Treating Borderline Lows on the Pump- Decrease Basal, Treat, or Both?

We are one week into pumping....and things are going relatively well, but highs and lows are responding a bit different on the pump. Lantus dose before the pump was 3 units/once day/PM. Our suggested start basal rate was 0.100 u/hr. We had so many lows the first 24 hours we had to decrease it to 0.025u/hr. Well, that worked perfect for 3 days. Then, DS was waking up above 200 and pretty much staying there all day?? and so we increased gradually to 0.075 and we have better in range numbers again. Throw in more variables like swimming, playing with friends on summer evenings and here we go with no true lows.....but around 80-104 at bedtime and about the same before dinner (about 4 hours post lunch).

Fingerstick at 104 3 hours post dinner, we treat with 8 grams of "fast sugar," and then retest in 15 min. He's gone down to 80 (fingerstick). Okay, gave 5 grams of greek yogurt with a dab of honey. Retest in 30 and we're 240 and have been steady there for 2 hours. Ugh, now I'm going to have to correct again or I could increase basal. I'm going to go batty, feels like I'm chasing numbers much more than on MDI.

I think the ability to tweak basals in less than 24 hours as an option is a steep learning curve for us! So, any general guidelines on treating lowish numbers with carbs or just decreasing basal for a short period of time? Our CDE said people do both.....mentioning specifically that some teens will suspend basal vs. treat a low with food bc they want to avoid consuming extra calories. And, honestly, sometimes our DS is sick of "eating on demand" for a lower number. I can't blame him!

 

For us any change in the basal programing needs to happen about 1-1.5 hours before we expect to see the change in BS, so you always have to think ahead or actually push the pump back. Also basal tends to stack. So when you need to back off it may seem like you need a bigger change than you actually do. Don't be hesitant to add more basal rates if you think you need them. The closer you get to the honeymoon ending the more likely he'll need different amounts of basal at different times.

Treating lows with basal doesn't work for us. The time it takes for the lack of insulin to take effect is too long. The only time I cut the basal for a low is for one of those just won't stop lows. Now on those days when they're running high or low all day, temp basal IS your friend. There are other times when temp basal is handy, but for now you need to get the hang of it first.

If things don't start to work for you pretty quick post a pic of Dex in the time frame your having trouble. There are lots of good pump trouble shooters here.

Hang in there the first month on the pump can be frustrating but then it will start to make sense. All the freedom you'll have at 6 year old birthday parties will make it all worth it.

 

We've sometimes found that it is possible to tweak basal overnight to avoid lows.

On MDI, DD's nighttime target was 20 points higher than her daytime target. However, we didn't treat until she was below the daytime target (unless she was symptomatic or one of the other million reasons that might apply--exercise, etc.).

Now that we started using the CGM, those targets are still programmed into the pump for calculating corrections, but we are much more comfortable relying on the CGM.

So, at bedtime, if the CGM has been pretty accurate (and it generally is) and she is trending down quickly (or trending down but with a fair amount of IOB), we might reduce or even suspend basal. The slightly higher bedtime target gives us a little time for the reduced basal to have some effect. This works often enough for me to feel that it is worthwhile -- if I can avoid disrupting her sleep, I'd much rather do that.

We'll doubtless be doing something like that today as it is DD's birthday and DH has rented a bounce house, which generally means some low BGs.

 

You can use your CGM graph to get a pretty good estimate of how much time elapses between when you bolus and when the insulin activity peaks. Use that time when you adjust a basal rate. For example, for my daughter, insulin action peaks at 1.5 hours after the dose is given. Let's say I notice a pattern of lows that happen around 3:30 p.m. every afternoon. I'll take 3:30 p.m., subtract 1.5 hours to get 2:00 p.m., then decrease the particular basal rate that corresponds to 2:00 p.m. Then wait to see what happens over the next few days (at least 3 days). I hope my example makes sense.

I'd recommend that you figure out a few different basal rates per day. With only one basal rate, 24/7, it's not much different from using MDI with a long-acting insulin analogue that gives you essentially only one basal rate. Good luck and keep asking questions!


ETA: In addition to the knowledgeable pumpers on the Forum, I found Gary Scheiner's book Think Like a Pancreas extremely helpful for figuring out basal rates.

 

We have decent success with decreasing basal when there is borderline low. When their CGMs show 80-ish and dropping, we reduce basal. If they haven't flattened out and get down to 60-ish, we feed the low, but less than usual because the basal was already reduced.

And keep in mind that the advantage of a pump is that you can have multiple basal rates throughout the day. If .1 is good at some times, .025 at others and .75 at more, blend them into one basal profile. Some great books, IMO, are Think Like a Pancreas and Sugar Surfing (although I'd only jump into Sugar Surfing if you use a CGM...and I can't remember what your signature said).

 

Thank you everyone, for your time to give me some nuggets of wisdom and advice. I so appreciate it. Last night I went to bed so frustrated.....I opted out of the yo-yo game I felt like we were playing, didn't tweak or correct anything, and just rechecked him every 2 hours via CGM. From 1 am-5 am he came down from 240-160 and that was without any coverage of his late night low treatment. Honeymoon still at play some here, I guess.

How much of factor is the outside temp and deactivating the insulin/making it less effective?? I contemplated changing sites at 2 days (vs. 3) since he was playing outside in hot, humid NC weather the day he was running high all day despite corrections. Frio wallet for a pump maybe??

 

Exactly what I need to figure out. My head is spinning trying to take in all the variables and filter out what is a basal issue vs. all the other gazillion reasons. I'm refreshing myself on Scheiner's book today for temps. I heard "Pumping Insulin" by Walsh is a good and I've ordered that too. He seems incredibly more sensitive to basal Novolog vs. Lantus. I'm hoping in a couple weeks I'll have some patterns figured out............until they change again.

 

Had to do this today! Completely untethered for 1.5 hours....although I question if 0.075 basal is really enough to matter? But, I tried it and he came back up faster. We repeated a treatment 3 times and he still hadn't leveled out above 100, but he did after we disconnected. Will be calling the endo tomorrow because right now I feel D has us by the tail and I'd like to feel like we have a better handle on things instead of switching programs throughout the day. Phew!

 

Sounds to me like you're doing a good job keeping your eye on what's happening and doing the right things to correct. Don't get too frustrated or worry too much: this is pretty much how things go at first when you start pumping. Unfortunately, your endo/CDE advised you to use only one basal rate. Based on my daughter's patterns gleaned from review of her Dexcom info, our CDE recommended several basal rates throughout a 24-hour day/night. (They were all too low, but it gave us a good starting point.) If you have the same edition of Think Like a Pancreas as me (copyright 2011), check out p. 105. The little graph at the top of the page helped us immensely, once we realized there was an error in the labelling of the different lines. THE TOP LINE WITH THIN DASHES ACTUALLY PERTAINS TO AGES 11 - 20. Either the second or third line is for children your son's age. I used this graph to estimate about where my daughter's basal rate should be based on the time of day and went from there.

Something else that really helped me get a little bit better of a handle on things was to estimate my daughter's ISF (insulin sensitivity factor) using the 1800 rule. I took an average of her TDDs for the previous 14 days, then used the following equation: 1800 % average total daily dose = ISF. ISF can be up to 40% lower overnight, if I remember correctly. My gut told me that my daughter's ISF didn't vary from day to night that much, so we only use about a 10 - 15% differential from day to night.

Soon you will feel like you have diabetes by the tail instead of the other way around. Pumping is a huge exercise in trial and error at the beginning, then settles into the usual constant tweaking craziness I'm sure you're already used to. Hang in there!

 

We take it on a case by case basis, but we treat with carbs far more often than lowering basal. If it's a low we think will persist, or if he's too tired to get up and eat (we are talking very mild lows, nothing super low), we might lower basal. It's not that helpful to say to follow your gut, but here really are no rules--it's case by case, trial and error.


You'll. get the hang of it! Give yourself time. . And don't be why about asking questions.

 

For us how we react to a borderline depends on weather the number is holding steady or still dropping, if it's holding steady I will reduce insulin by 75% over 1 hour and that usually works, it sounds like during the times before he wakes you need less basal around then, it's pretty easy to get decent basal rates overnight when you don't have the food factors at play I we see any steady rises or drops we tend to up or reduce basal 2 hours prior to the rise or drop through to when it stops rising or dropping. I think it's pretty rare for kids to have the same basal rate all day and all night, you will soon learn what your childs needs are. Dont' expect too much from yourself or the pump in the early days.

 

I am so so thankful for a dedicated endo team. This weekend continued to get crazier on the pump. After a night of battling lows we then had a night of highs. Our tried and true I:C ratios were sending him crashing after 2 hours to top it off. His Dex data looked like a roller coaster. My brain was fried reading and logging and trying to make sense of it all. I couldn't wait until Monday at 7:59:59 am...8 minutes of the on call endo's time and helping to troubleshoot saved our sanity. If we have to battle D there is no other team or community of friends (online and local) that I would rather have! Thank you all again. Onward we march...