Created in Denmark, Tresiba basal insulin has been around for a while in Europe. Recently it crossed the ocean. Diabetic North Americans are suffering a bit of Tresiba-mania. Rumor has it you can inject one unit and it will last you 10 years. Alright, I’m exaggerating. But the company’s website does claim “Once-daily injection.” Yet if you read on you’ll see that they are referring to a study involving type-2 diabetics.
But will one-shot-a-day do the job for people with type-1 diabetes? How could it possibly be effective for 24 hours? Even if the insulin released itself evenly for a 24 hour period there’s a bigger obstacle: Most people with type-1 diabetes need more long-acting nsulin at night than during the day. How would Tresiba magically adjust to twilight hours?
Last week, I did a short phone consult with a woman in Illinois. She had switched to Tresiba insulin. The day before she had taken 16 units (ironically split into two shots) all in the morning. She went to bed with a blood sugar in the high 80s. The next morning she awoke with it more-or-less unchanged. For her, one dose-a-day seemed to be working.
But then I saw her insulin log…
For meals she was taking only 1-2 units of insulin. Despite being on a low-carb diet, that’s not enough insulin for most people with type-1 diabetes. An egg will use up 1/2 a unit of insulin all by itself. When I see clients using so little insulin with meals I suspect one of two things: too much basal insulin or gastroparesis (or both).
“The once a day [injection of Tresiba] sometimes does the job… if you give an excessive dose…” said Dr. Bernstein in his most recent teleseminar. “That leaves a big bolus of insulin under your skin, wherever you inject. [It] slowly is released into the bloodstream because it’s so big… But the problem is because you have been given so much your forced to eat to keep up with the insulin. And that’s not the definition of basal insulin. Basal is to cover the fasting state when you are not eating.”
Nonetheless Bernstein now recommends Tresiba. But he advises you take Tresiba immediately before bed and upon arising. He even stated that it covers the dawn effect (a sudden spike in blood sugar experienced upon arising). So that’s two less shots than one would usually need.
Por ejemplo: My wife, Nicole, arises every night around 12:30am, to give herself a second shot of Levemir. For various reasons, sleep tends to interfere with insulin and raise blood sugar. One shot won’t last the night. Then in the morning she takes 1.5 units of Regular (in addition to more Levemir) to counteract the dawn effect.
With Tresiba, she wouldn’t need that midnight injection. But, does it really mean one can skip getting up in the middle of the night?
In addition to taking her basal insulin at 12:30am, Nicole also checks her blood sugar. If it’s high, she takes a Humalog correction. If it’s low, some Glucolifts. Sleeping the entire night without making a course correction almost ensures she’d wake up most mornings with her blood sugar out of range.
Additionally, the longer we sleep the more we tend to over-breathe. This lowers CO2 (carbon-dioxide) levels. Lower CO2 levels constrict blood vessels, impairing insulin perfusion. It also raises stress hormones, which raises blood sugar. Awaking in the middle of the night reduces breathing and lowers blood sugar. Especially if one performs a few minutes of the Buteyko Breathing Method.
Alas, Nicole still needs to wake up like a Trappist monk to check her blood sugar, reset her breathing and maybe hum a chant. Of course, not having to jab herself, penitently, with a sharp piece of metal would be nice.
At this time, we haven’t tested Tresiba. And don’t plan to anytime soon. The small benefits aren’t worth the time and effort involved in convincing Nicole’s doctor to scribble a new prescription. It does not appear to make any significant difference in blood sugar control. Of course, for someone who currently uses Lantus or an insulin pump, I’d encourage them to “speak to their doctor” about switching to Tresiba. But for Nicole, Levemir’s been doing the job quite well — maintaining her A1C below 5.5%.
In short, Tresiba seems to be the best choice of long-acting insulin. It wins first place over Levemir for sake of convenience. But it’s not the 24-hour pancreas in a bottle the ads seem to suggest.
Thinking outside the type-1 matrix,
–John C. A. Manley
P.S. For a big tip on correcting high and low blood sugars (whether in the middle of the night or the middle of the day) check out: Blood Sugar Cheat Sheet: Quick Corrections Without the Stress, Math and Risk