I am using the the 780 and I find that Smartguard doesn’t address my dawn phenomenon. How much extra should I bolus to compensate for it?
This is the problem w the Medtronic algorithm. Where on my tandem I can program in basal rates and control it just adjusts from there. At 4 am I increase from 0.9 to 1.3 units per hour and it goes back to 0.9 at 630 when I wake up. So for me it comes to about 2 extra units. Of course I know nothing about your settings or how strong the DP is for you.
Waking up to bolus is a bummer though
I have been on the 780 since the 22nd of March. It still doesn’t address my DP. My only other option is to add bogus carbs which aren’t really as my sugar rises as I wake up and I need that extra insulin to handle it. They said that when it was named automode that you might need to bolus for things that you never did before. When I had the 770 I would bolus for protein and fat about 1.5 -2 hrs after a meal and it did’nt seem to hurt the algorithm. I was getting 90%and better daily. I adjusted active insulin time to 2hours to make the algorithm more aggressive. So yesteday it delivered a bolus of 1.125 and today I did 1.825. Yesterday it went up to 11.5mmol. That is unacceptable IMO.
I tested at 708am about 45 min after eating and it was still 11.8 despite the increase in insulin. About 2 weeks ago I was playing with doses and see that I needed at least 3.2 units in the morning for DP and food. I have to add a crazy amount of carbs to make it work. I am thinking of exiting smartguard and do a bolus manually by the pump.
I wonder if something else is happening.
DP usually happens while you are still in bed. For me it’s about 1.5-2 hours before I get up and my pump corrects it.
There is something similar called feet on the floor, where when you get out of bed your sugar jumps up similar to DP.
However you seem to have trouble with high sugars after you eat your first meal. I’m not sure it’s related to DP, but maybe you need a stronger carb ratio for your first meal.
There is DP, Dawn Phenomenon which is hormones released that cause an increase in blood sugars for your body to get ready to waken for the day. Usually it commonly is around 5-6 AM. Then there is FOTF, Foot On The Floor, which is sort of the same thing, That happens after you are awake and your body increases blood sugars to get ready for the day. It’s called FOTF, because often it is after you put your feet on the floor and start moving around.
You can have one or the other or both. For me I have both, but for me one is usually significantly worse then the other. My FOTF actually occurs about an hour after I am awake. My DP is only requiring 1/2 unit extra, but my FOTF is requiring 1 1/2 units extra plus. They both usually cause insulin resistance for a few hours after since the release of hormones cause it.
I have extra insulin programmed into my Omnipod, but on a lot of days I am adding more for FOTF. I avoid eating in the AM unless I am snorkeling as it’s hard to judge insulin needs for food. I skyrocket easily if I eat in the AM. It’s like a blood sugar overreaction to food. I have a higher carb ratio in the AM, which is never enough. It’s easier for me to just avoid food most days in the AM. Unfortunately these things can vary which can drive you nuts.
This was the problem for me with the 670G and why I stopped using it. Just couldn’t get it to recognize and head off DP even though it’s one of the most consistent patterns I have as well as being common as dirt among PWD as a whole. It was pretty much WHY I started using a pump to begin with, and I think for a lot of others as well. MDI just can’t handle it without you having to get up at stupid-o’clock in the morning for a bolus.
As @Timothy says, the Tandem approach is to USE your basal schedule rather than trying to replace it wholesale as Medt does, so you can still program in things like DP that recur every 24 hrs like clockwork and the algorithm just steps in to make adjustments as necessary. Nearest equivalent with Smartguard is to just turn it off overnight and revert to standard basals. Do you have a lot of unpredictable overnight instabilities that you’re trying to account for? Otherwise, if Smartguard’s not helping there’s no obligation to use it. I don’t think shutting it off when you don’t want it screws up the algorithm or anything. It’s not really that sophisticated.
No, I agree, the pump is not that smart. The only time I need to fix is breakfast. My assessment graph showed more variability in the morning because the 780 wasn’t giving me a big enough bolus no matter how low I put my carb ratio. So this morning I exited smartguard and did a manual bolus. I still need a little more so i have adjusted my carb ratio accordingly. All my other meals are ok. I find if I eat some carbs /protein it keeps me more level at night but 3/4 of the time the sensor is off. It will say something like 4.2 when it is really like 5.6. I just leave it if I am not below 5mmol. I also started using the angled insets. I was using mio advance 90degree infusion sets and I kept getting them in blood and they weren’t very comfortable to wear. I could sometimes feel the cannula under my skin. The angled sets work much better for me. I insert them with a silserter. It is really easy.
Your ICR should have no effect on your morning fasting level. That’s determined by your basal level, CF, and the algorithm’s targets.
How do you know that you have a dawn rise? What’s your BG 5 hours later and how much does it change in the next 4 hours/per hour? If in manual mode your basal rate is right, or the algorithm is compensating correctly it shouldn’t change. If sometime after 3:30 a.m, your BG starts climbing steadily for several hours when you aren’t getting up or eating, that’s uncorrected dawn effect.
imo Most problems people have with automated pumps not working right come from nit having realistic expectations or not using them in manual mode long enough to accurately set their basal rate, ICR and CF - and if they do, never testing them again. If you don’t know how your body reacts without a pump interfering, you can’t easily determine whether the pump is working as designed or why it isn’t. If you don’t know how to use your parameters manually you can’t make rational adjustments to an automated pump or handle emergencies.
If I have a sensor fail or a site degrades, or my pump goes up in smoke, I am able to switch to manual mode, finger sticks, and syringes, and maintain control, not as good as if I did +200 tests per day, but good over hours and days. I couldn’t do that without knowing my control parameters and how to use them. .
If you must bolus to correct you always use your CF (units insulin per unit BG) and the offset from your target BG, no differently than if you were using syringes and MDI. If you are experienced you use an idea of your IOB and FOB to moderate corrections.
The problem with doing that every day is that 1: your basal rate or your CF may be off and 2: if the algorithm is capable of adaptation, you might impair it from adapting to handle your dawn rise.
Half-smart closed single loop control algorithms are crude. When they can adapt, their design compensates for day to day variability by being slow and cautious to make changes to basal delivery. And if it can “learn” it depends on what triggers adaptation, ie how far off you must be before it “thinks” there’s a problem it needs to react to.
Setting a very slightly more aggressive CF or raising the basal rate might trigger adaptation and help the algorithm adapt faster. If you try this give it 5 days or longer to work and look at the average result before making another change.
It is most likely FOTF syndrome asi as soon as I rise the number increases. I was talking to someone on Facebook that said I should talk to one of my Healthcare Providers about why in the morning when I bolus tthe bolus isnt near big enough. Whenmmy sugar is normal in the morning it does it. I eat a bowl of puffed wheat no sugar ceral with soy milk nocarbs in that. Some blueberries and a cup of coffee. I bolussed in manual mode today to get the size bolus I needed. I prebolus. My carb ratio is at 2.8 and when I input the 25 carbs I am eating it will only give me a bolus of 1.125. I trusted once and tried it and I ended up with an 11.9 1hour after. Very frustrating!
I think it is more Foot on the Floor syndrome. My bloodsugars rise aftr I get up.
I have my basal rate set as .300 at 6am. The basal rates in the Medtronic pump have nothing to do when in Smartguard. I can’t increase my basal and hope that the algorithm adjusts. It goes off of your total daily dose. I don’t know why it doesn’t give me more insulin in the morning. It has been a long time since I have fasted so one day I should delay breakfast and see how the algorithm handles the morning. What do you think?
If the pump doesn’t let you adjust your insulin to carb or your correction factor then I think that it has a disability.
The only way that those factors could be determined by a pump automatically is if you had consistent and predictable behavior over a period of time and it had inputs for your diet and activity that were reliable.
I can can’t imagine the FDA or the EU trusting any machine to do that and be safe while it learned
I think you need to see diabetes educator who is familiar with your pump. If I were in your situation that’s what I would do
If you choose not to do but the rely on the kindness and wisdom of strangers then you have 2 choices.
You can ride it out and hope that the algorithm is “smarter” than I believe it is and will eventually learn, or you can switch to a different system whose algorithm lets someone who understands what they are doing adjust your parameters and trust them.
If it were me and I chose to ride it out, I would limit my corrections to extreme situations, not make meal corrections or fasting corrections., but accept any corrections that the algorithm offers.
In Smartguard of the Medtronic 780 insulin pump the only things that you can control are the carb factor and active insulin time. By shortening the active insulin time you make the algorithm more aggressive. I had mine at 2.15hours but switched it to 2hours as I would like the algorithm to kick in sooner. It does automatic corrections. I also lowered my target from 6.7 to 6.1.
I am wondering that when I go high should I leave it alone and let the pump’s algorithm take over? I had to change my site early because I normally fall between 3-5pm and this time I did a temp target at 3pm for 1.8 hours. My sugar rise all the way to 9.5mmol and that was before eating at 515pm. I delayed supper until my bloodsugar went to a more acceptable level. At 645 it rose after eating as I didnt get the full bolus. Right now it is 13mmol. I’m not even sure this site is working. Urghh!
I’m not sure what you were trying to say. Go - where? Why did you need to change sites early? Did you run out of insulin in the pump?
If your pump knows the insulin to carb ratio and the insulin duration then could potentially learn over time your glucose to insulin correction factor. It’s going to take a longer time to do it if you keep changing settings or what you do for corrections, diets and activity. If I were designing the algorithm I’d use your sleep period from midnight to 330AM for the test interval to eliminate as many variables as possible,
You are right to wonder if any new site is working right. Also a +2 day infusion site if you are using flexible cannulas.
I watch and monitor after EVERY new infusion site and sensor change using BGM finger sticks until I’m sure that the sensor’s highs and lows are close to my meter which I trust. I use a 4g glucose tab which raises my BG by the 0.5 mmol/L (10 mg/dL ) the same amount that my calculated correction drops it. After the first day I can tell if one or the other is “off” and when it is failing.
As far as lowering your target, if you mean your A1C that’s a moderate goal. If it’s your BG in mmol/L, it’s aggressive. In either case, if your sensor isn’t accurate, lowering your target will increase the likelihood that you will need to intervene with quick carbs or a correction bolus (sometimes one 30-60 minutes after the other).
Personally, I never worry about going high. I know how much of what I eat, my pump has my ICR and CF tuned in. I only get concerned if 1) if I drop low, 2) if my BG goes above 10mmol/L(180 mg/dL) and 3) if it stays high for more than 30 minutes. When my sensor and site are good I rarely get that high unexpectedly. The very few times I got above 9.5mmol/L it was from a bad site or a poorly measured or estimated meal.
I found that if I adjust meals, meal bolus timings and work to keep “in range” during the day with just mealtime corrections, then my A1c, my overnight level, fasting BG and A1C all take care of themselves.
My TIR steady at 97%, last A1C was 5.2, but frankly I think A1C is a garbage metric that we using sensor loop pumps shouldn’t even consider. It’s only a totally unhelpful red flag if it’s higher than 7. We should be able to see why it’s high or low long before the stupid test assigns it a broken clock average score.