My CDE taught me “if your BG is too high you need more insulin.” So you are thinking correctly about what you see. Now lets get into the detail.
The first thing to consider is whether the basal is right. If the BG stays more or less steady when the meal is skipped or delayed, then the basal is right.
If the basal is about right, the next thing to consider is the meal bolus. There are two ways the BG can go too high when eating. Either there simply wasn’t enough insulin given, or the insulin would have been enough, except that it was too slow compared to the carbs.
In the first case the BG tends to just climb and climb and climb, and maybe eventually level off at a way high level. That’s fixed (next time) by changing the insulin:carb ratio to give a larger dose of insulin.
In the second case, the BG spikes early, goes too high and then either comes back down later, or just gets stuck high. The first thing to try in that case is to give the insulin further ahead of the start of eating, so that the insulin gets started before those fast carbs hit the bloodstream. That can limit the spike. The second thing to try if pre-bolusing is too hard is to give an overbolus: Too large a bolus will help blunt the spike of fast carbs, but you’ll have to give additional carbs after an hour or two in order to prevent going low.
That sounds like a victory. It doesn’t always work out that neatly, but with experience you’ll get that kind of result more and more often.
It’s a little like tuning a guitar. No matter how exactly you get it dialed in, it won’t stay there. It’s not because the guitar was tuned incorrectly, it’s just not a static thing. The BG is variable like that. With experience it becomes more routine to adjust to the changes so they’re no big deal, just a nuisance.
So I think the amount of basal insulin (Lantus) he gets about right, but I do think the delivery isn’t quiite optimal. Much earlier in this thread I believe @Eric recommended splitting his lantus dose, and do feel that may be a better route for many reasons. I have not done that yet, in part because in eliminating the bedtime carbs we were settling in quite nicely. But also I don’t feel quite comfortable doing that “on my own” and do want to consult with his endo first. His next appointment is this month, so I’ve opted, at least for now, to wait till then. I do not feel like calling the CDEs because, . . .well, in my experience its never been that helpful. I don’t have a good feel for his endo yet (we may end up loving her! I don’t know- we’ve only met once in the hospital and one tele health appointment).
In the first case the BG tends to just climb and climb and climb, and maybe eventually level off at a way high level. That’s fixed (next time) by changing the insulin:carb ratio to give a larger dose of insulin.
His response to dinner for the past week or so has been more akin to this. It will be in range for the first 1-1 1/2 hours after his meal bolus, hovering comfortably in the 120s-130s, say, but then he starts a steady climb at that point. Interestingly, last night he got out to play after dinner, had a bit of a low with a few carbs, but then was at 101 when we were coming in. I thought “Great! SNo climbing sugars tonight!” but I was wrong and within about an hour of being in he climbed to 180. I did nothing for it, and he did come back down on his own through the early night. But it does make me wonder if part of this climb I’m seeing at night is his basal is running out, and it might be exacerbated by certain slower digesting foods at dinner. He gets his lantus at 8:30 pm, so there just may not be much basal helping him in those evening hours. I’m probably way wrong.
It’s a little like tuning a guitar. No matter how exactly you get it dialed in, it won’t stay there.
I’m realizing that. I guess I’m still at the point where I don’t feel like I’ll ever “catch on” on how to best optimize his insulin needs, or realizing when exactly that guitar needs tuned. Like I’m always just taking a shot in the dark or trying to trust a gut feeling even if I can’t even explain why my gut feeling seems right. And maybe sometimes it works and maybe sometimes it doesn’t. I’m so impressed with all you who seem to know what to tweak and how and when!
BUT, GOOD NEWS! Just got the call this morning and I am scheduled for the pump information class on June 3! They will go over all pump options, etc, and from there we can choose to proceed with a pump that we choose. I am thrilled to finally be getting on that path. I think I will start a new topic to get anyones input on pumps/pros/cons etc. I’ve already been doing a lot of research on my own and want to be more than prepared that day.
@T1Allison I give you tons of credit managing your own diabetes while “momming”! The mental gymnastics you must do every day to manage yourself AND your young ones is no doubt exhausting! And I so much appreciate your encouragement. Truly. It is just such a mental and emotional boost knowing you guys are out there cheering us on, so to speak. It just helps so much.
Please don’t try and go too fast, the learning and experimentation you are going through is very valuable. When I reached my pinnacle of dosing decision (before my son took fully over) we would take into account current blood sugar, recent trend stability (up/down; fast/slow), recent daily patterns, activity over last 2 hours, activity forecast for next two hours, late afternoon sporting activity and desired blood sugar starting place and active insulin time (need most of active insulin out of system before sporting event), carbs in meal, composition of meal (size, fat content, etc), personal history with the meal, current health status (getting sick/getting better) when making dosing decisions. It gets easier, honest, it just takes time and there are probably a few variables I missed. (It has been a while since I have been calculating doses)
It sounds like somebody analyzes 3 dozen parameters through a system of hypergolic differential equations to approximate the right dose. I just count the carbs, look at the shape of the CGM graph, and apply some Kentucky windage; I don’t have the patience to do all that much work. There are lots of different ways to get a good result, so keep experimenting until you find what is comfortable for you.
That’s a valid approach. With more experience your accuracy will improve. But in any case it’s perfectly ok to do something, watch what happens, and make adjustments on the fly to push the BG in a good direction. It’s more like curling, not archery.
I’m rather glad to hear you say this. Sometimes I try to consider many of the above mentioned parameters by @Chris, and find myself juggling too many balls at once. I get a little overwhelmed and decide to to just let most the balls drop and only keep one or two in the air as I make a decision.
@diabeatit2020 Your description of the “climb” effect after a meal mirrors what I experienced, a slow steady climb from 120-130 to over 180 sometimes in the 200’s starting about the 90 minute mark post lunch or dinner. At first my response was to go use the treadmill, but at some point you’ve got to sleep, eh? Plus, while it would drop the BG for a period, it often didn’t last long, starting the climb back up. My Endo wasn’t too concerned because it would eventually come back down overnight. I figured, “yeah, because I gave a correction bolus and took my nighttime Lantus.” Finally, I decided to try increasing my night time Lantus…and it seems to have worked. Just one unit increase and my post meal BGs are much more in-line with my desires. I still get the occasional (and steeper) post meal climb or spike, but I attribute it to meal time carb/bolus mis-calculation and timing (my Lantus still seems to die about the 22 hour mark). I did have some concern the first few nights because I’d sit in the 90’s or low hundreds, and I really hate getting alarmed with a low in the wee morning hours. Still figuring it out, but making progress…
