Re-pumper thoughts/issues

So I finally got started on my minimed paradigm revel 723 this past Monday. It's been a roller coaster with my levels after the first day.


I'm still paranoid that I'm not getting the insulin. I had this problem last time too lol. I keep patting my shirt throughout the day to check for wetness and I can swear I can smell it just slightly on the infusion set (but my wife says that's probably normal)

An example of crazy levels. For lunch yesterday, I had 2 peanut butter and jelly sandwiches and 1 serving of chips. From my calculations:
4 x slice of wheat bread = 44g carbs
2 tbs peanut butter = 12g carbs
3 tbs sugar free jelly = 15g carbs
1 serving cheetos = 13g carbs

which gave me a total of 84g

my pre lunch levels were 154

I took 11 units of insulin (8 g / unit ratio)

2 hours later, my levels were 314

I took 4 units to correct and checked 1 hour later. I was at 254. 1.5 hours later, 180. Then checked at dinner time @ 8:20 and I was at 68

I'm wondering if I screwed up somewhere in the carb calculations

I'm waiting for my pump trainer to give me a call today so I can go over this with her but I'm curious as to other people's thoughts, ideas, experiences

I also had some highs last night as well related to some dreamfield pasta but that's a whole other topic :) 2nd time I've tried the pasta. The first time, my 2 hr levels were @ 130 and 4 hrs, I was still at about 120. This time, I jumped to almost 230 2 hrs later and an hour after that, I was at 280.

There was a time when I could eat a meal like you described and actually give a dose of insulin that would successfully counteract the rising glucose from the metabolized food. I actually spent years experimenting with various techniques to regain such control. I tried various prebolus times, the superbolus (borrowing from future basal insulin), and amping up my insulin doses to simply overpower the food. To my disappointment, none of that worked for me. I also struggled with frequent and sometimes scary hypos.

That’s when I finally decided to try a lower carb diet. I eat about 50-70 grams per day. I enjoy mostly predictable BG’s and good energy levels. This may not be the answer you’re looking for but it’s the method that finally restored some metabolic sanity to my life. The medical/nutrition establishment propagates a myth that a T1D can eat anything they want; they just have to correctly calculate the carbs and cover it with insulin. That lie has caused much damage to people like me. Any T1D that tries to eat their fill of pizza, breakfast cereal, or Chinese food can relate!

Everyone’s metabolism is different and you may be able to figure this out. I’m just giving you the benefit of my experience to consider. I wish I had changed to my current low carb way of eating many years ago, before I received a recent diabetes complication diagnosis.

Good luck to you. I’ll be interested to see what you discover. Don’t give up!

I don't have any specific advice re: insulin to carb ratio or anything, but I will say that when I first got on the pump, it took me a long time to get my levels in order - I'd say up to a couple of months. I don't know if it was my body just adjusting, or what. Maybe your basals aren't set correctly - have you done any basal testing yet? My point is that it may take some time to get adjusted. I'm really glad I stuck with it though, and I'm sure you will be to.

I have been trying to limit my carb intake as well since July and I've had great results because of it so I'm definitely happy with that approach. I do have some "slipups" (when my wife gets a chocolate truffle bomb cake for a party!) but I just dose accordingly and it's worked out for me.

For my basal rate, it probably will have to be adjusted. They took the amount of lantus I was taking before and took 25% of that and made that my basal rate (divided by 24 of course). This is my 2nd full day on the pump but I have to say I love love love not having to inject myself for every meal/snack.

This is actually my 2nd time on the pump (that's why I titled this re-pumper lol). I initially started on a pump back in 1999. I stayed on for about 6 months before stopping for 2 reasons
1) Parents were small business owners so our insurance didn't cover the pump. That meant we had to pay out of pocket for the whole thing. My mom was fine with continuing to pay for it but I felt it was just too expensive
2) I had issues with the infusion sets not staying in whenever I'd work out.

The newer infusion set's "glue" seems to be a lot better than it used to be. Plus I ordered some IV prep pads from medtronics which I've been told make it even "glueier"

I’ve never taken Lantus but 25% as a conversion factor seems too conservative as a starting point. Most pumpers develop a basal profile after experimenting with various basal rates. That means that the rates vary by time of day. For example, the basal rate is often higher in the early morning hours to counteract the effects of "dawn phenomena."

There is a specific protocol for testing your basal rates that involves limited fasting and periodic testing. The best description that I have seen is in Gary Scheiner’s book, Think Like a Pancreas. Once you discover your unique basal profile, the job of controlling your BG’s with a pump gets a lot easier.

Limiting carbs is a proven method to help control BG’s for T1D’s. Maybe you could experiment with a more mild limit such as 100-130 grams/day. You can also find your personal limit for any one meal. I have BG control problems if I exceed 25 or 30 grams at one time, especially for breakfast.

Good luck with the pump. It’s a very useful tool. I’ve been on the pump continuously since 1987. If I ever went back on MDI’s, I would face a steep learning curve.

I have to admit I'm feeling a bit discouraged (though I know it'll take a bit getting switched over) My sugars are just constantly high right now. For example, before dinner, I was at 168. I ate a salmon filet cooked in a foil pouch in the oven (with 2 tbsp of salsa on top) and a salad with italian dressing. Taking all the individual ingredients, I came up with about 30 g of carbs total. I took 5.7 units (my current ratio is 7 to 1). I just tested my sugars 2.5 hours later and I'm at 242

I’ve been there and done that. It is very discouraging, and that’s when I would start with the rage bolus–not a good idea.

Your meal looks like one that would produce good post meal BG’s. I love salmon. Has this happens a lot to you recently? Have changed any of your basal rates yet? If I understood your earlier comment, you took 25% of your MDI Lantus dose and divided it by 24 for a starting pump basal rate. Is that correct? As I said before, that sounds way too conservative to me. If it were me, I would start raising your basal rates but I would carefully document everything. Give your doctor a call and see if you can’t get some help managing this pump transition.

I know how miserable you feel. Just when you most need to have your wits about you, you feel sick and depressed.

Do you have a copy of Think Like a Pancreas or Pumping Insulin? Maybe you should go back on MDI for a few days, get stabilized, and study some of the pump techniques outlined in these books. Even if you’ve read them before, perhaps you could use some brushing up.

I wish you the best. Take care.

your carb ratios are not yet correct. The basal, card to insulin ratios and dosing schedule will all need tweaking. Also depending on when you put the pump in you may of had new pump highs. The reason is that it will often take a new pump almost 8 to 10 hours to saturate the surrounding tissue and thus deliver correct insulin levels.

Stick with it you will get it worked out.

rick phillips

I just noticed your bolus arithmetic. Your insulin to carb ratio is 1:7 and you ate 30 grams of carbs. I calculate that you should have delivered 30/7 = 4.3 units. Are you using the bolus wizard on the pump? Did you happen to add insulin to cover the fish protein? In any case, you didn’t go low but high instead.

Small update.

I have been using the bolus wizard exclusively for any boluses I've been delivering. I think it gave me a bit more because it was doing a correction (for me, they set it to 1 unit per 50). Since I last posted, my trainer updated my ratio to 1:7 and then 1:6. Since I've gone to 1:6, my levels have been a lot better! 2 hr after Ive been at about 120-140 (even after a chinese buffet which are always tough for me because of the trying to figure out what to eat).
My trainer did also email me some steps on basal testing. They mostly involve fasting and checking every 2 hours at different times of the day. I haven't got around to trying it out yet.
For the fish protein, I didn't add any insulin to cover that. I'm unfamiliar with that concept. I'll have to do some reading into that.

Is the 1 to 50 the sensitivity? I had always thought that that was how many mg/DL a unit will drop your BG. That might also be a number to play with. I'd been at 44 for a while, I don't even recall how I got there, and changed it to 40 as it seemed like I was running up more than I wanted to.

Re protein conversion, either 53% or 58% or some other number (I just use 50% b/c it's close enough...) of G of protein will "convert" to glucose so, if you have a 25G of protein hunk of salmon, 0G of carbs, it will produce a carbesque effect of approx. 12-14G of carbs, which might contribute to some of the elevated numbers you're seeing.

I would agree with Terry. When I first went on my pump, the doctor took my total daily Lantus amount and divided it by 24. My first basal was .6 per hour. I am not surprised at all by your high readings.

Also 84 carbs for one meal is a lot for most low carb eaters. I rarely eat over 60 carbs per day.

that's the pump word, sensitivity! It was the default value my endo started me at before I was on the pump so my trainer set my pump with that value as a starting point as well.

That protein conversion is completely new to me and I've never included it when calculating my total carbs! TY for the info!

ahhh I'm not close to that yet. I do like the idea of limiting my carbs as an additional "treatment" option. Just need to work on finding foods/meals that will work for me.

Why don;t you use the Bolus Wizard? i t will take a while for your endo to get the setting dialed in. Just be patient.

Oh I solely use the bolus wizard when doing my boluses. It's so handy! What I've been noticing is my 2 hr levels are high but according to my pump, I still have half my bolus still "active." I then check in another hour or so and they're down to the 140-170 levels usually.

For example, pre lunch today, I was @ 175. I had some frozen cauliflower and cheese (18 g of carbs total) plus a quarter rotisserie chicken (1 g carb, 17g protein so I tried the 50% of protein conversion) and gave myself a total bolus of 6.5 units (using a 1:6 ratio now). I think I rounded up the carbs to 30g (will have to check my carelink tonight when I sync up). I set my BG check reminder to 2.5 hours since it takes me about 20 minutes to eat. I'll report back here what comes up.

A couple comments, Deathjamm: If you are at 175 pre lunch you need to add a correction to your bolus. Do you have your ISF figured out yet? How many points one unit of insulin lowers your blood sugar? Otherwise, if you start out high you will just keep going higher. Secondly you said "your 2 hour levels are high, then you check in another hour or so and they're down to the 140-170 levels usually." 140-170 is still high. Most of us want to be under 140 at 2 hours. so you are staying high for at least three hours which means you are not getting enough insulin if this is typical. A couple options: Change your I:C ratio if you are always high for that meal. (Different meals can have different ratios). Pre-bolus. Many of us bolus 15-20 minutes before eating to give the insulin a chance to work. but most important I would be sure and add a correction in to your bolus if you are high before a meal. Finally if you are often high before or between meals, you might consider raising your basal rates for those time periods.

You are new on your pump, so don't get frustrated. but my suggestion would be not to wait for a doctor or cde to change numbers. Keep careful records and when you see patterns of repeated highs make a small increase in insulin and see how that works for a bit before tweaking again. It's the only way to get it right so that you ae in range more times than not.

Hi Zoe,

The bolus wizard is automatically adding the correction when it's doing my calculation for me. My doc had me do a 1 unit per 50 correction when my levels are above 150.

I thought about adjusting my ratio but the thing that worried me is that by 4 hours or so, I would be down in the 100-120s level. So I worry that if I give myself more insulin, it'll get me down faster but then it'll also drop me lower too? For the basal rates, I do plan on doing the basal tests this coming weekend.

Here is the worksheet my trainer emailed me for the basal testing:

Testing your Basal Rate

o Break up the testing into 4 segments for convenience
o Overnight
o Breakfast to Lunch
o Lunch to Dinner
o Dinner to Bedtime

Testing Your Overnight Basal Rate

o Start the test when your bedtime blood sugar reading is within target range
o Do not eat a bedtime snack or take a bolus
o Monitor blood sugar at 2or 3 am and upon wake up
o Document results
o STOP the test if your blood sugar falls below 70mg/dl or rises above 250mg/dl and treat appropriately

Testing Your Daytime Basal Rate

o Start the test when your blood glucose is within target range and your last bolus was 3-4 hours earlier
o Skip the meal (breakfast, lunch, or dinner) that starts the period you are testing and any boluses you would normally take
o Test your blood sugar every 1- 2 hours until next meal
o Document results
o STOP the test if your blood sugar falls below 70mg/dl or rises above 250mg/dl and treat appropriately

*Do not perform basal testing during any circumstance that might affect the result

• If you have an illness or infection
• After strenuous exercise
• After a serious low blood sugar
• During a major emotional stress
• After eating a meal that is very high in fat

For the basal testing, what exactly is my eventual goal? Do I want my levels to remain steady during the fasting time?

deathjamm, you asked -

"For the basal testing, what exactly is my eventual goal? Do I want my levels to remain steady during the fasting time?"

My own basal allows me to skip meals, and my bg stays within my preferred range all the time.

Basal testing is so very important, it is next to impossible to enter the other settings if your basal is not correct.

If your settings are not correct, the bolus wizard won't help...I would not eat if my bg was 175, I would correct that and when my bg was in my preferred range, then I would bolus for some food.

Perhaps someone else will comment on your basal testing plan. I don't do basal testing myself but simply tweak the time zones two hours before the times where I have a pattern of highs. But I believe the goal is to remain as steady as possible but not vary by more than 30 points. Do you having Using Insulin and Pumping Insulin by John Walsh. they are both very helpful.

Glad to hear you are doing corrections.I personally don't only correct if I'm over 150. I correct back to 110 all the time, especially before meals. 150 would be too high to be before a meal. Remember though that those numbers are programmed in and as the saying goes, "garbage in/garbage out". So if a certain number whether it be basal rate, I:C ratio or ISF is not giving the desired results than that number should be tweaked.

As for your concern that if you take more insulin you will be down in the 100s-120's at four hours, that's a good place to be! And you can drop further to 80-90 and have perfect numbers. The idea is it's all a balance between your basal and bolus. They say your basal has to be right first, than you can determine your correct bolus. If your basal is right, then you would stay more or less steady between meals or even if you skipped eating. So when you bolus and eat, you will go up, but not too far, and then come back down into target range which your basal maintains. Make sense?

Also, if you don't already, try pre-bolusing. It's another part of the equation to bolus a bit sooner and give the insulin time to work.