Help with overnight/morning basal rates

[donnellysdogs]

I went low whilst driving. Although I pulled over and was treating the hypo somebody behind me stopped and called ambulance and police.
So although anbulance people monitored me they did nothing. The police were ok but would not let me drive home and bundled me into a police car and got a van for my 2 dogs that were in the back of the car.
I then had to tell our driving licencing agency and had 3 months of hell whilst they decided if my licence would be withdrawn.
The hospital for the next day appt was a new one that I had never beeen to. The consultant literaly shouted at me in fromt of others that I deserved to lose my licence for 12 months at least. The nurse saw me and got me to see another consultant who listened. He really listened and backed me as did the wonderful DSN. Certain membees here backed me to the hilt and ai will never forget their kindness and support. Never. They saw me through my driving incident and getting my pump. ;i admit 5 years ago I didn't even know what a pump was!!
Then I moved back to England and met a fantastic consultant here. She always reminds me of the impact of hypo's etc but this consultant as well as the 2nd one and DSN in Wales have been true examples of the best NHS care anybody could have.

I will be eternally grateful for the support I had here and from the NHS.

 

[Spiker]

I think your pre-rise early morning basal rate levels have gone too low and this explains your mid morning high. Remember, when you adjust, adjust the rates around 2-4 hrs before the high, not at the actual time of the high. I think you had an effective rate to minimise your dawn high and getting-up high and you have removed those now.

By the way what's the insulin target on your correction calculator? Is it set for 7 mmol/L on the upper end? (eg 6mmol/L ±1)

 

[Janelle123]

I went low whilst driving. Although I pulled over and was treating the hypo somebody behind me stopped and called ambulance and police.
So although anbulance people monitored me they did nothing. The police were ok but would not let me drive home and bundled me into a police car and got a van for my 2 dogs that were in the back of the car.
I then had to tell our driving licencing agency and had 3 months of hell whilst they decided if my licence would be withdrawn.
The hospital for the next day appt was a new one that I had never beeen to. The consultant literaly shouted at me in fromt of others that I deserved to lose my licence for 12 months at least. The nurse saw me and got me to see another consultant who listened. He really listened and backed me as did the wonderful DSN. Certain membees here backed me to the hilt and ai will never forget their kindness and support. Never. They saw me through my driving incident and getting my pump. ;i admit 5 years ago I didn't even know what a pump was!!
Then I moved back to England and met a fantastic consultant here. She always reminds me of the impact of hypo's etc but this consultant as well as the 2nd one and DSN in Wales have been true examples of the best NHS care anybody could have.

I will be eternally grateful for the support I had here and from the NHS.

I'm sorry you had to experience that but I'm glad you got the support you needed.

Thanks again for all the help you've given me

 

[Janelle123]

I think your pre-rise early morning basal rate levels have gone too low and this explains your mid morning high. Remember, when you adjust, adjust the rates around 2-4 hrs before the high, not at the actual time of the high. I think you had an effective rate to minimise your dawn high and getting-up high and you have removed those now.

By the way what's the insulin target on your correction calculator? Is it set for 7 mmol/L on the upper end? (eg 6mmol/L ±1)

I've got it set to 5.5 ±1.5

 

[Janelle123]

I had very unexpected results this morning, not sure what to do at all now...

Rates:
00:00 = 1.000
03:00 = 1.050
05:00 = 1.250
06:00 = 0.900
08:00 = 0.600

9:03pm = 8.1 - 0.4 units
10:35pm = 6.1
2:00am = 3.7 - 10g carb
4:43am = 3.6 - 10g carb
6:35am = 4.2
7:19am = 4.2

I wander if it has something to do with my weight. I've been hovering between 62kg and 62.5kg for the past week and then this morning I was 61.4kg. Could that have caused me to require less insulin or do you think this is just a one-off unusual night?

 

[Spiker]

There is no way that a miniscule 0.5 - 1.0kg weight change has any effect on anything.
I think you need to make a rule not to change your basal rates more than once every three days, and don't make any change in response to an assumed 'pattern' unless you have seen that pattern 3 days in a row. Also, only change one thing at a time, and wait 3 days to confirm the effect.

In general, never change anything (basal rate, ratio, anything) based on an event that has only happened once. You will be chasing your tail forever.

 

[Spiker]

9:03pm = 8.1 - 0.4 units
10:35pm = 6.1
2:00am = 3.7 - 10g carb
4:43am = 3.6 - 10g carb
6:35am = 4.2
7:19am = 4.2

Are you sure you didn't take 4.0u by mistake instead of 0.4u?
What was going on before 9:03pm? Had you eaten and taken a bolus dose or an earlier correction dose?

 

[donnellysdogs]

Was your activity any different yesterday day time or heat/weather?
The only way I would get a difference like that would be:
A) foremost activity during daytime or evening or
B) Did you have any bolus (food or correction) within 5 hours previous to the 8.1 that could have still been active?
C) end of periods etc could affect like this...

The levels plummeted between 10 and 2 not at the times that were altered later although they stayed low.

 

[Janelle123]

Just checked my pump and I definitely only took 0.4 units at 9:03pm.

5:59pm = 4.5 = 5.3 units = 53g carb
6:59pm = 4.5
7:33pm = 4.5
7:41pm = 4.2 = 8g
7:58pm = 3.2 = 19g
8:43pm = 6.5
9:03pm = 8.1 = 0.4 units
9:31pm = 8.1
10:06pm = 7.1
10:35pm = 6.1

I may need to adjust my carb ratio but this was only an issue last night. Previous night I had these results:

5:22pm = 5.4 = 5.3 units = 53g
5:43pm = 4.8
6:01pm = 6.9 = 0.8 units = 8g
6:34pm = 12.2 = 1.4 units (correction and bolus) = 8g
6:45pm = 10.1 = 0.8 units = 8g
7:01pm = 9.0
7:43pm = 5.7
8:20pm = 5.8
8:39pm = 4.8 = 7g
8:54pm = 6.5
9:03pm = 7.0 = 0.25 units
9:33pm = 8.0 = 0.25 units
9:45pm = 8.0
10:05pm = 7.7
10:48pm = 8.2 = 0.4 units
11:16pm = 7.9

So with the same carb ratio I had very different results the night before last.

I feel horrible right now...
This morning:
7:19am = 4.2 = 0.5 units = 5g
8:10am = 5.6
9:14am = 4.2 = 4g
9:23am = 3.8 = 4g

This is soo different from yesterday

I guess it could be hormonal...

 

[Spiker]

So at 7:41pm and 7:58pm you took 27g CH, half your main meal, without any bolus insulin?
Try to avoid doing a correction dose only 3 hrs after a bolus. Wait 4-5 hours. In this case this confuses the picture but doesn't quite explain your night time lows.
Was the 53g CH meal the same on both days?
On the previous days you are also stacking correction doses (less than 4-5 hrs after previous bolus). Are you using an IOB calculator for this? Otherwise you do risk hypos.

Sorry none of that really answers the question of what happened. But if you can adopt some of these 'best practices' it may make it easier to figure out was has happened, next time around.

 

[Janelle123]

So at 7:41pm and 7:58pm you took 27g CH, half your main meal, without any bolus insulin?
Try to avoid doing a correction dose only 3 hrs after a bolus. Wait 4-5 hours. In this case this confuses the picture but doesn't quite explain your night time lows.
Was the 53g CH meal the same on both days?
On the previous days you are also stacking correction doses (less than 4-5 hrs after previous bolus). Are you using an IOB calculator for this? Otherwise you do risk hypos.

Sorry none of that really answers the question of what happened. But if you can adopt some of these 'best practices' it may make it easier to figure out was has happened, next time around.

Yes, since my BG seemed to be dropping quite quickly I didn't take any bolus insulin. I only planned on eating 10g carb at 7:58pm but the lolly was too yummy and I ate the whole thing lol. I know I shouldn't take any corrections within 3hrs but I didn't like seeing the 12.2. I did take IOB into account though.
The two meals were different. It's just a coincidence that they had the same amount of carbs. Tuesday night was wedges with sour cream and sweet chili sauce and last night was chicken nuggets and coleslaw (healthy I know!)

 

[Janelle123]

Do you think I should just leave my basal rates as they are and then see if the same thing happens tonight?

 

[donnellysdogs]

Agree with Spiker.

You need to have one meal, one bolus and one correction in a clear 5 hour period.

My best advice from my consultant was to keep my eating and bolusing 5 hrs apart when first starting on pump.

I had been advised to eat breakfast and lunch but I was not leaving 5 hours clear between the eating to see the full reaction of any actions. If I needed to do a correction I was only to do one and to wait 5 hours.

At 7.41 And 7.58pm you gave a total if 27g as a hypo stopper it appears and 15g in one go would have been better advised as you ended up over treating.

Have you done basal testing for evenings? If you have then your bolus at 5.59 is too much and you need to alter it. If you haven't basal tested snd missed your evening meal... Then you need to do this.
Having 4 separate bolus's the previous evening within 90 minutes is not ideal. It is stacking and not giving a clear picture later.

It is not any answers for the night hypo levels but ai believe that sll the corrections you had last night between 9 and 11pm impacted sugnificantly later....

Also can you remind me what your acting time is set to please? As I think this may also be a reason why your pump is giving you so many corrections within such a short time.

 

[donnellysdogs]

Have you had any corrections tonight?

 

[donnellysdogs]

If you have had corrections in the last 3 hours I would eat 10g long lasting carb before bed if your levels are under 6.0.

If you haven't had any corrections and your levels are around 6.0 I would not eat or give any corrections at all during the night if your levels were to go up even to 9.0. As you need to start at a fresh in the morning.

I would suggest that you

A) have main meals only and spread 5 hours apart.
B) only do one correction if needed and then wait another 5 hours before either correcting or eating. Yes, this would delay further meal times... But it would determine whether your correction doses are correct and what your acting time is.
C) do some basal testing for morning or an evening

 

[donnellysdogs]

Do you think I should just leave my basal rates as they are and then see if the same thing happens tonight?

I personally would not change basals tonight but have given instructions above as to what I would do.

 

[Spiker]

So it looks like you are going low in the early evenings. Maybe setting up a chain reaction for later. My gut feeling is we are trying to solve more than one problem at a time here - and that's fruitless. My other gut feeling is the biggest problem is not your basal rates but that evening meal bolus, the carb ratio there.

What we need to do is slow everything down, simplify it, and solve the biggest problem first. I think that's the evening meal. Now probably we will have to iterate and go through everything twice: first fix the evening bolus / carb ratio (approximately), then fix the basal, then do a second fix on the ratios and then maybe a final fix on the basal again. Unless you are able to go straight to a fasting basal test? I realise you are working and having a routine and stuff but that might be best.

But, yeah, fix one problem at a time and fix the biggest problem first. Stop stacking your corrections, regardless of IOB. You can try that stuff when you have no other problems going on, when you're confident in your ratios and your basal. Stacking will make you go hypo, regardless of IOB, if your correction ratio or carb ratio are wrong. Basically your basal, carb ratio, correction ratio, and IOB duration all have to be right, otherwise stacking/IOB will not work. So let's leave that for the advanced stage.

 

[Spiker]

I may need to adjust my carb ratio but this was only an issue last night. Previous night I had these results:

5:22pm = 5.4 = 5.3 units = 53g
5:43pm = 4.8
6:01pm = 6.9 = 0.8 units = 8g
6:34pm = 12.2 = 1.4 units (correction and bolus) = 8g
6:45pm = 10.1 = 0.8 units = 8g
7:01pm = 9.0
7:43pm = 5.7
8:20pm = 5.8
8:39pm = 4.8 = 7g

I have to disagree. The previous night you were also going low and taking carbs at 8.39pm, 3hr 20m after your bolus at 5.22pm (which you followed up with a stacked bolus). That shows you overdosed for the meal on the previous night as well as last night.
I can only tell this because you have such great records by the way

 

[Janelle123]

Agree with Spiker.

You need to have one meal, one bolus and one correction in a clear 5 hour period.

My best advice from my consultant was to keep my eating and bolusing 5 hrs apart when first starting on pump.

I had been advised to eat breakfast and lunch but I was not leaving 5 hours clear between the eating to see the full reaction of any actions. If I needed to do a correction I was only to do one and to wait 5 hours.

At 7.41 And 7.58pm you gave a total if 27g as a hypo stopper it appears and 15g in one go would have been better advised as you ended up over treating.

Have you done basal testing for evenings? If you have then your bolus at 5.59 is too much and you need to alter it. If you haven't basal tested snd missed your evening meal... Then you need to do this.
Having 4 separate bolus's the previous evening within 90 minutes is not ideal. It is stacking and not giving a clear picture later.

It is not any answers for the night hypo levels but ai believe that sll the corrections you had last night between 9 and 11pm impacted sugnificantly later....

Also can you remind me what your acting time is set to please? As I think this may also be a reason why your pump is giving you so many corrections within such a short time.

I can't remember how to find the acting time on my pump but I'm pretty sure I remember it being 4hrs

 

[Janelle123]

If you have had corrections in the last 3 hours I would eat 10g long lasting carb before bed if your levels are under 6.0.

If you haven't had any corrections and your levels are around 6.0 I would not eat or give any corrections at all during the night if your levels were to go up even to 9.0. As you need to start at a fresh in the morning.

I would suggest that you

A) have main meals only and spread 5 hours apart.
B) only do one correction if needed and then wait another 5 hours before either correcting or eating. Yes, this would delay further meal times... But it would determine whether your correction doses are correct and what your acting time is.
C) do some basal testing for morning or an evening

Thanks, I will try to stick by these rules. I think I just freak out once my BG is over 8 because my husband and I are trying for a baby and I've read that the limit for 1hr after a meal is 7.8. When I'm above 8 I worry that I'm harming a potential baby.