I think I messed something up with my automode settings


#1

I was getting irritated right before Christmas because my bolus wizard wasn’t cutting the mustard on my meals when counting carbs correctly. My endo/NP made my rates a lot more conservative in October, just as I was starting to feel comfortable with them because they saw some lows and I’m a new patient with them.

The basal bolus rate was 50:50 on Tidepool with my total insulin average at 40ish units, give or take 2 units.

Then I was 58% in range, 29% above range 180-250 and 11% above 250. Sort of ridiculous. my average blood sugar was 165. Average daily carbs were 115g.

So I adjusted my active insulin time to be shorter by 15 minutes, my insulin sensitivity I took down for correction calculations and carb ratios were lowered (more aggressive, from 11:1 all the time to 9.7:1 during the day and 11:1 at night to help with night lows.)

Y’all I’m getting LESS insulin now than I was before Christmas!!! (While eating at least 5 more carbs, probably more per day. On average 5 more. Some are big holidays including Christmas/NYE/My 40th Birthday…which btw, I didn’t even eat cake because I had too high of BGL.)

How in the ever-loving heck did this happen?

Now I’m getting an average of 35.1 units daily, my basal v bolus ratio is 44% basal to 56% bolus.

Not what I wanted. I’m getting less units in automode 15.5 units daily, and my boluses are exactly the same. But I need them to be more aggressive because I’m running around at 300 for 10% of the day…usually between 3-6 p.m. And my freaking kidneys ache.

Tell me if you have any suggestions on how to adjust now. This makes me feel so helpless/angry. I don’t know how to describe how the backward regression can be so frustrating. I’m going low carb for a while starting tonight to curb it.


#2

My understanding is that 670 pump (if that is what you have) does not use the settings in the way you might expect.

Maybe @Rphil2 can help.


#3

So a few things. It is usual that all the things you are moving do adjust using the 670g. You said you lowered your insulin sensitivity by 15 minutes. But you did not say what it is. Many of us have found that the sensitivity is less than three hours. Some higher but most lower. In my case sensitivity is at 2.5 hours. That is a little on the extreme low side. But if you are above 3 hours I woudl take 15 minute reductions until it seems more in range (the medtronic trainer can help with this)

The carb ratios are definitely a big deal. even small adjustments can mean a lot. I suggest you consider calling your Endo and talk over setting them back to where you were pre holidays until you get a better handle on sensitivity. Generally many have found moving these by one unit at a time is a large amount. I know for me I move them by the 1/10th and wait a week to see what happens. That means no more than 1/2 unit per month.

As for the carbs, I have found that the carb count are extremely important. If you are not using a carb tracker on your telephone you should consider one with a broad range of foods both thsoe that are purchased in the grocery store and those in restaurants. I use the weight watchers app (expensive and requires membership), and I have tired and liked MySugr and Carb Manager. Nothing is perfect so look around. The key I have found for me is that guessing is not the best way. If you have not as yet, I suggest you find one and use it consistently.

Finally take a deep breath. This system is difficult to get right but once i got there I have come to love it and rely on it, I hope you do as well.

Note: I am a Medtronic ambassador. My opinions are my own. They did not pay me to say nice things. OK, they sent me a shirt and a cup but even I am more expensive than that.


#4

Low carb, which usually means higher protein, and that can be harsher on the kidneys and I noticed you said you have kidney pain. You might want to get your kidneys checked.

I have 5 different carb ratio settings. 1 unit insulin to 3 carbs in am down to 1 unit insulin to 7 carbs by night, I also have 7 diifferent basal rate settings, 1.2 units basal in the morning from 6am to 9am to .20 at night between 12-3 am. A big difference for me as I have dawn phenomenon and I like to drop at night. So I like to go to bed at least at a 135 BG, because I will drop, usually at about 3-4 am and between 5-6 am I go up in various amounts, I can really skyrocket upwards pretty fast and sometimes mildly and then my extra settings take care of it.

I am just saying this as it shows how variable one can be and all the different adjustments that are sometimes needed. But I was taught to use small adjustments at a time when you are changing settings.

It seems like you are gliding along and them bam, things change! It just seems to happen!


#5

Hm. One misunderstanding I can clear up: insulin sensitivity settings only pertain to manual mode. In automode the algorithm adjusts microbolus rates for corrections according to its own, well, algorithm. What does affect that rate is Active Insulin Time (AIT). If it’s not being aggressive enough, and “running around 300 for 10% of the day” certainly qualifies, then further shortening AIT will help. Your I:C may need some more tweakage for bolusing as well to prevent spiking so high in the first place, but AIT adjustment is where you’ll see the most dramatic difference in bringing down highs. It’s the single most powerful parameter over all, so on the principle that you only change one thing at a time so as not to confuse the results I’d start with that. With automode it is wise to be incremental, because it takes a while for changes to settings to manifest in changed pump behavior and changed results. But I would try shortening AIT another 15min, see how it goes over the next 4-5 days, and take it from there.

Of course the other problem you have is this:

Medicos are way more afraid you might ever go low than they are of having you “running around 300 for 10% of the day.” Well, insulin is dangerous stuff but that caution can be overdone when dealing with an experienced, reasonably intelligent adult patient. Ultimately it’s your body and your health.


#6

So, my Medtronic 670G trainer and I worked for 2 months in February 2018 to get the settings fairly right. I continued to tinker until around July to get perfect, running where I wanted.

I was using 7 carb settings most were less than a 1:10 carb ratio and had an active insulin time of 2:15 hours.

When I moved and visited my new Endo in South Carolina the Endo/np were very incredulous that I had more than 1 carb ratio and said “you don’t digest differently throughout the day, we don’t set more than 1.” (That’s the very first time, through 5 states and 6 providers I’ve ever heard this in 28 years but I digress.)

They changed my AIT to 3.5 hours. And my carb ration to 11:1 only.

I started changing things back incrementally toward where my rates were before. I’ve reduced my AIT by 15 minute increments several times and it’s back to 2:15 at this point. And added back in more than 1 carb ratio. They vary from 9:1 to 9.7:1 and 11:1 with the lower ones around breakfast & lunch.

It’s super weird that the more aggressive rates yielded less insulin being delivered, but my blood sugar has run extremely high several hours post meal for a couple of weeks. And so no wonder my healthy kidneys are aching.

Also I was on vacation last week and ate out once a day and have still lost a couple of pounds. I’m calling Medtronic today and asking for an appointment with a rep who trains people.

I’m not impressed with my Endo though. They seem uninformed about pumps, particularly the 670G.


#7

DrBB - Does the sensitivity affect your correction boluses? That’s what I’m trying to affect. It shouldn’t take a whole day to bring your blood sugar down. And the calculations don’t make any sense for corrections. I will be 300 and get 2.2 units for a high and then it will also stop the microboluses when it starts trending down at all.

I just need the calculation to override the fact that it’s going to stop giving my microbolus, which was factored in.


#8

I went through repeated questions about this with my endo & Medtronic trainer team as well as the more expert 670G online group in FB, so I’m quite confident in saying no, not in auto. AIT will have a dramatic effect in bringing down highs, though. Here’s why: each microbolus is dynamically calculated, and a key part of that calculation is AIT. The longer your AIT setting, the teensier each microbolus will be, because the algorithm is using AIT to determine the overlap between this microbolus with the next. By shortening up AIT, you’re basically allowing it to overlap them more, therefore each one can be larger. If it’s set too long, you’ll get exactly the frustrating behavior you describe–stopping the microbolus flow prematurely because it “thinks” the effect of what it’s given you will be sufficient. You’re basically telling it to stack the insulin a little bit. On a standard pump that’s a no-no, but with auto it’s really the trick to the whole thing. With these little doses the question becomes not whether to stack, but how much.

It may seem like you’re kind of lying to the algorithm–But my actual insulin curve is xxxx!!! But that’s manual-pump thinking that doesn’t translate very well to looping, where there isn’t really a distinction between “basal” and “bolus.” It’s more of a continuum with this delivery method. “Micro-bolus” isn’t just a synonym for “basal,” because the rate is changing continuously. It’s one of the big mental shifts with this thing. Better to think of AIT as just a knob you can turn forward or back in order to fine-tune how aggressive it’s going to be—how much micro-stacking you’re allowing it to do—rather than the absolute correct scientific value of how long the insulin curve is in your metabolism. This is especially true when it comes to corrections.


#9

Seriously? I don’t like these guys at all. That’s a very top-down authoritarian attitude that doesn’t allow for the fact that a lot of us know more than they do about our own idiosyncratic instance of this disease. For experienced T1’s it should be a collaborative relationship and this doesn’t sound like that.

Good on ya, sounds like you know what you’re doing—you need endos’ help, not approval.

It’s really a very different beast from what the standard model has been for decades. Used to be we had two different insulins, basal and bolus. Then we had pumps, but we kept the basic concept of basal being one thing, bolus something else, even though it was all just the same insulin. But with looping the distinction really breaks down. It took me a couple of months to get my head around just how different it was, and that was for a 35-year T1 with 5+ years on a pump, using the thing every minute of my life. It doesn’t surprise me that people who aren’t actually plugged into one 24/7/365 aren’t fully grasping the concept.

Given everything you’ve told us, I agree, that is weird. The one thing I can think of is that the self-updating cycle of the algorithm is, what, 5 days? a week? something like that, so there’s a big lag between making a change and seeing its effect, one of the things that makes getting your settings dialed in such a headache.

Given all you’ve told us, yes, do this! :slight_smile:

ETA: one thing about that “you don’t digest differently” line that is demonstrably uninformed is that digestion, per se, isn’t the single issue. Many T1s still have some endogenous insulin production, which may be subject to the diurnal cycle. I almost always go low around 5-7pm, and learned years and years ago that it was probably due to having some endogenous insulin that wants to kick in at that time. My endo and I have worked out some strategies for dealing with it, both adjusting my basal (I gave up on automode) and setting a different I:C ratio. Nothing to do with my digestion!


#10

:+1:


#11

Thanks. I have obviously not gotten my head around the components of the algorithm. I do have an appointment with a new Medtronic trainer on the16th. I’ll ask some serious questions.

Also I’m going to be really assertive with my Endo and tell the NP that I know that I need several carb ratios and the AIT doesn’t work the same as in a manual pump.


#12

I also need to go back through the settings. I had lunch at 12:45, counted my carbs precisely. Boluses with the wizard. My sensor needed to be changed right after that. So I changed it, exited auto mode. My blood sugar is 426 right now.

I don’t know what’s wrong with my body but it’s just not working with me or with the pump right. I’m so sad and defeated. (Probably because high blood sugar makes me feel blur and teary.)


#13

I started out on the 670G with mine set the same as in manual: 4 hours. To get something resembling the same in-range performance I had had in manual, I gradually ended up taking the same setting all the way down to the 2 hour limit. So yeah. The thing is, in manual AIT isn’t controlling anything unless you’re doing a bolus, either meal or correction. Whereas in automode it is being invoked continuously to determine a microbolus every five minutes, and expecting each of those tiny bits to have the exact same effect curve as a whole unit of insulin when it interacts with your body is a very dubious assumption. So there isn’t some abstract principle, Thou shalt not stack insulin! that will guarantee the right outcome; there is only trial and error—informed trial and error, but trial and error nonetheless. You have to adjust and evaluate what works, and whatever that setting ends up being is the right setting. Like Duke Ellington said, “If it sounds good, it is good.”


#14

Uggh! I hear ya. Makes me sludgy and angry/frustrated that I am trying to do the right thing and it’s not working. Also that feeling that “I have to live with this thing plugged into me continuously and if it’s going to keep screwing me up like this I don’t know how long I can stand it!” I call that feeling T1 Claustrophobia. Important to remember that the problem of course is NOT YOU, and there are lots of tactics and fallbacks. You will be ok.

One thing you can always do, of course, is jump out of auto and manually administer your own correction dose. Kind of defeats the point of automode, but a fair tactic while you’re still struggling to get it configured right.


#15

My Getting started using Auto Mode for the first time states:

Individual Bolis Settings
To enter your Carb Ratio and Active Insulin Time as individual settings

b) Select Options
c). Delivery Settings
d) Bolus Estimate Setup
E) Select CARB RATIO or ACTIVE INSULIN TIME

This would indicate to me that you can change Correction Bolus values, but then the Guide may not be well written.


#16

Well, it’s actually the Insulin Sensitivity setting that is for corrections, and yes, there is one, but it is only used for doing a correction bolus with the Wizard in manual mode. It isn’t used in auto. There is no “correction bolus” as such in auto. You have to enter a carb amount for the wizard to do anything, and there is no manual bolus. Some people get around this by entering “phantom carbs,” but that messes with the algorithm. Better to just drop out and do it in manual.


#17

I guess I am confused with the terminology. When I go into History, Summary, I see BG Correction which represents the insulin infused when I enter a high BG number into the Bolus Wizard. To my mind, that represents a bolus correction.

Now, In auto mode, if I have two settings in the Carb Ratio setting. when I enter a high BG into the Bolis Wizard, will the Wizard infuse insulin based on the applicable time range in the setting?


#18

I’m sorry, I misspoke. In automode, if the sensor gives a reading over 150 the pump will recommend a correction bolus, but the method it uses to set the size of the bolus and control the microbolus rate as it brings your BG down is determined by the algorithm in a way that doesn’t make use of the Insulin Sensitivity setting. If it did, it would be vastly easier to get the pump to be more aggressive about corrections by tweaking that setting, but alas, no. I tried changing that setting for this purpose when I was still in training, because it’s completely intuitive that the algorithm would work take it into consideration, but it doesn’t do a thing. I’d be up around 240, ask it to do a correction bolus, and it would blip out a paltry .75 units and leave me hanging up there for hours, no matter what that setting was. When I asked my Medtronic trainer, she confirmed that the setting is only for Manual mode. The only thing that worked was dropping my AIT, which allowed the algorithm to calculate a larger initial bolus as well as a larger amount per microbolus.


#19

Went to my Endo for my second appointment. The NP grabbed my pump and changed me back to 1 carb ratio. Albeit, a whole 2 units lower than my previous setting. Which is what I was incrementally changing. Again she took my basal rates to only 3, the whole day.

This goes against what 6 other providers and 3 dieticians have explained to me about metabolism and glycogen production due to stress/life/busyness.

I like her as a person. She didn’t judge me or anything. She said I was in way better control than most of her cases. She says I just stressed to much and needed to relax and that was affecting my blood sugars a lot.

She also said I needed to start using dual boluses when I eat fatty foods. I didn’t even know you could use those with the wizard? I’ll have to read about it.

Also I do have type 1 my labs confirmed. I make no insulin and have no measurable antibodies anymore. She said it’s either age or I have an antibody type that is rare and they don’t test for.

I’m meeting with the pump trainer locally next Wednesday and I’m going to quiz her on what affects the algorithm and how many rates other patients have and her favorite providers in a 60 minute radius. I’m mildly concerned.


#20

Thanks for the insulin sensitivity info. I’ll ask the Medtronic trainer what she recommends to counteract the paltry corrections.