My doctor told me to ignore my blood sugar until 2 hours post-prandial, at which point I should be under 180. The AACE says 140 at 2 hours. Think Like a Pancreas recommended similar targets.
My question is what should I do now that I’m on a CGM and can’t really “not look” at the 1 hour reading? It can be quite high (200-250) and I’m not sure what to do about it. If I’m still coming down to my 2 hour target, should I just ignore whatever happened before?
I’m curious what others on CGM do. Are you picking a number, like 180/140, to stay under all the time after a meal?
Side question! I’m seeing odd-ball rebound spikes (even for high carb, low-protein/fat meals) 4-5 hours after a meal. So I get the big spike around 1 hour, it eventually goes down (though never to where I want it!) then starts going back up again. I don’t know if I should correct, or maybe change my bolus going forward…
Alternatively, I’ll come down to 180 at 2 hours, then … stay there forever. Again, not sure if that’s just another correction, or a bolus dose problem.
Basically, I am doing lots of post meal corrections and am unsure if that’s par for the course, or if there is more that I can do proactively. I am on MDI and am aggressively pre-bolusing, trying to watch for bend when practical.
Maybe this is in one of my books and I just missed it? I have Think Like a Pancreas, Using Insulin, Practical CGM and Sugar Surfing (still reading that one). If the answer is RTFM, just let me know!
“Patience grasshopper.” Correcting a blood sugar based on a one hour reading is asking for trouble. You could have a perfect dose but imperfect timing and have a spike. Trying to correct based on a one hour reading could result in a hypo. I also am on MDI and have a CGM. Even if I watch for the bend I am conservative. Only at 2-3 hours will you know whether your bolus dose of insulin was insufficient.
Yes, sometimes just 15 minutes like today. I usually do that when I’m already at a pretty good level. Other times I am starting higher than I prefer (like 120), so I will give myself 30-40 minutes, while watching my CGM.
Here’s my lunch today. I was super proud of not spiking high, but then it went up again later.
Oops, sorry I didn’t mean to imply that I am correcting at 1 hour. I am wondering if a high 1 hour spike, means that the bolus was too small, or if I’m just screwing up the pre-bolus timing.
When I do correct, it’s either after it’s all gone at 3 hours (based on my CGM, that’s how long it lasts), or I calculate IOB when I see that at 2 hours, I am still high and am not going down at all, and take an appropriate dose to get me back on track.
Being high at 1 hour can simply mean that your insulin profile didn’t match your meal glucose load. Even if you bolus dose was perfectly matched this can still happen and it can still happen if you wait for the “bend.”
In regards to pre-bolusing, if I don’t want much of a spike I often have to pre-bolus by an hour. Since I can’t usually orchestrate that, I tend to bolus by half an hour and eat lower-carb foods, which also works. On days that I don’t pre-bolus at all (which is a lot lately!) I tend to ride the rollercoaster.
I’ve never tried going an hour, but that’s a good point, the big spikes are from high glycemic foods and maybe giving it more time would help smooth things out. I’ll give that a try next time I’m at home again. Thanks!
Just be sure you watch very closely! It’s easy to accidentally dip low (especially if starting on the low end) if waiting an hour. Sometimes 45 minutes will be enough.
Yeah, you’ll have to experiment to see what works for you, and even then, it’s going to vary a lot—even separating food into high glycemic or low carb may not capture enough of the relevant variance and so many other factors… One other thing is that if you start to get a sense for how much lower the insulin you have on board is going to take you, and/or whether you have a fat/protein-based second peak coming, then stacking insulin becomes more of an option, but it definitely carries risk of going low. As someone on MDI, there are some meals (pizza, I’m looking at you…), I definitely need two shots to cover though, a pre-bolus, and a later shot.
Yeah, I’m on MDI (Humalog and Lantus). That’s one of several aspects of pumping that’s appealing to me, but there a bunch more that aren’t. The CGMS (and, to a much smaller extent, adding some Metformin) has made a huge difference to my control that I don’t think I’ve fully milked—went from A1cs in the 8s (yikes, I blame grad school/residency) down to 6.6 most recently, and I think I can probably get close 6.0 on current regimen without too much more effort. Whenever I do stall out, I may re-evaluate though, because extended bolusing, micro boluses, and variable basal rates have their appeal!
One hour is the standard pre-bolus time for me in the morning. And I do have to watch my post-dose CGM trace closely because sometimes it dives low at 45 minutes.
My pre-bolus is chiefly based on the particular insulin I am using, since I use either R or fast acting, depending on the meal. The pre-bolus interval is based on how long that particular insulin takes to begin working for me.
As far as targets, I don’t correct any earlier than 2 hours unless I have so badly underestimated the bolus that I am spiking horribly high. That doesn’t happen much nowadays; in fact, offhand I can’t remember the last time. A function of experience.
Having said that, anything much over 120 at two hours is unacceptable to me, and I will correct it.
This is a very important concept to understand for an insulin-using diabetic, and it a big part of why there is so much money being spent trying to develop faster insulins.
Rule of thumb, carbs are pretty much digested and in your blood after two hours, peaking at about an hour. Since current injectible fast-acting is about half this fast, it is nearly impossible to completely blunt spikes after eating, without risking hypo shortly after eating from pre-bolusing too early.
Afrezza (second pitch for it today – soon I’ll be accused by someone here of being a shill for Mannkind) is much closer to matching digestion, so this might be something to try if you’re really having a tough time with this.
Another thing to consider is how carb-rich the meal is you’re looking at. Even a T1 with no insulin resistance and otherwise problem-free (except for their broken pancreas) can not offset any size of carb load without limit because of the mismatch between digestion speed and insulin speed.
Again, Afrezza can help with this because it is so fast. Otherwise, you are limited to the size of carb load you can eat in any one meal and stay within certain BG limits, no matter how clever and experienced you are with pre-bolusing.
@David_dns, have you ever tried a serious attempt at working out the equivalent of a dual bolus on a pump – spike, followed by an extended release – using fast and R in combination?
I’m thinking one could approximate this pump function that way with MDI. Anyone?
I’m seeing odd-ball rebound spikes (even for high carb, low-protein/fat meals) 4-5 hours after a meal. So I get the big spike around 1 hour, it eventually goes down (though never to where I want it!) then starts going back up again. I don’t know if I should correct, or maybe change my bolus going forward…
I’m actually hoping one of the critics will step in and take me to task, as it would be fun telling them I not a user of the stuff (yet).