Adjusting pump settings

Type 1 and LADA
1

I'm curious when you will go in and change pump settings like I:C ratio and CR and basal rates (aside from temporary basal rates). Do you wait a few hours, a day, a few days? I feel like a big part of my problem with my control is that it's sooo variable from day to day and I think maybe I am either changing settings too often or not chancing them enough, I don't know. But, for example, I will have a day like yesterday:

5:55am - 6.7 [121] - Breakfast
9:04am - 3.8 [68] - Glucose tablets
9:51am - 5.1 [92]
11:41am - 4.8 [86] - Snack (no bolus) & exercise
12:39pm - 3.0 [54] - Lunch
2:22pm - 8.9 [160]
3:36pm - 8.1 [146] - Correction
5:20pm - 2.9 [52] - Glucose tablets & dinner
7:30pm - 3.6 [65] - Tons of glucose tablets - felt MUCH lower than the number suggests, mouth went completely numb!
9:30pm - 6.0 [108]

Followed immediately by a day like today:

5:54am - 9.4 [169] - Correction
7:17am - 6.8 [122]
8:34am - 4.8 [86] - Breakfast
12:13pm - 12.5 [225] - Correction
2:33pm - 13.4 [241] - Correction (via shot) & +20% temp basal
4:03pm - 11.9 [214] - Site change & correction
5:42pm - 9.9 [178] - Correction
6:25pm - 9.3 [167] - Dinner & correction
7:52pm - 10.5 [189] - Exercise
9:01pm - 6.9 [124]
10:01pm - 6.4 [115]

Updated to add today:

6:23am - 3.3 [59] - Glucose tablets
8:09am - 5.4 [97] - Breakfast
10:12am - 5.5 [99] - Snack
12:10pm - 4.2 [76] - Lunch

This is with literally the SAME settings as yesterday, and same breakfast (measured exactly). The only difference is that I was in a conference call all morning (and secretary, so taking minutes) and so couldn't exercise at 11:30 like I have been doing (not intense exercise, just 30 minutes walking).

But this is what drives me crazy - one day I'm going low constantly and the very next day I'm high constantly. Do I put my I:C and correction factor up? Or did I go low sometime in the morning and this is a rebound? Or do I just use a temporary rate and shots and correct all day and see what tomorrow is like before deciding whether to change settings? Knowing my body, tomorrow will be completely different!

Today I only ate chicken for lunch - I'm trying to not eat many carbs when high like people suggest - but my problem with that is my protein sources are extremely limited and with the way things go sometimes means I would end up not eating all day! This type of thing happens to me sooooo regularly (with either direction, high or low), probably every few days at least, or else I have days that are a mixture of bouncing from high to low and back again, and it drives me crazy!

I've been Type 1 for almost 23 years and am on a pump and try to keep meals to 25-35 carbs (or less if it works out - I can't eat nuts/peanuts, soy, eggs, or cheese so meat is my only real source of protein). And after all that time I still feel like I don't have a clue sometimes!

2

I have a set of basic programs based on my activity levels. Couch potato days, moderately active days and hyperactive days. My pump lets me set 16 time segments with different basal rates, I:C and C.F.s for each period. Have done repeated basal testing of the full 24 hour time frame every few months -using a dex G4 makes this a lot easier. I down load my CGM, meter and pump every week and review the data for patterns and will adjust as needed.
I find if I have my target set for 85 I have much better control- as in reaching the 100 range my team wants to see. I get it with much fewer swings. When I used 100 as my target I never got there and was much wilder in my ups and downs.
I do lowish carbs, try to pre bolus for meals by 15-30 minutes and dose for carbs, protein and fat with extended bolus and temp rates. I also find that walking 5-10 floors post meals will stop a spike with out needing to correct as much. Don't need the 20-30 minute walk I would otherwise need in its place.
Some times my datasets indicate it is the basal that is off for the time of day and activity level. Mine changes as the day progresses, higher in the evening and over night with a DP that starts around 4 am. It drops dramatically when I'm at work and on my feet. My I:C and C.F. also change through the day. I've had to test all of these out not only for time frame but for activity levels. It has been complicated and time consuming to get it done, but now that I've got it down, I am much more stable.
Finding the flatliners group and the taggers United group here on Tudiabetes has been a big help. Also I use Pumping Insulin by John Walsh as my go to pump bible.

3

I had a day of lows yesterday, myself, Jen. I attribute it to the seasonal change: It is getting hotter, I am outside enjoying the weather, my ankle has healed so I am walking more,( even inadvertently walking more, better, and faster :+). I just considered it a fluke as well as due to increased activity. And as the other posters say, I look at chunks of data before I change anything.. I have had lows every morning for a week, so I know the overnight is too high...and the CGM helps tremendously..The threshold suspend has not kept the lows completely away, but it has made a morning low of 66 or 65 more likely than one in the 30's.

God bless,
Brunetta

4

Hello Jen, do you think it would be helpful for you to share two or more months of your animas data with us?

5

I think that would be helpful, except at the moment I can't get my pump software work with Windows 8 (grrr!). It seems to be both the drivers as well as the software that don't work.

Last night I went for a walk and that got me down to 6.4 [115], and this morning I woke up at 3.3 [59]. I haven't changed any pump settings from yesterday or the day before except using a temporary basal rate for a few hours. I eat literally the same foods each day (I weigh all of them and use carb factors), and my activity level is similar except that my 30 minute walk is at different times (11:30 the first day, 8:00 last night). But that's a leisurely walk, not intense exercise—yesterday's "exercise" consisted of walking through a park for a few minutes and then going grocery shopping!

I have read a lot of the diabetes books like Pumping Insulin and Think Like a Pancreas and so on. I know about things like basal testing and testing I:C ratios and so on. I'll admit I haven't done basal testing and the like in a while, but that's mostly because the few times I have tried I can test three different days (as suggested by Pumping Insulin) and get three different results, which leaves me utterly confused as to how to adjust settings.

All of the advice I read, from books and also from here, is based on charting data and spotting patterns, and I think that's my big problem - there are no patterns that I (or endos or CDEs) can spot. Each day is completely different. Every time I go see my endo with a month of data I hope he can offer some suggestion (especially since he has Type 1 himself so "gets it"), and each time he can't offer me anything except keep doing what I'm doing, even though he really wants me to get my A1c lower. I also feel like every little tiny thing affects my blood sugar to a huge degree - but not always. A few years ago I tried to chart 30 minutes on an elliptical to figure out how much it dropped my blood sugar, and again, gave up because there was no pattern at all.

If I could look at figure out a reason - I'm more active lately, I'm more stressed this day, I'm eating unfamiliar foods - then I wouldn't have an issue. But none of those things are the case ... These are literally identical days (as identical as days can be) in terms of what I ate and activity level. Today will be, too, so I can post my readings here. It would also be relatively easy if I could look at my readings and see that I'm waking up low every morning, or going low every day after breakfast, or X activity always make me low, but I haven't been able to do that, either.

I'll see if I can figure out my pump software issues and get some pump data on here.

6

In regards to the infusion set, I use metal infusion sets and only wear them for two days. I used to have MAJOR issues with infusion sets getting extremely irritated and not working and sending my BG super high. That has been much better since switching to metal sets (I'm pretty sure I was allergic to something in the cannula). The metal sets still get itchy because I'm allergic to nickel, but they don't get horribly irritated. The site I removed yesterday had been in for about 45 hours when I changed it.

I'm going to see if I can get a few months worth of data to post here - because I (and my endo) have been utterly unable to spot any type of pattern to my readings. Maybe you guys will spot something we have missed!

7

Jen,
Basal testing is annoying to do right but well forth the effort. Do you CGM? It makes it a lot easier. If you do not can your endo hook you up for a week or two to do some basal testing with a CGM? I know it is billable as my endo group offers it to those who do not have CGMs to evaluate/adjust/reset basal rates, I:C,C.F. and DIA.
If you do have a CGM can you up load the data seperate from the pump data. I look at my Dex data on a regular basis. I can look at the pattern analysis and break it down in sections that reproduce/correlate to my pump program time settings.

The first thing I started with is what was my personal duration of insulin activity. This will be different for everyone Can greatly mess with all the other numbers if you have it set too long or too short. If it's too short you will stack and crash, if it's too long you will hang high forever and not be able to correct which is way frustrating. Pumping Insulin has a how to I like for this.
Once you get that piece on board,then start with your over night basal. It means no food or corrections after about 5-6 pm to do it right but is worth it. May take a time or two to see your patterns at various time frames in the overnight.
And yes it can and will change over time. As I have gotten a tighter control range overnight I'm starting to see a DP at 3-4 am that was not there when I first started CGM/pumping. And as a result have needed to up my basal at 2am to stay flat before breakfast.
I will eat dinner around 6pm and rarely go to bed with either food or bolus on board. With Dexter I can seem my overnight patterns on a regular basis. On the days I've been out late and partying I use my patterns to evaluate if my overnight C.F. is correct.
When you have the overnight down then move to the am segment, it means a longer fast than the overnight since you need to tack it on to the end of a good night. I found my basal rate needed to drop by more than half at 9am due to my pattern of increased activity at work, otherwise I would crash by about 11am.
As I moved through the rest of my time segments, I need to start to increase my basal around 4pm to cover my decrease in activity as the day winds down. It ramps up a bit higher at bed time and then even higher at 2am for the DP.
The carb factor and correction factor are seperate. I have different factors for different times of day. I find that there is an inverse relation to my basal rates. If I need a higher basal rate, I'm less insulin sensitive and I need a lower I:C and C.F.. but you have to test these independently.

It can be overwhelming, but if you start with the first piece and work from there, eventually it will all come together.
And one final thing to think about- if you do low carb, high protein, high fat it may be a lot more difficult to get the initial settings dialed in as the fat and protein can alter the carb curve. When testing it might be better to go higher on the carb load so you get a good look at just the carb piece. When that is dialed, then look at TAGing - total available glucose - as a way to adjust your delivery to account for the actions of protein and fat in your meals.

It can be done, it may take time and testing and trial and error but it can be done.

8

In another discussion I have read that Animas offers a new cable and drivers for windows 8 and 8.1. Maybe it makes sense to contact Animas about this.

9

I wish I had something to offer to this discussion, Jen; I don't. I too think of patterns and can imagine the frustration of never finding one. Uploading the data for people to examine sounds like a good idea.

What I do want to say is what a good job you do on a daily basis! I've had a few spells of crazy numbers and know the stress of dealing with them for even a couple days let alone ongoing. You are one of the hardest workers I know and always stay positive and goal oriented. Keep up the good work!

10

I have done a CGM for a week in 2009 through my doctor, but here it is not covered - I paid $80 for the cost of the sensor. I am interested in getting a CGM and in fact my endo thinks that it would make a huge difference, but I'll probably have to purchase one out of pocket so am waiting until I can save up to afford one.

I thought that you had to figure out basal before you could figure out DIA? Otherwise how will you know if your basal rate is playing a part?

Right now I'm doing moderate carb and relatively low protein. I'm allergic to dairy (cheese), and I have another allergy/immune condition that is triggered by eggs, nuts/peanuts, and soy, among many other foods, so I'm not able to eat any of those at the moment. As a result, most of my meals are 25-35 carbs (occasionally less). In terms of overnight basal, I rarely eat after dinner (around 6 PM) so essentially every night is a basal test. But this is what's so frustrating for me - even with that, I still get different results each night. How many times should you basal test if you do two or three of them and they are all different - not over time, but during the same week?

This is CGM data from when I used it in 2009 - so not useful now, but it illustrates what I'm talking about. Unfortunately I have no colours, but some nights I stayed level, some nights I went high and low, some nights I dropped ... This was all with no food or insulin before bed, same foods and activity levels during the day, and the same pump settings. The one exception to the IOB is that I did correct if I was over 10 (180) so there were two readings there where I did correct; one night the correction brought me down, the other night it did nothing. At the time this was done my A1c was 6.7% which is about the best control I have ever had. The lines are at 3.9 (70) and 10.0 (180). The numbers up the side (5.6, 11.1, 16.7) are equivalent to 100, 200, and 300.


This is the stuff the books don't talk about, how to make order out of chaos. If I had patterns, it would make it relatively easy ...

11

Jen,

Get the DIA setup first. When you have a midrange high with no IOB make a correction and test to see how long it takes for the correction to stop and go flat line. It does not matter if you get all the way down to target what you want to see is when does it stop working. This will give you your DIA. Once that is set then you can work on basal, I:C and C.F.

You do have patterns in this time frame. And they are fairly consistent. First things first, the sharp V shape with a drop and return is when you rolled over and slept on your sensor. It comes right back up once your move off of it and blood flow returns to normal.
What I see is that for most of your overnights what you start with is where you end with in the morning. I'm looking at the sections between 12 and 6am. So from that I think your basal rate from about 10 pm on till 6 is ok. There might be a slight up tick aound 4am but not a big one.

The rise till midnight or so is related to a combo of your evening basal and your dinner time I:C. and C.F. if you ate and dosed around 5-6 pm you would still have food and insulin on board till about midnight or so. If the meal had fat and protein the rise can be longer. The one drop till 2 am looks more like a correction to me?
Do you have other basal time segments you can upload? If they all show the same flat background pattern then you will need to work on I:C ratio and then C.F.s.
Does your pump let you have seperate IC and C.F.s for each time segment? I'm currently getting ready to head out the door to run my Sunday errands but will check back in a few hours. Will see if I can upload some of my Dex runs for you to compare to.

12

Thank you for the information about the V! The CDE could not explain it and I always found it a bit disturbing.

I was using Humalog at the time - does the DIA for that really last 6-7 hours? I thought it would be more like 3-5 hours. My pump is currently set to 4 hours. My pump does allow for different ratios at different times during the day. Right now my breakfast correction ration and I:C ratio is lower than during the rest of the day.

That drop was from a correction, yes. Unfortunately I don't have any other times during that week where I fasted (I wanted to see how food affected my BG). I'm looking back at the data now, though, and I took super detailed logs and it was really useful at the time (even more useful if the CDE had been like you guys and actually able to spot some helpful patterns!!).

If I end up having to correct today I'll try testing every 30 or 60 minutes to see when a drop stops (though I hate using so many test strips when I only get 10 a day ... *sigh*). I am curious, has anyone used Gary Scheiner's company that lets you try a CGM for two weeks and then analyzes the data? I think it's $250 and I am seriously thinking it might be worth the money for me, even though $250 is a lot for my budge to absorb right now.

I'll see if I can figure out how to upload my pump data today - I'll dig out my old Windows 7 laptop and, if it works, it should work with the software and pump. I may only upload the past few weeks, though, because a month or two ago I was adjusting to major food restrictions and not paying any attention to diabetes (some meals I ate were 100g of carbs, yikes!).

13

I usually let it ride about 3 - 5 days. Depends on who made the suggestion (my own idea vs the doctor / edno), I tend to put more weight in my ideas. I think I am what you might call, ahh stubborn. LOL

14

Jen,
If you can load the full data set for you CGM trial go for it and I'll take a look. as well as what you can get off your pump software. If it will graph your BG data then thst would be a big help. Does it integrate you meter data? The Tslim program will integrate the pump info with meter data but does not incorporate the Dexcom inf yet.
I can't figure out how to insert a picture of my dexcom lines into the text but have attached a pdf on a two week period. You can see that I have my ups and downs related to meals. But even with that you can see that the basic background is fairly flat.

If your data show a similar pattern through the day then you need to work on IC and CF not your basal.

Another way the dex info can be looked at is with the pie charts showing the distribution. You can see in the second pdf that before meals works ok for me and that I need to pay attention to after meals. Post dinner and into the night is my biggest issue, After lunch a little better and post breakfast not so bad. This is how I work on tweaking my ICs and CFs.

So you can see it is a step wise process. As for my DIA for me personally it takes about 3:45 for a dose to stop acting. Changing that to match how my body works helped a lot in getting a good CF.
How long food hangs around will also be individual - so depending on how much carb, fat and protein is in a meal will very much change when you trend up. Timing your insulin activity to you food can be an art form. It may take going high carb, low fat, lowish protein for IC test days.

878-2weekslinesonly.pdf (120 KB) 879-distribution30day.pdf (65 KB)
15

I'm not sure what's causing it. I've tried new drivers and that doesn't work. When I try the EZ Manager software it doesn't start - I get some error message about Java and assistive technology that I've never seen before, so maybe my AT is interfering with it somehow. Although I used it on my Windows 7 computer with no issues ... Very annoying.

16

Well, I give up - I got out my old XP computer and managed to download my pump data to EZ Manager with that, but EZ Manager is all but useless when it comes to charts. I tried downloading my meter with the OneTouch software (which is what I used to do in the past) and that didn't work. I'll try calling Animas sometime this week to see if they can figure out how to get Diasend to work - I don't think it's the greatest, either, but at least it's better than EZ Manager.

The only useful bit of information I could produce is this pie chart of the last month. EZ Manager doesn't have any type of modal day graph, unfortunately.

The table at the bottom gives the target ranges I have set as well as my pump settings, and an indication of its capabilities in regards to using multiple ratios and factors for different blocks. Keep in mind that this is without a CGM, so some of the times (like night and early AM) may not necessary be reflective of my actual blood sugar—just what my blood sugar happens to be on nights that I wake up and test. Also, since I wake up at 4:00 - 5:00 AM many mornings, a lot of the early AM readings are actually prior to breakfast.

17

Jen - I use a Ping also and regularly upload to Diasend. What's keeping you from from doing that? I like their charts. I find them helpful. I also upload my Dex data and Accu-Chek Aviva meter data. Diasend is the only place where all my data is combined. Let me know if there's anything I can do to help.

18

Hi Terry: The Diasend Uploader simply won't detect my pump. I've tried all different USB ports for the IR adapter, updated drivers for the IR adapter, re-installing the software ... The few times I've had it detect the pump it says it's an invalid serial number. I'm using Windows 8.1, so I don't know if that's the issue or what.

19

Jen.
I have the 4 am 12 pound plus cat kneading full bladder/pump site/ cgm site/one foot full weight on the girls or full bladder/why aren't you getting up to feed me/why won't you let me out etc etc, so am very familiar with that time frame. ;-) Have three cats so I get the same response from each one! Joy! Joy! Joy!

On a D note, can you see an average BG and a standard deviation for the data you can retrieve?
If your average BG is higher than you want but your SD is lower, (under 20-30) it means that while your are above your prefered range you do not have many extreme swings, and it is likely it is your IC and CF that need to be tweaked. If your SD is way higher than 30 and your average is higher than you want then you need to start with you basal first and then work on your IC and CF once you know your DIA.
I know how much attention to detail this can take to get set up correctly, but once you work out all the pieces it makes fine tuning/tweaking the day to day changes so much easier.

If any of this makes sense to you then shoot me whatever data you can upload, cut/paste etc and I will let you know what jumps out to me from your data.

20

Yes - my average BG for the past month (corresponding to that pie chart above) is 8.2 (148) and standard deviation is 3.7 (67).

I am hoping I can get Diasend working this week. I don't know why it's not working for me - it looks like for some reason the old driver just keeps coming back or is not being uninstalled, even though I disabled Windows from updating drivers. So frustrating. Why can't pumps just have Bluetooth?!?! All these cables and drivers and IR adapters are soooo old!