Need to learn how to calculate ISF, I:C ratios, and basal rates

[4youreyesonly]

I am a Type I for 41+ years, and a pumper for 1 1/2 years.  I recently switched to a new healtcare team, and they expect that I know how to set the various pump parameters.  I never learned from the Nurse Clinician how to do that, and never received training from Animas.  I used a cheat sheet given to me with various bolus ranges, and it has served me well.  The new group is very hands off and don't have the time to educate me after the fact.  Ditto for the pump manufacturer.  I am hopeful that somebody can point me in the right direction.

[JDRF-Team-SS]

Hello  4youreyesonly,

I am one of the volunteers here, so keep in mind that I am not a medical professional...simply a mother of a boy living with type 1.  My son was diagnosed at age 3.  He is now 10.  He is also on the pump, however, animas is not the manufacturer. (He started on the pump 1 yr. ago.)

My son's pump has the capability to set:
- a target BG
- insulin to carb ratio (1 unit to x amt. of carbs)
- and sensitivity (I understood this as being like a sliding scale, such as 1 until will lower the BG this number of points -we were first told to set my son's at 120, but now a yr. later it is at 50)

It has the capability to set more than one insulin to carb ratio at different times of day, if you need this option.

Our pump has what they call a "bolus wizard" and we used the "bolus wizard setup" to configure the target, sensitivity and the insulin to carb ratio and then the pump does the math for us after enterting the BG and number of carbs eaten or 0 carbs if he is just doing a correction, but not eating.  

We can set different basal patterns, as well, because his schedule is different on a school day compared to a non-school day.

Since I am unsure what capabilities your pump model has it is hard to answer this.  

What has been going on with your BG's lately?

I will tell you what I have been told.  I have been told that the way to find out if your insulin to carb ratio should be changed or not, would be to use a log with the following info. noted.

- pre meal BG (Do not have a snack in between meals unless low)
- 2 hours after meal reading
to see how big the jump is from the pre meal to the 2 hours after.  I hate to be so vague, but, if the jump in BG is significant at the 2 hour mark then I would lower the carb,so, if I had his ration at 1 unit to 20 grams, I might drop down to 1 to 18 or 1 to 15 and see if this helps.

My son's endo's office has a sign that says 2 hours after meals should be no higher than 140 and I think Yah, right!  LOL  Sure, we are trying to achieve this and sometimes do.
If my son had a pre-meal reading of let's say 140 and then 2 hours later it was 300, I would say there was a definite need for an insulin to carb ration change, however, I would NOT just go off of one 2 hour after a meal reading.  I would base this on a 3 day log.

Anyone out there who can add comments on bolus info. for pumpers, please do!!  Remember, I am not a medical professional or pump specialist, but I have been doing pretty well on my own at making changes to my son's settings, but since he is growing, there is constant change!

Also, please feel free to post a follow up and elaborate on your situation.  

Take care and I am sorry to hear that the manufacturer has not been of much help to you.  Can your team reccommend a pump specialist/trainer???  Ask for help from your team.

Warm Regards,
SS

[4youreyesonly]

Thanks very much for the info.  My IR 1200+ does a ton of calculations also.  But you have to have the original parameters to enter in before you can adjust up or down.

I was originally given a sliding scale and told my ratios were 1:20 for carbs and 1:50 to lower my glucose.  I was not given the magic formula of how they dtermine those numbers, nor any direction on how to make slight adjustments.  The Clinical Manager where I was before would look at my data every week or so, and recommend any adjustments.  Likewise I have no idea how the basal rates were determined.  I was perfectly comfortable in that situation to allow those with clinical expertise to advise me of changes PRN.

The new team I am with (my former doc quit her practice) has a Clinical Manager who has told me she does not have the time to review my data.  Animas tells me they do 4 weeks of intensive training at the beginning of treatment, but that this new practice has the people to help me now, plus the new doctor does not authorize their involvement in training.  

It is all very frustrating, and I feel abandoned.  I have all this expensive equipment, and still do not feel I have the tools to take over my adjustments.  I met with the new doctor to discuss my frustrations, and also to reinterate my lack of training and knowledge base to proceed independently.  She is assigning another Clinical Manager who is sup[posedly more "hands on".  The previous one never even returned my voicemails or e-mails, and like I said, I felt very vulnerable.

My sugars have never seemed to show any pattern to me.  I think it is hard to be objective.  I have virtually eaten and exercised and handled my diabetes the same way for over 40 years, and I still have profound hypoglycemia reactions, which are compounded by hypoglycemia unawareness.  I could be 30 or 300 and not feel the difference, which literally scares the you know what out of me.

Say a prayer the new Clinical Manager will be willing to impart her knowledge to me, so that I can feel reasonably competent/secure in making adjustments PRN, rather than waiting on someone to decide they "have the time".

[JDRF-Team-SS]

Hello again,

When my son started on the pump (medtronic) last August, a pump trainer came to our home and showed us basic stuff - how to change the infusion set and setup the bolus wizard, etc.

I have heard that Animas has a very good initial traning...better than our co., however, our customer services to follow the training is good, but the tech people at medtronic are really only there for problems with the pump.  

I do know that when the pump specialist or trainer came to our house for the initial training, she did some type of formula to start off with.  My son had been taking humalog and NPH.  He was on a certain set amt. of NPH for breakfast and bedtime and then humalog was a sliding scale, so we did not do what they call the "poor man's pump."  She took the amt. of insulin or approx. am.t of insulin he was using daily and did a certain formula that I was not too concerned with at the time and figured out a basal rate, a target, a sensitivity and an insulin to carb ratio that I gave some input on.  We started with 1 until per 30 grams and now are at 1 per 15.  

I failed to mention that my sister (33 yrs. old, dxd at age 24) started on the pump in Dec. 2004.  She has severe lows where she cannot move her legs.  I have been around her and it is frightening.  My son does not (knock on wood) have this happen and it is my understanding that every individual experiences lows differently.  My son usually knows when he is low.  About 10% of the time he will think he is low and he will be at 150 or something near that range and I believe that maybe he had a sudden drop in blood sugar casuing him to have the same sensation as being low.

The only thing that ever has clued my son into feeling high is having his eyes feeling very tired, so when he feels this way, he tests and there are many times he was not high, just very tired.  I can only imagine how frightening hypoglycemia unawareness is, as well as hypoglycemia in general.  

Do you think that after many years of having diabetes, your hypoglycemia unawarenss has happened?  (Sorry if I did not interpret you correctly)

We have had a change in docs in the past year, as well.  My son's endo of 6-1/2 yrs. passed away in Nov. from pancreatic cancer.  It was devastating.  I did not even know he was sick.  Now our situation is completely different.  We were spoiled by having a private practice doctor and now having a team setting, but I feel like I have the tools and I guess I am a control freak anyway although my son is very involved.  The first time I had to change his set without supervision, he was telling me what to do!!

I found a site with a page that gives a sample on how to challenge your basal.  I save it to my computer.  You should do the same.  It sounds like a pain in the u-know-what, but I am going to do this very soon for my son.  

    http://kidsendo.com/BasalChallenge(2).pdf

Take care and make sure you have juice in arm's reach from your bed.  (from a mother's mouth:)  

[J J's mom]

It would probably be well worth your while reading "Pumping Insulin" by John Walsh and Ruth Roberts,aswell as any other help you can get. It is widely reccomended for pumpers and those preparing to pump, and takes you through everything you would need to know. It is also good to have it as a reference and refresher.
I purchased it from The Diabetes Mall online.
Really hope you get things sorted.

[4youreyesonly]

I am on the trail of some good books at my local library.  The Walsh book is one of them.  Also a couple relating to carb counting, which I figure would address carb ratios.

If and when I find the magic formulas, I will be sure to share my resource with all of you who have been so kind to respond.

I have learned from this uncomfortable situation.  If I should ever change pumps, I wil make sure I know who my back-up is in case of changes in staff etc.  I will also clarify the role of the manufacturer in responding to situations such as mine.  And for sure I will make sure that I have the same tools and knowledge base as those who I will insist train me.

By way of follow-up, Animas is sending me some sort of workbook they use in training new clients.  They too recommended the Walsh book, and they again apologized for what seems like lack of support.  Their hands are tied without the doctor consenting to have them involved.  My new doctor has only authorized her team to do this, which is ironic, as they "do not have the time" to review my data on a weekly basis and make recommendations!

I have been told that the Animas pump is a good match to my specific diabetic patterns.  It allows for several basal rates, and various bolus delivery options.  I look forward to being able to utilize some of those options one day, but right now, I am trying to get the basics down pat.

[4youreyesonly]

I am awaiting a Border's order for the book, Pumping Insulin by Walsh.  I also bought a Hope Warshaw book on counting carbs, which has some information on pumping.  If you can believe the suburban library system where I live and the local Border's did not have the Walsh book at all!  You would think with all the people on pumps, there would be a need for such reference materials.

In the meantime, I terminated my unhappy experience with the big local medical center and the Clinical Specialists who did not "have the time" to review and provide me with direction on my test data.

I saw a new doctor yesterday, who was very reassuring.  He is at a local community hospital, and fortunately for me, he has the theory of patient-friendly guest relations down pat.  He gave me his personal numbers to call, and will be arranging for further training for me, which I did not get originally.  He promised to have the Animas CDE, who he works with, call me for assistance also.

I left feeling hopeful and a bit more secure that I was not hanging out there alone.

I will keep you all posted on my progress.  I still do not have the magic formulas or tools to take charge, but I at least know I have a friend to call until I reach that point.  Ironically, this is the hospital that diagnosed me over 41 years ago!  Who says things don't come around!