Pump basal settings and pregnancy

[LiveNormal]

I have been type I diabetes for 9 years, started pump 6 months ago, no CGMS, currently residing in foreign country and therefore no reliable endo to guide me on the adjustment of basal or carb ratio;current setting is the result of my consistent self home glucose monitoring.

I am 7 weeks along and soon to be 8 weeks. My current basal has been slightly increased (about 30%) compared to before pregnancy. If you consider below 3.5mmol/L as hypo, then I must admit that I encounter more than one hypo daily. My A1c tested last week was good at 5.4%. I do find that my hypo is threatening me at times since I am very hypo unaware. I test about 8~14 times a day. Everyday's readings seem to be so different. At one time I thought I see the trend of getting hypo after lunch, just when I was about the change the basal and carb ratio, the pattern change again. I would like to know how do you approach the change of settings (either basal or carb ratio) typically, do you change one at a time or both at the same time? Do you change the basal by the incremental of 0.05 or 0.10?

Also, one of the endo saw my basal settings and commented that my basal rate changes too frequently (like every hour's rate is different). I know this is a problem as I was so stressful when come to having to adjust the basal. She told me that typically basal rate can be divided in 7 segments, being 0h~3h, 4h~7h, 8h-9h, 10h-13h, 14h-19h, 20h-21h and 22h-23h. She also claim that 0h~3h typically is the minimum rate throughout the day and 4h~7h the maximum. I find that my rates are all over the place and my maximum rates seems to be in the segment of 10h~13h. She also commented that my before lunch reading was low (if I eat porridge for breakfast) and that could result in my after lunch readings rebounding from those low. Does it make sense? In that case, do I need to make sure that get rid of those lows before lunch? My 1 hour after breakfast is usually within range, however within an hour, the BS will drop 50%. I find that it might be due to my basal settings. I ususally take my breakfast at 0730hr and my hypo usually happen between 0930~1000hr. If I want to change my basal, does it make sense to change the rate from 0630~0730?

One good thing for now is that I don't feel any pregnancy symptoms yet. I just can't imagine myself handling all these symptoms and the insulin requirement adjustment at the same time.

I have the book called "Pumping insulin" by John Walsh and it has been a great help since I started pumping. However, I am starting to loose track now and would appreciate any advice.

Thanks, Lynn

[Subby]

Hi Lynn, the best advice I can give to find good basals is to look up "basal testing" in "Pumping Insulin", and follow the advice very carefully. In essence you do some short term fasting (even 6 hours at a time is enough) to get rid of the influence of food and boluses, and work through the 24 hour in different chunks, taking hourly or 2 hourly tests to "map" how your BG is going. Through the hours, it will reveal if your basal rate is covering your background needs. And if not, which direction to adjust, and when. The process is done through the day, in a number of segments. So you might do 12am - 8am one morning, find that the numbers are good, then a day later, do 8am - 12pm (skipping food for that period), and make some adjustments... come back and do 8am - 12pm again.... etc, moving through the 24 hour period at your leisure. Just to be clear, the set of hours you do each time are not testing one particular basal rate or anything like that, baal rates are changed, modified or added simply as your BG dictates.

You've got the best resource to describe the process so that you can do it properly, in the book. To follow this method to determine your correct basal rates is the absolute best way to answer almost every question you've got here! If you feel any confusion about the process after reading the chapter in the book, feel free to ask here about it.

A couple more points:

- great a1c. While I know exactly how volatile fluctuations are frustrating and can make getting through the day every day traumatic and stressful and have bad effects on the body and mind, you're still obviously getting good general results, and you're doing the right thing by trying to clear this up this way.

- It does sound like your basal rates are overly complicated. While I don't agree with doctors who try and claim the "max required" is 4, 6, or even 10, chances are you've arrived at the wrong rates and overly adjusted, from what you say. Trying to basal test 20 rates or whatever you have is really going to complicate the process out of sight. Try and generalise and simplify back to a smaller number, say 6 or if too hard, 10. From the position of too many, possibly incorrect rates, basal testing is like a very convoluted, complicated puzzle. From a base of between 1 and 8 rates, it's more like a simpler join the dots as you go, and you can add complexity (more rates) if the basal testing demands it. While basal testing, do rememer your basal has a lag of 1-3 hours - so if you see a trend at noon, you would want to change the rate at 11 or 10am, and see if it is effective.

- The doc's comments about typical basal rates are somewhat useful to reflect on, but only to a point. Yours may be different. Mine are different from his typical scenario. Worth thinking about but then throw preconceptions it out the window and use basal testing to reveal your particular basal profile. Chances are though, that he's right your rates are overcomplicated, expect more of a simple, flowing picture to emerge.

- As John Walsh points out in the book you need your basal to be sorted out before you can troubleshoot your boluses or I:C factor. The exeption is when the I:C factor is wildly out and produces the same obvious problems. For example, if you are going low after each meal, it would be pretty obvious your I:C is too high, and adjusting down based on that fact is a good idea.

However, when it's not clear and obvious, or you suspect basal settings and are not sure, you need to start with testing you baal over that period, first, as without knowing the basal is right, there is simply no way to know which (or both) is really to blame.

Finally I should say that I have zero experience with pregnancy and diabetes, bear that in mind. However, I think the basic advice of basal testing should be the sound and correct action for you. Maybe you will need to do it every few months as your body changes and needs changes to your basal rates, I don't know. Good luck, feel free to ask us about the process or how you are going.

[LiveNormal]

Thanks for the detailed response.

I was trying to be relaxed about the whole thing and what I have been hearing from other professional was that my readings were too low and that I will need to take special attention when I hit the nasty months when I will have morning sickness day and night. This fear was too much for me to bear. On one hand I do not want to over decrease my basal and result in high BS to harm my baby. On the other hand, I have heard enough how low blood sugar can result in fatal accidents with the mother and therefore lose the baby out of that.

I guess I have to trust the basic principle of finding the right basal and be hopeful that my basal will be fixed up soon.

Lynn

[Subby]

I guess I have to trust the basic principle of finding the right basal and be hopeful that my basal will be fixed up soon.

Lynn

I know that basal testing sounds very involved and technical on the page - it's not really. It's just a systematic way to test your un-affected BG levels to see what to do with the basal rates. It needn't interfere with life much or be more than an activity you do for part of the day, for a few days or maybe a week. Take it in your stead and you will make progress with your basal from the first testing session. No need for oodles of trust, it's just a process that will simply work if you take it on :)

This tool is your absolute best one for ensuring good basals and avoiding those lows. The docs simply have nothing better: general theories or hastily considered adjustments, that may or may not be wrong and may or may not yield stability.

Best of luck, keep us updated how you go.