Hello All...

I'm relatively new to TuDiabetes, which is to say that I've only recently begun to interact with it although I've had a profile for quite a while... I also apologize in advance for what will undoubtedly be a long-winded question!

I need the community's help sorting something out...or to tell me that it's just "normal". Background: diagnosed late-onset T1 ~ 2 Yrs ago...sequence of A1cs went 11.3 at diagnosis, 6.9, 6.7, 6.9, 6.5, 6.2 and Monday's most recent TBD... I strongly prefer injections and plan to stay that way until I cannot maintain a sub 6.5 A1c, and have recently started pursuit of the CGMS. I appreciate all of the enthusiasm those of you with pumps have for the device, but it's not for me yet.

I've been active most of my life (notable and mostly unavoidable exception of graduate school) and it took me about 9 months/1 year to get over my horror over exercise and insulin after diagnosis, although I got religion on carbs in about 2 days. I have a 14 month old son, my wife and I both work, and we do everything we can to exercise 4-5 X/week, which means we trade off mornings at the gym etc...

Breakfast is a complete enigma. I rotate between a couple of things (one Van's whole grain waffle - 12g carb with fat free cottage cheese and a protein shake with water - 2 carbs in the protein mix...eggs/egg whites/EggBeaters depending on my mood and one serving of McCann's steel cut oatmeal with LOTS of cinnamon (in cast what they say is true) with a handful of blueberries...or if I'm running late, I'll go with one of the egg/turkey sausage/cheese whole grain sandwiches from the store). None the less, most all of these meals have about 25 net carbs "all in". I simply cannot get the exercise/insulin/breakfast routine down.

Here's what happens: I wake up anywhere between 110 - 140...I go to gym...I work out (mainly resistance training in the mornings) for about 30 - 45 minutes and almost always end up ~160-175. Okay, I get it...either dawn phenomenon is still going and/or weight lifting causes adrenaline causes increase BG, etc... I get home, take my 22 units of Levemir and anywhere from 3 - 6 units of Novolog...2-3 correction + meal amt...(~1:10, sometimes I get aggressive and go 1:7). I try to account for lower circulation in the morning, an empty stomach and some morning resistance with timing etc, but sometimes nothing works and I'm just curious if there is any wisdom for me on the subject or if that's just the tuition of the disease.

Occassionally, 5 units won't move me even before I eat anything - like today. Took 5 units and waited about 45 minutes...nothing. I want to see a change in direction before I put any of that carb in my stomach and it just didn't happen, so I did what I usually do for a REALLY quick correct which is two units in the bicep...and again...nothing. So now I have 22 Levemir about to kick in slowly and 7 units of fast-acting floating around somewhere and am not budging off of 175 and too nervous to eat anthing because I've trained my body to abhor anything north of 190 and it hurts like hell...(I realize I will receive no sympathy from those of you with much higher spikes).

I'm just waiting for a massive crash, but it hasn't happened. (It's been 3 hours since the begging of today's saga) I'm certain it's not the insulin because it is basically brand new, was working last night, and was in the refrigerator all night. Lastly, I've had occassions where a 3 unit correction bolus sent me from 170 to 50 in an hour an a half without ANY physical activity so I'm reticent to take more...I'll just burn up some test strips and move on...

If you're reading this far, you have my gratitude. If you have any thoughts/suggestions, I am all ears and would greatly appreciate it. Heck, any suggestions on low carb breakfasts that DON'T involve eggs or egg derivatives would be huge. I used to love the suckers but cannot stand them now.

Many many thanks,

T

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Thanks Kenx,

I do split the Levemir...~22 in the morning and 8-12 in the evening depending on what I'm going to have for dinner, etc. I'd like to not have to have what I lovingly refer to as "cookie time" at 9pm just before bed when I'm sitting around 95 because I don't want the calories...I am very uncomfortable going to sleep unless I'm north of 120.

I can see how one large long acting dose may work, and would like to try it out, but am personally a bit tepid on the idea until I have the CGMS up and running... Just fearful of the overnight unrecoverable low even if it shouldn't be a concern. I don't mind waking up in the 130-140 range since that's my biggest fear. Perhaps I'm expecting too much out of synthetic insulin! :-) I'd also like to find out once and for all that my c-peptide and insulin production is GONZO before I get too clever while sleeping. :-)

I really appreciate your reading through my brain dump and helping out!

Best,

Thomas
The split in levemir sticks out a little to me too. Have you tried adjusting that so you're taking a little more at night and a little less in the AM? They don't need to be even, but I'm almost thinking that by the morning your previous morning's dose is mostly gone and your night time dose isn't quite enough to meet your basal needs causing your bg to rise. On the pump, I know that if I cut my basal too drastically for exercise then I can rise quickly and it can be difficult to get it to come back down.
Thanks Tom.
I think you're probably right...also, last night was one of the 8 unit variety b/c I had been staying ~85-100 all afternoon/evening. I'll get more aggressive with the evening's Levemir, but I think I'll wait until I have the CGMS. Man, do I admire all the folks who had to do this as children or the parents who do it on their behalf! I may hate this thing, but I have a healthy appreciation for the fact that I was given a 31 year head start and that I have all these tools available...long/short acting insulin, strips, CGMS, internet forums for advice, etc, etc, etc.
I'm gonna have to echo what Tom said..that was my first thought. Maybe you can go up two units every week or so at night until you become more comfortable with a larger Levemir dose at night and then of course after upping the nightly Levemir dose you can always set an alarm for 2-3am and test to help you feel more comfortable.
Thanks Lil MaMa,

I'll keep tinkering...could end up being a lifelong requirement anyway!

Best,

Thomas
Sorry to hear about your car accident! Rest well and get better. Hope the split Levemir keeps working for you.

Best,

Thomas
So I started on a pump less than a month ago. I can certainly understand your decision to stay with shot! That was my choice for a long time, too. I firmly believe that success with a pump comes from an internal decision to embrace that form of insulin therapy. Don't let anyone push you there until you decide you are ready!!

Anyway, I was talking with my CDE about my morning BS. I would wake up around 90 - 110 at 6:30am. I would take some thyroid medication on an empty stomach and go to work. I would test before eating at 8:30 or 9 am an would be up over 170 (usually in the low 200's...grrr!). She indicated that eating and getting my body out of fasting would solve the problem. However, the thyroid medication prevents that. Because I am on the pump, we are adjusting my basal rate to compensate for this rise. I agree with kenx that talking to your dr about adjusting your levemir may be an answer. Perhaps discussing if taking the Levemir prior to exercise would help?

(As a side, I never got the hang of Levemir - I was a Lantus-girl for 8 years. I know that's not true for everyone and I had to deal with the Lantus-burn side effect. But there it is for what it's worth.)

For food, I usually eat plain greek yogurt with a little honey and homemade granola (that is mostly nuts). It gives me the protein I need and it's about 30g of carbs. I love eggs, but CANNOT eat them every day!

I am also looking into a CGMs. For a trial run, my endo put me on a "blind" one (MM iPro CGMS). Basically, I wore the sensor for 3 days then went back to my endo to look at the graphs. It is not as good as the real deal as it doesn't give "real time" info - BUT it was good for a lot of things. I found out that I could wear that darn sensor. And after 15 years - I finally got to see what pizza does to me! Also, I know that I have to cover black coffee because the caffeine raises my bs.

Good luck with all this! I hope it all gets ironed out soon!
Thank you both. Truly.

My philosophy (right or wrong) with the variable Levemir is that if I'm wrong, I'll be wrong gradually rather than "immediately" and what I consider to be "dangerously" with the Novolog... Also, given the numbers I wake up with, I consider the outsized basal dose a bit of a "jump start". I feel far more in control over what happens when awake so that's the rationale behind my meager night time dose. I know that theoretically, the Levemir should work over a 24 hour period, but, pragmatically, I recognize that's impossible. We have literally thousands of hormones in our bodies stimulated by literally millions of variables, MOST of which raise BG...and there's only ONE that lowers it... Oh well...

I too have the associated mild hypothyroid and was taking my little bit of Levoxyl in the morning. But, I just switched to afternoon because I couldn't stand the waiting game (having to wake up an hour early to take it and basically not do anything else until an hour had passed). (Our little one is in 14 m/o "tornado mode" and so I need to get testing, medicating, eating, and exercise out of the way early so I can help my wife with the dressing, feeding, and off to daycare bit!)

Good luck with the pump Kate. Most people seem to adore theirs. I just have that irrational fear about trusting the machine to not frizz out on me and give me a massive bolus without my knowing! Silly, I'm sure, but while I have good control with the shots and my vanity doesn't mind the man-purse, I'm sticking with the current regimen! :-)

It's certainly possible (and has been discussed/brought up before by my various diabetes experts) that I may just have an enthusiastic liver... That is, when I take a bunch of insulin waiting to watch my number go down, my muscles and liver recognize that there isn't any food in there and they collectively act to protect me. I would be very proud of my functional organs if that turned out to be the case... 200+ still makes me feel sh*tty, which is good I suppose, and so I'm not all that enamored with putting any carb into my body near that number.

The other reason I hesitate to take one large evening dose of Levemir is that I am almost always between 80 - 100 when I get home from work. I test before I get up off my butt at my desk and almost no matter what I do (piece of toffee - 7g carb, few crackers, etc), I don't budge off that number between desk, walk to car, drive home, getting home, and eating dinner...therefore, conceptually, I'm just a bit nervous to take a big whopper when my BG is non-D level and holding!

Hope you guys have a great rest of the week and weekend. Thanks again and feel free to keep in touch!

Thomas
I know when I was taking Levemir it would not work for a full 24 hours so I had to split the dose. What has been explained to me is that Levemir's 24 hour action is highly dependent on the individual and the dose. I was taking a similar dose as you. On a single dose there would not be much action past 16 hours.
One thing I have learned after 17 years is DM is unpredictable. I will go for a couple years without needing much change in my insulin followed my massive adjustments (what I consider massive) and when looking back to WHY it happened I sometimes can find no logical explanation.
Thomas&Kate,
I too ran into this problem and I take my thyroid medications at night (synthroid and cytomel). Studies actually show that taking it at night is best anyway because you do not eat for several hours thus it has better absorption vs only waiting one hour or so in the morning.

Oh and Thomas your reasoning for not wanting the pump is exactly how I feel about it!lol
I know, but I am a sucker for a late night snack! It's easier for me to just wait an hour or 2 in the morning. Plus, if I took synthroid then, when would I take the other handful of pills? :)
I've been doing split does on Lantus for ~1 month now and then last week started working out in the mornings, so I'm trying to workout some issues too. It does make me wonder if there is something about working out in the morning (especially before eating or doing much else) that might cause more stress/increased hormones thus high BS compared to other times of the day. Like this morning I went up ~100 points after a 25 minutes run...when doing the same runs in the evenings it usually holds steady. I think some of it might be that a part of the basal is wearing out (the part injected 24 hours before) mixing in with morning stress.
What I'm thinking of doing (and a suggestion) is injecting ~1-2 units before excercise (I'm leaning to 1 unit, but the pen doesn't seem to reliably give 1 unit...also would depend on your sensitivity to insulin).
I luckily have a CGM which if I was around 100, but dropping I wouldn't inject...but usually ~5-10 minutes after getting up as I'm getting ready to excercise my BG shoots ups anyways. So I think a little extra of insulin might help to head off the spike.
The other thought I had was perhaps eating something small w/ injection (maybe with more conservative ratio).,..because I thought maybe the liver dumped extra glucose when you exercise after fasting all night, that the basal can't cover?

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