Insuline dilution : Toddler with type 1/ pump

Type 1 and LADA Parents of Children with Type 1 Diabetes
1

My two years old was diagnosed in December 2016. She has MDI ( breakfast, lunch, afternoon snack, supper are Novorapid and bedtime Levemir). On average, 14 units of insulin per day. We apply ratios for her dosage according to her meal
Plan. Carb counting, of course.

We selected the Omnipod… but the Endo said the insuline might need to be diluted. Is that sufficient to renounce to the tubless pump? Are we compromising on better treatment?

Also, this is her second A1C, and the score is the same as the first. It is so discouraging, the amount of work that I have put in, to have the same score.

2

Insulin can be diluted to give you more granular control when delivering small quantities of insulin per day. I’m sure there are a few parents of T1Ds here that will be able to give you relevant info.

One of the strong features of an insulin pump is the ability to deliver very small quantities of insulin, as small as 0.05 bolus increments and 0.025 basal increments. Maybe you won’t need to dilute because of that fine dosing control.

If you decide to dilute your insulin you will, of course, need to do that with the help and advice of the doctor and/or a pharmacist. You must use the manufacturer-provided diluent.

Good luck and let us know what and how you do!

3

Hi there, my daughter is 10 and has been using the Medtronic pump since she was 7. We have the older verson of the pump (530) but we chose it because it’s ratio’s can be changed in .1 gram increments. I just looked up the Omipod’s stats and it’s ratio’s can only be changed by whole numbers. That’s crazy!

My daughter uses about 34 units of insulin a day and still typically has ratio’s set at mixed numbers such as 9.6 etc. Medtronic also does very fine basal rates, but perhaps the Omnipod does too. You probably know this but only rapid insulin is used in pumps and so the pump has a ‘basal’ setting where it is trickling small amounts of novarapid into their blood 24/7 to act as basal. For a 2 year old these amounts would have to be very small as well.

I would say thought that in my experience any pump would make life easier for you and your daughter!

4

Hi there!

I’m sorry about your daughter’s diagnosis.

My son was diagnosed when he was three and started pumping with OmniPod a few months later. When he started pumping, he was using less than 2 units a day on injection therapy. Although he started pumping with undiluted insulin, the plan was for him to use diluted humalog. We got the prescription filled, but never ended up using it bc we didn’t have to.

Caleb had been using NPH and Novolog on injection therapy. When he stopped using NPH, we found his TDD increased pretty significantly - he was using closer to 3 and 4 units a day and we were able to manage with undiluted insulin and the Omnipod.

Two things required our specific attention to make it work. We had to be careful with corrections bc even the 500 ISF could be too sensitive for Caleb. Also, we manually shut his basal off at about 1 am every night for a couple of hours to prevent lows as OmniPod’s lowest basal rate is .05 per hour. An alternative to that would be to target a higher nighttime bg, but we preferred getting up.

If you are using 14 units a day, I think it would definitely be manageable, but knowing the distribution of those units would provide a better basis for analysis.

Caleb’s endo was reluctant about Humalog only bc the Yale Clinic (which is where Caleb was being treated) found that Humalog had a greater incidence of clogging in pumps as compared to Novolog. We could have given the Humalog a try, we just decided not to since we could otherswise make the Novolog work and didn’t have to worry about the increased risk of clogging. Only humalog could be diluted at the time. That was ten years ago.

5

I dilute insulin all the time. There is nothing wrong with using diluent. At 14 units you are on the borderline of maybe not needing it. What is your total basal dosage per day (not counting any meal time doses)?

Are you using a Dexcom?

How often do you dose the Levemir? If you are only doing it at night, you will have much better success splitting it into two doses, morning and night, about 12 hours apart. I swear to you, that will work better. I promise!

The only trick will be to figure out the amounts. You don’t have to split it evenly, you can split it any way you want, but you will get better coverage throughout the day. And if you need more at night than you do in the day, you can split it that way. For example if you are taking 7 units, you can split it 4 and 3, or 5 and 2, or split it however you need to.

Having a toddler without worrying about the tube is a really the best option. I can put you in touch with the parents of two different 3 year olds who use omnipod.

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Thank you for taking the time to respond

7

Thank you for your reaponse

8

I took notes. Thank you for all the important info. I will persue to research.
What is TDD?

9

Total Daily Dose. Caleb’s was less than two before he started pumping, it nearly doubled when the NPH was removed. Either case, it’s far less than the 14 your daughter is currently using.

Is there a specific setting you are worried about more than others? Like basal or correction factor? Or are you just uncertain about what to expect bc it’s all new?

When Caleb started pumping, we were told the OmniPod would never work for him bc it was too big for his body. We really pushed it bc it was important to us that he be tubeless. We didn’t feel like we had anything to lose. If it didn’t work, we’d try something else, but we felt we had to try.

10

We are only using 1 basal, once a day, 4 units of Levemir.
Injections of Novorapid : breakfast, lunch, pm snack and supper. Until last night I was giving a night injection. The endocrinologist ask me to stop to see how the Levemir is acting. It’s NOT correcting her, even if she has a nice number before bedtime 8pm she will be high as of 10pm.
As hard as I’m working to bring her BG down, two shots in the morning (spliting the long acting) breaks my heart.

My daughter doesn’t have any hypoglycaemia symptoms…the Dexcom is keeping the glucagon away!! I am not able to analyze her trends (beyond knowing she is high from 3pm to 6pm and after 10:30pm).

I would appreciate learning from other parents/caregivers of toddlers, thank you!

11

We are in Canada. The pump is covered by the government. The medical team wants to remain impartial and do not recommend one pump over the others. The pumps available are Medtronic, Animas and omnipod. We met with the sales rep from the companies. They slaughtered the pumps from their competitors. In terms of reviews andbtestimonials online, I don’t know if people receive perks (money or products) to post. One of the sales rep said that diluted insulin in the case of Omnipod would be detrimental to her! When the endocrinologist mentioned it, I was concerned.

12

Oh. That context is helpful.

“Slaughtered” - that’s unfortunate.

They all do the same thing - deliver insulin. They pretty much do it all the same way. There are some nuances bt them that are worthy to consider. I forget what they all are now. I remember Animas allowed for 0.025 basals which was a big advantage at the time. I think both Animas and Medtronic integrate a CGM display on the pump now. Animas is Dexcom and Medtronic is their own, Enlite. Omnipod’s advantage is tubelessness. My son has been using the Medtronic for a couple of months. The tubing is not as big a deal as I expected, although it is an inconvenience. But baseball season is approaching and we’ll have to figure something out for that. Summer and swimming are approaching and he can swim with the Pod - MM and Animas may be waterproof now, but the Pod seems more convenient anyway. To me, it’s all a personal preference. It has to be what the user is comfortable with. There is no wrong choice, just better choices than others based upon personal preferences.

Other than the .05 v .025 basal rate, I don’t see any material difference in therapy. And as far as diluted v undiluted, that seems like an issue that is completely separate from pump choice, with the exception of needing a basal rate of .025 throughout the day, so I don’t understand why anyone would say diluted insulin combined with OmniPod is specifically detrimental. There aren’t many people using diluted insulin, but I remember finding one user way back then. The hardest part was finding a pharmacy that diluted it. You also had to properly convert the settings, but that’s just math.

Just a quick, back of the envelope calculation, if your daughter’s dosing is half basal and half bolus, that leaves about 7 units of basal insulin, spread over 25 hours is about .30 units per hour. That does not seem to warrant diluted insulin anyway. Did the endo suggest why that would be needed? Maybe based upon her age? Or perhaps there are certain times of the day when she is very insulin sensitive?

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Can you tell me the time of day you are doing the meals and injections? For example, if she is fine at 8pm but high at 10pm, seeing the times of the meals and doses would tell us if it is a problem with the basal or the meal injection.

I am not sure what this means. You used to give Novo at night to prevent a high BG?

If she has flat and good BG 4 hours after a meal, and then starts to rise, that sounds like you might need to increase the amount of the Levemir.

I know this seems like it’s unpleasant to give an extra injection, but you get much better control with more injections. For many people, Levemir does not last a full day. By splitting up into two doses, you help to make sure you get coverage for the whole day.

If you can give a general outline of your schedule, that would help. The time of injections, the time of the meal, the amounts of insulin, and the BGs you are seeing. Just a general overview. Looking at typical day will help make sense of it.

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14

I wasn’t able to potty train as the onset of the diabetes was affecting her already. If we would be out of diapers, I would be more flexible with tubs, maybe… but she’s two and LOVES scissors!!! Every thing is a hazard and the tubs will not last. Another major issue are the available programs. Toddlers are unpredictable, between catching colds every 3 weeks in the winter, to going through their terrible 2s, having settings that can adjust to their little bodies and lives are an asset for the management.

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15

We are not on a pump but we apply ratios for dosage: correction (BG-8)/7.5
Breakfast 1:6.5 @7am (25g carbs)
Lunch 1:14 @11:30am (25-30g carbs)
Snack 1:13 @2:45pm (15 g carbs)
Supper 1:16@6:30pm (20-35g carbs)
Levemir @ 7:30pm/8pm

Night injection was to bring down BG.not to prevent.

16

Whoops! I missed this. 4 units a day is more like .15 per hour.

Caleb was only on injection therapy for a couple of months. He only had two shots a day. Even with just two injections, pumping was liberating. It’s more work to manage dosing and monitor bgs, but you have more control. At least that’s what I found.

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If you have to give an injection at night, it is either because your dinner dose is not enough, or because the Levemir amount is not enough.

If she is okay 4 hours after dinner, but then she starts to rise, that probably means your basal is too low. Unless it is a high fat meal, the food would mostly be gone 4 hours later.

Are there any other times when she always has high BG or when you always have to give her a correction? Does she have high BG between meals?

It might be that her Levemir is not enough, but you don’t see it during the day because the other meal injections are covering part of her basal needs.

Have you ever adjusted the Levemir dosage? The 4 units - did your Endo give you that number as a starting point, or is that what you have come up with after trying it and making adjustments?

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18

She does spike high between meals. Her BG rises after her nap at 3 pm and nighttime. The adjustments are tricky because the pen injections only had .5 units: either too much or too little / hypos it hypers. The initial Levemir dose was 0.5 and last night 4.5. We will be on the pump in 6 weeks. Now that winter is over, we may also see better numbers with the increase of outdoor play.

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With the pump you will be better able to adjust. Those .5 unit increments are tough on a young one (they are even tough on an old one, like me).

So as a general rule - if the food is completely gone and you had enough insulin to cover it but you still see a rise in BG several hours later, then higher basal is what you need.

But if the BG never came down from the meal, if it never leveled out, then you might not have had enough to cover the meal.

A very general guideline:

  • A problem 1-4 hours after a meal = a bolus problem
  • A problem more than 3 or 4 hours after a meal = a basal problem

If you want to share CGM traces along with the timing of the doses and meals, it can be helpful to troubleshoot that.

I am glad you are getting a pump for your daughter. Are you going to be using the OmniPod? This will help you a lot.

Don’t be afraid to make very small adjustments to basal settings with the pump until you get the correct settings figured out. Your endocrinologist or pump trainer may tell you to leave it alone for weeks and to contact them, but in reality, what you should do is wait a few days, make a small adjustment, try it, and readjust as needed. Always wait a few days to make sure, and then make only small adjustments. The settings the pump trainer or endo give you are just their best guess. You will know better after observing your results.

Also, with the pump you can set different basal rates for different times of the day. With the OmniPod you can set up to 24 different rates, in 30 minute increments. Don’t feel like you need to have the same basal rate all the time!

With the OmniPod you can give 0.05 unit doses as needed. Compare that to what you are currently limited to, 0.5 unit increments. That’s 10 times more granularity.

Also, one of the most important things is to make sure your basal rates are correct. That will make it so much easier. And the best way to do that is a little bit tough, but it is by not eating for several hours and closely monitoring the BG. So for example, after breakfast, make sure the BG is level and then just watch. Either skip lunch or have a late lunch so you can make sure that basal is perfect. I know this is difficult and not pleasant, but it will really help you. If you have to fix her BG with a bolus injection or a snack, then you know the basal was not right…

Let me know if you have more questions. I am happy to help you in any way.

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While you are waiting for a pump… what we do is adjust the carbs in the meal to match the 0.5 unit dose. For example if we give 1 unit for 30g of carbs, and he is running high, we can’t go to 1.5 units, so we would just give 25g of carbs for 1 unit. We make up the lots calories with protein.

I though about diluting insulin, but the convenience of the pens, the effort required to dilute led to the solution above. We have busy lives.

Good luck with the pump. We will get there soon too.

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