Basal/Bolus Adjustment Question

Diabetes Technology Insulin Pumps
1

My last A1c was 5.8, but I got there because 70% of my blood sugar readings were “in target,” 15% were high (over 130) and 15% were low (under 80). My internist and endo are disagreeing about how to handle the frequent lows. My endo says eat a snack, 10-15 carbs between meals and don’t cover it with insulin. My regular doc says he thinks I need to lower my basal rate and increase my bolus (carb ratio). He admits he has no experience with insulin pumps but he always did a great job handling my diabetes before the pump.

I’ve been losing weight since I got on my pump in September and each time I hit a magic number of pounds lost (I’m not sure what number is), I have problems and need to lower my basal, per my endo. Each time I’ve made that change, she has only had me decrease my basal, not change my carb ratio and I haven’t had a problem.

I’ve lowered my basal rate and changed my carb ratio from 1:8 to 1:7 and for the first time in lowering it over these months, my sugars are spiking much higer after I eat. I’m not taking about 2 hours post-prandial, I’m talking about an hour or an hour and 1/2 half after I eat, and they usually come down. Before my sugar usually didn’t go over 140 or 150 at the most before coming down. Now it rises to 180-190 before coming down.

Does everyone have this problem? Do I just need to change my carb ratio again to like 1:6 to take care of the spike? Having my basal up a little has always worked as a scaffold and stopped my sugars from rising so much. Some how my doc seems to think I can just play with it and I’ll figure it out.

It’s been a particularly bad weekend with two lows in the 40’s and then it’s rebounded at the next meal and wouldn’t not come back down for several hours. So I’m not using this weekend to do basal testing or make any decisions. Both lows were within an hour before the next scheduled meal. One was when I was driving and one was in the middle of the grocery store yesterday where I felt like I was going low, my legs went out from under me quickly, I fell and they called EMS. Very embarassing and scary. This never happened before and I don’t think I’ve ever been in the 40’s before. Now I need to find a new grocery store to shop at, lol.

I’ll be calling my endo tomorrow, but I feel like I need practical advice from people who are actually dealing with this. Thanks.

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I’m sorry you’re having all these problems, Carman,I have a couple thoughts. First of all, for me 70% of numbers in target is good and I’d love to have an A1C of 5.8! That’s what I aim for, but that’s just me, we’re all different. I also wouldn’t call “anything under 80” a “low”. I only treat under 60, though I know some people treat under 70. Now the lows you describe this weekend, those are no fun!

As for your endo’s advice to handle frequent lows by eating snacks and not covering with insulin, I think that’s absurd! First of all, if I ate 10-15 carbs and didn’t cover them with insulin, I’d spike. Second of all, I’d gain weight from all that snacking, though I’m older than you so I gain easily. But since you are working on losing weight, I would definitely not snack as a technique to avoid frequent lows! I also question your doctor’s advice to lower your basal and raise your bolus unless he has spent some time reviewing your logs and has surmised from them that you are on too high a basal which is causing lows between your meals and too low a bolus which is causing spikes after.

To me it is all about the patterns. I know everyone advises basal testing, and I’m sure that is the more exacting method to use, especially if the patterns are unclear. But I have had good results just looking at patterns and adjusting from there. When are the lows and highs? Can you look at your logs and see a pattern? areyour highs all post prandial and your lows all between meals? Can you pinpoint specific times of the day? What I did to set my basals on my pump was pinpointed the times of day when I was too low or too high (that were not obvious post prandials) and then tweaked those “time zones”, to target three hours ahead (per John Walsh Pumping Insulin). In other words if I had lows late afternoon around 4PM-6PM, I’d lower the basal for the period of 1PM-3PM. I ended up with six different “time zones”. Once the basal was set so I am pretty stable in between meals, then the bolus starts “showing itself” and for the first time in about a year, I changed my bolus rates a tad (from 1:7, 1:8, 1:18 to 1:6, 1:7 and 1:18. ) I’m not one of those people who never has highs and lows (hence the 70-75% in target goal), but they are now random and mild. (unless of course a site fails…lol).

I’m sure losing weight complicates things and means you have to tweak more often, but from what I have heard, it should mean an across the board decrease in TDD . Even though it seems backwards, the fact that you are spiking higher even using more bolus insulin could be because your basals are more in line “revealing” your bolus needs more accurately (like I mentioned above). Have your basal results been better? From the timeline you describe it sounds like the supermarket lows were between meals so perhaps you need to lower the basal for that time period even more? Depending on how much weight you have lost, I have heard of people having dramatically lowered insulin needs.

I hope I’ve helped some, and not just muddied the waters! I’m sure you’ll get other responses. One last thought: I always go low at the grocery store (though not that low!). I attribute it to the 12 block walk to the store and then all the walking up and down aisles. I keep remembering to try leaving to shop sooner after a meal to prevent this!

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Thanks Zoe. My lows are generally about an hour before lunch and an hour before dinner. I didn’t usually have lows in the night, but for the last couple of weeks, I’ve woken up several beween 12 - 2 with readings in the mid-50’s.

I’ll upload my pump tonight and hopefully my endo will look at it tomorrow. It’s just that over the last seven months since I got my pump, I didn’t have these problems. As I’ve lost weight, we’ve reduced my basal from 2/hr for 24 hours to 1.5 from 3:00 p.m. to 8:00 a.m. and 1.4 from 8:am to 3:pm without problems. Now, because of the lows at night, I tried to reduce my over all basal to 1.4 around the clock. But, I’m having the spikes before it comes down after meals and I’m still having some lows. With my basal higher, my pp numbers were between 115-125 which I consider great. Now, with the lower basal, my pp readings are more like 135-145.

As far as treating lows, I don’t worry about readings in the upper-70’s and 80’s. I feel better when I run between 80 and 100. However, once I get down to the mid-70’s, I start having some symptoms of low blood sugar.

I guess I’m going to have to sit down with the endo and go over everything with her. My changing stuff isn’t working for me.

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My guess, Carman, would be that you need a few more “time zones”. 3PM to 8AM and 8!M to 3PM are pretty long periods of time. If you are having the lows at, let’s say 11AM and and 5PM, I would create two separate time zones somewhere around the times of 8AM and 2PM and lower it a bit more then. Then, if you think your nighttime lows are hitting between 12 and 2AM I would create another time zone between 9PM and 11PM and lower that.



The lowered basal isn’t likely to be the source of the higher pp readings (though 135-145 aren’t bad!). It isn’t terribly effective to use basal to control pp’s, so you just might have to bite the bullet and increase your boluses a bit. Another question I would have is what you are doing to treat those lows before meals. If you are overtreating that might contribute to your high pp’s. If I got a low an hour before a meal I would either treat it conservatively with whatever number of glucose tablets works for you (for me it would be two), or wait it out if it weren’t too bad (like say 65-75) and then bolus right before eating rather than waiting. (that also helps with weight loss!) Also, for the post prandial spikes when you weren’t low before the meal you might experiment with bolusing earlier before your meal.

I wouldn’t necessarily say your changing stuff isn’t working, just that you need more tweaking. I’d say my first 1-2 months after starting the pump my numbers were definitely worse, not better. It really took awhile to tweak/see results/tweak some more, etc. And I couldn’t see my bolus needs clearly until after I got the basal as close to perfect as possible.

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Personally speaking… Correcting lows is a skill that needs to be learned. Although many people disagreed with me for years over this very issue. This is one of the reasons why I feel that WHAT we use to correct our low blood sugars, should be seriously considered BEFORE hand, rather than waiting till the last minute, and wind up choosing the wrong foods to correct while in panic mode (this includes myself)



I’ve used glucose tabs for years, because they are very low in calories & zero for everything else. People complain about the taste of glucose tabs, however, glucose tabs were never meant to be a treat!! it’s meant to do a specific job, and that is to quickly raise blood sugar.



I also use baby food, particularly “apple sauce”, “peaches”, “sweet potatoes” work pretty fast in my body, and they are also often low in calorie and usually low on everything else.



For me, the most difficult thing is patience, because even any “fast acting” food takes time to raise your sugar. Sometimes the same foods we always eat to raise our sugar don’t always work in the same way all the time.



Having a pump & a CGM really has helped me deal with some of this issues.



Excellent hbA1c by the way!!



-Yogi

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Thanks Yogi. I use glucose tabs as well. And, depending on the degree of the low when I spot it or when my CGM indicates I’m going down, I’ll use 1, 2 or 3. By using only what I think I need, I usually don’t spike up after treating a low. It’s that I’m trying to avoid the lows all together. Friday, my low was when I was driving and really scared me. I treated it with glucose tabs and when I got to my destination about 20 minutes later, it settled in at 100. I ate 1/4 of a peanut butter sandwich to stablize. A couple of hours later, when I ate dinner, it spiked up to over 200 and didn’t come down for like 5 hours, even though I did two correction boluses. That’s never happened to me. Something must be going on different for me right now and I don’t know what it is. I will find the fix though.

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This happened to my yesterday. I was celebrating a friend’s birthday party, and a guest made some virgin fruit daiquiri(s), for everyone. I had 2 very small cups (one banana, and the other pineapple), along with a light vegan dinner. my sugar spiked 220, and did not want to come down. gave my self a correction, two hours later it was still about 180. I figured it was because I was tired and went to bed. I woke up @ 91…



Lack of sleep and crazy hormones can be a pain in the *ss, for all us diabetics :-(…

By the way, one good thing that helps me with lows, is that I set my CGM to alarm when I am @ 80. If the trends are still moving downward, I have plenty of time to correct my low…



-Yogi

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Hi Carmen,
I agree with the different basals for times of day as mentioned by others. I’m a big advocate of pattern management. I always make my own adjustments to basals and such just based on the patterns.
Also, for PP spikes, do you prebolus for meals? By having the insulin in your system prior to the food, the insulin action will match up better with the absorption of the carbohydrate so as to “strike the spike”. For some people 10-15 minutes is enough but for me 30-45 minutes prior to eating is best. Even if I don’t know what i’m going to eat, I’m always guaranteed to have at least 30g of carbs so if I bolus for that prior to eating and then when i sit down and see that it’s going to be more then I can add that bolus in (the joy of pumps, don’t have to do two shots!).
Just a thought …
Good luck!

9

I do prebolus fore meals and it’s usually about 15 - 20 minutes. If needed, I can do a combo bolus and I usually use either a half hour or one hour for that. Tonight I went to a friend’s house to eat and they usually eat right when they say they will, which would have been about 15-20 minutes after my bolus. Since they basically live across the street, I did my bolus before I went because I knew what I was going to eat and probably how much. Well, to my surpirse, it was over an hour after I got there before we ate so my postprandial reading was slightly higher than I thought. Oh well, tomorrow is a new day.