NON-Flatliners (Problem Solving) Thread

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OK, in another thread I mentioned that I’ve thought of starting a non-flatliners thread so that people can share strategies they use to solve the difficult day-to-day rollercoaster diabetes throws at so many of us. So here it is. :slight_smile:

This is a thread to post about blood sugar highs or lows that you are trying to solve. It is NOT a place to just rant about a bad diabetes day, at least not unless you are also willing to do some thinking about why the day was so bad! If you post here, others are welcome to chime in about strategies they use, keeping in mind that we are a very diverse group of people here, so not everyone has access to the same treatment options. So saying something like “get a pump” or “use Afrezza” may not be directly useful to that person if that’s not an option for them, but if it’s a strategy you use then posting “I use XYZ” may be useful for others to know or may be useful for the original poster to know should that option ever become available to them.

I’ll kick the thread off with a post below, but feel free to add your own! I think, if we use the “Reply” feature properly, we should be able to keep multiple sub-threads going fairly easily and keep replies to individuals straight without geting too confused!

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Okay, I’ve waited half an hour to recover from this low and no go yet, so I’m just going to go ahead and post…

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This is a pretty average day-in-the-life-of-Type-1-diabetes for me. It sums up pretty well what I struggle with much of the time.

Three days ago I was running high literally non-stop—Thursday I spent 84% of my time high, Friday I spent 86% of my time high. So over the weekend I raised my basal rates and ratios gradually, and on both days I spent 50% and 46% of my day high, respectively, but knowing how these things go (and that I suspect I have increased insulin resistance when I’m high), I lowered my basal rates by 0.05 units an hour and left things as they were.

So, last night I bolused for a granola bar before bed because I was starving (I don’t typically eat right before bed unless I’m treating a low), and then went low at midnight. I treated with six glucose tablets (24 grams of carbs). I came back up but had a pretty sharp drop betwen 4:00 and 6:00 AM. That happens to correspond with the start of my DP coverage, and I noticed I had a drop on Sunday morning, too (I actually woke up low and then had another low, hence why I lowered things by 0.05 units an hour). So, I lowered the segment that runs from 4:00 to 10:00 AM by 0.1 units an hour. I bolused for 10 grams of carbs for my breakfast of scrambled eggs, sausage, almond milk, and almond bread and peanut butter. Seemed to be flatlining.

I had a meeting during the morning. I couldn’t eat most of what was there as it was all wheat-based stuff. But they did have a bowl of grapes, so I took a bunch of grapes and bolused for 15 grams of carbs. (I didn’t look them up and I didn’t weigh them. But I later checked and, according to Google, a cup of grapes is 17 grams of carbs.) At some point after eating them I looked at my CGM and saw that I was rising quite sharply (but not yet high), so I corrected the high. About half an hour later the CGM alarmed that I’d gone crossed my high threshold and there was now a straight up arrow. So I corrected the high again (taking into account IOB). Half an hour later I checked again to find that I’d spiked WAY beyond what I should hav spiked even if I had skipped bolusing for the grapes all together. This is the type of thing that, for me, can easily lead to all day spent high if I’m too passive about it. So, I decided to do a full correction bolus, ignoring all the IOB on my pump. This is a sure way to get a high down fast, but in hindsight I likely ended up stacking insulin on its tail end (my DIA is set to 4.5 hours). I did said bolus at 11:00. Ate lunch at 1:00, which consisted of a soy latte and a granola bar (not healthy, I know, but I forgot a proper lunch and there’s nowhere to stop to grab anything that I can eat). I debated not bolusing for that food at all, but it was 45 grams of carbs, and given what happened with those grapes, I decided to bolus for the whole thing. But, knowing that I tend to go low in the afternoon, I did decrease my insulin to carb ratio slightly.

At 2:00 the alarm I have set on my pump to remind me to try to deal with the lows I always get while commuting home from work went off. I’ve been decreasing my basal segment for that time of day, but no matter what my blood sugar is like, I always go low during that commute home. Even on Thursday and Friday, when 84-86% of my readings were high, I dipped low (on Thursday quite low) during that period. Yet, on weekends I’ve fasted through from breakfast until dinner and, without the commute, I do NOT go low, so I’m reluctant to fiddle with my basal rates too much. Right now, my strategy is to do a -50% basal rate on my pump for two and a half hours starting at 2:00. So this is what I did. Around 3:00 I noticed that I was going down, so I ate a small apple and about four glucose tablets (about 26 grams of carbs). Was on a conference call as I left work, and on the way home went low again and age six glucose tablets (24 grams of carbs), because I was wanting to go get a haircut and did NOT want to go low while I was in the hairdresser chair (but I made sure my Dexcom and glucose tablets were in my pocket, not in my bag, just in case).

Picked up some groceries and came home and posted this. Ate several more glucose tablets on the way home, maybe four. Got home and ate a few more. Proceeded to drop to LOW. Reduced all basal rates on my pump by 0.15 units an hour. Also reduced all my I:C ratios by two, except for the one in the morning, which I left as-is.

And that’s about where I am now. Dinner will be spaghetti squash and chicken, hopefully low-carb enough that it won’t mess things up too much. Unless I keep going low (and I’m still low as I type this), I’ll try to keep my pump settings the same for the next day or two to see what happens. I think my multiple lows this afternoon despite so many carbs (about 74 grams of carbs) is due to stacking insulin: I probably could have reduced my bolus at 1:00 by significantly more, but given that the lows have continued on more than seven hours after that bolus, my basal is probably too high as well. I think that, most likely, these huge fluctuations are due to hormones. But, I can never be totally sure. It’s a never-ending saga for me. I do basal tests that seem to work perfectly one week, and within a week or two my control has totally changed once again. At least for today I’ve spent 68% of my time in range. But the lows are definitely a problem. Three days ago the highs were definitely a problem. There is no easy balance in the middle, at least not that I’ve been able to find over 25 years, but I keep trying and on occasion I do get the balance right and have a glorious flatline day.

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Thank you, Jen for starting this. I think it will be very helpful to all of us. What you described has happened alot to me. It seems to fit some kind of pattern of a couple of days skirting lows and the next high even though activity and food is about the same. I haven’t figured out the pattern yet so as to plan for it. When I do get the pattern figured out, I plan to do the different basal patterns that I have put in my medtronics pump. Do you see patterns besides hormonal? I have even thought about full moons, etc. It seems a little silly, but we grasp for explainations, don’t we? I know when I do fight the lows all day (I call them wicked lows) I have to follow the quick acting carbs with some kind of protein as soon as I am in range. Otherwise, I will be right back down again. You probably do this too.

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I think weather is a pattern for me. I think the location of my infusion set is a pattern. Insulin potency… How bad my allergies are (they’ve been bad the past few days)… But at a certain point, the variables seem sort of pointless to me. If my allergies or the weather influences my blood sugar, what can I really do about those? I could try to anticipate them, but trying to anticipate them when there are two dozen other things that also need anticipating gets ridiculous. But, yes, I do grasp, because diabetes is just so confounding at times.

I actually don’t do this. I was told (or maybe I read it in a book) that on a pump there is no need to follow up with protein. In the “olden days” the protein was to take care of the peaks in R and NPH that were usually happening around the time lows hit. Theoretically, a pump’s basal rate should hold one steady at whatever level they’re at, and so protein shouldn’t be needed… And, for me, I do have many lows (like the one at midnight on my Dex graph) that respond perfectly to treatment with just glucose tablets, and others like the lows this evening that do not…usually a sign that my basal rate is too high and keeps driving my blood sugar down instead of holding it steady.

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Interestingly, @yeagen, even though I said I don’t combine low treatments with protein, I realized just now that I do. I’m up with a low (my own fault, I was again high before bed and overrode my pump in giving a correction), and since I’m low and have insulin on board and have many hours to sleep until morning, I realized that in this situation I eat enough carbohydrates to treat the low as well as cover the insulin on board. So, in this case, I treat the low with some glucose tablets, but then do eat something a bit longer-acting to cover the insulin on board, such as a granola bar (I’m doing chocolate instead, though, since a granola bar would be too many carbohydrates).

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I am trying out one of my other basal patterns today, as I will have the grandkiddos school run today. Stress sends me low, not higher. The traffic is horrific. We will see how that works. I hope today is better for you. Did you change your basal for today? There are so many factors to think about. Yesterday I met with my endo and we did talk about the lows some. She wasn’t happy with how many I had had, even though most of them were in the 60’s. Neither was I, but oh well. I am amazed by all you do, Jenn. Thank you for the info on the pump and protein. That could explain why sometimes my strategy doesn’t work and in the end extends my glucocoaster ride if I have too much protein. I wonder if there is some kind of ratio I need to think about such as so much protein for whatever bg my meter says and IOB.

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As to the middle-of-the-night hypo treatment, I usually just treat with glucose tabs or some carbs. If, for any reason, I think that the current low is a tenacious one, I’ll add a tablespoon of peanut-butter. I think both the protein and fat help sustain staying in-range while you sleep.

A little off-topic but, has anyone else tried eating glucose tabs with peanut-butter? I like it in a peanut-butter and jelly kind of way.

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My strategy ended up really backfiring, possibly in part from a rebound, since I didn’t over treat by that much.

I woke up at 2:00 AM with a low of 2.6 mmol/L, but my CGM was showing 4.9 mmol/L and therefore hadn’t alarmed. That’s a first for me. I still had about a unit of insulin on board, so I treated the low with glucose tablets and ate 14 grams of carbs worth of chocolate.

Woke up at about 4:00 AM to my CGM alarming and my blood sugar at 16 mmol/L. Corrected the high and went back to sleep. My alarm failed to go off at 6:0 AM (grrr, Siri!), so I woke up at 8:15 freaking out because I had to be at work in 15-30 minutes. I was feeling shaky, but I was 5.2 mmol/L, so it was probably from the adrenaline rush of sleeping in so late. Got to work (on time, miraculously!) and ate a 40 grams of carbs Clif bar for breakfast, since it’s all I had. Predictably, I spiked into the double digits (it seems carbs and me do not get along in the morning, even with a lower I:C ratio). I’ve been there ever since, and am currently sitting at 15.4 mmol/L. Seems I am back to being high, but I’m cautious of being too aggressive and having a repeat of yesterday afternoon. I also forgot my meter at home in my rush to leave this morning, and I’m wary of this sensor’s accuracy after a wildly inaccurate calibration late last night and missing that overnight low, so I’m reluctant to correct off the sensor without a finger stick verification, although I definitely feel high, so I’ve corrected once or twice. I’m going to fast through breakfast tomorrow and see if I need to change my morning basal rates.

Next time I have a middle-of-the-night low, I’m going to try your peanut/nut butter and glucose tablets idea. Seems it would be a smoother correction than using chocolate!

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Well I have two quick questions then I’ll try to look at this tomorrow to see if I can be helpful

  1. why is your pump dia set to 4.5 hours? Are you confident in that setting? I personally off-the-cuff consider dia in a practical sense as more like 2.5 hours or maybe up to 3.5 only if taking into consideration serious exercise. (With rapid analogs— don’t really consider it at all with afrezza)

2). Tell me more about your work commute? If the low tendency is only dependent on commuting from work-- lets figure out why this is happening? I’m all ears? Is it a scary subway where you have fight or flight instinct? Is it a grueling uphill bike ride? I know nothing about it except your bg plummets every day on your way home from work… Fill in the blanks and I hope we can troubleshoot

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  1. My DIA got set to 4.5 hours several years ago because I had several lows after “stacking” corrections (but subtracting IOB, so then I don’t really consider it stacking per se) that dipped into the mid 1s mmol/L. I can say that at three hours, I’m definitely still seeing my blood sugar drift lower. To my recollection, I’m not sure I’ve ever had that number set to anything lower than four hours (which is also what all the diabetes books like Think Like a Pancreas and the like recommend).

  2. My commute home is an hour-long combination of bus, train, and walking. Or sometimes just (more) walking and bus. It doesn’t only seem to be my work commute, either; it seems to be any longish commute on public transit. I don’t drive, so basically everywhere I go that’s farther than a few blocks is on public transit. The only time I don’t see this is in the morning. This year, so far, most of my commuting has been from work to home, but I also commute during the work day at times.

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Maybe because the manufacturers of the three rapid acting Analogs have carried out (and published) activity curves based on actually measuring insulin levels. The measured DIAs (i.e. the time at which 95% of the insulin has cleared the bloodstream are 5h for Humalog and Novorapid and 4 h for Apidra. John Walsh has actually suggested that the _real;_DIA’s are around 1 hour longer because insulin that has cleared the bloodstream remains bound to the receptors for around 1 hour.

I know a lot of pumpers set their DIAs at much shorter but these estimates are often based on measuring BGs (either by fingerstick or CGM) and these estimates are an indirect measure of insulin action that rely on basal levels being “perfect”, which they rarely if ever are! Setting a short DIA also _apparently___ameliorates the problem of insulin stacking as IOB disappears from the pump screen. This is illusory as the insulin is still there.

Joel

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This all matches my understanding/experience. I’ve always understood that this number tends to get underestimated rather than over. I think the default setting on my pump was 3 hrs but I’ve extended it to 4, which seems about right–unless I have to figure exercise in. If I have a zero-carb lunch that I don’t have to bolus for I can go for a bike ride 4 hours later with my BG at 100 and still be >70 when I’m done. But with a lunchtime bolus of 4 or 5 units, that bike ride will push me down in the 40s unless I carb up quite a bit before setting out, or set a very low temporary basal an hour and a half before the ride.

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Hi @Jen, first, thanks for starting this thread, and for posting a bg curve together with an account of what happened - that’s a great way to state a bg control problem. I am puzzled by the very first part: the midnight low after the granola bar dinner. Some questions come to mind: when did you have the granola bar? What were the granola bar carbs/protein/fat, at least on the label? How much did you bolus for the granola bar? Was it just a normal bolus? Did you have any prior IOB at the time you had the granola bar? Also, what is your ISF? What is your IC? (sorry for asking so many questions - can’t help it - feel free to ignore me :slight_smile: )

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I know we’ve discussed duration of insulin action (DIA) before. I’ve used insulin pumps for 29 years now and have experimented with various DIA times. Over the years I have found that when I use a DIA of 3-4 hours, I frequently experience unexplained hypoglycemia 3-5 hours after the dose delivery. These times correspond to using rapid acting analog insulins. I set my DIA to 5 hours and found most of my 3-5 hour post-meal dose hypos disappear.

I know that John Walsh has written about this so I checked the literature and found this National Institute of Health 2014 study that he authored. I think he makes a good case for setting pump DIA in the 5-6 hour range for most people.

Acronyms used below in quoted block: DIA = duration of insulin action, BC = pump bolus calculator (also known as Bolus Wizard), IAT = insulin action time, PD = pharmacodynamics.

Recommendations for Selecting DIA Times in Current Practice

Currently, we lack reliable data for DIA. Until respective research studies are performed and such data become available, we suggest the following approach:

BC DIA times should not be based on currently published IAT ranges.

PD data generated with higher insulin doses (0.2 U/kg or larger) currently provide the best estimates for DIA settings in a pump or BC.

Currently, times between 4.5 and 6.5 hours may provide better estimates for the DIA setting. For boluses that are typically larger than 0.2 U/kg, a DIA setting of 6.0 to 6.5 hours may be preferred. These estimates for appropriate DIA time settings may need to be lengthened when more precise DIA measurements become available.

When blood glucose readings are often elevated, discourage patients from shortening their DIA to increase the size of bolus doses because this is likely to introduce or enhance errors in other BC settings. When insufficient insulin doses are given, address the insulin deficit directly with higher basal rates or a lower carb factors or correction factors, or encourage a change in bolus habits.

Reading through this study I learned that IAT or insulin action time describes the rise and fall of insulin levels in the blood. IAT is often referred to as pharmacokinetics or PK. The effect of insulin levels in the blood follows some time later and is described as pharmacodynamics or PD. When we talk about DIA we are referring PD, not the earlier PK.

My take away from the study and its above conclusions is that many people who use pumps set an unrealistically short DIA and then compensate by adjusting their insulin to carb ratio (I:C) and basal rates such that the bolus wizard gives them good enough results. DIA, I:C, and basal rates all work together to produce an appropriate bolus dose that considers previous boluses that have not fully acted yet (insulin on board or IOB, also known as bolus on board or BOB). When actual I:C ratio and basal needs changes, this can cause problems with a DIA set wrong.

I think this is an area where we, together with our doctors, need more education about the real role of duration of insulin action.

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I love the combo and have done this many times.

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Excellent article Terry.

I really wish that the product datasheets that came with the insulin explained this better. I found them to be pretty useless from a practical perspective. Also have asked this question to my diabetes educators and they tend to side-step the issue and the answer to my question about insulin action is “don’t stack insulin”. I hate it when people give the answer to a different questions instead of staying I don’t know.

And off topic - what flavour of Dex4 pairs best with peanut butter?

I used to like the grape Dex4 but they recently changed - softer tablets but terrible taste - so I am on Raspberry right now. Raspberry and peanut butter sounds good to me.

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Most health care diabetes educators understand the concept of two bolus injections overlapping in time, stacking, and causing unexpected hypoglycemia. Their understanding seldom goes beyond this first level analysis. While they can talk about IOB or insulin on board, they’ll likely give you a funny look if you ask about “carbs on board.” Carb counting is not an exact science and the same body can process the same meal differently in two separate instances.

Insulin “stacking” is a pejorative in those educator circles and they would be alarmed if they heard someone like me say, “I stack insulin every day.” What they instinctively distrust is someone who deliberately stacks insulin even if based on lots of practice and personal history.

When any system is analyzed during the first exam, only ideal summaries can be made. When considering a second or third level of analysis, most diabetes educators and doctors are uncomfortable discussing.

As far as the peanut-butter Dex4 flavor combos go, I like them all. That sweetness contrasted with the fat satisfies me. Fortunately, I don’t often have reason to indulge. I currently favor the coconut flavor glucose tabs.

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Are we allowed to add our separate BG problems to solve to the thread? Or do we need to start another one?

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Help solve my problem! So this is the problem: My son is at daycare and repeatedly goes low during the first part of his nap, around 12:30 - 1:30 – then typically skyrockets after. Sometimes he just “flirts” with going low but often he actually reaches the territory. Either way, typically right around 1:30pm he begins rising even if he hasn’t gotten a carb correction. An image from today is included. His basal profile starts at .225 units per hour at 6am, jumps to 0.3 u/hr at 9am, then today I upped it to .375 units per hour at 1pm - 3pm. His morning carbF is 1:22, his afternoon carbF is 1:25 (down from 1:28). His insulin sensitivity factor, which is partly used to determine the size of high- or low- temp basals he will receive, varies through the day based on an automatic program, but typically ranges from 235 to 335.

I suspect part of the problem is that he is frequently going high about 1 to 2 hours after breakfast, openAPS cranks up the basal insulin, he typically plateaus by about 10:30 and then starts dropping by 11am when he is ready to eat. I then bolus for his lunch as he eats each piece, subtracting the IOB (depending on where his BG is), and bolusing for the remaining carbs. Confounder 1: Sometimes the Internet connection is crummy and I have no way of knowing IOB that was delivered by openAPS, so I have to guess based on an outdated number :frowning: .

Then he plays outside, goes down for a nap around 12:30pm and is typically asleep by 1pm. Confounder 2: His openAPS is often away from him as they are walking down the stairs and using the bathrooms – so it sometimes issues a high temp basal and then does not issue a low temp to counteract it as he’s dropping around 12:15pm.

Teachers frequently have to give him one, two or (like today, three!) glucose tabs or gummies to prevent recurring lows…and then right around 1:30, he begins his ascent into the upper reaches. Currently at 188 and climbing, but a high in the mid-200s is not uncommon. Confounder 3: Since he’s at daycare, I can’t just bolus him whenever I like; either I rely on openAPS, which sometimes can’t connect for whatever reason, and in the best-case scenario is time-delayed. Or I just have to watch him rise until the end of nap, when I pick him up.

So, what I’m looking for is a basal/bolus routine that will a) not routinely cause lows around 12:30 - 1pm. b) not cause the highs around 1:30pm. c) not require me to step in with manually delivered corrections except between the hours of 10:30am to 11:30 am or 2:30pm - 3:30pm. Honestly, if he wasn’t at daycare I’m pretty sure this wouldn’t be an issue because I could use sugar surfing and well-timed, healthy snacks and food to counteract lows and highs. But my surfing is handicapped by the fact that I’m away from him and can’t remotely bolus. No teachers are trained to do so either.

Any suggestions? I’ve thought that perhaps I need to up his basal for the mid-morning …but it’s also possible that maybe his carbF isn’t aggressive enough or his breakfast carbs are outlasting his bolus. Unfortunately I cant’ give a follow-up bolus for food because someone else takes him to school. I think the key is making sure he doesn’t have that mid-morning rise, so that he starts lunch with a clean slate and not a bunch of insulin mis-timed for an earlier spike. I’m also wondering if having openAPS clock in and out at set times may help me. For instance, I could always set a temp basal of 0 right after I give him a lunch bolus, IF I knew openAPS wouldn’t cancel it.

Any thoughts, ideas, suggestions??

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Yes, please! Feel free to share on this thread—that’s why I started it. :slight_smile: