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Share your insulin dose strategies

7K views 34 replies 6 participants last post by  Bunjee 
#1 ·
I would like to share snippets of my day, looking at my BG, meal macronutrients and the insulin dose that I picked. I'm just starting out and have found that even with books about dosing insulin, there's a bit of a leap from what they say and how it looks in practice.

If you are on insulin, I would love it if you would also share your advice or a look at your day too.

Note: There's no judgement on this thread! The point is to discuss and swap experience on dosing insulin, not judge someone's diet. People of all carb-levels and diet approaches are welcome.
 
#2 ·
To kick things off here's a look at yesterday's adventure. To prove that I mean no judgement, you'll see that I'm sharing a day where I totally was NOT low-carb. This is a safe place to share.

basal = levemir
bolus = novolog
target = 100. Since I'm just starting this makes my math easier (always the same even target all day), and is higher than my long term goal because I have no clue what I'm doing and this is a safer number to shoot until I learn more.

8am
- BG 138
- 25U basal
- 8U bolus

I'm ~40 pts higher than my current target of 100. This number is totally unscientific and I don't have a formula. I have arrived at it through upping my morning correction by 1U every couple days until I found a dose that lowered my BG close to 100 after 4 hours.

9am
- 8 effective carbs (I'm using a new formula from the ADA, http://www.diabetesforum.com/diabetes/83170-alternative-carb-count-strategy.html)
- I have decided to not bolus for this food because I've tested it before and doesn't seem to impact my BG much despite the carb count.

1pm
- BG: 110
- Lunch will be 40 effective carbs
- Bolus: 6U

I am using the starting i:c ratio (insulin:carbs) based on my weight, so 1:7. 1U per 7g carbs. 40/7 = 5.71, I rounded up to 6.

2:30pm
- ~1hr PP
- BG: 203
- IOB (insulin on board): 4.5U
No insulin correction at this time. I am still learning how long my bolus lasts in my system and wanted to see where things would go. Right now I'm going with the initial assumption of a 4 hour action time.

3:30pm
- BG: 183
- IOB: 3U
- Bolus: 6U
Since it looked like my BG was flattening out, I decided to correct with 6U. During the day (not morning) I am going by 1U lowers my BG 10pts (correction factor of 10), I have 3U in my system still, so in theory this should bring me down 90pts, to 90.

4:30pm
- BG: 131
- IOB: I think 6U? I suck at math...
Seems like things are going in the right direction so I go back to work.

8:00pm
- BG: 95 (HOT DAMN! Things are looking up for Daytona)
- 19 effective carbs
- Bolus: 3U
At the moment I'm using the same i:c for lunch and dinner (1:7). So 19/7 = ~3.

9:45pm
- BG: 135
- IOB: 1.5U
- Bolus: 3U
- Basal: 25U (Yes, I'm purposefully stacking my basal dose for more oompf in the late morning)
Doh! Looks like 3U wasn't enough... I probably should have bolused just 2U, which would have meant an effective amount of 3.5U getting me to around 100. But I went with my gut, and picked 3U.


Totals:
Basal: 50U
Bolus: 26U
TDD: 76U
Carbs: 78g

So there's a day in the life of Daytona learning how to take insulin. What I struggle with most is my i:c and correction factor. I'm using the starting values suggested for my weight, some finger in the air feeling for how my insulin sensitivity during the day but am really lost on how to adjust from those initial values. None of is scientific (which if you know me drives me nuts). I'm doing my best with what I think is happening based on as many fingerpricks as I'm willing to do. One more reason why I want a CGM!
 
#3 · (Edited)
Wow, such a lot of work to figure this out. I'm not having to do the bolus, so I'm sorry I don't have anything to contribute.

I do have a stupid question though, just curious, does your IOB include the basal dose? And how do you figure out how much basal to use vs. bolus?

And - I'm sure if you keep doing this - keeping such good detail, patterns will emerge and you'll get it down to a science as much as anyone could, I'm sure. :)
 
#5 ·
Wow, such a lot of work to figure this out. I'm not having to do the bolus, so I'm sorry I don't have anything to contribute.
No worries! If nothing else I hope it's amusing to follow along as I do mental math :D

I do have a stupid question though, just curious, does your IOB include the basal dose?
Here's how I'm calculating insulin on board (IOB).

First, figure out how long it takes for the insulin in your bolus to stop working (be used up). The doctor recommended starting with 4 hours. I've been testing that by watching how long it takes for my BG to stop dropping after a bolus (no eating during the test). So far 4 hours seems to work okay.

So if I bolus 4U, my IOB after 1 hour is 3U, then after 2 hours it's 2U, 3 hours it's 1U and 0U after 4 hours.

IOB doesn't include your basal dose. The reason why is that basal is supposed to be enough to keep your BG steady all day if you didn't eat. It shouldn't be lowering your BG.

It's important to keep track of IOB so that if you need to correct again, you take into account the insulin that is still actively lowering your BG, and don't accidentally take too much insulin.

And how do you figure out how much basal to use vs. bolus?
First I have to put in a disclaimer that this may not be the right way to go about this. I don't have a CDE or a doc who knows about insulin, so my methodology is a combination of what I understood from those books I referenced earlier and how often I'm willing to fingerstick myself. :D

The way I came to it was to start at the dose recommended for my weight (actually lower since my doc is hypo-shy). Then I would watch my BG through the night, waking up at 2am to see if it stayed steady. Then again around 5am. If I started the night at 100, and my BG went up more than 30 points in the night, I upped the dose by 20% (or at least 1U). I would see how I did for at least 2 days before deciding that the dose was too low.

I have trouble with my BG rising after 5am, which is why I went off the other times. If I chased my morning DP, I would end up on too high a dose, and go low at night. So I correct for the DP when I get out of bed. If I were on a pump, I could actually use a different basal at different times but this is the best I can do with MDI.

For my daytime basal, I would take my morning basal dose and then skip either breakfast, lunch or dinner (not all of them, but that would be legit too) and see if I was holding steady. I don't test if I've eating in the last 4 hours as I don't want post-prandial BG throwing things off.

Right now I'm at 25U in the morning and 25U at night, which is a bit simplistic. When I get a CGM, I plan on checking if that's the right split.
 
#4 ·
I've - temporarily at least - been freed from the steroids I've been taking for 6 months.

Pro: YEAH! No more sleepless crazy! No more insulin!
Con: I wanna play in this thread!

auntiekris - I might keep bolus around for times when I want to eat a formerly forbidden meal (quinoa!) which I knew would send me too high. My endo said she's willing to keep prescribing bolus if I want. So - you take your basal, I'll bolus, and then we can have an insulin meld and play with Daytona :D

Will be watching and learning ... steroids are not out of my life forever.
 
#8 ·
auntiekris - I might keep bolus around for times when I want to eat a formerly forbidden meal (quinoa!) which I knew would send me too high. My endo said she's willing to keep prescribing bolus if I want. So - you take your basal, I'll bolus, and then we can have an insulin meld and play with Daytona :D
This cracked me up. Such a good idea!

And this is good news, yes, about no more steroids?!
 
#6 ·
I found a nice (paid) app that I'm using to track, MyNetDiary Diabetes. It's not perfect (it doesn't do IOB for you) but I like that I can adjust what it shows me (such as hide calories, count carbs using a specific strategy), and set custom fasting, PP, bedtime BG targets.

It automatically tags my BG recordings with fasting, after breakfast, 2hr after lunch, etc. Plus it sets reminders so that when I log a meal, it automatically bugs me to test 1 and 2 hours afterwards. That's been very helpful as otherwise I always forget and end up testing at silly times or not at all.

I've been using the tags to remind myself why I took a bolus correction, how much IOB was when I did the dose, etc. So that I can look back and make sense of things.
 
#7 ·
Daytona, wow again. So involved this is! Thanks for sharing, this medical stuff doesn't come easy to me but I'm curious about it all even if it doesn't apply to me - at the moment anyways.

Definitely look forward to hearing how this goes.
 
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#10 ·
Don't let my ramblings scare you off! I'm the type of person who gets way too into things for a bit, over-analyzes everything, then eventually finds something that I can do mindlessly for when I inevitably get obsessed with the next big thing. :devil:
 
#11 · (Edited)
Ok, I will join in as I am also new to insulin. I follow lowish carb - usually 90 grm cap, although Friday Night popcorn night is a bit higher. I have discovered that delaying eating 1/2 hour after taking bolus is more effective for me. I plan for roughly 25 carbs per meal.

basal = levemir
bolus = novolog 9-5-7 +3 snacks
Target: Before meals <130 After meals = <140

Basal 36u at 8:30 p.m. night before.

8am
- BG 119
- 9U bolus
- 16 carbs
Amazingly FBS was good today. Not where I want but better. My 12 grain bread or oat nut bread is 22-23 carbs so I'm looking a smaller loaf size. Currently, 14 carbs, but it's white bread - not very flavorful.

11:30 a.m.
- BG: 100
- Bolus: 6U
- Carbs: 25 grams
- BG Post: 138
Really, no science here. I eat roughly the same amount of carbs at lunch every day, but I was having leftover Chicken Tetrazini, so gave myself an extra unit.

3:00 p.m. (snack)
carbs: 17
Failed to bolus.

5:00 pm
BG: 154
Bolus: 9u
Carbs: 32
After Dinner: 197
I think this is Levemir issue. I added 2 additional units because of starting the meal with a higher BG. I don't think Levemir is working substantially at all by dinner.

8 p.m. Friday night popcorn
carbs: 16 grams
bolus: 7 units
Used additional units because of aftermeal number at dinner and assumption about Levemir. I usually only use 3.

8:30 p.m.
Levemir: 32u

11 pm. Bedtime
BG 149

Total Carbs for day: 106 gr.
Total insulin for day: 63u

It's pretty clear to me that since I dropped metformin that Levemir is not actually working by 2 or 3 p.m. So, I'm moving the Levemir from the current 8:30 to 4:30 (when I take my bolus for dinner). If that doesn't work, then I have to start thinking about taking additional Levemir in the a.m. I haven't figured out the ratio thing nor do a correction unless BG is 200+. Heck, I'm still trying to get my basal dose right. My bedtime numbers are 149+ since a few days after quitting metformin, and, I think, part of the reason why my FBG is so high. Ok, maybe not. I could just be grasping at straws. :)
 
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#12 · (Edited)
Here's another day. 105 gr. is actually the absolute minimum that my CDE wants, so I will use this as another example day for new endo. I am usually lower than this except once or twice a week. I think my switch to taking Levemir at 4:30 instead of 8:30 has been successful. If I had been bolusing correctly, I'd have reached my goals all day.

basal = levemir - 36u
bolus = novolog 9-5-8 +3 snacks <---regular plan
Target: Before meals <130 After meals = <140

Basal 36u at 4:30 p.m. night before.

8 am
- BG 123
- 9U bolus
- 38 carbs
- BG 178 post meal
2 Eggs (1 gr) Toast (14 gr), cherries (23 gr) <--I have 2 fruits daily


11:30 a.m.

- BG: 122
- Bolus: 7U
- Carbs: 32 grams
- BG Post: 146
BLT. Lots of bacon, tomato, very little miracle whip. Bread: 14 gr carb per slice. This was unplanned lunch. Had I known, I would have skipped toast in a.m. (need for pills).

3:00 p.m. (snack)
Skipped snack

4:30: Levemir 36u

5:00 pm
BG: 91
Bolus: 9u
Carbs: 18
After Dinner: 116
Chicken with veggies, 1/2 mashed potatoes (haven't had potatoes in 3 months).

9:00 pm (snack)
Bolus: 3u
Carbs: 24
large apple + peanut butter

11 pm. Bedtime
BG 140

Total Carbs for day: 108 gr
Total insulin for day: 64u

So, what were my mistakes today? I should have measured the cherries AND skipped the toast. Alternatively, increased my bolus. Had the same breakfast this morning with no toast and 9 cherries (19 gr) and post meal was 140.

Lunch - I didn't know about the sandwich, but obviously 2 additional units weren't quite enough but not terrible. I will do 3u extra in future when having sandwich.

Dinner - went well. No problem there.

Snack - it was the last of these largish apples. Should have used 4u instead of 3 for bolus. I would normally split this size apple with family member but they had gone to bed and I was hungry! Going to bed higher resulted in higher morning reading so snacks at night just don't help like they did when I was still taking metformin.

I have tried to figure out ratio, but it's sortof pointless until I get that morning blood sugar titrated right. Going up another 2 units tonight.
 
#14 ·
Hi Bounty -

I didn't actually start insulin until about a week after that A1c test, so really it's only been about 2 1/2-3 weeks since I've been on insulin. I've started a thread here - http://www.diabetesforum.com/diabetes-treatment/82922-insulin.html and I'll update after my appointment.

And it just so happens I'm having a blood test tomorrow morning and then will meet with my doctor on Wednesday for the first time after being prescribed insulin.

She was afraid of lows so originally started me off at 2u but since I was in the 300's I upped it myself until I've found that 8u seems to keep me between the high 60's to low 100's for FBG.

Twice since starting insulin I've been over 140 and still bounce around quite a bit in the early morning and early evening so will be talking to her about that to see what can be done to even me out even more.

Thanks for your concern, it's very much appreciated. I'll keep you posted!
 
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#15 ·
Good to know. Wasn't aware that you had just started your insulin regimen. You'll do fine...I'm sure.

I was on Lantus from 2009 until 2013, 25 units. We were discussing in another forum what would happen if Armageddon rolled around and we could no longer get insulin...how fast those who took insulin would go downhill and what could we do to compensate for that. I volunteered to be a guinea pig, quit my insulin and report daily what was happening and how I coped with it.

The first few days my FBG went up about 10 points. On the fourth day it returned to normal (for me, FBG 101 mg/dL). It never went any higher after that...in fact my one-hour and two-hour postprandials got better. After two months of this I also quit taking Lipitor and Lisinopril and baby aspirin. As of last month...I've been drug and insulin free for 3 years.

I talked to my doctor about it and he said that mine was a unique case. Either one of two things happened. Either I had Flatbush diabetes and my pancreas recovered on its own...or I had abused my pancreas to the point it just said, "okay, we give up...when you decide to stop feeding yourself like you're 12...give us a call!"

Honestly? I think the withdrawals from Krispy Kremes are worse than those with heroin. :)
 
#16 ·
We were discussing in another forum what would happen if Armageddon rolled around and we could no longer get insulin...how fast those who took insulin would go downhill and what could we do to compensate for that.
Hahaha, I think about that ALL the time. Even if I could outrun the zombies* in an apocalypse, it wouldn't matter because the D. would get me.

*which I couldn't - a tennis teacher once told me I had the slowest feet he'd ever seen!

or I had abused my pancreas to the point it just said, "okay, we give up...when you decide to stop feeding yourself like you're 12...give us a call!"
Lol, this cracked me up. And still sadly this was my month of May before the last A1c test.

I'm glad you were able to get off of everything, that's amazing!
 
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#17 · (Edited)
At first they gave me a script for a Lantus vile and syringes. At my next visit to my PA-C I told him this vile thing's a bit fumbly...got anything else? He wrote me a script for a Lantus Solostar pen...with the 5/16" pen needles. What a difference.

I read up on injections and to not inject in the same place too often. I didn't know how often "too often" was. Neither did anyone else I talked to. Finally found a doctor who suggested a safe amount of time to keep from getting subcutaneous scar tissue would be about a two week rotation.

So, I got out a permanent marker, made 14 spots on my abdomen, numbered those spots on a graphic I made...then put those numbers on my calendar. Spot number 1 on Monday, number 2 on Tuesday etc. until two weeks were up...then start all over again. 4 years, never a bruise, never any skin complications or scaring that would need higher doses of the insulin. Below is the chart I made up. Worked good for me. :)





 
#18 ·
I'm pretty good about switching sides, but I'll definitely look down and think hmmm, where exactly did I inject the day before? Thanks for the great tip!
 
#19 ·
I inject my basal on the side of my butt, since it's much less sensitive there to a large dose and there's lot of places to keep poking without repeating. Then I save my fat tire and tummy for boluses, as they are easier to discretely reach.
 
#20 ·
@Bunjee Have you thought about splitting your levemir dose? It definitely does not last a full 24 hours, and I get much better coverage by splitting it up. I actually overlap them a bit for extra "oomf" in the morning but it's pretty common to do them 12 hours apart.

Also there's a new basal insulin, Tresiba, that looks really promising. It lasts real long, doesn't have a peak and you can take it anytime of the day (as long as it is > 8 hours after your last shot). In another forum, I've been following along as people (T1's and T2's) have tried it and lots are even coming off their insulin pumps because it works so well. If my new insurance covers it, I may ask for a sample to see if it works better for me.
 
#23 · (Edited)
@Bunjee Have you thought about splitting your levemir dose? It definitely does not last a full 24 hours, and I get much better coverage by splitting it up. I actually overlap them a bit for extra "oomf" in the morning but it's pretty common to do them 12 hours apart.

Also there's a new basal insulin, Tresiba, that looks really promising.
I have tried splitting my dose and the result was a high FBG as well as very high after post breakfast reading. I see the endo for the first time in a couple of weeks and decided to just keep doing the single dose until then. I forgot today (darn it), but moving it to 4:30 seemed like it would cover when I needed it better - evening and morning. Middle of the day I have stacking from the Novolog helping me along.

Daytona, thank you for noticing that about the 4 gr/unit. That will help a lot!

When I started using insulin, I was using 7-5-7+2 for the rapid (that's 7 for breakfast, 5 for lunch, 7 for dinner and 2 for snack). I have fairly consistent carbs for those meals. Since dropping the metformin, I've had to increase the bolus to 9-5-8 +3. From there, I've been figuring out the extra carbs to figure out how to adjust to meet my goals.

I had the same sandwich and dinner as yesterday. Increased bolus for lunch and had a HIGHER before lunch BG - same post meal numbers (146). Dinner - yesterday BD was 91, AD 116. Today BD was 109 AD 90. I know I'm a biological unit, but it's tough to figure this stuff out when you have such unexpected results for the same foods.

Thanks for mentioning Tresiba. I'll have to see if my insurance covers it before I see the endo. Note: info for this med says this: Never use a syringe to remove Tresiba® from the FlexTouch® pen. <--- any idea why? Makes no sense to be wasting a lot of insulin.
 
#22 ·
7pm
- BG: 107
- Carbs: 46g
- Bolus: 8U

9pm
- BG: 123

After bolusing I ate just the protein part of my dinner, and waited 20 minutes before eating the carby portion. That worked well on two fronts. Delaying the carbs a bit ensured that some of the insulin was working and ready to handle the carbs. Eating the non-carby parts first helped give me the patience to wait! :D
 
#24 ·
The insulin dose strategy strategy I have used is "keep it small" for both carb intake and insulin intake. Example is matching each unit of insulin to total carbs in order to maintain as steady and consistent level of glucose within a range of 65-125. I eliminate many types of foods and stay under 15g carbs for any serving. In past experiences many years ago I found the more insulin I took, the more carbs I required and harder it was to stay within a tight range. I want to minimize how many times I correct either because my glucose is too low or too high. My brain is like a circuit breaker with many switches and I shutdown those switches that contribute the most carbs. Examples would be :

Switch 3: turns off flour, bread, and starch
Switch 8: turns off bananas, apples, grapes
Switch 12: turns off dressings and sauces
Switch 19: turns off alcohol
The Main Circuit Breaker: no more than 15g carbs per serving
 
#30 ·
I don't use correction factor to calculate correction bolus. Sometimes ill take 1 unit of Humalog as a correction bolus if want my glucose to go 20 pts lower. An example for me would be if I see a glucose of 125 I would prefer to see it at 100.
 
#35 ·
Here's a link to a pdf handout from the American Association of Diabetic Educators (AADE) that includes a picture where you can figure out your own injection plan. There's a 'blank' abdomen where you can write in your preferred injection order. I'm going to try that method - the amount of bruising has gone down, but I'm still getting it. As mentioned, I use the abdomen for Levemir and thighs for Novolog just because this seems to work better for me.
 
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