LADA Bolus calculation dilemma

I am a LADA, misdiagnosed as T2 in 2015, rediagnosed at T1/LADA in 2017. I still have significant insulin production, as I currently take 6U Lantus for basal, and take bolus Humalog only for meals above 30g carb, at 1U/30g above the first 30g. However, this insulin:carb ratio is literally a SWAG. My question is how do other LADAs determine if they have a good/correct/optimal bolus dosing.

It seems there is little or no information available on how best to care for LADA diabetes. Insulin calculations for T1s have an inherent assumption of no pancreatic insulin production, e.g the 500 Rule for carb boluses, which would give me an I:C ratio of ~1U:70g

Until recently, I have been trying to bolus based on carbs, starting out at 1U/30g for carbs above 30g, but if I go low after the meal to reduce the bolus for subsequent (identical) meals. This strategy is inherently flawed, since my body produces enough insulin that, for any reasonable meal, my bg is back to normal at about the 2 hour mark, but any remaining bolus can drive me low in the second 2 hours.

The possible solutions to this are:

Don’t bolus, or only do minimal boluses.
Do something to shorten the duration of the bolus.
Or, always plan to have a snack (currently 15g) at the 2 hour mark, to give the leftover bolus something to work on. This is similar to early diabetes management in the era of “Daily Fatal Dose”, where diabetics had to have meals of a certain size at very specific times to match the response curve of the single (large) daily insulin shot.

However, solutions 2 or 3 still leave the question of how to determine whether a bolus is the right or optimal size? My current thought is to try to test at the expected peak (1 hour?) and keep the bg reading below a certain high level, and test again at the 2 hour mark and make sure it is not below a certain low level, but what levels?

Have any LADAs found a good solution to this dilemma?

2 Likes

I’m lada and had lots of trouble with humalog. I find better results with afrezza because it clears out much sooner.

If you are taking your bolus right when you start eating then that could be part of your problem. You might want to give prebolusing a try as I am inferring from your post that you seem to need extra insulin right after you eat but not in the remaining hours like a more advanced type 1.
BTW, I second @Karin7’s Afrezza suggestion. I’ve been type 1 since the early 1990’s but it works wonders for me without making me go low.

1 Like

My bolus shots are typically in the range of 0.5U to 1.5U. Does that work with Afrezza, or is 4U the smallest Afrezza bolus available?

If I know and can control when I am going to eat, I pre-bolus 15 minutes before eating, but that doesn’t move the bolus end up nearly enough. I average about 1 meal per day needing a bolus, and the others I limit the carbs to what my own insulin can handle. But, to minimize the spike of that bolus meal, I want to figure out how much bolus it should have, instead of having to rely on my current SWAG (aka Stupid Wild-Ass Guess).

The kind of prebolusing I was talking about is actually more like 30 minutes to an hour ahead of eating which admittedly is hard to do and something I never managed myself.

Afrezza is different than humalog in that it wears off very quickly so the 4 unit cartridge is more like 1.5 to 2 units of humalog depending on your insulin sensitivity and because it wears of in about an hour and a half it won’t make you go low. Seriously I’ve had times when I took my Afrezza dose and ended up being unable to eat for some time due to you know “life” and no low afterward.

Fiasp is another alternative fast acting insulin you might want to try…I find it to be much faster than Humalog. It’s still active at 2-3 hours but (for me) does not drag on for 4+ hours like Humalog.

A CGM would be the best way to get a solid handle on your timing questions. I have found that even with identical meals my BG at 1 and 2 hours can vary from great to high to low, so daily micro managing based on the rise or fall indicated by the CGM is very helpful. The Freestyle Libre is probably the lowest cost way to see what’s happening with your after meal BG’s. If your insurance does not cover it, they have some discount programs.

Do you count the carbs in the meal you intend to eat? Many of us calibrate our insulin doses to our meal carbohydrates. We use an insulin to carbohydrate ratio (I:C) to calculate a meal dose of insulin. For example if your I:C is 1:10 and you expect to eat 50 grams of carbs then your meal insulin dose will be 5 units (50/10=5). By paying attention to your post meal blood glucose you can change that ratio over time to better align with your needs. A good book that lays all this out is Think Like a Pancreas by Scheiner.

I’m also LADA and treating with Tresiba + Afrezza. Although the smallest dose is “4U”, that is only roughly equivalent to that much injected insulin… it works differently and as has been said, is out of the system much quicker. I tend to use it in two ways… 1) with meals that I know reliably affect me in a particular way, and 2) generally as my CGM shows BG creeping up, usually correcting at ~150mg/dL.

Bill, I may get in trouble for revealing this here, but because it really helped me, here it is: A very kind person showed me how to open the afrezza cartridge and split it in half (in a very unscientific, eyeballing manner). I split half of the powder into a used, empty cartridge. Or you can use the blank (red) cartridges doctors/reps have for practicing. I am very small and light and eat low carb. I most frequently only need 2 units of afrezza (1/2 the cartridge). When I was using humalog to bolus, I used a Jr pen and often took only 1/2-1 units per bolus. But like you, the tail was often too long. (You could look at getting a Jr pen too.) I like afrezza because it works fast and is out fast. I feel more comfortable “stacking” if afrezza wears off too fast with a little extra puff.

You sound like me. I’m very insulin sensitive and Bolus/basal in fractionated amounts. My ratios are 1:25 but the kicker is WHEN my pancreas decides to play the game. I’ve found for meals above 30 carbs I have to Bolus 20 minutes INTO my meal then correct if needed at the 2.5 hour mark. Sorta weirdly squaring waving it. It reduced the lows when my pancreas overshot it’s help and I didn’t have to eat any left over Bolus.
Not a perfect system but it works for me. I’d love to try other insulins but my carries only allow three insulins. I do hope you find some ideas here that might help. After meal chases/crashes stink.

Irish

I do count the carbs in the meals, often with a kitchen scale knowing the what percentage of the weight is carbs. I am currently using an I:C ratio of 1U:30g, but not for the first 30g in a meal. But that 1:30 was a SWAG, and I don’t have a good way to “test” that it is the most accurate. And, over time, it will need to change as my antibodies attack my pancreas, and I need a test methodology to determine when it needs to change and by how much. I’ve read Walsh, Using Insulin, and its methodologies assume no pancreatic insulin. Is Scheiner more informative?

Splitting the afrezza cartridge sounds interesting, but I don’t think I could use that argument well to convince my carrier that it would work for me, when my typical Humalog shots are 1U. But, since I hear 4U of afrezza is more like 1.5 to 2 of Humalog/Novalog, then the 2U split cartridge would be a good size. I also haven’t been considering pens since I hadn’t heard they come in half units, but the Jr pen sounds like a good possibility.

I’m not sure I understand what you’re doing, or why it should work. When you Bolus 20 minutes into a meal, are you just delaying the exogenous insulin, or do you have information to modify the size of the bolus. And does your pancreas usually “help”, or is that a relatively rare (and possibly inconvenient) occurrence?

:grin: To be completely honest, I’m not sure why it works this way. My Endo has worked with me for a year to figure it out. We’ve tried all sorts of dosing regimes with higher and low carb, studied my Dex reports, my pump reports, etc. I eat very low carb normally, so maybe that’s part of it. When I spring for Chinese or pizza with the crust, blousing into the meal works just a bit changes things… :woman_shrugging:t3:. Well, it’s not perfect but I’m don’t crash 4.2 hrs later. Skim into the 70’s but that’s much better than free falling into the 40’s. (One unit can drop me 80-90 pts. ) If I go high, I can correct that like normal.
As for my pancreas helping out…it’s hit and miss. Yes, it’s very inconvenient and random. It’s been more miss this last year as my C Pep is dropping quick. I wish I had a more logical/scientific way to explain it, but, even my Endo doesn’t know. He feels it’ll finally peter out in the next year and I can dose like ‘normal’ diabetics.:grin:.
Sorry if this wasn’t exactly helpful. Just wanted ya to know LADA is just weird and individual.
Irish

1 Like

The dosing system on Afrezza is very confusing. They should have labeled the doses small, medium, large, etc. Labeling them as units caused me to think there was no way I would be able to use it because I couldn’t remember the last time I had to regularly take 4 or more units of Humalog but when I researched it a little more I found out that it really doesn’t matter what amount of carbs you eat or even how insulin sensitive you are because it just does it’s job and gets out before it can cause any problems.

Think of it this way each dose is 4 units but those four units will take effect immediately and then be gone. The problem I always had with humalog is the long tail that would drop me low hours after there was any food left in my system to counteract the insulin. A company did a white paper for their own use but were so wowed by the results that they made it public.

This experiment was done using Afrezza on non-diabetics which no sane Dr. would ever suggest doing with humalog because it is so hard to counteract.

Hi there Bill! @billb57

Trial and error … testing often!

I’ve read and suggest you read Diabetes Solution by Dr. Richard Bernstein; Think Like a Pancreas by Gary Scheiner; and Using Insulin and Pumping Insulin (edited to add/fix: if you ever go on a pump), both by John Walsh. These will help you learn how and when to bolus (edited to add: and how to use basal insulin to your advantage).

Before you work on bolus amounts, you should have a sound, aka stable, basal level; which often times changes as your insulin needs increase or decrease, so you need to revisit basal testing anytime your numbers just aren’t adding up the way you think they should. Basal testing will tell you if your background insulin (aka basal) is working properly. Gary Scheiner has a web page devoted to basal testing.

Once you know your basal is right, then begin to look at bolus doses for carb and protein intake.

Use the law of small numbers (Dr. Bernstein) and remember to pre-bolus according to the carb/protein/fat and the type of insulin you are using.

If I’m going to eat something which turns to sugar the instant it hits my mouth, if I can, I’ll pre-bolus by an hour, so the insulin’s action is ready to take action, immediately. If it is something that may not effect me for an hour, give or take, I dose accordingly. How do I know the difference, testing, a lot! Before I eat, while I’m eating, and an hour, two, three, and sometimes four hours after I’ve eaten. Keep good records and refer back to them, often, so you can remember. I’ve had a Dexcom for almost as long as I’ve been using insulin. I highly suggest it. I can now dose off of the Dexcom G5 reading, but if there is a question, I test with the glucometer.

I log just about everything. The date and time; blood glucose levels I take (noting if it was a Dex or blood reading); the food I ate; insulin/medication taken; and, any exercise, stress, or corrections (insulin or sugar). I also note if it was a restaurant meal and where. I note the carb and protein count.

I have an insulin to carb ratio for morning, afternoon, supper, and evenings-out-on-the-town. I need more insulin in the morning than I do in the afternoon and my dinner and evening insulin doses are less than in the afternoon. It’s constantly changing, and I adjust to suit.

I’ve fallen into some great patterns in the past and they worked very well. There was a period where these great efforts didn’t work out so well and it took me time to figure out the reason. I was having absorption issues. Once I changed locations (edited to add: for my insulin pump - OmniPod), we were back to status-quo … until I created a new status-quo, going to a low carb, ketogenic way of life. Now, my basal and my insulin to carb/protein ratios has been greatly reduced.

We’re all so different. I hope you find the help you need to sort all of this out. But please, keep in mind, the moment you think you’ve sorted it all out … a new variable or a “gremlin” (an unknown cause) will change it all!

1 Like

I concur with @Tapestry, and want to add that I limit my meal carbs to under 30 and only eat two meals a day. Seven months ago I eliminated gluten and then grains and my control has been way better than when I was diagnosed 2.5 years ago (Age 62) and was erroneously told that all I had to do was ‘cover my carbs’. I manage this with many finger sticks a day (my endo says my control is too good to warrant a CGM!! Bleche!) By going low carb and no grain I have had to adjust my basal dose down by 20% and by covering only a maximum of 70 carbs per day my TDD is nearly 50% less. My fat/carb/protein macro %s are: 65/17/18 (about) but as I am daily experiencing, MDMV AND YDMV. (Every day!)