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Don’t miss this very useful comparison char advising what to review overall and also what to change when for specific pumps from @Bruce Stephens

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I’d like some advice. I use a 780G and 4 glucose monitor. When I get high, my pump gives me small automatic correction doses. Yesterday it gave me 25 separate extra correction doses over two hours and I still stayed level above twelve for four hours. At 2.00pm I gave myself another 2 units by pretending I was eating another 12mm of carb, though I wasn’t. It meant I had taken about 10.5 units of Novarapid where normally I would take 4 units and get to only 7-8 minimol. After I took the extra 2 units at 2.00pm I started to come down bit by bit, but my original bolus of 4 units and the pumps corrections seemed to have minimal correction value. I thought the correction doses were low, but they added up to 4.5. Today it is a bit similar but I had a severe hypo at 10.00 when I was working on the allotment and then I had too much carb so I could get back to work quickly. I was probably a bit too high before lunch, but 10.5 units seemed far too much insulin to cope with the situation.
Does insulin resistance change with blood glucose levels? I know you shouldn’t take correction doses with Smartguard without eating because it confuses the pump. I can’t be bothered to go out of smartguard and give a manual correction. I just want to go back to work. If I do go out of Smartguard, I have to do a finger prick calibration to be able to use Smartguard again. Any suggestions? My long term average blood level. Is 7.4. I am not ill with any infection.
Total carb about 100gm per day. Total insulin about 13.2 bolus and 12 basal per day. Time in range between 80-92%.
Weight 74Kg, height 1.83m. Old.
Adam
 
Maybe you could reduce the insulin action time. The pump algorithm will then be a bit more aggressive. But if you pretend to eat carbs you are not really helping things as you know
 
I agree with @Geniekeepcalm thatbit is not going to help try to con your pump. Its algorithm is going to be working out things based on your previous basal needs, and you are switching to bolus to tackle a high. I found this so tempting to do but resist now.

When I was on MDI and just a pump I definitely needed bigger corrections when I was above 14 and I am not sure that the pump addresses this, but unless I have very big meals (I am on similar numbers of daily carbs as you) I find I rarely get up there. Smaller wobbles around 10 are effectively dealt with by the HcL. If we do corrections ourselves they will take time to work as it still needs to get through our system and then become active.

If you reduced your active insulin time this will make corrections more aggressive, as will not think that you have active insulin for as long. I reduced mine when I was in a similar situation and mine is lower that than the standard settings.

I have become more willing to let the pump do its job. Where my levels have gone up out of range, it will bring me back in range, and tends to avoid me going too far up with its micro boluses. I looked at mine from last night when we went to a barbecue, and I ate later and bigger meal than usual. I was close to 10 when I went to bed but the pump brought me back in range and back to my flat line by the morning.

I work on the principal that the pump needs me to tell it what I am eating and this enables my pump to do its work, and so keep me in range for a lot more time than before (yesterday was still 95%). I am a lot happier with my management and I do so little to help it, apart from when she is uncertain about SG and BG match.

The only time I don’t tell it everything I eat is if we are out for a full days walking. This is addressed on the Medtronic webinar on exercise. In addition to using the temp target it suggests a top up of ‘free carbs’ (no insulin or reduced insulin) through the day. For me that is a Wurther now and then. It took me time to realise that on these walks I still needed the pre-bolus time for my meals.

Let us know how you get on.
 
Very helpful, but I can't reduce the active insulin time, it is and has been on the 2 hour lowest setting. I tried, before I saw the responses, to reduce my basal rates at night and in early morning and it made everything worse so changed them back. My diabetes hills and troughs have recently got much steeper all the time, going from 14 down to 3 in 30-40 minutes and up in the same way. I will stop lying to the pump but I have a 68 year long desire to correct imbalances quickly. Just recently, I find it takes 30 plus minutes for sugar intake to raise a hypo, very frustrating when there is so much allotment work to do. It used to take 10-15 minutes. I understand about interstitial taking longer than BG readings. I am taking the difference into account. There is lots of lifting and bending there and that makes me very unpleasantly dizzy. I used to take Finasteride and Tamsulosin. I stopped taking Tamsulosin a long time ago because it increased dizziness very badly.
The last few weeks, normal 8.15am breakfast of 18g carb and normal 4.3 unit insulin gets me hypo by 9.30. I reduced the insulin bolus to 3.6 and exactly the same hypos at 9.30. I'll try 3.2 and see if it makes a difference.
Many thanks
Adam
 
adamrit said:
Very helpful, but I can't reduce the active insulin time, it is and has been on the 2 hour lowest setting. I tried, before I saw the responses, to reduce my basal rates at night and in early morning and it made everything worse so changed them back. My diabetes hills and troughs have recently got much steeper all the time, going from 14 down to 3 in 30-40 minutes and up in the same way. I will stop lying to the pump but I have a 68 year long desire to correct imbalances quickly. Just recently, I find it takes 30 plus minutes for sugar intake to raise a hypo, very frustrating when there is so much allotment work to do. It used to take 10-15 minutes. I understand about interstitial taking longer than BG readings. I am taking the difference into account. There is lots of lifting and bending there and that makes me very unpleasantly dizzy. I used to take Finasteride and Tamsulosin. I stopped taking Tamsulosin a long time ago because it increased dizziness very badly.
The last few weeks, normal 8.15am breakfast of 18g carb and normal 4.3 unit insulin gets me hypo by 9.30. I reduced the insulin bolus to 3.6 and exactly the same hypos at 9.30. I'll try 3.2 and see if it makes a difference.
Many thanks
Adam
Click to expand...
Are you running in Smartguard? From your post it seems you are running in manual. If in Smartguard the pump sets its own basal and bolus doses are adjusted by the pump according to the input carbs and carb ratios as well as trends
 
Like you I found it difficult to trust the pump to do its stuff and sort out lumps and bumps in my levels. If you are telling it fibs it will definitely find it difficult to do its job as you are giving it the wrong data to use to sort things out.

In general when using Smartgaurd
If there is a pattern of going hyper regulalry you could review:
  • You could review your target level, optimally 5.5 (but I got hypo too often with this so stick to 6.1- each to their own)
  • If after meals you couod change your carb ratio to give more insulin
  • Whether highs are a rebound from over treating a hypo (easy to do)
  • Reduce active insulin time (But I know you are at the minimum of 2 hours)
If there is a pattern of regular hypos
  • Increase glucose target (I keep mine at 6.1 now)
  • Change carb ratio to reduce insulin
  • Have you given fake carb boluses (lied to the pump - Once I stopped doing this things settled down)
  • Check when you are setting target for exercise. Good to set the temp target 2 hours before you start exercise
  • Change meal bolus by about 30% if exercising after meal (As far as I know the only way we can do this is do a reduction on our carbs at the meal (so yes a contradiction as I am now saying lie to the pump)
From what you are saying your carb ratios may not be right for lunch, especially as you have a repeating pattern. Could you stick to the same lunch for a week to check this out. It could also be the timing of the bolus.

I find that I need to change my pre-bolus timing depending on the fat content of my meals, but do find that if I leave Smartguard to sort things out it will correct things for me if I get this wrong.

When I interfeered with Smartguard (apart from before exercise) I did go on a roller coaster of hypo-hyper, as I added in fake carbs to bring on a reduction in my levels then went hypo because the pump started to make changes as it did not see the glucose rise for the carbs you told it about.

For alerts before low I find it counterintuitive to tell it about the carbs that I eat to head off the low, but I have learnt that it needs to know about those that I eat before the low. Once hypo I eat them for free and don’t tell the pump, as advised. This was a difficult thing to do. I found that doing a few finger pricks helped me to get my method sorted for me.

I know the D is very frustrating and we each need to find our way of making our equipment work for us. It took me a good while to trust it, and now I do ignore things for a large part of the day, unless she gets in a strop or wants a bit of advice, or just some praise from me because she is doing so well!!
 
Geniekeepcalm said:
Are you running in Smartguard? From your post it seems you are running in manual. If in Smartguard the pump sets its own basal and bolus doses are adjusted by the pump according to the input carbs and carb ratios as well as trends
Click to expand...
I’ve always been in Smartguard. I think it is just Type 1. Smartguard uses the Basal patterns that are you set in Settings, It doesn’t make them up. I get different results every day which seem unrelated to BG, carbs or exercise. I will work through your offered suggestions if I can. It just feels like nothing is fixed, every day is different and the variations mostly counter-intuitive. I think the NHS overburdened with work has meant regular diabetic clinic and other visits are frequently cancelled, leaving us feeling a bit unsupported, which adds to the loneliness of Type 1. My lovely wife is endlessly supportive but doesn’t have diabetes. I need to look at longer trends of highs and lows to see if small adjustments will even things out better.
Very many thanks for advice, just a bit miserable today.
Adam
 
adamrit said:
Smartguard uses the Basal patterns that are you set in Settings, It doesn’t make them up.
Click to expand...
You set me thinking about this again, so I decided to check with Medtronic. When you are in Smartguard the pump is not referring back to your basal patterns that you have set up for when you are in manual mode. It will use the data from the past 6 days in its algorithm to make decisions about the basal pattern to use. But we are required to be in manual mode for two days when first wanting to use HCL, so it’s starting point is our profile that we have set up and used for those two days. After that it uses the data it is gathering all the time, and makes adjustments every 5 minutes as necessary. It does not then need to go back to the our manual settings. I think that this is why it worked well for me when I was ill as it lifted my basal insulin as necessary. In this sense my basal pattern is different every day as my life is in no way consistent, which is why it seems to work well for me.

As you say there is still the simple variability of Diabetes, that likes to remind us that it is rarely consistent. It is always good to have a partner who is supportive. I hope that things settle.
 
I've been using medtronic's 780 hybrid closed loop system for nearly 4 months. Initially it was great with 95% time in target.
Recently things have gone haywire and I'm struggling to get back on track.The last few days my best time in target was 40%, the worst 13%. I don't know why this is happening. Diet, timing of meals, activity level, no illness, no traveling, everything remains unchanged. I am conscientious about carb counting.
The problem starts approximately 2 hours after my evening meal regardless of the type of meal eaten, pizza or a simple salad. Levels rise rapidly with the HCL system giving lots of corrections. By late evening sugar levels are often in the high teens and low twenties. Repeated corrections by the pump are not bringing sugar levels down. The high levels continue all night and eventually start to come down mid morning ( I don't eat breakfast).
When I first started the HCL I was told to bolus 15 minutes before each meal. This caused me to go hypo before I started eating so the DSN advised trying 10 minutes. I played around with this and found bolusing 5 to 6 minutes before eating avoids a hypo. I use Fiasp insulin.
Could this be the problem, I'm bolusing to close to eating resulting in such high postprandial peaks? But if I bolus 15 minutes before eating I know I will hypo before the meal starts.
The other issue is the pump alarms. Because I'm running high they keep me awake all night. Tried turning the alarms off and putting my phone in another room but the pump still vibrates. I becoming grouchy due to sleep deprevation.
Suggestions gratefully received.
 
Half way through reading your post I started to wonder if you were using Fiasp and I see you are.
I don't use a pump but I find that once my levels get above 10 Fiasp seems to turn to water and I sometimes need quite alarming amounts of stacked corrections to bring me down.

Prebolus times vary a lot for me with Fiasp both regarding the time of day and also my BG. At breakfast I personally need 30-45 mins prebolus time but other times of the day it is usually anywhere from 5-20 mins. The higher my BG premeal, the longer my prebolus time needs to be. So if I am about 8mmols on an evening before I eat I will need 20 mins, above 8 and I will need longer. If I am 4 or 5mmols I might get away with prebolusing and eating straight away or just 5-10 mins. If it is a fatty meal like fish and chips or pizza or creamy pasta, I would need some up front and some later.

The other possibility if that your Fiasp has gone off (perhaps with the hot humid weather we have had) and is now less effective and that is throwing everything off.
 
@rebrascora has included my own thoughts
Has the insulin gone off?
Are you prebolusing?
Pizza!!!

You mention Pizza. I still find that that leads to a longer time before my levels settle but the HCL does sort it after a few hours. This is because of the high fat content and high carbs. I didn’t touch pizza until I went onto HCL and now only have a small portion when I do.

Certainly once I am high I find that things come down more slowly, and pre bolusing helps to avoid the spike and the consequent slower drop.

I tried FIASP and after a while I found that I got very skanky cannula sites, and so delivery was not good. Are you using the extended cannulas which last a week? I would not have been able to use those with FIASP and even with Novorapid abandoned them to return to the Minimed Miao which last 2/3 days which suits me better, with fewer site problems.

You mention that everything she’s staid the same. I find that my carb ratios differ with changes in temperature. Again less of a problem on HCL but worth considering whether these need a tweak
 
Thanks for your replies rebrascora and SB2015.
Good point about the insulin being off.
Luckily I can eat a slice of pizza providing I match carbs and insulin without it causing problems. Pre HCL I used dual and square waves on my pump.
It looks like just asking for some help was enough to put things back on track. Yesterday afer my evening meal (slice of pizza and green salad) no long postprandial peak. Stayed in target all night, even running on the low side. Time in target 82% this morning.
I can't explain what was going on before. The weather has been very hot so maybe that upset things. I know the insulin was OK.
Fingers crossed things stay on track.



​

 
Glad things have settled

Perhaps your pump heard that you had publicly shamed it for its poor performance and it decided to toe the line again.

In manual mode weird days were very frustrating at times and I guess we still have weird days on HCL but have got used to things being sorted for us in the background. When mine has a strop, usually at the most inconvenient times, I try to remember how much work it has taken on for me most of the time and try to be polite to her when she wants some help.
 
adamrit said:
Very helpful, but I can't reduce the active insulin time, it is and has been on the 2 hour lowest setting. I tried, before I saw the responses, to reduce my basal rates at night and in early morning and it made everything worse so changed them back. My diabetes hills and troughs have recently got much steeper all the time, going from 14 down to 3 in 30-40 minutes and up in the same way. I will stop lying to the pump but I have a 68 year long desire to correct imbalances quickly. Just recently, I find it takes 30 plus minutes for sugar intake to raise a hypo, very frustrating when there is so much allotment work to do. It used to take 10-15 minutes. I understand about interstitial taking longer than BG readings. I am taking the difference into account. There is lots of lifting and bending there and that makes me very unpleasantly dizzy. I used to take Finasteride and Tamsulosin. I stopped taking Tamsulosin a long time ago because it increased dizziness very badly.
The last few weeks, normal 8.15am breakfast of 18g carb and normal 4.3 unit insulin gets me hypo by 9.30. I reduced the insulin bolus to 3.6 and exactly the same hypos at 9.30. I'll try 3.2 and see if it makes a difference.
Many thanks
Adam
Click to expand...

adamrit said:
Very helpful, but I can't reduce the active insulin time, it is and has been on the 2 hour lowest setting. I tried, before I saw the responses, to reduce my basal rates at night and in early morning and it made everything worse so changed them back. My diabetes hills and troughs have recently got much steeper all the time, going from 14 down to 3 in 30-40 minutes and up in the same way. I will stop lying to the pump but I have a 68 year long desire to correct imbalances quickly. Just recently, I find it takes 30 plus minutes for sugar intake to raise a hypo, very frustrating when there is so much allotment work to do. It used to take 10-15 minutes. I understand about interstitial taking longer than BG readings. I am taking the difference into account. There is lots of lifting and bending there and that makes me very unpleasantly dizzy. I used to take Finasteride and Tamsulosin. I stopped taking Tamsulosin a long time ago because it increased dizziness very badly.
The last few weeks, normal 8.15am breakfast of 18g carb and normal 4.3 unit insulin gets me hypo by 9.30. I reduced the insulin bolus to 3.6 and exactly the same hypos at 9.30. I'll try 3.2 and see if it makes a difference.
Many thanks
Adam
Click to expand...
I will just have to accept the almost arbitrary nature of Type One. My 780g and 4 sensor copes brilliantly at night. I almost always wake up between 5.3-5.8. The graph is the very gentlest slope down. Daytime has always been a bit of an opposite nightmare. I’ve been desperate to find patterns, but they are all irregular and usually unrelated to carb intake, insulin dosage or exercise. I’ve been doing a 1/2 hr stretching exercise class 3 x a week at 9.00-9.30 for 3-4 years after the same 18gm carb nutty muesli breakfast and 4.2 units of Novorapid and almost always after 5.3-5.6 BG reading. The first year I was usually 10 by 10.00 am and had a correction of 0.5 insulin. Sometimes 12 before lunch sometimes 2.8.
This year with same breakfast (18gm C) I now only take 3.2 units of insulin and am almost always low by 10.00am so have to eat something.

I used to assume the 780g doesn’t give you enough correction insulin when you are high because Medtronic doesn’t want to be responsible for severe hypos, but it certainly does give you enough but the BGs still stay high for hours and hours and then six hours later my BGs shoot down to the 2 or 3.
I’m happy and very well for 84 years of age and 68 years with Type One, so I think I’ll have to admit that Type One is the patternless monster is and stop imagining I can really control it. I’m fine and should stop complaining.
love to everybody
Adam
 
It sounds like you have tried everything Adam. Sorry not to be able to think of anything else.
Perhaps now that we have @everydayupsanddowns onboard he might come up with other things.

Enjoy the good nights of sleep and do what you can during the day to keep your D in check.
 
Any of you old hands with MM780G know if it’s easy to end a sensor a little early, and start a fresh one?

Eg if the timing of your day would make the ‘expiry’ time a bit inconvenient, and you’d rather get a new one going an hour ow two early when the 2hr gap was less of a faff?

I’m sure I could find it in the manual, but thought I’d just ask here first!
 
There is no problem stopping a sensor early. I do that if it is more convenient to do a change over early. This has happened more as a result of me putting a replacement sensor midweek, after a failure, then still wanting to do changeover at the weekend, or if I am going away over a weekend and want to do the changeover before I go. You lose the time, but I have a bit of a buffer with my sensors so can manage that.

When I do any changeover I need to charge my transmitter, which you don’t need to do with the Simplera sensors. I turn off my sensor in settings, and it checks that I really want to. Then, once transmitter is charged, I insert new sensor and then turn sensor back in before I insert transmitter. Not sure what you need to do with the new ones. I shall be calling on you when I do the switch over in December.

I hope that you are finding the 780 system is working for you.
 
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