FUDiabetes

Correcting for very high peaks

[Split from Pediatric Afrezza:bouncedd twice now] This split discusses how to deal with correcting from very high hormone peaks.

I wish we could. The problem is tow-fold: first, his CF varies from a ridiculous 1:6 (even 1:4 sometimes…) to 1:20. i.e. 1U of correction to 6-20 mg/dl. So, when we are shy about correcting, he may stay at 300+ for 3-4 hours or more, even though we stack quickly. But we can’t stack any faster than every 60-90 minutes, because we can’t see the effect then. The other thing is that, when he is that high (peaks are hardly ever lower than 250 these days), it takes a heck of a long time to come down unless you have a sharp downward slope. So, between the two, we hammer these peaks (and still sometimes don’t give enough).

But, in particular when we underestimate the correction and end up stacking, the tail is incredibly long, truly DIA-long (5.5 hours), and he has taken up to 80 carbs to recover (most of the time, it’s more like 25, though, but often it’s a lot higher. We do take carbs early on, around 120 or so, and keep on taking them every 10 minutes, hand testing in between. Still, we often end low for a while.

I do worry about his weight, btw, although he is quite slim now, but the accumulation of carbs can’t be good

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Sounds frustrating for sure!

I would try doing it earlier, maybe once that double down arrow shows up even if he’s still high, and if you do it significantly earlier, you can consider a mix of carbs and protein (rather than fast acting carbs) which will give the carbs more staying power. Again, your risk will be he will end up a little high when he lands if he didn’t need it or as much, but that should be a relatively easier thing to tweak/less stubborn high.

And yeah, if he’s slim and active, I wouldn’t worry about the calories/carbs now—he probably needs them to go along with that growth hormone!

This sounds incredibly frustrating. I’m sorry your son has to deal with this. Swings like that can really impact emotional well-being too, so I imagine the variability actually amplifies the frustration for your son.

Have you tried using injections instead of the pump when you see a hormone spike? Was this as big of a problem when he was on MDI?

A series of large insulin doses from a pump can impact how well your body absorbs insulin at that time and also later on with that site.

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I’m thinking along the same lines as @cardamom. Having correction carbs at 120 may be too late - it leaves you with little room and time available for any further corrections one way or another. As rudimentary as the pump calculations may be, your pump keeps track of IOB. At the time when bg starts dropping convincingly, take a look at IOB as reported by the pump, subtract roughly what would be needed for the “normal” correction from that bg (not that crazy factor you see at times, because whatever was pushing bg up should be over at that point), and take some not-too-fast-not-too-slow correction (chocolate comes to mind) for the remaining IOB. As @cardamom mentioned, even if you over-correct, the worst that can happen is soft landing at somewhat elevated bg, which should then be easier to deal with a follow-up correction.

About the spike itself: is there any way to tell it’s coming? How about a stronger early bolus correction (as opposed to stacking after the fact)? (of course, be ready to correct if the spike was misidentified)

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We’ve done this with Samson. Once his pump was unplugged all night and he had high ketones when he woke up. We called the doctor, they gave us a dose to clear the ketones, and we doubled it. Then once he’d started dropping below 200 and ketones tested trace again we just let him snack on cheezits for an hour. He had a nice smooth landing to 100 mg/DL, +0.

Personally my rule of thumb is to take a look at the IOB and assume that roughly a third of it is going to be active in the next hour (that’s an overestimate, but it’s a good ballpark). So based on that, I calculate how many carbs it would take to mop up that amount of IOB in the next hour, and give him that many carbs, even if he’s above 150 or even 170 if the double arrows are fast enough. We may repeat that process over two or even three hours, but if I’m on top of it, he rarely goes low even when we massively overbolus for a high.

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Mmm, excellent low prevention snack choice! I’ve even treated a mild low with cheez-itz, the hot and spicy ones which are my favorite but probably less kiddo-friendly.

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@cardamom, @dm61, we did take your advice and start correcting earlier when he have a very sharp downward slope, as early as 140 or so. It actually has made the task easier: we still have to feed the lows for a long time but there are not as deep (or not low at all), much better.

We have not quite figured out how to deal with those frequent cases where the slope is not super deep but stubbornly goes on. We are going to start treating them earlier too—I am not sure yet how to identify the stubbron ones from the regular ones. Possibly we can do that based on the amount of IOB.

Yes: we do that almost systematically now, except when my son forgets. Not only are we concerned about the absorption, but we have also noticed possible tunneling in some circumstances, as pointed out by @Beacher.

We have definitely seen that problem.

There is a morning spike at school that is pretty predictable, about 90% of the school days. He now has a 6U extended bolus starting at 8:30, right after breakfast. Amazingly, we still see 250 mg/dl peaks after this preventive measure. We are discussing how much more we should inject preventively. The concern is for the rare days when he does not get the peak (maybe once every two weeks).

I like your rule of thumb, @TiaG. Ours is very similar. But I am concerned about over-eating in a teenager (I mean all these carbs you need to eat to correct). I would hate to see him gain weight unduly (for diabetes reasons btw, not because I am obsessed by looks).

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I would think IOB would be the key, yeah. Have tried adding protein to the carbs in either case when you expect a prolonged low? That’s usually a good call if there’s more insulin on board to continue driving it down, or to eat some fast acting if needed followed by some combo carb/protein.

It’s all a balancing act—one of the many reasons some of us don’t always have the best control is that many of the strategies that would simplest for achieving it drive weight gain (like superbolusing, or basically anything that puts you at risk for lows or requires eating to cover insulin). I think there’s only so much you can worry about at once, so again, if he’s ok now re: weight and physically active, then don’t worry about it and do what works for the diabetes control, since he’s a growing teenager. If it starts to be an issue, you can adjust, although it may require increasing flexibility with the diabetes control a little bit. He will likely have to adjust his diet eventually dramatically anyway, as do many men at some point when they grow out of that invincible “burning all the calories! bring on the calories!” teen boy/young man phase that many have, but by then puberty spikes will be over.

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Extended bolus (or, equivalently high temping) is a good approach. What do you typically have for breakfast? I continue to be astonished by how much insulin I really need to take for breakfast, and especially for protein+fat. If I bolused only for carbs, I’d see seemingly unstoppable, difficult to correct bg rise couple of hours after breakfast. But, this varies so much from person to person, no way to tell if protein+fat play any role in what you are observing. Perhaps something you may experiment with: a low carb breakfast, versus a low protein-fat breakfast, versus no breakfast.

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We have experimented s lot with breakfast :frowning: His highest carb breakfast is 13 carbs, and he often goes to 6 carbs or no-carbs. He doses 1:7 for breakfast, which is twice as much as the rest of the day, and he preboluses by 45 minutes.

We validated multiple times that he still gets the same peak when he takes no carbs. So I think we can truly rule out breakfast.

Those morning peaks are bad enough that some of them require upwards of 20U. For us that is huge, since a meal bolus for dinner is typically 3-4, 8 if it is a full carb-refueling meal.

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I am actually suspecting that spikes could be due to protein+fat, not carbs (a low-carb breakfast is a killer for me, but again I am aware of the fact that this is very different from person to person). Have you experimented with just skipping breakfast? Instead have a later mid-morning meal (if school schedule would allow for that)

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So when I eat a low/no carb breakfasts, I definitely need to take a few units of insulin, usually after eating works well. So if you’re not covering the protein/fat, that could definitely be a problem, but one relatively easily solved (my suggestion would be to cover the protein/fat rather than skipping breakfast though).

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Skipping breakfast a time or two would be a good test, I shudder to think of how big the delayed meal would be with the teenage hunger.

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Yeah, that’s true, skipping as a test might be informative!

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i have ALWAYS needed to bolus in the morning, no matter what i eat. even if there are no carbs, i still have to bolus for the protein. even for just 2 eggs, i need to cover for 10gms. (about 1 unit, for me, but YDMV)

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I rarely ever eat any carbs for breakfast. I usually have to bolus in the morning even if I eat nothing at all. Breakfast is very different from other meals because your metabolism is gearing up for the day, and your upper intestinal tract is essentially empty… unlike other meals of the day…

I don’t even try to calculate or carb count anything for breakfast… I eat approximately the same thing every day; a modest serving of protein and fat, and I bolus the same amount every day plus or minus any desired correction…

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Yep…here is a day I ate no breakfast and still spiked significantly. Most days I eat some eggs and may or may not bolus (this morning I didn’t), it seems to depend on whether I have IOB from an overnight correction.

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same here. Samson needs the same amount of insulin for scrambled eggs as he does for a bowl of oatmeal. But I know for many that is not the case.

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For me, I definitely would need a small amount of insulin for the eggs, but would be able to take the insulin after the eggs and entirely avoid a spike. With oatmeal, I’d have to significantly pre-bolus, take much more insulin, and odds are good would still end up with a spike or have to drive myself low before eating, because my insulin just doesn’t match oatmeal.

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These comments make sense to me. In our case, my son’s breakfasts are pre-bolused the same way, on week-ends, with no spikes. But we get these giant spikes most school days, despite the same pre-bolus as on the weekends, and a preventive 6U extended bolus starting right after breakfast. So it seems clear to me that school day spikes are not related to breakfast—although things can be so weird with D that who knows. Based on the evidence (same breakfast, no spike on weekend, spike on weekday), though, the conclusion seems clearcut.

These breakfasts, btw, are small both in carbs and no protein/fat: 2 eggs and 4 ounces of yogurt with blueberries, typically. In no way could they cause a 20U spike, after bolus.

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