you as to how well you're doing because it's the intraday values that are important, avoiding highs and achieving a normal blood sugar level 2 or 3 hours after the meal. Once you get good, you should be testing before the meal with a normal BG level around 80-90 mg/dl. If it's elevated above your target, say 110, 120 or 130 or something you'd need to add extra units to correct for the premeal high. You'll have to work out what sort of dose does that for you, in addition to what you'd normally use for a typical meal.

 

I would stay off Metformin because you'll want to get your blood sugars from protein if you avoid eating carbs. It's much easier to bolus for blood sugars from protein than to bolus for carbs, because they rise much faster. All drugs, including Metformin, do have side effects. Insulin is the most natural way to treat type 1 and LADA, so long as we choose the right mix of insulins and combine it with a high fat, moderate protein, low carb diet, which doesn't require large insulin doses.

 

 

Thanks - I will get the book Diabetes Solution as suggested and agree with you about the recommended carbs in Using Insulin.  It is a good book though for explaining the basics and I like the charts and easy to understand calculations on how to figure out carb coverage and corrections.  Gave me a good starting place to work from.

 

After being a "Type 2" for 2 years, I've given up most carbs anyway and find I don't miss them.  I tend to eat the same meals everyday - eggs for breakfast, salad and protein for lunch and dinner.  My carbs per meal are usually under 10 but I do snack a lot on nuts - I guess those carbs add up.  I also have a hard time not snacking after dinner - hopefully I'll break that habit as soon as it gets warm enough to walk outside after dinner.  I only bolus before dinner - my before lunch and before dinner readings range from 75 - 102 since I consume so few carbs during the day and am very active.  I'm pretty happy with my after breakfast/after lunch readings - usually under 120 and less than 10 points difference from my before meal readings.   But I might be better off lowering my basal and adding a bolus for breakfast and lunch for more even sugars during the day. 

 

Thanks also for the injecting suggestion - I was looking for an answer to that and will try injecting into my thigh at night and bolus in my tummy during the day.

 

I spent the weekend testing and did the first part of Using Insulin's basal test.  Woke up 103 this morning, skipped breakfast and was 92 before lunch.  So if the formula for changing basal is "rise no more than 30, fall no more than 15 without eating" - it seems I am in line today - but this is not always the case looking at my past data!  However, this rule does not hold for me if I compare my bedtime and morning - I will do the night time basal test when I get my evening readings in line and manage to bolus right for my dinner. 

 

Nice to hear from actual users that it is possible to manage your insulins optimally.  While I know I need patience to get it right, I just didn't feel comfortable with the high targets I was given!

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pat593

 

You didn't say what your BG was before dinner, whether or not you took a before-dinner bolus, or how long after dinner and bolus your bedtime reading was.  Assuming that the bedtime reading was at least four hours after food and bolus, a drop of 100 points between bedtime and 2 AM would tell me that your basal is set too high. 

 

Patience, patience.  You are still new at this, and an A1c is a great start, especially when it seems to me your medical team gave you so little help to start with.  My endo gave me a starting I:C ratio and a starting correction factor and I didn't see him again for eleven months.  I had to change both, but at least I had some place to start.  Your team really left you in the dark.  But give it a month or so and I'll bet you'll feel you have a fair handle on it all.

 

It is possible that it doesn't last a full 24 hours, and if you expect to continue needing a high proportion of basal to bolus, lasting 24 hours might be important to you.  I take my basal shortly after dinner, so if it doesn't last quite 24 hours, I have my bolus acting at the same time during those last few hours.  And besides I take such a low percent of my TDD as basal since I eat higher carb.  If it still looks like it doesn't last 24 hours after another day or so, splitting the dose may be your best bet.  I can't help you on that transition.

 

Each person needs to use whatever amount of basal she needs to keep her approximately level through the night and able to skip or have late meals at will during the day.  Our needs can be so different!  And yes, exercise really affects BG.  I've noticed that my own BG drops about one point for every minute I walk at a good clip.  When I do heavy work in the yard like spading or going up and down the ladder pruning shrubs I have to change my i:C ratio for my meals from 1:8 to 1:10.  Just be observant of how much different exercises affect you and for how long after the exercise, and you'll be able to work out your own adjustments to your ratios or decide if an extra snack would make more sense. 

 

My before dinner reading before my 319 reading was 122 - a little high but I was told not to correct for 122 before eating.  I took two units of insulin before dinner and tested about 6 hours after eating a pretty low carb meal (under 20 grams)  but I did fall asleep watching TV before bed. 

 

I think my basal is high too because I do have lows if I don't eat but as I posted right above, I've done one basal and it seems in line.  I will keep playing around with it but I feel I have to get my bedtime readings in line first so my fastings will be better. Everyday is different even though I eat about the same things every day. 

 

I like taking my basal right before bed - easy habit to remember and I can keep the pen away from my Humalog pen to prevent me from mixing them up.  But I may split the dose and take two doses 12 hours apart.  I will test and see if it helps as soon as I figure out how to make the change.  Using Insulin says (p 104) that I may be experiencing a gap in coverage after my bolus from dinner is gone and before my Lantus injection.

 

Thanks so much for the input - seems everything I figured out as a "Type 2" has to be rethought as a "Type 1.5."  I still find it amazing how quickly this disease progresses.  I must have been an undiagnosed diabetic for a long time.  So nice to have a few 1.5's to help figure all this out.

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Uff Da

I spent the weekend testing and did the first part of Using Insulin's basal test.  Woke up 103 this morning, skipped breakfast and was 92 before lunch.  So if the formula for changing basal is "rise no more than 30, fall no more than 15 without eating" - it seems I am in line today - but this is not always the case looking at my past data!  However, this rule does not hold for me if I compare my bedtime and morning - I will do the night time basal test when I get my evening readings in line and manage to bolus right for my dinner. 

 

Nice to hear from actual users that it is possible to manage your insulins optimally.  While I know I need patience to get it right, I just didn't feel comfortable with the high targets I was given!

My personal approach is to view the overnight basal as the most critical to get right. In the daytime one can usually detect and treat a low or correct a high (before the next meal if not sooner), but I want to be able to go to bed feeling safe that I won't have a low overnight - but at the same time knowing that I'll be in a good BG range for this extended period of time.

 

My endo set what I consider pretty liberal targets, too, but my interpretation was that these were just the initial targets and that they would likely be tightened up as I got more experience handling insulin, provided my situation warranted. His initial targets after food were to reach no more than 180-200 at the peak BG, 140-160 at two hours and 100 in three to five hours after bolus. He initially expected me to be at 140 or higher at bedtime and between 70-130 by breakfast. He never gave me any further targets, as by the next time I saw him, I'd tightened everything up and had an A1c of 5.8.

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pat593

I still have a lot of testing to do so thanks Uff Da.  I too agree that getting your basal dose right is key.  I think mine is OK because of the drop differential when I don't eat and I think my highs in the morning are due to not enough bolus for the evening meal. 

 

I have been conservative with only 2 or 3 units before dinner and it is clear that I have to slowly add a little more.  With a conservative carb correction bolus of 75 to one unit, I can easily add one more unit and not go low. 

 

Yesterday started so well - Fasting 103, 92 before lunch, 83 before dinner, 3 units of Humalog at 7 and 184 at 10 pm, 24 units of Lantus at 11 pm and 210 at 2 am.  Woke up high again at 139 at 6 am and was 130 at 10am (again, Lantus seems to be doing its job with the 30 rule during the day).  Just injected 1 unit of Humalog and had a no carb breakfast. 

 

Probably should have upped my before dinner bolus or bolused again for my evening snack (under 10 grams of carbs).

 

I still want to try splitting my Lantus dose but cannot figure out how to titrate to the new schedule so I will hold that constant for awhile.  I think I am going to try to see if I can contact Walsh from Using Insulin because on page 104 he says "Those who find they have a short action time can improve their control by taking Lantus twice a day to eliminate the gap in action (when Lantus works less than 24 hours)."  He, however, does not tell you how to titrate to switch over from one shot of Lantus to two a day. 

 

Still think I want to add an evening Met - looking at my records, the last time I had a good before bedtime reading was the last week I took Met, a 134.  Then I went to Yale and I can't seem to get it below Eating/exercise patterns exactly the same.

 

Thanks for letting me ramble and please keep commenting.  I see a new endo in early June so I will hold the course as much as I can and, hopefully, maybe I'll have some of it figured out by then. 

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Uff Da

While it is possible that you need to split your Lantus dose, I think it is too early to conclude that. Unless I've missed something, it seems to me that you have other things that need to be figured out first before you know if there is actually a gap. If I'm understanding things right, it seems to me that the increase later in the day could be just the result of eating lunch, dinner, and bedtime snacks with inadequate mealtime boluses. The 15-down or 30-point up rule only applies when you've had no food or bolus during the period or for four hours before the test period.

 

We can probably figure out how to substitute fast-acting for the Lantus for the time period you only have half the Lantus acting. (If your Lantus was actually correctly dosed at 24 units, that means you are using 1 unit an hour, so you could just get up and substitute 2 units of fast-acting every two hours overnight until it was time to take the second half of your Lantus in the morning.) But first things first. You really need to get the total dose right first. Otherwise you'd just be making things more complicated.

 

An overnight basal test without a bedtime snack to mess things up would be my next priority. But you'll probably want to wait until next weekend to do that, as it will mean sacrificing some sleep.

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