New to Pumping

Diabetes Technology Insulin Pumps
1

Hi,
I’ve taken shots for more than 26 years and just starting using the Medtronic 530G pump about a month ago. So far I’m hating it! I’m high all the time. I’m scared to change my basal rates by myself because there seems to be so much to it, insulin to carb rates, correction rates, basal rates, all of which are different at least 3 times a day.

I’m fed up with being 200 all night every night. I decided to raise my basal rate .1 (from 0.7 to 0.8 as the trainer recommended). I did this for 3 nights and each night I steadily rose to the 300s and woke up around 350. I’m wearing the CGM and it’s a steady line up. Any thoughts or ideas about this?

When I took shots, I would get the middle of the night dip. I have seen no dip when pumping.

2

Do you have a copy of Gary Scheiner's Think like a Pancreas or John Walsh's Pumping Insulin?
You can get both for e-reader on Amazon. Think like a Pancreas is written more for the lay person and is an easier read. Both books will walk you through all things pump. With your cgm it will be easier to see your patterns and the books will help you figure out what to change and when.
With your basal rate you need to make the change about 2 hours before you need the effect, But if you are flat all night and are going to bed high then your basal rate may be fine, but your IC ratios or CF may be off.
What happens when you do a correction based on your BG? Does it bring you down to your target? If it does not then that will need to be adjusted.
Also what is your DIA set for? You can see how long your insulin works by looking at your CGM when you correct when you have no food or bolus on board. Regardless of wether a correction brings you down to target the time from when you taken it till the number goes flat is your DIA.

Have you done basal testing yet? That will be the first thing to do. Then you will need to check you IC ratios for each meal. How confident are you with carb counting? If that is a new skill for you then using an app like calorieking or myfitnesspal can be a big help.

Are you prebolusing by 15-20 minutes before meals so food matches insulin speed? If you do and your post meal rise is no more than 40 points then your I:C ratio is good for that time of day.

I know this seems like a lot, but just know that once you get the hang of things it will be much easier. Reading either of the books I mentioned Will make things a lot easier as well. And having them means you have a resource available when ever you need one.

3

I'll look into the those books, thanks. I'd love to see the 'how to' of figuring out all these rates. After dinner I can get back to 140-150 but then steadily go up to about 200-250 which is why I think it's the basal and not the carb ratio, but I don't think the carb ratios are right either and they are different at every meal and other times of the day. I am new to carb counting, which is making this harder. I've used the apps you mentioned, but they seem like guesses at best. I have always just eaten the same amounts of food at the same times which worked fine for me and I don't plan to change. I'll just try to count the carbs more precisely.

When I correct for the blood sugar in the late evening, I go back down to 140-150 again, but raise again while sleeping. It's a mix of things, I need may need more insulin with dinner and more basal insulin. Should I start adjusting meal or basal first?

My DIA is set for 4 hrs, the doctor did that. I'll have to look if that seems right. Is that the same as the sensitivity setting on the pump? That's set to 50 whatever that means.

I have not yet been in the range they wanted for basal testing. They want me to start at 8 or 10 pm between 100-150 and test every two hours. There has yet to be any time of day I am in the 80-150 range except directly after meals and then my blood sugar quickly raises. 70% of my tests are above 150 weekly.

4

The fact that you are rising (and then rising, and rising some more) through the night definitely sounds like your basal is wrong. Continue to make small adjustments as needed. Keep in mind that if you start seeing a rise at 10pm you want to start the basal increase around 8pm. Also know that very rarely will you 'nail down' rates that work forever. For me personally, I have to make changes to my basal rates every 2-3 months. I have to make adjustments to my I:C ratios every few months as well. Insulin needs can vary widely over time.

Once you get to a point where your blood sugar is relatively level from hour to hour (even if it is high!) then you know your basals are probably good and you can start working on adjusting your other ratios to start lowering your blood sugar average.

I also recommend you look into both of the books 2hobbit1 mentioned.

As far as the carb counting goes, if you are eating the same amounts of food at the same times each day you should be ok once you really nail down the carb counts in what you eat. Measuring each food/item individually using a kitchen scale will give you the most accurate information, but if you don't have a kitchen scale measuring with measuring cups, etc. should suffice. CalorieKing is a great resource for taking the serving size info you get from measuring your food and figuring out how many carbs are in each of those foods.

I give you a lot of credit - going from shots to a pump is a big transition and doing that WITH learning to carb count just makes it more difficult! I started carb counting about 15 years ago and I began pumping about 6 years ago - I can't imagine starting both at the same time!

5

When you look at your CGM track when you do a correction how long from injection to when it stops coming down? Need to look when still high 4 hours after a meal with out a lot of fat. If you stop dropping in less then four hours then you will need to reset/shorten you DIA. It can vary from person to person and can also vary with type of inulin you are pumping. I'm using a Tslim with novolog and was first set up with DIA of 5 hours - for me its really about 3:45, so i had to change that.

Carb ratios will vary depending on time of day and when you work on those after you get the basal dialed in then you will need to keep records of food, bolus dose and time of day. I have a different IC ratio as well as a different CF( or sensitivity on your pump) depending on time of day. If you like to do set piece meals at set times then carb counting will actually be easier, Use a food scale to weigh your usual carb portions then use the info on label nutrition panel to calculate carbs. Once you have your usual meals down then you can keep a list of carb counts for meals. using a food scale in the beginning helps you learn what true portion size is so when you go out to eat you have a better wild a$$ guess.

Insulin sensitivity would be your correction factor - sounds like its currently set for one unit to drop your BG 50 points. This may not be correct for you at this time. When you do a correction with no active food or bolus, can you see from your CGM how much 1 unit really brings you down? you can just divide the drop by the amount of insulin to get that number. Be aware that like IC ratio this will/can change with the time of day. What I have found for me is that I need a bigger correction dose which means a lower sensitivity factor over night while I'm inactive than I do during the day when I'm on my feet all day. You will need to work this out for how your body and activity times/levels work.

Your basal will need to be adjusted first, if you dont then you IC ratios will be off as you would be using basal to cover carbs or if you off the other way using bolus to cover basal.

From you CGM you can see that you are heading back up over night with no food or bolus working. This means you need to correct your basal rate for the overnight time frame. If you can see when it starts to trend up then 2 hours befor that is when you need to increase your basal rate.I don't know how many time segments you can program with your pump, mine lets me have 16 so I use a few to help cover my dawn phenomenon.

How much I would increase my basal would depend on where it is now and also how much my total daily insulin dose was. How much are you currently using as basal, bolus and how much are you correcting. If you are a low total insulin user(10-15U total daily) then I would go with 0.1 U increments but if you are using a lot (30-40 or higher) then I would use a bigger increase.

Are you familiar enough with your pump to run a temp rate over night? you can use this to trial an increase. Another option is to set up a second copy of the existing program that you can play with. That will let you see what changes work and then you bring them back to your main program. That way you still have your original settings as a reference.

What is your target set to at this point? Is it different from what worked for you on MDI? I found very quickly that the 100 I was set up with on pumpstart did not work as well as the 85 I had successfully used on MDI. When I began to drop my target I got better results. I use a Dexcom G4 so was able to do this safely, and did it in stages. The combination of the tslim bolus calculator and my eyeball carb counts seem to work better when I use 85 as a target. It means I tend to run in the low 90's when no food or bolus working.

Just be aware that most pumpstarts get done with very conservative settings. Its alot easier/safer to bring highs down with changes than to have to deal with the endless low until the too high basal/bolus/correction doses wears off.

Give me a shout if you have more questions. If your doc wont help enough then you might want to check out Gary Scheiner's online site - they do remote/online pump tuning and lots of good stuff. He is the author of Think like a Pancreas and is a CDA with T1! He is also has a few video interviews on this site, so you might want to check them out as well.
http://integrateddiabetes.com/

6

Please note that you can change your basal rate in profiles, which means that you don't have to use the same rate (0.8U) all the time. you can for example use 1U per hour in the night, and then maybe from 8am to 10am 0,6, whatever you need.
those two books are awesome, please make sure to read this, pumps are so great if used correctly. also look into the "basal-testing" thing, i think it is explained in the book "think like a pancreas"
good luck on your ongoing journey!
SC

7

micarey - You've received some great advice here. Moving to a pump from MDI and learning how to carb count at the same time is a difficult but doable combination. As Kari mentioned, a digital food scale is a great way to calculate carbs. I use the scale for at home meals and then store the insulin dosing results for future use. I just use a simple scale without a built-in food database.

The the pump management skills that you are learning now are highly valuable going forward. Consider it a personal investment that will pay many dividends. I much prefer my own counsel for BG management than the awkward and inefficient process of seeking help from a doctor, nurse or CDE. No one can dose insulin nearly as well as a motivated, informed, and experienced PWD! I see professional BG advice as simply a starting point from which to experiment.

I encourage you to keep a daily diary of some type. You really need it to look past the proverbial forest and start to see "patterns in the trees." A daily diary is a bit of a pain in the tail to manage but it will help you learn things about your metabolism that are unavailable any other way. I don't do it all the time but when my BG control degrades, it helps me get back on track.

Many people that wear pumps do not make full use of its sophisticated delivery options. That's fine if BG control is acceptable. But if you want to exploit the full capabilities of the pump then you need the education upgrade enabled by the books mentioned, combined with a digital scale, CalorieKing (or equivalent app), some methodical personal experimenting, and a bit of time. Think of it as your own personal science experiment.

Good luck to you. You are headed in the right direction. It will not seem as nearly complicated when you look back and realize that you wrestled with this hard problem and won! Doing this will amp up your motivation and confidence to do well.

8

First off, good luck with the pump! I am a new Type I and using MDI right now. I am attempting to get a pump but right now I am arguing with insurance:(. Do you think you will end up liking the pump?, from the replies you are receiving there is some very educated and informed people giving you advice! I will be way over my head if I get a pump, can see that now. So again, wish you luck!

9

Frieda, As a new T1 and if you are considering a pump a good start for you new "normal" would be to read Think Like a Pancreas. The skills taught are necessary for good control regardless if you pump or use MDI. It will help you build your skill set, understand how to monitor and adjust your insulin so you can achieve good control safely.
It will show you much that should be taught by your Doc or CDE, but frequently does not get explained well.

10

Freida- I think I will end up liking it. I am frustrated by the lack of support from my doctor. I will figure it out eventually. One ‘shot’ every 3 days instead of the 5-6 I was taking daily is a lot less painful! I was very weary of getting a pump because of past experiences, but I think I will be glad I did after I can figure out how to make all the variables work together. Wait until you feel ready or you will feel overwhelmed.

11

I'd want to make sure I understood what's going on with your "food on board" as well as "insulin on board" and any other factors before totally suggesting a change although I agree with the generality that more basal might be the answer, although that doesn't solve the question of if .7U/ hr isn't enough, why would mlcarey's BG have gone up in response to .8U/ hr?

There's all kinds of things I've sort of gotten used to but I've noticed that if I eat late and there's food on board when I go to bed, I will see my BG rise overnight more than I would expect. I'd love to be able to eat dinner at 5:00 or 6:00 all the time but with all of our activities, that's the exception rather than the rule. I also have noticed that by day 4 or 5 of a reservoir, the insulin seems to be a bit less zippy than it is on day one. I will usually work around it as I like using all of the insulin but if you are running into that, it may also account for some more elevated BG? I don't ever do basal testing, more like basal observing. I use fasting BG to adjust basal rates and post-meal numbers to adjust carb/insulin ratios.

I've been pumping since 08 so there are many folks who are more experienced with it than I am but I think that it's reasonable to adjust your own basal rates. It will be much more effective if you can log your results to try to move things along although I am AWFUL at logging myself. I've found the CareLink reports to be pretty helpful, the one with the pie chart can point you to time segments that might benefit from some adjustments. I haven't found doctors to be quick enough to make changes. The last doc who'd proposed some, it took a couple of days and, by then, I'd already made the change they proposed myself and determined that it was correct by the time the nurse got back to me and said "turn down your basal rate". Then I switched docs. I like the guy I'm seeing now ok and I ran my proposal to do 1/2 hour .8U and 1/2 hour .775U by him as one seemed to be too much and one was not enough. He said "that makes sense..." so now I have like 34 basal rates in there. Sort of a hassle to manage but it seems to work pretty well!!

12

Thanks everyone for all the help. I am reading and rereading all these ideas. I did buy the books on Amazon and will read them as soon as I can. I feel like I had no education in new theories in diabetes treatments since the late 80s. I never saw a nutritionist until 3 years ago and learned about carb counting. I was doing the food pyramid guide lines until then (like 1 bread at breakfast).

I eat on a schedule and unless I'm low, I don't eat after 6:30 or 7pm. I really have no idea why adding .1 to the basal makes me go higher. I guess I'll just keep trying adding more using the temporary basal settings.

After carefully looking back at my CGM graphs, I really can't tell when I finish going back down after taking insulin. I'm almost always raising, even after insulin until the next meal. I guess that means I'm not taking enough insulin at each meal as well as the basal rates possibly not being enough. There are so many things to consider. I never had an insulin to carb ratio before trying the pump, so that is something to figure out as well. I'm going to experiment to see how long it takes for my blood sugars to go back down after insulin.

I had no idea there was so much to pumping. I figured it would be the same as shots, but with the background insulin seeping in slowing all day/night.

13

If your Endo/CDE/pump team did not have you do basal testing as well as bolus insulin to carb testing before you went live with your pump, then you are flying blind. All of that should have been done while on MDI so they had a reasonable idea of how to set you up. Typically a pumper will need about 25% less insulin while on pump vs what they needed for well controlled MDI.
That's not to say that you don't need to redo it all once on pump to fine tune your rates etc. And as time changes you will need to recheck periodically.
Learning to do this for your self will take the voodoo/mystery out of pumping.
Not to say that D won't happen and it will all be smooth sailing as we all have our ups and downs.
Once you do your homework come back and ask your questions. Some one will be here to help with answers.

14

I don't think that it's exactly "flying blind" as in the initial pump setup, they'd be using a calculation based on weight/ age schmoozed a bit based on what mlcarey reported their extant dosing with Lantus/ Levemir or whatever to have been, divided by 24 to figure a rough hourly basal rate. I think basal testing by not eating is counterproductive as I see my BG flying up in the AM when I blow off eating breakfast. DP will keep rolling and rolling. To me, it makes more sense to monitor the reports to get more realistic data. One of the biggest lessons I learned with the pump is that even little nudges, +/- .1U/ hour or +/- .1G/U ratiowise will make a difference, one way or the other.


These numbers are sort of a hot mess, as we were on a long weekend trip and I ate and drank all sorts of heavy, challenging foods. I would say though that the patterns are discernable, running up over night and then low afterwards (correction + the DP 'dose' of either bolus or basal, and I'm sort of hyper so I probably did both...) leading to lows after breakfast. Then there's a 10 mile run and some bicycling in there too. In the end, I think I moved the basal overnight to start at 2:00 AM instead of 3:00 AM, as that's where the graphs showed the lines "taking off" and turned down my pre-dinner basals as I'd been running lower in there pretty regularly too. I need to d/l another round of data and see if it comes out any better but I don't see the doc until October. Oh wait, it's almost October!!