How do you determine the need for a temporary basal spike or decrease? Then, whats your method of delivery? How you you prevent over-correcting? I never can figure out how this is supposed to work....
When I was on a pump, I was still thinking about this all according to the old syringe-insulin paradigm. So, if I was high, I would deliver 2 u of correction insulin. But, I also started treating patterns of highs with correction insulin, which led to stacking dosages of bolus when my basal needed adjustment. Now, I would never make adjustments without a CGM, so I think that I am a bit more protected and I understand the process a bit better. But, I am curious about what you all do. Since basal is the first thing you need to fine tune, I fear that I am in no position to ever be on a pump again, unless I have a procedure to follow....
Good reference books that help with this are Think Like a Pancreas by Gary Scheiner, and Using Insulin by John Walsh or Pumping Insulin also by John Walsh.
All of the books has good explanations of when and how to test and the info you need to track. Will walk you through and explains how to make adjustments. What you do with MDI vs a pump is different as far as the changes made but the testing techniques are the same.
Thanks a bunch. I have never found any good diabetes books - except for that one put out by Joslin, and that doesn't go into it. People always give me this book, which is lame, http://www.amazon.com/Diabetes-For-Dummies-Alan-Rubin/dp/1118294475 I just bought them both on Amazon. : )
I would probably get yelled at by my endo for this, but I typically "wing it" and base the results of that for what I need to do next.
I had a really bad high after going to Texas Roadhouse yesterday (completely worth it though). For a 280 BG, it took a total of 3.5 units of correction on top of the 6 units I bolused for dinner spread out over three hours of individual corrections to finally bring it out of the 280's. If I listened to the IOB calculator and did not correct what-so-ever, I'm sure that I would have gone higher. I noticed that I was dropping very rapidly after my third correction, but I simply went to bed with a few more glucose tablets next to me than usual and ready to decrease my basal if I start going constantly low during the night. In the end, I didn't have a single hypoglycemic event during the night and woke up within target.
As for temp basaling, I try to do a basal test if I am able to, base a temp basal off the results of the basal test, and then transfer that temp basal into a new profile if everything works. Of course, there are instances where basal testing might not be possible, so I typically do a 10-20% temp basal in the direction that I need (more or less insulin), see how that works, and then create a profile with adjusted basal specifications.
For instance, I'm having issues with going into hypoglycemia during a specific class. My class is later in the evening, which makes it more difficult for me to do a basal test. Instead, I did an 80% temp rate 3 hours before the class started and tested my BG during the class. I was still experiencing hypoglycemia, so I created a profile that was essentially a 70% decrease in my normal basal 3 hours before the class and will test out that profile the next time I have that class.
Interesting. Yea, the IOB calculator is not very smart at these things. So, are you saying that you took just over a unit of correction per hour for three hours? Thats way less than I usually take (although, I tend to drop quite low after highs). I'm curious, why did you extend the correction over three hours instead of taking it all at once? Is that to decrease the rate that it drops at? Thats kinda smart, but also very disciplined. Interesting. I would usually just take 6 units of correction immediately and hope for the best in 4 hours.
I am really cautious about basal adjustments (because I know that I don't know how to do them correctly), so I only ever do 1 unit per day increases and decreases. If I am really having repeated lows, then maybe I drop it 2 units per day. In three days, the biggest change that I make is 3 to 6 units of basal. But, let say I only adjust one unit out of a total of 35 units of basal per day. 34/35 = 0.9714. And, 35/35 - 1/35 = 1 - 0.9714 = 0.286. Am I doing 2% adjustments per day? Thats stupid. I'm barley even adjusting my basal. It would take me five days to adjust 10%, and you are adjusting 10% in one day. Geeze. I bet I'm way over correcting with bolus and way under-correcting with basal.
Thanks for the reply. Really makes me think...
Agree with Hobbit. Take it step by step with Gary Scheiner's book. Takes a little time to get into place but not very long and is worth it!
I work closely with my Endo. I call when I have a problem and we work on the adjustments. I had a bad injection site with my pump and did not know it and my reading went to over 500. I was in a true panic and called my Endo's office and got the assistance I needed. I was alone and didn't want to lapse into a coma and have my children find me that way "again". I apologized later for my panic calls. I have only been on the pump since February of this year and do not have a lot of experience with it. Still learning and this site has provided me with so much information. I work with my Endo through Joslin Diabetes Center and they have proven to be a great support system at the beginning of diagnosis five years ago, starting on Novalog pen and Lantus at night. Then the transition to a pump in February.
The purpose of a pump basal rate (as well as long-acting insulin used in multiple daily injection therapy) is to keep your blood glucose flat when fasting. The basal rate is intended to metabolize the ongoing glucose released by the liver. Temporary basal rates, plus or minus %, are usually made to compensate for non-routine events like an unusual amount of exercise or physical activity.
A temporary basal rate can sometimes be used as a trial for a permanent change.
Basal rates are not normally used to correct blood glucose levels. Instead, a correction dose of insulin should be calculated and given for highs or a quick acting source of carbs given for lows.
As an example, I walk 30-90 minutes each day, usually in two sessions on a flat course. If I intend to walk a hilly course then I know from experience that my blood glucose will go hypo with no change in my routine. If my walk in the hills lasts one hour, I will often cut my basal rate by 50% for one hour starting two hours before my planned walk. As an alternative, I can eat 20-40 grams of carbohydrates 30 minutes before this walk without changing my basal rates.
I use temporary basal rates in a few different situations.
If I'm above 180 (and especially if I'm above 200), I find that I am more insulin resistant. I will raise my basal rate 20-40% to compensate.
If I'm going to do something that generates stress hormones I will bump up the basal again to counteract insulin resistance. Once when I was involved in a couple of very stressful court cases, I used a 60% basal increase and even that turned out not to be enough.
My basal needs change with the end of summer and I make small changes usually 10-20% to try to come up with my new seasonal rates before I start changing settings. I follow a similar procedure as I get into tax season.
As you can see from the thread I started - Sobering.... - it isn't an exact science.
If I'm eating out, e.g. Texas Roadhouse or some other heavy, carby, greasy food, I will often redline (200% basal rate...) my pump for a couple of hours on the way there, depending on my BG. The basal increase insulin starts as a trickle so it doesn't hit me that quickly. I also do this at breakfast. Since January, I've been adding a large shake (protein+ Shakeology...like 40G of protein and 13ish G of carbs...) on top of breakfast. It seems to run up 3-4 days/ week and not the other days so the days my BG seems to run up, I also crank the basal to cover it, rather than let it get really high and correct it. When I do this, if it's still high 60-90 minutes later, I'll sort of eyeball the IOB and maybe hit it with a 1/2 CB as the basal "boost" is unaccounted for.
Cereal seems to shoot up very quickly but also seems to burn off pretty quickly when the insulin "eats" it so I will see like upside down V spikes and often kill the basal (I use 7% or 13%, "for luck" as Princess Leia said...). Some of this too is due to lifting/ bodyweight exercises (P90X3/ T25) first thing in the AM, when I "go for it", my BG will end up like 50 points higher so, even if I start at 80, I can be 115-140 by the time I'm done and then will also take measures to fix it. One thing I've noticed about those highs is that they seem to be very ephemeral so I'll correct and take a shower and get dressed and be back at like 90 with a couple U of IOB, in which case, I calculate a food bolus and subtract the IOB or just eat something light without bolusing, all sorts of different options. I don't have a plan and I'm not 100% sure what my sensitivity factor is, I leave my pump set at 40 which seems about right, and just adjust the ratios.
I totally agree with 2hobbits book suggestions. When I decided to get a pump in 2008, I had like 30 days to log and wait to get the gizmo approved so I 1) discovered the DOC and 2) bought those two books. While I was waiting for those books, I reread Dr. Bernstein, that I'd had lying around for a while, but I am not a huge fan of his "brand" of dietary asceticism nor his aversion to cardio workouts which seems to stem from avoiding the challenge of balancing carbs which he doesn't like. Mari Michelle Ruddy logged her food on her TdC century and I think it was c. 438 carbs. I might have been in that ballpark but, as usual, I didn't log it!! I still ended up weighing less than when I started!
I did three individual corrections. I was 280 1 hour after eating and did 1u correction. At 2 hours, I was still 280 and did another 1u correction. At 3 hours, I went down to 250 and did 1.5u correction... and finally began to get out of the 200's. I didn't do a full correction for the 280 (with my SF, around 2.75 units correction) at the one-hour mark due to IOB. I ended up doing a partial correction so that, in the event that my bolus insulin decides to be evil and actually start working and I start going really low, I am only fighting 1u IOB from correction instead of 2.75u.
My total basal needs are really low (about 14.95u), so I need to do +/- 10% changes in order to adjust my basal 1.5u for the day. For specific timed settings, like if it is only a few specific hours that need tweaking, I need to be a bit more drastic (adjusting a .6u/hr basal rate 10% would come out with .54u/hr, which is not a big difference when it comes to low prevention. Adjusting a .6u/hr basal 70% to .42u/hr is a larger difference).
Thats incredible. 60%, eh? I wouldn't have guessed.
Wow, your basal is less than half of mine. I'm glad you clarified that for me. I wonder if you are smaller than me. I'm about 170 lbs. Are you around 100 lbs? Just wondering how proportional these basal dosages are to weight and how much to other factors, like your own unique endo system.
When I'm ill, I can require up to a 200% increase in basal. Or during the same day a reduction down to 50%.
Thankfully those days are few and far between.
I've had to use far, far more, plus upwards of 300% increase in bolus when treated with steroids.
You shoud read edenseffot blog Nerves AND exercise - not a good good mix discussing some of the 'art' combined with the science of blood glucose management.
I am also on a Paradigm pump and being on a pump definitely was the best decision I ever made! It is a lot more work, but I have achieved my best A1C results since I've been a pumper. Don't be nervous, be excited and ask lots of questions. It seems like a lot of info at first, but once you are familiar with your pump
O.K., so this is totally not what I expected. It seems like you guys bump the temp basal up with some frequency. Are you using it as a sort of 'correction insulin?' Do you count it the same as 'correction insulin?' Maybe 'correction insulin' is antiquated terminology?
One question, what do you think?
What are the implications of taking a flat rate of 6 units at 9:00am in order to counteract a high bg, versus taking a fractional dose three times over three hours?
I guess I sorta always feel kinda bad at 300 and I want to drive it down as fast as possible, which still often takes several hours. But, maybe that's a little hyper-reactive and I am actually making myself feel worse by creating rapid swings. My bg are so variable that when I was on a pump, I over-corrected. Every time that the sensor read above 150, I gave 2 units of correction. Sometimes, as frequently as once an hour for four hours. I always felt like, with a pump/sensor, I tried to exercise too much control over a chaotic system and THAT made it go even farther out of control.
Thanks for the info and the Book recommendation. Sounds good. I just dont know what to make of these 50% basal increases. That sounds like something that could drop me to the floor in three hours, if I wasn't careful. But, then, maybe its only a couple units over a couple hours, which is less total insulin than I used to deliver with correction shots. I'll survive as a test animal in the next great pump experiment. I'll just try not to drive for the first couple of weeks...
More like a preventative. Since it is infused at a very slow rate, it's impact on your BG is a very different profile.
For example my basal rate right now is programmed to deliver 1.75U/hr, a 50% increase is 2.63. That's a 0.88U increase and it gets infused over a one hour time period instead of all at once. This as a bolus 'correction' of 0.88 is absorbed by you body all at once, this as a basal increase adds an additional 0.015 (that's 15 one-thousandths) of a unit a minute to my baseline.
Another factor to consider is that with a bolus correction, once it's in, its in and you can't change it. With a temporary basal increase/decrease, you can change at at any time.
What you explained, several corrections over a four hours period is called insulin stacking and can lead to a whole host of problems. Most pumps, when using their bolus wizard correctly, will not allow you to stack insulin. Unless of course you override it.
Remember insulin has a profile of it's action. It has a definite peak @ ~30 minutes (depending on type and how your body reacts to it), then a period of high concentration, followed by a reducing 'tail'. This entire time period, can be 3-5 hours, (again depending on type and your body) and is programmed into the pump.
Also remember that when using a sensor you cannot base treatment decision on it, at least until you are comfortable enough to do so.
First it's reading is delayed about 15 minutes from what your blood sugar actually is, so you would be treating a blood sugar from 15 minutes ago. With those of us with rapid swings, this can be problematic. Plus the accuracy is only within 15% of what your actual BG reading is.