My DD (15) is switching this weekend from Levemir x2/day (30u morning/20u @ 9pm) to Tresiba taken in the evenings. The last shot of Levemir she got was last night at 10pm - 20 units - she got no basal insulin this morning. So I’ve been watching on the CGM and her blood sugar is actually gradually lowering over the day instead of rising. I expected her to be high as soon as the Levemir wore off about 9am this morning. I am hesitant to start her into Tresiba tonight with 40 units (which is 20% lower than her Levemir dose). What do you think is going on?
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A few questions:
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She is a T1, correct?
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When was she diagnosed? is she still in honeymoon? (I doubt it given her basal but…)
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Was she particularly active yesterday or today?
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Could the lowering of BG be linked to her bolus doses today?
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Could it be that she actually took her Levemir dose this morning? That’s what happened to us the day my son switched to a pump.
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She is a Type 1, for 4+ years. Not particularly active at all - especially slow moving today. No, she has no bolus active either. No, she didn’t take any Levemir today. It’s been 19 hours since her last Levemir, still slowly moving down.
I am thinking I will hold off starting the Tresiba until I see her in an upward trend. Is that wise? Now I am really second guessing her starting dose of Tresiba. Maybe lowering the starting dose even further than 20%. Maybe the Levemir was more like injecting water for her.
@Sprocket1, I can’t help thinking that there is a lot of inertia in this system. Your Levemir likely remains active for a long time, possibly close to 24 hours for your daughter, plus she needs less basal during the day.
She is not in honeymoon anymore if she has been diagnosed for 4 years – so it is extremely unlikely that her basal needs have suddenly shrunk. If it was me, I would not wait longer than planned to start Tresiba, but possibly I would go down some on the first dose. I would not feel too good going much further than 10% down from the original estimate though. That’s me 
Have you considered calling the endo on call in your practice and asking them what they think?
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For women, menstrual cycles can cause changes like this. Are you familiar with what her patterns are, relative to that ?
First, in all my experience, you don’t want to with hold basal insulin. So, a call to the doctor might be in order if you don’t feel comfortable with reducing on your own.
And I do agree with the monthly cycle suggestion. I know it’s not the usual but I did run extremely low right before my period started. Her hormones might be in play here. Good luck with the new treatment plan. I have heard good things from people who have made the change.
Thank you everyone. No hormones are at play here at the moment. Her Levemir dose was 50 units per day (split) and the endo suggested starting at 44 Tresiba. However, I am thinking 40 or less would be a good place to start - just a little nervous of giving her a new insulin that might work far better than Levemir (which we has been working poorl for her lately)
But on the topic of hormones, does anyone reduce or increase Tresiba in relation to hormone fluctuations?
I’ll assume she wasn’t hypo overnight and FBG with the levimir.
If you are concerned with the dose, ask the doctor or start at 30U of tresiba and titrate up as you go. It will soon be apparent what the stable dose is.
you know the rules for basal testing?
I’m also wondering about insulin resistance, because 50U of levimir is substantial. Is your DD having weight issues, this could be a side effect of insulin resistance. T2s go on a lower carb diet to try and reduce IR
Since you mention she has CGMS, I wouldn’t reduce too much. It’s easier to bump up a low than add insulin to correct high.
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No, levemir didn’t take her too low. Yes, I know how to basal test. Oh yes, I believe she is insulin resistant - especially in the morning hours. She doesn’t have weight issues, she’s 5’8" 175 lb. of solid teenager (large frame and muscular).
Yes, I think I will start lower. She was stable at 44 units of Levemir for a long time, but after a school trip across the country and higher numbers than usual for a few weeks, she required a greater TDD. I think that’s now stabilized. I think I’ll start at 35 or 40 u and go up from there if necessary.
We already eat fairly low carb - not Dr. Bernstein low carb, but no more than 120 - 150 any day.
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Well, I gave her 36u. We’ll see where that takes us. Thanks everyone.
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Knock on wood – let us know how it goes!
So we’re 4 injections in and I am loving Tresiba already. Those dexcom lines are lovely! Our 36u starting dose was a good guestimate and it sure enough took 4 days to stabilize and work fully. I will be increasing 2 units tonight because my DD creeps up slowly overnight. So we’re about 25% less Tresiba than two dose/day Levemir - another bonus. My daughter loves not having to worry about timing of Levemir and waking up on weekends to get the dose in early enough. I love how I never have to wonder whether this bolus will work and how many other factors are in play with basal wearing off etc. Welcome to Canada Tresiba!
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I just switched to Tresiba from Levemir, and I am very happy with it.
I had to take Levemir 3 times a day and I tried the Tresiba once daily and it did not work for me because of DP.
But I have gotten the dose down I think, gonna give it another week and see how it looks. I may try the single injection again and see if the DP was related to the early stages of the new insulin.
Glad to hear it is working for your daughter!!!
I suspect that the Levemir is likely to still be in system a day or more after last injection. Likewise Tresiba likely will take a day or 2 to become fully integrated into the body. I would probably decrease the suggested dose of Tresiba by the mentioned 10% AND be certain she has with her glucose tabs & sweet carbs to counteract unexpected LOWS. I never go anywhere without 6 to 10 glucose tabs.
@Confuzzled - I had a similar transition from Levemir to Tresiba, and here’s the thing, unless you only sleep a few hours, or get up before your final wakening, Dawn Phenomenon always throws me higher than I want to be. It’s not a lot, but it happens.
Lantus (and its patent-protected successor Basalgar) allegedly work to tame this if you time it right, but I did not experience that, and there were other downsides of glargine that I was happy to be rid of.
DP is the main thing that makes me consider the value of a pump. I’ve been on the MDI-pump fence for a long time, but I do like Tresiba in most respects and it works quite well.
@truenorth
If it wasn’t for the cost, I would still be on the pump…
That being said, after 8 years of pumping, I do not miss the tubing and extra appendage to think about all the time.
The control was definitely better on the pump, but the freedom of not having a device attached 24/7 is nice. It allows me to go on float trips without a lot of fuss as well, it is amazing when you realize all the restriction the pump had compared to just shoving a couple of pens in your pocket.
But I am having adequate control and it is saving me about 350 a month in co-insurance using the pens over the pump.
But DP is easily fixed with a pump, so it may be worth it for you…
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My Dd takes her Tresiba at supper time and we have absolutely no trouble with DP (touch wood). I see that tresiba has a slight peak about 8-14 hours, so I tried to jive that with her most insulin resistant time of day - 5-9am. So the starting dose we guessed at seems to be bang on - 25% less than her Levemir. I increased it 2u for three days, but she drops about 5 mmol over the night, so that’s too high. Will take her back to 36 units and stay there a while. Loving it so far. So much better than Levemir for us.
You were exactly right about the inertia of the Levemir. It wasn’t until about 22 hours after her last Levemir injection did she start going up slowly.
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Pumps are expensive, but I am on the OmniPod, so I never have to worry about tubing or a pump hanging off my belt. If I want to swim, I jump in. If I need a shower, I take one. The OmniPod gives me great freedom while still having control over my D. If you want more freedom and good control with a pump, yet are adverse to the tubes and wearing the pump itself, try the OmniPod. I have had mine for over a decade, and I love it.