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Re: [IPk] temporary basal rate and walking

On 10 Apr 2008 at 20:16, Marisa wrote:

> I'd always thought that the reason for Isabella's regularly changing
> basal needs was to do with growth hormones, but maybe it's still her
> pancreas producing insulin in fits and starts, is this possible? How
> long might this go on for as it is really quite difficult dealing with
> changing insulin needs every few weeks, sometimes from week to week. We
> find that we just get her on a really stable profile and then hey
> presto we start to see climbing or falling sugars at a particular time
> of day and it's all change again. Do others with small children
> experience this? It was the same when she was MDI, and the first point
> of the day to change is always the time between 7pm and midnight for
> some reason. 

I read a piece of research a few years back in which several doctors 
(a doctor?) worked on finding the 'perfect' regimen for a patient. 
The worked out the best basal insulin dose (or rate, I can't remember 
if they used a pump) and the best bolus rates, correction factors, 
etc., for the patient and the result was excellent BG levels..... for 
about two weeks. After roughly two weeks the results started to drift 
off. The developed a new 'perfect' regimen, but again, after approx. 
two weeks it drifted out again. 

I'm not sure how accurately I'm remembering the details as it's a few 
years since I read the research and I've tried unsuccessfully to find 
it several times since. But the conclusion they reached was that 
diabetes control can only be attained by constant adjustment. I'm not 
sure if I find this depressing or reassuring that it's not something 
we are doing wrong, probably a bit of both.

> Also, quite a few mentions on recent emails of the liver chucking out
> glucose if there is too little insulin. I think we have experienced
> this a number of times after she's been stable on 0.05 basal for
> several hours suddenly her sugars will climb dramatically. Why does
> this happen? Is the only way to prevent it to have a snack and a bolus
> every couple of hours on a low basal? This would seem to defeat the
> idea of having a 'starvation' basal rate. 

It does sound as though the low basal rate may be causing a glucagon 
response. Presumably if you increase the basal rate you start having 
hypos? This is the situation we had with Emily in the afternoon but 
as mentioned before, when we started again from scratch, we ended up 
with less hypos despite a higher basal rate. Presumably we had the 
balance between lunch time bolus and basal insulin wrong and the 
hypos were caused by too much lunch time insulin. Have a look as see 
if hypos are more likely if the meal before the problem time is 
larger than normal. 

If the meal time bolus is set too high the error will be magnified 
the higher the carb value of the meal so you would see a pattern of 
hypos after larger meals and the larger the meal the worse the hypo 
would be. A ratio of 1:10 would give a bolus of 10 units for 100g or 
2.5 units for 25g. If the correct ratio is 1:12 the bolus should have 
been 8.3 units for 100g or 2.1 units for 25g so either 1.7 units or 
0.4 units more than necessary. An 'overdose' of 1.7 units is more 
likely to cause a hypo than an 'overdose' of 0.4 units.

This is obviously just one possible explanation from our experience 
and there are probably others that could explain these numbers just 
as well or better. Your suggestion of snacks may end up being the 
best answer, especially if the hypos cannot be linked to larger 
meals. It's strange that you don't see this every time after running 
low basal rates. Can you see anything different about the times it 
does or doesn't happen? Is she more likely to have had an extra snack 
with insulin when it doesn't happen or have had more exercise when it 
does, for instance?

Best wishes,

Mum to:
Emily (15), dx Oct '99, D-Tron Plus pump Oct '03, 
Robert (17), dx Mar '03, Novomix 30 am, Humalog Mix50 pm,
and Matthew (12). All home educated. Married to Tony.
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