POST-Prandial BG's just won't cooperate

Type 1 and LADA Parents of Children with Type 1 Diabetes
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So, we’re on our 3rd successful POD now and we feel that his sugars are coming under control…even if just a little! We’ll take what we can get. We are seeing many more “level” areas…or relatively level, for sometimes 8 to 10 hours at a time (mostly when he’s fasting…which makes sense, during the night.)

Our biggest problem right now are post-meal highs. It seems that no matter how we adjust bolus insulin, timing between bolus and meals, extended bolus, etc., the spikes never seem to be remedied.

Our Doctor’s have him on a 1:30 ratio, but we’ve taken that down to 1:24 because the spikes were just astronomical…we’re talking above 400 “High” and staying there for hours. Although the spikes are now getting lower, it’s a little unsettling to “need” so much bolus for a meal, for a 2 year toddler to avoid spiking over 300! We are already giving, now, 1 unit for every 24 carbs, or .5 for every 12 carbs.

We’ve extended bolus over a 1 hour, 1.5, 2 hour, 2.5 and 3 hour period and tested various insulin levels, often times correcting far above what’s recommended…yet we still get this huge spike after meals.

Let me give you today’s example to illustrate. I took pictures of the day’s activities that I’ll be including, with comments. If someone sees something obvious jumping out that we may be doing wrong, we’re always listening for advice!

So, last night his POD was expired at 2330. So, since he doesn’t need insulin during the nights, and since he was an easy 130 during the night, I removed the old POD while he slept (at 0532), and we planned on installing the new pod sometime early morning. As you can see, the new POD was installed and activated on 1017 this morning and the “daytime” basal insulin regimen kicked off of .10u/hr.

Here’s his current basal daily regimen:

Here’s what his sugars have looked like today so far.:

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(as you can see, lots of time “in range”, but two big spikes…AFTER MEALS.

…and here is a zoomed in pic of his most recent spike:

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Here is how we bolus’d Liam today so far:

And here are the screens from 10:30AM this morning, through 2:57PM, expanded:

He ate 32g at 1:20PM and was administered 1.3 units of Insulin, which was given at an extended rate of 40% up front and 60% over the next 2 hours.

.10 Units at 14:57 as a correction, even though 0.0 was recommended.

Here are his BG’s from 10:19 this morning (after new pod was installed), to 2:56PM.

20161005_171500.jpg5312×2988 4.74 MB

Not sure if this is enough information or not…but basically, we’re trying to figure out why such spikes when we’re trying every combination of things we can do. Yes, we’re pre-bolus’ing, sometimes 15 minutes before, sometimes little or no time before (if the BG is really low.) If BG is really high, we’re “correcting the high” first, then when he’s in range, we bolus for meal. We extend meals over different variations of times. We give just the recommended amount of insulin sometimes and other times we give more…sometimes as much as .2 or .25 more.

I can’t think of anything else I just might be doing wrong here. Like I said, I’m very happy with a majority of the day…it’s just the hours following a meal that are killing his A1C, and spiking him so high.

Any recommendations would be appreciated. And if you need more info, I can provide whatever’s needed.

Thanks!

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I get the angst of trying to control the BG of someone you love, who doesn’t like what you’re doing, doesn’t understand or care why it’s needed, and whose phsiology presents a rapidly shifting target. Let me just make one tiny point.

Consider where you are now compared to where you started from. And then extrapolate to where you’ll be a month or three or six from now.

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What I’ve found, though, is that if I feed him less carbs, more often, the spikes are eliminated…or not as common. I just hate the concept of “grazing” through the day…although, maybe that’s what’s called for at this point.

So, instead of 3 meals a day of 20 or 30 carbs, 6 to 8 meals a day consisting of 10 or so carbs each.

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If 1:24 isn’t working, you may want to consider 1:22. If that still isn’t enough, consider 1:20, etc.

Also, the higher the BG level is when your son is “flat-lining”, the higher the BG number will be at the peak. I’m definitely not suggesting you adjust basal so your son runs between 80 and 100, but there’s an unavoidable trade-off: the higher the “baseline” BG, the higher BG will be when he spikes. I’m not saying that the magnitude of the spike will be higher, I’m just saying that if your son is going to spike 200 points after eating, that means the peak will reach 350 if he’s running at about 150, whereas if he’s floating around, for instance (I’m not recommending this) at 100, a spike of 200 will take him up to 300 as opposed to 350 (which are both undesirable as far as I’m concerned.) The two graphs you posted don’t show a whole lot of “flat” time, which leads me to believe that both his basal and bolus need adjustment. If you feel like you’re needing to give a very high bolus dose, it could be that some of that bolus insulin is actually being used as basal.

I’m not trying to be a smart-a$$, but why are you uncomfortable adjusting his I:C from 1:24 to 1:20-something lower?

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We are definitely moving down incrementally with the carbs, but we’re just shocked, honestly, that he needs such a high I:C ratio! He’s already using more for the carbs he’s eating than someone over 100lb, or in late teens early adulthood. Is that normal??

That’s that part that is honestly baffling me most. From all I’ve read he shouldn’t be needing such a high I:C ratio.

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We are adjusting. As I indicated, the doctor wants 1:30. We’re SLOWLY moving down 2 every couple days just so that we have adequate time to test it. We’re now on 1:24 and from here, we’ll move down to 1:22. We don’t want to just jump from 1:30 down to 1:10 without proper testing in incremental stages.

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Most of the “flat lining” occurs at night. The charts here don’t show the really good flat-lining which ranges in the low to mid 100’s.

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So it sounds like the recommendation is just to continue refining the bolus / basal doses. This is what I thought, but I’m just shocked that his I:C ratio is already at the rate it is. Going lower (more insulin per carb) just confuses me because it goes against everything I’ve read for what range he should be in for his weight / age / size.

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I’m thinking that your son’s basal rates may be too low. Do you have to increase in 0.05 units/hour steps. Or can you increment in 0.025 basal steps? Those high post-prandial peaks seem like a classic too-low basal rate. If I were you I would try to experiment as conservatively as you can with cranking up the basal rate.

I’m not sure what your motivation is with the extended meal bolusing, but your son seems to need all that meal bolus right now, not extended into the future.

You will be able to write a book when this is beginning phase is over!

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Our rationale for extending is because the spike doesn’t usually occur until 1 to 1.5 hours after the meal, then it stays high for another hour, or longer.

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I get what you’re trying to do. A 100% up front non-extended bolus won’t reach peak effect for about 90 minutes, so it would seem to match the post prandial excursion better.

I think insufficient basal insulin is at the root of this. I could be wrong and I would counsel basal increments as low as you can while keeping a close eye on post-meal excursions with Liam’s favorite fast carb at the ready.

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I don’t have a child with T1, so I can’t offer any direct advice, but I wonder whether you’ve considered trying some coaching sessions with Gary Scheiner of Integrated Diabetes. Personally, the formulas and averages in books have never been anywhere near what my personal numbers are and I wonder whether it could be the same for your son. Someone like Gary, who is in contact with hundreds of T1s, might be able give you some really useful guidance and insight regarding your son’s situation.

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I haven’t checked into that…I fear the price that such a consultation could cost. But it may be worth it to at least check it out. Thanks!

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Gary and his folks have an enviable track record. Worth checking into at the very least.

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Do you, or anyone, have a link where such consultation request can be made, or investigated further?

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Definitely worth at least finding out how much it would be.

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I used Gary Scheiner’s services back in 2012 to get my basal rates set. I think I paid $500 for a 90-day retainer. I was reluctant to do this but looking back, it was worth it for me. By going through that exercise with Gary, I was able to learn how to do that on my own.

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Here’s the page on his site about how to start the process:

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My advice is to get over the shock and just roll with it. There was one day about 3 weeks ago when my son woke up and I noticed he looked taller. Since then we’ve had to dramatically increase his I:C ratios and overall basal dose, from around 4 to 5 units of insulin per day to about 7 to 8 units, sometimes 10! If your son is not in preschool, I’d just serve the same meal every day for 3 or four days and go up by 2, or 3 until you hit a point when you’re not hitting spikes. But first I’d do basal testing. Do you ever do things like eat brunch or skip lunch, etc? Use those periods to test out two, three hour periods of your basal rate. My guess is that your daytime basal rate is too low.

How much does your son weigh and exactly what is his age, and when was he diagnosed again?

Also, there was a study I linked before showing that well-controlled young children have more aggressive I:C ratios and weaker ISFs than adults or older kids. I spoke with a doctor. at Diabetes camp (who literally sees thousands of kids over a summer, and hundreds throughout the year) and she said she had a patient who had a 1:15 I:C from age 3 to 11 – for 10 years he just needed that much insulin for breakfast. So I wouldn’t worry too much about whether it seems high – just worry about whether the spikes are gone without “feeding the tail” later, whether the basal rate keeps you roughly levelish, etc.

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35 pounds. 2 Years old. Diagnosed this past Feb 29th.