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Basal Question

Discussion in 'Parents of Children with Type 1' started by forHisglory, Sep 6, 2016.

  1. forHisglory

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    I hope this question makes sense....I hope I can articulate it. Our overnight basal needs keep dropping (meaning we go low between 2-5 am if we do not adjust every week or so). Is a proper basal rate supposed to keep the glucose at a steady rate or does it "aim" for a certain "target point/range" in the absence of a correction bolus? Last night he went to bed at 172. It was a full day of activity at the amusement park so instead of giving a correction and potentially fighting lows all night we decided to get some sleep and recheck in 2 hours. He stayed 150-172 for almost 4 hours. We increased by +30% at our 2 am check and that brought him slowly down to around 110 at wake-up. Okay, then the night before, at the same basal rate he started out the night at 130 steady. Left it alone all night and he woke up at 80.

    What I'm trying to figure out is......if you have a set basal rate, should it hold you steady within a certain glucose range or drop you to a lower target range by a certain number of hours. I'm not finding the answers in our references easily.

    Thanks a bunch for any insight....I feel like so many factors can affect things and causes lows (and I'm aiming to correct some sleep deprivation so I can work part-time!) that at night unless he's over 200 I am shying away from correction boluses. Maybe that's an issue too.
     
  2. samson

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    It should hold you steady. You should wake up within 30 points of where you went to sleep, assuming you gave no corrections.
    That's the dogma, anyway -- I'm finding that the best basal rate is NOT necessarily the one that keeps you steady, just the one that prevents big spikes while not causing dramatic hypoglycemia. For example, our basal rate, in the absence of food, might cause our son to drift down over the morning, but it doesn't matter because he always eats between 6am and 7:30am and always eats lunch again promptly at 11am.
    Basal at night should definitely keep you steady though. So if he goes to bed high , you should expect him to be high in the morning if you don't give corrections.
     
  3. Snowflake

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    I'm pretty sure that Dr. Ponder says something similar in Sugar Surfing, but I don't totally understand it. What does it benefit to have a "correct" basal, if the result is a flatline of high numbers?

    We've had periods when my dd's basal would keep her nice and flat, but moderately high, all night -- for example, where she might run at 200 for 10 hours if we didn't correct her. But we can't just increase the basal by some magic percentage to get a flatline trace bg of110 for the same 10-hour segment -- we'll invariably confront resulting and unpredictable lows and highs if we mechanically adjust a 10-hour basal segment. So, I guess I don't get what Ponder means (and also lots of other people who are WAY smarter about diabetes than me) when they say that any steady trace means a correct basal; afaict, knowing that it's right doesn't seem to have any real benefit for D management. Or am I missing something huge here? (I probably am!! To the OP: I love this question, because it's the kind of thing I totally get hung up on at the 3 a.m. check!)
     
  4. rgcainmd

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    Basal's job is to maintain BG, not to correct it. Per Gary Scheiner, if you go to sleep at night at 250 (in the absence of other actions), you should wake up at around 250. Likewise, if you go to bed at 100, you should wake up around 100.
     
  5. wilf

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    Depends on if you're a beginner or advanced, and if you're inclined to be reactive or proactive

    Having been at it for 10 years we would say that setting basal so there is a gentle drop happening (in the absence of carbs) throughout the day facilitates good control. You don't want to try this at home unless you know the math and know your child, but it has worked for us. :cwds:
     
  6. wilf

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    I like that you're thinking outside the box and not accepting the accepted wisdom.

    There is no reason to set basal to hold BG steady, esp. not if your child is high and you have a pump but don't want to actually correct. Just set a temp basal to bring them down gently and have yourself good night's sleep. :)
     
  7. forHisglory

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    It's good to hear a veteran that does this too......

    I've read the all the replies. Thank you all for giving words to my thoughts. I tend to overanalyze so the back to basics reminder from Dr. Cain helps. Still, its confusing when the endo says "needs more basal" because how do you know if high numbers need a basal adjustment vs a correction bolus? For example, if he was 200 steady all night, the endo will tell us to increase basal during that time, not correct! It's clear as mud sometimes. If I was to go by the book......to do an overnight basal test I would have to make sure we were in range at bedtime without IOB and then see if he held steady. In theory I would have a basal rate to hold him in range within 30 points of where he starts off at.

    Another thing I've noticed......I've always heard that you have to make basal changes 2 hours prior to the event you are trying to correct (high or low). During sleep, we can decrease basal 30-40% and it starts to change numbers within 30 minutes. The mechanism from that does not make sense, but I've seen it happen multiple times. At times, it feels similar to adjusting fluid rates on an IV with a 30 minute lag! NOT the 2 hour wait I've been told. That's a real head scratcher, but I have the data to show it.
     
  8. rgcainmd

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    If you're talking about setting increased or decreased temp basals, we do that all the time (in addition to a correction dose or treating a low.) What I was referring to was the "non-temporary" basal rate. In theory (and in the complete absence of other mitigating factors such as carbs, more insulin, exercise, stress, the phase of the moon and all of the other numerous things that impact our BGs) basal insulin is supposed to keep your BG steady. If you need to lower your BG, that is what a correction dose is meant to do. Although my daughter pumps and therefore uses only one brand of rapid-acting insulin, I still distinguish between what I consider to be basal insulin v. bolus/correction insulin.
     
  9. forHisglory

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    My husband and I are about to go crazy in circles discussing this........here is what it boils down to. If glucose holds steady at say, 200, the endo will tell us to increase basal 2 hours from that time period where he is running high. The other theory is, "correct the 200" and the proper basal will hold him steady once he reaches the target endpoint.

    At its simplest form........it seems like 2 different ways to correct. Correct by basal adjustments, which takes more time and analyzing or correct by bolus (when you want to get them down faster). If the basal is too low, you will be constantly correcting. If its too high, you'll be treating lows constantly in the absence of food or in the presence of slightly increased activity. At night however, correcting by bolus is more risky.

    In reality, my husband and I are thinking slightly different about these things and it would be nice to be on the same page for management purposes as we value consistency. We might keep going in circles at this rate. :)
     
  10. wilf

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    Nope, talking about Lantus in our case. For us the ideal Lantus (basal) is an amount that has my daughter's blood sugars dropping gently through the day (in the absence of carbs).
     
  11. wilf

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    Both ways of looking at this are valid and reasonable. So I wouldn't get hung up on consistency and just let whoever is "on" do things their way, provided that there is an explanation of rationale at some point.
     
  12. forHisglory

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    Every time I start to get frustrated, I remind myself that at least I have someone to take over besides myself. I'm incredibly thankful we are a good team even if it makes understanding, "what just happened here" a bit challenging if you aren't in complete agreement on management strategy. I'm thankful to have a partner that cares enough to even discuss it with me. Even he reads the CWD posts now!
     
  13. wilf

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    Lucky you! :)
     
  14. samson

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    I think this is very important if you don't have an incredibly predictable schedule, because you don't want the default basal to force you to correct a low or treat a high when you're not expecting it. You do want a "set it and forget it" insulin level. Especially at night.

    But after watching my son's numbers I'm convinced a little extra insulin circulating in the system suppresses post-prandial spikes way out of proportion to what you'd expect based on the numerical value alone. I suspect this is because the extra insulin is suppressing a huge glucose rise when someone anticipates eating or the moment food touches their lips, which is the job of some other hormones T1Ds normally lack. I suspect this is also why doing a leader bolus of, say, 0.2 units for a 1 unit meal seems to work so well for us. We don't need to pre-bolus for the whole meal, just enough to prevent that initial spike that occurs before the food has begun digesting. This may also explain why my son routinely spikes to 300+ when eating a 0-carb meal. There are all these theories about protein and fat metabolizing into carbs or potentially some increased insulin resistance, and yes, those factors could be at play. But after seeing no such rise when he has a 0 carb meal and a little leftover IOB from a past bolus, I now believe this glucose rise is purely a liver releasing glucose phenomenon, rather than fat or protein metabolism that needs to be consistently bolused for.

    We did basal testing but found our son was spiking higher and crashing more at that "steady" level during the day, because even small error in carbF or a less optimal prebolus could leave him high, necessitating a big correction that left him low. So we've decided it's safer to set a basal that has him drift down because he is always eating before he has a chance to go low.
     
    Last edited: Sep 6, 2016
  15. rgcainmd

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    We have much better luck with corrections and temporary basal rates bringing my daughter back into range much faster with rare lows. She spends much less time out of range this way. YDMV.
     

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