I started insulin last December. I had worked to get my basal “dialed in,” and for a while things were pretty stable. But recently my needs seem to have dropped. Markedly. I’ve dropped my basal levels a total of 20% over the last two weeks and I am still seeing some mild hypos during the day. I guess everyone deals with changes and you would expect increases if you get sick etc, but it must be harder if you are LADA. And I wonder if I am going through similar issues (even though I am diagnosed T2).
So what I have been doing is simply changing my basal rates for my morning/evening shot by a single unit every 2-3 days based on whether my average before dinner/morning reading is above or below target. And I’ve been doing similar things with my bolus, increasing or decreasing my ICR by a small increment based on how well I have done after meals over a period of 2-3 days.
While this slow method works, it isn’t very responsive. I’ve been reducing my basal steadily all month it seems. And while my hypos are mild, in the 60s, I am not happy being in the 60s routine during the day.
Do you see lots of variability in insulin needs? What do you look for to gauge insulin demand? What techniques do others use to adjust to fast changing insulin needs?
Mine seems to change every few months. I am not sure it’s totally linked to exercising or not, as I’d had a recent change needing more insulin, right as my running “volume” has increased as well. Usually my basal is close to accurate and if I see premeal #s drifting up, for 3 days in a row, I’ll turn up the basal one notch (.05U/ hour) and if my post meal number goes high the same amount, I will nudge the ratio up a bit. Same thing for low although frankly, low would have to be really low before I’d let it bother me. With the recent change, I think I got frustrated because the “one notch” didn’t work and turned it up more and have been running lower so I am backing off a shade now.
Do you see lots of variability in insulin needs?
Yes, my insulin needs change all the time. They change based on my diet, how much I’m exercising, what kind of exercise I’m engaging in, the weather, hormones, which party is controlling Congress and/or the White House, the position of the moon relative to the earth, etc (ok, the last one is a bit of a joke, but you get the idea). There are SO many things that can change your insulin needs. Have you gained or lost any weight? There are days where I use as little as 20 units of insulin (especially if I’m eating very low carb) and days when I need as much as 45 units. It just depends. Also, I’m a woman so at certain times of the month, I’m far more insulin resistant than others.
What do you look for to gauge insulin demand?
I look for numbers that are consistently outside of my range. I don’t necessarily change anything if I peak at 200 but immediately start to come back down. But, if I stay at 200, or below 70, I will start with changing my basal rate. For some reason, I have had more success changing my basal rates than my I:C ratios. For awhile I had different I:C ratios for different times of the day, but over the summer, I found that an across-the-board 1:15 ratio worked best. This may now change with the cooler weather.
What techniques do others use to adjust to fast changing insulin needs?
For me, the only thing that works is logging my numbers and looking for any kind of pattern/trend. Being on the pump has helped A TON because it is so much easier to react to changing needs in my basal insulin. I love my pump for that reason alone. I have a hectic work schedule, I travel some, and I’m very active. Being able to change a basal rate and see a result in just an hour or so is incredibly beneficial.
I use Carelink and find the reports that I generate with that system really helpful.
Every fall I see a big drop (sometimes up to your 20% number) in insulin needs. I can look back over 30+ years and see this as a regular pattern now. Then the insulin needs go back up at some time or another.
Yes, like you relate, sometimes I feel frustrated that I can only react to the changed needs after the fact.
I think you are relatively new to this (me: 31 years. You: less than a year) and may have been misled by some books, or by some internet sites, to expect things to be stable at some highly precise level. My anecdotal experience is that the fine stability that a lot of the better controlled people talk about, simply does not exist for the vast majority of diabetics on insulin. Maybe those who have an especially easy time in control are more vocal than those who struggle with variability. Certainly those who have an especially easy time in control (both T1 and T2) get referred to a lot more often than those who admit it’s a struggle. I think it’s important that folks like you and me don’t get emotionally down because we have to work so hard and have such variability.
I’m 3 years into Type 1, so can’t be sure some of the trends I see are not coincidences, but each summer my basal needs have dropped as the heat and humidity arrived, and around this time of year my basals have increased. Because I still feel that I’m pretty new at this, I’m always a little reluctant to make permanent setting changes for a few weeks, though, until I am sure I am seeing a trend. So right now I’m spending a lot of time with temporary basals of 125%, which is a .05 unit/hour increase for me most times of day. While it doesn’t sound like much, it makes a big difference… I just don’t want to make the permanent change yet because I’m not sure we won’t have another midwest heat wave.
I also wonder if my needs are increasing due to my stage in life, but that’s another story.
I find my insulin needs change at least every couple of weeks, and more often if something changes like the amount of exercise I’m doing. I think one of the big reasons I have such better control with the pump is that I’m able to respond to changes much more quickly.
I use my morning reading to adjust my basal. If I wake up low twice or three times in a row or a short period of time, I’ll lower my basal rates by 0.05 u/hr (haven’t gotten into the 0.025 u thing the Ping offers). If I go low consistently at one time of day but am fine for the rest of the day, I will lover just that basal segment. Same with highs.
For I:C ratios and ISF I will gauge by after-meal readings, but this is harder because there are more variables and because even with the correct ratios it’s hard for me to stay below about 9.0 (160) after eating, so it’s harder to judge when I’m high. I adjust ISF so that it stays “in sync” with my I:C ratio. I never used to do this, but it seems to work well and makes sense to me.
I think changing insulin needs and all the variables is what makes diabetes so hard. If it were just a matter of testing and taking the shots (or being connected to the pump) while all the variables remained constant, it would be easy.
Your post sounds like a couple I have posted in the LADA forum over the last year. I’ve always seemed to have what I call a “drift” where I will be pretty stable for a couple weeks (stable for me anyway) and then suddenly have a cluster of either highs or lows. It took me a long time to not overreact to this and change too much too fast, especially with being on MDI and only being able to change by whole units. But I learned to make myself make one change and wait about three days. Sometimes the new numbers would “stick” and I’d stay stable with them for awhile and sometimes I’d “drift back”. The more conservative I was, the less that happened of course.
I’ve never ascertained why this happens. As I say I’ve posted on here a couple times asking if this was a typical LADA pattern and never got much response one way or the other from LADA’s. Before anyone could jump in with “female cycles” I have always reminded people that I’m post-menopausal, and before they could say “stress” I post that I really don’t have any! So that just leaves LADA or the inexplicable D goddesses. I’ve been diagnosed 4 years (two less than you) and when I had my c-peptide done 2 1/2 years ago (in search of my right diagnosis) it was either .38 or .70 (two labs) so I kind of doubt I’m making much now, but you never know. I can’t recall and I’m too lazy to search, do you know your c-peptide?
In general what I do is look at one “page” of numbers which for me is 4 weeks and look to see patterns that call for small changes in basal or I:C. I find my “drift” is a lot less when I can make the small changes a pump allows. I rarely “drift back” until a few more weeks passes. I try (but don’t always succeed) in not responding to just 2 or 3 days of numbers. I do better at resisting with highs than with lows. (I hate having to treat lows).
I don’t know if I’ve provided any answers to your question, bsc, except to say I have a similar experience and have pretty much stopped trying to understand “why” and just learned to respond conservatively. The response I did get when I posted was similar to what I see here now. “Classic” type 1’s saying “many of us have a similar variability” which makes me realize that once the initial adjustment period of decreasing insulin production has passed, that us LADA’s are, for all intents and purposes, just Type 1’s. So much for the joy of being unique…lol
Hi Zoe. One small point: When you say you can only change in whole units, I assume you are using pens. What you can do is get 1/2 marking syringes and extract the exact amount. I use BD 1/2 marking syringes (when you buy them, the word marking is key and you have to watch the pharmacy like a hawk every time). When on MDI, I take 1 1/2 u of Levemir at 8:00 AM, 1 1/2 u at 2:30 PM, 5 whole units at 9:30 PM. Those half units are key to my having stable basal in the daytime. You just have to be sure to prime your pen when next you use the pen needle after using the syringe.
I’m on a Ping, Trudy. I can change in .025 units…lol. I was speaking for bsc who I know is on shots. (and from my own experience when I was as well). I always used the pens. I’d heard about the 1/2 unit syringes but really preferred pens and besides lived in Guatemala where it was hopeless to find anything “special” and soon after I returned to the U.S. got on the pump.
I think you are right, diet can make a big difference, but I am pretty consistent with the diet thing. I have been pretty stable with weight, I’ve lost 2-3 lbs since starting insulin last december. That doesn’t seem enough to make much difference. I do think you are right that logging is the key, otherwise you will never identify the trends.
And you are probably right, I may have an unrealistic view of attainable control and what variations I would expect. But my total daily dose has dropped 30% and still appears to be falling. I look to be on track to reduce my insulin needs further, perhaps for those with waning insulin production (like LADA), the variation is greater.
And I do think that how we each detect these changes and react is important. I sometimes read about people who correct and treat lows many times a day and wonder whether I could do any better in the same situation. My situation and control in that context actually seems a blessing. So I may wonder about these questions, but I don’t think it is frustrating, just challenging.
I like the idea of using “hallmarks” for control, like morning readings, or my preprandial reading before dinner. But I worry that life is just so complicated, I could end up higher a bunch of mornings just from sleeping poorly and if I change my basal I’ll have changed something that didn’t need fixin. I think when things are stable, it is easier to look at 2-3 days and have some confidence, but it is just really hard when things are up and down.
And I really like your idea to change your ISF to stay in sync with your I:C. I believe that they are connected and that if you increase your I:C by 10%, you should probably increase your ISF by 10%.
It sounds like your experience is similar to mine. I am fortunate that things are really kind of “drifting” as you note. Since I am a big guy and my total daily dose is around 50 units now, I can change dosing in whole units and still only change things less than 5%.
The first time I had my c-peptide done, it was 1.8 ng/dL with a blood sugar of 130 mg/dl, still within “normal” range, but barely and not exactly classic high levels of insulin seen by some type 2s. So I have to think I am insulin deficient.
That makes it easier, bsc. Being insulin sensitive is not always better.
If that c-peptide was closer to your original diagnosis, that certainly makes it likely you are producing little or none now. I think one of the hardest things for me in managing this condition, is giving up expecting it to be logical all the time.
I am not a predictable person and I don’t live a predictable lifestyle, so I approach irregularities with corrections rather than adjusting basals and boluses. I have a CGM, and some days I have beautiful flat lines, and other days I bounce around. And some days I run high, and other days I run low. My lack of a regular schedule or regular sleep hours or regular amounts of food or exercise surely account for that. I have been known to take as little as 20u per day or as much as 50u. Mind you, the 50u was the day I ate a HUGE bowl of Cream of Wheat AND was running high in general. Doesn’t happen too often!
The nice thing about the pump is that you CAN accommodate fast-changing insulin needs – or even turn it off completely if you need to. It’s a lot harder with long-acting insulins.
I should have said, if I wake up high or low a few times in a row without a known reason, I’ll adjust … I sometimes will forget to decrease my basal rate on days I’ve exercised (which is most days) and wake up low in the middle of the night; or, if I eat a snack before bed I sometimes wake up high the next morning. On those occasions I don’t change things, but if I wake up low a bunch of times without being able to link it with anything, then I adjust.
Of course, it’s still impossible to know if maybe the changes were just random. That is one of my problems, too. Sometimes I am high for a day or two and turn my settings up only to go low the next day and have to turn them back down. Drives me crazy. One of the awesome things about the pump is that it’s really easy to “undo” mistakes like that and reset your basal rate if you find you’re running too high or low after a change.
I am trying to gradually figure out how various things affect me. I’ve already figured out the hormones and just recently nailed the delayed exercise hypoglycemia. Only about a million other things to figure out before I attain perfect control!
