Basal the low away
It’s day two of Blog Week, today’s writing assignment is how to treat a low BG.
My wife and I sat in CHOP’s pump class listening to the trainers tout all the reasons why insulin pumping was the way to go and we were on board with all of them. My daughter Arden had type I for about two years by this time, Arden was diagnosed just after her second birthday. She is a tiny little thing, on the day of her diagnosis she weighed just seventeen pounds. By the time we reached this pump class I had become a master of injecting dropsof insulin and I was adept at playing, what I refer to as, the scale game. I think of diabetes management like the scales of justice but the scale trays have holes in the bottom in my version. You put some food on one side and it takes the scale off balance, so you add some insulin to the other side. Sometimes the food runs out before it should and then the scale gets too heavy on the other side and so the day goes like a teeter-totter, gaining and losing riders. All I have to do is stand next to it and add the needed ballast to the proper side. Just that easy.
But back to that pump class. The trainer came around and asked if we had any questions. People had tons, about activity, swimming all the newbie questions that pop into your head. I only had one question, I wanted to make sure I was understanding basal rates correctly, I asked, “am I reading this right, can I shut off the basal rate?”
The nurse said, “yes” and with that I was sold.
To me dealing with a low as a MDI patient was particularly disturbing because of the slow acting insulin that is active in the body. Anyone that has used Levemir or Lantus will tell you that it seems to “burn” faster at times for no real reason, making it wildly unpredictable. The notion that I could just stop the background insulin was amazing to me. I now do it all the time, sometimes to slow a fall, sometimes to keep a BG level and often I do it just to buy me more time. I’ll give you some examples:
(Literally), our school nurse called just now, it is time for recess and Arden is 64, too low. It’s been 2 hrs and 30 mins since her last bolus and she is eating lunch in 30 minutes. If she wasn’t going to recess a would shut her basal off and retest her before lunch. Her are my reasons; we are well past the peak of her last bolus, she isn’t going to get any lower without insulin. I bet if I shut off her basal right now and sent her back to class (she has no symptoms) she would be 90 at her pre-lunch test. But she is heading out to play so I gave her a small candy (13carbs) and turned her basal off for 30 minutes (the basal isn’t probably needed here but I’m gong to trade a slightly higher BG for the nurse’s sanity). This will counteract the activity and address the low. She’ll be back before lunch probably at 160. If I’m still writing when they call back I’ll put the BG (here). UPDATE: Nurse just called, Arden is 165 before lunch and after recess. I’ll leave this space empty to receive your applause { }.
Last week Arden was trending very low all evening, she was in the 120s before bed and I expected the lows to continue, so I tested her at 1am. At 1am she was lower then I had anticipated (64) so I shut her basal off for an 90 minutes and went back to bed. When I tested her at 2:30 she was still in the 60s, a stubborn low. This next bit is a great example of how you can use restricted basal rates to control BGs. At 1am Arden hadn’t had a bolus in 5 hours, so there is no residual insulin from the 8pm bolus left. She is falling because of her basal. Now I know that you may think the basal is just too high but please trust me it isn’t, this is an isolated anomaly. Now the last thing I (any of us) want to do is wake up a 5 year old with a low BG at 2:30 in the morning and ask her to eat or drink, so I didn’t. Instead, I’m going to take what the previous BGs tell me and use it in conjunction with the upcoming ‘dawn phenomenon’ against the low. I also lend some credence to the knowledge that our meters have a 20% window of accuracy and with Arden her “real” number is usually higher then the meter indicates by 10-15 points. So I’m betting on a few things; her BG is probably more like 75, which is less scary, sometime after 3am her liver is going to start making glucose and there is absolutely no insulin left in her body. So I shut her basal off for a further 3.5 hours and went back to sleep. The next day I woke up early at 5:30am to check her BG and she was 125. I win!
I figured that there would be a barrel full of knowledge handed out today about foods that bring up BGs. I have my favorites as well but to be honest, if your BG is falling fast you need a fast acting carb, if it’s stable but low you can use something a bit more slow acting that won’t cause such a severe spike. None of this is brain surgery. If you really want to jump to the next level of care... learn how to manipulate the basal rates to get you where you need to be. For my money, the best feature of Arden’s OmniPod is being able to restrict or shut off the basal rate. It’s the best way I know to control a low.
Here’s where I tell you that I’m just an idiot with a computer, not a doctor and taking my advice may significantly shorten your or your child’s life. For the love of all that is holy do what my wife does... and don’t listen to me.
Seriously, you should talk to your endo about this method but be warned that they may not be comfortable with it and therefor just dismiss it out of hand. If I’ve learned anything, it’s that doctors don’t like to appear not to know, so do what you think is best after gathering as much information as you can.
I do want to add for clarity that if you gave a bolus that ends up being too large and an hour later you are very low, shutting off the basal rate isn’t going to make a dent in your precipitous drop. This method is to be used in a few very specific situations. Please be careful and test, test, test.
If you missed it, my day one addition, “A day in the life... with diabetes” to Blog Week is here.
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The following are archived comments from this post. You can post new comments below.
Great post! I think the pump is geat for kiddos. Oh yeah and I'm subscribing to your posts.
Tuesday, May 11, 2010 - 02:32 PM
Scott
Practiced what I preach early this morning. Arden's #BGnow was 64 at 6:30 am, shut her basal off for an hour and she woke up at 95.
Wednesday, May 12, 2010 - 10:41 AM
You've got it down! Good for you! Now, can you help me? :)
Wednesday, May 12, 2010 - 12:04 PM
Scott
I'd be happy to help everyone!
Thursday, May 13, 2010 - 07:55 AM
When I had my pump training, I was told not to correct a low by turning off my basal because it takes too long to work. Which you also pointed out in your post. But it never occurred to me that I could reduce my basal to fend off a low. Brilliant! I tried it just last night - before bed I was 71 with over 1 unit still active from a snack. I didn't want to eat again because I had JUST brushed my teeth. I know I've been staying fairly stable overnight - so I knocked my basal down to 70% for two hours. Worked like a charm, because I didn't get a single low alarm from my CGM. And when I woke at 4am (because the cat decided it was play time) my blood sugar was 82!!! Thank you for the great tip!!
Friday, May 14, 2010 - 10:21 AM
Scott
Karen,
It makes me so happy that my tip worked for you - you don't know. Because I understanding what your life is like (on the level that I do), your comments literally made my eyes fill up with tears. This comment alone made your Blog Week project worthwhile for me.
blog week - http://bittersweet-karen.blogspot.com/
Best,
Sunday, May 16, 2010 - 08:51 AM
I also think that this must work more quickly for children. I've utilized my two-year olds sons pump temporary basal setting to keep his BG stable or to come up over night quite often, mostly because he HATES to be asked to eat or drink anything once asleep (who could blame him). I have however had a difficult time utilizing it for exercise as it seems that the effects of it being shut off are longer lasting than I'd like and often lead to more drastic highs later.
But for us it's definitely the best way to treat nightime lows.
Sunday, May 23, 2010 - 06:38 PM
