In the interest of trying to get my A1c down, I have started to really try to crack down on highs (as well as try to really sort out variables). I've figured out that my main problems with highs seem to be going high after meals, and also that when I go high I frequently stay high for hours and hours. So, I have two questions related to that.
1. Pre-bolusing. I have found this makes a HUGE difference in my after-meal readings, when I can actually do it properly. But I find when I am at home it is easy to pre-bolus and then "forget" that I've done so, which is obviously not safe. This morning I woke up at 4.3 (surprising, since I spent about seven hours before bed high), pre-bolused 3.75 units for breakfast, and then 45 minutes later (got a shower and it took a bit longer than expected) felt low and tested at 2.0. I think pre-bolusing by 30 minutes seems to work best for me, unless I am high and it can be longer. But maybe pre-bolusing when I am 4.3, especially when I don't have a CGM so can't tell if it's rising or falling, isn't a good idea. I also find when I am at work or eating out I don't pre-bolus at all. At work it's because it's VERY easy to get delayed in eating, and when I'm eating out it's just because I bolus when food arrives so I can estimate, and then don't want to sit around waiting while others eat.
Wondering when those of you who do this do it (all the time or only at certain blood sugars), and any convenient methods you use to not forget to eat! The reminder feature on my pump would be perfect, except it only "reminds" in one-hour increments.
2. Correcting highs. I find that my blood sugars are great as long as I can avoid going high, but once I go high it takes hours and hours to come down. I've started using some tips given on this site, like using a temporary basal rate for a few hours, and that really helps. Sometimes I wonder if I should be more aggressive in giving an injection and/or changing my pump site, but I am never sure because most of the time I'm not extremely high and don't have ketones, I just seem stuck there for a while before suddenly coming down. For example, the day before yesterday I ate a small piece of dessert and then was stuck at 13-15 until mid-way through the next day. Yesterday I went high and was stuck at 12-14 for about seven hours. I think my A1c would be better if I could bring highs down faster. But I already change infusion sets every two days (due to allergy issues) and changing them just because it might be contributing to a high seems a bit overkill to me, not to mention expensive. But I know we get more insulin resistant when we are high, so maybe doing an injection would help (although then I don't get any IOB information).
So, what do you all do with highs that don't come down within a few hours of a correction? Do you just correct again with your pump, or use some other strategy?
I like pre-bolusing too but, unfortunately, it doesn't always work. My other solution is sort of a "cocktail hour" while I'm making dinner, bolus for like 25G of carbs and have a drink or a couple of beers while I'm cooking, taste some food, dip some taco chips into the spaghetti sauce or whatever and "cover" the pre-dinner bolus that way. This gets some IOB on board and if I get stressed out (wondering if I will burn the food before MrsAcidRock gets home, arguing with teenager, dog not going to the bathroom when I take her out 2-3 times...) to push it up, the "extra" is sort of "correction on board".
If I'm seeing it run high, I will take a CB and take the dog for a walk. We have a nice 1/4 mile loop, it takes about 10 minutes (we have to send/ read the pee mail...) and seems to help. It's not really a "workout" but I think that it makes a big difference. I can stick another loop in to get the 14 minutes for the Big Blue Test.
Thanks for the suggestions! I have actually started spreading my lunch out a lot. I sort of eat throughout the day instead of eating one set meal. It helps my blood sugar, but mostly I did it because I got hungry around 10:00 and would start eating then, and then wouldn't really be hungry enough to eat my entire lunch at 12:00 so would only eat part of it, and then would finish it off around 2:00. I don't pre-bolus when I do this but it does spread things out so all the food doesn't hit at once.
Thanks for the exercise suggestion. I think exercise helps a lot. I notice highs come down way faster on days I'm active compared to not. I used to have an exercise bike that I could easily ride for 15 minutes or so if I was high and it wasn't coming down after a few hours. Now I'm in an apartment where there's no room, but there is a fitness room downstairs I have not visited yet (just moved a week ago!) that I will have to check out for this purpose when I am at home. When I'm at work it would be a bit trickier, but work is pretty flexible about when we take breaks as long as we're not in the middle of working with clients.
Hi Jen. Sounds like a great project of getting things more in line! For the pre-bolusing: for a long time I set a kitchen alarm that I put on my fridge so I wouldn't space out eating - I'm famous for getting distracted! I only pre-bolus 15-20 minutes so the only time I don't pre-bolus is if I'm down into the 60's. But at your 4.3 (77) I think you might want to come up with a formula to move it up a bit..maybe to like 15 or 20 minutes?
For the highs, yes it does seem like you get "stuck there" for quite awhile, which definitely is to be avoided. I think the biggest factor in my getting my A1C down was to correct promptly and definitively. Have you tested your ISF? Is it possible it isn't enough? I have a different ISF for daytime and night time (1:42 and 1:62). Maybe some testing because it sounds like it's insufficient. Then, yes, I do correct again if it's not coming down sufficiently after 2 hours (counting the IOB of course). As for using shots or changing sets: I totally understand what you mean about not wanting to change your sets "just in case". I was doing that too much for awhile. (But I also discovered a problem with my insertion procedure so it probably was valid!).I do use the Inset 30's where you can see if there is a problem some of the time. I would only use shots as a way to "test" if the site is bad - if it brings it down promptly I would suspect the site. Maybe I would consider a shot if I were towards the upper 200's (your 15) and it wouldn't come down. Finally I would avoid much in the way of carbs if you're that high. If you don't normally eat low carb maybe have a couple meals in mind to use if you are high.
Thanks for the suggestions! I think you are right, that I should move my pre-bolus up sooner if I am in the 4s (or definitely 3s) in the morning.
I have tested my ISF (though not recently ...) and it seems to work sometimes and not others. In fact, the confusing part is that sometimes I correct a high (say 11 or so) and then crash low within the next hour or two. I think not being able to tell if my BG is headed up or down might be the problem there, but it's definitely annoying! It's also what made me wonder fi it's sometimes a site issue rather than just being high. It also seems to depend on my day, and active day where I am at work highs come down much faster than a weekend where I'm just lazing around not doing much. I should probably try and test my ISF at different times of the day and see if it differs, but I've done that in the past and it seemed different every single time, so just confused me even more.
I like your idea of using a shot as a test if I am high and not coming down. I already eat sort of low carb (most days around 100g total, try to aim for 30g or less at any one time), but when I am high I do avoid eating carbs and still stay high for hours sometimes, which is why it's so annoying!
Ok, here are my two suggestions. The "superbolus." You use this for meals to amplify the peak and timing of your carb bolus. You can use this in place of pre-bolusing or with pre-bolus. Basically you suspend basal and feed the missed bolus back into your meal bolus creating a sharper insulin peak.
My second suggestion is for correction. And that is to do a manual correction with a syringe and do an intramuscular correction which is much faster. Dr. Bernstein has a video which shows how to do the injection, I don't know if you can see it. He uses his delta muscle (shoulder) and makes a quick perpendicular injection. I use my quads, I have little bodyfat there. I can just inject with a 8mm syringe, others might need a 12mm syringe.
I have heard of the superbolus but hadn't thought of using it in place of pre-bolusing. That makes sense and could work really well, I will have to give it a try. Thanks!
Do you know if they make pen needles long enough to do an intramuscular injection, or if pens work as well as syringes for this? I can't see the markings on regular syringes to measure the insulin. (There is a device for measuring syringes accessibly, but it costs $50!) Actually, I just checked and the ones I'm using now are 8 mm, so maybe they would already be long enough if I did the shot in the right spot.
copied from your posting : " so maybe doing an injection would help (although then I don't get any IOB " ...I disconnect the tubing when I give a needle shot , let the correction amount leave the tubing and have a record in the pump of IOB ..gosh , did I make this clear ??
Thanks for the suggestion! I have done this occasionally in the past, so it could work.