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.

Cured

I remember the two saddest days of my life since Arden's diagnosis very vividly. They came at a very inopportune time. It was six months after Arden's diagnosis which was two months after I fooled myself into thinking that I had mastered type I diabetes. These days began strangely because Arden's blood sugar was eerily steady and a little on the low side. After breakfast her BG got significant low, almost as if she didn't need any insulin. She ate more to stop the BG fall. The food worked but there was no spike at all, which of course was strange. In the moments after I got her BG stabilized I thought, "maybe they were wrong and she doesn't have diabetes".

Having that thought, was the beginning of the longest, saddest two days that I've lived through since Arden's diagnosis. I knew enough about type I to be sure that I was wrong but everything that was happening said that the insulin wasn't necessary and it certainly seemed like she wasn't diabetic anymore. By the end of that day I wasn't giving injections for meals and I had to skip her pre-bedtime Levemir. I didn't sleep much that night, I was waiting up and testing. Waiting because I was sure that her BG was going to suddenly rise - but it never did. It just stayed between 90 and 107 all night.

This trend lasted through the next morning and then I did something that I knew I shouldn't, but had to do. I needed to tell someone that I thought Arden didn't have diabetes. I called my friend Adam who is also Arden's pediatrician. When Adam got on the phone I said something that I still remember to this day, "I'm about to say something that I know is wrong but I have to say it... I need you to set me straight and then I'll get off of the phone". Bewildered he asked me to proceed.

"Arden doesn't have diabetes. She hasn't needed insulin in over a day... is it possible that she was misdiagnosed?"

I knew that she was most likely experiencing a honeymoon period but I needed someone to tell me. With each moment that passed, I was convincing myself a little more that Arden didn't have diabetes. After a long pause Adam said, "no, she was not misdiagnosed, this is a honeymoon period... Arden has diabetes".

I thanked him, there was some awkward silence and then we said goodbye. I went into the bathroom and cried. The remainder of the day was emotionally excruciating, it felt like a cruel combination of every bad day that I had ever lived through.  Later that afternoon we ate dinner and Arden's blood glucose jumped to over 400. I actually felt better when it climbed so far, so fast. 

Today, after so many years of living with type I diabetes, I have seen countless anomalous days. Highs, lows, insulin resistance, sudden drops, more unexpected stuff then I could have ever imagined. I'll never know for sure what happened over those two days. What I can tell you for sure is that it's happened many times since then, including yesterday. Never again to the degree of those days (not needing any insulin) but there have been days when Arden only gets 15% of the insulin that she normally does and her BG never goes above 120.

Last night as we got ready for bed Arden's BG began to jump and then drop, I could see it on her DexCom and finger sticks confirmed what the CGM was saying. Arden's BG was 72 and then 125, then 93 and then 160. It was rolling up and down like a small boat on a very large ocean - this went on all night. The next morning things seemed to be back to normal but sometime around noon they went right back into that tiny boat. Lunch required much less insulin then we thought and then her BG hovered between 70 and 96 all afternoon. Never wanting to waste a day that Arden doesn't need insulin we went to dinner at the Hot Wok Cafe for Chinese. It was there as we looked over the menu that I did something that I've never done before...

I wrote this post to show how something that once seemed so terrible will one day feel very different. Today, we don't blink an eye when Arden doesn't need much insulin for a day or so. We refer to those days and their events with one word, "cured". Now when the cured days come I don't dream of a misdiagnosis or call Adam and I definitely don't go into a bathroom and cry. I just manage them as best that I can and get Arden a nice meal with a ton of carbs.

In my next blog post, I'll tell you how badly our meal at the Hot Wok Cafe went... I may call that post, 'Whisper Down the Lane' or perhaps 'Confusion at the Hot Wok Cafe'.

Overnight blood glucose checks

A few days ago I remarked to Arden's school nurse while Arden was checking her BG that, "I can do this in the dark". I had just finished changing a pod that experienced an error during the day and was hanging out for a moment to discuss how much insulin to bolus for the basal that was lost (while I was driving to the school). My comment sparked a brief conversation that ended as all conversations about overnight BG checks seem to, with someone asking if Arden wakes up when her finger is pricked.

Arden doesn't budge during those checks. Up until this morning I though it was because she was so accustomed to the feeling but it turns out that she may just be an amazingly sound sleeper.

I took this picture today as I was getting Arden up for school, as you can see there are no sheets on her bed. The sheets are on the floor, ready to go into the laundry. I took them off of her bed while she was sleeping... she never stirred. When I pulled the bottom sheet from under her, she literally came off of the mattress and turned 180º - bouncing when she landed.

It looks like I have a new answer the question, "does she wake up when you check her BG".

I just unintentionally saw Twilight

Arden and Cole both received the same Christmas gift from their grandmother... Gift certificates for dinner, book shopping and a movie with Grandmom. Arden wasted no time and exercised part of her gift tonight, asking to see Twilight. My mom isn't able to manage diabetes on her own so I tagged along to set Arden up with snacks and insulin. I was going to sit in the lobby or another movie so Arden could feel like she was by herself with her grandmom.

In the beginning things were going well. Arden's BG was 120 and drifting down as we took our place in the concession line. Everything was set up perfectly for Arden to enjoy the evening and I thought that we had handled an earlier meal well, putting her in a great position to watch Bella and the gang stare lovingly into the camera and/or off into space.

The concession line was very long and moving insufferably slow so I suggested that Arden and my mom head into the theater to find their seats. Arden was so excited, she was about to spend two hours feeling independent and hanging out with her grandmom. I was equally happy and loved the idea of her spending this time away from the constant overseeing... sadly diabetes had other plans. I watched the time closely as I waited for the popcorn because Arden's DexCom was still indicating a diagonal arrow down when she walked away. The concession line continued to crawl along, taking twenty plus minutes to get snacks and return to the girls.

I thought that I'd find Arden with a BG of around 100 when we met next.

When I arrived at Arden's seat she said, "did you get my text - I feel really dizzy". The long wait in line had set me back about ten minutes but I didn't think it was an issue becasue Arden was going to text if there was a problem. It turns out that I wasn't receiving my text messages (due to a week cell signal in the lobby), these messages came through a few minutes after I got to Arden...

Arden didn't take steps to control her BG drop because she thought that I'd be there any second with her food and "(I) didn't want to get too high so I waited".

I tested Arden as the opening credits rolled, her BG was 47 and still falling. I quickly gave her a glucose tablet and she began to eat her movie treats but it was too late, she was beyond dizzy. It was then that Arden asked me to take her home... I immediately felt incredibly sad for her.

I suggested that she stay, promised that she'd feel better soon and that she could still enjoy the movie. She agreed, I sat on the floor in front of her (the theater was full), she continued to eat. The DexCom finally indicated that her BG fall had stopped so I bolused for the snacks, she said that she felt better so I went to the lobby to give her the alone time that she had so wanted. fyi, I did get to see Bella marry that British kid before I left.

About twenty minutes later I received this text from Arden, "I feel dizzyer and the cgm says that I am 108". I went back in, we talked and she asked for some candy. A little while later she indicated that she felt better and said the sweetest thing. She said, "a feel a little better but I think that I get more dizzy when you leave", she paused and looked a bit uncomfortable. I told her that I could just stay with them but she indicated that I should go... I could tell that she wanted me to stay. I asked her why she looked conflicted, it was then that Arden told me that she believed that I was in a different movie and she didn't want me to miss it. Her concern for me was so sweet... I told her that I was just reading in the lobby and that I didn't mind staying, she smiled and sat back in her seat. I tried to find a good position at the top of the stairs to watch the last hour of the movie. By the time the film ended my left leg, butt and lower back were numb, perhaps as dead as Bella after she completed her transformation but I didn't mind. After the movie I tried to apologize to the woman sitting next to Arden but she wouldn't let me, she smiled in a way that said she understood and put her hand on my arm.

I am happy to tell you that while this evening didn't go even slightly as planned, it was still a success in Arden's eyes. She had a great time and called the movie "creepy but good". I am so proud of her, she never gave in tonight, she's the toughest person that I know.

My Twilight seat

Without a CGM and the information that it provides we would have never been able to make the adjustments necessary for Arden to remain in the theater. In kind, having an insulin pump and the ability to suspend background insulin was equally pivotal in navigating this diabetes moment. Type I diabetes made this night a challenge but having the correct tools and attitude were the key to not letting it get the better of us. Tomorrow, lunch and book shopping with Grandmom. I'll be outside... just in case.

Bionic contact lenses?

Here's an interesting article about emerging technology. It mentions how the tech could be used to monitor glucose levels. So much fun to wonder what tomorrow will bring... check it out.

A link to the source article is just below... Click 'References' for more.

Thanks to Arden's Day reader (and Arden's mom) Kelly for the article!