Hey there, Diabetes Community!

Welcome back to another round of our weekly advice column, Ask D'Mine, hosted by veteran type 1, diabetes author and educator Wil Dubois.

You may remember that last week, Wil offered his thoughts on insulin pump bolusing as part of a two-week focus on pump questions.

This week, we've got a patch-pump-specific query that's kind of a brain-teaser... so read on, and please offer any of your own input too!

{Got your own questions? Email us at AskDMine@diabetesmine.com}

News nuggets from around the diabetes community

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A New Square Patch Insulin Pump
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Jeff, type 1 from Texas, writes: Wil, you have helped me lots and I thank you. Now I've a question for you my CDE and endo haven't answered. I've been on the Omnipod for 6 weeks and occasionally have unexplained overnight highs. My morning BGs range between 60 to 200, and more. Sometimes the pump lowers my blood glucose, and other times no change. An overnight temp basal rate has been tried (5% more for 2 hours) but did not seem to help, plus didn't know when to use it to prevent a dangerous low. Thanks in advance for any clues to figure this out, I'm perplexed!

Wil@Ask D'Mine answers: Oh boy, I do so love a good mystery, especially of the blood sugar variety! Of course, nothing in the world is more vexing or hard to figure out than an intermittent problem. It's like when you get that funny pinging noise when driving both to and from your mechanic's garage, but can't get the damn car to make the noise for the guy to hear for himself while you're there.

But to be honest, I'm as perplexed as you are, given the evidence we have so far. And remember: I'm not a doc and am not your medical pro, so just because yours haven't been able to offer clear answers at this point, please don't stop working with them on this.

That said, I have some ideas to help us rule out a few things, then maybe we'll be able to get some clarity. I also have some thoughts to share about the mindset needed for programing any insulin pump, and the bottom line is that it takes more patience than most of us have because a finely-tuned insulin pump is exactly like a finely-tuned orchestra.

But I'm getting ahead of myself. First some basics.

When do you change your pod? If you do it at night, please slap yourself on the wrist to save me the omnipod bellytrouble. Always change your pod—or any infusion set for that matter—in the morning. The reason for this is that if you're going to have any trouble, it's best to have the trouble when you're awake. Some podders report infusion difficulty early in the pod's lifecycle, so if that's at nighttime, it might explain why your mornings are so different from day to day. You might be waking up high on mornings following a new pod insertion, and lower on mornings with established pods.

But, damn! Sixty to 200+?! That's a hell of a range. I suspect something is really out of whack on your pump's programming. The challenge will be ferretting out if it's the basal that's off; if it's the insulin to carb ratio that's off; if it's the correction factor that's off; if your carb counting skills are rusty; or all of the above!

Ain't life grand?

As to your temp rate, 5% for two hours isn't likely to be enough to really help. I don't know what your basal rate is, but if you crunch the math I think you'll be surprised how little extra water you tried to throw on the fire. But that said, I wouldn't mess with temp rates at all while the basic settings are still in question.

So here's what we need to do: We need to work the problem by limiting the variables.

To do that, within the limits of threat to life and limb, I'd start out by NOT correcting above-target bedtime numbers.

Huh?

Remember what I said about the orchestra? Well, programming an insulin pump is a bit like conducting an orchestra. When it all comes together it's beautiful music, but the parts make the whole. If the stupid violins are off playing the wrong piece of music, the entire composition will be ruined. And yet, an amazing number of pumpers try to fix all the parts at once. You need to make sure everyone knows his or her music perfectly before you combine the sections into a performance. So let's start with the foundation. The basal.

Remember that basal's job isn't to fix shit. It's to keep shit where it is. If you go to bed at 180/mg/dL and wake up at 180mg/dL (or thereabouts) the basal did its job. Again, its job is to hold the line, nothing else. Now, if the line is in the wrong place, you've got a problem, but it's not one you should be fixing with a basal rate.new-omnipod-pdm-color

It should only take a few nights to establish whether or not your basal is doing its job. If your morning is always lower than your bedtime (with no correction nonsense) there's too much basal overnight. If your morning is always higher than your bedtime there's not enough basal overnight. That takes care of the flutes and horns.

Now, once the basal looks good, work backwards to dinner. You need to look at the curve, not the numbers. Don't let those numbers get you tied in knots! A good meal bolus should land you four hours later right back where you started. If you are at 140mg/dL before dinner and take the right amount of insulin for the food, four hours later you should be at 140 again. Now we have the drums, clarinets, and bassoons.

Once your basal is working, and your insulin-to-carb ratio is working, you can tune up the strings on the correction factors.

Basal first. Insulin-to-carb ratio second. Correction factor last.

When all the parts are working separately, you can let them play together. And then the music will be beautiful.

This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.

 
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This content is created for Diabetes Mine, a consumer health blog focused on the diabetes community. The content is not medically reviewed and doesn't adhere to Healthline's editorial guidelines. For more information about Healthline's partnership with Diabetes Mine, please click here.