New PING startup... basal questions

Diabetes Technology Insulin Pumps
#1

Looking for a little advice.

14 year-old daughter moved to the pump on Tuesday. Endo office “outsources” the pump startup to Animus. The Animus “diabetes management team” hasn’t really given any meaningful feedback. They are gone for the weekend… but the diabetes keeps going! :slight_smile:

We think we need to make some changes, and want to make them today, so we have at least a day to watch them. Daughter returns to school Monday after a week-long spring break, and we believe changes are probably in order.

Here is a little background.

She was on 12 units of Lantus, and TDD was maybe 22-26 units depending on meals.

On the pump now for about 4 days. Round the clock testing, generally every 2-3 hours.

Insulin to Carb ratio is set for 1:20.

From midnight until 3:00AM, her basal is set to 0.425. Almost all of the readings we have are in the 85 – 115 range. One time she dropped to 73. Her numbers are always lower at the end of the cycle than they are at the beginning.

From 3:00AM – 6:00AM, her basal is set to 0.450. Almost all of the readings we have are in the 117-126 range. They seem fairly consistent… if anything they go up a few points, but not much. It’s a pretty tight range.

The next basal setting is from 6:00AM to 6:00 PM, and is set at 0.450. During the beginning of this basal she is usually sleeping (spring break), and while sleeping she will usually stay in the 110-125 range. She will usually eat as soon as she gets up.

There was only one time she did not eat immediately after getting up; she was up for about 45 minutes before she ate. She dropped from 111 to 95 in that 45 minutes.

During this basal period (6AM – 6PM), when she eats, it looks like it usually will take about 4 hours or more before she gets back down to her pre-meal level (depending on what she eats). After that, she’ll just keep dropping. We generally run into the next meal, or, she will start to feel a bit low (slight shaky), so we will test (confirming low) and snack with 15 carbs. That gets us to the next meal.

From 6PM to 12AM, her basal is set to 0.475. We usually eat around 8PM. She will generally be in the 95-110 range before dinner. Approximately 60 carbs for dinner. Between 10PM and midnight, she’ll be 170 – 200. Eventually she’ll drop into the range described in the first basal cycle.

So………….

We are thinking that we should make the following changes:

Move her from an Insulin to Carb ratio of 1:20 up to 1:17 because of the long time it seems to take for her to return to her pre-meal readings. When she was on shots, she was at 1:15, and that seemed to be working OK. We thought we’d make changes slowly, so we picked halfway between 15 and 20.

We believe the basals are too high, given that she seem to continue to drop, rather than stay constant, during at least 2 of them.

We are thinking that we should drop her basal in the Midnight to 3:00AM to 0.400 (from 0.425). Maybe the 85-115 are good numbers, but at this stage of the process we are thinking that they are probably good numbers for the day, but are worrisome for a nighttime number. Plus, she’s entering this basal cycle at 170 – 200 from dinner, and gets into the 70-90 range by 3:00AM.

We believe we should keep the 3:00AM to 6:00AM where it is, given that she seems to stay fairly even.

We believe we should drop her 6:00AM – 6:00PM basal from 0.450 to 0.425. This is based on our observation that she continues to drop until she eats. (We also think we’d need to adjust the time slots of these two basal cycles; she seem to do well with a 0.450 dose while sleeping, but should drop down upon waking. During school, we’d set the changeover for when she wakes at 5:30, and then reset it for the weekends, when she typically likes to get up at the crack of noon!)

We have no idea whether we should do anything with the 6PM – Midnight basal because it’s not clear that we have enough data to draw any conclusions. She seems to drop until we get to dinner, but she is generally pretty high for the remainder of that basal phase (because of what we believe is an insulin to carb ration that is too low). We expect that increasing the insulin to carb ratio will help. And, after making some adjustment to the other basal rates, we’ll do some basal testing next week for this basal cycle.

Do these changes should reasonable? Again, we’re new to this, so trying to understand the thought process. Too many changes at once?

Thanks!

==> Mike.

#2

Ok, first some general comments. You don’t mention during the day how high she goes after meals but just that it takes 4 hours or more to drop to pre-meal level. What is important is that she not spike over 140 two hours after (some use 120). But I’m going to assme it’s similar to her dinner? She is obviously going too high two hours after dinner. I’m not sure who suggested you change your I:C ratios, and especially not change them by that much at once! Mine have gone only up a very small amount since MDI’s (I’ve been on the pump 3 months). I believe that is because my basal on MDI’s was covering a bit of my bolus needs. The belief is that you should get the basal correct first than the bolus will follow. According to John Walsh you should rise or drop no more than 30 points overnight and during the day you should stay fairly level (I don’t know that many people’s blood sugar is stable enough to always return to the exact pre-meal level, for many of us that isn’t a reasonable expectation).



As for the basal, yes, if she is dropping that much during the day (going from what I assume is high after meals to lows before the next meal) then her basal for that period is too high and your idea to drop it a tad and see what happens is sound. Remember that John Walsh suggests a three hour lag for basal action. So if she is low say from 10AM to 6PM you would want to drop it from 7AM to 3PM.



I think you are definitely on the right track. I agree that too many changes at once can muddy the water, and the protocol is to get the basal right than worry about the bolus. But my gut tells me you are right that your bolus is quite off and is probably closer to your original bolus. I don’t know if you use paper logs or meter logs but whatever you use be sure and look at the patterns of when she has highs (for example 2 hours after meals that equal bolus) or when she has lows (between meals, waking or before bed) that indicate the basal for those time periods (with the three hour delay) are too high.



Also if her highs after dinner are persisting for four hours: If she is eating 60 carbs and the meal also includes a lot of fat, she is taking longer to absorb the carbs. You might want to consider an extended bolus if this is the case. But first try with a lower carb less fat meal with a better I:C ratio to see if fixing the ratio fixes the problem. Also,if you don’t already do this you might want to bolus at least 15-20 minutes before the meal to give the insulin time to work. But this timing thing is really fine-tuning after you get the basal and the I:C more accurate



Hey, you’re doing a great job,; I think it’s especially hard with such a recent diagnosis to learn all the ins and outs of D management AND the pump basically at the same time. I was on MDI’s for almost two years before I started my pump and it was still a steep learning curve! Keep up the good work!

#3

Thanks for the thoughts! We do have the Walsh “bible”, but Animus seems to have other ideas.

Here is a brief look at two days of readings (TH/FRI)

08AM: 119 bg, 54 carbs (b’fast)
10AM: 190 bg
12PM: 145 bg 56 carbs (lunch)
02PM: 192bg
05PM: 105bg
08PM: 97bg, 17 carbs(dinner – wanted low carbs to try basal testing during night)
10PM: 184bg
01AM: 103 bg
03AM: 86bg
04AM: 94bg
06AM: 122bg
09AM: 111bg
12PM: 122bg (59 carbs)
02PM: 185bg
04PM: 94bg
05PM: 76bg (17 carbs, uncovered)
06PM: 124bg
08PM: 106bg

I am going to go back to re-read the Walsh lag time on basal. I understand what you mean… that if she is not a level we like at, say, 1AM, then it could be caused by the basal setting at 10PM.

Oh, and another peice of info… they have her target number set at 140 +/- 10 during the day, and 150 +/- 10 during the night.

I’m so glad that we signed up for this board… we learn alot. THANK YOU! :slight_smile:

==> Mike.

#4

Looking at that list, Mike, it definitely looks like her I:C ratios are off, because she is consistently going high even with the low carb dinner. I don’t know if Animas told you to change those ratios from what you used on MDI but they obviously are not working.

Also, at noon when she had lunch, since she started out at 145, If it were me, I would have included a correction dose with the lunch bolus. I’m guessing that you didn’t because you were following the Ping recommendations. Since you have her target number set at 140 plus or minus 10 the ping would not have recommended a “Bg” addition (correction) because 145 is within the parameters. But when you start at 145, where else can you go but up unless you take some extra insulin? The solution to that would be either to ignore the recommendations and add a correction dose (do you know her correction factor?) or to reset the target. It took me a really long time to comprehend the purpose of the target number on the pump settings because I was thinking it was like on MDI’s when I thought of a target as where I wanted to be. My after meal target is to be under 140, but the target on the pump is different (John Walsh explains this too!). It is the number the ping corrects to. Maybe someone else will explain this better, but especially before meals I would think you would want to be lower than that so you might want to change that.

#5

Looks like the changes you are suggesting make sense. I did not have to change my I:C or correction factor when I started on the pump (YMMV). I use Humalog, so if I am having issues dropping, I start by lowering the basal about an hour before the drop starts. Her sensitivity factor is really high (that’s a good thing!), so make the changes as small as you can.

Good luck!

#6

Hey Mike, it sounds like you need a new endo!! Seriously, my doc set my basal settings and adjusts them when we met. That being said, ideally you should do basal tests - which means fasting for portions of the day. I wouldn’t necessarily adjust basal rates with unfasted bg values. There should’ve been a handbook with the pump that explains how to do fasting basal rate doses.

#7

This particular ped Endo practice is very busy, and you really don’t see the docs (maybe a couple of times per year. I believe there is only one other in the area, and it sounds like the same thing. And ours is the only peds Endo covered by our insurance.



I’m sure it will be fine once we get some experience with pumping. I think we’ll only need the Endo if we run into a really strange puzzle, and need a good troubleshooter. I think they would be good at that.



Really, the problem is that they are just to busy to do adequate training. They rely on Animus (or Medtronic) for that. Our initial startup was OK, but now that we are seeing numbers, and trying to fine-tune, we are lacking a strong support mechanism.



We do have the Walsh books, and the written documentation. We are trying to work through the basal testing on our own. What would be helpful is to have support from animus or the Endo practice.

… Someone we could call to bounce ideas off of… to guide us as we are feeling our way through n



I know we’ll get there. What is frustrating is that it’ll take longer than it needs to, and probably require many additional finger pomes, and nights of interrupted sleeping for my poor daughter!

#8

Thanks Emily.



Because we are attempting some of these tweaks on our own, we do intend to go slow. Problem is, I’m told that sometimes the slow changes don’t have much impact. For example, a few weeks ago, we were keeping in a nice range. Then, out of the blue, our daughter started trending downward. It looked like the I:C was working predictably, so we started lowering her lantus dosage. She was at 17, so we tried 16.5, then 16. We were eventually able to speak to someone at the Endo practice, who indicated we were on the right track, but that we needed to drop the lantus by at least 10% before we’d see changes. We would’ve been very reluctant to make a change of that magnitude on our own.



I even posted this same question to another group, and was told that trying to change 0.025 would not likely change anything… that you really need to change by 0.1 or more.



Of course. We are not ready to try something like that after just 4 days on the pump. Caution is the wise approach.

#9

I have a TDD of about 45-90units (depends on stress level at work). When I change my basals, I do it by about 0.100 units (my basals run between 1.0 and 2.0u/hr). I would expect for you to see a little bit of a difference. However, if she is dropping by approx 50/hr, I might try 0.050.

#10

Do they not have CDE’s you can work with or RNs that have more time? However it sounds like you probably have way more know how than the normal RNs do with the Basals changes and ratios. I must say I think you are doing awsome. If I ever need some help I will be shooting you my ratios. :slight_smile:

#11

One thing to keep in mind while making changes is the “Domino Effect” . . . as a tiny change in one place impacts everything else. Making basal and bolus ratio changes at the same time also muddies the picture . . . as you don’t know what impacts what. TINY incremental changes in basal rates make a HUGH impact on blood glucose . . . relative to the impact of a ratio change, and the adequacy of “insulinization” from basal insulin, prior to a meal, significantly impacts the post meal rise.

If there is delay in return to baseline, following a bolus, but you actually do return to baseline, then the bolus ratio is probably close to accurate.

And, last but not least . . . everything is going to change once she goes back to school . . . stress, activity, sleep schedule etc. etc.

Your records and analysis show that you are doing a great job in deciphering the waters of pumping . . . and experience will help you learn how your daughter responds to insulin from a pump!

#12

Thanks Leilani.

Yes, it’s the return to school that has us more worried than anything else, specifically because of the increased activity, stress, etc.

What we believe we have been seeing over the past several days is that she would return to baseline after a meal, but then keep dropping. Not a sharp drop, but a slow drop nonetheless.

There was one day where she did have activity, and that seemed to accelerate the drop. Mild activitity, and certainly much less than she’ll have a school.

We did a little basal testing, as best as we know how. We ate a breakfast, skipped lunch, and tested every hour. She just kept going lower until we finally decided to abort the test and let her snack. We then set a temp basal of -10%, and that seemed to keep her more even. We tested at 2AM and 3AM, and again at 6AM, and were more comfortable with her numbers.

We are watching and testing again today, with the temp basal set at -10%. We need one more test in order to help reassure us that we’re on the right track, but so far, so good.

Of course, it’ll all be out the window tomorrow when she goes back to school. But, our experience over the weekend gives us a baseline that we are more comfortable using as a starting point, and a bit more confidence in our abilities to look at this and make decisions / adjustments.

Still a long way to go, but you’ve got to start somewhere. What’s the saying, “You eat an elephant one bite at time.” In this case the question is does one bolus for an elephant? :slight_smile:

==> Mike.

#13

I have to agree. YOU are doing a fabulous job.
Thoughts:

  1. Is your daughter (and you) open to a CGM? Go with Dexcom if possible.
  2. FDA requires an Animas employee handle the first 30 days of insulin. Blame the gov’t for this, not the endo outsourcing.
  3. Remember “dawn effect”. BG goes up about 10-12 hours after last meal.
  4. Call the Animas CDE and ask for a 7day contact information. When I went on my Ping 2.5 years ago, I had my Animas CDE’s cell phone number and permission to call 7 days/week. None of this weekends off stuff.
  5. What is the half life of the insulin you are using in the pump - although it is published, what do you see in your daughter?
  6. What is her activity over the day? emotions? stress?
  7. I wear a CGM but still test before every insulin dose and three hours later. So about 6-8 times per day.

Jay

#14

Thanks Jay.



I’d love to be using a CGM… and the Dexcom in particular. I believe our endo practice would prefer that we take this a step at at time. I pushed hard – real hard – to move to the pump this early. I think I’ve used up my favors for a while! :slight_smile:



That FDA ruling is downright scary. I’m glad you told me that. Do they need to “approve” us?



Oh my… this could get ugly!



What is the Animus CDE? We are in an unusual situation. The sales rep is gone, and the local sales manager is gone.



Anywhere I can read up on this FDA rule?



Now I’m worried… I thought the doctor was the only hurdle between us and the pump!

==> Mike.

#15

I kinda really don’t think the FDA requires an Animas employee to handle the management of their pumps/insuiln for first 30 days . . . or they wouldn’t have to have a Doctors order to do it. They of course need to be available as needed for consultation . . . but the Endo or ordering physician is the one in control or the one deferring control.

#16

If she is dropping below target it is reasonable to adjust basal and/or bolus down. Some Doctors actually start with basal rates/ratios that keep BG above target so they can slowly tighten control downward . . . as lows make it very difficult to determine actual basal/bolus need due to rebound and need for treatment of hypos.

#17

Just started on my Ping 2 weeks ago, and the CDE at my endo’s practice ‘handled’ everything, there was no input from Animas. Maybe the ruling has changed?

#18

I think it is according to the Endo office b/c ever single time I’ve ever started on a different pump I have also had my Endo’s office handle it. They had a set trainer for all the pumps.

How is it going with your Ping start up? Do you like it? I think it is a wonderful pump and now that Animas has Diasend I think this will be fabulous!