Diabetes management is not easy for me to learn: it takes me a while to figure things out. Here are a few things that I have learned in the past year about sickness BG management that I did not know a year ago:
The core problem is basal need
- basal needs vary incredibly fast and by a huge range when sick. I now control sickness much better by radically changing basal as opposed to dealing with instant BG level
Sick peaks may not be sick peaks
- same idea from another angle: these sudden rises we see when sick are in general NOT momentary sick peaks (there are exceptions) but sudden increases in basal needs. To deal with them, you need to both (a) increase basal radically and (b) administer a bolus to deal with the rise itself. Otherwise, we keep on injecting many units of bolus insulin every 1.5 hours.
Decreased insulin needs are as much of a problem
- When sickness ramps down, dealing with decreased insulin demand is as hard if not harder, and requires as much anticipation as possible. On the pump, I find half-hour suspends a powerful help when caught (more than that sometimes creates unwanted peaks for us).
Pump is easier
- it is a lot easier to deal with sickness with a pump than on MDI, because changing basal is so much easier. With MDI, you need to compromise in your basal increases/ decreases or you are badly caught later.
Short basal changes on MDI
Last year, thanks to many of you, I discovered the use of NPH as a “short basal”, which worked well with us, particularly at night. For some people, levemir may also work when their levemir DIA is short.
- sleep makes a huge difference to recovery.
Timing of insulin need changes
- Insulin need changes can precede sickness symptoms, for us by one to two days. For us, they also persist after sickness symptoms are gone, often for several days, up to 1.5 weeks.
- there are daily rhythms to insulin needs in sick time. For instance, when my child is past the worse but still quite sick, his insulin needs may be radically lower between 2-3am and 1-2pm than the rest of the day (for instance, yesterday he needs +20% basal in that period, but +80% the rest of the time).
Technique: extended boluses
- Because of these radical changes in insulin needs, I find that it can be very useful to use extended boluses when unsure of what is coming up, because it is easy to cancel them before they are fully administered and you don’t have to fully deal with the consequences of a large insulin overdose due to a wrong guess. For instance, if I see a peak that I suspect may be high (but I am not sure), I may increase temp basal by another 30 or 40%, administer a 2U immediate bolus and an extended bolus of 3U over 1.5 Hours. If, 20 minutes later, I discover the peak steadied out, I just cancel the extended bolus and reestablish the original temp basal. The same technique applies when it looks like a big bolus seems to have activated while doing nothing, and I feel I need to stack.
What have you learned about sick day management with experience that you did not suspect?