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Prebolusing below 100

Discussion in 'Parents of Children with Type 1' started by forHisglory, Jul 7, 2016.

  1. forHisglory

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    I thought it was supposed to take 20 minutes or so for Novolog to start working. However, that is obviously not the case. Each morning my son wakes up around 85. If we prebolus 10 minutes out, he goes into the 60's or lower. If we shorten the time to 5 minutes out he has terrible spikes. It's so frustrating!

    We don't always have time to feed a small amount of uncovered carb, wait until he rises, then prebolus, then eat. But, is that just what we're going to have to do? I prefer not to lower his basal in the morning hours as we've finally got good steady numbers from 2 am-7am......but the spikes with a shortened pre-bolus are in the low-mid 300's and he's been telling me lately he feels bad when he's that high. We add protein, fiber, etc., but the prebolus seems to be the only thing preventing him from spiking like that.

    I've actually been known to pre-bolus, feed a glu tab, then let him eat breakfast. Glucose tabs with a side of oatmeal......breakfast of champions. :cwds:
     
  2. Christopher

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    It is amazing to me that 5 minutes makes that big of a difference. This probably isn't optimal, but what about slightly reducing his basal a few hours before he wakes up. That way he would awake at a slightly higher number and the 10 minute out pre-bolus wouldn't drop him into the 60's? Just a thought. Good luck.
     
  3. samson

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    Do you have a CGM? If so, "waiting for the bend" is a great tool. Dose, wait until you see the BG numbers drop by more than a few points, then feed.

    You can also prepare the food in advance, have it at the table, ready to go, and wait exactly 7 or 8 minutes and even set a timer. You can also serve a small portion of the main meal uncovered, then bolus for the entire serving, NOT wait for the rise, then give the second helping after the insulin has had its 10 minutes to work. Might blunt the low and keep it in the 70s instead of the 80s, while you've still pre-bolused for the whole meal. I've also been known to give my kid a very small handful of raisins the moment he gets out of bed if he's running low and that will sabotage a prebolus. Not as fast as glucose tabs but if he's not low yet there's no time urgency and they're at least a real food.

    Also, just some food for thought. Non-diabetic people are routinely in the 60s and 70s and even have CGM readings as low as 59 in their daily life, one study found. About 80 percent of the time was in the 60 to 100 range, with a mean daytime BG of around 83 mg/dl. So if your sone is in the mid-60s for five minutes and is not hypo-symptomatic, it's not clear this has dire consequences. Many older diabetics set their low threshold at 65. So I'd aim to avoid the mid 60s but don't sweat it too much if he dips low before rising normally.
     
  4. forHisglory

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    It is crazy. I don't understand how it seems to work so fast. Maybe there is something I'm missing. We fingerprick and the Dex is right on. It does not catch the drop to the 60's. He feels it and we retest, sure enough he's there. I wish we had gotten the ping with remote so I didn't wake him to adjust basal. I'll have to toy around with it more on the presets...and we set a timer but maybe I'm incorrect about the 5 min difference. I'm going to be more disciplined about logging. Breakfast isn't the same exact thing every day so perhaps there is a food making him spike more some days vs prebolus lag.
     
    Last edited: Jul 7, 2016
  5. forHisglory

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    These are all good ideas. I'm going to play around with each of these. Thanks!
     
  6. glko

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    We have a hard time avoiding spikes in general in the morning so try to go low carb most days and do not pre-bolus. Trying to time the bolus for a moderate-high carb breakfast never ends well for my 12 year old, he is either low or 300 after.
     
  7. forHisglory

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    Saw the endo today and despite crazy spikes lately, his A1C fared well. I also then realized we had this problem last fall and I had asked the same exact question on this forum. I felt a bit dumb when I found the old thread!! Geez, sleep deprivation must be getting to me! Some really great input from a lot of people that I am rereading again but it's been interesting to see the new replies too as the saga of taming the morning spike (that goes away for months sometimes) continues....
     
  8. rgcainmd

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    If it were up to me, we'd always pre-bolus (down to about 66) and wait for the bend. (And we usually do, when I'm in the driver's seat.) But you know how it goes with a teen; I'm lucky if she pre-boluses and waits for 10 minutes. It usually takes 25 to 40 minutes to see the bend.
     
  9. quiltinmom

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    This is a little far fetched, but is it possible he's going low from basal (or some other factor), not the prebolus? Are there any changes in basal profile around an hour or 2 before breakfast time? Does it happen with every 10 minute prebolus, regardless of time of breakfast? Has he recently skipped or delayed breakfast, and was he low then?

    Spikes are very much affected by what the food is, as I'm sure you know, so make sure you log what the food is along with the results. :). That might help you figure out a pattern.

    Best of luck!
     
  10. caspi

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    I'll be honest with you - if my son had to do this everyday or if I was to have done this when he was younger, he would have hated it. In a perfect world we prebolus as often as possible. In situations where he's a bit lowish, he boluses midway through eating (if he remembers :wink: ) Spikes are unavoidable with a lazy pancreas. As long as it is back down within 2-3 hours after eating, we're good with that.
     
  11. forHisglory

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    The reason I stress about spikes into the 300's or higher is that numerous articles I have read talk about later complications (especially related to coronary issues) being more of a result of extreme fluctuations in glucose over time. Recently read an article interviewing Joslin medalists and they were examining older T1Ds (50 yrs+ with type 1) and said a history of severe lows and highs was worse than a less than ideal A1C. I internalized that information to mean that a good A1C is still important but also important was avoiding big spikes and severe lows.

    My son doesn't mind prebolusing at all. What he hates is how he feels when he goes below 60 and also above 300. He told me recently, "Mom, I can't stand when I'm low. I just hate it." Same thing when he was coming down from a high. I'm trying to minimize it as much as I can.

    Thanks for all the ideas. We decreased basal by 20% before waking and are adding it to the prebolus so he starts out breakfast around 110. So far, it's been a good move. I'm sure things will change at the next full moon. Or for whatever reason.
     
    Last edited: Jul 10, 2016
  12. caspi

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    Wow, this is the first I've heard about this. I would love to read more about this. Do you have links to these articles? Thanks!
     
  13. Christopher

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    I would be interested too. Because I have heard conflicting things. I have heard that big swings high or low are bad. But then I also heard that going high or low and staying there for a while is bad. But I also heard big swings high or low are ok as long as they are quick. So who knows??

    The other issue is that you hear of people with very poor "control" and have no complications yet others with good "control" do have complications. So I think it is very difficult to predict who will get complications or why.
     
    Last edited: Jul 12, 2016
  14. forHisglory

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    Yes, I will relocate them and link them up. I will try to pull them together by this weekend. I would love to be able to disregard it because it has stressed me out since I read it. It was a credible source too....but please tell me what you think too once I post them.
     
  15. forHisglory

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    That last part of what you said....ugh! I've read that too but all we can do is try our best and hope what we do makes a difference. Ultimately, we have no control over it all. But, we can utilize the info we have to the best of our ability in the here and now. I shouldn't stress about the spikes, but I do when I can't seem to tame them.
     
  16. forHisglory

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  17. Christopher

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    Thanks for posting. The first thing that struck me was that this was a study in 40-70 year old people at risk for TYPE 2 diabetes. Additionally, while 582 people might seem like a lot, I would like to see a larger, more comprehensive study before I lost any sleep over it. I am not dismissing the possibility, just need to see more evidence. As you said earlier, what we do is just try our best to keep our kids in range but often times that is not entirely in our control.

    #spikeshappen
     
  18. jenm999

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    Chiming in a bit late to say that if we wait for the bend he WILL go low. Our CDE said not to sweat the spikes (usually <250 for us) that are short-lived. We could probably flatten out our trace a bit with more pre-bolusing but since A1c is good we try not to sweat it.

    Our strategy for mornings (inevitably only school mornings when we're up with him) is to correct for a high (if present) upstairs before getting dressed etc. which buys you some time. Then, carb count and dose breakfast but serve protein first (sausage, greek yogurt) - so he's eating right away but he doesn't eat the really carby stuff for another 10 minutes or so.
     
  19. samson

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    I've seen inconclusive or conflicting evidence on whether spikes are problematic.. will try to dig up the research studies. As far as I can tell, both moderate hypoglycemia and wild swings are something that doctors strongly suspect are bad for you, but that the only validated biomarker robustly associated with reduced complications is A1C (and avoiding DKA.) The other thing I've seen studies tie to complications is a wild deviation in the average A1C over time. So someone who is swinging between 5.7 to 9.6 to 11.2 to 6.3, etc. But those swings are operating on the months-to-years time scale, not in the day-to-day.
     
  20. samson

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    Here are a few studies. The depressing fact is that, while decreasing A1C dramatically reduces complications, most of the rate of complications in DCCT was down to things other than glucose levels (probably genetics).

    Beyond A1C -- Seems like a few cell culture studies implicate "excursions" in damage, but that most of the evidence for reducing spikes is for older T2Ds.

    Studies on genes and risk of complications:
    Genes that quadruple or double the risk of nephropathy and end-stage renal disease

    Genes with protective effect
     

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