So far, my 14-year-old daughter’s A1c’s (omitting her diagnosis A1c of 12.7) have all been within my range of tolerance: 5.2 to 6.8. As my daughter is a growing and constantly very hungry teen (who remains thin) and who wants to eat what all her peers are eating, I have decided not to apply for a position with the Carb Police Force. I do not want to deal with an eating disorder on top of the typical adolescent mishegas with which I am currently struggling. (I do not recall my older daughter’s adolescence being this challenging, which is not surprising in light of the fact that it didn’t include D.) But the Dexcom graphs have slowly but surely evolved into an endless series of “W’s” and “M’s”. Fortunately this has not included a total time spent low of greater than approximately 7%.
Here is the current regimen:
*Apidra insulin in an OmniPod pump:
I have recently resculpted her basal profile to include 7 different basal rates (down from 10) and have tried to more closely follow the recommendations of Gary Scheiner to include only one peak and one valley. My daughter experiences what I call a reverse Dawn Phenomenon. After essentially flat-lining all night at a respectable 75 to 110, she dips low beginning at about 4 AM. I have successfully and almost completely eliminated these lows by programming in a reduced basal rate, so this is no longer an issue. She then experiences the “When Feet Hit the Floor” Phenomenon, which I have also pretty much wrestled into submission with a corresponding higher basal rate. However, the remainder of the day and evening descend to the depths of D Hell, despite what I believe are thoughtful adjustments of various pump settings (ISF; I:C; DIA) which I undertake only after I recognize trends. And I also frequently employ temp. basals.
*Dexcom G5 with Share:
G_d bless Dexcom! As my daughter is so exceptionally sick of dealing with D, I have assumed the role of long-distance Head Sugar Surfer. My Dexcom app is set to alarm when she goes over 140 or under 65. Whenever this occurs (which is currently averaging about 10 times daily), I text her with instructions on how to correct, taking into account her class schedule (she has a tendency to run low during PE but shoots into the mid-to-high 200’s to low 300’s during color guard practice; no surprises there), and directional arrows. The Bolus Wizard on her PDM takes into account IOB, and I instruct her to override its recommendations frequently because she definitely becomes insulin-resistant once she hits 200. I do not believe that I am routinely observing either rebound highs (no preceeding lows that accompany these highs) or an excessive frequency of highs due to inadequate prebolusing or lazy SWAG-ing. (Although there is clearly room for improvement in the latter two departments…) I have arrived at that dreaded destination where the slightest increase in basal rates results in lows while frequent corrections have not been effective in decreasing my daughter’s time spent high. (I have come to accept significantly more time spent over 110, but the 200-pluses have got to go.)
I have a box-o-beautiful U-200 Tresiba pens which cost me a small fortune despite “good” health insurance (there’s an oxymoron for you ️) ready and waiting in the butter compartment of our fridge, and I am feeling Tresiba Ready . However, I am only interested in continuing to pump “untethered” while using Tresiba adjunctively. At this point in time, a regimen of Tresiba + Afrezza (while appealing to me) is not feasible because my daughter’s endo is not comfortable prescribing Afrezza off-label to a teen (and I respect and accept her decision). Plus this is a moot point because the idea of inhaling Afrezza does not appeal to my daughter in the least for reasons that remain unclear to me and which my daughter is unwilling to share. Tresiba as basal + Apidra as bolus/correction is also out because my daughter has absolutely no desire to return to what she considers the rigid hassle of MDI. OpenAPS or the Medtronic hybrid closed loop system is out (OpenAPS is waaay over my head, both the set-up and maintenance), and both of these options are moot because my daughter would willingly surrender her dark lipstick and thick black eyeliner before she would utilize a tubed pump.
I will be very grateful for any and all suggestions surrounding how I might proceed with a transition to pumping untethered with Tresiba. Thank you in advance!