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.

Comments

[Jennifer]

I have the same problem with oatmeal and cereals. I do get mad that I cant eat them. I told my doctor about it and he told me to bolus then wait 15 mins and then eat.

[Rob Bihun]

I think you are absolutely on to something. I have the same issues with my "poor meal" choices and anything I eat at breakfast. I believe that the monomer "square wave" bolus is intended to work the same way, I'm going to have to look at it and start using it!

[Scott Benner]

Rob,

It is very close to a square or extended bolus with a small but important difference. A square bolus can't offer the balance of large initial and large over time insulin delivery. You sort of get one or the other and if you try to spread it out over more time you loose the initial insulin 'burst' during the 20 - 90 minute window when a high glycemic food is working it's hardest to elevate your BG.

Please let me know who this works for you and if you make any adjustments, what they were.

Thanks!

[Stacey D.]

Ironcially, I just ate ceral for the first time in forever over the weekend. And I was reminded why I don't. BG shot up close to 300 even though it didn't stay there for very long. I thought I was being healthy eating cheerios too ;) I may have to be more creative next time.
I actually use a temp basal on work days to try & ward off the damn dawn phenomenon. And it works pretty well. I'm a really big fan of temp basals in general. I would say I use them a few times a day.

[Melissa]

This is exactly what the dual-bolus is on my Medtronic pump. (if I understand correctly)

You give 2 percentages of insulin. The first is given immediately and the 2nd is given over the time you set. I almost always do a 80%-20% with the 20% being over either a half hour or hour. I always use caution for fear of low, but someday I hope to get it down using math as you did so I know exactly what percentage to use.

I'm glad it worked out for you!

[Penny]

Hi Scott,
Great detailed post, this for sharing. I do a lot of temp basals for various foods that Grace eats. Pastas, cereals, popcorn, rice, tortillas, French fries...and more that shall remain nameless. I have different ratios that I upfront Bolus for, then extend a % for for about 3-4 hours. I have not tried the reducing the amount of insulin by the basal rate. Like your example of reducing the 1.0 unit by .30. I'm not quite sure I understand your reasoning behind it, but if it is working for Arden, then great.
My only concern is that in taking away the basal rate from the unit, you are messing with the ratios of the basal/Bolus. So, after you do these temp basals and reduce the Bolus by an hours worth of basal rate, what kind of ratios are you seeing? I try to stay in the 60/40 or 50/50 range, then you know that each is doing their job. When Grace is off track, I often look back at lousy days and see that I am letting basal work as Bolus, or Bolus as basal. Ending up with 70/30 or 30/70. I'm curious how what you have done affects the ratios.
Grace is entrenched in pre puberty and the insulin resistance in the mornings has built over the past year. I agree that temp basals often bring down highs quicker than a straight Bolus. I often use them or bring down night time highs, or bring up a low by reducing a basal while giving a juice.
I'm also intrigued that the shower makes you smarter. My shower only gives me five minutes of peace. :0)
Thanks for a great post and for sharing what works for Arden.
Penny

[Sara]

What you describe is similar to how I use the dual wave bolus. Bernard Farrell wrote about another similar tip a few years ago that you might be interested in - http://www.bernardfarrell.com/blog/2007/10/super-bolus.htm