Advice please

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jusme

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Type 1
I got my pump 640g and was on saline the first week then went onto insulin but I am having a heck of a time with it having many high BGs, at first I was doing CDs with my pen got told off and had to do them on Bolus Wizard however because they have me on such a low dose of insulin I am still running high. A DSN phones now and again but says she is happy with running high as I am not having Hypos - now want I want to ask is would you increase the basal dose without asking permission? My next appointment is Thursday.

jusme
 
Generally speaking, people need less total daily insulin on a pump than they did on MDI, so clinic teams are cautious when you first start on the pump. You need to do some basal testing (skip a meal and test hourly until next meal due). BGs should stay within 1-2mmol of starting point, and if not, your basal needs adjusting. Don't touch your ratios or correction factors until you have your basal set correctly. If you are confident doing basal tests and making adjustments to the basal, then I'd say don't wait for the nurse, just report back to her what you've done.
 
Thank you Redkite - no one has mentioned basal to me they just took my total daily insulin amounts took 25% off and divided the answer into half one half was divided up for my 24 hour dose and the rest was left for meals depending of course what carb rates I was eating and the bolus wizard worked my amount out together with any correction dose required according to the BG reading. I will start the Basal at 6pm until midnight and it will be pointless doing one from midnight to 6am because that is when my dawn phenomenon sets in (23.2 - 12.30 to 15.3 - 4.50am). Then I will start again tomorrow morning as it will be nice starting with a cooked breakfast for a change.

jusme
 
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I'm sure you meant a cooked "breakfast", lol!

But the pump will be fantastic at sorting out your dawn phenomenon! The biggest advantage of a pump is that you can programme your basal in half hour increments if necessary, so for example in your case you could have a much higher basal rate running from 12 midnight to 5am, if your levels usually rise during this period - although they seem to have dropped in the example you have quoted, just that they started very high. The clinic has to start you off with a flat rate across the 24 hours because this is just a starting point, but they should be encouraging you to basal test each section of the day at a time, make changes, run the test again, and so on, until you have optimal basal settings. Have you got the book "Pumping Insulin" by John Walsh, and "Think Like a Pancreas" by Gary Scheiner?
 
Do you know what your average doses were before you switched @jusme? It might give you an idea of whether a 50:50 split is likely to be a good starting point for you. People are different but usually range from 40:60 through 50:50 to 60:40.

I tend to be 40% basal and 60% bolus, but if you were more like 60% basal and 40% bolus on MDI then it may be that the cautious starting point was never going to be right for you. One of the reasons for the caution is leftover MDI basal insulin which can hang around much longer than you might expect.

As Redkite suggests, proper basal testing is your best bet - and you will need to continue to do it every few weeks/months to keep things pottering along nicely (or just make occasional guesswork increases/reductions).

If I suddenly find I'm having lots more highs or lows than normal in a week it's often a sign that my basal could do with a tweak.
 
Yes my average doses were 12 basal and 13.5 bolus. I only had 4 Levemir at 6am that morning so not a lot as the previous evening one at 6pm would have run out at midday.

Redkite I already have a slight increase running from 1am - 5am but it never does any good and the only reason I dropped from 23 to 15 this morning was because I did a manual bolus of 4 and then followed by another manual bolus of 2.5 at 4.50am the bolus wizards rate was far to low but it is all recorded on my pump which I am sure they will check on Thursday.

I don't have 'Pumping Insulin' but will look it up and the other one I have but loaned it to someone else and it hasn't been returned yet.

Thanking you for all the information and as already mention I am doing the 6pm - midnight today and will do the 6am - midday tomorrow then follow on with them as suggested. Sorry about my unusual breakfast error! at least it raised a LOL.

jusme
 
The 'breakfast' boob - ROFLMAO - I had to read what you said several times before I actually could see what the heck Redkite was on about! DOH.

You know all the things you already know about how much insulin you need and when, from being on MDI, jusme?

Well - forget it! - because what you REALLLY need, and will eventually be able to titrate on your pump - most probably won't resemble it all that much. I know this will sound ridiculous - because it did to me - but it is true.

The other thing is - why some DSNs tell you not to mess - people WILL try and fiddle with stuff - whereas here we have a situation where we need patience NOT to fiddle with stuff until we have given it a chance to see what it's going to do. So that means every change you make - even though you will see some effect pretty immediately - you need to give at least 2, preferably 3 days to settle itself in to see what it really does and make sure it's right. And eensy teeny weeny changes in hourly basal rates can make maHOOsive difference to your control - try never to increase or reduce by more than 10% at a time. So if your rate is 0.25, inc or red to 0.27 or 0.23 at the most in one go.

The other thing you can do of course is a TBR - but you can't programme them in advance to start and stop in the middle of the night so you need to resign yourself to the fact that you WILL have to do some very early morning testing as you are the only person who will be able to counteract your DP ! You may be surprised at that too - how early does it actually start did you say?
 
TW I have been on the basal rate that they set 9 days ago and only do CDs when prompted by bolus wizard except for a couple of impatient moments - have you heard the saying 'Patience is a virtue unfortunately it's one I haven't got' but I am learning!

Examples you asked for are 9.15pm - 7.2 - 0.45am -16.8 / 9pm 13.5 - 0.30am - 23.2 / 9pm - 11.9 - 1am - 18.7 / I can do some early morning testing because I have to get up every night doing BGs and correction doses, if I get up as usual tonight and not do any correction doses and carry on though tomorrow I will have 24 hour from 6pm tonight until pm tomorrow TBR to show them. It will be scary though to go 24 hours without a correction dose and I hope I don't start showing ketones but will test if I need to. By the way I have salad 365 days a year so it will not be a hardship for me and OH says he will stick to it with me.

jusme

PS - DSN just phoned and altered my basal rates from midnight until 6am and I have put the new rates in my pump and I am going to carry on with my 24 hour BR until 6pm tomorrow.
 
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Those aren't dawn phenomenon. You have a lack of insulin in the late evening. Could be basal or bolus depending on timings of bolus. What time do you eat your evening meal? Do you have a bedtime snack?
 
That's not basal testing, sorry! You don't start with a period of testing until all bolus nd correction insulin is used up - so therefore start not less than hours after taking the last one.

Then you don't eat or take partic heavy exercise, just do whatever's absolutely normal for that time of day, for the next 6 hours and you test every 2 hours. Read http://www.diabetes-support.org.uk/info/?page_id=120 for instructions.
 
Redkite I eat my evening meal at 6.30pm it is always salad and no I do not eat a bedtime snack and my basal was always taken at 6am and 6pm, the peaks have been confirmed from the charts I printed off from my Freestyle Libre.

TW I haven't had any bolus insulin since lunch time today just the basal and every afternoon is the same, walk the dog straight after lunch and that could not be called heavy exercise as she is only tiny, I then sit and read or rest or do craft work, I had a green salad at 6.30pm - nil carbs and I understood that a NIL carb meal was allowed. I will test throughout the evening and night and I will do my best to keep to 2 hourly I do not have an alarm clock and I certainly wouldn't set it and wake up my OH if I did - my Freestyle Libre will be with me and will get used every time and will be a back up to my BGs. and I will continue to do so around to 6pm tomorrow evening. That is all I can do and if it is not good enough well hard cheese and at least it will show what has happened on a 24 hour no carb try out.

I am going to bed now and I have got a good thriller to keep me awake.

jusme
 
Yup a no carb meal is allowed. It's not usually recommended to do more than 6 hour chunks though, (well they are 10 hour chunks cos you'd eat, then start the test 4 hours later) will not having even any protein. Dunno if you'll get the same results TBH cos you aren't really mirroring a normal day - unless you ONLY have a green salad every night? when I say I had a salad I will have had meat fish or egg with it at least, if not some carb too - but anyway - worth a try !
 
Good luck Jusme 🙂 Life is not meant to easy is it o_O When you think you have the thing sorted & something else adds.
 
I still remember my own lack of patience at the pump start. It takes some time to sort out basal rates, but it is worth all the effort as it it one of the greatest benefits of the pump having the variable rate for your basal insulin.
I did a few useless tests as I had not cleared all the earlier carbs and bolus. Waiting for 4 hours before starting the test and also making sure that the meal before you start is higher GI and low in fat (to ensure that it is all clear within 4 hours) is important. I found the table of reminders for the basal rate tests in Think Like a Pancreas were very helpful, or if you are with Accu Check they provide simple charts for the Basal rate tests with reminders about the preparation for a test. Just give them a ring and ask for a pad.

It will take time to get the rates sorted but it is well wort it in the end. Each of the pumps include facilities that overcome the lack of flexibility that I found with MDI. Hope it all goes well.
 
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