Hi Everyone,

At my pump group meeting last week, we had a guest speaker who is a nurse practitioner running her own business helping people set up their pumps.
She uploaded all of our pumps and showed the various Carelink reports online.
When she looked at mine, she said my basal rates were too complicated. My endo has told me the same thing.
They were:
midnight .3
3AM .35
4 AM .40
6:30 .50
Noon .45
10PM .40
11PM .35
Total 10.25

She noticed I had a lot of lows. I admitted that I eat some glucose to prevent lows at least once each day. She offered to help me. I was very excited, since both she and my endo seem to think that it's possible not to need so much glucose, and to have a basal pattern with fewer rates.

First she had me run all day at .4 That resulted in a lot of highs, and clearly showed a dawn phenomenon. She changed me to midnight .45
4 AM .50
9 PM .45
Total 11.65 - a lot more than my previous total, and we're trying to eliminate lows!!!!

I wound up with lots of overnight lows, and changed my midnight setting myself to .40

I sent her some reports today but she didn't reply yet.

I'm just curious whether it's worth going through this. Does my previous basal pattern look too involved to you? Do you also watch your CGMS and gobble a glucose or two at least once a day?

Let me know what you think,
Linda

I have two patterns on my normal setting
12:00AM 0.60
08:00AM 0.55
for 13.6 units a day . I rarely have overnight lows. I like to be around 140-160 at bedtime.
I would work on the overnight lows first and work from there.
When were your lows occuring on your "complicated" pattern ?

This is mine.

Midnight-6AM- 2.5
6-10 AM - 3.5
10 AM-1:30 PM 2.0
1:30pm-12 AM 5.5

Total 9.35

It's less complicated that yours but when I lowered that 5.5 to 5.0 I was spiking. Now I am having lows around dinner time. This worked until I recently changed my eating habits. Maybe mine needs more fine tuning. I'm going to wait until I go back to the gym.

it is not necessary to "simplify" by reducing the number of basal rates. I have DP and have 5 rates. been doing that for many years--works great. have u read Pumping Insulin, by John Walsh yet? it's our bible and perhaps after reading that, and keeping a log for a while, you avoid dealing with the endo on such things. it's best to be autonomous with a pump (ie dont rely on your endo). btw, I used to have 6 rates and that also worked well but for some reason that I have forgotten, I changed it up a bit, a long while ago.

I've messed with my basal rates more since I moved out here to the East Coast than I ever did in Colorado. I'm now running just essentially 3 basal rates:

12:00-2:00 am - .50
2:00-4:00 am - .55
4:00-noon - .60
noon-midnite -.50

Total 12.9

It's rare that I have more than 2-3 hypos every two weeks. Been having a few lately, though. May have to reconsider things.

One of the interesting things I've done is adjusted my I:C ratio to be the lowest for breakfast (when my basal is the highest). I don't know what the deal is with this, but it seems to work.

Tom

If having multiple rates works better for you then keep them. Sounds like it's harder for the doctor to get a picture of what's going on by looking at too many numbers. In january/February I was having a lot of highs, especially after dinner through the night. I hate waking up high. I changed a bunch of rates. I had a week or two when my needs were even more insane so I created a new pattern, the first time I tried that. For the past week I've now been having too many lows, especially overnight so I have to lower everything again. Last night before bed I tested and was 109 (I think) but I could see my sensor was slowly trending down. I set a temp basal of 30% for 3 hours and still went low.

I am being more careful about what I eat and that does really change everything for the entire day.

I guess my basal rates are the most complicated of all:

12:00-2:00am - .3
2:00-4:00am - .25
4:00-6:00am - .3
6:00-8:00am - .35
8:00am-6:00pm - .4
6:00-8:00pm - .35
8:00-10:00pm - .3
10:00pm-12:00am - .25

Total 8.2

My rates were higher, total about 10, until recently. I was having a lot of nighttime lows. I kept looking at my readings and lowering rates for the time periods before I was going low. I think I would have fewer rates if I was on an Animas and could have the .025 increment. From 8pm until 6am I alternate between .25 and .3 but I think it would work to have a .275 rate for that whole time. If it's all .25 (or all .3) for that period, I go too high (or low).

Like Linda B, I also am correcting lows (glucose tabs, teaspoons of honey), or eating in anticipation of a low, almost every day, depending on whether I'm at my computer, or shopping for groceries (lower BG). It's hard to anticipate how many times I will walk up and down my stairs (lower BG). I have a jar of jelly beans (1 gm carb) that I pop as needed.

Barbara

It's hard for me to believe that after running the CGM + finger stick testing and looking at
several years worth of CareLink reports one would still be questioning there basal settings.

For those of us that are fortunate enough to have a CGM there should be no
problem getting there basal's set.

I Know my basal settings are not perfect every day, but there as close as there going to get
until they close the loop or the pumps start making basal suggestions based on past CGM trend history.

JohnG

I have been pumping for 14 years, and using the CGMS since the first day it became available. I tend to over-react to a one day incident where my BG rises or falls too quickly. I was adjusting my basals every time that happened. I didn't really question my basal, my endo AND a new CDE did when looking at my settings and the carelink data.
Since the CDE offered to 'recalculate' my basals I thought it sounded like a good idea, especially since I tend to go low at least once each day.
When the CDE wasn't available yesterday, I thought I'd see if anyone else had as 'complicated' a basal pattern as what I was running.

Basals do need to be tweaked now and then. I thought maybe starting from scratch would find a pattern where I did not have as many lows.

Linda B.

I do the same thing! And then when things go back to how they were before it takes me forever to change the basal back.

I changed a bunch of rates yesterday and still woke up with a low around 4:00am. I know I need to do proper basal testing but haven't been willing to skip meals lately. One time when my rates were crazy I just set everything to one rate for 24 hours. Didn't work, obviously, but it was easier to see where changes had to be made when my rate was so even.

I've nearly identical rates for many years. when I need to make a change, it's usually done via the temp rate. when I am very active day after day, I'll switch to a basal profile that is roughly 1.5U less per day than my "normal" basal profile. When I am too sedate, I set my pump to around 112% temp rate for 24 hours and reset it the next day if I am again being "lazy". I've not had to drastically ever alter my rates in the last 13 years except when I have had a steroid shot, in which case I might as well be pumping water.

My opinion is that whatever method gives you the type of BG control you want, is the method to use.

About a year ago, I found that I wanted to make corrections to my basals at times that were not available with about 6 values. Since insertion of basals is not possible on the MM 522, I made an entry for each of the 48 times available. Now, when I notice repeated highs or lows around the same time each day, I can adjust the basal 4 hours earlier. It works for me!
The last time I saw my Endocrinologist, he wanted to get the settings from my pump. I handed the pump to him, and he copied all 48 settings by hand! He didn't request that I simplify the basal profile, but I felt sorry for him and offered to print out my settings before my next visit. It could save about 5 minutes in his office.

DaveD

WOW - I can't imagine having 48 entries - too many keystrokes to make a change towards the end of the day!
I had hourly entries from 3 AM till 9 AM because those were the times that I keep adjusting.
I'm surprised your doctor didn't combine your entries into groups (assuming you run the same rate across several hours).

I've had issues trying to get the pump settings report from Carelink. Sometimes it spins for hours without producing a report. It's the only report that I have problems with.

Linda B.

The settings report took about 2 minutes to appear a few minutes ago, so your problem may be the time of day that you try to get it. I don't get that report often enough to have seen a problem.

DaveD

I find that the device settings report takes a long time. Eventually it does generate a report.

You may be amused/horrified by my basal pattern. Keep in mind that I'm a type 2 with a weak pancreas so I have some natural insulin.

00:00 0.1u/h
01:00 0.75u/h
02:00 0.86u/h
03:00 1.15u/h
05:00 2.0 u/h
06:00 2.7u/h
07:00 3.55u/h
08:30 2.5u/h
10:00 1.8u/h
12:30 0.25u/h
14:30 0u/h (yes, zero!)
22:00 0.1u/h

Yes, I actually run with no basal for 7.5 hours/day! My pancreas still puts out enough insulin to cover my afternoon/evening basal needs. I've done enough basal testing to be sure. Anyway, as strange as that pattern may look, it looks me fairly level in basal testing, as confirmed by CGMS.

[Edit for typo]

I'm doing some basal testing right now. It seems like my basals change after any alteration to my body chemistry, like after I've gotten over a virus, or after my period. Then there's stress. My basal rates need to be much higher during the school semester, although that's definitely not a convenient time to skip meals in order to fine tune them. My rates are pretty complicated too. Right now I'm working with

12a .65
2a .70
5a .65
8:30a .65
11a .55
1p .60
3p .65
6p .55
8p .75
10p .65

Total: 15.45

My endo told me once that was too complicated, but after doing a series of testing with her, she only reduced the number of settings to 8. I kept records of each basal test and each adjustment she told me to make so that I could apply the same approach myself when only small changes need to be made. But I hate that I have to do it so often.

I used to have at least as many basal rates as you but when I set up my loaner pump for our trip to Galapagos in April I simplified and ended up keeping the simple version. They seem to work as well as before. I'm due to do some basal testing but I can't make myself get to it. Here are my settings:

12:00am .4
4:00am .5
8:00am .45

Total: 10.8

I guess when we're not skipping meals, our bolus ratios make up for flaws in our basal rates and vice versa. I SHOULD do the basal testing!

Barbara

12a: .275
5 a: .375
7a: .4
10a: .275
1:30p: .55

Total: 10.075

I prefer the term "whatever works" over 'complicated' This is me:

12am 0.70
2am 0.75
3am 0.90
5am 0.85
10am 0.70
2pm 0.60
5pm 0.50
7pm 0.70

My endo also says you don't need so may basal rates and I only had about 6. Yet he doesn't do anything to change it. I think if what you've got is working for you then stick with it. When i see a problem of reoccurring highs or lows i change the basal sometimes this means an extra rate sometimes one less. I don't care as long as it fixes the problem.

I have four different basal profiles though. I just changed my arvo run one and now it is the same as my workday profile anyway.

Basal profile 1 WORK DAYS
0:00 0.65
3:00 0.60
18:00 0.75
21:00 1.05

Basal profile 2 LAZY DAYS
0:00 0.65
6:00 0.85
9:00 0.75
15:00 0.80
21:00 1.05

Basal profile 3 6AM RUN
0:00 0.65
4:00 0.60
8:00 0.75
15:00 0.80
21:00 1.05

Basal profile 4 ARVO RUN
0:00 0.65
3:00 0.60
18:00 0.75
21:00 1.05

I only have one!

That is REALLY unusual. Most people need more than one. Are your BGs stable and predictable? Are you back to 'normal' before each meal? Do you go low or high at any particular time of the day? Having more than one basal rate can fix those issues.
If you don't have them, then you are very lucky!

Linda B.

Whats a arvo run ?

JohnG

12am 1.10
9am 1 .15
1130am 1.25
4pm 1 .45
9pm 1.35
10pm 1.65

:

I meant I only have one profile! I don't think I'm very lucky when I look at everyone else total basals.

12am 1.25
4am- 2.55
10:30 2.0
3:00pm .35
7:30pm .80

Total 35.8

Wow you all seem to be on such a tiny amount of insulin?! Am I wierd? I only weigh 117lbs 5'4" my basals are

12am .75
3am .70
6am .75
9am .75
12pm .75
3pm .80
6pm .70
10pm .75
total 17.80


They were higher, but recently lost 10 pounds because of stomach problems.

Bolus wizard is at:
12a 14
5am 8
12pm 8
5pm 8
10pm 8

There's nothing unusual about the amount of insulin your using. The average Type1 pumper uses
43u--TDD (Insulin pumpers.org surveyed 1000 Type1 pumpers)

I use 23u of basal insulin each day and my TDD is +/- 50u. In 2007 my TDD increased
dramatically it's was around 30u for 20 years. I'm not as active and may be showing
some signs of metabolic syndrome and my weight is 20 lbs less now than when I was
younger.

I have mentioned this before, but comparatively, I seem to be using a lot of insulin (and yes I am type 1). I seem to use between 80 and 100 units daily (occasionally going over 100 units). The 20 unit difference is mostly due to what I eat on different days and partly due to corrections.

I feel like a slacker... I've only got four but I've only been pumping for a couple of weeks. I had my pump basals programmed before my first "post delivery" meeting with the CDE. I based these on my records and what I "knew." When I showed up, the CDE arrogantly erased all of my entries without even looking at them and started with just one. As time has gone on, she has entered more rates. I have to keep from laughing when she does as it's starting to look like what I had before she wiped my entries. I'm not sure how long I am supposed to subordinate myself to her settings. I am a TII and she says TIIs do not get DP. Well, I do!. As soon as I can, I am going to program a morning "kick" for around 5AM.

Have you considered finding a different CDE? The level of ignorance exhibited by her statement boggles my mind!

Here is a paper published in the NEJM that talks about type II and DP.
Maybe you should share this with your CDE.

http://www.nejm.org/doi/full/10.1056/NEJM198403223101203

You must be a subscriber to NEJM to see that entire article. All I could see was the abstract...

Tom

IMO, wearing a MM CGM or other brand that might be available in your case, should be the first step taken by your endo or G.P. in starting to get insurance approval for your pump. By downloading a graph showing your daily trends over each 24 hour segment, DP and other odd phenomena would be clearly shown. This would give your endo, CDE, pump trainer guidance in accurately setting basal rates for a new pump user.

Shaku, my Medicare + private insurance requires that I see my endo every 90 days. Insurance coverage of my pump supplies requires this frequency. On each visit, instead of downloading pump records using the MM "Carelink", my endo instead just downloads a 90-day history of BG tests from my One Touch Ultralink meter. In my last visit, the graph showed a trend at about 10:00 AM upward, past my target range. He asked me to raise my basal rate from the present of .500 units per hour to .600, then return to the preset rate at 12:00 PM. Since my average BG's are so much improved on a pump compared to MDI, such a small adjustment would not have occurred to me on my own.

Do you see an endo, and/or does your CDE use trends shown by your long-term meter records to make the basal rate adjustments? If not, and assuming that your meter stores enough info. to print out a trend graph of long periods of time, you could use those trends to guide you in adjusting your own basal rates. If you do that, be conservative and feel your way slowly. When my endo says "use .6, not .5", I trust him enough to just do it. On my own, I would probably try a larger increase and just learn from the consequences. Good luck!

I cannot "fire" my CDE as she is part of my Endo's practice. I have not seen my endo in more than 90 days. I am not sure whether the CDE is considered a sub for the Endo or what. The CDE has me E-mail the TDD chart and the log, but doesn't seem to care about the BG charts. I feel quite capable of managing the basals on my own, but I don't want to get into a brawl with the CDE. The next time I see the Endo, I will probe a little to see if he will support me doing the basals largely on my own. The obvious thing to do is to just make the basals the way I want them. but the history section on the pump could tattle on me.

Why are you worried. It's your body. You don't work for her.

I agree with Arlene's statement, but I can imagine that a conflict with your health care professionals could possibly put your easy access to supplies at risk. All Diabetics need to make their own intelligent decisions, but for most, insurance regulations require us to work in partnership with doctors and CDE's.

It might be worth your time to go doctor shopping, but it's obviously your decision to make- good luck!

I learned several years ago that it is productive to push back against your medical team a bit. I use to leave visits and later on, wonder why I just accepted things without saying anything. I guess it came to a head when I thought I was seeing my endo and next thing, my visit is with a nurse practioner (is that what they're called, I'm drawing a blank right now, but a nurse that has some of the same abilitiies as a DR., like able to write rx's). I saw that my copay and the bill to the insurance company was the same as my endo. It just got under my skin a bit and I felt like I was having to educate her and some of her advice/ comments was different than my Dr.

Since that experience, I've been a bit more assertive about what I want from my medical team and I am happier with the results.

Peter B

The last time I saw my endo was also the first time I saw her, back in March 2005. When I went back in April 2005 for a follow-up she sent me in to the CDE and that's who I've seen ever since. I know that the endo is the one who has to sign off on all my pump stuff (annual prescriptions and things like that) but the CDE writes all of my regular prescriptions (Humalog, Levoxyl, even my Advair inhaler that has nothing to do with diabetes). In the beginning (after getting my pump) I was calling & e-mailing the CDE all the time when I had questions or when I was running high and knew it was a basal issue. She woul;d tell me what to change. After 3-4 months I stopped asking her and just made changes on my own. At my next appointment I'd tell her what I did (or she would look at the pump settings and compare them to what she had written down at the last appointment) and she would sometimes ask me why I made certain changes. Sometimes she's change things back. Sometimes she'd change things and I'd fight with her about it. Now she usually doesn't say anything unless she feels I made a bad call. She doesn't go in and change things without asking me. She is happy that I make changes on my own and said she wishes more of her patients did.