Hi all, for those of you following my story, I am likely early LADA, ant GAD antibodies but I am 15 weeks pregnant and that pushes me into diabetes land.
I recently started Levimir, which helps but I also asked for short acting insulin. My doctor gave me the Echo pen as I wanted to be able to do 1/2 units.
I am not maintaining the tight control I want with just Levimir. I try to stay under 97 fasting and 120 or less at 2 hr pp. I am mostly meeting fasting but my meals are 120-170, largely on carb load. Last pregnancy I tried to eat just 50 g cho day and I exercised after most meals. The endo says I should be able to have 50 g a meal, but to eat that I am going to need to add meal time insulin, which I think is a fair trade for a more normal life.
Those of you familIar with Novolog, any tips on regulating how much based on carbs? I did not get specific instructions, probably because my doctor trusts me to be conservative and knows I am a vet. However, in pets we don’t normally use Novolog or similar, just twice daily basal insulin.
I think I need to start with dinner as that was my 170 last night, and by then my basal is gone. Thinking I will see what 1/2 unit does and go from there?
I also am a runner and need to play with that. I did a 5 k this am and ate a larger carb breakfast, a high fiber bagel and that gave me a 2 hour 145. Then I ran and after running it was down to 111. Not sure about doing Novolog before runs and whether I might “bottom out.” Even though my swings are not drastic by diabetic standards, I know I don’t feel well when I am having these swings.
Any help greatly appreciated and gratefully accepted. Nothing like “the trenches” for wisdom!

Hi Catvet (some of my favorite people!) A couple thoughts: First I encourage you if you haven't already to check out the Pregnancy group on here as managing BG while pregnant has very specific and fairly rigid parameters.

As for mealtime insulin: You need to figure out your I:C ratio. Some people start with 1:15 (1 unit for every 15 carbs) and go from there. In other words, keep careful records of your two hour post-prandials. If you are consistently high then try increasing your insulin to say 1:13. If you are often low, decrease to say 1:17. Eventually you will hone in on your own I:C. Many of us find it is different for the different meals/times of day. For example mine are 1:6, 1:9 and 1:15.

Finally I encourage you to get the book Using Insulin by John Walsh which some of us consider a bible on insulin use.

First, let me get the off-topic part of this reply out of the way. Below, our new baby.

That being said, some facts about insulin--

Levemir is a basal insulin, as you know. Basal insulin is not designed to deal with meal spikes. Not at all. Its purpose is to keep BG on an even keel in between meals, or when fasting. So it's not much use for food.

Regarding the efficacy of Novolog (or any insulin, for that matter), it's like nearly everything else related to diabetes: "it depends". The amount of bolus insulin required to cover a given amount of food depends on many variables, but by far the most important is your own individual sensitivity to insulin, which may or may not be the same as anyone else's. Usually not.

The reality is that guidelines for this can only be determined empirically. You need to determine for yourself what your particular insulin sensitivity is. Then you'll know how many units of insulin are required to balance a specific amount of consumed carbohydrate.

You've probably guessed the next part: the only way to find this out is by controlled testing. Some time when your BG is relatively stable, consume a measured amount of carbohydrate. Test every few minutes until your BG reaches its peak and stops rising. Then administer one unit of insulin. Keep testing and see how far your BG drops before stopping. Do this a few times and average the results and you'll have a reasonable rule of thumb for matching bolus insulin to food.

Just to throw yet another curveball into the mix, be aware that for many people, insulin sensitivity varies according to time of day. Most of the time, people are less sensitive in the morning and more sensitive later in the day. In my case, for instance, 1 unit of fast acting bolus insulin covers about 12 carbs in the morning, and about 16 at night. Isn't this fun? :-D

Aerobic exercise generally has a profound (downward) effect on BG. So if you know you're getting ready to do that, you'll want less insulin on board than usual. Again, actual metrics can only really be arrived at by trial and error and careful monitoring.

The reality is that every physiology behaves individually. We have an acronym for it: YDMV ("Your Diabetes May Vary"). Or as one long time TuDiabetes member put it, "If you want to treat diabetes 'by the book', you need a separate book for each diabetic."

P.S. In addition to the book by John Walsh, which is quite good, there are a number of other excellent ones out there. Here are two of the very best:

Gary Scheiner, Think Like A Pancreas (Boston: Da Capo Press, 2011)
Richard K. Bernstein, Dr. Bernstein's Diabetes Solution, 4th. ed. (New York: Little, Brown and Company, 2011)

Thank you too, John and I like your kitty! Keep all black cats inside Halloween as there are evil people in the world. They are always safer inside for that matter.
Your very precise way of figuring dose is very useful. And you are right, insulin sensitivity varies, especially with pregnancy. What works for me this week may not work next.
The two books you mention are the only two diabetes books I have. I have found them helpful, especially Bernstein, though I can’t manage his cho level. 50 g a day was the only level I could maintain for months and that was a bit painful!

Very adorable kitten,David! I was just wondering about your procedure for ascertaining I:C; I've never seen it done that way. If you didn't dose until your BG peaked, somewhere between 1 and 2 hours after eating, wouldn't the I:C average you obtained call for more insulin than you actually needed dosing right before or 20 minutes before eating?

Are you just doing the levemir once a day? Many find it helpful to split it into two doses - either in half, or perhaps a slightly higher nighttime dose if dawn phenomenon is involved. I'm just asking because you mentioned your basal running out by dinner (although you do mention 2x/day for your vet patients). If you take it twice a day that might keep your non-mealtimes more even.

Mealtimes, I agree with Zoe that it's a matter of experimentation and that insulin-to-carb ratios can vary greatly depending on the meal. Mine range anywhere from 1:7 to 1:20.

Congrats for your reason for having to ponder the insulin question at this early stage!

I am using the Levimir once a day. My endo did give me instructions for that. It is a thought, though. I think I will make one change at a time. My next change needs to be the Novolog, but I will keep twice daily basal in mind. Thanks!

Hi Zoe,

Good questions. I do this test with NO basal insulin in my system, so the bolus insulin is the only thing working. All I can really say is that the procedure I outlined above yielded numbers that have been pretty dependable for me. Doesn't mean they would work for someone else. Also, I do the test several times and average the results. IMHOP that's important; one single test, no matter how carefully conducted, has too great a chance of being "off the curve".

Good point about splitting the basal insulin. I started out doing it once a day, and later split the dose in two. Turns out I get a much smoother response that way.

Again, one approach may be more effective than the other for each individual. Only way to know is to try them out and keep detailed records.

You guys are a great help. I did hear from my endo via email. On a weekend no less. He confirmed how I was planning to use the Novolog but said come in with my sugars and he would help me figure out a dose. That is ok, but a bit like closing the barn door after the horses are out. I think I will make the appointment only if I can’t achieve tight control, which I think I can, especially with the support you all have given.
It is ironic that I thought I would need Novolog to cover indulgences and it is quickly apparent I need it for regular food. 2 hours after 2 cups homemade split pea soup I had 156, and that is high fiber cho. My fasting this am was 70. So I figure my basal dose is ok but I have no room to up it at present. I am starting Novolog today definitely with supper and maybe earlier depending on what I eat.

Yep, whatever works, works! Thans for the explanation!

The "everyone responds individually" principle apples equally to food as it does to medication. The way you respond to a particular food may be quite different than the way someone else does.

As an example, many people find that they react differently to different starches. I know folks who can handle potatoes without great difficulty, but whom rice sends through the roof -- and vice versa. In my own case, it doesn't seem to make much difference. Any carbohydrate is pretty much like pouring gasoline on a fire and it doesn't much matter what it is. We vary.

Some people find that high-fiber forms of carbohydrate have a slower and less pronounced effect. For others, it doesn't seem to matter. We vary.

One effect that does seem to apply to everyone in some degree is that high fat meals do slow down absorption so the rise in BG is slower and less pronounced. Again, you need to observe your own reaction.

So as it is with meds, it is with food. You have to determine by observation and measurement what different things do to you.

This disease is not for the lazy. A touch of OCD comes in quite handy.


David, I hope you don't get offended by some constructive criticism of the technique you outlined:

You've probably guessed the next part: the only way to find this out is by controlled testing. Some time when your BG is relatively stable, consume a measured amount of carbohydrate. Test every few minutes until your BG reaches its peak and stops rising. Then administer one unit of insulin. Keep testing and see how far your BG drops before stopping. Do this a few times and average the results and you'll have a reasonable rule of thumb for matching bolus insulin to food.

This is a pretty effective way to determine Correction Factor in a simple way. Taking what you've written above and turning that into an I:C is missing some additional needed clarification, in my opinion. The following should be added:

"Continue doses of insulin and recording the following BG drop until your BG returns to the starting level before you ate the carbs.

From these three pieces of data -- Carb count, insulin used, BG swing -- two critical dosing factors can be determined. First, the "insulin to carb" ratio: Divide the carb count by the units of insulin needed to fully bring your BG back down. This is your IC ratio (while it's upside-down, and really the carb to insulin ratio, this is the terminology used, backwards as it is :-)). The other parameter is your Correction Factor -- how much your BG drops for one unit of insulin. Divide the total change-to-peak of your BG by the total amount of insulin administered.

You use the CF to figure a "correction bolus" when your BG is above target, and the IC to figure a "meal bolus" when eating.

Example: Lunch, 50g carb, BG before lunch 120. CF=25, IC=10, target 85. Correction = (125-85) / 25 = 1.6, 50/10 = 5. So, you would bolus 5+1.6 = 6.6U 15-30 minutes before eating.

All things being equal, you'll be down around 85 in 3-4 hours after eating.

I strongly agree with others here that if you don't need basal (at this point), you don't need Levemir. It's far too blunt and instrument to manage BG by itself, and places some rather bothersome additional burdens of having to eat to a schedule.

Probably the reason you weren't offered a bolus insulin initially is because you're pregnant, with gestational diabetes (which is usually relatively "mild", as these things go). With a developing baby, the risk of hypos for both of you is an issue with a fast-acting insulin.

I can't emphasize the following advice any more strongly: Get exceptionally well educated on bolus insulin administration, what it's used for (meal and correction boluses), how to calculated them, what carb counting is all about, and for bonus point if you have a smartphone get going on a nutrition app for easily counting carbs (many of us like MyFitnessPal), and an app for calculating insulin dosing and tracking IOB (residual insulin).

It sounds like a lot, but then, you sound like a pretty smart person, and really you can become a near expert on all of this by spending some hours reading through discussions here and asking questions.

If you walk into your appointment with your endo armed to the teeth with information and tools, and a plan, you'll likely be one of your endo's favorite patients. Also, any sort of fixed or "sliding scale" dosing is a non-starter... Carb counting and proportional dosing is the only way to go. The former is old school, and far more likely to result in hypo and hyper glycemia, as well as rollercoastering.