Into the Looking glass....pump possibilities?

I just saw you flagged me here. But I'm not entirely clear on what the question is.

As far as bolus (including correction) insulin goes, a pump is just a fancy syringe, with the ability to help you calculate doses, keep track of insulin on board, extend a single dose if you prefer, etc.

As far as basal insulin goes, a pump gives you granular control relative to something like Lantus, i.e. you can adjust your profile to give you varying basals over time and you can adjust on the spot to affect your basals in the subsequent hours.

So controlling spikes isn't very different with a pump than a syringe, except that the pump gives you more options. One nice option is if you overcorrect, you can kill your basal for a few hours, and reduce somewhat the impact of that overcorrection.

I hope that helps. I'm not on here as much these days, in part because I've been doing a ton of international travel.

So many questions and thoughts. Forgive my bluntness. I am not trying to be mean, but trying to understand your dilemma.

My first take in looking at this data is that your conclusion of 150 mg/dl rise/hour is counterintuitive unless all your exercise is anaerobic. IOW, from my perspective, I doubt your conclusion.

As I get a bit more granular, I wonder if it is possible to actually come up with any conclusions with this big of a swing in BG values. 57 mg/dl @ 3:40PM and 20 minutes later, you start DH skiing? Yes, that seems like a public (and personal) health threat!

Questions from the data:

You had a 9AM cereal of unknown carbs and bolus?

What type of soda did you have with the Egg salad @ 3:13P?

How are you treating your lows and how much do you think 1 carb gram raises your BG (when not exercising)?

What is your I:C ratio? It seems like part of your later low was the last of the 10 unit correction kicking in starting @ 10PM.

What do your BGs look like on a "normal" day? Do you think your basal insulin is appropriately working?

I agree it’s hard to figure out these sort of D-problems!

I think I was gonna ask you if you could take a big 12 unit bolus on a pump, which I guess you can, but maybe that's not the best way to go about it. No problem, appreciate the reply. Have fun running around! Steer clear of gypsies and chicken feet. That advice should cover you wherever your going. Have fun!

I don't think I really understand my dilemma either, no prob.

I think downhill skiing is anaerobic, but I'm getting similar spikes during x-country, which is more aerobic.

I think the front end of the exercise data is 'noisy.' I don't know whats going on there, but I suspect I may have been dropping because I was getting little increase in BG after eating quite a lot.

Cereal was 45g, 6 unit Humalog, at 9m, but I blacked out the data because I didn't have sensor readings to go alongside it.

Diet soda.

12-15 grams may increase me about 60 points. So, about 4 or 5 points per gram.

I:C is 2 units per 12-15 grams of carb.

Basal is working O.K. If I'm stable during the day, with 35 units of Lantus, I might take 6 units of correction mid-morning (around 10am) and will tend to run low in the evening. Its remarkably stable overnight - it might vary less than 10 points. Until I wake up and it starts to rise, requiring a mid-morning correction bolus - 6 units on a good day, 12 units on a bad day.

If I lower the Lantus to 34 or 33, I run much higher in the morning, but will stabilize in the eave. If I do that, then I might wake up around 3am and bolus an extra 4 to 6 units to counteract the highs that develop.

I don't know what you consider appropriate for basal behavior, but I am have certainly identified a greater need for basal insulin between waking and 2pm. A pump might have to come to bat for varying basal requirements, especially when I add exercise into the mix.

It gets real bad when I patrol at a mountain with all double and triple black diamond runs. When I started doing that, three or four years ago, I really started to see how volatile the system becomes during exercise. I think I need to be a better diabetic, now, in order to be a better athlete. God help me if the ski patrol has to come to my rescue. I would rather eat a cyanide pill in the woods.

When I skied downhill, I found it to be aerobic (but, I tried to avoid double and triple black diamonds, and especially mogul patches). My BG always dropped. In addition to glucose tabs, I almost always found myself consuming Reese Cups or a giant Snickers Bar for the protein from peanuts. This was really before protein bars were widely available.

Your I:C is somewhere in the 1:6 - 1:8 range. How much does one unit of Humalog lower your BG (your ISF)?

Your basal sounds problematic (aka not "appropriate") because it appears that you have a strong Dawn Phenomenon that the basal can't cover. This is one of the key areas where a pump would be helpful to you. Have you discussed taking some Humalog hourly starting @ 6AM with your endo?

The other area where a pump would be helpful is with exercise. This was one of the primary reasons I wanted a pump. I found that exercise was nearly impossible on MDI and required frequent breaks because my BG would drop precipitously and dangerously. When I played tennis, I would pack my cheeks with peppermint candies to give a "constant drip" of sugar into my system. That was a real hit or miss deal. I also found that afternoon or evening exercise would regularly result in severe lows around 2 - 3AM.

With a pump, I can modulate my basal rates way more effectively to allow exercise. Yesterday, I rode my road trike 36 miles. Before breakfast, I set my basal rate to 50%. At the start of the ride 1 hour later, I set my basal to zero with a BG of 114, One hour into the ride, my BG was trending mildly down and it was in the mid 70s, so I ate 3 glucose tabs. Just over an hour after that, I finished the ride @ 123, took 0.3 units to correct and restarted my basal. I have had other rides where I have worked harder and had to eat a protein bar, and have had my BG down into the 40s, so it's not always perfect, but I feel confident that I can handle those lows because I know I have little to no insulin on board.

FWIW, I found that my TDD of insulin dropped along with my I:C when I went on the pump; many others have had the same experience.

Yea, I dunno if increasing the intensity of the skiing makes it more anaerobic or more aerobic - kinda both, that's why Iv'e been try to do some Xcountry tests. If I had to guess, I'd say downhill is mostly strength and balance, until your really jumping all over the place like a goat.

I see my Doc Wed, so I will inquire about adding some hourly Humalog. Thats a good idea. I hadn't thought of that. I've been discussing it with the pump group, so I'll take your vote as one for pump AND TDD decrease. Thanks for looking so closely at the data, I know that's a pain.

ISF...I dunno if I can answer that. Its all over the map, according to time of day and activity level. I generally use 1 unit to lower BG 25 points. Sometimes that works and sometimes not.

Here, I run the exercise test with some active insulin in my system and that prevents the peak, but I over do it a bit and run low. Its a work in progress...

The thing that jumps out at me, is if your basal is correct, then your BG should come down more after the correction, but if your basal is off, then your corrections are just a pure guessing game.

I think the basal is as correct as it can be, as one solid dose. 35 units of Lantus is what keeps the data stable overnight. If I wanted to target that DP more, I could bump up to 37, but that's gonna lead to overnight lows and increased lows in the eave. Do you follow my reasoning? I would agree that there are periods of the day and during exercise where corrections are largely educated guesses.

I definitely get your reasoning. Increasing the basal might help some with the morning, but then leads to a crash later, a real "damned if you do, damned if you don't" scenario.

But, with your seemingly variable basal requirements, a flat line basal insulin just doesn't match up, and that leads to a whole bunch of other variables because you are are hitting the increased basal BG with a bolus sledgehammer.

Have you talked with your endo about splitting your Lantus dose (maybe 60/40)?

Nope. I've never split or delivered anything other than one basal, even when I was on a pump. I will ask her. That, as I think about it, might do the trick. And, its pretty simple and easy to implement. Thanks for the perspective!