Basal Setting Advice Needed, Please

I am on a 530G pump, This is my fourth pump, so I am pretty good with it. Here’s my problem:
I have two basal settings for 10PM to 7AM: 10PM to 7AM is .225. At 7AM it raises to .65. This has been my standard rate for a very long time.

What has been happening is around 5AM my BG skyrockets. Sensor this morning shows it went from 97 at 4:53 AM to 163 at 5:23 AM. Went to bed at 110 (meter reading) and woke up at 343. That jump occurred 11 hours after dinner. This has been happening consistently for the last 6 days. Monday night, I tried raising the 10-7 basal to .250, and moved the .65 to begin at 6AM. Woke up at 25.

I am flummoxed over this. Small changes have a large negative effect, but then it is taking over 3 units of insulin to bring down the high BGs. I had also had this sort of thing happen in the evening twice during these 6 days, but those could be food related. I changed the pump out yesterday–new insulin, tubing, etc., so I am convinced it is not mechanical.

Thoughts? Ideas? THANKS!!!

Sounds like Dawn Phenomenon (DP). This is a common problem where BG’s rocket up typically around getting-up time. It is caused by the release of hormones like corticosteroids. Quite why it has started to occur at this stage of your pumping career is probably unknowable. However the solution is pretty straightforward. The recommendations would be to put in an increased basal rate starting 2 hours before the time your sensor shows the BG starting to rise. I your case this seems to be around 5 AM - if so I would put in a new basal segement into your program, starting around 3 AM and running until just after breakfast. You will have to figure out the amount to raise it to and the exact timing by trial and error, but with a CGM it’s not too difficult to do.

At present you only have 2 basal rates - 0.225 and 0.65. That’s quite a difference! I believe that the average is around 5 or 6 and that the rates change less dramatically moving from segment to segment. Moving the 10 PM to 7 AM segment from 0.225 to 0.25 probably is not going to cut it. If your BG is flat overnight (or at least till 5 AM) you don’t want to mess with your overnight rates. You will almost certainly need a much bigger increase at 3 to 4 AM to deal with the DP. Perhaps double or even more. However it would probably be sensible to restrict the increases to steps of 0.100.

Give it a try -

Joel

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What I have come to realize in the last year or so is that there is no one perfect basal profile. That misconception leads us to conclude that when we find basal settings that are good enough, that we are close to the perfect formula and we should not change them.

My body’s basal needs change and if I’m to maintain reasonable blood glucose control then I must not be afraid to change these rates. They are not sacred.

If my sensor BGs started to rise at 5:00 a.m. then I would change the basal rate two hours prior, at 3:00 a.m. It takes about two hours for the insulin to gain traction.

Perhaps you need to break up that nine hour basal segment into smaller ones. This whole process will require trial and error testing. Maybe you could start by breaking the longer 10p-7a segment into a 10p-3a and 3a-7a periods.

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I would agree with what @jjm335 suggested. Furthermore, before making any basal adjustments, I would first make sure that any possible delayed food effects are eliminated. In my experience, a low-carb protein+fat rich dinner can sometimes result in overnight spikes delayed by many hours. So, I’d first repeat one or two nights with your original overnight basal rates, but after either skipping dinner altogether, or having an early, small carb-only dinner that should be easy to bolus for. Then, look at the overnight bg curve and make basal adjustments as needed (most likely as @jjm335 suggested). If you wish, feel free to post your overnight bg curve, so we can give you more concrete suggestions. Also, setting CGM alarms would be a good idea - no need to wake up at 300 or at 25 while you are experimenting or making adjustments. Good luck!

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I would agree with the other posters here.

Any change in your eating habits? If you have added high fat or high protein to your evening meal, you could be seeing a delayed digestion bump.

Any change to your daily life? If some stressors have suddenly been added to your life, you might be seeing an increased DP. Your description sounds like a perfect example of increased DP. I would also consider a basal increase @ 3A, not 10P - 7A. I would also strongly urge you to set a 3A alarm and finger-stick while you are getting a handle on this.

And like @Terry4 said, I no longer think there is a perfect basal rate. I am frequently tweaking based on activity, stress, etc.

Thanks all. It is nice not to be alone in this. Food was not an issue. I had a 2"x2" piece of salmon, and 1/2 cup unsweetened mashed acorn squash. I used Calorie King for the carbs and basaled appropriately. I did make basal changes. Left the midnight at .225, but went to .5 at 3AM, .65 at &AM and back to .225 at 4PM. We will see. I have raised my basal from 8.8 to 10.325. That’s 1.52 units increase. BUT I have already bolused 6.1 units for the corrections. My endo will have a cow if she sees this.

It just happened again. I had a standard frozen food lunch I eat all the time. Tested at 67 pre lunch, basaled based on the package carb amount, ate at 11:30. Tested at 2, as I noticed my sensor was rising quickly, meter BG was 284. Washed hands, tested again, was 274. Corrected with a shot. Replaced the entire pump set up and inserted in a new location of the body I haven’t used for months.

I regularly have a lot of trouble when the weather changes, and it has gotten colder here. Maybe it is just weather.

Hmm, looks like you may also need to look at your I:C ratios. By the way, how many carbs were in that lunch according to the label? And how much protein and fat?

Frankly, I would not worry about that. There is no one under the sun who can manage your T1D better than you can.

I have a hard time wrapping my head around what this implies. Does your endo want you to seek permission for every pump change you make? If that were true then s/he should be open to the 3 a.m. call any day of the week as often as your body requests a change. Is s/he really up for that level of support?

Does your endo think that diabetes is a static condition? Does s/he think that even if you maintain perfect discipline, eat the same things at the same times, get the same amount of sleep, exercise the same intensity and duration at the exact same times, endure the same intensity and duration stress at the same time every day, that you could tweak your pump’s settings to the perfect? Is s/he a believer that you should be able to use the same basal profile day after day, week after week, year after year?

The only real practical solution that would work for both your doctor and you is to encourage and support you to sit in the driver’s seat, making all the decisions you need to make when your body changes things up, something that is a part of every body, every day.

I don’t mean to come down hard on you or your doctor, @Sue27, but this apparent attitude your doctor assumes is one that many doctors take to some degree. It’s uninformed and attempts to simplify a much more complex situation. To some extent they think our job is easier than it is.

You need to be in the driver’s seat, not your doctor. I apologize for the rant. I hope you can untangle the current challenge you’re facing and I also hope that you learn some things that will empower you. I salute your seeking information here!

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She could care less about my seeking permission. I see her as little as possible. I have posted about this before. She wants my A1C at 7 or above. My last was 5.6. I refuse to be that slack about my BG numbers,…53 years T1 now…I haven’t seen her since last December, as I needed pump scrips She is a big believer in the basal bolus ratio. Mine sucks, as I am over 60 and my appetite is small, so basal is usually well over 60%. I don’t eat much.

Endos don’t get it and I love your comment about being available at 3AM. I generally don’t care about Docs. It was a random comment, as no one can do this, but me.

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22 carbs, 13 fat, 6 protein. Been eating them…not daily… for a long time and never had a problem.

@Sue27, sorry I lost track of your personal history. Now I remember the basal/bolus ratio nonsense in a prior thread.

Sounds like you have a good handle on your BG numbers. You have a non-diabetic A1c. Your doctor should take advice from you!

My sentiments, exactly. Be well.

That looks very reasonable. Indeed, very strange bg spike after that lunch. I think I would have done the same thing you already did - correct with a shot and change set. Stay cool and work through the challenges - hope things get better soon.

Bernstein recommends checking for a non-obvious infection like teeth when unexplained high BGs happen.

OK. Tried the I:C ratio change. Added the 3 AM basal. Was really low (46) from 9PM over night. Obviiously too much. Even with about 16 ounces of juice overnight–60 carbs, still tested at 54 at 7:30AM. More juice, and was 79 at 9AM. Ate a 12 carb breakfast, something I eat regularly. Stayed flat, 70s/80s until 11AM. Went from 100 to 191 by noon. Ate a sandwich–30 carbs, bolused with correction. Two hours later, tested at 201.

I just finished a lot of dental work, so teeth are fine. No disease, as this is the 7th day of all this, so would be sick by now. No wounds or infections.

Pretty much, NO IDEAS!!! Going to ride it out for a while and see if it calms down.

I think that’s the best approach. I would not rush into changing everything too quickly or by too much. First, just make corrections as needed to keep bg in control. Then, make adjustments only when it becomes clear that there is a need to change basal rates and/or I:C ratios.

What about site rotation?

I had a period where I was not doing an adequate job of rotating my sites when I went to the harder to reach locations on my back and buttocks. The result was wild BG swings especially on the high side.

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I swtched all pump stuff yesterday. Moved site to upper arm, which I haven’t used in months.
Should be good with that.

you keep saying, " basaled based on the package carb amount"…you do mean, bolused, correct? Also, do you wear a CGM. Could you be having a rebound low - high in the middle of the night. Your lows are quite concerning, especially in the middle of the night.

all those carbs you’re consuming to bring your blood sugars up with hit you eventually, plus carbs for breakfast and lunch, too.

I should have said boulder. Sorry. Yes, I wear a chm…have for years. I generally do not have rebound lows, high, yes, after a low night, which is certainly affecting all this.