Hey, y’all. I’m reading, reading, reading trying to understand how to get my BG’s down into the “as normal as possible range” and I came across this conundrum in the book, “How to Think Like a Pancreas”. Apparently I think like a spleen, or perhaps a rutabaga, because it makes no sense to me:
"…if your bedtime reading was 185 mg/dl (9.2 mmol) and your wake-up reading was 122 mg/dl (6.8 mmol), your basal insulin dose is too high since the blood sugar dropped by 63 mg/dl (2.4 mmol) while you slept. Had your bedtime blood sugar been closer to normal, you would have experienced hypoglycemia during the night. Reduce the basal insulin dose by 10%, and run the test again the following night."
WTW???!!!???
122 mg/dl is 52 mg/dl above the cut-off for hypoglycemia (70 mg/dl or 3.9 mmol) and 32 mg/dl above a “normal” fasting of 90 mg/dl (5 mmol) Why in the world would you reduce your basal when you’re still so high?
If your goal is to normalize your blood glucose without going hypo, wouldn’t you look at that range of 185 to 122 and say, “Hmmm, my evening readings are still too high, gotta bump up my basal a spec until I’m getting down into the normal range.” ???
This is on page 108 of the paperback, and you’re supposed to perform the first test at night at least four hours after eating/bolusing (one test before bed, one in the middle of the night, and one upon rising.) He wants you to keep reducing your basal until the drop between bedtime and morning is no more than 30 mg/dl, no matter what your starting number is, as long as it’s under 250 mg/dl (13.9 mmol).
According to this book, if you drop from 240 mg/dl (13.3 mmol) to 190 (10.5 mmol) while you’re asleep – a 50 mg/dl drop – you’re supposed to reduce your basal.
Huh?
I just don’t get the whole basal thing. Every book and article I read has a slightly different take on the “right” way to set your basal. As an insulin resistant T2, my Lantus values will seem pretty high. Right now I’m injecting 55 in the morning (two injections into my thighs in order to enhance absorption) and my BG’s are usually still way too high (fasting in the low 200’s, ditto five or six hours after a meal/bolus.) I’ve been bumping it up every four or five days and trying to test a lot. I thought I knew what I was trying to achieve but this book’s approach is giving me a big headache.
Thanks!!!
He just means by that: Your basal rate is causing you to drop by 63 points. So if it had been in the normal range, that size of a drop would bring you too low. He isn’t saying anything about how the person got to 185. (Could have been from their dinner), just about the size of the drop. In theory at least the same basal dose will always drop you about the same amount and 60 points is too big of a drop. Make more sense?
I thought actually the rule is to not have more than a 30 point change in either direction overnight.
As a person on MDI’s given the examples he gives, what I would do is look to see why I was so high at bedtime. First I’d look to dinner and test enough to see if I went high after dinner and kept going up.
Have you thought of perhaps splitting your Lantus dose or else changing to Levemir? You’d get a smoother action. If you have a particular problem with your fasting and/or DP as many type 2’s do, you might consider that your morning Lantus just doesn’t make it 24 hours from when you take it in the previous morning. You’re on the right track by bumping it up every few days until you see the numbers you want, but also playing with the doses timing might make it easier
The point Gary Scheiner is making is a very important one. You don’t correct with basal insulin and you don’t cover carbs with basal insulin. If you go to bed high then you should (1) think about increasing your dose at your last meal and/or (2) taking a correction with rapid insulin. If you are only on Lantus (a basal insulin) you have to figure out some other way to get your blood sugar closer to range before bed by looking at what you’re eating, increasing exercise or changing your other medications. I can’t be much help as I’m T1.
Maurie
Thanks for your reply, Zoe.
Yes, I did try a split dose, but I found it maddening as I was always chasing my tail trying to keep the two doses exactly 12 hours apart. I know more now and I’m not so afraid of them fluctuating a bit, so I should probably try that again.
My silly HMO won’t cover Levemir, which is a drag because sometimes the Lantus burns in my leg for a long time (with twinges of pain even hours after I inject). Grrrr. I guess that must happen when I get it too close to a nerve.
Nevertheless, I still don’t understand why it matters if you drop 30 or 40 or 50 in the night, as long as you’re not going anywhere near hypo. I mean, if you’re dropping from 200 down to 160…who cares? And why? I mean, if you’re consistently dropping from 200 down to 160, how is that a problem? Wouldn’t it only be a problem if you started dropping from 110 down to 70?
Your basal should keep you stable. Dropping 50-60 points during the night is not stable. If you went to bed at 100 you would wake up in the 40s. John Walsh is actually a little tigher than Gary Scheiner. Gary says not go up or down by more than 30 points. John says not drop by more than 30 but don’t go up by more than 15.
Like Zoe said, you aren’t looking at how you go to 185. You are just trying to figure out the right basal rate to keep your BS stable. Ideally, you should be able to skip meals and not worry about going low. When I do basal testing, I actally do mine for 24 hours so I know my rates are set right.
Look at your basal settings like the foundation to a house - you can have a nice big, beautiful, well-built house but it it is on a crappy foundation, it will come tumbling down.
Thank you, Kelly. Like I said, I must have rutabaga brain tonight, because I’m still not getting it. I’m sorry! Maybe it will make sense to me tomorrow.
How can you set a basal rate if four, five, six hours after you finish a meal/bolus (no more food in your gut and no more Novolog on-board) you’re still consistently way to high, and you continue to be too high through the night and into the morning (12-15 hours after dinner) but there was a drop in the night (say 40 points, from 200 down to 160)?
Won’t you just be perpetually MORE high if you reduce your basal to “fix” the drop?
I am making some of my own insulin, and it seems to squirt out at random times just because it can. Ditto my liver squirting out random shots of glucose. There are mysterious hormonal forces at work here that are more than just insulin/glucagon – perhaps due to my adrenal hyperplasia, thyroid disease and ovarian cyst? Not to mention perimenopause? I’m a mess!!!
Please don’t hate me for saying this, but I have a serious case of T1 envy right now. If I could trade my insulin resistance/hyperinsulinemia and random roller-coaster for straightforward non-functioning beta cells and zero insulin resistance, I’d take the trade in a heartbeat. Just the thought of being able to set a basal rate and have it WORK even 70% of the time makes my heart go pitter-pat.
Thanks Maurie!
My first CDE agreed with you. She said she’d much prefer T1 to T2 because it is so much more straightforward. Of course, she was lucky - she had neither 
Maurie
I don’t hate you for saying that because I would be pulling my hair out if I were you! I can’t imagine trying to figure out whether or not your pancreas is going to show up for work today and whether it plans to work full time or part time. That would drive me nuts.
No, you won’t be perpetually more high. What you may need to do though is take bump up your fast acting with your meals. Since you are dropping at night, you are taking too much Lantus and probably covering your meals with it. You should not really cover meals with it. If you want to skip a meal or eat late, you should have that option. Sometimes when you are taking too much Lantus, it can cause rollercoasters – even if you are not seeing low, lows, you are going high and dropping.
You probably want to get to the point that you are not going to bed at 180 either. Even you go at 120 and drop 60 points, you will be low.
I understand about the whacky hormones – thyroid and diabetes do not get along! I don’t have adrenal problems but have/did have the others. None of them are fun. The thyroid problems also can cause you to have highs for a couple weeks then the bottom falls out – it could be your thyroid and not your pancreas waking up, but since you can’t stick a little hormone calculator in, you won’t know which is causing it.
Your basal insulin should simply hold your blood sugar steady, not cause it to either drop or rise. If you are going to bed high every night then you should find out what’s causing the bedtime highs and adjust whichever insulin contributes to that, not adjust your basal so that it drops you into range by morning. If you have a high at bedtime the way to lower it is to take a correction dose on top of your basal insulin.
The time to adjust your basal would be if you are going to bed at 100 and waking up at 200 every morning. Or, if you are consistently at 150 two hours after a meal but are then up to 250 before the next meal.
Hope that makes more sense.
No envy please …( T1, I am struggling lately ) …I use about 20 u daily , a pumper, am testing my basals and oh , my …this is NOT done in 2 days , trust me …I do fast more than 5 hours …for instance : for the day test : eat light breakfast , start testing 5 hours after eating light breakfast with poking every 1 1/2 hour till about 5 pm .
My pump nurse suggests : on a day , when you wake up with a readfing in the 4.0 to 10.0 range , skip breakfast and your breakfast bolus .The correct basal rate will keep BS flat ( less than 1.0 to 2.0 mmol/L difference ( x 18 for you ) over the next 5 hours If BS varies by more than this , make an adjustment 2 hours before the BS rises or falls
and …repeat this test until the basal rate is correct on two consecutive tests at this time of day .
Lets wish each other well !!
PS I prefer the way my Helper Nurse has put it down on paper …much easier for me to follow .
PPSS I realize you are not a pumper , so hope , what ever I typed here makes sense for you too
Are you on a rapid-acting insulin at all, to cover food and correct highs?
The high you’re referring to: Is it that you went high after your meal (at the 2 hour mark) and then just kept going higher? If so, your carbs are not being covered well. You want your bolus to keep you from going over your target at the two hour mark or whenever your peak comes. I say that because if you eat a fair amount of carbs and also high fat, your peak might not hit till the 3 or four hour mark. Once you’ve correctly bolused for your meal, your blood sugar should - if your basal is set right - return pretty much to baseline. If you can tolerate it, the way to truly know if your basals are right is to fast. You don’t need to fast all day but can do it in segments. John Walsh gives good instructions on this. You should have very little fluctuation without eating. You don’t use basal to fix bolus problems if that makes sense.
The answer to your question about altering your basal if you are at 110 (so you don’t drop too low). It doesn’t work that way! Especially if you are doing your basal in the morning! You don’t vary your basal according to meal results. That’s what the bolus are for, and that’s what bolus corrections are for. If you’re 200 close to bedtime, do a correction so you go to sleep at a good number and then when your basal is right it should stay within range during the night. I personally test while I’m reading in bed, so if I’m high I can correct and then check again before bed.
As for the type 2/type 1 thing? It’s apples and oranges. I know that insulin resistance is a ■■■■■. That’s why I’m always “preaching” to type 1’s who are into the eat whatever I want and bolus for it, because they could then be an insulin resistant type 1. But I think you have an overly optimistic idea of how stable type 1’s are. Yes, there are type 1’s who say their blood sugar is between 70 and 100 all the time, but not this Type 1!
And yeah, if you’re tired and your brain isn’t tracking, it’s time to go do something mindless (or sleep, depending on your time zone!) and come back to it fresh tomorrow!
Yes, I’m using Novolog. I’m still adjusting my I:C ratio, right now it’s at 1:4. I’m also still adjusting my mealtime correction factor. Right now it’s at 1 IU for every 15 mg/dl over 100. I think I’m getting close on these as my BG is returning to the starting point (or pretty close) within two to four hours, but I thought I should be creeping up the basal because the starting point is always too high. Right now I’m not sure.
I haven’t been injecting a correction bolus at any times other than mealtimes, but perhaps I should be?
Part of the added confusion is that my sleep schedule is erratic and I often miss meals (i.e. go 9-10 hours between meals.) I don’t consciously do this – it’s not on purpose. It’s more of an unconscious habit. I might wake up and have a couple of eggs and some bacon at 11 a.m. and then realize it’s 9 p.m. and I haven’t eaten anything for ten hours. Where does the time go? Maybe I did housework, did some shopping, took a shower, checked my e-mail, read the news on-line, etc. and oops, it’s getting dark and I haven’t even started to cook dinner. WTW?
I know things will settle into more of a routine once I start working full-time again.
OK, but hold it steady where? What is your basal four to six hours after your last bolus/meal?
Isn’t there a target range we’re aiming for when we’re riding the basal and the bolus is out of the picture?
Thanks!!!
Actually, Jean, when you mention that you often don’t eat for so many hours, you are in effect doing basal testing! If your seeing high numbers even when you go without eating for that many hours, than your basals are definitely too low!
Not to further complicate things, but do I remember you saying you were denied a pump or that your insurance didn’t cover it? If that’s not the case, you might want to think about it at some point. It’s really great for people who live unpredictable schedules. Also the ability to set your basals for each time period is invaluable!
It should hold your blood sugar steady at whatever it is four or so hours after eating (once your bolus has worn off). If you have a reading before bed of 250 and don’t take a correction of rapid-acting insulin, you should wake up at around 250. If you go to bed at 400 without doing a correction, you should wake up around 400. If you go to bed at 100 you should wake up around 100.
So nope, your basal is not supposed to lower your blood sugar into a pre-set target range, only hold you steady at wherever your bolus leaves you, whether that’s within your target range or high.
If your seeing high numbers even when you go without eating for that many hours, than your basals are definitely too low!
I think this depends … If your numbers are starting out in range but are creeping up even without eating, then yes, your basals are too low. If, however, you are starting out high to begin with and not taking a correction and your numbers just stay high for hours and hours without eating, then your basal is fine, you should just be taking a correction to lower the high instead.
Thanks Zoe. Re. highs: I am always too high. My last A1C was 9.1 or so. I’m probably running an A1C of >= 8 now, despite using both Lantus and Novolog.
All the amounts my doctor set me on were way, way off. He started me at 40 Lantus, now I’m up to 55 and counting. He set me at 1:15 for my I:C ratio, now I’m up to 1:4.
My Novolog to md/dl correction factor was in the neighborhood of 1:30, now I’m up to 1:15.
And I’m still way too high most of the time – except when the planets get out of sync and I drop hypo – almost always as a delayed response to making a change in my exercise without knowing how to change my insulin to compensate. I just recently figured out that I do this delayed drop, 24 to 48 hours after, for example, taking an unusually long walk.
Yeah – my head is hurting now. I’m going to look at this with fresh eyes in the morning. Thanks!
OK, light bulbs exploding over my head!
Thank you!