Caleb has insulin resistance in the morning - this is common. After being still all night, the body is less efficient in using insulin. His IC ratio is the smallest - by far (meaning the number is small but the insulin dose is big). We have been able to utilize a super bolus to keep him from spiking while also avoiding lows later. This may be difficult to achieve with a very low basal though.
His carb ratios increase (insulin doses get smaller) as the day goes on and he loses resistance from activity. That makes the dinner meal most likely very little insulin which makes overnights easier to handle.
What you see at lunch time when he skips breakfast could have something to do with the fact that he has no tail of insulin from what is likely a large breakfast dose. It may not have anything to do with the fact that it’s the first meal of the day, except that he did not have a prior meal bolus that’s still lowering his bg.
Many people keep mentioning starting at pump at 80% of the previous insulin doses. That works for many people and is a safe way to start. But many of us who had low insulin requirements and good absorption before pumping often end up at exactly the same total daily dose that we had before.
Laddie, the thinking was (at least back in the late 90’s) that long acting insulins weren’t as “efficient” per unit, as quick acting insulin used in a pump. It’s about the efficiency of a quick acting insulin being used for basal purposes. For example, we first had Velosulin (buffered version of Regular). then we got Humalog in late 1996. It really had nothing to do with absorption. It had to do with the TYPES of insulin used on MDI, ie, long acting, as well, of course, a quick acting insulin. I doubt that anything has changed since then in relative efficiency, but if you have proof to the contrary, I’m “all ears”.
Thanks for the tips. He eats breakfast around 6:45 and lunch isn’t until 12:30. Do you think he has breakfast insulin still working at lunch time?..I usually dose around 6:15.
Over six hours would be a long DÍA. When he eats and boluses for a regular breakfast, what happens after four hours (the length of time you mention he stays high)?
He comes back down and usually hits right at 80 before lunch. Which is weird because his Humalog should be wearing off at that point. He also has Celiac Disease and recently started taking Dicyclomine for IBS issues.
Hm. So if he’s correctly at that point, then the tail of humalog could be that long and helping avoid the spike for lunch.
Did his endo give specifics about why pumping would help this particular situation? Our experience with longer lasting insulins is that they pack more of a punch and “soak up” some margin of error, whereas using only fast acting insulin, while it’s more flexible and easier to tailor dosing, is less forgiving. What comes to mind to help a spike is to front load insulin. I’m sorry if I missed this - did you mention how old your son is?
@T1Mom6 - As FYI, we have our X2 configured for an “Insulin Duration” of 4.5 hours.
Initially this was configured at maybe 3 hours? We then extended it to 4.5 hours and found this is more realistic. (We based this from watching cgm data for when the graph will go back to straight and level.)
For breakfast, have you tried increasing the pre-bolus from 30 minutes to a bit longer? Ideally, we find if we wait on the breakfast until the cgm starts to turn from straight to the initial drop and then eat that it gets the timing of the insulin with the breakfast pretty good. That usually takes 45 minutes for us.
I would suggest to try and deal with the breakfast spike first. Once that is resolved then deal with the lunchtime BG. As mentioned, our approach to breakfast is a significant programmed basal increase a few hours prior as well as a 45 minute pre-bolus.
(We also have Celiac in the mix - sorry to hear you have to deal with it also. Just makes it all a bit more complicated.)
He is 11. His diabetes educator said we would work on it. See if he needs a little extra basal in the morning or if he needs to spread his breakfast dose out a little or a combination. His basal is at a good level right now because for the rest of the day his blood sugar stays good between meals and over night. This has only been happening for a little over a month. He started out with a carb ratio of 1:80 and went all the way to 1:15 with no change at all. His lunch and dinner doses haven’t changed in around 5 months.
That’s what I’m thinking. Basal increase in the early morning along with maybe dosing him for breakfast before he wakes up for school. Hopefully something works! Ugh Celiac Disease. The boy was good with shots, carb counting and everything to do with diabetes…but taking away his favorite foods almost broke him.
Dicyclomine is unrelated. Gastro thinks he had an IBS flare up caused by the anxiety from going back to school. His Celiac blood tests are normal now. He always had a belly ache before diagnosis. He has always had a colorless rash all over his body that disappeared a couple months after going gluten free. Constipation was a big issue before diagnosis. He never had any immediate reactions to gluten until after he’d been gluten free. He was given a caramal candy at school that contained gluten and he had diarrhea for a day. We’ve found replacements for almost everything he likes but he says it just isn’t the same. I can not figure out how to make chicken and dumplins gluten free. I see all of these recipes for the fluffy dumplings and tried them but we like the dense ones. The cracker barrel type. I’ve tried my recipe and just substituted gf flour and the dumplings just disappear while cooking!
The gluten reactions are lousy but if you are a “glass half full” sort of person then a reaction could be viewed helpful. The alternative could be a child who sneaks gluten 'cause it seems to have no impact but they are causing long term digestive problems.
In terms of eating out, we find the Celiac to be a much much bigger issue than the T1.
The result is we very rarely eat out - it usually is just not worth the risk.
I can’t help with the chicken and dumplins - way past my cooking skills. lol. But we do have a number of different flours. There seems to be a pretty big variety depending on what sort of food you might be cooking. We have a flour for pancakes, different flour for bread, different for pastry, etc…
Oh and we will start weening dicylomine in a couple weeks. He takes it twice a day now. Gastro said to cut to once a day and then hopefully he can be off of it before Thanksgiving. We tried cutting it back a couple weeks ago and he started having the stomach aches again. School makes him so nervous and I think contributes to his morning highs.
If that was my graph, I would increase the pre-bolus time. I would bump it back an additional 5 minutes each day and see what the impact was. Even if it means waking up earlier - it would be worth it as a test to see if it is effective. You might find it does not do the trick and you need a different tactic. Or you might find that not only it fixes the issue but also the ideal pre-bolus time. In which case then you could figure out how to practically get the pre-bolus in place long term in conjunction with wake-up time and such.
For us, once the cgm crosses 180 ~ 200 then we hit insulin resistance and it becomes difficult to get it down. The ratios do not work the same for us above that threshold. So, if we can keep the breakfast spike under 180 then it is all workable even if we did not match up perfectly the insulin and food. But if we really get the pre-bolus wrong and the cgm crosses the 200 mark then it is going to be a long drawn out struggle and basically just pumping insulin and probably followed by a low later on.
We actually buy different flours as well. We have an large Amish store couple of miles away and you wouldn’t believe the gf mixes they have! It’s amazing. The owner told me thay Celiac Disease is strong in the Amish community. Yeah, I can see how it would be easy to fall back to gluten if there was no immediate reaction to it. It’s hard.
What’s as far as you would go back for prebolus? I think I am going to take your advice and keep moving it back 5 minutes at a time. After we had tried everything the team recommended…they just said the next option is pumping.
