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Off-the-meter high and I don't know why...

Discussion in 'Parents of Children with Type 1' started by Mama Salty, Aug 27, 2015.

  1. Mama Salty

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    Hi. I'm wondering if anyone can help me figure out my daughter's crazy numbers, and in particular last night's. I'll start with Monday though. After dinner, she felt low - she was 59. I gave her 15 carbs and when I rechecked she was 94. Since it was bedtime then and she's supposed to be at 120 for bed, she had 10 more carbs. Awhile after she was asleep, I wiped her finger with a clean damp towel, dried it, and checked. It was 459. I wiped and dried and checked again. This time it said 336. So I corrected for that and she woke up in the morning at 209. Fast forward to after dinner/bedtime on Tues, she washes her hands, I check and get 488. I have her rewash and meter reads "HI" - she felt fine and I felt certain I'd given her her dinner bolus. I thought maybe the meter had gone crazy so I got out the Precision Xtra meter that I'd never used (got for blood ketone testing but never got the ketone strips) and checked with that - 500. So I gave her correction, made her drink some water, checked her ketones (none). She woke up today at 195. Skip to dinner tonight...Remembering how she went low then high on Mon, I decided to do some extra testing. Her reading at dinner was 391 (don't know what was up with that cuz she was with her dad for lunch), so I corrected and bolused. 90 mins later she was 120; 45 mins after that she actually felt low and tested 88; unfortunately, I didn't check her til 2.5hrs after that at which point she was 359.

    So...about the "HI" on Tues night - I have a specific memory of *thinking* about giving her her dinner bolus, but not of actually doing it (but that doesn't necessarily mean I didn't). And there were pen needle covers and whatnot on the kitchen counter and it's really unlikely (though not impossible) that they'd been there since lunch. So, I guess I'm wondering, does it seem possible that she's having some sort of rebound effect at dinner where she goes low and then spikes? Or do I need to just face the fact that I f**ked up? Any insights appreciated...

    For reference, she's 8, diagnosed 15mos ago. Her readings have been seeming high lately, particularly after dinner/bed and in the morning (even after correcting at night). Due to the high morning readings, we upped to 10 units of lantus last week but I'm not sure it's made a difference.
     
    Last edited: Aug 27, 2015
  2. nebby3

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    I think there are so many what-ifs it's hard to say (isn't that always the way with D?). For the first night my guess is that she was still coming up from the 15g of carbs you gave her and then the added bedtime carbs shot her pretty high. Maybe it was also a meal with a lot of fat or protein that delayed the carb absorption? That could explain both the low and the later high.

    I find myself in the situation of wondering if I've bolsed way too much. We do those things so often it's hard to recall specific instances.
     
  3. sszyszkiewicz

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    It is probably more than one thing

    1) 25g of uncovered carbs probably jumped your daughters numbers the first night more than you think. For a typical 8 year old that was probably ~250 or so points of blood sugar right there. We found the information in this article very good. http://diatribe.org/issues/55/thinking-like-a-pancreas They send you home with this 15g rule, but I honestly think that is to make it simple to remember, but for kids that weigh less than 60 pounds that is alot of carbs.

    2) There is a book called Using Insulin that gets into formulas for Total daily dose of insulin, how much should be basal, and what the ratios and correction factors should be. It is a very good resource for someone on MDI. all of the calculations start with your daughters weight to see what the Total daily dose should be (about). About half of that should be basal Lantus. the other half is fast acting. There are rules of thumb for ratios and correction factors. Of course all of these things are interrelated but near the top of the decision tree is deciding how much Lantus/basal. Once that is dialed in everything becomes, in the scheme of things, easier.
     
  4. dpr

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    If it were my daughter the first thing I would look at is basal especially since she's been high in general. You probably need to up the Lantus again until she runs a little more level. If your basal isn't right it screws up everything else and you chase your tail constantly.
     
  5. jenm999

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    My thought as well!
     
  6. Mama Salty

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    Thanks for the input. I agree about the 15gm rule for lows not necessarily working. Then again, there's been times when she's had stubborn lows where I needed to give her 15 + 15 + 15 + 15... I guess there's no good way to tell ahead of time (unless you think you know what caused it). And very interesting website, Sszyszkiewicz - thanks.
     
  7. funnygrl

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    It seems maybe you might be correcting a bit too aggressively, too. To drop from 391 to 120 in 90 minutes is pretty quickly, and almost guarantees going low by the time the insulin is worn off, thus starting the yoyo. Are you looking into a pump soon? If not, perhaps you could consider a pen with memory like the Novopen Echo to take some of the mystery out of, "Did I bolus?"
     
  8. wilf

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    I have some questions and then may have some suggestions:
    What's her weight, and her correction factor?
    Also, what is her total daily dose (TDD) of all insulins (all boluses and basal) on a typical day?
     
  9. Mama Salty

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    I'm trying to learn more about the pump, but at this point, she doesn't want it. However, I plan to pass my learning along to her so she may change her mind. I do have a lot of questions and concerns about it, but maybe I'll make a separate post someday. And I asked about the Nova Echo at her last appt because even though (up til this time) I'd never missed a dose (still not sure I did even), her dad has on numerous occasions. (She's with him every other week.) Unfortunately, insurance (Medi-Cal and California Children's Services) won't cover it.

    She is 74 lbs. Skinny but tall for her age. At her last appt, they changed her to a *less* aggressive correction - 1 unit for every 100 over 150 (or over 200 at bed). I couldn't tell you at the moment what her TDD is. She's with her dad now and her log goes where she goes. Also, TDD is something I've been seeing a lot on this forum, but had never heard of before (as in discussed at her appts). Do you include correction doses in that total?
     
  10. wilf

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    I suspect that at least some of extreme highs you are seeing may be due to rebounds and subsequent insulin resistance following hard lows. The correction factor of 1:100 suggests she is very sensitive to insulin. What carb ratio are you using?

    Finally TDD is the sum of the Lantus, all boluses, and 50% of all corrections (ref. Using Insulin, by John Walsh). You want to average her TDD for a few days to get a good handle on it - and once you have this average TDD it can be used to make rough estimates of appropriate correction factors and carb ratios.

    But in the meantime, I would be watching her closely after meal-time injections and corrections. Try measuring 30, 60, and 90 minutes after a few meals to see how the insulin is affecting her.
     
  11. Mama Salty

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    I had been giving her 1:15 at breakfast, lunch, snack, and less at dinner (like 1:18 - usually involves choosing to round up or down). Can't say for her dad.

    I have her for a visit today, so was able to look up her numbers. It's an average of 4 days that I had her last week, not including the day at the fair because that was...atypical. And her dad records everything differently than me, so I can't figure the most recent days. So...18 was the average for meals, plus 11 for (half of) corrections, plus 10 Lantus...so 39 TDD?

    Unfortunately, school started this week and so everything has gone completely wacky. Her dad had just upped her to 10 units of Lantus back on 8/19, and after talking on here, I was thinking we should dial it up to 11 (because she was still high a lot, especially mornings), but I just noticed that her dad randomly switched her back to 9 units on Monday night - which was good, because she's been mostly low the last couple of days. Which is probably due to the extra activity from P.E. But anyway, I think it's going to be hard to figure things out for a couple of weeks.
     
  12. wilf

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    Ok, so here's how I see it. Your daughter is getting overdoses of insulin, going low on a regular basis, then rebounding high with insulin resistance. Something has gone wrong somewhere in your medical team's oversight - bottom line is she is getting too much insulin.

    She weighs 34 kg (74 pounds). She is getting an average of 10 Lantus plus 18 bolus plus 22 units of corrections a day = 50 units (or about 1.5 units/kg body weight/day). That is way too much insulin for a girl her age. At the peak of puberty some girls may reach those levels of TDD, but more normal is between 0.5 and 1 units/kg/day - which for her would be 17 to 34 units in total.

    If this were my daughter I'd stick with the 9 units Lantus, dial the meal-time boluses back to 3 units per meal instead of 6 units, and see what happens. The worst thing that could happen is she goes high, but that's been happening anyways. My guess is that all of a sudden things will get easier to manage.. :)
     
  13. Mama Salty

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    Interesting. I am confused about something though - wouldn't her TDD depend on how many carbs she's eating? I mean for the same ratio, if one day she wanted a smallish fresh peach and a piece of toast at snack, that would be about 30 carbs, but if she wanted an entire bagel and applesauce with "Craisins" that would be 70. So she'd get quite a bit more total insulin for the latter even though the insulin:carb ratio is the same...Am I making any sense? Like...I could reduce the TDD by just not letting her eat so many carbs? (Not that I want to do that - just confusing.)

    In any case, I think we'll definitely be sticking with 9 Lantus and less mealtime insulin for awhile, so we'll see where that gets us. Thanks for the advice!
     
  14. wilf

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    You are correct - TDD does depend on diet. But given anything approaching a normal diet, my sense is that your daughter has probably been getting too much insulin.

    Good luck with this. :cwds:
     

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