Basal the spike away

Standard Disclaimer: I'm not a doctor, please read the disclaimer at the bottom of the page. Always speak to your doctor, especially before trying something that came to me while I was in the shower. 

Stubborn Highs: Arden's blood glucose can rise and at times be resistant to returning to 'normal'. Happens to all of us. I bolus and wait but nothing, so I bolus again and sometimes again. It's around the second bolus when I begin to wonder, "is the site bad", "maybe the pump has been on too long", "did I grossly miscalculate carbs", a person can go batty trying to decide what has happened. It's likely that before you (or I) can ever come to a conclusion, the BG in question will return to 'normal' or head in the complete opposite direction. Either way, the whole unsightly mess is forgotten becasue you're busy chasing the next problem which leaves you no closer to understanding why this happened or figuring out how to avoid it next time.

Sound familiar? 

This type of BG struggle isn't just associated with stubborn highs: Breakfast or meal time spikes can also lead to an urge to bang your head on a nearby firm surface. Over the last few months I've been experimenting with an idea that came to me in the shower one day and I'm seeing a lot of positive results. I'm going to do my best to explain without being boring or confusing... Please note that what follows will only work for pumpers because it involves manipulating basal rates... sorry MDI and pen users!

Using increased temp basal rates in place of a portion of your bolus

Arden is a really good eater, that is that she eats healthy foods most of the time and in acceptable portions. If the kid has one 'vice' it's that she likes a bowl of Fruit Loops in the morning - just one cup. The BG devastation that this handful of cereal visits unto Arden was, in the past,  terrible. Her BG would rocket to 400 or more after a bowel of the colorful rings. The Loops would seem to laugh in the face of a pre bolus and administering more insulin before the meal or an extra bolus after could not penetrate their sugarific force field. Once I even thought that I saw Toucan Sam give me the finger as I put the cereal box back in the pantry.

I hate this song and dance. I hate that Arden can't have a flippin' bowl of cereal once and a while and I double hate the feeling that I live with when she eats cereal and her BG goes crazy. Foods like this don't just send her BG too high, they ruin most of the rest of her day. I'm full aware that cereal isn't a good choice for my diabetic daughter but I'm not writing about that today. Today I am talking about how, with the help of an insulin pump, we can all fight meal time spikes associated with not so great food choices and manipulate stubborn high blood glucose values more easily and smoothly.

My formula

Things you need to know to follow along: 

• Arden's basal rate is .30 in the morning and much of the day.
• For a serving of Fruit Loops she requires 2 units of insulin.
• Giving say 2.5 units for the cereal does not change the trajectory of her BG.
• If I go higher (say 3 units) the spike is not effected enough, topping out at 350 and Arden's BG will plummet between the three and four hour mark.

Time to visit me in the shower where I am apparently about 20 IQ points smarter then I am anywhere else. (I've heard that the hot water on the back of your neck may be the reason why).

I was in the shower one day pondering life and Arden's breakfast BG spikes when I first began putting the pieces together. Overnight Arden's basal rate is .20, if she's high I have to put her basal back to .30 for a bolus to have the desired effect... I wondered what would happen "if I increased the basal beyond .30", could I bring a high BG down in a safer way, steadier perhaps (because she's sleeping) then if I just bolused? I tested my idea at the next opportunity and not only did a significant temp basal bring down the high overnight BG but it did it with less insulin then a bolus would have required and the drop was smoother, it's 'landing' less erratic. My inner mad scientist was intrigued and I had just unknowingly found a big piece to the puzzle that is stopping mealtime spikes.

Proof of concept: Arden sits down and begins eating on a school day at 8:20 am. Today at 7:45 am her bg was 140, I bolused for the first 15 carbs of her upcoming breakfast, which was 1 unit or half of what a serving of Fruit Loops requires. This is a pre-pre bolus, I find that after a long night of no boluses and a decreased basal rate it can take a little longer for insulin to begin working (maybe this is part of the morning insulin resistance many experience?). At 8:10 am I bolused again this time for the remaining 15 carbs but I reduced the 1 unit of insulin by .30 (the equivalent of an hour of Arden's basal rate). Last, I increased her basal by 95% for one hour. (OmniPod won't do 100%), giving the last .30 of the 2 units via an increased basal rate. The temp basal in conjunction with a significant pre bolus seems to be the key to eliminating a BG spike. Pre bolusing alone won't effect a severe spike enough because you can't perfectly sync the insulin peak with the food spike so the BG rises quickly, drops suddenly and often bounces back up. However, when you add a pre bolus to a significant temp basal, the basal acts as a constant drag on the spike and the two together win out.

Breakdown

15 carbs or 1 unit, 40 minutes before breakfast - 7:45am

I can prebolus that far off in this situation without an issue because her basal was .20 all night and she's resistant in the AM, so the insulin is a bit slower to respond first thing in the morning. Plus, with Apidra, Arden rarely experiences significant BG falls so prebolusing this far out feels safe. Additionally, I have 70 points in her BG to play with and the cereal will be releasing sugar into her blood far before she gets too low... (having a DexCom CGM doesn't hurt either).

Another 15 carbs 15 minutes before the meal (withholding the equivalent of an hour's worth of basal)- 8:10

This insulin won't begin working until after Arden begins to eat, so I'm not worried about stacking. Two boluses also mean two insulin peaks while the Fruit Loops are trying to spike her BG. 

Double the basal rate for an hour to complete second 15 carb bolus.

This .30 will work better then if it was given as part of the bolus, why? I don't know, I told you, I'm not a doctor... it just does - Maybe I know this because hot water in the shower makes me smarter. btw, more then an hour of the temp basal is too much and results in a fall in the 3-4 hour range. Doubling for an hour is perfect.

Result: At 9:30 am Arden's nurse called... Arden was 240 by her CGM. The CGM indicated 2 arrows up (which was why she was with the nurse) but the double arrows only lasted for about 4 minutes. So my little science experiment took a double arrow up event that in the past would have sky-rocketed to 400 (or more) and held it to a 4 minute double arrow that never went above 250!

Arden's BG (by the CGM) at 11 am (pre recess) was 145 diagonal down, she drank 2 ounces of juice (7 carbs) and went outside to play. When she returned her BG at 11:30 am (post recess, pre lunch) was 129 by a finger stick, 140 and steady via the CGM. 

I choose and extended bolus for lunch because she was having a bagel. 60% of the 2.20 units at 11:30 am the balance over an hour (to combat the slow breakdown of the bagel). Her BG was 145 three hours later before snack time.

Summation

It goes without saying that what works for Arden won't work for everyone but after months of using this method I am 100% comfortable telling you that what I wrote here is well worth speaking to your endo about. The concept of using a temp basal to complete a bolus holds many possibilities beyond what I wrote about here today. Slow to break down foods and high carb meals for example are also good places to try this method. I'm using a temp basal as part of Arden's bolus on almost a daily basis. It is also invaluable in bringing down stubborn high BGs and getting a BG lower during sleep, avoiding the fear of a sudden drop and without going too low.

I wish you all good health, luck and steady BGs. I'll do my best to answer any question if you have them.

Apidra SoloStar supply news

Looks like Sanofi will have the supply of their Apidra SoloStar pen back to normal levels in the second quarter of 2012. Sanofi has made the FDA aware of their timetable and SoloStar users should be happy again in just a short time.

The company has produced a web page that can help a SoloStar user navigate the supply issues and they've also extended their free Apidra offer as a way to help soften the sting of this inconvenience. We've taken advantage of the free offer even though Arden doesn't use the SoloStar pen... Nothing better then free insulin, right?

Arden's A1c is at it's lowest ever since we switched to Apidra so I'm more then excited and happy to let you all know that it's out there and for a while longer, free. 

The lowest A1c ever

Yesterday was Arden's quarterly endo appointment and it could not have gone any better! At her last appointment her A1c was in range but a bit higher then usual, though still at the high end of acceptable for her age. Arden's A1c is always very stable and in range but never as good as it could be. Our endo likes that it's steady, I am usually unhappy with the number and trying to make it lower.

I don't know about your endo's office but Arden's does her A1c test on site. Today, I was just too on edge to wait for the nurse to bring the news, so I snuck back into the lab just as the test was finishing...

10, 9 ,8, it counted down, 7, 6, 5, I actually said, "c'mon be lower", 3, 2, 1... Test complete. It wasn't just lower then last time, it was .7 lower! Almost a full point! I held in my excitement and made my way back to the exam room (where Arden was blowing up a sterile glove for our now traditional game of VolleyGlove). I told her how far her A1c had fallen, she smiled coyly and offered a high five or three. Then we volleyed that glove like it was our first time.

The NP came in a few minutes later and she began asking the standard questions but I just couldn't wait. I said, "did you see her A1c yet?", she replied, "no". I responded, "Well I have and it's amazing!".

She asked me what it was (I don't share Arden's exact A1c here) when I told her she began clicking furiously on Arden's file and found a list of past test results.

"I thought so" she said... "lowest EVER!", she congratulated Arden and then me. I found myself thinking that my smile must look ridiculous because my face felt like it was about to break. As soon as we got into the car I called Kelly to share the great news and we celebrated all over again.

It's ten hours later and I'm still as excited as I was in that exam room. Even when things are going well with diabetes it can still feel as if they aren't. Yesterday was a much needed and well deserved chance to celebrate and feel accomplished. I hope everyone gets a day like this very soon, it was reinvigorating.

DexCom CGM: Buy 4 sensors get 1 free offer

DexCom is offering a free sensor with your next order of four. This buy 4 get 1 free promotion seems to be an effort to get customers introduced to their new online store. Looks like you just have to register and then place your order via that online store. The offer ends in March 31, 2012.

If you are an adult (users under 18 see below) DexCom user this is a no-brainer, we've all been waiting for the company to set up an easier way of placing an order. Now you'll be able to order online or set up a auto-reorder. You can visit the DexCom website and choose the link that looks like the image below (they banner rotates), it will take you to this link.

Now if you are the parent of a Dex user things get a little confusing but you can still easily take advantage of the offer and set up an auto-reorder (they call it 'Schedule Ship'). Since minors can't register to make purchases through their online store the form on the website is not going to help you. I had to call customer service, wait for a call back, etc. I asked my CSR if there was an easier way for the parents that read my site to take advantage of this offer, he and I came up with this...

Parents of minors that use DexCom can take advantage of the buy 4 get 1 free offer by simply calling...

Brian at 877-339-2664, extension 5561

Tell Brian that you were sent by Scott from Arden's Day, that you would like to set up a Schedule Ship and receive a free sensor as part of their offer. Brian will email you the 'Schedule Shipment' form, you send it back to him and you'll be finished signing up for their Schedule Ship program... getting your free sensor in the process.

Speaking of free stuff:

Apidra is free until 4/30/12 

I have a 3 year supply of Spring's Universal Infusion Sets to give away

Trusted my instincts

 

Last night before bed, Arden's BG unexpectedly spiked up. I resisted the urge to play it safe and trusted my instincts to bolus. I covered the high BG and encouraged a small snack that I did not cover. We had an early dinner and while I didn't understand the spike I knew that the insulin without anything in her stomach would likely cause a low later. So I popped some corn and Arden had a few (of her) handfuls with melted butter to get some fat into the mix.

I must have been a bit unsure initially because I posted on FaceBook that I just bolused and didn't know what to expect. Two hours later her BG was in a good place and drifting gently to where she woke this morning, 85.

This morning she woke up in such a pleasant mood and immediately began talking about all sorts of funny stuff. She hopped out of bed when I asked her to, didn't linger in the bathroom or mess around while she ate... she didn't even complain about brushing her teeth! All of that makes me wonder just how much varied and fluctuating blood glucose levels effect her personality, mood and feelings.