That is what happens to me often in the early evening if I'm active when my basal kicks in, I drop a lot, but eating something, candy, nuts etc. when I'm only at 80-90 often heads it off. I can often feel when I'm going to go hypo, and it usually starts then before I go lower. My evening basal usually kicks in 2 hours after I take it.
If you're treating the lows from a basal drop when they've dropped a lot, not long before the dp starts and then you go up that rise may be getting combined in with your dp. I think you take your evening basal later than I do(5-6pm). The 2am dose usually helps to stop a the big dp rise for me, but then at some point I need 1 unit doses, sometimes do that before I sleep if I'm 80-100 to stop a bigger rise while I sleep. I have also been told to try a pump many times because of my basal not keeping me stable and dp. I was also going hypo/waking up hypo with a larger evening basal dose and I still sometimes wake up hypo depending on various things.
In my experience Levemir has a spike and the higher the dosage the later and less pronounced this spike will kick in. Levemir is not designed to cover 24 hours. It wears off after 14 hours and this is why two shots combine nicely. It is just that small dosages are not sufficient to reach a sufficient coverage. This is because the duration depends on the dosage as well. Sarah injects 4 units for the night and that might be the reason for the DP in the morning.
Another important aspect is that the dosage of the basal insulin is often fixed. It is good for a "normal day" meaning normal activity and normal routine. However our daily lives and activities are not fixed but rather spontanous. For our spontanous endevours we will pay a price with basal insulin on board. We will have to prepare, eat, correct what ever necessary. With some time ahead a pumper can react by setting a temporary basal rate. But depending on the uncertainty of these endevours the result might need the same corrections as being on MDI. Same is true for our reaction at night to physical activities of the day. Our muscles might refill causing lows, growth hormones might induce a more pronounces dawn phenomenon in the morning etc. Under these conditions it is difficult to find the basal rate that is appropriate for our "normal days".
Levemir is designed to cover 14 hours with 10 units. It has a longer activity but its potency is greatly reduced after the 14 hour mark. Thus the overlapping of the Levemir with two shots will help to get a more even profile. One shot fades out while the other fades in - in an ideal situation of course.
With Lantus the splitting might result in the graph Dave has provided. Although it is more a reduction in potency than a direct fall to 0. I have tried Lantus for myself and I found it very difficult to handle the split. One shot was insufficient for me but the split resulted in a chaotic system. Sometimes it worked and sometimes the potency was gone long before the next shot. Here it was as if the duration of the Lantus was less reliable the lower the dosage. The switch to 2 shots of Levemir was quite a relief.
yes, as I said the graph is a crude approximation, and actual pharmacokinetics in real people won't be that flat and theoretically perfect.
However, it does serve to illustrate the general behavior of overlapping doses and how ones basal rates are affected by different dosing strategies.This can be helpful in identifying patterns in basal levels and comparing then to BG patterns, then making adjustments to compensate.
Acidrock, have you considered using the untethered approach on your vacation where you use Lantus/Levemir for about 75% of your basal and your pump for meal and correction boluses and the last bit of basal. Or you can even use pens for meals on the go. It gives you the ability to leave your pump in your hotel room most of the day and surf/swim freely. My blogpost: http://testguessandgo.com/2013/07/01/untethered-at-the-beach/
That seems interesting however I am thinking I would just do shots before I'd do that. The last time my pump blew up (Labor Day 2013, caught in massive squall running...), I was shocked at how easily using Levemir worked. I have no problem whipping needles out or anything like that. It's just a shot away...
I think I prefer syringes as there's ways to nudge an extra whiff of meniscus over or under the line and that sort of thing too.
oh geez, AR...I wish that was a pic of 1973 Jimmy Page...have a huge girl crush on him, especially the 1970's time frame, just sayin'. ha! I remember you mentioning how easy you went from pump to Levemir...so I don't know why I'm having such a d@mn hard time with this. 71 at 12:30am last night, 4:30am 169. ugh! I'm going to drop AM dose 1 unit and see if that works, thanks! good luck with your surfin'..dude. Are you a skier, I haven't skied (which I LOVE) since Dx'd. I'd also LOVE to try surfin, my big bro is an advid california dude surfer, big time..ha!
OH, I think maybe you were able to transition to MDI easily because you have your basal needs down on a pump so the conversion was easier, no? I still have NO clue how much basal I need.
i know, ellie, it's so dang frustrating, no? I just want to wake up to a good number, I'll settle at 130 even. the thing is, too...when one changes one dose, it takes 3 or so days to see a change, then maybe one needs to change the second dose, that takes three days, then the first dose doesn't work with the second dose and we're (I'M) back to square one again trying to work this out.
I did only 9 units AM of levemir (I'm rather insulin sensitive) I stayed flat all night, totally flat at around 100 but then at 4AM the rise started very quickly and very high. So, again was this levemir running out or DP? I don't know. So, i've tried to split but can't get the doses right or timing. Thus, if I can do one shot...that's what was hoping to do but that's not probably going to work either. Plus, every change I make takes days to even show an effect. Half the time I don't know what change is making it better or worse. UGH...double ugh!
Probably it helped that I had my TDD pretty accurately calculated, albeit perhaps a bit hot, on my pump so I figured I'd do 2/3 in the AM and 1/3 in the PM and cut it a bit, like from 22U to 20U or something like that, I think. Or maybe I took more? I don't totally remember. Maybe there's a post about it lurking around somewhere.
Re figuring out basal, I don't mind a little downdrift (which I also refer to as "running hot" but I think I gain weight when I do that. I finally got things flattened out with the 1/2 hour increments allowing me a bit extra fine tuning. The recent DP mess I've had, I think was just getting greedy and turning it down too much, coupled with a lot of late dinners due to the motor of the world and a lot of eek "woah, look at that IOB, I'd better eat something to cover that IOB" at bedtime when I should have remembered the food on board. It may be that bedtime snacks might masquerade as DP because at night it seems my metabolism slows down so food hits in 4-6 hours rather than a couple. I do much better when I eat dinner earlier but I don't see that being an option until we retire!
One option to figure it out your basal might be to throw out everything you are doing and start from square one, recalculate a TDD based on your age/ weight like in the Think Like a Pancreas/ Using Insulin books. You may be close but maybe not. I think that's what the doc did when I started my pump and they guessed very closely and I've never strayed too far from what it was set at.
I know you've been pretty adamant over the years that the only way to treat T1 is with insulin, and "true T1's" don't use anything else. However, in light of the continued challenges you mention it might be worth it to consider some complementary alternatives. You really have nothing to lose.
Specifically, I'm talking about Metformin and incretin memetics like Victoza or Byetta (the latter two are injectables, by the way). Metformin is not just for addressing T2's with insulin resistance, but can also help both T1's and T2's with reducing the liver's production of excess glucose. In your case, it might help with the BG spikes you refer to. As I've mentioned before, I take Metformin XR at bedtime and found that it helps with stabilizing my basal and minimizing DP. I've seen several posts from T1's on this site who use it successfully.
Although Victoza and Byetta were initially developed for T2's, it's showing potential benefits for T1's too. Right now Novo Nordisk is running trials of Victoza for T1's. In fact, Gary Scheiner recently wrote about using it for himself, and a patient of his writes an interesting article about the benefits it provides her as a T1: http://diatribe.org/issues/26/test-drive
I got tremendous results from Byetta, but ultimately decided to discontinue its use due to the controversy around its long-term safety. However, I'm reading more these days about how those perceived risks might be over-stated and debating if I should start it again.
There is a lot of great advice in this thread about setting and optimizing basals using only insulin. Definitely give it a try. However, if you continue to struggle, consider some of the alternatives I've mentioned. They might just provide you that extra basal stability you're looking for.
well, i increased to 5 units PM, again....had a huge drop and now I'm 251 after bolusing since 4am, again, with high ketones. i'm getting very concerned and if I can't get my BG's down I'll call my doctor. I can't take MORE it doesn't do me any good. something weird is happening. thanks!
Have you tried bolusing before 4am? Like at 3am or even 2am? With the pump we are told to change our basal rate 1-2 hours before our BG actually starts rising or falling. My basal rate change is at 3am because it's at 4am that my blood sugar starts rising. When I was on MDI and got up in the middle of the night, I'd get up at 3am as well. I think if I waited until 4am to address things it would be impossible to "break out" of the rising blood sugar without a ridiculous amount of insulin.
yes, i had a huge drop then a rise and at 2am i was 173 took 1 unit, 4am 223. jen, i have large ketones when do I know if it's seriously. i'm getting very concerned and don't feel well.
Also, I looked back in my logbook and when I was on MDI I had a bedtime snack of about 10g of carbs, otherwise I would drop around 2am. I took Lantus at 10pm and I understand it does have a small peak at something like 6 hours (which could probably vary by person). Between the small bedtime snack and getting up at 3am to bolus I had good morning numbers, but I wasn't willing to do that forever. Now my pump is set so that the lowest basal rate of the day is 9pm - 3am, and the highest basal rate of the day is 3am - 9am, and that keeps things pretty stable as long as my insulin needs aren't actively changing due to weather or hormones or activity.
Sarah, also please consider that stacking issues might be in play here. Are you using anything to track/manage IOB? Without some way to do that "accounting", rollercoaster BG is really easy to fall into.
Holger's Glucosurfer app is a great tool for this for people managing with MDI. What makes me think of this is the corrections late at night to combat a high, then the plunge back down to possible hypo territory.
I know when I was doing MDI avoiding stacking was an added complication that made it harder to accurately correct highs. Keeping track of whether a "high" has already been covered -- by meal bolus insulin -- or is a truly uncovered quantity of glucose is impossible for me to handle in my head when I'm injecting meal and correction boluses 5-10x a day.
