[nashscan]

I started pump therapy yesterday. Before that, I was taking 12 units of lantus at night, and an I:C ratio of about 1 unit per 8-12 carbs, depending on how active I was. It kept me from spiking much at all after meals, and my blood sugars were kept within 30 points from bedtime to sunrise.

My new CDE now has me taking .65 units/hour, which comes out to 15.6 units/day basal. She's got my carb ratio of 1 unit/11 to 13 carbs. I'm spiking up well into the 200's after meals, and my increased basal is very slowly bringing down these high post meal sugars over a period of hours.

I've e-mailed her about this, and she replied if the blood sugars stay high like this over the next few days, she wants to increase my basals. I really really don't think that's the answer. I feel I need to be more aggressive with my bolus, and ease back on my basals. I e-mailed her again and she said

"the way pump therapy works, the basal rate controls blood sugar
overnight and to some extent, between meals. The meal boluses control
blood sugar for the first 2-3 hours after eating a meal. People often
need significantly more or less insulin over night compared to daytime
hours."

Well, yeah. Mmhmm. What do I do? I REALLY REALLY don't think more basal insulin is the answer!

[fenagle]

Hey Preston, I have the same issue, post meal highs. My endo doesn't seem too concerned at this point. I am though. I was on two shots of 70/30 before the pump and I just wanted to even out the peaks and valleys. Maybe we can figure this out together. Have you gotten a copy of Pumping Insulin by John Walsh yet? Everybody on the other forum I am on recommends this book as the bible for pumpers I find it very technical but well worth it's weight in gold. Good luck and stay in touch.

[fgummett]

While your CDE is correct that getting the basal set is the key to successful pumping (or any insulin regime), I'm not 100% convinced that this is the best way. There are threads here on DF about basal testing that you might want to check out. In the meantime... the beauty of a pump is that you can correct those after-meal highs by pushing a couple of buttons

[gettingby]

nashscan, you probably should do a couple of overnight and daytime basal tests.
Check out this site:
Insulin-Pumper's HOWTO
I know it has helped me a great deal.

[Gordonm]

The basal is not supposed to bring post meal BS down. It is there to maintain your BS if nothing is eaten. Your requirements during the day and evening and morning can vary. The only way to do this is with proper basal testing. The bolus is to cover any food intake you have eaten. Many people and even educators get this wrong. You should be able to go for as long as you want without food on your basal settings and maintain your BS. It should not go up or down with basal.

[BlueSky]

I agree totally with what the others have said. Basal insulin covers background insulin needs and should keep blood sugar stable in the absence of food. Basal testing is the way to find out where where your basal rate is too high/low. You then adjust the basal rates accordingly. Typically, people need higher basal rates in the early to mid morning hours, and finding the optimal levels is something you really need to do by yourself. IMO, the CDE is just too far from the action to be able to give useful input. And when you have got your basal rates sorted, you can start fine tunig your bolus dosages.

[Subby]

Originally Posted by nashscan

I started pump therapy yesterday. Before that, I was taking 12 units of lantus at night, and an I:C ratio of about 1 unit per 8-12 carbs, depending on how active I was. It kept me from spiking much at all after meals, and my blood sugars were kept within 30 points from bedtime to sunrise.

My new CDE now has me taking .65 units/hour, which comes out to 15.6 units/day basal. She's got my carb ratio of 1 unit/11 to 13 carbs. I'm spiking up well into the 200's after meals, and my increased basal is very slowly bringing down these high post meal sugars over a period of hours.

I've e-mailed her about this, and she replied if the blood sugars stay high like this over the next few days, she wants to increase my basals. I really really don't think that's the answer. I feel I need to be more aggressive with my bolus, and ease back on my basals. I e-mailed her again and she said

"the way pump therapy works, the basal rate controls blood sugar
overnight and to some extent, between meals. The meal boluses control
blood sugar for the first 2-3 hours after eating a meal. People often
need significantly more or less insulin over night compared to daytime
hours."

Well, yeah. Mmhmm. What do I do? I REALLY REALLY don't think more basal insulin is the answer!

I had a similar kind of "fuzzy logic" applied when the pump doctor was apparently trying to help me work out my doses. Actually, in my case it the opposite, (boluses doing the work of basals) but the result was similar, confusing the role of one over the other. I spent 2 weeks in phone conversations every second night requesting to put up my basal and discussing the reasons and evidence why I should (they insisted every decision went through the doc). These "conversations" would run to 30 minutes she was so concerned at me upping basals and so insistent on upping boluses which I knew would give me major lows. It was simply a brick wall.

After 3 weeks I went ahead and made the change with instant improvement and relief. I felt it was unfortunate that I had to go directly against her advice but very relieved at the improvement. At that point the contact had turned to email. I emailed her to tell her that I finally did up my basals and the good, trend bucking results, and was careful and appreciated her help and appreciated her support (I was supposed to get another 2 months of contact). I never heard from her again. Personally that was upsetting and disappointing but in the end I don't think she was any use at all and was severely obstructing my control (I say that sadly).

Sorry for the digression there nashcan, but it seemed to be pertinent. Hopefully you can stick to your guns and at least "get permission" to "try" a higher I:C and not up what sound like already aggressive basals. I'm hoping your DE turns out to be far more reasonable than that endo, if you just state yor case firmly.

But I wanted to describe what sometimes does happen in this situation - and if you are like me of course you want to have a productive relationship with your team and you don't want to go renegade at all - but at some stage if you don't get joy cutting across incorrect assumptions and attitudes about the pump and this blocks your way to finding control, you may not have the luxury of a choice. Best of luck in this tricky time.

[nashscan]

After much thought (and support from my fiance) I went ahead and lowered my basal rate to the 12 unit/day Lantus shot I was doing just two days ago. A VERY low blood sugar that came seven hours after my lunch bolus today convinced me that NOW was the time to make an executive decision in my treatment plan. I also changed my I:C ratio from 1 unit/13 grams to 1 unit/10 grams. Again, this was similar to my MDI treamtent plan which was working very well. I did this right before dinner at 6:30 tonight and I have seen MASSIVE improvement already. My post meal BG's stayed in the 100's and haven't moved much. Tonight until tomorrow until lunch will be one big long basal test.

I really hope this doesn't sabatoge my relationship with my CDE, but I'm the quarterback of my team, and I have to ultimately make the calls. If she supports my decision, I'll be so grateful. If not, I'll be a little bummed. I'll find out tomorrow when I e-mail her.

[BlueSky]

Originally Posted by nashscan

... I really hope this doesn't sabatoge my relationship with my CDE, but I'm the quarterback of my team, and I have to ultimately make the calls. ....

I have for many years made all the day-to-day treatment decisions myself. I have found that I get a good response from doctors and CDEs as long as I tell them what I have done, why I did it, and what the results were. They do their best to ensure that I have the situation under control and provide whatever support is needed. Most doctors prefer their patients to be in control, and I really wouldn't want to work with medical advisors in any other way.

[nashscan]

My CDE e-mailed me back yesterday and said looks like the changes I made served me well, and if I keep it up, they may have to hire me in the diabetic clinic. HA!

[Subby]

Good one, sounds like she is listening. If you go take her job, can you send her over here?