FUDiabetes

Things that make you go hmmmm

So obviously we are still very new to this adventure, and with the gracious help from all of you on here we’ve been able to start finding a better understanding of how to treat Jayce (my son).

However, we still find ourselves scratching our heads quite often when things like this happen out of blue!

He spiked last night (all night long) and again this morning. We’ve bolused for every meal, done corrections to bring him back down, and he just wouldn’t budge.

He hovered super high all morning/afternoon then 2 hours after his last bolus/meal (also 7 hours after his Lantus) we get alarms going off left and right for double arrows down from 250 to 80 in just 1 hour… we gave him one apple juice (24g crabs) at 80 because Dex was showing now signs of slowing. 30 minutes after the apple juice he’s back up to 200!!! 24g of carbs has never spiked him that much, that quickly before…

We did one finger poke around the 115 mark on dexcom and it read 104, so not far off, Dex has been on point with the readings.

He was not playing heavily or doing anything strenuous.
Not under any stress or having any emotional outburst of any kind.
Last insulin injection (Humalog) was over 2 hours ago.
Dexcom sensor is only 2 days old.

We’ve had these crazy “rollercoaster” spikes and drops at random times before (confirmed by finger pokes) where we just can’t find a logical reason for any of it. It’s been as crazy as like 100+ points in less than 45 minutes! We never ever load him up with insulin (so no major overlap) and same with eating (we always treat “lows” in small increments as to not over do it).

We’re at a loss. It’s just so odd. Any ideas?

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Do you remember how much IOB there was when he was 250 double down?

So, in Liam I wait until he’s around 150s double down before i treat. And even then i make note of how much IOB he has and give him just enough fast carbs to slow the fall but not too much to cause another spike. It’s something that takes practice but only knowing what you have said so far, the 24 juice carbs was probably double what he needed. If that were Liam, 24 carbs would have caused him to stop the double down in 10 min and immediately (in another 10 min) turn into a double up again taking him right back up into the high numbers.

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This sounds like basal being too low if he has no COB and is still high. More basal may be necessary or change up the timing of the shot(s).

Did you give additional insulin on top of the basal?

This is ok in my view. I’ve had 250 to 80 in 5 to 10 minutes many times! Over 1 hour isn’t bad i don’t think.

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Since we’re still MDI, I only have a rough estimate, but he only took in 1.5U for his last meal bolus + correction (bolus was 1, correction 0.5). 2 full hours had passed since he took that in, so we assumed most of that had peaked already and he was probably down to a very small amount in his system.

TDD for insulin today is only at 9U (5U for Lantus, 4U bolus/corrections).

This is exactly what happened, but normally with him, 15-25g fast carbs brings him up average of ~50 points (most between 30-80 depending on other factors). So it was like he had a sudden unexpected drop and then went extremely insulin sensitive and spiked back up. Now he’s heading back down (nothing has changed, he’s been playing on his table the whole time).

Yes we’ve been moving his basal back in 2 hour increments from 8pm to now 8am. Thursday he took it at 10am and was relatively flat all day/night around his target range. Yesterday and today he took it at 9am/8am and he’s been a non stop rollercoaster.

We did give him a meal bolus with his basal yesterday and today.

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I would experiment with giving much less carbs at a time (10-15 carbs) wait 15 min, see what that does (with finger stick), if still going down very fast, give another 10 to 15. It’s easy to give more carbs to bring the BGs up, but it’s tough to bring BGs back down once high.

I give less carbs more often to Liam rather than giving him a huge amount up front. It’s kind of like salt… To little and food is bland but slightly more, or way more, than is needed is tough to come back from.

Less is more. If you think about it, it makes sense… The less carbs and insulin (smaller corrections either way) the less severe the roller coasters

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Sorry, specifically talking about during the nighttime high. Did you give additional bolus insulin during the night to help bring him down? You indicated he was high all night and that tells me thr basal is too low assuming it was post prandial and no carbs were on board.

Also make sure you’ve done adequate ISF testing.

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As you will find there are certain parts of diabetes that are VERY individualized. My 180lb son can never treat with 24g of carbs without seeing the topside of 300-400. In fact in the situation you showed, my son would treat 15g and give insulin at the same time to blunt the crazy rise. My first reaction to seeing your graph is basal isn’t dialed in correctly. The problem is that it might not be dialed in for today, but it could be dialed in for tomorrow. With MDI you need to see patterns of multiple days before reaching conclusions, but for certain even after all these years we still have bad days/nights so sometimes you have to chalk it up to the fairies or moon phase.

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Very good point @Chris raised and a very important one you’ll do well learning very early on… Never make corrections to settings until you observed a pattern; otherwise, you will never have peace.

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Just as an aside, in our first 3 months of learning how to treat our son, I would have chalked the night you just had as a success, not ideal, but not a bad night either. With time you will get better at taming the beast.

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Just as a quick sanity check on the insulin… since you are using a pen, you don’t really see the plunger moving to know that insulin is moving from the pen into his body, like you would see with a syringe.

So make sure to swap the needle, and then prime the pen with a few units to make sure you see insulin coming out of the needle. Sometimes needles get clogged, or pens can malfunction.

That might not be a reason for what you saw with the spike, but anytime I use a pen, I make it a habit to prime it and make sure I am seeing insulin come out of it.

Since you said the corrections did not make him budge, the first thing I am thinking of is just making sure the insulin is going in. Just rule that out quickly.

EDIT:
Also, prime with the needle pointing directly down. I can explain why a little later, but otherwise you will wonder why insulin is leaking out of his body even when it’s not. :grinning:

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Yes, I gave it to him at 2am and stayed awake until 5am and he barely dropped. He eventually came down gradually by 8am into the low 100’s without another correction.

I assume they gave you a formula, based on his weight. Like they said your total daily insulin (basal and bolus) is 0.55 x weight in kilograms, or something along those lines. And they they told you that around 50% of his total daily insulin should be from basal, or something like that.

Anyway, those are all starting points. Obviously you need a starting point.

But the key is to try and identify if the spikes are related to meals and mealtime insulin, or just a lack of sufficient basal. Or maybe it is a combination of both!

It takes time to really know for sure, but if you start looking at it from that perspective, that can help you see what the fix is going to be.

Since you said that it was “7 hours after his Lantus”, we can assume it was not an issue of the Lantus having worn off already.

I will say this - having a strong sufficient basal is really helpful. Basal is the foundation of the house. If the basal is weak, you are always playing catch-up with every meal bolus. You are always correcting, etc.

EDIT:
But if you are seeing drops that are several hours after his last meal bolus, then it might not be basal.
But if you are seeing drops that are several hours after his last meal bolus, then it might not be that insufficient basal is the cause of the problems that you are seeing.

So it just takes time to see which of the possible causes makes the most sense - is it meal bolus, is it basal, or is it a combination of both.

And then the last thing is that his pancreas will still on occasion be putting out insulin on occasion, at least for a while. So that will make it super confusing to figure out.

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Our son is 7 and uses a total of about 12 units per day (about 4-5 basal, 7-8 bolus). We treat his lows with 5 g of carbs and that is almost always sufficient, especially if you’re willing to wait the 25, 30 minutes for Dexcom to log the change. So if I had to take a guess, I’d say 24 g of apple juice was probably too much, even for the steep drop.

Next time, try treating earlier but with less (maybe 10g?), allowing you time to see if it will plateau. If, after 20 minutes, the drop is just as steep, then you can give another 5-10g.

Also, I’d say that after 2 hours, you may well have 50% of the insulin left from his meal bolus. The typical duration of insulin action is about 5 to 6 hours, so to a very rough approximation, maybe a quarter of it is used up each hour in the first few hours? Are you only bolusing every 3 hours or more frequently?

But the steep drop followed by the sharp rise from what should have been a mild carb treatment we’ve seen before, typically when he’s more insulin resistant due to illness/growth/etc. At those times we increase basal. However, with MDI, I’m not sure if you’re able to do anything like that for transient days of running high.

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@Dusty_19
Sorry, I edited my previous post above because it was not very clear.

The points are simple when given like this:
(and these are just general troubleshooting guidelines, not hard-and-fast rules!)

  • If you are seeing problems with spikes or drops soon after a meal, look at adjusting the meal bolus.

  • If you see drops or spikes several hours after a meal (like at least 3-4 hours), then look at adjusting basal.

  • Be conservative with corrections for lows (unless it is a very bad and dangerous low, in which case - no holds barred, guzzle the juice!) And by that I mean - if you are 170 but dropping quickly, you can be conservative. But if you are 50, it’s time to pound some sweets.

  • And not now, but later on after enough time has passed and you have become more comfortable with everything… be aggressive with the corrections of highs.

  • Try to only change one thing at a time to make it easier to figure out the result of your changes.

@ClaudnDaye, @TiaG, @Chris - I am trying to come up with very simple generalities that are good starting guidelines for troubleshooting. Like not really anything specific, but things that would apply for most any person and any situation. What did I miss?

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You guys are awesome! I have been so busy these last few days I haven’t had a chance to sit down and read through all your replies. I will be doing so this afternoon at the in-laws and will take some notes.

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It looks good @Eric, can’t emphasize enough how important it is to give SMALL corrections (carb wise) when heading down. You’d be amazed at how 5 or 10 carbs will turn that double down into a single arrow in a matter of 10 minutes. If you give too much, then it will IMMEDIATELY turn into an up arrow (or a double up arrow) and you’ll be playing roller coaster all day. Small carb corrections every 20 min or so unless, as Eric indicated you are in DANGEROUS territory (under 100 to 80, double down is what I would personally consider dangerous territory for Liam), then be more aggressive.

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Our corrections of choice are Skittles (1 carb each) and glucose tabs. We did juice as well and Liam was able to drink it in his sleep. He also chews glucose tabs in his sleep.

Honey was too much trouble. Lol

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I find Smarties work a lot better for me—maybe they dissolve a bit faster?

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We do have those as well in the event he tires of the other things.

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I’ll add to this, too, @Dusty_19 that I find Dex to be slow on the upswing when it comes to correcting lows. I’ve learned if I pay too close attention to the CGM I’ll end up over treating a low or overdoing trying to stop the drop. If he’s truly low, I find its in my best interest to treat the low (10 - 12 carbs), wait about 15 min, and check with a finger stick. I’ve found that often the blood glucometer will show he’s rebounding (maybe he was at 60 on Dex, I treated, and now he’s say 90) but Dexcom will still have him low.

I’m finding patience is so crucial in so many many ways in dealing with diabetes, yet sometime one of the hardest things to practice!

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