Advice, please

If my pre-meal blood sugar is fine, but my post-meal blood sugar is high, what do I do?

"Take a bigger bolus" is the obvious suggestion, but even with post-meal high blood sugar, I'm generally low before my next meal, and my basal rate is quite low (ranging from 0.100 to 0.300 during the day).

I always wait 20 minutes between bolusing and eating. Should I wait longer?

Advice, please!

Presuming that your basal rate is locked in, then going low before your next meal suggests that your total bolus is too much. Going high (at 2 hrs?) suggests that your bolus timing and profile is not matched to your meal.

If you eat low carb, you may find that meals produce a blunted blood sugar response over 2-4 hours (rather than 1-2 hrs) and an extended bolus works better. If you eat simple carbs, you may find a quick spike and that adjusting the timing (injecting sooner or later than 20 minutes before) helps. Different insulins have different onsets, most people find the Apidra is fastest, followed by Novolog and then Humalog.

A good way of checking what is happening is to test your blood sugar profile over time, at 1 hr, 2hrs and 3 hrs (even at 4 hrs). That will give you an idea of which pattern you are seeing.

Wow. Thanks. That's a very helpful answer.

Yes, the high is 2 hrs post-prandial, and yes, I'm eating low-carb. I will try an extended bolus next time and see how it pans out.

I use Humalog, which I know is pretty slow to act, but I'm hesitant to change after using Humalog for 15 years. It's illogical, I know.

I think what you are describing is similar to what some of us call the "rollercoaster". Except in some ways, your situation is simpler, because you aren't doing the correct with insulin-go hypo-eat and go high again cycle, you're just doing the hypo part of the cycle :-).

If your threshold for "high" is too low, it's easy to end up rollercoastering. e.g. I think that's high, but it's only high because the insulin already on board isn't absorbed yet, but because the number looks high I take a correction, then not only the correction kicks in but the insulin previously on board kicks in as well. Then I go hypo, I correct the hypo, I might overcorrect the hypo, lather rinse repeat.

And then to top things off, if the cycle is repeated a couple of times, the repeated hypos mess up my hypo sensitivity, then boom I'm in the ER with glucagon.

OK, it's not always that serious, but it's seriously wearing and not fun. Sometimes the best thing to do is just relax the standards for "high" a little bit, back off on doses just a little bit, and not get to a pattern of hypos. I know that's an anathema for those here who believe a single reading of 140 means doom and gloom, but seriously, it's no fun to believe in the doom and gloom all the time, occasional high numbers haven't put me in the ER yet (30 years in) but I have been to the ER several times (once with a lights and siren ambulance ride that I regained consciousness during!) with hypos. I'm not saying that we need to be deathly afraid of occasional hypos, they're going to happen, but if they are happening regularly then seriously, it's time to back off on the doses (either basal or bolus or both) just an eensy bit. OR, and this may or may not be possible for you, bolus the way you are now, but make the meal a little smaller and eat a snack later on to avoid the hypo. Others will tell you the snacking is absolutely verboten but really it sure beats the regular hypos.

Moving the bolus earlier, I'm not a big fan of, because I've had hypos during the meal as a result. If you are using the fast acting stuff (e.g. novolog or humalog) I find it hard to bolus more than half an hour before a meal without having to have a snack before the meal, or aborting the meal for a high-carb hypo correction, kinda defeating the purpose.

Hypoglycemia is not the problem--it's the post-meal highs. I'm not taking corrections, yet I still go low later, which I why I said "take more insulin" is not the solution to my problem. And boy, I wish it were 140 mg/dl [7.7 mmol/l] I was worried about.

OK, I was equating "low" with "hypo". Maybe they don't always mean the same thing :-)

But I would not sweat the after-meal highs too much.

If you are never having hypos before or during meals, you probably could bolus a little earlier. It makes me nervous because I know that's resulted in hypos for me.

And Humalog is the fast-acting insulin as far as I'm concerned! Maybe you aren't old enough to remember good old Regular :-). I regard Humalog is the instant neutron bomb in comparison.

Post meal highs mean certain foods produce that high. Check out which foods are producing the high and get rid of them.

You're right--regular is before my time. My diabetes was diagnosed just after Humalog came on the market. So, lucky me, I guess. ( :

I second to try different brands of insulins to find the one with the right profile. It just takes one vial and at any time you can switch back to humalog. If the problem is more related to the breakfast then I would adjust the basal too.

But the logic in the second paragraph sounds odd to me:

After 15 years your absorption may be slightly slower. So try taking your bolus 30, 45 or even 60 minutes before breakfast

If the absorption is slower why giving the insulin more time to unfold its action? In my opinion the opposite is true. The slower the absorption the lower the time between injection and carb intake. I also question that there is a problem with the absorption because a spike is a good indicator for a good absorption of the carbs. People with absorption problems often do not have to wait at all. If they would wait they would very likely go low because the insulin is acting faster than the digestion can deliver the carbs.

FYI - I've only ever used Apidra and I've never had a problem with it lasting in my pumps. I would keep a single reservoir in for 4-5 days with my Minimed and now w/ the pod, it's against the heat of my body for up to 80 hours with no degradation.

I think the degradation is not due to heat. To my knowledge it is the reservoir that is made of plastic. This material allows the diffusion of oxygen into the insulin and this causes the degradation. In general this might depend on the lifetime of the reservoir.

What is your definition of low carb? How many carbs do you eat at each meal?

For this breakfast, in particular, it was 15 carbs.

I use Apidra in my pump as well with no problem for 3 or even 4 days.

I agree that trying a new insulin (Novorapid) makes sense, but what a pain to switch! I am set in my ways. I used the Glucometer Elite for 10 years (and not even the one that had a memory!).

How long do you think it would take for me to notice the difference between Humalog and Novorapid?

I have an absorption problem in the evening. I bolus for dinner and get low within an hour. Then my blood glucose gets really ghigh about 4 hours later. Some of that is from slower absorption of the food after having diabetes a long time.

I use a square wave bolus at night and it really seems to work well. My problem is different than yours, but theYou could try a dual wave: give some at mealtime, and the rest an hour later.

Your basal rates are really low. I basal 12.1 units over a 24 hour period and thought mine were low.

So glad the rising BG just because of getting up (at different times) isn't just me. It happens if I nap, too. I've learned to bolus a small amount as soon as I get out of bed.

Thanks, bsc. This was really helpful to me.

I was told not to worry about waiting to eat after I've injected my rapid acting insulin. I have frequently wondered whether or not this is 'true', especially when I experience similar issues as the OP.

I'm not being as vigilant right now with getting everything under control, because my schedule is still crazy. What I wouldn't give for a predictable few weeks... lol.

I woke up at 143 and stayed there for hours today... too big of a chicken to correct it as it was hovering just under 150. My insulin pen does not do 1/2 units.

Finally in the afternoon, it dropped to 100 of it's own accord..