Adjusting pump settings

My wife and I are new to all this. She became type 1 at 48 years old. Picture perfect health before that. We are both medical professionals, but oncology, not diabetes.
Her A1c was lower (7) on MDI, but 7.9 on the pump. She has been on the pump for 6 months now with 1 visit to the endo, another coming up in a few weeks.
She has a fear of going hypo so she is resistant to increasing her dosages, but I have a fear of long term complications for her if we do not get her numbers under control. She exercises regularly, but rarely has a BG under 100. She wears the dexcom.
My inquiry is to discover how prevelant is it for users to test their ISF, I:C ratios and basal rates on their own and make adjustments? We would submit this data to the endo, but appointments every 3 months right now is not good enough.
All input is appreciated.

Steve, we’re also new at this. My 2 yr old baby was diagnosed T1 back in August, but we have been at the endo so many times, I’ve lost track already. Also, the Dr is in constantly asking for 3-day readings, so she can make adjustments on the settings of the pump. I e-mail the readings & get an e-mail back from her. Maybe you can try this as it’s easier for them too.-- well, you guys are Doctors too, so you know how busy Drs’ schedules are… I have made minor adjustments with I:c ratio for meals w/o her approval, but they’re minor. I wouldn’t make a basal adjustment bc that can trigger hypos pretty fast… god bless .

Thanks for the reply. We are not MD’s. My wife is a dietitan, and I am a dosimetrist ( design radiation treatments).
We bought the book “Pumping Insulin” and are trying to become well informed

Five words - “Pumping Insulin” by John Walsh

First, keeping BG’s under 100 is a noble but difficult goal, especially if trying to avoid Hypo’s. Don’t let your wife beat herself up if she’s in the 120 range, and don’t get upset about it yourself.

Second, self adjusting the pump is fine. We all do it in order to maintain control because waiting three months for the endo appointment is unacceptable. The main points to remember are 1) go slow, 2) make small adjustments and 3) adjust one thing at a time. Keep a record of the adjustments and make sure you tell the endo what the current settings are the next time you see him/her.

Get a copy of John Walsh’s excellent book entitled “Pumping Insulin” which will give you all the advice you need on setting and testing basal rates, I:C ratios and everything else you needed to know about pumping insulin.

Happy Thanksgiving,

Terry

Hello!

I was started pumping just this February. I have had a really long honeymoon phase, but it seems to be coming to an end and therefore have to readjust my basal rates, I:C and ISF every few weeks. I understand the fear of not going low, too. My blood glucose goal is 120 + - 10 for the majority of the day, and 120 ± 20 at night. If her A1C is higher than you would like, the first thing to do is to check your basal settings. If those are good (meaning you do not change more than 30 mg/dL for the duration of the test), then I would look at what you eating and try to decide if it is a matter of not bolusing enough for carbs (due to poor carb counting skills- something I still have issues with) or if it is due to inadequate insulin delivery when carbs are known (ie your I:C ratio may be too high). finally, what is her goal set at? If it is say, 150 all day, then an A1C of 7.9 would be consistent with that. However, I doubt that is the problem.

there is a really good book called Pumping Insulin by John Walsh which is an excellent starting point and will give you tips on how to adjust all of these settings. If you concerned with adjustments yourself, then consider a diabetes educator who can help you with your pump settings. Your endo should know one/employ one.

All good advice and suggestions above. Mine is to find a Pupmers Support Group in your part of the world and go to a few meetings. There is nothing like talking to people with diabetes who are actually pumping insulin. You can ask all your questions and you will hear how others handle the issues and situations that you are facing and come up against. You can try some of the very practical tips, suggestions, hints,and see what works for you.

I’ve been a practicing Type 1 for 42 years. This coming Friday is my D-Anniversary. I have been pumping for 3 years now using an Animas PING with Novolog. I started going to a Pumpers Support Group about 2 years ago and have learned so much from the people who have been pumping since the pumps were worn like backpacks. Most of the members are health professionals working in the diabetes care area and I can’t say enough about how friendly and helpful they are and have been. The best thing about the pump for me is better control and elimination of the 911 Hypos. The next step is a CGM and many in the pump support group use them so I know I will get the help that I need to fine tune and step it up another notch.
Good luck,
Florian

I’ve only been pumping since the end of July and recently had a change that has caused me to have to make several adjustments. I’m still working on it. I’ve done only one adjustment every 24 hr period and only by a small increment. John Walsh “Pumping Insulin” is the best as everyone says. If you are low, he says you need to look at TDD first, etc. This book is the best answer to learning how to do this yourself. It is very explicit and helpful. You can order it from Amazon and it is not expensive. It addresses all types of scenarios and changes and tells you what to do and how to do it. Buy the book. You won’t regret it and if you have it already, read it. One more suggestion. Your wife needs to face her fears. Assure her that you are there if she has a Hypo episode and if she’s alone during the day, I suggest a neighbor or someone to have a key to enter your house. You can have phones at many sites and if she goes low she can call the neighbor who’s been instructed on what to do and to call 911 if things get too far. That might help her fear. I’m 62 and live alone and recently had a very severe Hypo episode. I have now set up my neighbor to be there if I need her. Even though I don’t look forward to ever having a low like that again, I have a system in place and no fear. Good luck.

OK, I understand she’s new to diabetes, but the reason anyone goes on a pump is to improve control, not reduce it. Fear of hypos is way overblown IMHO. I’ve been diabetic for over 53 years now, and have long accepted that hypos will happen occasionally no matter what we do, and they aren’t likely to be emergencies as all too many people, particularly doctors, keep saying.
She really needs to learn how to make adjustments, NOT to raise her levels in fear, but to lower them gradually for her long term health. Relying on her doctor to prescribe doseage really only makes things confusing. She has to learn for herself. You both need to understand that diabetes is NOT treated by a doctor’s close supervision, They are advisors, SHE is her own primary care provider.
I’ve also been on pumps for the last (not quite) 16 years, and just received my forth model, an Animas Ping, today. My last A1c was 6.8, which I feel is too high, and 'll be doing all I can to get it lower. The reason I got my first pump in 1993 was that my foot neuropathy was slowly growing worse, and then the DCCT was printed, saying that better control, particularly with an insulin pump, could not only stop but reverse diabetic complications. It worked, my neuropathy was reduced greatly.

So getting back to fear of hypos, the ones that people are scared by are caused by 2 situations, 1 of which is controllable. HypoGlycemia Unawareness (or HGU) forces some people to aim at higher levels in self defense because they get no warnign signs of oncoming hypos. This is fairly rare, and unless your wife suffers form it she really shouldn’t fear hypos as long as she can sense them. HGU appears to happen in certain situations, either long term poor control or a reaction to artificial insulins. If s it may be possible to use a different brand on fast acting insulin to avoid that. Totally academic if she gets reasonable warning signs of hypos, such as seeing a halo effect around people or objects, confusion, loss of strength, disorientation or sudden changes in mood or demeanor. These can all be kept in mind and if any of them appear she should take a test, if it’s easy to do wherever she is at the moment, or get some fast acting carbs in to be sure. A few glucose tabs, LifeSavers or other small candies should get her back in good order within a few minutes, at most.

The other thing that may cause unforseen hypos is having such poor control that more than 1 hypo happens in a day. Our livers store glycogen, a storage form of glucose, which is released in plenty when we go too low. This is reasonable once a day or so, but trying to correct for a high after overcorrecting a hypo with too much insulin AND then the liver pulls glucose back in to replace what corrected the earlier hypo. THAT can lead to another sudden hypo at an unexpected time, but she shouldn’t have that problem with a pump as long as she learns what to do.

My doctor instilled hypo-phobia in me.He advised being somewhat high before bed in case I had overnight lows. This didn’t help me at all. Hypos are awful & Ihate the feeling when they do happen, but high BG is a major concern.

Most people do fine-tune & adjust their rates frequently. It’s the only way to effectively deal with the ever-changing nature of diabetes. Adjustments I make are in small units & I keep records. I was told to keep a new dose the same for 3-4 days to get a better idea if it’s more accurate.

I have been a diabetic for 18 years. I have been on the pump for the past 8 years…
what I can tell you is I continue to learn something all the time about my diabetes… as pumper you need to be proactive about your care and the pump is designed for you to do just that and make adjustments… there are safety settings you can set so you can control the fear factor. And help her find ways to always be prepared to handle one should it occur,… which can be as simple as always having a granola bar in her purse. etc. Like anything… knowledge is gained through experience. I usually adjust my basal rates once or twice a year and have different settings dependent upon that time of the month, stress, etc.

Great to see she has the support and care she needs to deal with diabetes
Good Luck!
M

I had this same fear as well whenever I use my Bolus Wizard. It’s something that takes time to adjust to, but you REALLY do need to trust it. If its setup correctly it can really really help your/her A1c’s.

I am a retired cardiologist, Type I for 32 years and on the pump for the past 14yrs. I fortunately have no diabetes related issues with HBA1c in the 6.2-6.5 range… My secret to success, I believe, is the fact that for years I have monitored my blood very often, usually @12 times per day. If higher than I like, I bolus and if heading down on other occasions, I take tablets. Doing it this frequently allows me to safely make pump adjustments if a specific pattern is seen such as the need to increase the basal rate. It also keeps me from having frequent lows. My suggestion would be that your wife consider such a strategy. Ken

Well, getting used to the pump and its nuances takes a little time. The beauty of the pump is you can adjust basals for an hour or two, depending on what goes on in your day. Temp basals are helpful as well. DOing delays also let you know if your basals are in the right range. Do you see a diabetic nurse educator ? I find ours so helpful. Initially, I called her constantly, now, after 4 years, we are able to do alot of the adjusting ourselves. As a matter of fact, when we met with her prior to seeing the endo, I asked about further education for us, and she laughed saying, remember how often you used to call me ? well, you know a lot more than you think. If you don’t see a diabetic nurse educator, try to connect with one. I find them invaluable with figuring out basals and carb ratios and just general support etc… Only our first endo who did all of our education when my son was first diagnosed was patient and so informative - he unfortunately retired to become an organic farmer ! ! ! !Good luck. Nancy

Hi there… It’s all a overwhelming at first. I’ve been diabetic for most of my life - 25 years (I’m thirty). I wouldn’t worry too much about the A1C result for now. While it is an indicator (and an important one in the long term)… I would worry more about the day to day numbers since the A1C is more like a four month average… The thing about an average is that you could have a lot of lows and a lot of highs and average out somewhere in the middle. While your wife’s A1C is higher on the pump, that doesn’t mean that her control is necessarily worse. It may be that you are reducing those highs and lows… but that’s just a maybe. It could also be that her basal rate is not right. She should really contact her endo and look at her numbers. What I would suggest that you do until then is to track the numbers - record pre-meal numbers and post-meal numbers. Do a few tests at night as well to see if she’s hypo in the night time. Be a good record tracker and give your endo as much info as you can so that he can make an informed decision about what to do about her basal rates etc…

Best of luck to you both!

Read “Think Like a Pancreas: A Practical Guide to Managing Diabetes with Insulin” It should be required reading for all T1D’s. A major diabetes medical device and BG testing supplies requires their field sales personnel to read the book before selling.

Yes, true enough. What most people don’t realize is that for a few people the A1c always reads lower than the actual average becua their blood chemistry is different. A good friend in a diabetes list I used to be in has her red blood cells replaced at a faster rate than the average replacement speed the A1c test assumes to be correct. As a result the damaged red blood cells don’t stay in her bloodstream nearly as long as normal, and since the test measures how much damage glucose has caused to the cells her number reports lower than it should.
Fine as long as the diabetic and doctor recognize this happens and adjusts their response to the A1c results accordingly.