Hypo management: dodgy advice?

[Subby]

What do you think of this advice I got from my pump endo?

The protocol for hypos I was given was: if below 4.5 mmol/ have 15g short acting carbs, wait 15 min, test, if still below, repeat, until above 4.5 mmol/l.

I know that's pretty standard and I'm happy with it as a protocol.

When I was having some repeat hypos when first on the pump and I asked for answers, the pump dr asked if I was following the hypo management up with some long acting carbs. I said "no". She said that of course I should always be taking long acting carbs after the short, to avoid going low again. She seemed almost irritated I wasn't.

Now, this didn't seem good advice to me then, nor now, and I felt annoyed that it seemed like she was avoiding dealing with pump adjustments. It seemed to be an outdated attitude applying more to MDI therapy than pump, which should keep you stable if you get back to a good level with quick acting, provided you are not dealing with some bolus mistake.

If you are having repeated lows this would be a sign of overly agressive I:C, ISF or basal rates. Going low informs you of this. Taking long acting carbs without a bolus just muddies the water considerably, leading to inaction and not fixing the problem. This is how I feel, is it fair enough?

What do you think of the advice I was given? Am I wrong or being harsh thinking it was pretty poor? Is it fair enough to throw some long acting carbs in to fudge on through?

[fgummett]

I agree with your assessment... long-acting carbs only makes sense if you are also using long-acting insulin. Fine advice for MDI but not so much for a Pump user.

[milfordj]

Seems to me her advice would only be good if you were engaging in an activity where you might need ExCarbs.

[Jan B]

Subby,

I think you are 100% correct. Some of the things my pump trainer told me had me all screwed up. She said I could/should have 3 snacks per day (what??). She also said if I was eating less than 15 carbs, I didn't need a bolus! Again very wrong for me. Then, when I was repeatedly going low in the afternoon, she wanted me to have a snack every day at 3pm. Good grief; I had to let her go! She was new at her job, and a diabetic pumper herself. One of my big reasons for wanting to pump included not being forced to eat when I didn't want to.

I still can't believe her telling me about not needing insulin if I was having less than 15 carbs. I even pre-bolus before disconnecting for a shower -- it works great, and she told me it wasn't necessary . . . OH, and one more thing . . . she said I didn't need any extra insulin if I was disconnected for an hour or less. Good grief. Not true for me at all . . . I'd be up approx 50 points.

[Subby]

Thanks for the comments. Jan, you are hitting the nail on the head. The context behind my question is that I am thinking of tossing this pump team (they all come together as one) because the more I think about the quality of support they have given me the more I think it's just not good enough.

There's this trap I fall into that I've "made it" being a bit more stable 4 months on... and that it doesn't matter if the team is a bit inept. But really my eyes are being opened to thinking the journey is still just begininng towards better control, and I need better live support. (Already got fantastic net support here :) )

Just like you Jan I have found all these little bits of bad advice were major stumbling blocks... and even if I was dubious it was hard to shake them off. Perfect example was the nurse telling me that pre meal bolus pauses were a thing of the past. You assume these people know what they are talking about, you assume that it's dangerous to muck around with this unfamiliar new bit of tech... so instead of trying it earlier and discovering I can need a substantial pre-bolus, I struggled with bad post-meal BG for over 6 weeks before finally shaking off the "advice". Stupid of me not to question it before that, perhaps... but sometimes you just get caught out.

I just don't think these people think how much a bit of dodgy advice can throw a major spanner in the works!

I don't want to jump to conclusions, and I am still open to reasons for the long acting carbs... thanks milfordj that's a good point about the exercise, but sadly wasn't the situation.

[Gary_W]

For someone as educated and switched on to what their own profile is as you clearly are, it's not good advice; I've heard far worse from some doctors, but it's not the best. For some people the advice she gave is not unreasonable.

As you rightly say, it may be more reasonable of someone on MDI who has the added bonus of guessing whether it was their basal or their bolus insulin that got them. On a pump you only have the pleasure of guessing your current absorbsion characteristics of rapid (which can still vary quite a bit).

I think it is the kind of blanket advice given out by a doctor who believes that the average patient doesn't understand their own insulin profile. And, as the average patient she sees probably doesn't understand their own insulin profile, it isn't such bad advice to give out for the sake of safety even when a patient is only on rapid. It's amazing how many people are completely convinced that Novorapid only lasts 3.5 hours tops when the profile on the website shows a bit is still active after 6.

Keep doing your own thing but realise she is guilty of tarring you with the same brush as everyone else rather than poor advise as such. And that tarring irritates me as well :)

Gary

[Emm]

I agree with you subby - the idea of taking a slow acting carb after fixing a low was only suitable for those on MDI with unreliable basal insulins. It leads to a lot roller coaster BGs as you end up high and have to dose again.

On a pump, or even good MDI insulins, you shouldn't have to do this at all - unless you're planning to go jogging soon after the low!

[xMenace]

Subby,

You sound exactly like I did when I started almost two years ago. I felt such measures were atiquated. My "team" was not helping me use my pump to control such episodes, rather they treated me exactly like an MDI patient. Finally I stopped going to my weekly "adjustment" meeting, I was working at the hospital, and started following the advice I was receiving here. TYVM Spike!

A hypo should not be looked at as a point in time. A whole raft of variables need to be examined and assessed such as
- recent boluses
- recent episodes and tendencies
- food!
- activity
- set "confidence"
- planned activity
- historical reactions (liver dumps)

I have treated hypos with more food, but more often than not I'll end up bolusing and/or upping my basals for my inevitable dump.

The 4.5 is rather high too. Mind you a 4.5 will trigger my spidey senses, but I'll assess risk before treating.

[Subby]

Thanks for the words of wisdom Gary, you are absolutely right, I know exactly what you mean about expectations, anhd a bit of reality check of what to really expect is nice cold water in the face.

xMenace, thanks for your comments, what you say kind of confirmed suspicions in my head as to how to approach hypo treatment. I will keep this attitude to factors firmly in mind.

You are right about the 4.5 a little high. Thing is, again, they are happy with "ok" control, ie 7, 8, whatever, and that's where I think the "throw extra carbs in" attitude comes from (as you point out Gary). I am realising that I simply don't stabilise well around those numbers and I HAVE to aim for 5s and 6s. As background, I am very sensitive and any stability from hour to hour under 8 is like a tightrope walk with blindfold on. My experience with MDI was that 5s and 6s were simply too close to low for stability as well - due to the inherant movements I experienced on MDI.

I am finding out the pump can potentially afford me stability to "hover" in the good range of 5, 6, and if I do this a certain stability does assert itself. But to do it I have to make sure I'm not making all those bad little decisions, and starting to be aware of those extenuating factors like you hint, Xmenace.

Actually, my problem is not so much a non awareness of them, but more a puzzled scratching of the head of how to act on these issues. I am learning, though.

[xMenace]

Try some "profiling." Do some basal testing, skip meals and test hourly, and track pre-post meals with some intense testing. Better yet, use a cgms.

I found doing these exercises very informative. They solidified my expectations of where my bgs tend to track. I now know my two hours before lunch have downward pressure. I know my mid afternoons from 2:30 to 4pm also tend to drift down but then stabilize. I was so confident that one day I drove home in rush hour with a 4.5. I had a juice handy and was focussed on my condition (after the road of course). I was 4.5 or 4.6 when I got home.

These 6 or 8 a day tests we do are ok for determining whether you are on your expected track, but to find out what that track is, go crazy with the sticks!

[Chappo]

I follow this a lot, especially if you tend to suspend or reduce Basal when low.

However, one thing that your team may be contributing to the advice that you should take long acting carbs when having a hypo with your short acting carbs is that you may still have IOB during & after the Hypo (depending on what insulin you're taking).

However, the above advice seems plausible and remember:

Everyone's diabetes is different. A team of people cannot tell you how to manage your diabetes best - they can give you advice, but if something is working better, or their advice isn't working, then you have every right to tell them and change how you approach it.

[HollyB]

The long-acting carbs can be a useful short-term fix for one of those days when you're going hypo over and over -- Aaron just had one when we went from winter to summer overnight. Suddenly in one day he biked, played soccer, played frisbee, walked miles... he tends to think too late of reducing his basal. Then you get the delayed lows into the night. So if there isn't a snack or meal coming up soon, the follow up with a protein/complex carb snack can prevent the hypo that's still lurking after your glucose tabs have run out.

But as a long-term strategy, instead of making needed basal/bolus adjustments? Plain dumb. That's what a pump is for, so you don't have to stuff your face with snacks you don't want.

[Subby]

I am indeed going to go another round of profiling again, with tighter control in mind. I need to stop overreacting so much to hypos and overreacting to getting down around 4.5. My body is used to feeling higher, so at the moment I have to try and sit with "feeling" low and shaky, as I know the way forward is hold there and let things adjust. This conversation has really helped me realise I need to aim lower. Thanks.

Alex, you are righ of course it does depend if there is excess IOB. As everything seems to be the case one has to keep aiming for flexibility to the situation. Regardless of that advice being good/bad/indifferent, I'm trying to foster that flexibility, situation awareness!

Thanks for pointing out again I have that right to try and communicate with the team. It reminds me that I can but try the way you say. And, if the relationship simply doesn't work after reasonable amount of trying, then life's too short and I should just move on find some other people to work with. And be positive :)

[Subby]

Since this thread, I adjusted my target range to 5 - 5.5 (previously 6.5) and I have made a concerted effort to put up with the usual spidey feelings (great description!) and hypo effects that I get around 5.5 down. And I've stopped following my gut reaction to trend up a bit for safety/long term, ie the philosophy behind safe MDI and the dr's comments.

I had a very rough 15 hours of feeling constantly slightly low - a horrible night. But things stayed very stable around 5. I have now had a whole day of the best control yet. By that I mean that I've stuck for a long time around 4.3 - 7, rather than spiking up towards 10 and beyond post meals and "times of resistance". Tho boluses seem to work quite a lot better if starting from 5, than my usual 7 - 9 I was "aiming" for before. I used to think that absorption/resistance problems occured above 10 or 12, what I am seeing suggests it's a factor even once I start hitting 7 or 8.

So, what with a definite improvement in hour to hour stability, that I feel is here to stay (at least partly), I'm pretty happy, and very grateful to you guys for sharing your experience and advice.

One last point, now that I have gone through the rough patch and my body has adjusted better to "sticking around" 4.5 - 5, It seems that hypos are less traumatic, too. (less detectable, perhaps too. But less physical impact of the type that leaves me wasted.) The apparent improved stability by keeping BG lower makes me suspicious of automatically accepting the logic of "stay higher for a safety margin"... as it appears that staying higher could potentially encourage instability. I believe this has been part of my difficulty so far.

Great to be making a little progress.

[pegasus]

Great to hear your progress, Subby.

I never knew about much less followed the 15-15-15 protocol until I started pumping, and have found that my body does not respond to 15 gms w/in 15 mins. When I have found myself still too low and taken more, I zoom up and over within 15-30 mins. If I wait 30 mins for the next test, I'm near normal.

Since she was new, it's not surprising that she'd try and try to follow strict "guidelines," but her attitude that this was the only way tells me that she has some personal issues or she was poorly trained in being an educator. Smart ones know how to listen to the patient!