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Is this stacking?

Discussion in 'Parents of Children with Type 1' started by Knittingfor4, Aug 8, 2012.

  1. Deal

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    When I start seeing a big pull downwards around the 5-8 hour mark after giving morning Lantus coupled with overnight numbers trending upwards then I suspect the Lantus might be getting old.

    I keep all new vials of Lantus in the fridge until I start using it. I then only use it for one month. As the Lantus gets older it is the property of long lasting that seems to fail. The insulin still works, it just starts working quicker and runs out sooner.

    If you have not started a new vial recently, then I would try that.
     
  2. nanhsot

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    Maybe I'm missing something but I see the night time numbers trending significantly DOWN, not up. From midnight to 730a (that first night) she drops 180 points, assumably without any fastacting. The second night looks better, but still a drop, not an up. The up trend at 11-1 is from the juice, and then it starts dropping again and we don't really know how high it went before the drop started.
     
    Last edited: Aug 11, 2012
  3. Knittingfor4

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    It's marked on the calender to be changed Aug 19. The pens are in the fridge until we open them, then room temp. I can change it tomorrow, as well as the Novlog, I like to keep them on the same day ;)

    1/2 unit at 8:30pm plus whatever was left of the 2 units at 6:45pm

    I agree that 1:10 is too much. I went down to 4.5 Lantus today. My understanding is to give that 3-4 days to fully show the effects, then I can lower it again if needed.

    Should I change her ratio to 1:15 right now, or wait until the Lantus change is complete? I feel like doing too much too fast, esp w/out her team's supervision may be dangerous?
     
  4. nanhsot

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    I would only make one change at a time, and IME getting basals set is the most important, getting those nights safe and reliable are key. We find that waking up to a good number makes all the difference in our days.

    That second night looks pretty good though, did you leave that 100 to stand? If so, congrats, I know that must have been scary as you are not used to her sleeping that low. You are taking some big important steps, and it shows! Keep up the good work.
     
  5. caspi

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    I agree - your #'s are definitely improving, even after such a short time. Good job! :)
     
  6. Knittingfor4

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    Ok good, that's what I thought. I wrote everything, so if it doesn't say insulin after the #, then none was given. I did not correct anything in the 100's. Scary but, I keep telling myself it shouldn't be, that it's okay, it's actually healthier. I'm on ch 4 of Think Like A Pancreas, that is helping temendously to see what the actual dangers have been these past 4 years, and it's not #'s under 70!
     
  7. hawkeyegirl

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    Also, you'll note that the 61 supper carbs were uncovered.
     
  8. nanhsot

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    This is one of those moments where CWD needs a LIKE button!:)
     
  9. Jordansmom

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    You are doing great and getting lots of good advice. I'm just going to disagree with one thing. If it were me I would immediately change carb ratios as you have figured out.Usually you'd only change basal or carb ratios one at a time. But you can clearly see the meal doses are WAY too much. Dangerously so. I'd move to stop the after meal lows quickly with that drastic of a drop and all the extra testing and carbs you are needing to give to keep her safe.

    If you add up dinner only, you already instinctively cut back on insulin. Giving 2.5 units for 42 carbs. That's already a 1:17 ratio. And you didn't even correct the 293 and she dropped at dinner from 293 to 61. And you had to treat with 12 carbs.

    Breakfast and lunch are blending together to cause lows after lunch. Because she ate at 9:00 and 12:00 the breakfast insulin was not finished working when you got a good lunch number. The low after was caused by both breakfast and lunch ratios being too low.

    Changing two things makes it harder to see what's working and what still needs to be changed. But one quick move to decrease the chance of dangerous lows is important. Besides that, all the extra carbs you have to give to treat the lows also makes it harder to see things clearly.

    IMHO it's most important to get her into a safer place all around and then fine tune doses from there.

    You have good instincts and are doing well. Good luck too you. And sorry to give conflicting advice and confuse your situation even more.:cwds:
     
  10. hawkeyegirl

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    I absolutely agree with everything that Jordansmom wrote above.
     
  11. Charlotte'sMom

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    I agree. My daughter is 5 and about 50 pounds and her ratios are much, much higher. It seems like a lot of insulin for a little girl. I know they say "your diabetes may vary" and everyone is different, but that seems way too high.
     
  12. Knittingfor4

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    Well now that makes sense to me too. Grr. I wish her team was supervising us through this. But giving less insulin isn't as dangerous as giving more. Worst case she runs high, and that's normal for her anyway. I talked to DH about starting a 1:12 first and seeing how that goes. But maybe we could just jump to a 1:15 now? Maybe I should just call her team and tell them what I'm trying to do, and telling them that this IS happening and they need to be prepared to recieve her numbers on a daily or weekly basis for a little bit. It just seems counterproductive when just yesterday they told us to increase to 6 Lantus and we did the opposite w/out telling them.

    Aha, thank you for finding that. I would not have known (patterns are invisible to me). Usually breakfast is 7:30am/8am but it was delayed that day. They did tell us that carb covering is okay between meals, but blood sugar number corrections should be 3 hours apart. I wish I could get a list of rules tattoo'd on my arm!
     
  13. Charlotte'sMom

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    In the Think Like a Pancreas book on page 124 there a table showing approximate I:C ratios based on a person's weight. For someone under 60 lbs the approximate ratio is 1:30.

    ETA: Not to say that your DD's ratios couldn't be lower than that. My (50lb) DD's current breakfast ratio is 1:23 and it may even need to be lower still. We're in the middle of basal testing too, so I may change it.
     
  14. caspi

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    I know you feel like you're in a tough spot with your endo team but you have to remember that YOU are ultimately the one in charge of your daughter's D care. By NOT following their advice you are actually seeing improvements. Remember that. :cwds:
     
  15. MommaKat

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    Agree with Jordansmom completely, just adding one thought to the breakfast lunch combo, and subsequent lows. Did the OP say that she gives lantus at 8am in the morning? If her dd has a peak effect with lantus, that combined with the carb ratio may be contributing to the huge drop that follows lunch.
     
  16. Mish

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    yes ^^^ yes.

    And like Caspi also said, I know it's hard but I get the feeling that in 3 days you've learned more about managing diabetes than your endo team has helped you with in 4 years. I think a great endo team is so wonderful, but not everyone has a great endo team.

    I'd probably just start faxing things in and saying, "this is what we're doing." At least then they can be kept in the loop and you can have a place to explain why you're now doing what you're doing.
     
  17. Brenda

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    I have no experience with Lantus, but it looks to me as if OP's daughter is NOT experiencing a peak with Lantus, that it's the I:C ratio causing the lows, as with the 2 units for 24 grams carbs. Seems to me that the child in question should be on a 1:20 ratio for now, maybe 1:15 at breakfast. This should help with the post meal lows. The fact that she is dropping so much overnight shows that the Lantus is working quite well after 11 p.m. Am I wrong in assuming that this means no early peak? As I said, I have no experience with Lantus.

    So, in my opinion, I would think that changing the I:C ratio is more important than changing the basal. This would require overnight checking and resisting the temptation to treat anything over 140 mg/dl unless it were a night when mom knew her daughter had extra exercise or ate poorly.

    Is there a way to dilute NovoLog? Last I heard, there was no diluent for NovoLog, but I don't need it so I don't know. We diluted Regular insulin until Marissa was about 7 years old so that we could get better dosing. I would think this would let mom giver her daughter 1/2 units via syringe for those 10 gram snacks and such.

    In the meantime, OP needs to try to find a new diabetes team, but sometimes a change is not an option. If there is no one else in Portland, her next best optioin would be going to Seattle, but that's about 3 hrs away, not exactly feasible. For now, she needs to keep working with her current team because it is that team that knows her daughter best. They might even know information that the OP has inadvertently neglected to tell us.
     
    Last edited: Aug 11, 2012
  18. Lee

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    Can you please point out where you see criticism, because I think everyone in this thread has bent over backwards to help this mom...maybe reading the entire thing would help clear that up :rolleyes:.
     
  19. wilf

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    Thanks to the OP for these new numbers. You are on the right track! :)

    The above post by Jordansmom is right on. Time to get your daughter safe, and then you can go more slowly to fine-tune things later.

    Looking at yesterday's numbers, I would offer the following comments:


    1) Lantus
    The big drop from 329 to 143 the first night suggests too much Lantus, but the next night's numbers were fairly steady between 108 and 141 which has me wondering if your daughter is still producing some of her own insulin (which would be unusual but not unheard of).

    If so then there may not be a great need to reduce Lantus much further from the 4.5 units you gave today. So I'd stay the course with the 4.5 units for another day or two at least, and focus on establishing safe carb ratios and a safe correction factor.


    2) TDD
    Your daughter had a Total Daily Dose (or TDD) of 13.5 units of insulin yesterday (5 Lantus +3 + 3 + 2 + 0.5 Novolog), and was still going low a fair bit. So let's assume her TDD should be 12.

    TDD is important because it allows you to do some rough calculations to establish a safe carb ratio and Correction Factor (we want to get you away from that sliding scale asap). The calculations are based on equations you'll find in good reference texts like Type 1 Diabetes by Dr. Ragnar Hanas, and Using Insulin by Dr. John Walsh.


    3) Carb Ratio
    Calculating and using this ratio is described in detail on pages 139 to 150 of Chapter 12 of Using Insulin by Dr. John Walsh. To calculate it you use what's called the 500 Rule, and divide 500 by TDD to get the carb ratio.

    In your daughter's case based on yesterday's numbers 500/TDD = 500/12 = 41.6

    So the 500 Rule is suggesting a carb ratio of 1:40 (1 unit of insulin to cover 40 g carbs) would be appropriate for your daughter! If this seems like too big a change from the current 1:10 carb ratio for you, then please consider going at least to 1:20 or better yet 1:30.

    Each day's numbers will provide more data, and will allow you to refine the carb ratio. But for now what is clear is that the current carb ratio is unsafe and needs to be changed immediately.


    4) Correction Factor
    A Correction Factor is used to bring down blood sugars if your daughter is high. The sliding scale that your medical team had you using was based on a Correction Factor of 1:100, meaning that above a blood sugar of 250, they had you giving 1 unit of insulin to bring her down by 100 mg/dL. Their sliding scale was not conservative, and was putting your daughter's health at risk. :eek:

    There is another empirical equation which is used by competent clinicians to calculate the Correction Factor. It is called the 1800 Rule, and is described in detail in Chapter 13 of Using Insulin.

    You divide 1800 by TDD to get the Correction Factor. In your daughter's case, 1800/12=150. So 1 unit of insulin is going to bring your daughter's blood sugars down by at least 150 mg/dL! You need to be careful with corrections! Note that most children need even less insulin for corrections at night.

    I would only be doing any corrections at meal time for the time being. I would also only be correcting to the higher end of your target range.


    5) Example of Correction
    If for example your daughter's blood sugar was 320, then using the Correction Factor we've calculated using the 1800 Rule you would give 1 unit, which would bring blood sugars down by 150 points as follows (320 - 150 = 170 mg/dL).

    *****

    I think this is lots for your to chew on, so I'll stop here. Bottom line, you are on the right track and the changes you are making are rapidly improving the safety of your daughter. Keep at it! :cwds:
     
    Last edited: Aug 11, 2012
  20. Knittingfor4

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    Thank you for the breakdown and examples Wilf, that really helps. I do not have that book, but I saw the 500 rule online the other day. I wasn't sure how to determine TDD since it can vary greatly day to day. But for now I will try using your numbers. DH and I decided to try a 1:20 carb ratio for a few days, while keeping Lantus at 4.5.

    EXACTLY!!!!!!
     

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