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.

Switching from MDI to an insulin pump

This post is in response to the question that Melissa posed on 'Ask Me Anything'.

Hi Scott,

I was wondering how you felt when you got Arden's pump. Alison has been doing MDI since July 2010 and we just got her first pump yesterday.

I have to admit that I was really excited when the girls and I opened the box up. The little ones were excited to see the unit power up and hear the sounds it made and it was a really positive experience.

Once both girls were asleep in their beds, I took another quick look in the box. I was overcome with tears. I felt this enormous weight and sadness, almost like I did when we were coming to grips with Alison's diagnosis.

Just thought maybe others could share how they felt (excited, nervous, sad) about the changes in their child's lives. - Melissa

To answer your question simply... I was nervous beyond compare when we made the move to pumping. In my opinion switching brings up a lot of those old diagnosis feelings becasue it again challenges you to learn something foreign and learn it quick. That should be the definition of pressure, "figure this out or here's the list of bad things that'll happen to your child".

The long answer is this... In a few days we'll be celebrating Arden's third anniversary with her OmniPod insulin pump. I can remember getting more and more nervous as her pump start appointment approached. On the way home from the endo's office that day we stopped for lunch and I thought that I was going to cry right at the restaurant table. Switching from MDI to a pump instantly reduced me from a seasoned type I parent to a rookie. In that moment everything felt new and I was confusing myself with every move that I made. Basal, bolus, cannula... why did they have to rename stuff? What was wrong with long acting and short?

I just about fell apart... Then I looked over at Arden and she didn't care that everything was new. She was beaming, thrilled that the shots had ended... that's all she knew or cared about. I figured that if she could do it then so could I. So I took a deep breath and thought to myself, "bolus is the shot, basal is the long acting insulin, this is going to help her... lower A1c, no more shots... bolus is the shot - I can do this." A week later I felt like a pro again (I wasn't but at least I wasn't scared).

Melissa, I've been overwhelmed by a great many diabetes related moments. My best advice is that we have to go through these things so we can become the people that our children need. The first few years and the changes that come with them are our diabetes education. No one is going to be able to fully explain this disease to anyone else, we all have to live it to learn it, we have to suffer with it to master it.

One night as I was putting Arden to bed she asked me, "what am I going to do when I go to college", referring to overnight management. Poor kid, she's seven years old and she is concerned that she won't be able to be safe ten years from now. After I explained that by then she'd have a system just like mine, I went into the next room and cried. The trick is that I left my sadness in that room when I was finished. I choose to let those moments strengthen me. I considered them a hurdle crossed instead of another chink in my armor. I may be fooling myself but if I am... it's working.

Living this life demands that we get scared and even cry sometimes but always push on...

Congratulations on moving your little girl to insulin pumping, I hope and expect that it will be a wonderful addition to both of your lives! I know that my stress decreased significantly when the OmniPod came into our lives.

If anyone would like to share how changes in their child's care has affected them, please post your remarks after Melissa's at this link.

Great thanks to Melissa for sharing!

DexCom and Tandem Diabetes Care Announce CGM Development and Commercialization Agreement

Breaking diabetes tech news!

DexCom and Tandem Diabetes to develop a "CGM-enabled insulin pump"

Read the blurb and then continue to the link for the rest... New diabetes tech innovations are always good news, I can't wait to hear more about this and other collaborations. 

SAN DIEGO--(BUSINESS WIRE)--DexCom, Inc. (NASDAQ:DXCM), a leader in continuous glucose monitoring systems, announced today that it has entered into a Development and Commercialization Agreement with Tandem Diabetes Care, Inc. to integrate a future generation of DexCom’s continuous glucose monitoring (CGM) technology with Tandem’s t:slim™ Insulin Delivery System, the first ever touch-screen insulin pump.

You can read the rest of the announcement at this link

Current Tandem Pump

Current DexCom Receiver

Your opinion is needed: Insulin Pumps and Glucose Monitors

I am in the throws of launching a charitable foundation whose focus will be assisting diabetic children that want but can't afford insulin pumps and continuous glucose monitors.

The necessary paperwork to form the charitable entity is getting very close to being submitted. In the meantime, I am diligently working on ways to make the charity as successful and far reaching as it possibly can be. I will be involved in a number of meetings and presentations over the coming weeks and months and I was hoping that you could help me to better understand how the costs associated with managing diabetes effects your financial life. I am very interested in hearing from the parents of children with type I but if you are an adult with diabetes I am still very interested in your answers - you never what the future will bring.

If you would be kind enough to anonymously answer a few questions, I will be able to use the data you submit as I search for the funding necessary to make this fledgling dream a robust reality. You won't be asked anything that would identify you and none of your personal information is collected by this site.

The answers that you provide will help me to make a better presentation when speaking with potential donors, supporters and sponsors. None of the answers are 'required' by the form and you can skip any you like by choosing "left blank".

Your support is greatly appreciated!

The data collection form is located here. http://www.ardensday.com/anonymous

OmniPod Rash?

If you've ever experienced a rash under your OmniPod, CGM or infusion set adhesive, read on.

Before I begin I need to say that I'm not a doctor and you should never confuse me sharing my experiences with health care advice. Never make adjustments to a care plan without first checking with your physician.

In the summer of 2010 Arden began to develop a rather severe rash under her OmniPod. I was confused because she had been wearing her OmniPod for a rather long time with no issues and it seemed random that she would suddenly have such a reaction. I turned to the internet, called Insulet and was presented with a number of "solutions". My problem with the answer that I was given was that it included buying more stuff and it complicated the pod application process. I really believe that the simple answer is often the best, so I held off on putting the conventional fix into practice and took another shot at diagnosing the issue myself.

Before I could put my thinking cap on I noticed that I was rubbing my finger tips against my thumb and that my finger tips were sore. I looked at them and saw that they were dry and begining to crack. I drifted away from Arden's issue momentarily to wonder about my own and then it hit me - I'm always touching alcohol swabs, that's probably why my fingers are so dry.

That realization led to an epiphany and suddenly I (thought) knew why Arden was developing rashes. At Arden's next pod change and every DexCom and OmniPod application since, I have cleaned Arden's sites with warm water and a clean towel - nothing else. Not only has she never had another rash but her pods don't stick to her like they've been cemented on when it's time for them to be changed (don't worry, they don't come off prematurely).

Turns out for Arden, chemically wiping away the oil that her skin makes naturally and then covering the area with an adhesive strip, wasn't a good idea.

I've shared our process with Arden's endo NP. She wasn't thrilled that I stopped disinfecting Arden's sites before poking a hole into her but she does acknowledge that we may have had to discontinue using Arden's pump without this adjustment. For us it's a calculated risk, you and your doctor can decide if it's the right thing for you to do. I wish you much luck!