So I’ve been on insulin for about 2 months now and I think things are going well… I have a few questions so thought I would ask here. What would you consider a low blood sugar? I’ve had a few 3.2s (57ish) and corrected with juice or banana. Is this dangerously low or just low? My Dr is still insisting I dont bolus for snacks which doesn’t make any sense to me. He told me it would be too many injections and I already have the Lantus working anyway. I could theoretically have a snack higher in carbs than my lunch for example. Should I for example, bolus for snacks above 5carbs? One night I forgot to take my Lantus and didn’t take it until the next evening, would it be ok to take half in the morning if that happens again?
Sorry for some of these newbie questions and thanks again for the advise… Paul
Hey - never apologize for questions – only way to learn. I’m not a doctor, so I can’t give you medical advice, but I will tell you what I do. The question of “how low is too low” is always big - and to some degree varies by individual. I do not consider 57 to be dangerously low, so long as my BG isn’t falling rapidly at the time. (I use a CGM, so I have a good idea of the trends.) That said, I certainly do correct any lows in the 50’s, though a whole banana is too many carbs for me!
Doctors don’t like you to “stack” insulin - to take more than one shot within 4-5 hours. I was initially given similar advice. I also did not like the results I got from not bolusing for snacks, so I started doing so. If you do, you will have t otest more frequently to make sure you don’t overdo it and go low (or high, for that matter). My eventual “compromise” has been to avoid snacks that contain many - or any - carbs, such as a handful of almonds or a piece of cheese. Currently, I rarely snack at all.
If I missed a basal dose when I was taking Lantus, I did take half in the morning; however, for me, Lantus (and certainly Levemir) did not last a full 24 hours, so I split my doses, anyway and took half at night, half in the morning. If I missed the night dose, I increased the morning dose by a little. You have to be extra careful with long-acting insulin – since it lasts so long, mistakes mean a LOT more time that will require close monitoring!
Low blood sugar is anything that effects/affects you. But “by the book” anything below 80 can be a low.
The most important thing is to take care of lows right away. If I put off treating a low, I can get in a pattern. See below.
What’s dangerous? Any of them can be dangerous. I categorize two distinct types of lows:
There are lows that you notice because your BG is dropping fast. You FEEL them.
The boiling frog lows. You drop so slowly that you don’t notice. Then all of a sudden, you don’t feel right. Your BG meter reads 1.5 (28).
If you’re on insulin, you should be bolusing for snacks. But if you know you’re going to be active very soon, 5 grams of carbs won’t do much to your BG. When you bolus only YOU can figure out, but I’ll bolus for 10g of carbs. But I’m on a pump, and I can bolus very small amounts.
Half of your Lantus if you miss a shot is reasonable, but be prepared for the fact that you might have elevated BGs for a while. Better to be a little high than too low.
What fast-acting insulin are you using? Do you know your insulin-to-carb ratio? Do you know your insulin sensitivity level? Do you know how long your fast-acting works in your body?
The answers to these questions will inform how you bolus for food and corrections.
I really like that description! When I’m really concentrating on something or working in the yard, that can happen to me quite easily. Now that I use a CGM, I set the alert higher during activity so I can head off a low. Before that, I sure had some doozies (into the 40s), ugh.
Thanks… I’m currently on a 6:1 ratio of Apidra 3 x day and 9 units of Lantus at night… I’m not sure what my insulin sensitivity is… I’m 6’-1" and 158 lbs and very active so probably insulin sensitive?
Your insulin sensitivity is how far one unit of Apidra moves your blood glucose. This will give you an idea of how much insulin you should take for a correction.
You also should know it’s not a set number, because your insulin resistance will lower when you’re active and increase when you’re sedentary.
That two units you took after three hours at the computer will be WAY too much when you’ve been playing football for a few hours (even if you’re on goal).
This varies so dramatically from individual to individual that there is no meaningful general answer. Some people feel low at 70. I don’t notice it until about 50. Each person you ask will have their own “trigger point” at which they know something’s happening. Physiologies just vary too widely from individual to individual for any fixed rule of thumb.
Just as general background, fasting blood sugars for nondiabetic, nonpregnant, nonobese people typically fall between 75 and 90, give or take. Again, this isn’t precise. Each body has its own preferred point of equilibrium.
The one part of your doctor’s advice that is . . . well, debatable at least, is the part about not bolusing for snacks. IMHOP, the distinction between “snack” and “meal” is a meaningless red herring. I don’t care what name you give it; I bolus for whatever spikes my blood sugar. That’s the bottom line for me.
Someone else made the point that doctors worry about stacking insulin, and it’s true, they do. Not without reason; it can get you into trouble IF you do it haphazardly. But if you know your insulin to carb ratios and insulin sensitivity factors, it becomes a fairly mechanical exercise. So much food requires so much insulin. You just do the math. Which, as a matter of fact, is the only way to use insulin safely and effectively, stacking or no stacking.
I think it is fine to be conservative. It takes time to really understand how to account for insulin stacking. After six years, I still struggle at times. It is easier if you just don’t bolus for snacks. You can correct before the next meal and you will still be far better than when you couldn’t bolus or correct.
The duration of action for modern insulin is five hours, it is very hard to have a snack after an hour or two and bolus for the snack. It is much better to just have a lower carb snack and not bolus. Over time you will become really competent and you can figure this stuff out, but just take it one step at a time.
As to missing your basal. I never fail to inject my basal at night, but when I do I make up the dose. I inject a “proportional dose.” I correct any high blood sugar and then if I missed my dose after 8 hours I inject 2/3 of my dose (that is 16/24 hours of dose), that keeps my total daily dose of basal correct. Not that I ever miss my dose (ok, I’ve missed my basal twice in the last month and suffered for it).
I agree. There will come a time to be more assertive with insulin. Your insulin needs are in flux right now.
It is true that “by the book” the modern insulins have a 5 hour duration. Remember, that’s an average. Yours could be shorter or longer. Novolog stays in my system for 3 1/2 hours. It took a long time to figure that out–and it can vary at times.
Anything under 70 is “low”. Some of us never want to be below 70, 80, 120 - it really depends on your management and what sort of range you choose to consider “normal” for you.
I couldn’t have figured out any of this without the books “Think Like a Pancreas” by Scheiner and “Using Insulin” by Walsh. Written by T1Ds for T1Ds. Both taught me more than any dr or CDE and I refer to them often when things go wonky. My husband read them so he has some idea of all the extra stuff we have to do/think about all the time.
Good for you for questioning your dr. This is a self management disease so you need to figure out what works best for you. If I eat, I bolus. But be careful with stacking as said above. You’ll figure out what works for you.
Your insulin needs are weird. Lots of short acting (Apidra), very little long acting (Lantus). Not wrong, just weird. Are you waking up with a bg in a range you are comfortable with? When you get the books, do a basal test. Just remember things will change over time, sometimes pretty suddenly, sometimes slowly.
When I forget to take Lantus, I don’t take any when I realize I screwed up. I give myself small numbers of units of Apidra every couple of hours. Sort of like pretending to be a pump. I test a lot and inject a unit or two as needed. If I take half the Lantus in the morning and then my full dose in the evening, I will have way too much Lantus (1.5x) in my system that night and will have dangerous lows. It’s easier for me to inject often for 12-14 hours. I take the Lantus 2 hours or so early. I have an alarm set on my phone that won’t go off unless I turn it off so I don’t forget.
I think your right… I’ll probably stick to no snacks or close to zero carb as I can… I’ve been told to only check BG at 2 hours so that is what I’m doing and so far numbers are averaging between 4.5-8.5… What do you think about checking at 1hr or 2hr?
Thanks for the info… I do feel the lows at 3.2 (shaking hands, a little sweaty and fuzzy head space). I had half a banana and quickly came back to 5.5. I’m still trying to figure all of the out but glad we have this forum
I actually think that checking at 2 hours is the first step. Checking at 1 hour isn’t useful and if your blood sugar is > 10 mmol/L (200 mg/dl) you will just get pointlessly stressed out. You have diabetes, of course your blood sugar will spike after eating, what really matters is that it is back down at 2 hours.
Start with getting your blood sugar under 10 mmol/L (180 mg/dl) at 2 hours (which you seem to have achieved) and then work down to a lower number (I try to target under 8 mmol/L (140 mg/dl) at 2 hours with my low carb diet)), but it really depends on your goal. You don’t want to be too aggressive with the mealtime insulin as it can cause you to then go low a couple hours after a meal.
And as to snacks, remember 1g of carb raises your blood sugar 0.3-6 mmol/L (5-10 mg/dl), so if your blood sugar is back to 5.0 mmol/L you can eat a 5g snack with no bolus and still pretty much keep your blood sugar in target range with no insulin.
I just want to thank everyone for their comments and inpput. I really appreciate them all. I have one more quick question. I’m taking 9 units of Lantus before bed time (usually about 10:30-11:30). I typically wake up in the 7.5-8.5 range. I think this might be a little high (I’m sure my Dr doesn’t). Do you think this is too high for morning BG?
7.5 to 8.5 mmol/L (135-155 mg/dl) is actually not too bad. I often will awake with those sorts of numbers. One key goal in establishing a basal rate is to not have a significant rise or fall overnight. So if you go to bed with say a blood sugar of 7.5 mmol/L and arise at 8.5 mmol/L that is pretty close. If you go to bed at 5.0 mmol/L (90 mg/dl) and arise at 8.5 mmol/L (155 mg/dl) then you should probably talk to your doctor about increasing your basal. You may find that there is a difficult balance between keeping your overnight numbers and Darn Phenomenon under control and avoiding hypos during the day.
That would be a little higher than I am happy with, but it does happen occasionally. However, it’s not high enough for me to get upset or worried about. When it occurs, I just take a unit of fast acting insulin and get on with my day.
