I have a question about basal levels. My DD is still honeymooning and will stay steady all night. But she recently changed from being steady at 100 all night with no insulin or food on board to steady at 120. In response, we increased the basal dose and now she’s running steady at night and in between meals at 140-150. Does this mean she needs more basal?
I’m confused because the basal testing information I’ve read says basal is right if you remain steady at night, which she does, but it doesn’t say at what level.
Which basal insulin are you using? Is it one injection per day with basal? I assume you are concerned about 140-150 after meals, and wondering if need more basal?
With MDI, single basal injection makes it difficult to get optimal/variable dose throughout the day.
It might be basal or meal time insulin that results in the 140-150 post meal. Since she is in honeymoon, there may be less insulin from pancreas to cover meal now. Does she have fast acting insulin with meals? If so, may need to increase that, or start using it.
So overnight she had been steady at 100 for a while. Then for the last two weeks she’d be hovering around 120-130. In response I thought maybe increasing her basal by a unit (from 5 to 6) would work but now she’s resting at night between 140-150. I’m not sure if raising the basal was incorrect or if she’s just starting to come out of honeymoon.
This may be the cause, but no way to know for sure.
Does she have CGMS? If yes, that’s great and you could continue to increase Lantus. Risk is it might result in lows later in day, particularly when she is more active, but having CGMS would alert this.
Has your medical team given you guidelines regarding dosage changes? What do they suggest to deal with unpredictable honeymoon?
Basals are tricky, especially when you’re transitioning out of honeymoon (although in some respects, getting to the other side where pretty much all your insulin is exogenous can be kind a relief without the unpredictable endogenous variable). If you’re stable through the night - at whatever level - that’s a good sign you’re doing it right. Just make sure you go into that period where you want to be.
Lantus is my least favorite basal but a lot of people swear by it.
I’ve used Levemir and liked it, but it has a shorter active period, so you really need to use it 2x/day (or even 3x).
Currently I use Tresiba, once a day, and it works well for me.
I agree that a cgm would provide good data for getting it right, and just in general for going forward.
I think this is my confusion. She’s steady at 130-140 at night but I think that’s too high. Once the dinner is out of her system (4-5 hours later) she pops back up to this level.
The doctor thought this 130-140 steady was ok but I’d like to get a lower number for that 10 hour period. She does have a Dexcom G6.
If she’s eating relatively high protein/fat diet, that’ll contribute to a rise well after 4 or 5 hours.
I agree with your goal and it seems like you have the right approach to get it right but while you’re working on it I wouldn’t stress about 130-140 for the short term.
Lantus does not have a completely flat activity curve, and does not work a full 24 hours for some people, so you may be seeing some of that effect as well
The trick with basal is it’s supposed to only be taking care of the glucose your liver is making. So hence the at night when you’re not eating, you should start the night with the same level you wake up with. The trick does sometimes become what level you are starting the night at. I do remember my doctor years ago saying aim for a 150 level at night. They really don’t like lows. And generally don’t like adjustments before bedtime.
The easiest way to really test your basal is not eat for 24 hours and see what your bloods are doing without food influencing them. This is hard for some people and that is why they have time segment testing protocols.
Keeping in mind this can all change next week, especially when you are in the honeymoon period.
Doctors will be happy generally with a 130-140 level, like I said they hate lows and the honeymoon period can be variable so it’s a safer level. Just keep in mind any adjustments you make need to be in really small amounts and wait for a few days usually before making another adjustment. Plus to top this off, some people need more of a basal level for part of the day. That is one reason people split their basal into two doses for a variance night and day level.
The Dexcom should really help with spotting trends.
It is frustrating when you want it lower but I do kinda agree with the doctor. That range isn’t a bad stop to be over night, especially for a child.
A good basal level keeps you level. It shouldn’t raise or lower just keep things flat. And it sounds like it is. My thought here might be carb ratio for dinner or evening snack. If this number is not good, it will cause that overnight rise.
And just to throw a kink into this, are we talking puberty age? Your doctor might also be thinking about those hormones that might be raging soon. If that is the case, after another visit, you might have to increase everything due to those pesky hormones. I think those were the most challenging years from a management timeframe.
Good luck! And once again, you parents of us type 1’s… God’s gift!
“ basal is right if you remain steady at night, which she does, but it doesn’t say at what level“
The Clif Notes version is that the job of basal insulin (any/all kinds) is to keep BG steady; changing BG up or down is a job for fast-acting insulin.
Steady at night (at any number) is an awesome thing, because it means changing that number is simple enough with fast-acting insulin… just do a correction dose to get from say, 150 down to 100, and since her overnights are pretty steady, she should then stay at 100 the rest of the night.
Increasing basal much higher would mean she stopped being steady, and while she might wake up at 80, starting at the same 150 means a decent drop throughout the night (even though both numbers are “fine”) which probably means theres a similar drop during the day but we usually cover those up with food & exercise & adjusting carb ratios so they’re a lot harder to tease out (and thats why when using MDI they tell you to use the night numbers for checking basals). Although its easy enough to add carbs or fast-acting insulin to fix daytime challenges without even noticing, eventually if the basal is too high (or low) the carb ratios get adjusted to make up for it in the other direction (too low or too high) and the correction rates get bungled accordingly. While they can all still be used to stay in range, when something out of the ordinary happens its a lot harder to be quick and nimble if all of the rates and ratios and doses are a tangled web of compensating for an ‘incorrect’ basal setting.
For sure thats the simplified view; throw in some pizza, hormones, a possible dawn phenomenon, allergies or Monday morning stress and the neat & tidy logic gets a little shaky, but to the extent possible, basal insulin doses should just keep nights flat & steady, and if the level at which flat & steady occurs needs changing make that adjustment with fast-acting insulin (or carbs).
