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Does this look like Somogyi?

Discussion in 'Parents of Children with Type 1' started by Theo's dad Joe, Jan 21, 2016.

  1. Theo's dad Joe

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    Please stay away if you aren't going to bother to understand the issues. See the next post if you care. I am having to treat midnight lows multiple times 7 hours after dinner, but having dinner peaks 4 hours after dinner after him being 95 two hours later, lower than pre-prandial for 2 hours and with 10:1 ratios. With corrections he's at an 8:1 ratio yesterday, but he goes low with more basal even though its 5 units of Lantus in the morning.
     
  2. mom24grlz

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    there are so many pages to this thread, that i may have missed it. Is Theo on one shot of Lantus or a split shot? If he's only doing 1 have you considered splitting it? Ashleigh does a split shot (20 units at 7am and 17 units at 8pm) we tried doing 1 shot and her numbers were crazy. 300s in the morning, 80-130 in the afternoon, and then lows 50-70 in the evening and overnight. By splitting it she's had numbers that are closer in range.

    ETA: also remember pumping in not a cure all. Just a different way of delivering insulin. Ashleigh pumped for 4 1/2 years. 4 years on Animas ping and 7 months on the tslim. She decided to return to MDI back in July. She has no desire (at this point) to go back to pumping. Is very happy and her numbers are happy on MDI. Actually her numbers are better on MDI than they were the past 7 months using the tslim. Even her endocrinologist says they look great on MDI.
     
  3. Theo's dad Joe

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    I did try splitting. I will respond in the next post.
     
  4. mmgirls

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    Have you been tracking protein and fat on meals? I wonder if the nights he is staying higher are the nights with the largest protein/fat content?

    Are you using I:C and Correction factor for all meals? I know you are thinking about IOB but how are you calculating it, an app?

    Regarding a Pump, you need to figure our what pump looks the best for you guys, your son is ten so depending on your family dynamic he may have a good say in the matter. and depending on how sensitive your son is about how "visable" the pump would be. All the pumps basically do all the same thing just in different ways. For instance Animas figures IOB with a curvilinear graph and Onimpod with a linear, and Accu-Check uses a proprietary algorythmn. IOB can be calculated soleyly on the correction dose and some will calculate based upon meal and correction bolus.

    This is why it can be like being DX all over again, the pump can challenge the way you have been thinking about the math, or it can fit and just fold right into your life.

    Something I have to say is that even though a pump has the ability to do so many things and it gives you so many options, like running a temp basal and comboing out a meal bolus for 4hours both at the same time. or you can just use it as a precise insulin delivery device and not utilize any of its features. Many people keep it simple, while others combo bolus and temp basal daily. Its up to you how complicated it gets.

    Over the last 9.5 years of pumping 95% of the time we have been using Animas, we did use the POD for about 6 months. I ordered but sent back the t:slim and Accu-Check pumps for different reasons opting neither had any feature that sold me on switching and they both (at the time I tried them had feature that I could not live with compared to the Ping)

    With that said, I am currently awaiting a 4-8 week tial of the Medtronic pump and CGM system. My oldest's pump is now out of warranty and Medtronic is the only mainstream pump I have not tried, and their new "Connect" device gets data to the cloud similar to Nightscout.

    other than that I will wait for Bigfoot.
     
  5. Theo's dad Joe

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    The reason I posted about Somogyi was because my son had an early morning rise after I had raised his basal insulin trying to get more normal meal time curves in the day (by normal, I mean ones that go up and then come down rather than ones that go down and then come up as the insulin wears off, usually coming up to around 150, and also needing ratio that are dipping below 10:1). When I split Lantus, he would often go into the 60s around midnight when the morning dose was still working well and the evening dose was peaking. This could even be if he was over 150 4 hours after dinner in bed.

    I will start a new thread because people are stopping by to make fun of my problems maybe because the blood sugar curves look good and they can't see the issues that are obvious to others who take the time to look at the patterns.
     
  6. forHisglory

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    Sounds incredibly stressful. I hope the lows stop, but this point in particular is interesting. How are you sure he is "self correcting" 100 points in 4 hours? This relates back to a previous post where I asked the question about knowing exactly what is at play and when. The dramatic drop 4 hours later is what we also experience and the endo and I have been scratching our heads about whether is basal or I:C bolus. Because, if Humalog has a longer tail than Novolg, the meal time bolus could be doing this. If not, the basal at that time is too high. But, I am amazed if it's truly the pancreas pulling him down that much. I also had the same question for the endo when he kept asking me to be comfortable with my son falling to the 70's at night...said I was fighting his pancreas. However, once I decreased BASAL during that low time period, he stopped going low and stayed more in the low 100's. I sleep better now. If it was truly his pancreas, he would still be pulling down with the decreased BASAL correct?
     
  7. Theo's dad Joe

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    As for this one, no, not necessarily. People with pancreatic insufficiency or types of mody, or insulin resistance who have some of their own insulin can maintain an equilibrium with their other hormones that sets a fasting level, but higher than optimal, like 125 or 140. Their pancreas is working 100% to produce an optimal blood sugar, but they just don't have enough to balance other hormones. Giving them some basal such as a dose of Lantus can change that equilibrium so that they naturally come to stop at a lower level, say 110, or 95. The higher the dose the lower the equilibium. They may be getting 75% of their basal needs met by Lantus or basal injected, and 25% by their own pancreas, but it still holds the shut off switch in case one gets too low.

    So I was mentioning before, and have also talked about this with older LADA type 1s I have worked with who have type I but retain honeymoon levels of insulin for a LONG time that if they take the right Lantus they can go to sleep at 110 or 140 and wake up at 85 consistently because they still have enough endog insulin to control the "bottom" bit of the fasting level, and their body still turns off the endog when they reach a certain level.

    So for someone in a honeymoon, I believe, and have also observed that raising basal will at first just set a lower equilibrium blood sugar and only at a certain point will it cause one to go progressively lower even into hypoglycemic levels.

    When we first started Dexcom we were using 20:1 at breakfast and dinner and 30:1 at lunch, and 1 lantus at night kept us about 105 all night, with a little drop to the 80s at wakeup, while 2 lantus at night had him running 85 all night. This was 6 months ago and we got daily averages of 100 at that point. I cut the night Lantus from 2 to 1 because dexcom would read a 68 when he was 80, and a calibration still guessed low at that point and had him back at 68 in an hour.

    Here is another thing. His correction factor I use is about 45 per half. It is odd because it works much better than that to correct when there is not a meal, but not as well at a meal. Anyway, for him to go down 100 points would mean that he still had 1.1 units on board from a 3 unit bolus at the 4 hour mark. But in the daytime, he does not come down after the 4 hour mark anymore. My best guess is that he is much more sentitive to basal insulin at night than in the day when he may even drift up a bit.
     
    Last edited: Jan 25, 2016
  8. forHisglory

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    I'm tracking, but my brain hurts. :confused:

    1) Regarding the body mechanism of endog glucagon/insulin shut off valve....you have to be pretty darn sure when you're lowing the equilibrium with increased basal that this mechanism is still intact. Otherwise, you're playing Russian Roulette with seizures. Here is where I'm not willing to compromise my sleep, my son's health, and my sanity. I'll take the higher A1C if it means less hypos. The endo assured me the endog glucagon mechanism should still be intact for a honeymooning kid like we have. The other problem is the Dex saying 68, and the meter saying 80. What is real time value of glucose at that point? We don't know without a labaratory.....either one could be 20+/- points off in either direction. STRESS. That is why I understand how stressful this is for you.

    2) About the 1.1 units still remaining at the 4 hour mark.....this is where I'm trying to pick apart other factors that come into play. That much remaining doesn't fit studies showing the DIA, however, I have read resources that suggest end activity is further out in some individuals (even 5-6 hours). Is there any support for up-regulation of insulin receptors at basal levels that are too high? Enough so that even the tiniest amounts of endog or bolus insulin are going to have more of an effect than usual? The article I linked up in the last post we interacted talked about the effects of digestive enzymes and pancreatic inefficiencies that HAS to be a part of the answer you are seeking with the correction factor issue and the strange rise at 4 hours post meal. Maybe his endog or basal insulin cannot act because the receptors are clogged up during the day? At night they are more available.

    I feel like I just ran around a maze and banged my head a few times, but I'm hoping that digging deeper increases my understanding. You're in deep space and I'm still in the atmosphere. Below is the insulin receptor signaling pathway. Maybe the answer lies there. :p

    Insulin_receptor_pathway.jpg
     
  9. njswede

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    We have the exact same problem. He goes into rebound lows if I give him the "correct" evening meal bolus. If I lower the bolus he goes high instead. Solution: I program a 2-3 hour temporary basal on the pump when he goes to bed, reducing basal by something like 30%. That's what's so good about the pump. It does the thinking for me.
     
  10. DiabetesMama

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    Theo's Dad- I just wanted to let you know that I think that you are an amazing dad! The amount of dedication you put into everything is overwhelming. I can honestly say that I am not following this post at all, except seeing it on the activity page, but I did want to say something. I am concerned about your well being because if you are not careful, this disease will strip you down to the bones and spit you out. I understand you are trying to make your son's life easier without complications, but at what cost? I have the perfect graph of 80-100 right now, but it hurts my heart because I know something else is wrong with my son. I am worried about him having celiac and it is worrying me so much. I totally understand what and why you are seeking for answers, but, truth be told, when those hormones kick in, that beautiful graph will be even harder to achieve. I admire the dedication and study you have put into all of this, but then I see that handsome boy in the snow on your posts that is smiling up at you, and for that split second in his life, diabetes is not on his mind. But was it on yours? I mean, yes, as parents as we are watching them play in the snow, we have the worries of numbers...but that's just it. You missed that moment of just being there enjoying him be a boy. He will be grown before you know it. Please, try to balance your worries and your research with just being his dad. Of all the things that could help your son's life be easier or with less problems, I guarantee that he would give up all the time you are putting into this research to just be with him. The sooner that you understand that every day will not have perfect numbers, the sooner your life and his will be just that, life. I think that some of the veterans here are also trying to tell you that in their own way, maybe coming off as harsh and uncaring, but I think that they are trying to help you see that this isn't a game that can be won all the time. As parents we are supposed to do all we can do for our children, but sometimes that comes in just being there for them. And please don't misunderstand, I am not saying that you aren't spending quality time with your son, I am just suggesting that maybe you can put more time into just enjoying those special moments that are forever fleeting so fast. He is a handsome fellow! Don't loose site of what's right in front of you. We are a team here, and I just wanted to encourage you and praise you for your great dedication and please know that you and your son are in my prayers. I hope that his numbers get more manageable for you. Hugs and prayers!

    P.S.- Every time you post something, he makes me smile! He has a contagious smile!
     
    Last edited: Jan 26, 2016
  11. MomofSweetOne

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    Just wanted to add to this thread that while a pump will allow you to have differing basals (why we switched) and the wonder of temp basals, you will gain a whole 'nother realm of problems to trouble shoot. Bubbles in the tubing, occlusions, kinks,....it is far from a cure or ideal numbers. Most of us no longer even dream of one day like you describe after the betas fizzle over the years. An AP won't solve these problems, either. Only a true cure will.
     
  12. njswede

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    Ain't that the truth! I just had a fight with my wife over whether his high numbers were due to sinus infection or a bad site. We settled it by injecting 1U. Nothing happened, so it's not the site. Just the stupid infection.

    Now that being said, I still prefer the flexibility of a pump.
     
  13. Theo's dad Joe

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    Thank you very much. This thread is about how to do what you are saying, to transition from having great honeymoon numbers to good enough, and dealing with things as they come, and what I want to do is do my best to know his patterns so that we don't have midnight lows or have him going low at school lunch before he comes up and then having to leave class. It is the patterns that make it hard for me to do dad stuff, or be more flexible, and it is basically not about corrections or meal boluses. I have those pretty good, and they can always be watched and treated or repeated in due time.

    I am concerned because my son seems to have abnormal mealtime patterns that are not consistent with what I have been lead to expect. My son's endo told me at three months to expect him to be high in the first 2 hours. Well, he's LOW, in the first 2 hours. He's lower 2 hours after most meals then when he started, and only just coming up. I don't know why. He will eat breakfast at say 110 and be 85 at half an hour, and only breaking above the 110 start at 2 hours. He drops 30-40 points after his lunch bolus even though he eats right away so I've had to try to get him to lunch at 120-140 if it works perfectly so that he only goes down into the 70s or 80s and doesn't have to leave class and loose time and have to be "different" any more than necessary. When he didn't have dexcom last year, I am pretty sure that he dropped into the 60s for a while after lunch, but never really felt it, or got used to it because he feels great at 65.

    And then he goes lower than his pre-prandial numbers for 2 hours at dinner, only to rise up at the 3-4 hour mark, sometimes high. And he's got 12:1 carb ratios and still ending up higher, and the doctor told me that at his age he should be 20 or 25:1 if I could just get his basal right. So then I raise his basal lantus, and he can go to bed at 120 and run perfectly, or he can drop to 58 at midnight with no explanation. Again without dexcom I might have done one check last year, but I just can't get the basal to work for us. And I'm worried that he doesn't eat enough of the right kind of food. I thought it would be like, OK its time to let him run a little higher, do corrections and treat if needed, but I would be fine with all of that, I just want to avoid those pattern related issues that don't let me relax.
     
  14. mmgirls

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    Have you ever tried to bolus after the meals? Since he has a pretty good honeymoon going on I don't see why it would hurt to try, you most likely would get rid of the lows from prebolusing and the Dexcom lag time.
     
  15. DiabetesMama

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    I second mmgirls suggestion. Maybe try to treat after he's eaten. Give him maybe 15-20 minutes to get things down and then let the insulin catch up with the food. We went through this exact thing too, but it did eventually stop. Maybe this simple trick will work. Can't hurt to try, right? It's better for him to be a bit higher at school away from your watchful eye than too low with less attention being given. Give it a try and see if it makes a difference. The endo told me that you need to try it for at least two to three days to see if it will make a difference and allow the body to adjust. Just keep us posted and let us know how things are going. You and your son are still in my prayers. Hugs!
     
  16. Theo's dad Joe

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    Yes, that was my next step for school, to bolus after, or at least if he was say under 110. Last semester I had them give him some pretzel sticks before getting his shot if he was under 100 for his lunch check and it worked. When I can watch him at home I still like to bring them down for dinner, but when we went swimming after dinner on vacation I had him eat first, and he was over 100 and rising and he still dropped to 50 in the pool in half an hour. So I'm picking up a little knowledge. I would definitely give him a few grams of fast carbs before getting in the pool in the evening, and I'd give him a few automatically before bed that night from what I've seen.
     
  17. Theo's dad Joe

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    Thanks. Again I don't mind him running 80-100 for two hours after dinner at home before rising when I can watch him because he doesn't get low and even if he ends up high the overall period is not so bad, but at school I think it might be the way to go for lunch if he ends up in the office again.
     
  18. mmgirls

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    Are you seeing his school numbers via Share? Or are you finding out school issues during or after the fact?
     
  19. forHisglory

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    This is the best post I have read ever on CWD. Priceless. Thanks for taking time out of your busy day to write this Diabetesmama.
     
  20. wilf

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    I agree with the prior suggestions of reducing or eliminating the pre bolus and maybe even bolusing after meals. Can't hurt to try and may help smooth things out. Consider too the possibility that he is a slow digester, and what that implies.

    Finally I agree with others that notwithstanding the fascinating nature of this discussion, you need to be spending more time on family/self and less time on-line. A decade from now your son will be entirely in charge of his D management, and I guarantee he won't spend as much time on it as you are. And he'll be less likely to "rebel" against the good practices you are trying to establish if he sees that they are measured and reasonable.

    While it is nice to have good numbers, beyond a certain point there are diminishing returns. I think you're at that point, my friend. :cwds:
     

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