Hi all,

I have been diagnosed as a LADA diabetic for 7 months now and so far I have gotten by with eating a low carb diet, exercise and small amounts of Bolus insulin if I have more than 15 g carbs in a meal..

That worked great until recently, for a while now my fasting BG has crept up to what is now averaging around 115-125, I also noticed that during the day in between meals I find it hard to ever go under 100. (But then I DO see the occasional 75 too! But I used to be around 80 regularly before I ate again)
I have to admit I am a little anxious of taking that jump to having exogenous insulin in my system ALL the time, especially since I still have phases where my pancreas seems to suddenly decide to go back to work.
Because I m a photographer my daily activity level greatly varies, sometimes I run around all day on a shoot, sometimes I sit in front of my computer all day long, not moving at all.
That is why I was/am quite scared of experiencing lows/hypos frequently as soon as I go on basal.
I m worried I will have to check my BG all the time, and being forced to snack between meals not to go low.
Can anybody (esp. any LADAs maybe with some function left) share some experiences of first getting into basal and avoiding lows?
Maybe split the dose?
How about starting on a very low dose before bedtime, say 2 Units, would that do anything?
Should I do some nighttime testing the first few nights, at 4am, 6 am etc?
And is it possible that I d have to rethink my bolus (IC ratio) if I have basal on board too?
And finally, how much does my basal effect extra physical exercise - would I have to make sure to "start high" when going running, to avoid lows?

Of course I will discuss all this with my endo at my next appointment, but I ve noticed the tips I m getting from here are usually more diverse and helpful ;)

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Personally, I would worry about lows much more with bolus than basal insulin. Because it is long acting it affects us much more gradually. Yes, you might have to alter your bolus ratios a bit when you start basal, just see how it goes. I would definitely start with a low dose like 2 units before bedtime and see how that goes, gradually increasing it as needed and leaving the new dose for 2-3 days before making another change. Some people do basal testing (Using Insulin explains the process). I never have, but just, like everything with insulin keep careful logs and go by trial and error. It might take a little longer but works just as well. As you have learned it's all a process. You might start with 2 units at night, increase that a small amount, then eventually find you get smoother coverage with two doses. Some of us do better with Lantus, some with Levemir. Down the road a pump may make sense to you as you can dose different amounts for different times of day and do "temporary basals" for exercise. I will let other people give you tips for exercise on MDI as I'm not an exerciser. Again, I don't think basal is a threat to lows as much as rapid acting bolus, especially once you determine the correct dose which you will do gradually. I think you are doing great taking such a proactive approach to your care!

Hi Julie-

I agree with Zoe that starting on a very low dose makes sense. You might just start with one unit and see if that brings your fasting blood sugar back down to under 100. Trying to get your fasting numbers back to the 80 will significantly increase the frequency of lows.

One or two units of basal probably won't require an adjustment of your insulin to carb ratios but if you start to go low two hours after eating you can adjust the IC ratio one carb at a time.

Once you're on a full basal/bolus regime your life does become more regimented. You'll have to test more often - although it sounds like you're already testing before and after every meal so that the additional tests might only be around driving and excercise - and you'll have to carry around juice boxes or glocuse tabs to deal with lows. It will help if you can integrate at least some exercise into your routine on days you're not on a shoot just to keep your daily patterns more regular.

It's an adventure :-)

Maurie

Hi,

I am most likely LADA. I actually have to use basal and have been mostly in the past using basal rather than bolus - though that may be changing for me now... been having some unsual highs. Basal acts much more slowly and so is more predictable. Also I reckon avoiding highs may help make your pancreas less likely to kick and splutter unpredictably...

Anyway, I agree start low dose basal. I'd personally (and am personally)be most concerned about getting my fasting down. Daytime I can always correct with a fast acting. I'ave found that my fasting numbers are strongly affected by what I ate the night before - even if my numbers after that food were ok, if it contained much carbs they won't be ok the next morning.

On the exercsie, it's trial and error..but the best approach is to start close to normal and then gradually consume just that amount of carbs to keep you stable.. rather than being high and hoping the exercise will bring you down enough.

My experience is that Levemir is far more level than Lantus. I had Lantus lows frequently because it peaks. Your doctor will probably deny this. Lantus also loses potency faster than Levemir & it stings.

Whatever basal you use, it's more effective in split doses. Lantus doesn't cover 24 hours as claimed.

When you start experimenting with doses, keep that dose the same for three days before increasing. You can't really make a decision based on one night or day.

One unit may do fine since your fasting isn't that high.

I agree- Levemir seems to have a more subtle, stable effect on BG than Lantus, and splitting the dose also allows for better continuous coverage with less of a peak.

Your situation is identical to mine. My advice would be to keep monitoring a little while longer before you start basal. Countless times now I've thought I was going to have to start basal, but things have tended to level out on their own without basal. Changes to routine, illnesses (even minor viruses that you aren't aware of) etc can all cause fasting numbers like you describe... A week or so longer with slightly higher than ideal fasting numbers won't hurt you in the long run.

I would tend to agree with Sam. As long as you are not going over 140 mg/dl you should be fine. But should you note readings of 140 mg/dl in the morning or before meals, then it is time. And when you do start, remember that the exogenous basal insulin will fill in the deficiency in your own production and act as an offset. If you take a tad too much basal, your body will reduce your own production. So as long as you retain some insulin production, you will actually have some buffer against lows caused by your basal.

that is amazing – I didnt know that! So why does the same mechanism (body reducing own production) not work with bolus?

It does, but our bodies actually have a two phase insulin response to meals. Normally, our bodies store insulin and when we eat, they release this stored insulin as a phase 1 response. This is a fast and effective surge of insulin and is the reason that a non-diabetic can eat a half dozen donuts and not have a blood sugar rise. Then, if the stored insulin is not enough, our bodies crank up the pancreas to produce insulin, this is the phase 2 response. Unfortunately, the phase 2 response is slow and sluggish.

By the time your fasting blood sugars start to go, your pancreas can no longer produce enough insulin to maintain a fasting, let alone store up for a phase 1 response. But before then, your body could produce some insulin to offset the meal and this is really helpful. In fact, if you can preserve some insulin response, you can bolus exogenous insulin for most of the meal and leave your natural insulin production to "fine tune" things. But sadly, at this time it is likely you are not seeing much help at meal time.

Thank you all for your fantastic and incredible feedback. I might hold off a little while longer with the basal and see how I go in the next couple of weeks.
You sure have all taken away some of the concerns I ve been having about "taking the plunge!"
I just love this community :-)

I think the same mechanism does work with bolus. That explains why early in our diagnosis we don't need very much bolus to keep our blood sugars where they should be (because our pancreas are doing the rest), but later on as things progress we need much more to keep things in place.

I personally believe it is important to use injected insulin (or schduled exercise) to keep our numbers as close to normal as possible (I follow Bernstein and target blood sugar ideally in the 80s all the time) so that our remaining beta cells can stay functional as long as possible. If you only need a small amount of bolus to keep blood sugars in target then the risk of going low is much less than if larger bolus is required (ie. 1 unit drops me by 40 points. Dropping from 100 - 60 may not feel great assuming I hadn't eaten as planned (though if I did eat as planned that same 1 unit will keep my blood sugars pretty much on target in the 80-90 range), but it's not going to cuase me to go unconscious.

At the momenet (without basal) your bolus is actually bringing down blood sugars that your basal may have taken care (or kept at a lower baseline) than if you were using it. When you start basal you may find that you actually need less bolus and may need to recalculate your rates for that.

My best advice is don't be scared of basal. When I eat low carb my basal does most of the work and boluses are very small if at all.

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