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How to manage basal rates at night with a pump and CGM

Discussion in 'Parents of Children with Type 1' started by Theo's dad Joe, Dec 2, 2016.

  1. Theo's dad Joe

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    My son is on a T-slim now and I am wondering if people can post basic strategies that they use to manage night time basal without going overboard in terms of intervening.

    How many segments do you divide the night into?
    How do you set your alarms, usually? Need sleep mode? Really need sleep mode?
    Do you run temp basals or very long square boluses for late rising dinners?
    How quick are you to change basal rates?
    How much variability do you get?
    Do you find temp zero or temp reduced basals to work if you see a low coming on or are they just too low to take effect?

    Anything else? We can get 60 point drops or rises on a given night with same basal rates so I tend to set the basal low enough to avoid lows and then correct if I can afford to lose the sleep. I also am dividing the night into 9:00-midnight, midnight-3:00 and 3:00 to 6:00. Definitely see more need in midnight to 3:00 period.

    I am also surprised a little having read Sugar Surfing because Dr. Ponder says that he thinks most people can stay in a tight night time range with a single basal rate, or even 1 shot of Lantus. Is that easier to do for adults than with kids or something?
     
  2. Ali

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    This may be a repeat. I am not seeing an earlier reply. Joe, I am a 60 plus year old T1 diagnosed in my early teens. My overnights still and have always involved a source of candy on my nightstand. When on shots I always set my alarm in the middle of the night to get up and check my number:( Once on the pump better but I still checked at least four times a week during the night. Then on the CGMS, I could go longer without checking but only if I set my basal at 90percent or 85 percent. So I am going on Medtroncis AP system this Fall, hoping for a few more nights without having to wake. But I sleep with a Sprite bottle on my nightstand if I want to sleep straight through I have to aim for a BS of 120. That covers a 60 point drop but it also means I have to be willing to wake up to 180:(. It is not a happy arrangement. I am way more stable than before the age of 60 but I still drop or rise 60 points. The AP system will hopefully help me to sleep through the night 5 days out of 7 without waking up close to 200 and not rolling over and drinking sprite a few times during the night. Th nighttime stuff for many T1s is just brutal. Sorry, hope some young parents of T1s can pipe in with some more help, I may be the more unstable T1 for hormonal reasons than others.
     
  3. rgcainmd

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    While a great deal of Stephen Ponder's advice is excellent, I have come to realize that all bets are off when it comes to dealing with children because the unpredictability of somatotropin and puberty hormones will repeatedly screw up the best laid plans. Add to this the fact that D frequently does not "follow the rule book" and that there are far too many variables that affect D-management that are inconsistent and over which we have no control. Even as an adult, I would consider the science and wisdom offered us by people such as Gary Scheiner, Hanas, Ponder, etc. as rules of thumb or (albeit quite sound) guidelines. YDMV; every PWD will have different and essentially constantly evolving needs, and you just have to roll with the proverbial punches. I can keep my 14-year-old's A1c's between the mid-5s to mid-6s with a great deal of constant, hard work and ongoing, frequent adjustments. Unfortunately, what works for others does not always work for us. I believe I have saved a good deal of sanity by going with the flow and letting go of the unrealistic goal of finding the "right" basal rates/times, or the "correct" ISF's, I:C's, DIA's, etc. because these are constantly changing and evolving. What may work effectively one day will not be as effective the next or, if we are lucky, will work better another day. If what you are currently doing is not optimal (and you have to settle on what "optimal" realistically means for you) you need to correct and move on. It is not realistic to expect not to have to treat lows or highs overnight (or during the day for that matter) if you want very tight control. Period. If I want tight control, I expect to correct/treat a minimum of twice overnight and more frequently than I'd like, I do this 6 or more times overnight. And this is with the personal assistance and advice of Gary Scheiner and his team at Integrated Diabetes.
     
    Last edited: Dec 4, 2016
  4. Theo's dad Joe

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    Thanks for providing a model of management that I can compare mine with. When I told his endo that I usually corrected with the pump at night if he hit 130, sometimes 2 or 3 times, she remarked that that is a reason why she hesitates to prescribe a CGM, and that it was blatant overmanagement and dangerous and unsustainable. In our situation I don't think it is any of those things. Also, it is helpful to know that it may not be a search for the perfect basal level that works 7 days a week.
     
  5. Snowflake

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    That's my thought! It is a great book, but I can't imagine that we could make a single pump setting work for our 6 yr old (maybe with Lantus, not sure about that because we didn't use it long enough).

    However, Ponder did convince me that we had way too many basal rates -- after reading Ponder, we moved from about 6 to 8 to between 3 and 4. This improved our overnights a great deal -- we have not achieved perfection, but we do have less variability now. Here is a thread that I started when we were condensing basals and that led me to read Sugar Surfing; other CWDers offered some good resources relevant to your question in their answers:

    http://forums.childrenwithdiabetes....4-optimal-basal-chart&highlight=optimal+basal
     
  6. rgcainmd

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    You said your son's endo "hesitates to prescribe a CGM." Isn't your son already using the Dexcom G4?

    Your endo's comments RE your management of your son's D being "blatant overmanagement" and "dangerous"?!?!? I don't think what you are doing is overmanaging or dangerous in the least. If it is, then I guess I, too, am overmanaging my daughter's D and am endangering her. Fortunately for me, my daughter's new endo thinks we are doing a great job.

    That being said, your endo may have a point RE the sustainability of our (yours, mine, and I suspect quite a few other parents on this Forum) level of management. I must admit that I am not certain how much longer I can keep this level of tight management up. I am a single mom and do this without any breaks or nights off (except for 5 nights per year during D-camp.) Plus I work 50 to 70 hours a week. Throw my age into the mix (59 in less than a year) and you get the picture. I've been doing this for just shy of 3 years, and TBH, I have to admit that for the past month or so I feel like I've been running on fumes. But I think I can keep this up until 2019, the projected release date of the OmniPod closed loop system. Medtronic is releasing their's much sooner, but my daughter will not consider a tubed pump, and I will respect her wishes on this. I realize that I am burning the candle at both ends, but I can't bring myself to cut back on my level of management just yet. If my daughter develops complications later in life, I won't be around for as many years as most parents to help out because I am already nearly as old as many of my daughter's classmates' grandparents. So I can't envision "backing off" until my daughter is able to use a closed loop system (which will hopefully happen in about 3 years.)

    My advice to you would be to keep up the good work but (we've discussed this to death on an earlier thread) try to stop finding the "perfect" pump settings and/or strategy that will all but eliminate all highs or lows. It doesn't exist because T1D has a mind of its own. However, "backing off" is easier said than done because how do we know for certain when we've crossed the line between "could be better" and "not realistic"?
     
    Last edited: Dec 5, 2016
  7. MomofSweetOne

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    I would recommend you both loosen up control for both you and your children's sakes. I was in your place a few years ago, only I think I set the high alarm to 160 back then. Now it's at 200 or sometimes even higher. My health tanked, and I couldn't sustain what I was doing. But my recommendation is because my child is older than either of yours, and I'm seeing the guilt and concern she carries when she watches the effects of diabetes on me. Not only that, being that overtired makes us less good at parenting...and it's also so much easier to see patterns when we can focus. Our kids have the benefit of the technology that even if the alarms are loosened, they will be still be so far better off than kids dxed in prior years.

    I am so thankful so many automated pump systems are being tested, so that our kids don't face a life of what we've done instead of sleep.
     
  8. rgcainmd

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    Words of wisdom, MomofSweetOne. Thanks!
     
  9. Theo's dad Joe

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    Thank you. I was thinking of you when starting this thread. In part I wanted to know if it was really possible to keep kids in a textbook range of say +/- 30 points most of the time (which did not match with my experience) and second I wanted to see know people survive-where to set boundaries, alarms etc. Days are easy for me as I work from home on my own deadlines now, so I have the energy to do night time corrections on a pump, and even micro corrections and micro treatments (3-6 grams). In part, for me, I probably would sleep worse with higher alarm settings than lower ones, but I will push my high alarm up to 140, 150 or 160 depending on what I need, and also whether I have already corrected (if I correct once in the 130s, I may add a little for the rise rate, but I will bump my alarm up to 140 or 150 at that point too.
     
  10. rgcainmd

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    Any textbook that even implies that the BG of a child with T1D who is not honeymooning or on a closed loop system can be maintained in a range of +/- 30 points (we're talking mg/dL here, not mmol/L right?) "most of the time" should be pulled from the shelves and burned IMO. Perhaps if said child were utilizing a true bi-hormonal AP while consuming a very low-carb diet... But enforcing such a diet in a child who is old enough to have a preference and in cases where such a diet represents a significant change from that child's pre-diagnosis diet is asking for an eating disorder and/or a devastatingly severe resentment of their T1D.
     
  11. Theo's dad Joe

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    Apologies for being short with the wording. I meant within +/-30 points during the night, or fasting starting at least 4 hours post prandial for a 6-8 hour period such as during a basal test. At the Barbara Davis center they have said at pump training that ideally you could fast for 24 hours on a correct basal but they admit that it doesn't work at least with kids. I think Gary Scheiner has some good starting goals to stay under for post meal spikes "most of the time".

    http://www.diabetesselfmanagement.com/managing-diabetes/blood-glucose-management/strike-the-spike/
    http://www.diabetesselfmanagement.c...blood-glucose-management/strike-the-spike-ii/

    But as for now, I don't believe that +/-30 is going to happen during an 8 hours fast, consistently night after night for a kid. It is good to realize that, because I was making small changes in basal rates through the night, and needing to correct or treat anyway, but hoping that I would dial up some magic basal that would suddenly work most of the time. Now I just get the basal close, don't waste much energy on fiddling with it and decide how often I want to correct/treat versus what kind of night time numbers I am good with.

    I have talked with adults with mid 6s who target 150 at night and don't mess with anything between 90-180 because they just want to sleep, and they get more aggressive during the day, so it is about managing mental, emotional and physical health.

    I am not in favor of a low to very low carb diet, but I have not seen better control on lower carb days than on higher carb days. More surfing or extended boluses, but not lower peaks time out of range.
     
  12. rgcainmd

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    Despite having consistently acceptable (in my opinion) A1c's between about 5.2 and 6.8 (if memory serves), puberty is now kicking my butt and it is winning. Dexcom tracings now resemble a series of M's and W's. I tweaked pump settings thoughtfully and repeatedly until the cows came home, and I am now readying my towel for throwing. I am currently exploring pumping untethered with Tresiba (off-label for children) to replace part of and augment the Apidra we use via pump. I am impressed with the reports I am reading from PWD who are finding this long-acting insulin to be the best thing in the history of diabetes. Quite a few folks who already have a positive history of achieving and maintaining tight control are singing Tresiba's praises as they experience nearly flat lines with significantly fewer lows without needing the variable basal rates provided by a pump. Wish me luck!
     
  13. Theo's dad Joe

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    I hope Tresiba helps. I don't understand how it would make people more stable, but if it does it does. Maybe for kids who are hitting triple digits on TDD, it will keep their insertion site fresher as well as allow 3 days with one cartridge. Even on 20-25 units a day, we sometimes see his site become partially resistant on day 3. The first 2 days are usually so good that we take an occasional third day with more corrections and a little higher averages.

    Do you have any idea why Tresiba would provide more stability than using variable pump rates? Even if it gives flat basal that you can't get with 1 shot of Lantus, isn't part of the problem that the basal needs are rather un-flat?

    Also wondering, do sites get resistant faster when you are doing a very high TDD?
     
  14. Theo's dad Joe

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    This was very helpful.
     
  15. MomofSweetOne

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    This is the hardest part of passing the baton for me as mom, that my kid will have to take on both days and nights for the rest of her life. I am so thankful the automated systems are so close to coming out before she leaves, that they will take on the part of diabetes I've helped with the most. She emphatically doesn't want the Medtronic, but so many more are close that options will be close or out at that point. BigFoot is probably at the top of our list, with the Omnipod system in second place.
     

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