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Permalink Reply by Paul on May 20, 2010 at 9:33am

Thanks Elizabeth--I started with one basal rate, as a sort of baseline. I've only been using the pump for a few weeks. With Lantus, I was seeing rises in the morning without eating. With the pump, the rise in the a.m. is very small. That's one thing I really like about the pump, it seems to help with the dawn effect. But I do need a bit more insulin in the morning than during the rest of the day, so my basal rate is .1 unit higher from 7 a.m. to 11:30 a.m.

I'm trying to take all this information in--and I've ordered the Pumping insulin book. I'm trying to reduce my basal rate and increase my bolus a bit. It's helping with the spikes, but I'm still going low after about 3 hours.

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Permalink Reply by Roxanne on May 14, 2010 at 6:19am

My son (4 years old) was having this issue when he first started pumping. His CDE recommended trying a SUPER BOLUS. He is on Humalog with a 3 hour duration. When you bolus, you add your correction (if needed), amount to cover your carbs, and 3 hours of basal. You then set your temp basal to OFF for 3 hours. That gives you a much larger initial bolus but turns the basal off so that you do not bottom out. It worked for him for a few weeks until his body got used to pumping. Every day is an experiment! Good luck!

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Permalink Reply by Jan on May 14, 2010 at 7:22am

Very informative thread. We still have this problem. The reason, I believe, is that her D.I.A. is four and a half to five hours on Novolog. Using Apidra has lowered the spikes. Still go up to 200 for a brief period of time but she does eat a substantial amount of carbs at two of her meals. Apidra helps because, even though her DIA is still four hours with Apidra, there is less of a tail or drop from hours 2.5 to 4. Still drops, but much less than with Novolog. Super bolus sounds like a great idea (haven't tried it yet; have heard of it). If you are alert and can check at the two hour mark, overbolusing works great. You would analyze and feed the insulin with a few carbs at the two hour mark. This will eliminate the postprandial high; but you cannot forget to check and adjust or you will have a problem. Another thing you could try is to temporarily lower the basal after meals for hours three and four. In our case, can see the results of a basal increase or decrease one hour after making the change; though endo recommends making the basal change two hours before. Superbolus seems more sensible in this instance. Many great ideas on this thread and I will also try some of them. Worried about her going low while at school so have not perfected the postprandials during the school day.

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Permalink Reply by Franco on May 14, 2010 at 10:16am

Hi Paul, don't feel like the lone ranger, this is very typical for type 1 and it takes lots of trials and errors to moderate the post prandial spike. If you are an auto immune caused type 1 remember that most type1's don't have pancreatic beta cells that produce insulin, they've been destroyed by the immune system. You may already know that the beta cell not only produces insulin but another hormone, amylin. We can't live without insulin but we can live without amylin. Amylin is an important hormone in that delicate balance of keeping blood sugars normal. Also important in that balancing act is glucagon, a counter regulatory hormone to insulin, which is also produced in another pancreatic cell, some of us type 1's also can have abnormal activity/production of glucagon, especially if we've had diabetes for many years.

The reason I've mentioned all this is that understanding this delicate balance helps one in our efforts to normalize Bg. The human body is pretty efficient in normalizing Bg with this system of counter regulatory hormones which are able to deal with an almost infinite variety of factors which influence Bg whether its food, insulin, exercise, time of body clock cycles, infection, stress, and hundreds of others. We can manipulate as many of these factors as we can to try to outguess what the non-diabetic body can do automatically. One of the big factors missing to many type1's is that hormone amylin, especially for that post prandial spike.

Amylin is not needed for life support like insulin and many doctors write it off, feeling that we can do without it, which we can, but it's so important in fine tuning that Bg regulation. Much of the post prandial spike is not only the response of the food intake but from the liver "squirting" in glucose from the glucagon/glycogen response as part of the balancing act. That's one of the roles of amylin, it temporarily slows that liver response after eating.

Symlin is the synthetic version of amylin and is injected preprandial and is very effective for many in moderating that post spike.
It's not very popular with many Doc's because it's another very tricky timing and learning curve on how to use it. It's relatively new, compared to injected insulin. I've found that most endo's don't even mention it to patients as an option, I've even run across docs who don't even know what it is. If your endo hasn't mentioned it to you it might be worth exploring it, there's also a group here on Tu for Symlin users. Check it out.

Sorry if I've rambled about stuff you already know but others who read this might not have heard about Symlin. For me it's been fantastic as I've battled those post spikes for years. It is not a magic bullet by any means and is real tricky to use timing wise, but, it does lower ones insulin requirements and if some of the theories that too much insulin can be part of the diabetic complications keeping our insulin requirements lower may stave off those complications. And if non diabetics have this hormone why should we not have it!

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Permalink Reply by Franco on May 14, 2010 at 12:47pm

Hi John G,
At first I did have to learn new timing to avoid post prandial hypo's and yes you have to be aware of your exercise but you can learn how to adjust to that, too. It takes some getting used to but other than the inconvenience of an extra shot in addition to my pump bolus I find no draw backs only benefits. I can sometimes keep my Bg 90-110 after eating and using about 60% less bolus insulin than I used to.
Here's a enlightening webpage about a CDE who uses Symlin: http://www.diatribe.us/issues/20/thinking-like-a-pancreas.php

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Permalink Reply by Mike Ratrie on May 20, 2010 at 10:45am

From your description and some of the comments here, I would definitely focus on getting your basal rates fine-tuned. Not the most fun exercise in the world, since it involves skipping some meals and you have some risk of going low when you discover that some of your basals are too high.

Once you have your basals more established, if you were to see the PP spikes followed by a low like your first example, I would bolus the 10.5u and then do an extended bolus of 2.0u over 2 hours. I do something similar for breakfast when I'm pretty sure my post-breakfast activity is going to be low.

Fair Winds,
Mike

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