recently on pump having the worst hypos

[Gembles84]

Hi I wonder if anyone can relate to this. Recently been changed to the pump about a month ago, having hospital checks changing by basal to suit me and seemed to be going well. The past two nights I've tried square wave dose with my tea. Readings both tea times have been under 9.0 so I've taken doses, eaten tea and not even an hour later I've gone low...3.7 then to 2.6 and for the next 3 hours I haven't been able to get my blood sugars back up! Its been horrible..then eventually by 11pm (ish) heading up....then by 2am you can imagine....15 - 20 readings. Waking up like I don't want to face the world to be honest!! Please can anyone offer any advice/tips and also how to get out of a hypo straight after eating. Many thanks

 

[tim2000s]

Hi @Gembles84 , firstly can I ask why you elected to use square wave boluses with your meal? Secondly, in comparison to the amount of carbs you ate in your food, what amount of insulin did you give for your square wave? A square wave acts like a temporary basal rate, so the effects can last quite a long time, but without knowing the bg levels beforehand, what you ate, and what drove your decisions, it's hard to give you a huge amount of help.

With regard to your question about hypos immediately after eating, is that on a normal bolus or with square wave? When do you take your bolus in relation to your food?

 

[catapillar]

Did you cancel the extended bolus when you dropped? Or was that square wave running for the whole time you were hypo - if so, that might explain why it was difficult to get back up again.

If you cancel any extended bolus/increases Tbr when hypo, that should let you treat without having to over treat and end up hyper - you can always resume a (reduced) increased basal later to mop up any delayed carb action, which I'm assuming was the reason for square wave in the first place (?)

 

[Gembles84]

Hello @tim2000s thank you for replying. I had been advised square wave would help with the more higher carb meals and both tea time meals I had chips. First meal being sausage and chips from the chip shop (naughty treat I know!) my blood was 9.0 before hand, I counted 100g carb (going by my carb book, chip shop looks very high carb) and took 10 insulin dose as square wave over the hour. The second tea (yesterday) was chicken, oven chips and baked beans...again thinking quite a higher carb meal I took 9 insulin dose with this as I counted 90g carb, weighing my oven chips and thinking I was counting my carbs correctly. My blood sugar was 6.3 before hand and again I chose square wave over the hour. Also I started my doses as I sat down for both meals. I know its all trial and error to the individual, but its been awful...bit scared for tonight's tea to be honest! Thanks again

 

[Gembles84]

Hi @catapillar the square wave had gone in over the hour I'd set it for and shortly after I'd felt hypo. The active insulin was in my body and I put on temp basal while hypo so there was nomore going in, but it was already too late. I'm still learning with the pump, its all fresh for me...maybe I've used square wave incorrectly by the sounds of it? Hard getting that sugar in when there's all that food in there! Thanks for your reply

 

[Juicyj]

Hi @Gembles84 To be honest I only use the square ware feature when I eat either a curry or pizza, I find chips tend to get absorbed a bit quicker so I need to pre-bolus about 20 minutes beforehand (I only eat a small handful at the most if I do eat chips though) and as with any meal I test around 3 hours later to see that the bolus delivery hit the mark. Maybe do this a standard bolus delivery instead and report back what happens ?

 

[tim2000s]

@Gembles84 - you have it right there as to where the problem is. Basically, your square wave is too short for the meals you are eating.

For chip shop food I use Dual Wave rather than Square as I find I still get a carb rise early on, but the picture below hopefully explains what's happening. In order to manage the late food spike you get from this type of food, the square part of my bolus typically lasts for 4 hours.

*Don't take the timings in this as accurate, they are for illustration only

I wish we drew more pictures. Things like this are much easier to explain with pictures.

 

[catapillar]

Yeah I'm not sure there's any point doing a square wave over just an hour.

Have you got pumping insulin by john Walsh? It's a good guide on what the pump can do and how to use it.

 

[iHs]

Fish and chip shop chips are probably high in fat, whereas frozen oven chips have a bit less because they are lightly sprayed with sunflower oil.

 

[Gembles84]

Hi @Gembles84 To be honest I only use the square ware feature when I eat either a curry or pizza, I find chips tend to get absorbed a bit quicker so I need to pre-bolus about 20 minutes beforehand (I only eat a small handful at the most if I do eat chips though) and as with any meal I test around 3 hours later to see that the bolus delivery hit the mark. Maybe do this a standard bolus delivery instead and report back what happens ?

Thanks @Juicyj that's really helpful and makes sense...so much info to take in at once! But that's really helpful thank you. I'd rather be avoiding these horrible hypos straight after food when I'm already too full!

 

[Gembles84]

@Gembles84 - you have it right there as to where the problem is. Basically, your square wave is too short for the meals you are eating.

For chip shop food I use Dual Wave rather than Square as I find I still get a carb rise early on, but the picture below hopefully explains what's happening. In order to manage the late food spike you get from this type of food, the square part of my bolus typically lasts for 4 hours.

*Don't take the timings in this as accurate, they are for illustration only

I wish we drew more pictures. Things like this are much easier to explain with pictures.

Thanks @tim2000s picture makes much more sense its having a fresh mind outside the box to see what I'm not seeing myself which is hugely helpful, thank you. So this would explain the horrendous low for over 3 hours and it not shifting until later then. Thanks once again

 

[Gembles84]

Thanks

Yeah I'm not sure there's any point doing a square wave over just an hour.

Have you got pumping insulin by john Walsh? It's a good guide on what the pump can do and how to use it.

Thanks I'll give that guide a go. I'm only going by the book I got with my pump and the info from the nurses, but there's so much more to learn by the sounds of it. Just want to avoid these after meal hypos Thanks again



Edit: Cleaning up a bit.

 

[noblehead]

I had been advised square wave would help with the more higher carb meals and both tea time meals I had chips. First meal being sausage and chips from the chip shop (naughty treat I know!) my blood was 9.0 before hand, I counted 100g carb (going by my carb book, chip shop looks very high carb) and took 10 insulin dose as square wave over the hour.

Tbh I'm not surprised you went hypo, a Square-Wave bolus over an hour isn't the best option for a meal that is high in both fat and carbs, I would only use a Square-Wave bolus if I was eating over an extended period of time.

A better option is to use a Dual-Wave bolus, which means you bolus a % of your bolus dose upfront ahead of your food then extend the rest over a period of hours, this works for most of us but how long you extend it for depends on your bg results.

 

[Gembles84]

Thanks @noblehead I've been looking at the dual wave options as well. So would it depend on what you're eating and what your bg is before meal as to how long you do the dual wave for?

 

[noblehead]

Thanks @noblehead I've been looking at the dual wave options as well. So would it depend on what you're eating and what your bg is before meal as to how long you do the dual wave for?

It does depend on what your eating and pre-prandial bg levels, it's all trial & error really just the same as it was on MDI.

I find keeping a diary and recording the results is a good idea so the next time you eat a particular meal you can refer back to it, if in doubt how to use the extended bolus features of your pump just ask your pump DSN for assistance, but the books Pumping Insulin and Think Like a Pancreas both discuss the bolus options on a pump and using them for difficult meals like those that are high in fat.

 

[Gembles84]

That's really helpful @noblehead. There's so much to consider isn't there when all you want to do is eat and enjoy some delicious food!! 20 years on and you'd think it'd get easier ha! Thanks again

 

[Gembles84]

I have tried today just doing my normal one dose of bolus and 2 hours later my bloods dropped down very fast. My bg was 12.2 before tea, I had a chicken tikka masala with pilau rice (ready meal) with carbs of 72g, quarter of a naan bread which I counted as 15g (small bit) and took 9units of insulin due to the correction bolus amount added on my machine. I've waited just over 2 hours and tested and its dropped right down to 3.3 and after Lucozade it won't budge again! I even had a cheeky half of cream egg after tea which I didn't account for in hope it'd keep me up!! Would this be my basal too high? Or bolus? I'm on 10:1 ratio for my carb count and its usually spot on Fed up now!

 

[catapillar]

Were you on 10:1 before starting your pump? Usually, insulin delivery via a pump is more efficient and so when people start on a pump, their ratios drop a little bit. If this is only happening at dinner, it might be that you need different ratios at different times of day.

You might also need to check that your correction factor is correct.

To look at whether your basal rate is correct, have a look at the info in the link - https://mysugr.com/basal-rate-testing/

 

[Gembles84]

Were you on 10:1 before starting your pump? Usually, insulin delivery via a pump is more efficient and so when people start on a pump, their ratios drop a little bit. If this is only happening at dinner, it might be that you need different ratios at different times of day.

You might also need to check that your correction factor is correct.

To look at whether your basal rate is correct, have a look at the info in the link - https://mysugr.com/basal-rate-testing/

Thank you @catapillar. Yes I was on 10:1 ratio, but I feel I'm having too much around the big meal times for this to be happening. So would the more insulin I'm receiving at tea times be more active in my body for longer? (could explain the hypo 2 hours after food) whereas if I took less, is it in my body as active insulin for less of a time?

 

[catapillar]

I don't think delivery via pump affects the timing of the insulin action, as far as I know. Hypoing 2 hours after bolusing doesn't suggest a particularly extended insulin action timing.

However, delivering insulin via pump makes the insulin action more efficient. This is because you have rapid insulin being delivered both for you bolus and your basal. Also there is something about insulin pooling from pump delivery that is thought to make if more efficient.

You might want to think about:

1. Reducing your tea time bolus by a unit or two if you know you are consistently going low after tea. Or, if you think it's clear you are having too much, make the changes to your tea time ratio now (1:12 or 1:15 or 1:18, whatever you think is appropriate on the basis of the lows)
2. Performing a bit of basal testing to check your basal rates are correct now you are getting settled on a pump
3. When you are confident that your basal rates are correct, have a look at your carb ratios and consider whether they need reducing/adjusting

I would highly recommend getting a copy of pumping insulin to give you confidence to do these checks and make the changes

https://www.amazon.co.uk/Pumping-In...id=1477692791&sr=1-1&keywords=pumping+insulin