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Teenager High Food Bolus levels

Discussion in 'Parents of Children with Type 1' started by ChrisDadT1, Sep 11, 2017.

  1. ChrisDadT1

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    My 14 year old son is using a Dexcom G5 and a t:slim pump. He is currently dosing a Bolus of Humalog of 1 unit for 4.0 carbs for breakfast, 1u/4.5 carbs for lunch, and 1u/4.2 carbs for dinner. He eats about 75 carbs breakfast, 60 carbs for lunch and about 90 carbs for dinner. We are going through so much insulin every day! And it seems like we may need to up the food bolus dosage to about 1u/3.75 soon. Could this be a pump site issue (i.e., poor absorption)? Insulin resistance? We were thinking of maybe changing to a steel cannula - would this help? Is this just a puberty thing? Is it normal to need so much insulin at this age, or should we be concerned?
     
  2. Sprocket

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    My Dd has a 1/3.5 or 1/4 ratio at breakfast. She drinks about 30 carbs for breakfast (coffee and protein milk drink). Her lunch is about 1/6 and so is dinner. She takes about 46 units of Levemir too. My DD is 16. I think these ratios are not unusual for teenage years - I suspect especially for boys that age that are eating like crazy. Her levemir is down from a few years ago. Her TDD is 75 to 80 units. She is on MDI - levemir and fiasp.
     
  3. Christopher

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    If it is a site issue, and you are rotating sites properly, you should see a difference in the next few days when he does a site change. The way I have always looked at this issue is, the body needs what the body needs. In my opinion there is no "normal" amount of insulin the body needs. If his pancreas worked properly, it would provide however much insulin he needed at any given time and you would have no idea how much that was. My guess is that it is due to puberty and you just need to ride it out. Good luck!
     
    Last edited: Sep 11, 2017
  4. wilf

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    Puberty and the years around it are a time of high insulin needs in all children. For our Type 1 kids we have to give the insulin, which you're doing.

    What he needs is what he needs, and the Dexcom will let you know that.

    The only question I would have is in regards to bolus/basal ratio. How much of his total daily input of insulin is basal, and how much is boluses/corrections?
     
  5. ChrisDadT1

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    Thanks for the replies. I'm glad to hear that it is most likely a puberty thing. I hope his ratios go down as he gets older.

    Regarding his site rotation, yes we always do that, but we do notice that by day 3 the insulin doesn't seem to work as well. So by day 3, even using the above ratios, we often have to give multiple corrections throughout the day, or just change the cartridge & site. We hate wasting insulin though, since we barely get by with the approved amount of bottles.

    As far as his bolus versus basal ratios, his basal is surprisingly low (says our endo.) So after the last visit, we ran a series of basal tests and made adjustments until we got steady numbers with boluses. It took a few weeks to tweak it right, but we believe the basal seems to be correct at this time. Here is a breakdown of his insulin usage daily averages broken down by food boluses, correction boluses, and basals over the past month from his Tandem report:

    Insulin Ratios2.JPG

    I really appreciate your response Sprocket. It's comforting to know that other teenagers are using similar amounts of insulin. In your TDD above, is that including both the levemir & fiasp? Also - just wondering - why MDI? We're so used to the pump, I'm just wondering if going back to MDI might be a better way for us to to go for our teenager.
     
  6. Sprocket

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    Yes, the TDD includes both Fiasp and Levemir. My daughter has never wanted a pump - was diagnosed when she was 11. Despite her doctors and nurses pushing her towards a pump, she held her ground and has never agreed and I respected and understand that. She feels like she has more freedom with mdi. She doesn't mind injections whatsoever and feels more in control when she administers it herself. She also doesn't have any interest in being tethered to anything ( I know there is omnipod). She knows all the math and corrections and duration of action and has an excellent understanding of what's going on and why. I am really glad she has this foundation because if ever in the future she decides to pump, she will always have that knowledge in the event she decides to take a pump break or in case of malfunction. I have to admit, I also like having her basal insulin being delivered twice daily in the form of a long acting. If she ever misses a dose of fiasp, we always know she still has lots of basal insulin working in the background and the transition into dka, I would think, would be less likely. She does have a Dexcom G5 which we both LOVE and she wouldn't be without it.

    Her basal makes up about 60% of her TDD. We set her evening basal to have a nice straight line and her daytime basal to have a very slow decrease over the day. We've had our issues with Levemir (running out before the 12 hours and causing highs) and getting the exact dose was very challenging. However, as soon as Tresiba hits the pharmacy in Canada (I know it's been available in the U.S. for a few years and has great reviews), we will be the first in line to give it a whirl.
     
  7. wilf

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    I am wondering about the meaning of the phrase "we ran a series of basal tests and made adjustments until we got steady numbers with boluses".

    At our end the goal is to set basal so that numbers are steady or dropping very slowly in the absence of food and/or boluses. We don't use a pump either, so we just set her basal (Lantus in our case) to whatever amount gives a very slow drop in blood sugars over night.

    We had been on Levemir previously and were getting up to using the amounts your son is needing, and then made the switch to Lantus. Levemir had worked will in smaller doses pre-puberty, but didn't seem to work so well when we approached 50 units.

    Good luck with this. :cwds:
     
  8. ChrisDadT1

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    That's what I was thinking. We're looking at possibly going back to MDI because of the reasons you listed (and also because he wants to play HS Football next year - tough to do with a pump.) We are also looking at the inPen by Companion Medical, although we need to wait until it comes out to see if it will be right for him.

    Same here. We love the G5, don't know how we lived without it before. I just wish the Apple app didn't have so many "Signal Loss" and "Bluetooth" errors.

    Wow, that's a lot of Basal! Guess that's why our endo says my son's appears low (currently about 20% of his TDD.) I don't know much about the different long-lasting basals, since we only used Lantus at the beginning, but it looks like you've done the research to make sure you get the one that works best for your daughter.

    Thanks again for your response. :)
     
  9. ChrisDadT1

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    Sorry - not "WITH" - should have been "WITHOUT."

    However, we did bolus a couple of hours before we ran the tests to try to get him to level out at a decent number (100-140) with no IOB remaining, and then we ran the tests with no food, no corrections, just basal only. We did many tests with different periods - first we did overnight (easy since no food during sleep anyways), and made adjustments each night until we got level numbers. Then we did mornings which was more difficult, since he wanted to eat but we made him wait until lunch. After tweaking and getting level numbers, we went to afternoons and did the same thing, and then we did evening basal tests, and then night tests before bedtime. Overall we did end up making quite a few adjustments, and tweaking the time periods was a bit difficult, but we feel like it was worth it. We still run tests often to make sure his basals are keeping him level and making adjustments as needed.

    I'm surprised how much basal you and Sprocket are using - I wonder if long acting basal requires a higher dosage than fast acting humalog given evenly throughout each hour via the pump. In other words, if we changed to MDI, I wonder if his Basal would be 50 units of Lantus also, not the 17 of Humalog he is getting now. I'd be interested to see the TDD of Basal of other teenagers using Humalog in a pump to know if our 17 is really abnormal or just a little below average.

    Thanks for all your replies. :)
     
  10. MomofSweetOne

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    This is about how much basal my daughter needed at the height of puberty, and according to Pumping Insulin, that is typical. Now, at 18, my daughter is using about 50-50% and down to 45 units from 90+.

    I, too, wonder whether the basal and bolus doses are upside down. We lowered bolus ratios at the beginning of puberty, but from then on, it was basal that needed upped and upped. Is he steady at night without corrections? My daughter also needed DOUBLE the morning basal insulin compared to afternoons during that period. She still needs more in the mornings, but not near that drastic of difference.
     
  11. MEVsmom

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    Our endo aims for us to be somewhere between 40-50% basal assuming her diet is not super carb heavy. If you are having that much correction every day, I would suspect a basal increase might be in order. My daughter is almost 12. She pumps and her total daily basal is probably somewhere around 20 and we are inching that up every week recently and still having numbers higher than we want due to puberty. Her I:C ratios are only 1:10, 1:13 and 1:12, depending on the meal. We find that the more accurate our basal dosing is, then the more the spikes from meals are controlled and the less bolus insulin she needs. For us, a number like 140 for basal testing would be about 50 points higher than we target. So, even if the line was steady, we would probably up the basal. Do you think maybe that is contributing to much of the correction?

    As for the equivalent dosing, when she has gone on pump breaks with Lantus (split into 2 doses), it was about equivalent to her pump basal dose. We have much better numbers splitting Lantus and giving slightly more in the daytime than the night. This summer, we used Tresiba, which was great; however, it took us about a week to realize that the dose she needed was about 40% higher than her pump basal dose. I have heard of others that have the opposite experience and needed less Tresiba. I think that is just different for everyone.

    I hope you get it figured out. I know how frustrating it can be.
     
  12. wilf

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    Since puberty her insulin needs have come way down, and she is currently around 27 units a day. I'd say that's on the order of 55-60% of her daily insulin needs, and that ratio has been the same for many years..
     
  13. ChrisDadT1

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    Thanks for all the replies.

    @MomOfSweetOne
    Yes and no. Depends on the day of his insulin cartridge. We have noticed on Day 1 (new site, new cartridge with fresh insulin) his Basals typically make his numbers steady or sometimes decrease. We often have him reduce basal on those days via the pump temp settings. On day 2 of a cartridge, they usually go up slightly. So we end up doing some corrections. But by day 3, we have noticed, the basals don't work well at all. So we often use the temp settings to increase his basal (i.e., 150% Basal for 2 hours, adjusting as necessary every hour or so.) See our recent chart below (please excuse my sloppy computer pen writing on the picture.)

    Dexcom Day1 2 3.JPG

    @MEVsmom
    You may be correct. Please see the picture above. We are considering having 3 basal profiles in his pump based on his typical Day 1, Day 2, and Day 3 experiences. So Day 2 and Day 3 would definitely require more Basal (which we are giving by temp higher basal rates and corrections now.)

    That is exactly the results we would like to achieve - less spikes after mealtimes.

    140 is just for testing, not our target BG. After the basal rate per hour is tweaked, his target is 100 and we double check to make sure it stays there as much as possible with the adjusted basal rate. Basal testing at 140 has its advantages. In case there's too much basal and you fall asleep, you've got a 70 point cushion. As far as the corrections, yes I agree, definitely the day 2 and day 3 scenarios we are experiencing are leading to those excessive corrections, along with spikes after some meals.

    Thank you! I know we will get it figured out eventually, and we appreciate yours and and everyone elses help and replies.
     
  14. MomofSweetOne

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    If you see such a drastic difference on Day 3, why not consider changing out at Day 2 or 2.5?
     
  15. ChrisDadT1

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    We have considered that. But a few reasons make it difficult - limited cartridges, insertion sets, and insulin currently approved by insurance, we don't want to waste any insulin left in the cartridge since we barely make it with the bottles we have now, and DS hates the insertion process. But at our next endo visit, we will (once again) ask for an increase in all supplies and insulin to be submitted to the insurance, so hopefully we can start doing this. It's also one of the reasons why we are considering going back to MDI, or changing to the the upcoming inPen or the Omnipod Dash.

    BTW, I see your DD is using the t:slim like us. Are you gong to be changing infusion sets with the new t:lock connector, or are you already using one that they are offering? We will be forced to change - there is no direct substitute for the one we are using now.
     
  16. MomofSweetOne

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    I asked, and they said a version of the Contach Detach will be available with the new connector. I wish they would come out with a version of the Cleo. The t:90s are junk IOO; they kink everytime, whereas the Cleos didn't.

    Have you considered Cut-The-Cord for the Omnipod? We have it & T-slim. T-slim is the definite favorite here, but there are times the pod is really, really nice to have.

    Have you upgraded to the x2? My daughter is enjoying having cgm integration again (she'd had it on Medtronic 723), but G5 and the phone is another matter for a new thread.
     
  17. ChrisDadT1

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    Yes, we are using the Cleo and I voiced my frustration to them that there is not a good substitute IMO. Where do the t:90's kink - in the cannula or the tubing itself? We are still trying to decide which one to switch to. I don't like the clumsy insertion of the "Autosoft 90" they are pushing. Why is it all connected? It looks like we will have to support the pump and the tubing while we hold a giant insertion device, and it looks like it will be extremely hard to accurately pinpoint the insertion spot. Because of this and his (possible) absorption issues, we are also thinking the "TruSteel" (similar to the Contach Detach) might be best for us. Very easy insertion and no chance of cannula kinks, but the downside might be the discomfort of the steel itself (especially since we insert on his buttocks,) and having 2 patches on the skin. I case you haven't seen it, here is a link to the 4 sets they are offering: https://www.tandemdiabetes.com/products/infusion-sets

    We have considered the Omnipod cut-the-cord, but DS didn't like the large size of the pod when we tried their sample a few years back. Now, he is more open to it as he gets frustrated with his tubing and pump interfering with his daily activities - i.e., going to the bathroom, changing for PE class, etc. The Omnipod Dash looks promising - I think they will have G5 integration (eventually), and the phone pod looks to be similar in function to the Tandem. The only thing I don't like is that the phone will be locked to only the app and cannot be used as a phone. So yet another device for him to carry around. Why can't they just make everything work in one device - specifically an unlocked phone - so DS could have the flexibility that every other teenager enjoys? Guess we'll never get rid of that SpiBelt.

    Our 4 year warranty on the original t:slim just expired last month, and we are considering the X2. I do like the G5 integration, but he already has the iPhone for that - it will only be truly useful for us once the basal algorithms are incorporated. So we are on the fence still trying to make a decision. We don't really mind waiting for a few months until the Omnipod Dash comes out and making a decision at that time. But we're also worried a bit about the longevity of Tandem (the company) as they appear to have financial difficulties (stock price at about 50 cents right now.) So maybe in the near future we won't even be able to get the X2 anymore, which makes the decision even more difficult, and the odds of the future algorithm software update uncertain.

    Question - since your DD has the X2 already - are the alarms on the X2 louder than the Dexcom receiver? Because he hardly ever notices the receiver alarms, but the iPhone alarms are nice and noticeable. Any bluetooth issues with the X2 connection to the G5? Because we're wondering if he'll need to carry the receiver, iPhone, and the X2, and also if it's even possible to connect all 3 at the same time. Right now, he carries all 3 of those items, because the original t:slim has no integration, and since the iPhone has frequent "bluetooth off" and "signal loss" issues, he carries the receiver as well since that is the only thing that stays connected to the G5 all the time. Also, it is our understanding that the X2 does not upload to the cloud, so that will still require the iPhone in order for us to use the Follow app.

    Sorry this conversation is getting off the original topic, but I'm interested to connect with other T1 parents who face similar situations and frustrations and can possibly help by sharing their experiences and opinions. Thanks again.
     
  18. MomofSweetOne

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    With the X2, the G5 cannot pair to the receiver. It's one or the other. I honestly have rarely heard the X2 alarm. I'd love to say that's because BGs have been ideal, but she's been sick....so definitely not the case! It may be that I'm not tuning into what it is. The x2 doesn't have the attentive option that we always used on the receiver.

    My daughter wears the contact detach in her butt. She has too much muscle and very little fat every place else to be use them. Her rotation plan is pods on arms. She tapes the site with Hypafix to make it more secure, but unless it gets bumped, I don't think she notices it. She doesn't stick the second one onto her; she just folds over the sticky to itself. With the hypafix, she doesn't need theother secured.

    She says the idea of a metal site sounds worse than it is. The worst part about the contact detach is they don't carry well at all in bags, which is what we liked the Cleos for.

    The t:90s kinked at the base of the cannula.

    She far prefers the G5 on the x2 rather than her phone. She feels like she can look at it and not have it look like she can't stay off her phone in public.

    We ordered the x2 in anticipation of the low glucose suspend and then Type Zero, knowing her T-slim had another two years under warranty. She leaves for college next fall, and I want her to be able to sleep without worrying so much about waking to alarms. She was gone for seven weeks this summer, and she came home utterly exhausted. She said she tried not to let herself sleep deep for fear she wouldn't wake. But that caught up with her by the end, and she wasn't waking to even phone calls one night. If the LGPS isn't out by then, we'll be seriously looking into getting her Looping with the pod.

    Many thanks to you and Meg for your helpful suggestions!
     
  19. ChrisDadT1

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    Excellent info, thanks!
     

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