correction factor, and total insulin doses.

Haven't been around in a while. Having a really hard time with Ben's blood sugars and his last a1c was 13!!!
In the past year we have almost doubled his lantus dose to 60units, and his I:C ratio is 1:4. (apidra) His correction factor was 1:35.
So with the increase in insulin I was figuring a new correction factor. 1800 divided by total daily dose. (about 150 units) so new correction factor of 1:12!

Am I figuring this correctly?

Now to figure out persistently high blood sugars. Some of it is teenage boy who doesn't want to test or dose when out with friends. But the past few days, we have been on top of it, and we are still aren't seeing blood sugars below 200.
I am counting most of his carbs and figuring most of his doses.
(so i know it is being done correctly) of course increasing the amount of correction he is getting should help.

One thing that occurred to me is maybe his lantus is too high and he is having undetected lows and rebound highs. He usually feels his lows so I didn't suspect this and haven't been testing regularly at night.

 

That seems like a LOT of insulin. I'm guessing that he eats 200-300g carbs per day as a teenage boy (possibly even more?) so he is getting upwards of 120U/day? Whether or not that is normal depends on a lot of things (e.g. activity and weight), but I would definitely be doing some intensive overnight testing. Honestly, I might even try testing BG hourly for a night.

 

CGM would come in really handy right now, but I don't think we even have a hope of insurance approving it.

and I estimated his total daily dose as 150 units.

 

if he pumps there should be an average in there...but yes..its
1800-TDD=ISF...

 

Have you thought about trying a different insulin? My son became somewhat resistant to Humolog after about one year of being on it.

 

Jake's Mom, yes, we recently switched from Novalog to Apidra, I:C ratio quickly went back to 1:4.

 

With an I:C of 4, his correction factor should be how much 4 carbs raise his blood sugar; my guess is that that's a little bit more than 12, but it could be 12, especially if he's a large guy.

With an A1c of 13%, I would think he is plain old not getting enough insulin, no fancy explanations required. Is he having absorption issues, do you think? Is he injecting into areas that show evidence of lots of shots?

 

An a1c of 13 doesn't really scream undetected lows to me. This sounds like a person who needs more insulin for whatever reason. Regardless of how well his basal or carb ratios are set, if you can't get him down in the first place he's going to stay high. The 1:12 may be correct. If you're concerned do a couple corrections at 1:20 or so, see if it starts bringing him down. Once he starts running lower, his resistance and TDD may come down a bit. Also, if he's been running high enough to have an a1c of 13, "normal" will probably make him feel low and really bad. He may need time o adjust to the feeling.

 

Just to mention, we don't find the 1800/TDD=ISF to work for us. That would put her ISF at 60. We have it set at 100, and it works great...may even have to up it in a couple time frames where she seems to go low after correction.

Just wanted to throw that out there, so people realize that it may be a good place to start without being the actual number.

 

Me neither. 1800/TDD gives me 56, but my ISF is set at 120, and it's about the only thing in my dosing that I think is correct. The 1800 rule has never worked for me (and I'm not honeymooning).

 

We are trying a correction of 1 unit for every 15 pts over 140..
brought him down from 261 at breakfast to 200...

Feel neglected by dr. no one ever suggested maybe he needed more correction.
They just see that he isn't compliant 100% of the time and tell him they can't help him until he is. He tries and gets really frustrated when he is still high, so he gives up.
I am keeping detailed records for a few days and will post numbers.

Thanks everyone for your input.

 

There is a good chance that this is happening.

How much does your son weigh?

 

I have read about type 1 people who have added an oral diabetes medication like the one's a type 2 person would take to enhance the insulin they were injecting. I know that sounds kind of crazy but it if all else fails it may be worth looking into.

 

I agree that it might be worth looking into, even before all else fails.
And that reminds me that when the volume of dosages get really big, absorption gets worse, which is why there's U-500 insulin (concentrated). Right now I believe there's only one insulin available at that strength- Humulin R (regular insulin).
I've read some very good things from people who had high A1cs while taking over a hundred units per day and switched to U-500.

 

Wilf, Ben is 6 foot and between 150-160lbs. active, but not involved in organized sports.

I posted numbers in a thread on the parents board.

I think we will ask about Metformin at another appt.

 

brandon is 15..6'2" and weighs about the same as your boy..He is on 80-100 or even 110 some days..we have had an amazingly huge increase also over the past 3 months..his A1C was 11.5 and then last month 10.7...brandon sometimes is frustrated too...I think sometimes doctors forget these are kids dealing with not only a life threatening illness,but peer issues too...I wish you luck,and if you ever want to chat let me know..seems like we have something in common...

 

Assuming 155 pounds, that is 70 kg body weight. You previously indicated his TDD is about 150. That means that he is getting about 2.1 insulin units per kg body weight per day (IU/kg/day)! Normal is somewhere between 0.5 and 1 IU/kg/day, though during puberty peak levels of up to 1.5 IU/kg/day are possible.

He is getting far beyond peak puberty amounts of insulin, and has an A1C of 13?!

If he is actually injecting these amounts of insulin (150 units a day), then I am sure he is locked into a chronic cycle of lows followed by insulin resistance and rebounds - this has been the case of every child/teen I have ever heard of who was getting more than 2 IU/kg/day.

I would urge you to get a CGM right away. If that is absolutely not possible then it is worth considering radically cutting his insulin amounts what is normal for his weight - 30 to 40 units Lantus daily and 10 units apiece for a normal breakfast, lunch, and supper (with only free snacks in between). You may think this sounds crazy, but in my view it can't hurt or be worse than the status quo.

I would urge you to give it a try for a few days, and post numbers here. I think you may be very surprised at what happens. :cwds:

 

Dr thinks cgm might be helpful too, but insurance says it is not covered. Ben has Texas CHIP and I have a feeling an appeal would be an exercise in futility. Especially because we want the Dexcom and it is not FDA approved for children or teens.

Wilf, wouldn't we be seeing some lows somewhere? He has always felt his lows. One time before when we got Lantus dose too high we were seeing afternoon lows. I've started checking twice at night and more during the day, and we aren't seeing anything below 100 ever... Since I've started intensive management we are starting to see some in range...

We have had several incidents in the past few months where he hasn't taken insulin and ended up HI. He likes to go out with friends and eat and drink whatever and not take any insulin. Sometimes the only insulin he was getting was lantus, because I almost always draw it up and watch him take it or give it myself.


Here is the thread where I posted numbers for past few days.
http://forums.childrenwithdiabetes.com/showthread.php?t=68552

 

Hi there

I don't post much but thought that I would throw in my support .Matt is 6ft 200lbs ish so a bit bigger and he has approx150 units day. He is 19 in a few days and has been like this since about 14. He is pumping and has cgms'd many weeks. He feels all his lows and didn't miss any.

He has had horrible hba1c but now seems to be getting back on track.teen years are awfull and now that he is "adult" mum can't help.

He has started taking metformin which he feels has helped knock the top off his numbers when he remembers to take it.

Hba1c will be done in a couple of weeks so that will be telling.

Good luck with your teen journey.

A final thought I did discover that growth hormone is at its greatest at the end of puberty. I keep patiently waiting for it to go away but maybe Matt will just continue to need large doses.

Lisa

 

I just can't wrap my mind around more than 2 IU/kg/day - that is an enormous amount of insulin. How long has he been getting the 150 units?
Does he have a really fat and carb-rich diet?