Someone Help me Get this Straight

Type 1 and LADA
1

Alright - Here we go. One final attempt or I am throwing in the towel (Okay--this isn't possible, but still, humor me.)

Let's pretend I know nothing about Type 1 Diabetes. I know nothing about modern day treatments and I have never visited a doctor in my life. God simply just came down, handed me Novolog and Lantus, and said have at it.

Alright, before God left he told me to take 45 units of Insulin before bed each night-- Thanks God.

However, he forgot to talk about the Novolog.

The last time I visited my Endo, she put me on a 15 carb to 1 Unit of Novolog ratio. She set my target BG at 120. She told me to take whatever my BG was at the time (EX: 320) and then subtract my BG Goal(120) then take that number (200) and divide by a "correction" of 20. In this case the insulin I would need to just correct my high of 320 would be 10 units. If I had a sandwich (30 carbs)this would be an additional 2 Units; so a total injection of 22 Units.

NOW. When I check my BG level 2 hours from the moment I put the fork down... Let's say my sugar is at 220 now. DO I CORRECT THIS? or do I wait FIVE hours and check before the next meal.

Should I be using this ratio or should I be on some sort of Sliding Scale and Diet and Hell. I am just so flustered. It seems sometimes my dosage works and sometimes it doesn't. Sometimes I get it right, Sometimes I don't. I know it's an art and not a science, but I suck at both subjects. I can look at numbers all day and plot graphs and log journals, but I can't do much without understanding the full concept of what I am working with. I have the insulin; I just don't know what to do with it. I do not have a pump. I give myself my injections and I do not have the health coverage to see a specialist or and educator right now (hopefully soon, after another 90 days.)

Can someone please help me? I am really trying here. Can someone just put it "simple stupid" for me.

2

Your correction is huge. I would not have to take 10 units to correct a 320. That would make me go hypo for sure. 15 to one sounds about right for most though for your carb ratio.
I wonder why your corrections are so high. Your daily basal of 45 units also sounds average.
So I wonder if your sensitivity numbers are incorrect (20) should be more like 35 or 40 based on your other numbers). My ratios are very close to yours, but I would take 5 unis to bring down a 300 to 120.

On top of that you made a math error. You should be taking 12 units even by your own set of numbers, not 22. You might want to check with your doctor about altering or checking your formula.

I don't think I have ever taken more than 10 units at once. I think I was having dka at the time, Normally I bolus around 4 -6 units. Plus maybe 1 or 2 for correction.

3

Use ratios, not sliding scale. Sliding scale is not accurate.

Doctors typically start patients at a conservative 1:15 ratio. From there, insulin is fine tuned with both dosage & timing. Ratios can be different for different meals. Many find that breakfast has a smaller ratio when people are more insulin resistant/carb sensitive. Changes to ratios are done in small increments, usually 1 unit at a time. Any change should be kept the same for three days before making another change to get the broad picture.

ISF, insulin sensitivity factor, is used for correcting highs. It's how much 1 unit of rapid acting lowers BG. So, the next time you have high BG, take 1 unit of insulin & test. Usually starts working in 15-20 minutes & peaks around 2 hours. With frequent testing, you'll know how much 1 unit lowers you. One unit consistently lowers mine 60 pts, but everyone is different based on sensitivity & weight.

Test at 2 hours from when you start eating. Also good to ocassionally test at 1 hour in case you may need to bolus earlier to head off a spike.

While tweaking insulin, it's important to keep carbs & protein pretty consistent day to day so you can discern patterns. It's a constant process, unfortunately, because nothing is static. Illness, infection, exercise, stress all effect sensitivity/resistance.

Most learn all this through trial & error. Doctors & CDE's really aren't all that helpful. They give broad guidelines, but diabetes is self-management. No educator is going to be there to fine tune.

Using Insulin is a great book.

Dosing is easier with less carbs. Large insulin doses=larger mistakes. Meals that are high in protein & fat slow digestion, so a spike can occur later.

Hope this helps. Ask whatever you need to know.

4

my ratio is 1:15 except for breakfast, where I'm 1:9. my correction factor is 1 unit for every 50 I want to lower my bg. I test a lot (10x/day) so I usually head off those highs before they get into 300-land. I'd never eat a sandwich if I was 320, I'd have a salad with just the meat/cheese from the sandwich. yes, Gerri's right, small numbers=small problems, big numbers=big problems. hope this helps

5

Other than a couple of "chosen few" here who always have perfect bg's...

DO YOU THINK THAT ANY OF US "GET IT RIGHT" ALL THE TIME?

I think it's important for you to compare yourself to say, me, who doesn't get it right all the time either, sometimes it feels like I'm getting it wrong all the time. And don't compare yourself with the chosen few with perfect bg all the time.

And regarding ratios and corrections... dosing for food, and correcting bg is a valuable tool for the majority of us who don't get it right all the time, and ratios are important. (And I suspect those who do get it right almost all the time, know their ratios very well!) I'm a little confused from your post, if you are dosing for the food at/before mealtime, or if you are just doing corrections. I agree, it can feel very frustrating to chase everything with corrections. And while it's certainly a goal to have "ideal" numbers two hours after the meal, I think that very few "real diabetics" are getting perfect numbers at that point all the time. If your numbers are always on the high side two after the meal, it's very reasonable to move your before-meal bolus a little further before the meal to get the insulin kick to line up with food absorption better, and increase your bolus a little from where you are now.

6

I agree w/ pretty much everything everyone else said. I’d also suggest lowering expectations of what yr doctor can do for you? Even if they’re readily available, there’s limitations on what they can do. A lot of docs aren’t too concerned about 200s after meals either. Insulin is strong stuff and, if you are at 320 and your sensitivity ratio is 40-50 mg/dl/U, you may only be off by a couple of units and just have to walk the rounds onto the target? I also agree w/ Gerri about getting a copy of “Using Insulin” or maybe “Think Like a Pancreas”, both have directions for how to figure out and adjust doses.

7

There is no simple.
Your correction is 10 units. Hold off eating awhile to get stability and learn what resistance you have up there in your highs. Livers don't like working on two jobs at once.
At one hour (& maybe 20 min. later since the insulin doesn't start acting for awhile), you test to see how your shot of 10 units did. You write it down. You figure you have half still on board to work. That 5 units is still going to work - YOU have to KNOW how far each one of those units takes down your blood glucose.
And you can correct then - IF YOU KNOW how far down a unit of insulin drops you.
My guess is that it drops you less up there in the 300s than it does in the 190s. Your sensitivity will change over time. You should record just how far a unit drops you when you're in the 300s and when you're in the <200s. Correction should be carefully done if you have been riding in the 300s for awhile. Too rapid/constant correction seems related to retinopathy for those who have been long time highers. Yes, the diet way to prevent being at 300 is by limiting carbs. Better yet, limiting carbs doing a bit of research with your body can help you deal with small numbers and gain confidence in giving insulin to match the number of carb grams you intook. There is nothing more satisfying than taking 7-10 grams of a vegetable, knowing it's able to be handled by a certain amount of insulin.
You have to research what different foods do to your body, take small small amounts to gain confidence in bringing down your blood glucose. Write it down and repeat the same food the next day and see if you've figured it out.
Since there are different types of carbs, e.g., starch, milk, veg, fruit, each strikes differently, and some in high numbers may never really be covered well by insulin. Giving up eating something is a whole lot easier than persisting in eating it, denying that no amount of insulin will ever handle it, and dealing with 300s over and over.
The idea is to find the amount of an item that you like eating and that you know x amount of insulin covers it, e.g., you don't go above 140.
Try each kind of carb = to 7.5 grams. How far up does your blood glucose go with it? I say 7.5 grams because so many foods are listed in 15 gram portions and small amounts are needed when testing. Just spend the next 3 months figuring all this out. Write down the amount & what you tried, what amt insulin worked. Add in some protein for each meal so you don't get hungry. Your own research project that every diabetic has to perform that the government gives no grants for.

8

Like they all said-- there just doesn't appear to be anything simple about this. I'm at a conference center all month. Eating the same exact portions of the same exact foods at the same time every day-- and taking the same doses-- (in an attempt to figure this out) and my numbers are still all over the place. The problem is that we are only able to control two variables (insulin + food) in a process which involves many other factors as well, which we aren't capable of predicting, or even understanding. All we can do is our best.

9

I definately agree with what everyone else has offered. I think figuring out your ISF will help. There is a standardized chart based on height and weight as a place to start and then, yes by trial and error, tweak it. I have become a Dr B fan and prescribe to the rule of small numbers. And for me, it works.

10

One thing at a time. Trying to figure out ISF, I:C ratios, etc. all at once is a definite recipe for frustration. I have 3 I:C ratios for different times of day - it took a lot of experimenting to figure them out, and it'll never be perfect because of factors other than food/insulin.

I totally agree with figuring things out with small numbers. Maybe start by eating the same breakfast every day, low carbs so there's less room for error, testing an hour and 2 hours after, and tweaking till you get it right. Then move on to the other factors, one at a time. It does take time, but is well worth it in the end!

11

Forgot to mention... there are loads of smart phone apps that will calculate how much insulin to take for the amount of carbs you're eating. You need to input your ratios/correction factors then the app does the rest. If you're not confident doing the calculations, that would be a big help.

12

which particular smart phone apps have you found for this? I resisted getting a smart phone for about as long as I can-- but I suppose it is time.

13

It's also sort of useful to keep track of changes. When I was "off the ranch", I'd just guess all the time, if it'd run up, guess and take some more, etc. which led to lots of hair raising ups and downs. With a gizmo (e.g. my pump...) it's pretty easy to see where I've been and come up with ideas about where to go next?

Re specific apps, Glucosurfer.org is run by a member and has a couple of things I like a lot: a very good graphic rendering of your BG graph, incorporating insulin boluses, food and exercise in a convenient picture. At one point, they also were incorporating a means of taking pictures of food so if you had x square inches (or CM, as they are in Germany...) of pizza or salad or whatever and got a result that was "off", you could have a pic of it handy for next time? I used "Lose It" to track food for a while, although it didn't incorporate BG into it's measures, it was handy and I noticed a few things BG-wise, simply by tracking what I was eating.

14

In 90 days you could ask for a CGM, a Dexcom.

15

why 90 days?

16

Well, there's a few things wrong with your post here:

1. If I was that high, I wouldn't eat! I would get my BG down first (preferably under 200) and then eat something.

2. When you're high, your correction factor is going to probably be different. Usually, my correction (or insulin sensitivity factor) is 1:40 - for every unit I take, my BG will drop by about 40 points. HOWEVER, once I'm over about 280, I get more insulin resistance and my ISF becomes more like 1:20.

3. I think you also made a math error (which someone points out below), but no, I would not do a full correction again 2 hours after eating. You would still have some insulin working in your system and correcting again at that time would probably cause a really wicked low a couple of hours later when all that insulin kicks in. That said, if my numbers hadn't budged, I would probably do a partial correction.

But I think you hit the nail on the head - this is an art form. And everyone reacts differently under different conditions.

If you are able to obtain health coverage that allows you to get a pump, definitely consider it. The bolus wizards really take the headache out of the math factor once you get everything set properly.

17

I second all of the other advice. Most likely, any doctor or diabetes educator you encounter will not be diabetic. The information they give you will either be textbook or clinical. Not first hand. Novolog / Lantus will not work like it says it will on the bottle. Smaller shots will be more accurate and consistent than large shots.

Go to Walmart or some place, and buy a cheap monitor and a couple hundred cheap test strips. I reuse lancets a lot, just cuz i'm too lazy to change them, but it's never caused a problem. Then, just test your BG a lot. This is the only way to figure out how your D works.

Be patient and relax. Consider yourself fortunate that you have much, much better tools available to you now, than if you were diagnosed 50 years ago.

18

Sam - I like your advice here. While the textbook and clinical advice that we receive from doctors and diabetes educators is generally ok, it is simply a starting point that each of us can use for further experimentation.



Matthew - I’m sure you’ve seen the auto industry disclaimer that “your mileage may vary” or YMMV. Many here have adopted the sentiment that “your diabetes may vary” or YDMV. In fact many believe, including me, that your diabetes will vary.



As much as the medical professionals may consider their advice as definitive, your acceptance of their advice as such may be hazardous to your health!



If you want to do well with your diabetes, you must test, test, test. It may help to write down your experience so that you can begin to spot some patterns and start to see the forest instead of individual trees.



If you take this disease seriously, you will never cease to test, analyze, adjust, and test again. Diabetes control is a moving target. Just when you think you’ve settled on the right algorithm, the rules will surely change.



As a few others have suggested, you need to understand the concept that insulin is used up over time and if you check your blood sugar two hours post meal, then you need to estimate how much insulin is still active (also know as IOB or insulin on board. Then you can factor that amount into any needed correction.



It may seem like a lot to learn but your efforts will make life easier, not harder.



Good luck to you!

19

I would also add a simple rule: You can NOT eat whatever you want.

20

Chill. Take a happy pill. Relax and educate.

There is a huge difference between the insulin to carb ratio and the correction ratio. Correction will tell you what 1 unit of insulin will reduce your glucose level. Mine is 1 to 65. So, if I am 180, one unit would bring me to 125 in 4 hours. So you need to understand both ratios.

Also be wary of the insulin on board. It takes about 4 hours for fast acting to be disspated in your body. The bolus wizard is a fantastic tool for all ratios and on board insulin. If you have one, program and use it--it does the thinking (well, calculation) for you.

Good wishes to you!