Basal the spike away
Standard Disclaimer: I'm not a doctor, please read the disclaimer at the bottom of the page. Always speak to your doctor, especially before trying something that came to me while I was in the shower.
Stubborn Highs: Arden's blood glucose can rise and at times be resistant to returning to 'normal'. Happens to all of us. I bolus and wait but nothing, so I bolus again and sometimes again. It's around the second bolus when I begin to wonder, "is the site bad", "maybe the pump has been on too long", "did I grossly miscalculate carbs", a person can go batty trying to decide what has happened. It's likely that before you (or I) can ever come to a conclusion, the BG in question will return to 'normal' or head in the complete opposite direction. Either way, the whole unsightly mess is forgotten becasue you're busy chasing the next problem which leaves you no closer to understanding why this happened or figuring out how to avoid it next time.
Sound familiar?
This type of BG struggle isn't just associated with stubborn highs: Breakfast or meal time spikes can also lead to an urge to bang your head on a nearby firm surface. Over the last few months I've been experimenting with an idea that came to me in the shower one day and I'm seeing a lot of positive results. I'm going to do my best to explain without being boring or confusing... Please note that what follows will only work for pumpers because it involves manipulating basal rates... sorry MDI and pen users!
Using increased temp basal rates in place of a portion of your bolus
Arden is a really good eater, that is that she eats healthy foods most of the time and in acceptable portions. If the kid has one 'vice' it's that she likes a bowl of Fruit Loops in the morning - just one cup. The BG devastation that this handful of cereal visits unto Arden was, in the past, terrible. Her BG would rocket to 400 or more after a bowel of the colorful rings. The Loops would seem to laugh in the face of a pre bolus and administering more insulin before the meal or an extra bolus after could not penetrate their sugarific force field. Once I even thought that I saw Toucan Sam give me the finger as I put the cereal box back in the pantry.
I hate this song and dance. I hate that Arden can't have a flippin' bowl of cereal once and a while and I double hate the feeling that I live with when she eats cereal and her BG goes crazy. Foods like this don't just send her BG too high, they ruin most of the rest of her day. I'm full aware that cereal isn't a good choice for my diabetic daughter but I'm not writing about that today. Today I am talking about how, with the help of an insulin pump, we can all fight meal time spikes associated with not so great food choices and manipulate stubborn high blood glucose values more easily and smoothly.
My formula
Things you need to know to follow along:
- Arden's basal rate is .30 in the morning and much of the day.
- For a serving of Fruit Loops she requires 2 units of insulin.
- Giving say 2.5 units for the cereal does not change the trajectory of her BG.
- If I go higher (say 3 units) the spike is not effected enough, topping out at 350 and Arden's BG will plummet between the three and four hour mark.
Time to visit me in the shower where I am apparently about 20 IQ points smarter then I am anywhere else. (I've heard that the hot water on the back of your neck may be the reason why).
I was in the shower one day pondering life and Arden's breakfast BG spikes when I first began putting the pieces together. Overnight Arden's basal rate is .20, if she's high I have to put her basal back to .30 for a bolus to have the desired effect... I wondered what would happen "if I increased the basal beyond .30", could I bring a high BG down in a safer way, steadier perhaps (because she's sleeping) then if I just bolused? I tested my idea at the next opportunity and not only did a significant temp basal bring down the high overnight BG but it did it with less insulin then a bolus would have required and the drop was smoother, it's 'landing' less erratic. My inner mad scientist was intrigued and I had just unknowingly found a big piece to the puzzle that is stopping mealtime spikes.
Proof of concept: Arden sits down and begins eating on a school day at 8:20 am. Today at 7:45 am her bg was 140, I bolused for the first 15 carbs of her upcoming breakfast, which was 1 unit or half of what a serving of Fruit Loops requires. This is a pre-pre bolus, I find that after a long night of no boluses and a decreased basal rate it can take a little longer for insulin to begin working (maybe this is part of the morning insulin resistance many experience?). At 8:10 am I bolused again this time for the remaining 15 carbs but I reduced the 1 unit of insulin by .30 (the equivalent of an hour of Arden's basal rate). Last, I increased her basal by 95% for one hour. (OmniPod won't do 100%), giving the last .30 of the 2 units via an increased basal rate. The temp basal in conjunction with a significant pre bolus seems to be the key to eliminating a BG spike. Pre bolusing alone won't effect a severe spike enough because you can't perfectly sync the insulin peak with the food spike so the BG rises quickly, drops suddenly and often bounces back up. However, when you add a pre bolus to a significant temp basal, the basal acts as a constant drag on the spike and the two together win out.
Breakdown
15 carbs or 1 unit, 40 minutes before breakfast - 7:45am
I can prebolus that far off in this situation without an issue because her basal was .20 all night and she's resistant in the AM, so the insulin is a bit slower to respond first thing in the morning. Plus, with Apidra, Arden rarely experiences significant BG falls so prebolusing this far out feels safe. Additionally, I have 70 points in her BG to play with and the cereal will be releasing sugar into her blood far before she gets too low... (having a DexCom CGM doesn't hurt either).
Another 15 carbs 15 minutes before the meal (withholding the equivalent of an hour's worth of basal)- 8:10
This insulin won't begin working until after Arden begins to eat, so I'm not worried about stacking. Two boluses also mean two insulin peaks while the Fruit Loops are trying to spike her BG.
Double the basal rate for an hour to complete second 15 carb bolus.
This .30 will work better then if it was given as part of the bolus, why? I don't know, I told you, I'm not a doctor... it just does - Maybe I know this because hot water in the shower makes me smarter. btw, more then an hour of the temp basal is too much and results in a fall in the 3-4 hour range. Doubling for an hour is perfect.
Result: At 9:30 am Arden's nurse called... Arden was 240 by her CGM. The CGM indicated 2 arrows up (which was why she was with the nurse) but the double arrows only lasted for about 4 minutes. So my little science experiment took a double arrow up event that in the past would have sky-rocketed to 400 (or more) and held it to a 4 minute double arrow that never went above 250!
Arden's BG (by the CGM) at 11 am (pre recess) was 145 diagonal down, she drank 2 ounces of juice (7 carbs) and went outside to play. When she returned her BG at 11:30 am (post recess, pre lunch) was 129 by a finger stick, 140 and steady via the CGM.
I choose and extended bolus for lunch because she was having a bagel. 60% of the 2.20 units at 11:30 am the balance over an hour (to combat the slow breakdown of the bagel). Her BG was 145 three hours later before snack time.
Summation
It goes without saying that what works for Arden won't work for everyone but after months of using this method I am 100% comfortable telling you that what I wrote here is well worth speaking to your endo about. The concept of using a temp basal to complete a bolus holds many possibilities beyond what I wrote about here today. Slow to break down foods and high carb meals for example are also good places to try this method. I'm using a temp basal as part of Arden's bolus on almost a daily basis. It is also invaluable in bringing down stubborn high BGs and getting a BG lower during sleep, avoiding the fear of a sudden drop and without going too low.
I wish you all good health, luck and steady BGs. I'll do my best to answer any question if you have them.
Apidra SoloStar supply news
Looks like Sanofi will have the supply of their Apidra SoloStar pen back to normal levels in the second quarter of 2012. Sanofi has made the FDA aware of their timetable and SoloStar users should be happy again in just a short time.
The company has produced a web page that can help a SoloStar user navigate the supply issues and they've also extended their free Apidra offer as a way to help soften the sting of this inconvenience. We've taken advantage of the free offer even though Arden doesn't use the SoloStar pen... Nothing better then free insulin, right?
Arden's A1c is at it's lowest ever since we switched to Apidra so I'm more then excited and happy to let you all know that it's out there and for a while longer, free.
Phillies Spring Training: My diabetes free vacation
It took some maneuvering, we had to cash in our frequent flier miles but Kelly and I were able to give our son Cole a Christmas gift that we thought he'd never forget... Phillies spring training tickets.
I don't leave home often without my kids. Being a stay at home dad by definition means that they are almost always with me. Arden is especially always close to me, be it in distance or contact and I don't often have the opportunity to relinquish her care. Last week however was a boys week, Cole and I went to Clearwater, Florida to watch the Phillies get ready for the 2012 season while Kelly stayed at home with Arden.
This trip was to be my second diabetes free week in five years. I still maintained communication with the school nurses but after Arden arrived home from school, Kelly took the reigns. Kelly deserves a big shout out... she did a terrific job!
Our son Cole plays and loves baseball more then I'd be able to express here in a few words. An hour after we landed in Florida we were standing at the Bright House practice fields. Not five minutes after we arrived Cole turned and saw former Phillies manager, Dallas Green. His was the first signature on Cole's ball that would eventually include Mike Schmidt, Charlie Manuel and Ruben Amaro, Jr. and that signature marked the beginning of our week in the sun watching the Phillies.
We stood and watched as the players took batting practice, ran sprints, fielded their positions and more. Every few minutes a horn would sound and the guys would run to another station. Cole was enjoying himself in a way that I've never seen, his smile truly reached from ear to ear.
CLiff Lee, Carlos Ruiz
Every day around 10 am Cole would stand outside of the outfield fence and try to catch home run balls as the sailed over. After he was finished, I'd get out my glove and he and I would throw a ball. This was my absolute favorite part of the trip. Standing just outside of where his baseball idols were playing, having a catch with my son. It was so relaxing and so heartwarming. Imagine your child's favorite thing in the world, imagine being at the place where it happens and feeling so close to it that you could imagine that thing for yourself. That's what this was for Cole and I was fortunate enough to be there when he felt it.
We attended a game each day, five in all. In the evenings we'd have dinner and laugh together, never once did I wonder how many carbs were in the food we were eating. It was nice not to think about diabetes. One evening at dinner I consciously thought, "this is wonderful... not having to look across the table, trying to guess how many carbs are in Arden's meal". The good feeling that accompanied that thought only lasted a moment because my follow up thought was so incredibly sad. I found myself pondering the idea that Arden would never experience this feeling as long as diabetes was a part of her life. I felt an incredible guilt for being able to escape diabetes when Arden isn't able to do the same. Those thoughts and feelings were incredibly sobering, they literally showed me where the term, "feels like a wet blanket" came from. I instantly felt the weight of her reality, I realized that Arden likely won't feel this release for a very long time, if ever.
Type I has given me a heightened perspective, I feel like knowing just how difficult life can be with diabetes allows me to properly put other situations into their place. I used that perspective, summoned up the resilience that diabetes has given me and shook off that terrible notion. I turned my attention back to our dinner conversation and was able to separate what was happening in my life in that moment from what I knew was happening in Arden and Kelly's back home.
Spring training was a marvelous experience, one that we may try to do again one day. I want to thank the Phillies Director of Public Affairs, Scott Palmer for the kindness he showed to Cole while we were in Clearwater. I wrote to the Phillies and told them that we were coming to spring training, I explained how often diabetes effects out lives and how wonderful Cole is at supporting his sister and patiently waiting while we treat low BGs, wait to eat and more. I expressed how much I'd like this trip to be just about Cole and that I wanted to make it extra special for him if I could. Mr. Palmer met us at our seats, spoke with Cole and gave him a ball signed by Phillies pitcher Cole Hamels. In a week full of ear to ear smiles, this moment ranked right at the top for Cole and I am grateful to Mr. Palmer and the Phillies for taking the time.
Cole with Scott Palmer
To see more photographs from the trip please go to the Visual Record.
Guesstures
Quick post today. Our family was playing a board game last week called Guesstures. Fun game, it's charades with a slight twist. You pick four cards that you then have to act out for your partner before the timer runs out. Arden was playing on Kelly's team and I was on Cole's. At one point Arden chose four cards, she examined them and then asked, "can I use something from my bag to help me act out this word?". We said, "sure!".
I set the timer and Arden began acting out her first word, Kelly guessed it correctly and Arden moved to the next card. Without hesitation, Arden picked up her MultiClix lance, pushed it to her finger and struck the button. She squeezed her finger, put the lance down and pointed to the drop of blood. Kelly said, "blood", Arden smiled and moved on to the next clue. Not wanting to waste the blood we tested her BG and then kept playing.
I couldn't help but to think that while diabetes certainly has thousands of detracting effects on one's life... It sure does teach you to be fearless!
Manny Hernandez interviews Dr. Denise Faustman
I'm reposting, with Manny's kind permission, his tudiabetes interview with Denise L. Faustman, MD, PhD.
Dr. Faustman is the Director of the Immunobiology Laboratory at the Massachusetts General Hospital (MGH) and an Associate Professor of Medicine at Harvard Medical School. - Her research regarding type I diabetes is exciting and encouraging, this interview is more then worth watching. http://www.faustmanlab.org/