Any Advice on Insulin Dose Change?

Have you ever been there? Everything seems to be going perfectly with your ratios and then slowly over a matter of weeks what used to be a walk in the park becomes a nightmare?

I've sent the numbers to the Endo, but she's so slow at getting back to me that I thought it might be useful to find out how to figure this out myself. Up until now I really only adjust basil insulin depending on my son's needs and I leave the ratios for Carbs and correction to the Doctor.

My son is 10, 66lbs (30Kg) 4"10 seems healthy with no current signs of illness. MDI with NovoRapid (Novolog) and Levemir.

I give him 6 units of Levemir 2X day.
His carb ratio is 1:20
His correction factor is 1:4 (mmol/l) I think that's like 1 unit to 72 for the U.S. measurement.

We traditionally have Breakfast, lunch and Dinner with 60g of CHO each.
I give a 10AM and a 3PM 15g CHO UNCOVERED
8PM bedtime snack partially covered.

A month ago, the above stats worked so perfectly it was too good to be true.

For the past two weeks this has become progressively worse and worse. Now we are seeing 17 (300)-22 (400) 2hrs after meals and over night he's rising from 9 (162)-14 (260)or higher

I've raised his Levemir to 9 units 2 x day. And I have started over-estimating his bolus by 0.5 units. For the past 3 days I've totally cut out all uncovered snacks.

Todays numbers were:
9.2 last night at 8pm gave 2 units
18.3 this morning at 6AM gave 6 units
17.3 at 9AM and gave an extra two unit correction
3.6 low at 11AM treated lightly
7.5 at 12noon gave 3 units
17.8 at 2:15pm
9.8 at 4pm


I've changed vials of insulin just to insure it's not bad.

Any advice would be greatly appreciated. If you know a formula to figure this out, please share.

 

I put the conversions in red.

First question, what did the 2 units last night cover?
Second, did you correct the high at 2:15?
Third, do you prebolus at all?

My initial guess is that he needs more carb coverage, and he might not have needed the increase in basal. It's also entirely possible that he needs different carb ratios for different times of the day, and maybe different basal doses. We did a split Levemir dose as well, but it wasn't a 50/50 split for very long. I would try to get a basal test done.

 

I think going from 6 units to 9 for levemir seems like a very aggressive increase to make. If you don't prebolus, it would help with the 300s seen in between meals. It's made a big difference with my daughter's numbers.

Maybe he's starting to go through puberty? Not sure when boys go through it. That would explain, at least to me, being high in the morning.

However, my daughter's BG will raise significantly after I give her her basal in the morning if I don't follow it very quickly with a bolus for breakfast. I wouldn't think you would have that issue since you split his basal, we don't split my dd's lantus. Her lantus just doesn't kick in that fast in the morning. Her BG also raises between 9pm and 12am, then will go back down between 3-5am. When not on a pump, I think this is stuff we just have to kinda deal with because you can't fine tune the basal.

Is he eating differently? Maybe food higher in fat? That can cause crazy spikes.

 

Thanks Danismom79 for putting the conversions on there for me. His basil was working great last month, a very predictable drop during the night that I could really count on. Now, he's rising substantially at night, so that really makes me think he needs more basil since the 2 units I give at 8pm is to cover his 30g bedtime snack. Basil testing is a good idea and definitely needed, thanks for the input.

Oh, and we didn't correct the 2:15pm high, because he was just leaving school on a 1.5 hour bus ride, so he skipped snack and I tested when he got home and he was 9.8 with dinner just an hour away I decided to eliminate snack altogether and not correct till dinner time.

missmakaliasmomma: We don't prebolus because he's autistic and even though he eats everything he's given, sometimes it takes a lot of prompting and is very time consuming.

I don't really look at these numbers as post meal spikes. These are hours after his meal, not spikes we would see before his insulin can take effect.

He's also a very picky eater and on a very limited diet. So, there's been no change as to what type of food he eats. He's also a fairly inactive child, there's been no decrease in his activity.

I totally agree it's either puberty, a growth spurt, illness (or karma for our happiness last month at his perfect numbers)

The increase in his basil has been gradual over the past 3 weeks. It's only been since yesterday that I put it to 9. I'm just trying to get it to the point where his glucose falls at night again.

Thanks for the advice, if I don't hear from the Doctor tomorrow, I think I might treat this like he's sick and use our chart for increasing insulin for sick day management.

 

The first thing I would do is significantly cut back or eliminate that bedtime snack. If you're covering it with rapid, then he doesn't need it to hold him over until morning. I would also check at least once, and probably twice, overnight to see what his bg is doing. I'm thinking you're masking incorrect ratios with the increased basal.

 

Personally, I would eliminate all uncovered and partially covered snacks and reassess. I believe uncovered snacks only confuse the issue and do not recommend them. Once those are gone, it may be easier to see trends in basal vs bolus.

 

Agree, agree, agree.
Ali

 

I think you're all correct especially about basil vs bolus. Still waiting for the doctor to get back to us. I know in my heart that the uncovered snacks and bedtime snack are most of our issue on any given day. My son has a BMI of 13 which is underweight. Cutting out snacks isn't a good idea. Covering the snacks would mean 8/injections per day instead of an already whopping 6/day.
I talked it over with my son last night and he's very emotionally charged when it comes to changing his snacks. This is going to be an uphill battle. But I'm pretty sure this will be the suggestion his new doctor makes.
A pump would solve so much of this but we have no private insurance and the Quebec provincial insurance plan only reimburses for the pump; which means I would need to come up with the money up front not to mention supplies.... I'll ask his Doctor if she knows of a way around that issue...we'll see.

 

For the hell of it, I just did my daughter's BMI. It's 13 also. She's always been underweight though, about the 25% when she was an infant and toddler, probably still now as well. It doesn't shock me. What I did see was that on webmd's kid's BMI calculator, 5-85% is actually considered a healthy BMI not a low one.

My daughter really only gets 1 snack during the day and that's at school. We'll sometimes do snacks that need insulin later on but it's not the norm. We opt for bigger meals (she'll eat everything on her plate)

I'm not too familiar with autism but I do know one child who's pretty severe and I know that anything out of his daily routine makes him very upset so while I don't have the exact experience, I can definitely understand how it's hard to change things up.

 

Is it possible to come to some agreement with him on what the snacks will be? Find lower or no carb options that will also pack on some pounds and nutrition. Ham chunks, slim jims, beef jerkey, pepperoni slices, cheeses, olives, pork skins (ok so not so nutrionally dense...), avocado chunks, small amounts of peanuts, carrots in ranch dip, cheese and more cheese/meat and more meat! These are all snacks that won't need an extra shot. You might also consider upping the basal just enough to warrant a dip when it's snack time. Feeding the insulin is something I know many people do, but I'd only advise that if he's pretty well aware of his lows (and/or it doesn't cause night lows), otherwise it's a bad idea.

 

His weight and BMI are a concern because he also has chronic/recurrent pneumonia and is really susceptible to other infections. Although right now he's healthy he typically drops 10lbs when he gets sick which is pretty often. It's certainly not the only driving concern for us but I wanted to explain why I'm concerned about limiting his food intake.

He's pretty picky about what he eats but I think we'll really need to sit down with his dietician and see what we can do to reduce the amount of carbs in his snacks. He loves nuts and cheese but his school is nut free and we're having issues with constipation due in part to all the cheese he consumes. At home it would be really easy to just give him nuts for snack.

Our old ENDO at diagnosis is the one who set the current routine of 15 g uncovered snacks twice a day. I wish we never started that routine now.

 

So, just now we proved two of these issues. He was 10.2 @ 2:15 and had a 12 g snack with a piece of cheese without insulin. At 5pm tested for dinner and he's 17.6 So yes, his uncovered snacks are the major culprit.

Then we had another heart to heart about his snacks; reducing carbs or eliminating them or even covering them and he's in tears screaming how horrible his life is. He's very delicate when it comes to diabetes impeding his life. He's on meds for depression since 1 year after diagnosis. So, if we make a change to his routine it will have to be handled with his Doc, counselor and dietician in a way that isn't going to make him feel worse about life.

 

Your Dr. Should be able to work with you in developing an insulin dosing scheme that reduces additional shots and allows for snacks. You have such a unique situation that working with an experienced Endo team is going to be the best. There are different types of insulins out there. Simple things, check that you are using the best syringes/pens for your son in terms of needle length and gauge as well as the sharpest thinnest lancing device for blood glucose testing. Sorry.

 

Good advice,

I know we really need an overhaul. We have a new Endo that we've only seen once so far. When we met her, there was so much to go over because my son has multiple medical issues, that we really didn't talk much about what a typical day is like regarding meals and snacks and such.

Hopefully, we'll hear back soon and get some advice that will get us through to our next appointment on Jan 9th. At that appointment, I'm going to try and focus on just the Diabetes and get a really good plan in place for managing his daily routine better.

 

Well, one option, while not a great one, is to use NPH for the daytime basal insulin.

We're still on NPH for the daytime basal insulin (Levemir for overnight, and NovoRapid for all bolus), and with the peaking action of NPH, a morning dose covers our son's lunch & daytime snacks. We've been doing this since diagnosis 10 months ago, and are still doing it since our son isn't ready to self-inject and we have no nurse help at school. Our next phase will be the pump, hopefully early 2014.

We find NPH is fairly irregular with absorption, and we see some crazy swings day to day. But if it works for you, it can help to reduce the number of insulin shots per day (ie. snacks, lunch).

If you haven't tried NPH in the past, then it might be something to discuss with your endo. Though I see you're from Quebec, so I'm guessing they started you off on NPH when first diagnosed?

 

Our old endo did the same thing with the uncovered snacks (on NPH), which led to high highs and low lows because of the whole "trying to time it right"

I try not to give my dd too much cheese either because of the constipation BUT we do eat a lot of broccoli so I think that kind of counteracts the cheese. She has a lot of fiber in her diet. Also, I understand the nut thing. My daughter's classroom is nut free, which limits what I give her as well. she loves almonds so she has them a lot at home. Healthy fat, not too many carbs so they're good. They actually sell 4g carb packages of almonds. My daughter has the flavored ones. They're sold in a green box. I can give her those (most of the time) without trying to cover anything

 

We've never used NPH. We just moved to Quebec from Prince Edward Island and have always been on MDI of NovoRapid and Lantus. Recently switched to Levemir. I'll talk to the Doc about all possibilities including trying NPH.

Our current routine used to work for us very well. It's just recently that we've begun to struggle. I guess with Diabetes we just need to roll with the punches more and expect a lot of rapid changes during puberty and adolescents.

Thanks again for the advice.

 

Why not "overbolus" at meal time? Give enough to cover the meal, and a snack 2 hours after?

Alternatively, get yourself some Regular (aka Toronto) insulin, and give mixed injections at meal times. Regular peaks later than the Novorapid, and given with a meal will cover a snack 2-3 hours later.

I am wondering what is happening overnight. Do you measure then?

 

I would do what Wilf recommended. Be sure snack is a couple of hours after the meal and give enough insulin in the meal injection to cover a healthy sized snack.

 

I'm very nervous to give extra NR at meals to cover snacks because historically this has made him low after meals but that's not based on his current numbers. With his current numbers so high I think I'll give it a shot this week while he's at home (it's a four day weekend for his school district)

I never considered using Regular insulin. That's something that I'll talk to his Doctor about. Maybe there's a way that can help us.

For everyone who's asked about night testing....
I test him before bed at 8pm then again at 10 in case he needs a correction from his bedtime snack/bolus. I generally test him one more time between 12-2AM (prior to going to bed myself) I rarely test after that.
However, prior to logging on here this morning I set a recurring alarm for 4 AM because his readings last night were 9.2 @ 10pm 7.9 @12:30am 7.6 @2am and then 10.8 @ 6am. So, I'm thinking we're dealing with the dawn phenomenon and the only way to deal with that on MDI is to get up and correct him in the wee hours.

If there's a better way of dealing with the dawn phenomenon please let me know.

I'm thinking that I really need to find a way to get him a pump. We really have never missed having coverage for one because we really were doing fine on MDI. Now it seems with the snack problems and his early morning rises, there's really no other way to manage him. It's been a drastic change in the past few weeks.