Thanks! I can sustain this rhythm 4 or 5 days out 7 now. Only took me 32 years to figure it out which emphasizes that tenacity has it’s good points 
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Very good! I did 5 days once and 4 days once and other than that, 3 days seems to be my limit!
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Im happy
Way to go, Dan! What’s your secret? That image is the best antidote for diabetes burnout.
Very very low carbs.
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I appreciate your very thorough write ups. In addition to the Afrezza, you also took IM. Would the same 3 units delivered as a single bolus by the pump provided you with a similar BG drop in about 2 hours? IIRC Afrezza acts pretty quickly. Bolus insulin delivered by a pump ought to theoretically peak at about 1 1/2 to 2 hours.
Afrezza is fast to get into the blood stream but not instantaneous bringing down blood glucose. The best part of Afrezza is its lack of a tail. It starts working, for me, in about a half hour and in 90 minutes its mostly done.
The intramuscular (IM) correction is faster than one delivered by a pump. I find it takes the IM shot about 45 minutes to start dropping the BG and is mostly done in 2 to 2.5 hours.
A pump correction dose, delivered sub-q, starts dropping my sugar at about 60-70 minutes and peaks at about 90-120 minutes and can last as long as 4-5 hours. So, to answer your question, I find my pump-delivered dose does not work as fast as an Afrezza or IM correction. At two hours, all other things held equal, the Afrezza or IM dose will have dropped my BG more.
These are all nominal times for me and vary from dose to dose.
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For the past month or so I’ve been really struggling with highs and lows and feeling as if things are completely out of whack. I’m pretty sure it’s because I’m on summer break and have lost the strict routine of work—don’t realize how much that sort of thing matters until it’s gone (this is the first time I’ve not been working since using a CGM). I had also tried reducing the number of basal rates I was running after reading Sugar Surfing, which I don’t think worked for me at all.
Here is an example of what my days have typically been like:
Over the past week or two I’ve been trying to get my basal pattern back on track. I feel like getting my overnight numbers sorted out gives me a good start to the day from which I can then start to work on other things, like my basal throughout the day and food boluses.
What I’ve done over the past week or so is look back each morning and look at where the line began to bend upward or downward. Then, I’d make tweaks to the basal rates starting two hours before those bends. When doing this each day over the course of a week or two, my overnight blood sugars began to slowly get better and better until they were flat.
Now I can start working on the rest of the day. I also start back at work on Monday, which may either help things settle down, or may throw things completely out of whack again…
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Jen - Your efforts with your overnight basals are really paying off. (I have a basal rate post to make, too.) I’ve also discarded Stephen Ponder’s idea about using one basal rate for the entire day. Unless you totally embrace his dynamic blood sugar tactics, one flat basal rate will not work well. I’m thinking that his surfing tactics, or boluses, compensate to some extent for his flat basal rates.
If I’ve learned anything with my time with diabetes is that “just winging it” might get you by for an evening out or even a weekend break from the diabetes daily demands, but it doesn’t work out well in the long run. Diabetes demands attention. At times it seems like a bottomless pit of demands but I’ve found there is an end to those demands or at least a great slacking where you can then devote more of your time to your “other” life.
Great overnight line! Keep up your efforts.
I love it when this happens
I’ve been struggling for the last 2-3 weeks with insistent lows in the midnight to three a.m. period. These were not ordinary lows. They resisted repeated glucose tab treatments and endured up to two hours. I wrote about them in another thread. This was really eroding my quality of life as I wasn’t getting my needed sleep.
Here’s one sample, but I experienced many nights with this problem:
Since they didn’t respond typically to quick acting glucose, I considered other possible explanations. I thought, perhaps, that my digestion problems stopped the glucose from quickly reaching my digestive tract where they could be absorbed and drive my BG back up. I also thought that perhaps my liver was losing its ability to put out a stream of glycogen, kind of like the vacation it takes when it metabolizes of few glasses of wine.
Well, those were nice theories but the real explanation was the simplest one. Occam’s Razor wins again! When I finally started ratcheting down my 9 p.m. to midnight basal rate all the way from 0.6 units/hour down to 0.2 units/hour, the problem started to melt.
Yesterday’s CGM trace washed over me with welcome relief:
Why do things make much more sense when looking back on them and seem so confusing when considered from the chaos of the moment?
Sometimes I need to be reminded to grant much more weight to the simplest explanation with the fewest assumptions. Occam was right.
ps - The graphs were produced by the new Dexcom Clarity web-based analysis software.
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[quote]I’ve also discarded Stephen Ponder’s idea about using one basal rate for
the entire day. Unless you totally embrace his dynamic blood sugar
tactics, one flat basal rate will not work well. I’m thinking that his
surfing tactics, or boluses, compensate to some extent for his flat
basal rates. [/quote]
I’ve decided that I’ll pick some Sugar Surfing strategies that I like, but use them in conjunction with strategies from other books (Pumping Insulin, Think Like a Pancreas, Dr. Bernstein). Diabetes is so complicated and individual that I think it’s impossible for one book or strategy to be entirely right for everyone.
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While I’m not adopting the complete Sugar Surfing philosophy, I am quite taken with the underlying thesis that we live with a dynamic disease. Clinging to static formulas is not a good idea as my example above underlines. We need to bend or we’ll break.
Like you, I am adopting some of Ponder’s ideas and rolling them into my unique set of tactics. Live and learn.
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zoe,
i also have strong feelings about this topic. i work my D regiment extremely hard. i am hard on myself w/ what i eat, how i exercise, carb counting, giving up certain foods that i love for which i cannot, no matter how hard i’ve tried, figure out an insulin solution to. still, even w/ my pump, my cgm, basal changes, life changes, stress, illness…LIFE, i cannot continue a day to day flatline on my cgm. my settings are 80 for lows, and 180 for my highs. i keep meticulous notes: what i eat, what time i eat (the same times very day unless its a holiday,etc) what my pre-bolus was, my carb counts…blah blah blah. then, i have a friend who barely needs any insulin at all to cover even more food than i am eating. i feel, sometimes like either giving up or shooting her. its a relentless disease. all i can do is continue trying and to remember that i “am not my number.”
Diabetes does not stand pat, neither should we
Continuing on from my recent comments about basal rate changes and the overall dynamics of diabetes, I have more to add. Here’s my trace from the fist half of yesterday:
The yellow line = 140 mg/dl and the red line = 65 mg/dl. A well-behaved trace. Yesterday afternoon things swung to the low side and rebounded, in part due to life distracting me and a delayed treatment of a low I could have easily seen developing. OK, I’m not a machine!
So, I probably slightly over-treated the low but I didn’t bounce up too high or stick there like sometimes happens on a rebound. I ate my dinner during the high but it was trending down and I planned a post-dinner walk. Well, the walk worked like a charm and I went to bed around 10 p.m. with a BG of 85 and very little IOB. I took a glucose tab or two when my dog, Norm, woke me up around 11:30 p.m. With my recent reductions in my 9 p.m.to midnight basal rate, I figured the low was taken care of. I was wrong again:
This trace is an almost exact copy of the problem that I have been dealing with for a few weeks now and one I thought I had extinguished. Upon waking to a 200 mg/dl BG level, I took 4 units of Afrezza and 1.5 units via an intramuscular injection as corrections. That combo cleaned things up within two hours, something I count as a victory in the context of a losing overnight trace.
I further adjusted my evening basal rates and also decided to change my dinner insulin to carb, or I:C ratio, from 1:7 to 1:8. While this long standing problem, one I thought I conquered earlier in the week, persists, I take comfort that I am rolling with the punches and making changes as dynamic diabetes does what it does.
The lesson I draw from this scenario, especially, is that we should never get married to any of the settings we use to program our pumps or base our MDI claculations on. You should always be ready to question every last formula and ratio. This is how nature works. Healthy non-diabetic humans also experience ebbing and flowing of their metabolisms. Why should we expect anything different?
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Congrats on rolling with the punches, @Terry4.
What do you think is causing the high rebounds for you?
I have been finding that sometimes my version of the 15/15 rule - 3 glucose tabs (12 carbs) and test in 15 minutes, yields a lot of variability in results. I also feel some of the variability is caused by how active I have been over a period of days, but not all of it can be defined that way. For example, I woke this morning @ 67, took my 3 tabs and 15 minutes later my BG was 78 (I normally expect something closer to, but not over 100). Two days prior I woke with a 65, took my 3 tabs and 15 minutes later, I was 143! I performed another finger-stick, because I couldn’t believe that and I got a 138. Sheesh!
On a more positive note, my last 7 days have been awesome. No real exercise, as I have been recovering from a minor outpatient surgery with stitches, where the doc said, “No exercise!” My SD is under 30 which is unheard of for me, and my averages (pre-meal, post-meal, bedtime, etc) are all under 100
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Thanks for the reply, @YogaO. The rebound depicted topped out at about 170, what I consider a moderate rebound. That fact that it wasn’t sticky and stay high for hours tells me my body’s response was not very strong. I think the cause of that rebound was the two glucose tabs I took near the end of the low as well as the counter-regulatory liver and hormone action.
The challenge with treating any low is adding the glucose you need and not any more. It’s always a guess. The mistake I hate making is over-treating, so I’m usually conservative with one or two tabs to start with and watching from there. Of course, if there’s significant IOB then I’ll add extra glucose.
I don’t believe the 15/15 rule is appropriate for me. I’d rather treat with 4-8 grams of carbs, observe, and treat again if needed.
Your recent variable experience with similar lows a few days apart typifies what we all face. The game is the same but the rules seem to change.
Congrats on your 7-day run of good numbers. That is awesome.
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The 10 minute video of Dr Bernstein has him saying the ideal is 83 before during and after meals with an a1c of 3.something.
Shoots. Running way higher than usual the few days… I finally decided the lantus has degraded so I’ll switch out to a new vial tonight. I think it must have gotten too hot sitting in the car while I was bike riding last week. That’s my best guess, anyway.
Any suggestions and/or tips are most welcome
On a roll
I’ve had a good run recently. I’m fortunate to be the beneficiary of the insulin pump, CGM, and the data that they throw off. As much as I think that technology and science are moving agonizing s-l-o-w, I would have never been able to paint lines like these without these advantages. I count my participation at TuDiabtes as a special motivator. This is the absolute best time to be alive with diabetes.
August 31, 2015
September 2, 2015
September 3, 2015
September 9, 2015
September 10, 2015
Yes, the omitted days were not as pretty!
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I’ve really been enjoying the posts from @Terry4 and others about how they manage such good control on a daily basis. So I thought I’d throw something out there in hopes that it’s useful to others.
Hormones and Blood Sugar
Before I got the CGM, I often felt that my blood sugar was totally random. I felt like insulin doses worked one day but not the next, and that things were very inconsistent even when I was consistent. It was very frustrating. Since getting the CGM, I’ve learned that I was actually partially right. One of the biggest things I’ve learned is how much hormonal changes impact my control as they shift throughout the month. Since getting the Dexcom six months ago, I’ve begun to respond to these shifts as quickly as I can, and I think it’s the biggest reason that my A1c has seen such improvement (from 23.5 years of being mostly above 7.0 to being 6.1 and 6.0, my lowest ever two consecutive times in a row). I’ve read that the main hormone that causes havoc throughout the month is progesterone, which is a steroid, so no wonder it has a huge impact on some women’s diabetes control!
Here is an illustration of the type of changes I need to make and the type of clues I use to help me learn when to make them. Typically, I need to increase my pump settings significantly two or three times throughout the month, and then over the course of two or three days things crash back down to where they started. But the exact dates and amounts are not always consistent, so it’s not as simple as marking dates on a calendar.
The green area on Diasend is 4.0 - 8.0 mmol/L or about 70 to 145 mg/dl. I do not eat low carb, but I do pre-bolus for meals (usually 30-45 minutes), eat moderate to low GI meals, and try to limit meals to about 30 grams of carbohydrates. I also try to pre-empt highs and lows by treating or correcting before my blood sugar crosses the alert limit and by using temporary basal rates if I think I might go high or low from exercising or stress. All days I ate the same meals and was at work (except for today, Saturday), so my schedule was identical.
Wednesday was a pretty usual day for me. The spike after breakfast was from not pre-bolusing and the evening highs were from snacking, but the rest of the day was good.
Another regular day on Thursday, except that I had a larger than usual spike after dinner that required a correction to come down into range. In hindsight, this was my first clue that my insulin sensitivity had changed, but I don’t make drastic changes after just one high, so I brushed it off at the time as a fluke.
On Friday, I rose overnight and woke up to my Dexcom alarm at 4:00 AM to take a correction bolus. Another clue that my insulin sensitivity had changed. And then I spiked after breakfast, despite adding a unit extra (trying to prevent a spike when I don’t have a lot of time to pre-bolus in the morning), and had to correct twice more during the morning to get back into range at lunch. At that point I increased all my basal rates by 0.1 u/hr. But it continued in the afternoon: spiking after lunch and needing multiple corrections to get back into range for dinner, including completely overriding my pump’s IOB tracking. At dinner I again had a big spike and had to correct multiple times. At bedtime I was still not down into range, even with a site change, so decided that it must be hormones. I increased all my basal rates by 0.1 u/hr again and also (from prior experience) adjusted my insulin to carb ratio from 1:10 to 1:8 and my insulin sensitivity factor from 2.0 mmol/L to 1.5 mmol/L. I did a final correction before bed using these new settings.
This morning I woke up to find that I’d had a great overnight period. Alwyas a good sign. Breakfast went as expected. Although the day isn’t over, I suspect the rest of the day will be as expected. But I’ll be prepared for the need to bump settings up probably twice more over the next week or two, and after that will be on the lookout for the need to quickly lower everything back down.
In all, I raised my total daily insulin dose by about 10 units over the course of one day, between the basal changes and the changes to pump settings. My total daily dose is about 40 units at its low end amd about 65 units at its high end, so it’s a change of more than 50% throughout the month. Incidentally, as I’m writing this my Dexcom is again trending upward without having eaten anything, which makes me think I may be increasing my basal rate another notch depending on how lunch and the rest of the day goes.
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