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Friday, March 4, 2011

Crash and burn

It seems to me that I may have asked this question before. But I don't remember and am much to lazy to search for it, so here it goes:

Lately we have to give Elise her rapid-acting insulin at least 20 minutes (and sometimes 30) after she STARTS eating her dinner, or she will CRASH. For example:

Yesterday her BG before dinner was low 100s. She ate (and finished her dinner - 40g), and I gave her her shot 25 minutes after she started. One hour later she was 45.

Two days ago she was low 300s (not sure why) before dinner, so I gave her her shot at the same time that she ate. She had 35g, and about 45 minutes later was 151 with double arrows down on the CGM. I rode it out and she ended up steady in the low 100s.


She gets between 35-40g of carbs at dinner. It used to be 30g, but we usually have to give her between 5-10g when she crashes, so we just added it to the meal time. Anything over 40g, she goes high after she crashes.

It's like her body absorbs the food soooooo slowly at dinner. This is the only meal it happens at. Breakfast I can bolus her up to 30 minutes prior to eating with no problem.

She only gets 1 unit of humalog at dinner. I don't want to give less because it is so imprecise to measure up 1/2 a unit. And I don't want to go back to diluted either.

So, any ideas? Anybody have this happen to them? I know I could work around it on a pump, but with everything going on in our life right now, we have put the pump decision on the back burner.

Edited to add: This has been going on for about three weeks. We dealt with it about 3 months ago, but it went away in it's own. Unfortunately, it's back and doesn't seem to be going anywhere.

Edited further to add: So tonight she was 191 going into dinner. I gave her her insulin right as she started eating. Via the dex, her BG went down to about 150, but always with a flat arrow (her BG would lower by a few points each update). Weird. We never saw a crash, but we never saw a spike... just a flat line for almost 2 hours post-dinner. Maybe she's starting to come out of whatever this is. Glad to know we're not the only ones.

14 comments:

  1. Sorry, I've got nothing... truthfully we have been pumping for so long that MDI scrambles my brain a bit. But you have me curious... so I will be checking back to see what the other more brilliant than I commenters say. :)

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  2. We have just been going through this with Ally, but it was happening at different parts of the day - randomly. We are pumping, so I did play with basals a little bit too. I wondered if she was getting a stomach bug or something and her tummy was just not absorbing the food like normal.

    I am curious, though, since it is only happening at dinner for Elise. If you were pre-bolusing, I'd say to wait and bolus after the meal. Since you have the CGM, can you let her eat and watch the CGM (or set a temporary high alarm at a certain point??) and only give her the insulin when she starts rising?

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  3. And just for the record, I was at a complete loss when we were going through this too...and still don't know what was going on. I really don't think it was anything that I did to correct it.

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  4. My son is 10 but we had the same issue. What has really helped is using regular insulin for dinner.

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  5. I wish I had advice, just wanted to say hope it gets better!

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  6. It appears you ARE bolusing after the meal. Correct? Have you tried a softer ratio? Has she been having baths right after her shot...sometimes the hot water of the bath would increase the absorption rate of Joe's insulin when he was younger...he would always go low on bath night. Thank goodness he didn't take many baths - LOL. Otherwise...I would push back the injection by 15 more minutes. Good luck Jo - Love you guys.

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  7. We always give Cara her shot after she eats just because we never know how much she is going to eat. Some days tons other days nothing. But at dinner the last 2 nights after dinner she has crashed on us. Low both times at snack time, we followed everything right and I have NO idea why this happened?? I know that different types of carb absorb differently and the one night was pasta and we are so hit and miss with that. Sorry I guess that really does not help!!

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  8. We've been dealing with this same situation...actually what happens is after dinner he crashes, we make up for it with a fast acting carb and he comes up to the 100's nicely...then bam at 2am he's HIGH. What we're beginning to see, I think, is the effects of slow digestion and fat spikes. His I:C ratio is set so that he's receiving half the amount of insulin for dinnertime than breakfast his basal is pretty much similar to what it was from about 3pm on. This is an odd question, but does Elise go #2 soon after waking? Here is the odd part for us, as soon as Isaac goes poo his BG drops at least 50 or more pts within about 10 minutes...no joke. We have no solution, his Endo said there is no solution right now because it just has to do with digestion slowing for bedtime. What we've tried and it works sometimes, better than nothing, is a square wave bolus after he eats dinner covering the entire amount of carbs for a four hour period. I am not sure how to work this on MDI, not sure if NPH would be better with slow digestion or not. What happens if you don't cover dinner until about an hour after? Just wondering since it takes H about 2 hrs to peak maybe if the peak were later coinciding a little better with digestion it might help. Not sure, really..but if you figure something out let me know :)

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  9. @ Reyna... yup, she's been getting her insulin 25-30 minutes after she eats. Sometimes she's even done eating before she gets it. And we always wait to do the bath after the crash.

    As for a "softer ratio"... am I stupid for not knowing what that is? Sorry, my brain has been pickled and I'm not so s-m-r-t these days (that's smart for any non-Simpsons fans)

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  10. I hope she is coming out of it, but just in case it does happen to happen again for you tomorrow, here's my suggestion:

    It sounds to me like either her insulin ratio needs lowered, or maybe shes going through a growth spurt and that might be causing the lows and the food absorbtion rate to be different. If ya do give her less than 1 unit to prevent these lows, they do have half unit marked syringes on the market (we had to get them for Lenny when he was on MDI's, and our insurance paid for ours), so you could always talk to your endo about getting the half unit marking syringes instead... that way, your not guessing at where "half a unit" is on the syringe, because the line on it will show ya :)

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  11. I wish I had an answer for you! Right now I'm kinda in a d funk with figuring out stuff. It's like my mind just can't take one more number, one more calculation... IDK! NO HELP I AM! Just wanted to tell ya I'm thinking of you!

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  12. We do have a pump and we use Apidra to help with spikes after eating but the evening hours from 6pm thru midnight have always been our most difficult hours of management D-wise. First, you probably know this but BD does make half unit syringes if you want to use half units. What I notice for us is this period of time is when there is the most basal fluctuation which, in turn, causes contributes to lows and highs. Easy to see on the pump when you have settings for this time period. These go in weekly or biweekly "waves"; high waves, normal flat line followed by the low wave. The lows always seem to follow after a three, four or five day period of really normal management. So just adjust the ICR or give more food, watching the pattern and when it shifts again, so do you. Certain foods we dual wave or even bolus after. While riding the low "wave" I would just do what you do, give a few extra grams of free carbs with dinner or if you don't want to do that, bolus after. You are surfing in the ocean and respond in the moment.

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  13. P.S. I forgot to mention.... Insulin does NOT match the digestion of food correctly. Period. You are doing the best you can with a very imperfect type of insulin, injected insulin under the skin. No first phase insulin response. No secretion of Amylin from the delta cells to slow down the speed at which sugar is released from digestion into the bloodstream. Sometimes the insulin is too fast and gets there before food digests; sometimes too slow, and insulin gone before digestion. not to mention some new findings re too much glucose being released after eating in Type 1, not for non-Ds from the liver. You have experienced how you can give the same amount of insulin, same food, different results on different days. Generally speaking, breakfast is a nightmare, lunch and snack pretty darn good and dinner is a crapshoot. Each and every night. You are doing the best you can and a good job; you are observant and dedicated.

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