Day vs night basal

Interested to hear if anyone has experienced similar problem to me - I am currently trying to get my basal rate sorted out after some recent problems - I’m 210lb 6ft man fairly active - probably 10lb overweight - and I currently am taking 24 units of tresiba each morning
This is giving me really good nighttime stability - I go to bed at between 90-120 and I get up pretty much the same - when I check my cgm it’s flat all night - not even a dawn phenomenon really - so all good
My problem is daytime my basal needs seem to be all over the place. I Dont eat carbs until lunchtime and then keep it to less than 20g from green vegetables - total carb intake a day is about 50g-60g
Even fasting for the day I find I need 3 units of humalog at 7am then another 5 at 9-10 and then 5 at 1pm then 5 at 4pm - if I don’t do that my sugar will go up to 200 from increased basal and it’s a conplete pain to get it down again - I have to get the timing exactly right as if the rise from basal starts I will be at 180-200 and then have to work to get it down - and that is before adding bollus and carbs to the mix
Does anyone get this ? My doctor says my basal should be consistent 24hrs but it seems my liver goes into overdrive during the daytime. Maybe I need a pump so I can increase the dosage during the day ?
( I can fix the problem by raising my tresiba to 32 but this is too much given I can get a flat reading at nighttime with 24 units and I don’t want to pile on the pounds )

Yes, I get that. It pushed me from manual injections onto a pump. However, before I made the switch, someone on this site recommended taking half my basal before bed and then the 2nd half when I woke up in the morning. This helped. I never knew that you could split dose the Lantus, but you can.

Your Lantus may be consistent, but your body probably demands more during the day. You may still need a pump, but I would try splitting the dosage first. I’d start with 12 before bed and 12 in the am. Then, bump up your morning Lantus as needed. Your night time and morning dosages will overlap a little, which will help with daytime BG’s. Since you typically take your Lantus in the am, it might be nearing the end of its efficacy overnight, generally, so be on the lookout for overnight lows if you split (might have to bump it down a little).

Thanks - I’m on tresiba though not lantus but will give that a try

I’ve read other comments about people using Tresiba as part of an MDI regimen will split their dose. It’s worth a try – keep good records of what you’re doing so you’ll be able to adjust as needed. Changes to the Tresiba dosing schedule should be allowed to stand for 2-3 days as it takes that long for the effectivity to settle in.

Your comments about having to add Humalog during the day shows that your Tresiba dose is deficient. You need more insulin. It’s hard adding those four doses to every day as that requires more attention than it should.

I tried Tresiba with only a single dose and had pretty good control after being on a pump for 29 years without a break. But I found that I could not find a single dose that kept me level through the night without driving me low in the late afternoon. The pump did solve that challenge when I returned to it after five months.

You should be able to discover the dosing schedule you need but you’ll have to experiment. Write stuff down! That’s the key.

There was another thread where I ragged on doctors a bit for saying stupid things. And then I backtracked and apologized for saying bad things about them. But I guess this has me going back the other way again.

If your doctor is saying that tresiba will give you a 24 hour steady basal amount, that’s fine. It is correct.

But if you doctor is saying your basal requirements should remain steady for 24 hours a day, and you have tried but they are not, what you need is a smarter doctor.

Your basal needs are what they are. If they are not the same throughout a 24 hour day, then tresiba by itself is not the answer.

There are many ways you can fix this, with either different types of basal insulin, or with a pump. You can do it many different ways.

But splitting tresiba into multiple doses will not fix it.

First off, are you sure you need more basal during the day? If so, let’s talk about ways to address that.

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As I said above, I have no direct experience with splitting a Tresiba dose to good effect but I understand that Dr. Bernstein recommends this tactic. And he’s not the only one to do so. Your diabetes may vary …

I have heard him speak about taking a large dose and breaking it up into several smaller doses and injecting it in different areas, to help with absorption. But I have not heard him suggest breaking it up into different times of the day to make it more or less level. Those are two completely different things. If you have a reference or quote from him, I’d love to see it. Splitting it up into different times of the day seems to totally go against the intended purpose of a 40 hour basal insulin, so I’d love to see his comments if you have them.

Dr. Bernstein YouTube video, August 2016.

Do you by chance drink coffee? Some diabetics find that spikes them and that they need to cover it like it’s carbs, even though it has none.

Definitely not coffee - don’t see spikes from that and anyway it’s not a spike it’s a steady basal rise - happens every day at about 11am if I don’t dose with humalog

That thing is an hour long. Can you give me a ballpark? (time-wise)

Tresiba dosing is the very first topic.

I listened to it. He did not explain anything. He said people need to take it twice a day, but didn’t give any type of information about why. He didn’t discuss anything about the duration of it. What he is saying is totally contrary to what other endos say about it, and what the Tresiba pharmacodynamics show.

He also did not make any mention of people who have various basal needs, at least not in the first 30 minutes of his video, which was all I got through.

You can look at all the Tresiba documentation, and look at the GIR and time graphs, and all the euglycemic clamp studies. People can chase their tail splitting Tresiba into two doses, but if they have various basal needs, and need more basal at night or more in the day, I have yet to hear a single valid explanation of doing that with only Tresiba.

Using both Tresiba and Levemir would work for something like that, as long as your Levemir dose remained low enough so you did not go too far beyond the 12 hour mark (generally under 0.2 units/kg keeps you close to 12 hours).

I am not here to defend Bernstein’s take on Tresiba. I have not held myself out to be well-versed in Tresiba use. All I know is that Dr. Bernstein has used “unconventional” methods for his entire medical career. His opinions have often started out as outliers and over time moved into the mainstream. Given your eagerness to make this argument, please don’t think I am the person to take the other side.

I’ve learned over the years with my own diabetes, as well as experience shared here, that coming to rock-hard definitive conclusions about diabetes will often lead to lessons in humility. I respect people who maintain a degree of uncertainty in their expertise. People who have some notion about what they don’t know earn my respect more quickly than over-confident certainty.

One thing that earns an unusually high degree of respect from me is a willingness to do the test! State the hypothesis, design the experiment, observe the data, and then draw conclusions. It’s important that this all be done with the understanding that an n=1 experiment can not conclude much of a general nature but can be highly instructive for personal learning.

There is a huge amount of data on the subject of basal duration.

Another poster suggested that he split his dose of Lantus. And that is useful for Lantus or Levemir. But since the OP is on Tresiba, that is not very useful. So sending him down that path is not going to help him if his issue is indeed a problem of different basal requirements.

I asked if the OP was sure that his basal needs were higher during the day. I wanted to establish it was the real problem.

You say “do the test”, but I have yet to hear any reasonable explanation why splitting Tresiba in this instance would help increase only his daytime basal level and leave the nighttime level as it is.

I am not picking a fight with you, Dr. B, or Tresiba, but I would like to hear some rational for the suggestions. Some kind of reason that makes sense. Dr. B gave none.

I gave a solution that absolutely would work. Leave the Tresiba dose as it is, but add Levemir in the morning, which would increase the daytime basal, but fade off for nighttime. And I even gave dosing numbers that have research behind them (0.2u/kg for a 12 hour duration).

So, again, not looking for a fight over the issue, but I would like to hear some reasoning or basis for splitting Tresiba that makes sense. We are here to learn, so I am looking for some information or knowledge on it. That would be great to hear. I am not one to blindly listen to someone like Dr. B say split it, and then not explain “why”. If there is a reason behind it, then there should be some science behind it also. I don’t think that is an unreasonable approach.

Hi - I hopefully can answer some of the questions posed in your dialogue - i was taking 32 units split twice a day a few weeks back - my dose had gone up as I was trying to combat the afternoon highs with the tresiba
But it had no effect - the high was still there when fasting during the day
Since then I have slowly been reducing my tresiba dose and my endo told me that it was pointless doing it twice so I have only been doing it once - swiTching back to once a day tresiba at 32 made no difference
Interestingly as I have slowly reduced my tresiba from 32 to 24 the impact on the afternoon high has been neglible (it hasn’t got worse) and also the impact on my nighttime readings has been neglible also - they have stayed flat
My endo says the extra tresiba is doing nothing except making me keep on the weight - doesn’t make sense to me but the readings can’t be ignored – he wants me down to 20 tresiba and then we will fix the afternoon high - therfore the levemir idea I like as I won’t have to keep injecting during the day and getting the timing wrong most of the time
I’m also hoping when I get to 20 I’ll lose the extra 10lbs which won’t shift now as I have all the extra insulin on board

Possibly what he is saying is that taking too much basal insulin is causing you to feed the basal. If you are going low, you will eat, and that will keep the weight up. Insulin by itself does not cause you to gain weight, it is food. So that is probably what he is saying.

So if you take a bit of Levemir in the morning - and take a small enough amount to be less than 0.20 units per kilogram (Not pounds! Kilograms!) - that would generally be gone in 12 hours or so.

Basically you take your Tresiba which gives you your baseline basal requirements, and then Levemir in the morning gives you a little more for daytime, but fades off for nighttime.

At your weight, about 19 units or less of Levemir should put you in the 12 hour ballpark for Levemir duration.

IMPORTANT:
I am not saying you need 19 units, I am saying that amount or less should keep it about 12 hours duration or less.

Of course, consult, test, and adjust as you need to. But if you want to stay on Tresiba but just add a bit more for daytime, Levemir can help you with that.


Some info on the dosing/duration, which I posted above:
ncbi.nlm.nih.gov/pmc/articles/PMC3108694
Plank et al24 also found a dose-dependent duration of action for insulin detemir in type 1 diabetes from 5.2 hours at the lowest dose of 0.1 U/kg to 23.2 hours at the highest dose of 1.6 U/kg and a flat and protracted pharmacodynamic profile

If you read the pamphlet that comes with Tresiba, it clearly specifies some people will see weight gain. I take 23 units of Tresiba daily, eat approx 60-100 carbs daily, yet I’ve had weight gain. I’ve had Type 1 for 55 Years, am on MDI, yet my A1C is a great 5.7 ever since I started Tresiba in Aoril 2016. My BG control is more important to me than weight gain. I don’t like it but I accept it.

The pamphlet does say it can cause weight gain, but these sort of cause/affect things are not very well explained.

Take an insulin naive patient who has a very high A1C, is unhealthy, has frequent urination, diabetic ketoacidosis, etc., and then put them on Tresiba. When their A1C comes down, it is reasonable that they may gain a few pounds.

A couple quotes from the article below:

"...in most cases, a significant lowering of A1C will likely result in some weight gain."

and

"Weight gain is more likely for people with frequent low blood glucose who must take in more carbohydrate to regulate blood glucose."

Which is like what I said, “Insulin by itself does not cause you to gain weight, it is food.”

@Eric2, actually my a1c prior to Tresiba was not out of control, it was 7.2. I just wanted better. Since I’ve been on Tresiba, 16 months I have had only 2 nighttime low BG , which is awesome! I only switched because I still wanted to improve. I do not want to argue with you, I just want to say that yes, Tresiba can cause weight gain. If anything, I have less low BG episodes since starting Tresiba.