Addicted to insulin...help me quit!

Type 1 and LADA
1

Well, not quite, title was meant to be provocative. :slight_smile:

But I do feel like I’m sort of reluctant to ramp down my son’s insulin dosing even though I know I need to.

Here’s the story. My son pretty much always heads towards low somewhere between 9:30 am and 10:30 am. Like clockwork. Every day. He never goes low because it’s so predictable and on cue that the teacher basically just hands out the gummy without thinking about it, but that means he’s getting a 4 gram shot of glucose as his “snack” every morning.

Then, he slowly rises just barely over his low threshold, eats lunch, which I don’t bolus him for at all, and then he just drifts from about 80 to about 110 over the course of his nap. If he’s running a little higher I set a temporarily low target, which ups the automatic basal rates issued by openAPS.

The issue is that I KNOW this morning low means either his basal or his bolus for the breakfast is too high…but it’s also really helping me get work done and his blood sugar numbers are pretty great for the rest of the day. The fact that I don’t even have to go to school to bolus for his lunch is HUGE for my work productivity. Plus, by not bolusing him for lunch there’s no chance of him going low during nap time, when their staffing is the most erratic.

I’m also scared to try dropping the insulin dosing because when I have lowered the basal by 0.025 units per hour in the past, or weakened his carb ratio by 1 or 2 points, he winds up going hugely high in the mid-morning, which messes up the rest of the day, leading to lows later, plus I have to go to daycare five times in a day, rather than once or no times.

But clearly this is not the “correct” dose for him.

I guess I’m asking for advice on How would you go about deducing what causes the low, and if I fix this problem, is there a way to still get the basal to mostly cover lunch so I don’t have to go in and administer insulin?

For instance, should I try shifting when he eats before I make changes? Should I try ramping down the basal more gradually before 10:30 am ? (I sort of don’t want to do that because his basal program looks quite erratic as it is and it’s hard to debug and make changes when there are too many basal segments.)

He usually eats between 6am and 7:30am, but the amount he eats varies from about 28 grams up to 45 grams of carbs. carbF is 1:20 for the morning (1:28 later in the day).

His program looks like this:
Basal:
6am .325 u/hr
7:30 am .525 u/hr
10:30 am .225 u/hr
12:30 am .425 u/hr
2:30 pm . 25 u/hr

Clearly, the zig-zagging in the basal rates is a compensation for some other problem. But it mostly works well…so I’m loathe to switch it up.

What would you try first?

2

Personally, I would start by trying to adjust what he eats, slightly - like add a little protein or fat to slow digestion a bit. I’ve never had experience with that level of sensitivity.

3

Tresiba.

4

I’d leave things as they are. You need to be productive at work and not burn out. If one of his basal rates is a little high, then so be it, because he is doing just fine. Plus, he is growing so that basal rate won’t be a little high for all that much longer…

5

Yeah unfortunately it’s not approved for 2-year-olds and also our endo
won’t prescribe anyways. Plus, with openAPS it sort of takes away one of
our key control tools – the ability to dial back basal or ramp it up as a
proxy for bad meal boluses.

6

Not if you use Tresiba to replace only part of the basal supplied by the pump.

7

I would probably add new basal setting at 8:30 or 9, maybe at .4 or .450.

Or add fats/protein, such as a spoonful of peanut butter or cheese stix at the end of his breakfast.

8

@MM1, I’ll have to try the lower basal rate. It’s just a bummer because the more sections you have, the harder it is to keep track of and change, but if it works, it works!

9

I agree with you about too many basal segments getting tricky. I have a similar problem going low almost every weekday afternoon (yet weekends are fine), so I understand how difficult it can be to fix without messing other parts of the day up!

I’m inclined to agree with @rgcainmd: if he’s not actually going low and the current course of action is working for you, I’d leave it be. I’ve sort of done this for afternoons. I just know that I’ll have to eat 4-6 glucose tablets, which I don’t like, but I’ve been trying for months to fix this with no success (haven’t yet had a day where I haven’t still gone low or ended up high).

If I were to do something, though, I wonder what effect moving the 10:30 segemnt up to 10:00 or 9:30 would have?

10

@Tia_G, need more information: What constitutes “hugely high” as you describe, and for how long?

Based only on the (very scant) information in this discussion, I’d say you are setting your targets too low for a child that age.

11

Hugely high is mid-300s for several hours. Our son according to clarity
spent less than 1.8 percent time below 70 and just 0.1 percent below 55
according to his two week average so I feel like his target is fine.

12

I’d say that’s fantastic, extremely tight control for a Type 1 and especially for such a young child! It sounds like you’re doing great. (My endocrinologist wants <5% of readings low, and I find that very challenging and fail to meet it most of the time.)

13

That sounds very good – I wouldn’t change anything w.r.t. trying to deal with lows.

Unless your little one is gaining weight, I really don’t see what the issue is with a few g of carbs mid-morning. To me, this is no different than taking an insulin correction.

It’s not something to be eliminated – something that “shouldn’t be”. Based on what you posted in the first post, sounds to me like you have a treatment plan dialed in that’s working very well. Again, unless the gummies are causing a problem (weight gain), to me it’s just part of the treatment plan.

Carbs are not something to be absolutely avoided (unless your trying to live a ketogenic diet). Sugar is every bit a part of the treatment regimen for diabetes as is insulin.

My 2cents.

14

Yeah, I guess if this was just my plan to implement I would never change anything. The only reason I worry a little bit is that it makes more work for his preschool teacher, who is also looking after 10-12 other kids and I don’t want them to say it’s too hard to take care of him. I want to make it as easy for them as possible. Early in his care plan (when he was still on shots), they told us that they couldn’t care for him without some modification because the lows were too time-consuming to treat. But we had a much more laborious plan (wash hands, finger stick, give gummy, isolate him, wait 15 minutes, wash hands again, finger stic,k if not rising another gummy) and he was going low repeatedly during the day because of the unpredictable nature of Levemir. So I guess I’m sort of paranoid that if we make it routine they would say his care is too involved. But it really just takes a few seconds to hand him a gummy…

15

It looks to me that you are using basal to help cover his breakfast and lunch, but as others said, if it works, it works. The danger of the morning lows is “what if they forget to give him the gummy?”

I’ve had Type 1 for 40 years and I have still not figured out the morning reliably. I ramp up the basal and even give a “get-out-of-bed bolus” to stop the morning rise because if it goes high, it is incredibly hard to get it to come back down. (Some of the staff at the Vienna headquarters of mySugr calls that rise “Foot on the Floor” but it sounds much cooler in German.) But then I often get a low in the morning. But the low is easily treated. So I am experiencing exactly what it looks like your son is experiencing. If you figure it out, let me know!

16

When I was on the pump, I had a doctor advise against too many changes in the basal rate (meaning a different basal every couple of hours). When I asked him why, he couldn’t really provide an adequate explanation.
As others have said, your child’s blood sugars appear to be in excellent range. Maybe his teachers/caregivers would be open to giving him a gummy if it was a more routine situation. I imagine their concern was over more unpredictable lows/highs which may occur if you switch his basal. It’s easy to see how these could make it difficult for them to help him and oversee the other children at the same time.
I personally feel that doctors can be so concerned with getting things “right” that they fail to recognize what works. It sounds to me like you found a system that works, and your child will thank you when they’re older for reducing their chances of complications.

17

Tia, kinda feels like I hit a nerve or something. I’m sorry, whatever it is.

Just thought your plan looked like it was working pretty well, so didn’t think there was any reason to mess with it. Of course, you’re right, I didn’t consider the workload of the teacher, and obviously have much less knowledge to go on there so I guess I really don’t have anything to add other than good will :slight_smile:

18

Thanks, for the goodwill, much appreciated :slight_smile:
We have some baggage for sure and I’m definitely a little paranoid about making it as easy as possible for the teachers. I suspect once my kid is 3 and the public schools are legally required to provide care, I’ll breathe a sigh of relief because I’ll know that he will have somewhere to land if things aren’t working at his current daycare…even though of course rationally I know public schools can be as much or even more of a PITA. But at least on paper we have legal protections against discrimination that are more robust then…

19

To me any “planned” or “expected” low should be avoided at all costs. Not all days are exactly and reproducibly the same - throw some physical activity, seasonal changes or hormonal imbalance into the mix and the low could become serious.

First I would lower the bolus dosage. If it is a combination of bolus and basal then I would try to lower the basal setting too - in a window one hour before the low. If necessary I would increase the basal afterwards - in the one to two hours after the low.

So in my opinion with these fine adjustments of current pumps at hand you can reach the same sweet spot without the low. Yes, it might temporarily affect your current routine. Yes, it will need some days to figure it out. But finally you can find a better solution.

1 Like
20

Thanks @Holger. I’m following your steps. I stepped down the basal an hour earlier but it seems like the low is caused by aggressive bolusing for breakfast. So we’ll see how much we need to weaken the carb ratio to see effects. To prevent those spikes equally well, it may be that we need to prebolus some portion before breakfast to prevent the spike, then use a lower overall carbF to finish up. We’ve just been bolusing all of it upfront.