I’ve been working on getting my a1c down to <6.5% and have been making some great progress! Ill keep chipping away at it until I’m stable with a high % of time in range.
I see a lot of people post about correcting higher numbers ‘aggressively’. What do people mean by that?
I’m on a Medtronic pump and often override the ‘bolus wizard’ to give myself a correction even when it suggests I wait for IOB for be used up. I’ll hover at roughly 9-11 (160-200ish) at times for approx 2-3 hours. I think I should be definitely correcting sooner for this?? I do get concerned about going low though (I can get crazy delayed highs from bad lows). I don’t overtreat lows anymore. I’m also on a CGM so can watch so that’s definitely a tool I can use more effectively.
Aggressive correction for us means when past the 180~200 range, that the “wizard” becomes the “dolt”. lol. But really the pump does not take into account (for us) what appears to be a temporary/dynamic ?? insulin resistance that seems to kick in at higher numbers.
So whereas 1 unit of insulin might correct 40 BG points below 180, when running over 200, we might only get 25 BG points or so out of 1 unit. This is what I would take to mean aggressive correction as in knock the BG down using the real knowledge we have and the Wizard is a good starting point but not the final answer.
With the CGM, we do not have the same concern about going low as opposed to strictly fingerstick/meter. We could actually target 80 or even lower when calculating our correction bolus. Based on CGM trend and Insulin on Board (IOB) we might give 12 fast acting carbs (Apple Juice works well for us) when going down and around 110 or 100 with the intention of trying to get the “drop” to level out in the 80~90 range.
I can even temporarily set the CGM to alarm as soon as it hits 100 such that we don’t have to keep our eyes glued to the CGM but on the alert at 100 can decide based on the CGM data if we are good or if we need some carbs to level out and avoid an impending low.
Also - we would never wait for the IOB to be used up. Our Duration of Insulin Action (DIA - in Tandem terms) is set to 4-1/2 hrs. I am not likely to give a correction bolus any sooner than 2 hrs after the previous correction but at the same time, I am not going to wait for the entire 4-1/2 hrs to play out. However I would take the remaining IOB into account when computing the next correction bolus. We might let the Wizard use the entire IOB or we might decide to be more aggressive and discount some of the IOB - mostly based on what we see from the effect of the last bolus per the CGM graph.
I’m not sure if you have heard of something called a super Bolus. It’s worth searching the forums on here for. You can Bolus greater than the correction amount by using future basal insulin. I am too lazy to actually calculate mine when I have a high glucose but if I am within a few hours of eating I don’t worry about it too much because I know I can correct any impending low with a meal.
I don’t know if I’ll call what I do “aggressive,” but during most of my pregnancy (I’m about to deliver any day/hour now ) I actually corrected pretty much anything over 140 as soon as I caught it. I would advise that you read the general pattern of what to expect during the different weeks (changes happen on that time scale and not just by trimester) in books such as Cheryl Akon’s Balancing Pregnancy with Pre-existing Diabetes and Ginger Vieira and Jennifer Smith’s Pregnancy and Type 1 Diabetes: A Month by Month Guide to Blood Glucose Management. They are both based on the experiences of women who have other health concerns in addition to the T1D, but overall give you good general ideas what to expect and ways to deal with it.
Again from my experience, once you pass the period of lows (earlier in pregnancy), you will need to adjust your basal and I:C ratios ALL THE TIME to prevent highs. I was also cautious with this since I am pretty insulin-sensitive, but realized quickly that I am very unlikely to go low (and certainly not dramatically so), but very likely to go high. You want to avoid having to correct at all, because it is the time spent high that is much more problematic for your developing baby. All in all, my highest TDD eventually rose to 3.5 TIMES what I was used to! (All of this is assuming you are NOT on a low-carb diet; I don’t know how things would work then.)
(The comments others already left re: the non-linear nature of corrections above a certain level also apply to me – maybe over about 160 or so (or if I am going to eat more than 60 grams of carb in one sitting too). This has been the case before and during pregnancy. Then I add an extra portion to the bolus, above and beyond what the wizard would suggest.)
Important disclaimer: I am on MDI, not a pump, so the strategy may possibly be different than it would be if I were pumping. I have no direct experience with a pump, so that’s just a “maybe”. That being said . . .
For me, “aggressive” is less about the dose and more about the timing. If I’m over 120, I correct, almost without exception. Under 120, I correct sometimes, depending on what I think the likely trend is, e.g., did I just eat something that wasn’t already accounted for? If so, I have a pretty good idea what the trend is going to be . . . . In either case the dose is based on my known ISF and I:C ratio and I seldom miss by enough to matter.
However, if I’m extremely high—say, over 250 or so—it usually pays to use a bit more than the formulas call for, as indicated in the previous posts.
I will “correct aggressively” if for example I’m sick and finding that I’m always giving more insulin throughout a whole day. Part of this aggressiveness, if I need to do it for more than a day, is also to aggressively increase my basal. So the aggression isn’t just against spot readings.
Even though a long string of spot readings in high 200’s or higher is a good sign that I’m getting sick well before any other symptoms might occur.
The aggression includes knowing that the bg drop from a unit of insulin, is less effective when I’m already high or sick.
When the illness suddenly clears up (it happens sometimes!) there’s a similarly aggressive reduction back to normal insulin needs.
If you are at 180 for 2 or 3 hours each day I don’t think that’s the worst thing in the world.
If it’s the same time every day then there’s an opportunity for you to tweak your dosing pattern such that you aren’t high to begin with.
If it’s at random times through the day that’s not the worst thing. But worth looking for patterns that maybe will help you prevent or predict and dose in advance.
I prefer the term “Rage Bolus.” Captures my mood during highs a little more accurately
I changed all the alarms on my CGM for pregnancy to warn me of highs earlier (used to be 200, but I dropped it to 140 during the day, 120 at night). This way I can keep my eye on highs before they start. As I tend to rage bolus too often, I try to make myself wait for that 1 hour after meal point before doing anything. 9 times out of 10 the high peaks and drops back into the normal rang within two hours. But if I see it start to plateau at all (or worse–continue to rise!), then I correct. I usually start with a 1/2 correction (unless I am over 180, then I might do a full), then wait half an hour, and correct again if I am still not dropping (I would suggest testing at this point instead of trusting the CGM, you may be dropping quickly and your CGM just hasn’t caught up yet), and so on. Going on a walk usually helps move things along as well.
Hit 40 weeks yesterday! I managed to hold off my doctor’s insistence on induction last week, but – partly as a compromise with my husband who is starting to get worried – agreed to get scheduled for Sunday evening (which will be 40w3days) if nothing has happened by then. Will only do the Foley balloon (mechanical, not chemical induction), for which thankfully I seem to have met the minimum requirement of 1cm dilation.
Since yesterday there are some minor signs I think might be promising for a natural start – I am still hopeful! (This is our first and it’s hard to know what is what, even after all the research and reading we’ve done.) I hope I have a good birth story to tell soon… And will accept any and all good vibes from across the universe for a safe natural labor to start ASAP.
That’s so great. Thank you for all the replies! That really helps me. I am already doing some of the above, especially when sick/resistant/high high.
I’ll lower my high alert level I think (currently at 14 (250) down to 190-210 to catch them faster. I also tend to correct and not closely watch it 1/2-1hr after to see if it needs anything else. I like to forget about
So that’s definitely an area I can utilise my corrections more effectively.
If it was just me for me I don’t panic too much around a 180…but not ok for me when we start TTC!
It’s also really nice to know people have fine tuned their corrections to avoid those lows-I can do that too. Little more self belief
Pretty sure that “aggressive” means many things to many people. Lots of ways to tackle this situation…first of all, you are to be commended for your hard work!!! I had 4 healthy babies as a T1D without the help of a pump or CGM. You CAN do this! My first thought is to get your heart rate up (assuming you have some IOB) rather than always treating persistent highs with more insulin. I’ve found that doing my age in jumping jacks once or twice will often get the numbers moving down. I’m 54. I also jump on the mini trampoline that I bought for about $30 at Wal-mart. If I don’t have any IOB, I’ll sometimes take half of my correction bolus and go walk around the block, jog in place or do one of the above-mentioned exercises. I’ve been known to do jumping jacks in bathroom stalls while travelling!!
) I actually corrected pretty much anything over 140 as soon as I caught it. I would advise that you read the general pattern of what to expect during the different weeks (changes happen on that time scale and not just by trimester) in books such as Cheryl Akon’s 
. In either case the dose is based on my known ISF and I:C ratio and I seldom miss by enough to matter.
