It’s like trying to do it with one hand tied behind your back. Yet I’m told I have to get my basal sorted before I’m started on a bolus regime. Wha?
Sounds like something a GP who is not very knowledgeable about D would say!
Great analogy (and even better description): without bolus insulin it is trying to do it with one hand tied behind your back. May you be given your second hand soon! 
3 Likes
Over the course of the day your liver releases a somewhat steady stream of glucose into your bloodstream. If you don’t do anything about it, this will steadily increase your BG. So you “cancel” this somewhat steady stream of glucose with your basal insulin.
If you are able to keep your BG reasonably steady with your basal insulin, then the next problem is to adjust your actual BG (which is now roughly steady) to where it should be. If it is too low, you take sugar. If it is too high, you make a correction (bolus).
An upcoming meal will disturb this balance between your liver and your basal insulin by suddenly increasing the glucose in your bloodstream. So you counteract it with bolus to exactly neutralize the addl glucose coming from the meal.
In theory it seems really simple:-)
3 Likes
I understand that ok. But I keep reading that basal determines/effects your fasting level. If you have trouble with a high FBG, basal will sort that out and then you can deal with post meal numbers with bolus plan.
If I awaken at 4am my level appears a lot lower than my bedtime (not enough basal ?) but if I awaken at 5am it is stable compared to my bedtime (dawn phenomena?). if I awaken at 6am it’s much higher (not enough basal or still rising from dp). Then say I eat breakfast and don’t bolus at all. Four hours later I check my levels and I’m way lower and still dropping (too much basal?). So which scenario do I go with?
My first thought is seeing I’m going noticeably lower twice during a fasted state (during night before dawn rise and four hours after meals) then I could adjust my basal down 1unit & see what that does.
I suspect I’ll always be high overnight and in morning until I can bolus correct my nightly meal.
I’m a type 2 who uses basal insulin and low carb diet to regulate my blood sugar. I slowly titrated when I got out of the hospital until my fasting was around 100.
One additional thing to keep in mind, your meter can easily be 15-20% off on the occasional test, so the fluctuations may not be completely accurate. Most of the time, it should be close. I try to watch mine for trends and not make adjustments with only a single data point.
Between my basal and my diet, I stay between 70-135 probably about 90% of the time and find that I’m even happier with myself when I stay below 120. I’ve never had a real low (only been doing this for 8 months now, so take that with a bit of context). I’ve tested in the high 60s a few times, but I suspect that was meter error since they were anomalies.
hi. When you say you titrated until you reached 100 What sort of numbers did you start from ? I’m trying to reduce my bedtime/fasting wake up numbers from 200+. Did you do it only on basal, no post meal insulin ? Oops, you said that. Did it take 8 mths to get to 100?
When I first got out of the hospital, my fasting numbers the first week were around 200. I was started at 25 units of Lantus with a bolus before meals. My GP took me off the bolus three days later and told me to go up two units a day until I was where I wanted to be. No one told me what my goal should be, though. I went off of what I “knew” about diabetes. Turns out it’s the only thing I knew that was right.
Your basal needs at night can be significantly higher than during the day (because during the day you are much more active than at night) so it is possible a given basal level would bring you too low during the day and keep you good during the night. A few weeks ago my son was in this situation. Eventually, we lowered his basal much more than we expected was reasonable. Surprisingly, his night numbers remained good, and suddenly his daily lows became much more rare.
If you had some dawn phenomemon that could explain going up in the early morning. So one possible explanation would be a combination of the two.
But it is not the only one I think. When you go up or down fast and high/low, your body tends to generate a hormonal response to correct (and sometime overcorrect) it. For instance, I remember reading on this forum (I may be wrong on some details but the essence of the story should be correct) about someone who had blanked out while driving and crashed a car at 110 miles/hour. When the paramedics found him his BG was 70. He had hit a big low while driving and crashed his car. Onece he was low enough, his body has brought him back from a deep low to 70 BG. So it is possible that you are seeing some of your body’s autocorrections as well.
A CGM would be a big help in figuring out exactly what is happening to your metablism, of course.
As a note, I am one of the least experienced people on this forum - so the input from those who have had many more years of experience should really be the one to trust (as opposed to mine).
I appreciate all advice and you’re right a CGM would be the way to go. This guessing business just doesn’t cut it. I will collect more data. 
Okay, I just skimmed through the thread and read enough, I think, to get an idea of what’s going on.
First, we didn’t discuss your diagnosis; I’m guessing T2, with a lesser chance of LADA. Either way, the piece of the puzzle you’re leaving out in this whole analysis is your pancreas.
You are not a full-blown, no beta-cell function T1, as is evident from your BG behavior. As such, you can’t analyze and treat your situation as such. That’s a mistake that’s been present in much of the discussion here.
Your pancreas is still producing a lot of insulin. This is responsible for the large swings in your BG. The steady, background, low level from the Lantus is most certainly NOT responsible for these swings.
The fact that your pancreas is capable of dropping your BG from 250 to 150 after eating breakfast is all you, not the Lantus injection.
The basal/bolus T1 regimen that is being discussed in this thread is all wrong for you – WAY wrong. You don’t need basal insulin. Your own body does just fine meeting your basal needs.
However, one approach to treating T2 is to use long-acting insulins to “assist” the pancreas in bringing BG back down to fasting levels after a bolus demand from eating. Because it is more commonly used to meet the basal needs for T1 diabetics, it is incorrectly termed “basal insulin” in these treatment modalities, but in fact it really has nothing at all to do with meeting basal needs – it’s a compromise means to match bolus needs in an easy way for patients.
Administering bolus insulin properly is much more complicated, and fraught with much more significant risk. It is for this reason that T2s are prescribed basal insulins first, rather than bolus, when what is physiologically going on is exactly the opposite problem.
So, all this said, keep it in mind when applying the concepts from Think Like a Pancreas, etc. You are not solving a basal insulin problem, you need to keep your BG from going high after eating, which is a bolus issue.
Your best best IMO is to get on board with an endo, discuss these concepts, and then go for a fast-acting bolus regimen. I’d recommend giving Afrezza a try. I haven’t yet, but many people here have, and this could be the ideal solution for you.
A fast acting bolus regimen when you eat, and then test, test, test, test. Get a CGM if you can.
As long as you have a functional pancreas, you will never, ever be able to map some deterministic relationship between fasting BG and basal insulin dosing. Not ever. The best you will be able to do is get a decent general relationship between daily carb consumption, daily dosing, and average BG. Actual pre-meal fasting BG will be all over the map depending on what you ate prior, how much, and how long ago.
1 Like
By way of example, I’m T2, pump humalog. I can set my basal on the pump to anything between 0.05-1U/hr with no apparent effect on my fasting BG.
Try that, T1! 
I would not be so quick to make such a bold statement, it may be correct but not necessarily so. There are instances where a basal only regime will work for someone that still has some insulin production.
Your pancreas may be able to satisfy basal needs and most of your bolus needs but not be able to provide a first stage insulin response. First stage response is insulin stored by your pancreas for quick release. It is meant to counter act the sudden influx of glucose from a meal. This first response insulin is produced by your pancreas when its workload is low. When you pancreas is stressed it is constantly playing catch up. BG spikes after meals because there is no first stage insulin response and your pancreas spends all its time trying to recover and never gets around to the task of storing insulin for that all important first response.
Basal only insulin in a person with some on board insulin is meant to relieve part of the stress on your pancreas and allow it to catch up.
2 Likes
KThanks for both comments. I’ll definitely discuss all this with my endo. Looking at my graphs before I started lantus I seemed to be in a stable pattern just around the 200-260 mark. In think like a pancreas he said if you’re regularly over 200 it will be difficult to tell which (basal or bolus) you will need and maybe a combo of both. Also read somewhere if your lowest low is over 8mmol (which mine is) raise your basal 2u.
Also add my fasting this morning was below 200 for first time so perhaps lantus will lower it gradually if I’m patient. 
It’s more important to deal with what’s happening to YOU than to worry about a label. That is, what you NEED should drive your treatment. I am a Type 1, but when I was FIRST diagnosed, I was producing enough insulin (through oral meds) to NOT need bolus insulin. I took Lantus and oral meds for 18 months. When my pancreas would not respond to my pharmacological flogging anymore, they administered the autoantibodies test and said, “here’s Novolog for meals. You’re Type 1.”
But your diagnosis and progression may be different, so seek to deal with what your body is doing. I have rarely met any adult whose Type 1 diagnosis and progression was “typical”-- unless by “typical” you mean a random amount of time to develop full-blown Type 1 diabetes.
Type 1, for me, is where I try to count my carbs, time my insulin doses and mediate my activity to try and keep my BG between 85-180, hopefully more like 100-140. Perfect control is not gonna happen, but the idea is to do your best and don’t punish yourself when things go sideways. Because diabetes can randomly drag you sideways. Don’t take it personally–even though it’s understandable–it’s happening to YOU. You’ll get this. It just takes a little time to figure it out.
4 Likes
I agree that we can get too hung up on terminology. At the same time, there is a very important distinction between the state of the metabolism when it is consuming insulin that we call “basal”, and when it is consuming insulin we call “bolus”.
@Stemwinder_Gary, your description of the finer details is, in fact, EXACTLY what I was talking about. Trying to compensate for first-phase insulin release (which is insufficient in a full-blown T2) with slow-release long-acting is exactly the wrong way to treat it. Isn’t this why we have – and use – fast-acting insulins in the first place?
I’m not saying that the long-acting approach doesn’t work. It does, it’s just a very crude, low-resolution response to the problem. Rather than try and duplicate the natural response to eating and glucose metabolism, basal insulin for T2’s is targeting a1c, not postprandial excursions.
This approach may be the best approach depending on the patient. As many of us know well, dealing with bolus insulin properly is a lot of work compared to one or two injections a day of long-acting. Many T2s are simply not ready, not willing, or not capable of doing the bolus dance.
This is one of the reasons Afrezza is so exciting, BTW.
Anyway, I question very strongly why anyone who’s own body can hold their BG in range without problem needs basal insulin. I’m about as certain as I can be that, given what @PemW has shared about how their diabetes behaves, if they got their BG down in range (80-120) with bolus insulin while in fasting mode (>3h after last food), it would stay there without any exogenous insulin. It would only go up after eating carbs.
This screams “bolus” to me, not basal. Long-acting seems like the wrong tool.
1 Like
Oh, it will. It’s insulin. Take enough of it, and it will do its job. The point earlier of my posts, however, is this: It shouldn’t be coming down. Or going up. Long-acting insulin should be assisting (or entirely) keeping your BG stable and steady. That’s the idea.
Now, it is possible that a bit of background basal may take enough pressure off your pancreas that it can then mount a sufficient phase 1 response when you eat and get you BG back down after 2 hours, so you don’t need bolus insulin. I think this is what Gary was getting at. The only way to know if this is actually working is to do a few “studies” by testing a bunch 1,2,3,4 hours after eating, once you’re down in range with the basal regimen. If the Lantus has given your pancreas enough rest so it can mount a sufficient phase 1 response, you’ll see your BG come back down in range after 2-3 hours.
If not, fast-acting bolus insulin is called for.
1 Like
I can see your logic. Last night went to bed after 10u Lantus at 8pm. Bg 194 before bed, 196 when I woke up at 5.30am (midnight reading of 163 still within range of a good basal). After low carb breakfast went to 216. Five hours later, no snacks, I’m at 162. Super hungry, tired etc.
I’ve decided I’m going to stay on 10u til my endo appt. and let her sort it out. It’ll be interesting. It’s a lot harder than I thought. If I can’t even work out long acting I’m in for quite a ride dealing with rapid. 
I’m guessing that “5 hours later, super hungry” means you avoided eating to keep from raising your BG even more.
That’s NOT managing this condition. You need to eat. Especially when you’re hungry.
I’m not criticizing you – you’re doing the best you can with the tools you’ve been given. You just haven’t been given the right tools.
Now, keep in mind that 10U of Lantus is like giving yourself a constant background of 0.56U/hr each hour over the next 17 hours. Generally speaking, for a T2 (I’m assuming that’s your diagnosis) this is almost non-existent insofar as dealing with any meal carbs. ANY carbs.
Typical T2 insulin:carb ratio is on the order of 1:5 to 1:10. Even 1:10 (which insulin-using T2s would be ecstatic about!), a 25g low-carb meal still calls for 2.5U of fast-acting insulin to cover the carbs. At the levels of long-acting you’re taking, if your pancreas wasn’t up to the task (which it obviously isn’t), it would take 4 hours for the Lantus to offset the carbs. That’s if all this stuff is linear and follows basic linear mathematical behavior, which it doesn’t. So, since the 2.5U you need is dribbling in so slowly, it pretty much gets lost in the noise, so to speak. 2.5U of extra insulin stretched over 5 hours doesn’t cover 25g of carbs the same way it does delivered all at once.
1 Like
I waited five hours just to see what would happen. I feel hungry, shaky, vague on 150-160 which is ridiculous really. I’m certainly in no danger of a hypo. I personally think they’ve given me one nightly shot of Lantus to just get me used to self injecting. The serious stuff is all ahead of me. Baby steps and all that.
This screams dead wrong to me. My point of contention is that neither you or I know what is best for another person. We are not doctors nor should we be so adamant about what is the best treatment.
I offered my alternative to your scenario to show that that your advice offered is not the only way. You are doing a dis-service by offering advice with an air of authority and expertise that you do not possess.
Any of the good advice offered in this discussion may be true, even yours, it is wrong to practically scream that your way is the only correct way