MDI strategies thread

No same insuln! However I believe IOB is different in different people. We calculate that 95% will be gone in the First two hours. So if he is high after 1h and 45 min and he will not exercise or something he does a correction.

 

I would really appreciate some help with figuring out how people manage late evening and night time issues.

My son currently runs almost flat for two hours after dinner. He eats pretty early, before 5:00 pm, and yesterday for example he ate dinner at 120, and over 90 minutes he actually slide down slowly to around 90. Then over the next 2 hours he again slowly rose up to about 160, so he peaked out at 8:00 pm 3 1/2 hours after dinner without any peak at all in the first 2 hours. (I will attack a dex trace). Anyway, I moved his Lantus from 8:00 pm to 4:30 pm so that it would help out with the late 3+ hour spike.

By the 4 hour mark he was around 140 with presumably no fast acting left on board. Now at this point, he still has just enough honeymoon that about 3 hours later he had gone from 140 to a flat 100 for the night.

All in all that is great right now, but what happens when he doesn't have anything getting him down those last few points at night? Ideally if you go to bed at 140, 4 hours after dinner do you literally sleep around 140 all night after the honeymoon or do you get a little bit of correction as hormones come and go at night?

Anyway if people could explain their basic bedtime strategy I would appreciate it.

1) At what point 4+ hours after dinner do you try to correct a night time blood sugar? Would you be fine with basically running 120, 130 or 140 all night? If a child comes up a little at night do they usually just stay there?
2) What bedtime number do you shoot for?
3) What do you do with your night time high alarm?

Is there a natural bump up around bedtime for kids of a certain age due to hormones and does it eventually just last all night if you don't fix it?

At what point after a bedtime or night time correction do you do a fingerstick? Do you trust night time fingersticks based on your experience? (I have had IC nurses tell me that night time "asleep" fingersticks can lag several hours behind because circulation to the fingers is very slow at night, but if a patient wakes up and moves around they often get 20+ points lower fingerstick numbers).

I know we have dexcom but sometimes it stops giving data so I'd like to know the best way to be safe on night time corrections.

At what point at night do you do something about a lower blood sugar? If you check at midnight and you get 75, 85, 95 etc? Part of my problem now is that our correction factor for 1/2 unit is almost equal to my son's range, so if he was at 160, and got an 80 point drop he'd be at presumably 80. Then when he was sick of course I threw 1 1/2 units at it and it came down about 30 points at most.

 

When we were 10 months out from diagnosis our only strategy at night was to have her go to bed over 100. If she ate dinner early then we would often still do a bedtime snack. Her doctor pretty much suggested that 130-150 would be great to aim for but it was fine if she were over 100 as she went to bed. We were advised to treat her if we checked her at night and she was below 70 but if she were a little above 70 (like 70-85) to recheck her in an hour and most of the time-back then- she would occasionally drop to 75 ish but invariably she would creep back up on her own and always woke in the morning between 85-100 (unless a crazy huge and late restaurant type meal). We never had a real low back then although sometimes I would treat her at 75-80 so that I could sleep.

Now, nearly 2 years in we probably have just a tiny bit of her honeymoon left if any but we also have dexcom. We have gone through alot of struggles at night. We have had months were she skyrockets at about 11-12 no matter what she had for dinner or when. It was maddening. We would aim for the lowest number we could get without going really low between dinner and 11 because she was going to climb after that. We tried changing diet, changing lantus time and giving regular insulin (plus humalog) with dinner vs at bedtime. It was/is scary though giving insulin at night when she is not high just because you suspect that she will go high in a few hours. Sometimes I would just wait until she started to climb around 11 and then correct with humalog but it was always a gamble on how high she was going to go if I didn't correct and whether I was going to make her go low. The regular was more gradual and often better but I had to do it well before her peak rise to get the timing right and it was hard to do. I think it was alot of growth hormone issues though because the effect is not as pronounced right now as it was for quite a few months. The other issue for us is that she is much more sensitive to the late effects of meals now so the slow absorbing and higher fat foods cause alot of problems. Some foods seem to hit about 4-6 hours and sometimes a high fat load won't hit until 6-8 hours. For the most part I do not correct her at night until she is 200 or close to it and climbing. Half a unit will drop her 120-140 at night (if not unusually insulin resistant when she is sick or something) so I can't do it lower than that unless I am really really sure a spike is coming. (and of course I am never completely sure).

I would be thrilled with her running 120, 130 or 140 all night although i'm happiest when she comes to breakfast at about 100. Generally speaking though she doesn't stay very level at night except sometimes when she settles in around 80-85 and sits there all night. Usually she has a little spike and then drifts down around 4am. My advice to you, such as it is, is to relax a little on the differences between those nighttime numbers. Your son is still in his honeymoon and will do alot of corrections on its own. I would probably not correct a low unless you were below 70 or maybe 75 because you have dex and can watch it. I would also be conservative on correcting highs since your son comes down on his own. Enjoy it as much as you can because it will get worse.

I do worry about the fingerstick numbers sometimes but never really heard any warnings about them being unreliable. My daughter has taken to sleeping with her face on her hands so when i pry her hands out they do not seem to have good circulation and sometimes she has drooled on them too! Still for the most part they are similar to dex.

Sorry if my response is rambling. Its late and I'm at work. No sleep on my days off and no sleep on my nights at work

 

Hello, my son is 14yo. We are much less specific/structured in what we'd because teens are erratic and I have much less control over his choices. But he is MDI.

How do YOU use Lantus? --- He does one dose of levemir before bed. We do not make daily adjustment. We increase if we see a trend of numbers rising independent if food intake.

Do you dose Lantus at a level that would typically result in a low if a child can't eat on schedule. --- No. Our goal is to stay steady over night and between meals.

Do you avoid warm baths after or before Lantus and for how long? --- Yes, not before but for a couple hours after.

Do you split mealtime boluses. -- no we do not. He still doses after he eats.

Are you concerned about bolus for food/meals within 2-3 hours of bed time? -- I struggle here because he will eat huge carb loads before bed, hence huge amount of novolog. I always set alarm to test 4 hours later. He is usually very high then. Maybe a combo of his food choice and inactivity?

If you get a meal that ends up falling between two normal meal times do you adjust the carb ratio? --- no. The only time we adjust carb Ratio is before planned activity as he is sensitive to exercise.

At what point do YOU correct with MDI? -- We only correct if it has been 4 hours since last insulin dose. We don't even test after meals. We know it is high. At meal times we correct for any number above/below 100. At other times we correct anything above about 175 if nothing is planned - or above 200 if planned activity. When on his own that is probably more like 250. If he eats at noon he will correct and do his food bolus. If he eats again at 2pm he corrects for food only no matter what his number is.

would you correct for example a blood sugar of over 300 more than 3 hours from a bolus of fast acting? --- yes. 4 hours is my general rule. There is an app that calculates insulin on board. I'll post it after I'm done here.

When do you usually see mealtime spikes? -- we don't look at them. I know that sounds awful but we aren't going to do anything different either way. He is not ready to learn about foods and how he responds to them or for bolusing first so until then there is no point. His A1C is 6.7.

I wonder how you deal with an 85 blood sugar an hour after eating dinner -- He treats lows if he is below 70 - or below 100 before driving or bedtime. Since he boluses after he eats - we hardly ever get this but if it was pizza or something we know he would come back up. It is tricky with driving now. He would probably treat and correct later because I have to make such very clear/strict rules about driving.

Do you treat mild lows shortly after a meal with food on board? -- no but that has not ever happened since honeymoon ended - or at least never low enough for him to feel it.

How do you work down carb ratios if you raise basal?-- they seem to be unrelated. Increasing basal just means fewer corrections. The carb ratio is changed when, if he starts out in range - the dose is not bringing him back into range after 4 hours.

If you have good averages do you try to keep the TDD the same and then take away from typical bolus at the three meals to make up for the basal increase? -- no. If any changes are made with that kind of info the endo does it for us. The novolog is for food and the levemir for keeping steady without food. That is what we were told.

Will answer your night question in new post

 

First I appreciate the thread. There isn't a lot of discussion on MDI. It has been nice to read what others do.


The phone app I mentioned is Rapid Calc.


Ideally if you go to bed at 140, 4 hours after dinner do you literally sleep around 140 all night after the honeymoon or do you get a little bit of correction as hormones come and go at night? --- There seems to be fluctuations of 30-60 points.

1) At what point 4+ hours after dinner do you try to correct a night time blood sugar?--- 175 and above.

Would you be fine with basically running 120, 130 or 140 all night? --- yes, absolutely. We were told that waking up at 120 was considered 'tight control'. I am finding it quite difficult To achieve lately but I think that is because of my sons habits and cooperation

If a child comes up a little at night do they usually just stay there? -- no dex. I don't see the lines. When everything goes according to plan he wakes up within 25 points of the middle of night check.

2) What bedtime number do you shoot for? -- 120

3) What do you do with your night time high alarm? --- If he is 200 or above at middle of night check - he corrects.

At what point after a bedtime or night time correction do you do a fingerstick? --- 4 hours.

Do you trust night time fingersticks based on your experience? --- Yes, never heard the thing about being hours behind.

At what point at night do you do something about a lower blood sugar? -- Below 85/90. If lots of exercise that day, below 100. When he was more up/down it was below 125.

We were cautioned to not over correct or correct to soon, that the resulting swings would create a day of problems. That has been good advice for us.

 

I was hoping to get help with certain meals that peak a little later, say 2.5 hours after eating but still come down within about 4 hours. If a certain meal of the day, or certain kind of food runs pretty well for say the first 90 minutes, but comes up around 2.5 hours, but still comes down by around 4 hours, then is it better to bolus earlier (so long as there is no low) to just knock all the numbers down leading up to the peak, or is it better to bolus later so that the peak action of the insulin matches the peak?

My son's endo says that the way to reduce peaks is to bolus earlier (as long as the dose is right to have you about where you started by 4 hours) but other's have told me that you want the peak action of the insulin to match the peak of the meal because the meal will send the liver a signal to release glucose and if there isn't enough insulin to tell the liver to hold back, it will make a bigger spike.

Is it generally a GOOD idea to see numbers go down on prebolusing as long as they don't get low. A few times my son will hang low under 90 for a long time on a prebolus but come up big after 90 minutes or 2 hours. It may just be a basal issue though since our basal is so low that we have had some gap on Lantus.

 

For these foods Joe we use regular insulin. He takes novorapid with his food and then after 45min -1 hour he takes regular.

 

Re the nighttime questions-- we shoot for 120 but would be fine with 140. Generally between 90 and 160. I know my dd may drop the first part of the night but rises toward morning so when it is in the night makes a difference. I would not expect steady nighttime numbers after the honeymoon. Honestly our nighttime numbers are pretty good most nights lately but that has not been the norm over her 12 yrs of D. Usually I think whatever happens during the day comes out at night-- whether it's fatty meals or exercise-- plus growth and puberty hormones can kick in and shoot them high very quickly.