Are spikes inevitable?

[Becca]

It's odd though take how many children with diabetes we know.....most are told by consultants to look at the 2hr figure to see if ratios are right. But as an adult do you think it's premeal as levels aren't likely to swing about or be as sensitive to insulin as a childs? It's all confusing...

 

[rossi_mac]

It's all confusing, thats the triple word score of the board allright!

It's still all new to me, but I understand that i've got it easy and you parents are doing a sterling job, kids growing = a lot harder to control!! Before you even think about the kids being kids bit!

 

[bev]

Absolutely bring on the pump - any news yet on when?

Hi Adrienne,
I got a reply to my email today (a gentle reminder from me asking if the pct had agreed funding) - and the answer was that they had agreed 'in principle' - whatever that means - and that the dsn had emailed them to ask if she can go ahead and order the medtronic pump - but hadnt bothered to ask which colour he wanted or anything - so i emailed back with the colour etc and asked what the phrase 'in principle' meant! Still havent heard. But i have made it clear to them that it has to be in the summer holidays - it is so much easier to deal with - lack of sleep etc. Also i think it better for A to get used to the pump whilst not having to worry about school etc..🙂Bev

 

[Northerner]

I think things are definitely different for adults. I don't have a huge amount of experience, but I never give a correction for a 2 hour spike. If I spike, I spike, and I might think a bit harder about that particular food combination. But if I am in range by the next meal, then I'm fairly happy. Like Rossi says, I feel I am getting the insulin doses/ratios correct, just need to watch out for certain foods. If I go correcting I'd be almost certain to have hypos before the next meal.

I must admit, I don't understand why you would correct before the bolus is 'expired' - it's very difficult to predict peaks, absorption and duration and it makes a bit of a nonsense of carb counting if you add more insulin half-way through the 'cycle'. Surely, if you are at 20 at the 2 hour mark, giving more insulin isn't going to take effect for another hour, by which time the 'on-board' insulin has been bringing you down anyway

 

[Adrienne]

I think things are definitely different for adults. I don't have a huge amount of experience, but I never give a correction for a 2 hour spike. If I spike, I spike, and I might think a bit harder about that particular food combination. But if I am in range by the next meal, then I'm fairly happy. Like Rossi says, I feel I am getting the insulin doses/ratios correct, just need to watch out for certain foods. If I go correcting I'd be almost certain to have hypos before the next meal.

I must admit, I don't understand why you would correct before the bolus is 'expired' - it's very difficult to predict peaks, absorption and duration and it makes a bit of a nonsense of carb counting if you add more insulin half-way through the 'cycle'. Surely, if you are at 20 at the 2 hour mark, giving more insulin isn't going to take effect for another hour, by which time the 'on-board' insulin has been bringing you down anyway

I see what you mean but the idea is that the insulin dose shouldn't allow you to go up to the 20's or high teens anyway which means you needed more insulin or to inject it at a slightly different time or in a different place.

 

[Adrienne]

Just had another thought about why we would correct at 2 hours and that is because the insulin is at its peak (in theory) and working its strongest and if its strongest is allowing you to spike then it ain't working properly.🙂

 

[Northerner]

I see what you mean but the idea is that the insulin dose shouldn't allow you to go up to the 20's or high teens anyway which means you needed more insulin or to inject it at a slightly different time or in a different place.

Agreed, Adrienne, that it is a timing issue - but not a dosing issue if you correct and are low by next meal or have to add carbs to prevent it. It strikes me that in some people/children in particular it's very hard to ge the timeing right. Believe me, I appreciate how lucky I am and hope it will last!

 

[Becca]

Another thought would be how long your quick acting insulin generally lasts in your system - R's we know is about 4 hours it will be out, some people it's 3 hours, others it's 5/6 hours...

When, as adults, you have your daily readings, do you generally know what will happen to them? Are your patterns the same (nearly) with certain foods etc...? I'm really interested if this happens (as it gives me hope lol!) With R, for example, we find that she can eat the same breakfast and do the same things up till lunch as the next day but we'd have widly different readings. Sometimes, for R there is no consistency - is this do you think because she is a child or do you guys find it to be like this?

 

[Northerner]

I'm the poster boy for stable and predictable levels and knowing what will happen with food I've had before. It may happen one day, but I haven;t been above 15 since diagnosis, and that was a while ago - now a spike to me would be 10 at the 2 hour mark. It's impossible though to compare, I think, although there does seem to be less fluctuation the older you get! (I'm 50 BTW)

 

[Adrienne]

Good question Becca.

Northerner I can only wish for levels like you for Jessica. I worry so much about her and her future and the problems. There are no written papers for congenital hyperinsulinism and future problems, it is too new a condition (not really but as people did get it before but not a lot was known) to know what will happen. I am constantly being told by the two hospitals I cannot compare Jessica to any other child with diabetes. I just get worried. They don't even know if there would be future problems. We think there could be due to high levels so like 'normal' diabetics we strive for great or good readings but we don't have ketones ! No pancreas, no ketones. I test every so often (not that often to be honest). So what else could or couldn't happen we just don't know.

 

[aymes]

I think things are definitely different for adults. I don't have a huge amount of experience, but I never give a correction for a 2 hour spike. If I spike, I spike, and I might think a bit harder about that particular food combination. But if I am in range by the next meal, then I'm fairly happy. Like Rossi says, I feel I am getting the insulin doses/ratios correct, just need to watch out for certain foods. If I go correcting I'd be almost certain to have hypos before the next meal.

I must admit, I don't understand why you would correct before the bolus is 'expired' - it's very difficult to predict peaks, absorption and duration and it makes a bit of a nonsense of carb counting if you add more insulin half-way through the 'cycle'. Surely, if you are at 20 at the 2 hour mark, giving more insulin isn't going to take effect for another hour, by which time the 'on-board' insulin has been bringing you down anyway

I've always been told not to correct while there is still bolus insulin on board, assuming the carb count/ratio is right then it should bring me down to the right level by the 4 hour mark so any extra insulin would mean I'd hypo, as you say I'd look at the food combination/dose timing rather than the dose.

Of course, as always, it's a personal thing. I was told not to correct less than 5 hours after the meal as the bolus could still be doing its stuff then, but from experience I know that after 3 1/2 hours the novorapid seems to stop doing anything in me so if I have the need to correct I'll wait until this point.

 

[aymes]

When, as adults, you have your daily readings, do you generally know what will happen to them? Are your patterns the same (nearly) with certain foods etc...? I'm really interested if this happens (as it gives me hope lol!) With R, for example, we find that she can eat the same breakfast and do the same things up till lunch as the next day but we'd have widly different readings. Sometimes, for R there is no consistency - is this do you think because she is a child or do you guys find it to be like this?

From my experience, generally speaking yes, if I'm in a routine, eating things I often do etc then I can pretty much predict where my levels will be. But there are always times when I get a totally unpredictable result and have no idea where it come from!

I remember one doctor asking me the dreaded it 'do you ever get hypos' question and looked absolutely horrified when I said yes. He asked me what was the reason behind one particular one and I said I didn't know. He then quite angrily told me that there is always a reason for different levels so why didn't I know the cause! Now I agree there is always a reason, but there are always going to be things we can't predict and so reasons we don't know!

I suppose a significant spike for me after food would be in the low teens, although usually I'd expect to be at 10 or under 2 hours after eating. Whether having smaller spikes is an adult thing or just something that happens to me I don't know....

 

[Twitchy]

Wow, great thread!

My theory is that the following affect spikes, not necessarily in order of magnitude!:

Insulin type, GI rating & load of meal, exercise within the last 24hrs, hormone fluctuations (for us lucky ladies out there), stress levels/extreme emotion, illness, amount of sleep recently...not much, then!!

At least, those are the things that seem to affect me personally. I'm on Lispro for my quick acting, and I sometimes find with the higher fat & carb meals (fish & chips, yum!) that if I inject before or just after I eat, the lispro kicks in too quickly & then runs out of steam when the carbs do peak. I've often wistfully thought about asking my doc for a fistful of different insulins to counter such GI effects he he! (I've only recently heard about splitting the dose - should have been obvious doh, but shows how you get stuck in a rut...)

Re the testing...when I did DAFNE I seem to recall them disuading you from testing other than before meals (& before bed & first thing), & I can kind of see why because the temptation to correct is strong & I often end up on a rollercoaster of sugar levels if I don't keep calm! That said, when pregnant, with my consultant's approval I was testing 1 hr after meals & correcting if over 7 mmol...that's when I got the HbA1c of 5.2%, but I also put on around 1 1/2 stone from eating to address the frequently resulting hypos so not the best long term practice alas! 😱 I'm really hoping the pump will give me the flexibility to tailor my insulin to what I'm eating / doing at last...roll on tuesday!!!🙂

 

[rossi_mac]

I'm not as stable as young northener, but still find regularity, when I do the same thing day in day out, if I run a round like a headless chicken a bit more than usual it can mess me around etc. So Chin up your children will find control!

I'm trying to understand GI and get my timing of injecting right to avoid big spikes, and like some of you know how long your short term stays in you I've no idea (aymes how did you work out it's left you by 3.5 hrs??) but would really like to know!

Twitchy your list of factors I agree is spot on and as such adults probably have it easier than kids and some men easier/less variables than women! good luck with getting a pump.

 

[NiVZ]

This is a very interesting thread.

Like Aymes, I've been on DAFNE and they encourage you to only test 4 times a day at the following times.

Before Breakfast
Before Lunch
Before Dinner
Before Bed

and as long as your within range at these times that would indicate that your ratio's are correct.

They try to discourage testing too often or 'micro-managing' as they called it. One girl on the course was testing two hours after her meal and giving correction doses for spikes, but was having horrendous hypo's as she had 2 lots of bolus insulin working.

The spikes are definitely something to think about though and I might do a few tests as I've never looked for these before.

I've got my annual DAFNE review next month and I've got a lot of questions from what I've read on this board to ask them.

Again theres no right or wrong way to treat your diabetes. It's all personal choice and what works best for you.

@Becca - I find I can generally predict what effect that food I'm familiar with will have on my BG's as long as I've not been doing anything else (increased exercise, etc)

NiVZ

 

[aymes]

I'm trying to understand GI and get my timing of injecting right to avoid big spikes, and like some of you know how long your short term stays in you I've no idea (aymes how did you work out it's left you by 3.5 hrs??) but would really like to know!

Nothing scientific I'm afraid! I just know if I test at 3.5 hrs and again at 5/6 hrs I won't really have changed. My basal seems to be pretty much spot on when I've tested that so I can make the assumption that the bolus is doing little or nothing after the 3.5hr mark.

 

[Becca]

This is so interesting 🙂 It's weird with R, for instance before she had swine flu here are 3 readings:

day 1: 7.30am 5.4mmol/L 10am 8.5mmol/L
then next day exactly the same breakfast, no added exercise
day 2: 7.30am 6.4 mmol/L 10am 2.2mmol/L (eep!)
but then on another unrelated day, same breakfast and no added exercise
day 3: 7.30am 5.8mmol/L 10am 13mmol/L

The randomness of it as times is so frustrating! We can micro manage down to all factors and environment, come up with no difference and yet still different readings! Guess it's being a child 🙂 Growth hormones and stuff.....

Interestingly, on MDI and under bad hospital her HBA1c went up to 11% (argh!) by testing 4 times a day they looked beautiful readings all between 4-10. So something was obviously a miss! It was only be doing 2 hourly testing after breakfast we saw the humungus spike (up to 30mmol/L which had faded by lunch. (The clinic's view on how to manage this was to not test as we wouldn't know!?) By eradicating (at most) that spike her Hb has obviously come down. We still do 2 hourly testing most days as no 2 days are the same, being able to adjust basal/bolus ratios after 2-3 of ''odd'' levels is very handy.

I'm very relieved to see that at some point there will be some ''stability'' in her control when she's older (lol! that's without other factors like alcohol and her own self control lol!)

 

[HelenM]

See this is not what we have been told and our team are one of the top in England. Bear in mind it is a paediatric team though but shouldn't be that much difference.

In theory you should be able to tell two hours after eating if the insulin ratio is ok, if you eat a basic meal (forgetting pasta and rice here). The only way to test an insulin ratio is by testing two hours after eating. All the good teams amongst our group of 200 odd all say the same. You can only really test this if your level is ok and within range pre meal. If your level two hours after eating is within 2 mmol either way the ratio is right

Its not that different to the advice (for adults) here. From the start I've been told the target rise is a maximum of 50mg/dl (2.7mmol) so the 2 hour reading is important for that. That said they don't advise you to correct until 4 hours but to use the info to inform future dosing. If your 2 hour reading is correct but you often have hypos or hypers 3 or more hours later you're usually advised to adjust the basal. If the 2 hour reading is too high/low then to adapt the carb/insulin ratio.
What they do stress is the importance of eating regular balanced meals, (ie main meals containing, a starchy low gi carb , veg/salad, some protein, a fruit, some dairy (30g cheese or a yoghurt/fromage frais) plus a little uncooked oil, normally as a dressing, total carbs kept to similar amounts, if you've exercised more or been less active then adjust carb intake appropriately).
Keeping everyday meals similar reduces variability. It doesn't stop you eating more variably for meals outor special occasions but on a day to day basis it makes it easier to control post prandial spikes and rollercoaster readings.
Luckily its a fairly normal pattern of eating here, so I think its easier than in the UK. Snacking (except for children's tea) is frowned on in general and there are far fewer takeaways, ready meals etc.

 

[rossi_mac]

Nothing scientific I'm afraid! I just know if I test at 3.5 hrs and again at 5/6 hrs I won't really have changed. My basal seems to be pretty much spot on when I've tested that so I can make the assumption that the bolus is doing little or nothing after the 3.5hr mark.

I'm happy with by basal, so if I have a meal and inject and am confident my ratios are good, if I test say at 1 hr 2 hr 3hr 3.5hr, 4hr and so on, I should seem when it stops working for me??? Obviously a one off isn't concrete, maybe I could repeat this a few times, sounds like a good idea I like the idea of understanding what the hell is going on!!

Cheers.

 

[sofaraway]

Interesting thread,

I seems that what each person considers a spike is different. I would generally say that apart from my after evening meal reading I will be below 10 at 2 hours so would consider anything over 10 as a spike. I don't tend to correct at 2 hours anymore, but I believe that i could as novorpaid lasts less than 4 hours for me.

For those like Adrienne who say that they can correct at 2 hours for a spike then the pump must allow them to do so by working out how much insulin is on board and if it's going to be enough. If there was only a moderate spike it wouldn't allow a correction because it would know that there will be enough insulin to bring back to target. I think John Walsh gives a good example in using insulin where someone is high at 2 hours but if you work it out then no correction is needed and the person will end up low by 4 hours, took me several re-reads to understand it.

If the blood sugar is back in range at 4 hours but high at 2 then it's a timing issue and probably the insulin needs to be given a bit earlier before eating. Adrienne explained well how to get over difficult spikes by giving too much insulin than needed then mopping it up later. You just have to remember that it needs mopping up.