Question about bolus/basal amounts

[Diabetesnet.com]

My daughter (nearly 12) has been dx nearly 6 years. Pumping for 5.

Frustrating time of it these last few days. Need to make several changes it appears. +30% increase in basals is not even touching her numbers. ( i run temp rates to see what, if anything works and when /how much etc) before I actually change the program in the pump.

Is there a magic formula that says if you tighten I:C ratios say by 10% (which is usually where I (or the endo) starts) and it also seems basals need adjusting that I can do X amt for the basal increase and have it balance? I am thinking that surely she wouldn’t need a 30% increase with tighter I:C ratios? I do tend to be aggressive and tackle two things at once. (don’t remember if I have ever changed 3,but i also thought it’s probably time to tighten our Correction factor as well. I am sure our endo has changed 3 things at once. But it’s been awhile. Since it’s easy enough to go back if there are times the increases (in this case)end up being too much.

Our A1c’s have been consistently under 6 for the last couple of years at least. and under 7, i think since after the first year of pumping. The last few days I cannot keep her under 200, or rarely does she stay there. And have been correcting at least .5u and sometimes 1u at a time. No ketones thankfully.

I also know that as parents we call this The Curse of the Endo appt. since it appears that generally all of our kids tend to have these major highs shortly before the endo appts. (ours is in just under 2 weeks).

Thanks,

C

P.S. Perhaps one of these days I can get to a CWD conference and sit in on some workshops that you do , or am blessed to hang out at meal time table talk. That i have heard also takes place.

[John Walsh, PA, CDE]

No, the Curse of the Endo appt. is when the major highs start shortly AFTER the endo appt! Tell your daughter she has excellent timing. And congratulate yourself on the excellent control.

Unfortunately, your question is complicated and can’t be answered here. At 12, your daughter may be starting the teens when glucoses get a lot harder to control for very good reasons. Expect a 4 year or so period of excess growth hormone, estradiol, and sometimes stress hormones fighting the efforts of both of you for control. Your daughter is certainly at the right age – recent weight gain may indicate a routine growth spurt, while sex changes suggest puberty.

When puberty starts, I encourage my teens (with their parents) to try a Type 2 medication called metformin which works to:


reduce unneeded glucose production caused by growth hormone, mostly during the night
lower their need for insulin
usually make them feel better with lower glucose levels. A teen without diabetes just puts out a bit more insulin from the pancreas directly to the liver to handle this, but the teen with diabetes needs a very large increase in subcutaneous insulin to reach the levels needed by the liver. Metformin shuts off the liver’s excess and unnecessary production of glucose, reducing the need for insulin. See http://www.medscape.com/viewarticle/447833 for information or search on childrenwithdiabetes.com for discussions on this.

During the teen years, a body sometimes needs double the insulin per pound of body weight as during the pre-teen years. The basic approach is to check the blood glucose often and give as much insulin as is needed. Her endo will help with increasing doses.

Use of temp basal rates, as you are attempting, is a good solution in these unclear high glucose situations. For growth spurts or for puberty, a temp basal increase is needed around the clock until you and her endo can figure out new settings. To clarify this for others in the blog: lowering the I:C ratio number increases the size of carb boluses, which, as you suggest, is probably also needed. Again, something you’ve probably already done, but be sure to start a fresh bottle of insulin – bad insulin is not a common problem, but it happens.

Other things that teen parents have to keep in mind: If losing weight is an issue for your daughter, some teens find that skipping insulin is a quick way to lose weight (and ruin their health). I doubt this is an issue – she’s at an age where you expect her to need a LOT more insulin, but is one of the things your endo has to keep in mind. Teens also sometimes reach a point where they tire of the routine and they think they don’t need insulin and stop it or reduce doses to find out. Again unlikely, but something to keep in mind. Both of these issues are usually accompanied by a decrease in glucose checking, so if checking frequencies are good, these problems become unlikely. A pump’s history also provides good oversight for insulin doses.

Let us know how it goes, and I look forward to more discussion with you both at one of our table talks.