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Sugar Surfing with a CGM
Stephen W. Ponder MD, FAAP, CDE
Managing “d” well requires…
• Comprehending a system with basic
principles/concepts
• Adjusting to changing or shifting
co...
Appreciate the flux of sugar levels in non-d persons
Remember: Sugar Surfing is all about managing…
Diabetes is best approached 1 day at a time
8 versus 1440 “decision points”
7:03 115
9:33 129
12:15 95
3:34 131
6:12 168
9:49 107
11:53 114
3:05 132
*
*
*
*
*
*
*
*
Don’t pass up an opportunity to assess a trending
BG
• Choose what you consider
“actionable”
• Set personal action thresho...
(Glucose production – Glucose disposal) = FLUX
Here is a picture of FLUX and DRIFT
How much sugar is in the bloodstream for a
100 mg/dl BG level?
Human circulatory system
165 pound (75 kg) man
(5.1 grams)
...
static vs. dynamic diabetes care
static
• Actions predetermined
• Minimal flexibility: RIGID
• Outcomes don’t immediately
...
present
past future
Actions Actions
A pancreas can’t predict the future
• It acts so fast it doesn’t need to.
• Can shut off insulin immediately
• Can release...
Set “actionable” thresholds
• Upper/Lower limits
• 80 mg/dl and 140 mg/dl
• 90 mg/dl and 180 mg/dl
• Rates of change
• Up ...
Traits of effective CGM users
Wear it most of the time
Check trend line often
They “work the lag” times
FOOD lag
INSU...
Principles of Sugar Surfing
1. A CGM is no better or
worse than the person
responding to it.
2. If you can measure it, you...
“THE TREND IS YOUR FRIEND” CHECKING INSULIN BOLUSES WITH CGM
6 pm 8 pm 10 pm
300
200
100
60
Carb bolus Correction bolus
6 ...
Turnaround Time : glycemic inertia
Corrections may need to be adjusted 10-20% to compensate
Goal: Try to stay between the lines
As your skills improve, lower the glucose for the upper alert
Timing 101 – 20 min. match
Insulin
Food
Timing 101 – 45 min. mismatch
Insulin
Food
Be realistic
Accept that the first 6-12 months
are on a “learning curve”
Set higher and wider targets
Have low expectat...
BG awareness vs. alarm fatigue
• Set reasonable alarm thresholds
• Depends on your goals
• Avoid high spikes?
• Avoid lows...
Cal-i-bra-tion (noun ˌka-lə-ˌbrā-
shən)
• Comparing the sensor to an
accepted “standard” value
• The accepted “standard” v...
Calibration tips
• The first sensor day can be
erratic as it “settles in”
• Don’t over calibrate!
• Try to calibrate on a ...
CGM calibration tip…
steady
2 hours
Whenever possible: calibrate the CGM
system when on a “steady” sugar trendline
2 hr “w...
Daily calibrating on a steady baseline
Steady trend
2 hours
Calibrate your CGM…
On a steady trend when you can…
In the BG range you want to be most accurate in…
...
4 hours post start up calibration (extra)
Settling in at 6 hours: wobble
Sensors are not always right
Or is it the meter that’s off?
Morning madness?
After 14 hours after new
CGM sensor insertion…
After calibrating with
112 mg/dl, the sensor
immediately r...
Overnight basal testing
Overnight basal in range (glargine)
Overnight in range!
Overnight control in range
Basal testing…
Overnight basal control - Lantus
Learning from the Line Graph – Insulin Timing
8a 10a
70
140
210
350
280
8a 10a
70
140
210
350
280
TodayYesterday
Insulin b...
Why timing is everything
3 units @6:10 28 gm @ 6:50
Timing…waiting for the bend
“window”
3 U lispro @ 6:22AM
28 GM CHO @ 6:52AM
Timing insulin and meals to prevent a spike
Wait for the bend!!
6U @146
mg/dl Eat here @132
mg/dl
45 minutes
Wait for the “bend”!
Stopping sugar spikes
3 units
(5:32AM)
Meal
(5:48 AM)
Point “A” Point “B”
sugar trend
Insulin “correction”
Carb “correction”
~ 2 hours for insulin
~ 15-30 minutes for carbs
Ran...
Noticed rising trend at
1:43 PM: 165 mg/dl
Took 5 units lispro
@ 1:45 PM
4 hours
Late BG rise after the
morning: no lunch ...
Although subtle, this can be “felt”
BG = 157 mg/dl
Inj 4 U lispro @3:15
2-3 hours
20-30 minA
B
C
Correction tips
(on a steady trend)
A. Remember the lag
time ...
Micro-bolusing (dosing)
Steady baseline BG trend
BG 136 mg/dl
2 units lispro
Wait 2 hours
Target zone
• Very advanced
• CG...
BG 137 mg/dl
and rising slowly
3 units lispro
“Micro-bolusing”
BG 124 mg/dl injected
1.5 units lispro
@3:56AM
2 hours
Microbolus experimentation
Lag time
112 mg/dl to 78 mg/dl after 1.5 units
by injection on a “steady” BG
baseline
1.5 units
~ 2 hours
3U lispro
@ 3:40AM
4 unit lispro “push”
“Course correcting for smooth sailing”
Well balanced basal insulin
6 unit “shove” at 133 mg/dl 
Mealtime insulin @
8:30PM 7 units lispro
Duration of insulin 3hr
Insulin correction dose
@ 2:53AM 6 units lispro
lag
2 hou...
6:53PM BG 108 inj 6 units
7:15-7:35
9:52PM BG 125↑ inj 4 units
“Effective duration” of insulin action: 3 hrs
“Active
insul...
Duration of insulin effect can be determined
here
~ 4 hours
IOB after 6 units and fried meal
6 units
3.5-4 hours
2 units
WalkFried
Meal
Rising BG trend (132
mg/dl) @ 2:06AM
5 units lispro @ 2:12
Fried Chicken
2.5 hours
8 U 6 U 5 U 5 U3 U Lispro
20 Lantus
“Inflections”
calibration
Tex-Mex Dinner
calibration
“Remember the Alamo”
Correction and meal
6 units (161
mg/dl)
Meal
(26 gm CHO)
~ 45m
126 mg/dl
5 units @ 5:43AM; 25 gm CHO @ 6:23AM
5 units
Meal
(25 gm CHO)
40 minutes
Correction with 20 grams carbs
20 gm CHO
121 mg/dl: 3 units
@ 10:04PM
80 mg/dl: 7 units
lispro @ 6:36PM
Meter: 55 mg/dl
@ 7:56PM
My estimated duration of insulin a...
121 mg/dl: 3 units
@ 10:04PM
80 mg/dl: 7 units
lispro @ 6:36PM
Meter: 55 mg/dl
@ 7:56PM
My estimated duration of insulin a...
“Fried-food revenge” and correction
Fried food earlier in evening
@ 8PM
BG = 194
6 unit correction @ 7AM
BG = 115 in 3
hou...
“Revenge of the Ribeye” and “The Insulin Strikes
Back”
BG 167: 4 units
LAG
2-3h
Slow BG rise from protein-fat laden meal
Slow overnight rise and early AM
correction
Correction at 2:45 AM after slow post
dinner rise with 5 units
5 units
~ 2 hours
3 units lispro
Breakfast
BG 173 mg/dl
5 units lispro
Meeting
A “random rise” in BG during a routine day.
2-3 hours
Working it…(i.e., glucose control exists “in the moment”)
~ 2 hours
Oops! I Ate
an EXTRA
breakfast
taco!
BG 142 ↑ : took 5...
And thirdly, the correction and carb ratios is more
what you’d call ‘guidelines’ than actual rules
“Most of our assumption...
8 U @ 9:30AM
7 U @ 10:54AM
6 U @ 12:29PM
60 grams carbs
Ultimately 21 U lispro
Insulin to carb ratios are only a start
7
5
4
5
Large bowl turkey soup and 2
small pieces cornbread @ 6:30
…flux?”
“What the…
Duration of insulin
9 units lispro for 90 gm
Mexican food lunch @3:30
6 units lispro @ 6:30PM for
rising BG after 3 hr IOB
Stabilization
Two gulps of juice (15-20g CHO)
5 gram CHO “nudge”
@ 66 m/dl
Dropping < 1 mg/dl/min
“The nudge” (aka microcarbing)
5 gram CHO “nudge”
@ 66 m/dl
Glucose counter-regulation
Glucagon
Epinephrine
Cortisol
Growth hormone
Leisurely walk from 7:00 to 8:30: straight
line
Exercise “bump up”
Moderate intensity
75 minute duration
Glycogen  Glucose
2 units
1 hr walk
“Walking down” a trend
Blood sugar correction 160 mg/dl to 100 mg/dl in 2 hours
with 4 units insulin lispro by injection
4 units
~ 2 hours
Correction: 151 mg/dl to 103 mg/dl with 2 units
insulin lispro after walk
2 units
~ 2 hours
127 mg/dl @4:47AM
Injected 3 units lispro
1.5 hours
“Pushing sugar”
BG 137 mg/dl : dose 5 U lispro
Lag time
Eat breakfast here
Timing insulin and food is like shooting clay pigeons
6 U lispro @ 1:45AM
@ 170 mg/dl
30 min lag
3 hour wait
Taking the drop…
“Taking the drop”
BG 160 mg/dl @ 1:47AM
Injected 5 units lispro
Lag time
Drop time 2-3 hrs
perfect bottom turn
froth
Woke up at 3:55AM at
184 mg/dl
Took 4 units lispro
Wait (slept) about 3 hours
Bingo!
Tamale Soup at dinner
(slow carbs, sl...
182 mg/dl : 7 units lispro
Insulin lag time
30-40 min
Eat breakfast here
Food lag time
124 mg/dl
Timing is everything…do y...
Missed 9PM basal dose (glargine)
Normal time
Lantus taken (9PM)
Detected rising sugar
level @ 2AM
Humalog dose (7U) AND
us...
What happens when a basal insulin dose is missed
Usual time Lantus
dose is taken: 9PM
Rising BG
discovered here
Insulin co...
Stress effect
Endocrinology Board Exam taken every 10 years
Stress and
Sugar
• Strong emotional stress
triggers release of a several
hor...
Crossing 140 mg/dl @ 3AM
and a 2.5 U lispro correction
~ 2 hours
Lag time
Why act?
• Slow upward BG trend
(red arrow)
• Cr...
Microbolus at 7:55AM when BG
was 151 mg/dl took 2 units (after
surgery)
Awakened by CGM alarm to a
BG below 60 mg/dl
Lag time
20gm
Rationale
• Slow downward BG trend
(red arrow)
• Crossed person...
This can be “sensed too”
CHO
A steady trend
The body’s defenses
against low blood sugar
include the brain
Downward shifts,...
Feel the drop and level off
Subtle
correction
• BG 125 and rising
• Took 4 units lispro
• 2 for the slow rise
• 2 for the
correction
• Waited almost 2...
This feels stable> 1-2 mg/dl/min
~ 1 mg/dl/min
“Working down” a rising BG
4 units @
173 mg/dl
2 units @
167 mg/dl
7 units @ 2PM for
Whataburger and rings
4 units Humalog
@ 11:07PM
BG rising after insulin effect
is“waning”. BG = 146 mg/dl
Dinner (soft tacos,
refried bean and
c...
Anatomy of a nighttime low
A) 4 hour window
B) 24 hour window
C) 6 hour window
D) Resolution
34 mg/dl
36 grams CHO
2.5 hou...
6 month CGM data summary
Average BG = 103 mg/dl
Standard deviation = 34 mg/dl
Aim to keep the average BG in range and the ...
Day vs. Night: any thoughts about why?
Interpret these two images
Hint: sensor is over two weeks old
What is it a good time for and why?
Straight line trend
Straight line trend
= 10 grams carbs
60 mg/dl
90 mg/dl
6 U
4 U
4 U 4 U
5 U
6 U
28 GM
90+ GM
1. Stacked insulin + delayed eating
2. “Hyper-treated” severe low
3. Fought “rebound”...
Dislodged insulin pump site…
Picked up early by CGM
Pump site changed, insulin dose given,
carb correction taken…$13,000 s...
Penny stock day trading strategyCGM is “sugar surfing” board
©
“Kickin’ D’s Butt”
Sugar Surfing with a CGM (copyright) TLC Advanced Diabetes Retreat April 26 2014
Sugar Surfing with a CGM (copyright) TLC Advanced Diabetes Retreat April 26 2014
Sugar Surfing with a CGM (copyright) TLC Advanced Diabetes Retreat April 26 2014
Sugar Surfing with a CGM (copyright) TLC Advanced Diabetes Retreat April 26 2014
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Sugar Surfing with a CGM (copyright) TLC Advanced Diabetes Retreat April 26 2014

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Advanced concepts for applying continuous glucose monitoring data in daily diabetes self care decision making. This deck is for ADVANCED USERS ONLY. I will be delivered whole (or in part) on April 26, 2014 at the Texas Lions Camp in Kerrville Texas by Stephen W Ponder MD, FAAP, CDE

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Sugar Surfing with a CGM (copyright) TLC Advanced Diabetes Retreat April 26 2014

  1. 1. Sugar Surfing with a CGM Stephen W. Ponder MD, FAAP, CDE
  2. 2. Managing “d” well requires… • Comprehending a system with basic principles/concepts • Adjusting to changing or shifting conditions/situations • Frequent assessments and re- assessments LIKE…. • Driving a car • Flying an airplane • Walking a tightrope • Surfing
  3. 3. Appreciate the flux of sugar levels in non-d persons
  4. 4. Remember: Sugar Surfing is all about managing…
  5. 5. Diabetes is best approached 1 day at a time
  6. 6. 8 versus 1440 “decision points” 7:03 115 9:33 129 12:15 95 3:34 131 6:12 168 9:49 107 11:53 114 3:05 132 * * * * * * * *
  7. 7. Don’t pass up an opportunity to assess a trending BG • Choose what you consider “actionable” • Set personal action thresholds • Use situational thinking: consider recent, current and impending actions • Check your BG results over time • “treat to target” (repeat as needed, but don’t “overstack” your insulin)
  8. 8. (Glucose production – Glucose disposal) = FLUX Here is a picture of FLUX and DRIFT
  9. 9. How much sugar is in the bloodstream for a 100 mg/dl BG level? Human circulatory system 165 pound (75 kg) man (5.1 grams) 55 pound (25 kg) girl (1.75 grams) 110 pound (50 kg) boy (3.45 grams) = 4 gram glucose tabaka “glucose transit system”
  10. 10. static vs. dynamic diabetes care static • Actions predetermined • Minimal flexibility: RIGID • Outcomes don’t immediately affect subsequent actions • Easy to teach/learn • Less time-intensive • Favors concrete thinking • Less motivation needed dynamic • Actions are dependent on situation/circumstance • Flexible and adaptable • Outcomes constantly influence subsequent actions • Training needed, plus ongoing reinforcement • More time intensive • Favors problem-solving • Requires ongoing motivation
  11. 11. present past future Actions Actions
  12. 12. A pancreas can’t predict the future • It acts so fast it doesn’t need to. • Can shut off insulin immediately • Can release premade insulin • Insulin it releases can start working in minutes • Can rapidly respond to shifts in sugar levels
  13. 13. Set “actionable” thresholds • Upper/Lower limits • 80 mg/dl and 140 mg/dl • 90 mg/dl and 180 mg/dl • Rates of change • Up or down arrows • Factor in recent/current/future events as you are able • Test your skills, experiment a little within reason
  14. 14. Traits of effective CGM users Wear it most of the time Check trend line often They “work the lag” times FOOD lag INSULIN lag SENSOR lag Not afraid to experiment Not expecting perfection
  15. 15. Principles of Sugar Surfing 1. A CGM is no better or worse than the person responding to it. 2. If you can measure it, you can predict it. 3. Flux and drift happen… manipulate them! 4. Keep your eye on your line. 5. The trend is your friend 6. Learn lag limits; be patient 7. Zero in on your zone 8. Master micro-dosing 9. Factor in glycemic inertia and insulin momentum 10.Don’t let “good enough” be the enemy 11.Calibrate carefully 12.Pre-empt when you can
  16. 16. “THE TREND IS YOUR FRIEND” CHECKING INSULIN BOLUSES WITH CGM 6 pm 8 pm 10 pm 300 200 100 60 Carb bolus Correction bolus 6 pm 8 pm 10 pm Goal: green lines
  17. 17. Turnaround Time : glycemic inertia Corrections may need to be adjusted 10-20% to compensate
  18. 18. Goal: Try to stay between the lines As your skills improve, lower the glucose for the upper alert
  19. 19. Timing 101 – 20 min. match Insulin Food
  20. 20. Timing 101 – 45 min. mismatch Insulin Food
  21. 21. Be realistic Accept that the first 6-12 months are on a “learning curve” Set higher and wider targets Have low expectations to start It’s still a finicky technology PLEASE BE PATIENT
  22. 22. BG awareness vs. alarm fatigue • Set reasonable alarm thresholds • Depends on your goals • Avoid high spikes? • Avoid lows? • Toddler? Child? Teen? Adult? • Make sure you can hear/sense the alarm • Anticipatory action can minimize alarms
  23. 23. Cal-i-bra-tion (noun ˌka-lə-ˌbrā- shən) • Comparing the sensor to an accepted “standard” value • The accepted “standard” value is a fingerstick BG level • So the sensor itself can be no more accurate than the BG meter it’s compared to…or how well the BG meter was used
  24. 24. Calibration tips • The first sensor day can be erratic as it “settles in” • Don’t over calibrate! • Try to calibrate on a steady trend • Try to calibrate when in your target range
  25. 25. CGM calibration tip… steady 2 hours Whenever possible: calibrate the CGM system when on a “steady” sugar trendline 2 hr “wait” time between “turning on” sensor and providing 2 calibration BG readings to start session steady baseline
  26. 26. Daily calibrating on a steady baseline
  27. 27. Steady trend 2 hours Calibrate your CGM… On a steady trend when you can… In the BG range you want to be most accurate in… Steady trend
  28. 28. 4 hours post start up calibration (extra)
  29. 29. Settling in at 6 hours: wobble
  30. 30. Sensors are not always right Or is it the meter that’s off?
  31. 31. Morning madness? After 14 hours after new CGM sensor insertion… After calibrating with 112 mg/dl, the sensor immediately reads this Take home message: a new CGM sensor site might take a day or so to properly “settle in” or “read” properly. Take this under consideration and don’t give up on a session too soon. But BG meter calibration shows THIS…
  32. 32. Overnight basal testing
  33. 33. Overnight basal in range (glargine)
  34. 34. Overnight in range!
  35. 35. Overnight control in range
  36. 36. Basal testing…
  37. 37. Overnight basal control - Lantus
  38. 38. Learning from the Line Graph – Insulin Timing 8a 10a 70 140 210 350 280 8a 10a 70 140 210 350 280 TodayYesterday Insulin bolus: 7:30 AM Breakfast: 7:30 AM Insulin bolus: 7:10 AM Breakfast: 7:30 AM M I MI
  39. 39. Why timing is everything
  40. 40. 3 units @6:10 28 gm @ 6:50 Timing…waiting for the bend “window”
  41. 41. 3 U lispro @ 6:22AM 28 GM CHO @ 6:52AM Timing insulin and meals to prevent a spike
  42. 42. Wait for the bend!! 6U @146 mg/dl Eat here @132 mg/dl 45 minutes Wait for the “bend”!
  43. 43. Stopping sugar spikes 3 units (5:32AM) Meal (5:48 AM)
  44. 44. Point “A” Point “B” sugar trend Insulin “correction” Carb “correction” ~ 2 hours for insulin ~ 15-30 minutes for carbs Range of possible BG outcomes “the trend is your friend” Blood glucose level
  45. 45. Noticed rising trend at 1:43 PM: 165 mg/dl Took 5 units lispro @ 1:45 PM 4 hours Late BG rise after the morning: no lunch eaten 135 mg/dl @ 2 hours “Direction affects correction ”
  46. 46. Although subtle, this can be “felt”
  47. 47. BG = 157 mg/dl Inj 4 U lispro @3:15 2-3 hours 20-30 minA B C Correction tips (on a steady trend) A. Remember the lag time before insulin starts to effectively lower BG B. Remember the length of time it takes to accomplish the desired task C. Patience and practice make these kinds of results possible
  48. 48. Micro-bolusing (dosing) Steady baseline BG trend BG 136 mg/dl 2 units lispro Wait 2 hours Target zone • Very advanced • CGM needed! • Note flat BG “baseline” trend • Calibration good • Not “correction” per se • More of an “adjustment”
  49. 49. BG 137 mg/dl and rising slowly 3 units lispro “Micro-bolusing”
  50. 50. BG 124 mg/dl injected 1.5 units lispro @3:56AM 2 hours Microbolus experimentation Lag time
  51. 51. 112 mg/dl to 78 mg/dl after 1.5 units by injection on a “steady” BG baseline 1.5 units ~ 2 hours
  52. 52. 3U lispro @ 3:40AM
  53. 53. 4 unit lispro “push” “Course correcting for smooth sailing” Well balanced basal insulin
  54. 54. 6 unit “shove” at 133 mg/dl 
  55. 55. Mealtime insulin @ 8:30PM 7 units lispro Duration of insulin 3hr Insulin correction dose @ 2:53AM 6 units lispro lag 2 hours to correct Teaching points… a. Know your insulin “umbrella” b. Slow carbs cause unexpected highs c. Insulin onset of action = lag time d. Rise in BG levels has vector qualities e. It takes time to correct a high a b c d ea b
  56. 56. 6:53PM BG 108 inj 6 units 7:15-7:35 9:52PM BG 125↑ inj 4 units “Effective duration” of insulin action: 3 hrs “Active insulin” • Example: Slow carb meal (fried food) • e.g., Chicken fried steak, cream gravy and 3 onion rings and 8 French fries • Estimated 60 grams: 6 units: inject 6 units lispro • NO rise in BG for 3 hours, then rapid ascent • Time until rise reflects “active insulin” effect • Must do this many times and take the average
  57. 57. Duration of insulin effect can be determined here ~ 4 hours
  58. 58. IOB after 6 units and fried meal 6 units 3.5-4 hours 2 units WalkFried Meal
  59. 59. Rising BG trend (132 mg/dl) @ 2:06AM 5 units lispro @ 2:12 Fried Chicken 2.5 hours
  60. 60. 8 U 6 U 5 U 5 U3 U Lispro 20 Lantus “Inflections” calibration Tex-Mex Dinner calibration “Remember the Alamo”
  61. 61. Correction and meal 6 units (161 mg/dl) Meal (26 gm CHO) ~ 45m 126 mg/dl
  62. 62. 5 units @ 5:43AM; 25 gm CHO @ 6:23AM 5 units Meal (25 gm CHO) 40 minutes
  63. 63. Correction with 20 grams carbs 20 gm CHO
  64. 64. 121 mg/dl: 3 units @ 10:04PM 80 mg/dl: 7 units lispro @ 6:36PM Meter: 55 mg/dl @ 7:56PM My estimated duration of insulin action: 3.5 hours Slow carbs • Experimented here: • Ate a pasta meal at the Olive Garden • Took a single insulin shot (70 gm = 7 units) • Sugar dropped at time of usual peak insulin action: ~60-90 minutes • BG recovered without treatment • Late rise in BG required second injection Leveling off Olive Garden 2 salad servings, 1 breadstick and Lasagna lispro
  65. 65. 121 mg/dl: 3 units @ 10:04PM 80 mg/dl: 7 units lispro @ 6:36PM Meter: 55 mg/dl @ 7:56PM My estimated duration of insulin action: 3.5 hours Fast insulin + slow carbs = low BG • Ate a pasta meal at the Olive Garden • Took a single insulin shot (70 gm = 7 units) • Sugar dropped at time of usual peak insulin action: ~60-90 minutes • BG recovered without treatment • Late rise in BG required second injection • Notice the insulin-food “balance” and how it effects BG levels Leveling off Olive Garden 2 salad servings, 1 breadstick and Lasagna lispro Insulin effect Food effect
  66. 66. “Fried-food revenge” and correction Fried food earlier in evening @ 8PM BG = 194 6 unit correction @ 7AM BG = 115 in 3 hours
  67. 67. “Revenge of the Ribeye” and “The Insulin Strikes Back” BG 167: 4 units LAG 2-3h
  68. 68. Slow BG rise from protein-fat laden meal
  69. 69. Slow overnight rise and early AM correction
  70. 70. Correction at 2:45 AM after slow post dinner rise with 5 units 5 units ~ 2 hours
  71. 71. 3 units lispro Breakfast BG 173 mg/dl 5 units lispro Meeting A “random rise” in BG during a routine day. 2-3 hours
  72. 72. Working it…(i.e., glucose control exists “in the moment”) ~ 2 hours Oops! I Ate an EXTRA breakfast taco! BG 142 ↑ : took 5 units hypothetical real
  73. 73. And thirdly, the correction and carb ratios is more what you’d call ‘guidelines’ than actual rules “Most of our assumptions have outlived their usefulness” Marshall McLuhan
  74. 74. 8 U @ 9:30AM 7 U @ 10:54AM 6 U @ 12:29PM 60 grams carbs Ultimately 21 U lispro Insulin to carb ratios are only a start
  75. 75. 7 5 4 5 Large bowl turkey soup and 2 small pieces cornbread @ 6:30 …flux?” “What the…
  76. 76. Duration of insulin
  77. 77. 9 units lispro for 90 gm Mexican food lunch @3:30 6 units lispro @ 6:30PM for rising BG after 3 hr IOB Stabilization
  78. 78. Two gulps of juice (15-20g CHO)
  79. 79. 5 gram CHO “nudge” @ 66 m/dl Dropping < 1 mg/dl/min “The nudge” (aka microcarbing)
  80. 80. 5 gram CHO “nudge” @ 66 m/dl Glucose counter-regulation Glucagon Epinephrine Cortisol Growth hormone
  81. 81. Leisurely walk from 7:00 to 8:30: straight line
  82. 82. Exercise “bump up” Moderate intensity 75 minute duration Glycogen  Glucose
  83. 83. 2 units 1 hr walk “Walking down” a trend
  84. 84. Blood sugar correction 160 mg/dl to 100 mg/dl in 2 hours with 4 units insulin lispro by injection 4 units ~ 2 hours
  85. 85. Correction: 151 mg/dl to 103 mg/dl with 2 units insulin lispro after walk 2 units ~ 2 hours
  86. 86. 127 mg/dl @4:47AM Injected 3 units lispro 1.5 hours “Pushing sugar”
  87. 87. BG 137 mg/dl : dose 5 U lispro Lag time Eat breakfast here Timing insulin and food is like shooting clay pigeons
  88. 88. 6 U lispro @ 1:45AM @ 170 mg/dl 30 min lag 3 hour wait Taking the drop…
  89. 89. “Taking the drop” BG 160 mg/dl @ 1:47AM Injected 5 units lispro Lag time Drop time 2-3 hrs perfect bottom turn froth
  90. 90. Woke up at 3:55AM at 184 mg/dl Took 4 units lispro Wait (slept) about 3 hours Bingo! Tamale Soup at dinner (slow carbs, slow rise) “Livin’ la vida Gluco”
  91. 91. 182 mg/dl : 7 units lispro Insulin lag time 30-40 min Eat breakfast here Food lag time 124 mg/dl Timing is everything…do you have the patience or the time? Slow BG rise overnight from fried meal BG drop time 20-30 min
  92. 92. Missed 9PM basal dose (glargine) Normal time Lantus taken (9PM) Detected rising sugar level @ 2AM Humalog dose (7U) AND usual Lantus taken (20U) Sensor “gap”!! dinner Fell asleep! All back in range by morning!
  93. 93. What happens when a basal insulin dose is missed Usual time Lantus dose is taken: 9PM Rising BG discovered here Insulin correction given If not treated: high BG and ketones Treated: In range BG and NO ketones
  94. 94. Stress effect
  95. 95. Endocrinology Board Exam taken every 10 years Stress and Sugar • Strong emotional stress triggers release of a several hormones • These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body • Stress hormones also make the liver produce sugar from substances like protein and fat • This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood • CGM allows for more aggressive anti-stress treatment of rising sugars
  96. 96. Crossing 140 mg/dl @ 3AM and a 2.5 U lispro correction ~ 2 hours Lag time Why act? • Slow upward BG trend (red arrow) • Crossed personal “action consideration” threshold: 140 mg/dl in my case (yellow line) • Knew the CGM would alert me to a rapidly dropping BG later if I over treated • Have done this many times before: practice, practice, practice
  97. 97. Microbolus at 7:55AM when BG was 151 mg/dl took 2 units (after surgery)
  98. 98. Awakened by CGM alarm to a BG below 60 mg/dl Lag time 20gm Rationale • Slow downward BG trend (red arrow) • Crossed personal “action consideration” threshold: 60 mg/dl in my case (yellow bottom line) • Drank 20 gm grape juice and went back to sleep • Knew the CGM would alert me to a rapidly rising BG later if I over treated • Have done this many times before: practice, practice, practice
  99. 99. This can be “sensed too” CHO A steady trend The body’s defenses against low blood sugar include the brain Downward shifts, even small, can be sensed by the conscious brain Once sugar levels off, the brain senses stability Rationale • Blood sugar control is complex, it includes the brain and nervous system • Long term damage to the autonomic nervous system can result in loss of classic signs/symptoms of low blood sugar • But, the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (e.g., < 50 mg/dl) • A CGM device can serve as a “biofeedback” device of sorts in adults willing to develop the ability over time.
  100. 100. Feel the drop and level off
  101. 101. Subtle correction • BG 125 and rising • Took 4 units lispro • 2 for the slow rise • 2 for the correction • Waited almost 2 hours (yellow arrow) • Notice lag time before BG “turns” (red arrow)
  102. 102. This feels stable> 1-2 mg/dl/min ~ 1 mg/dl/min
  103. 103. “Working down” a rising BG 4 units @ 173 mg/dl 2 units @ 167 mg/dl 7 units @ 2PM for Whataburger and rings
  104. 104. 4 units Humalog @ 11:07PM BG rising after insulin effect is“waning”. BG = 146 mg/dl Dinner (soft tacos, refried bean and chips/salsa); 7 units lispro taken 20 minutes premeal at 7PM My “DIA” = 3-4 hours Notice the obligatory “lag time”! Anatomy of a preemptive correction
  105. 105. Anatomy of a nighttime low A) 4 hour window B) 24 hour window C) 6 hour window D) Resolution 34 mg/dl 36 grams CHO 2.5 hours
  106. 106. 6 month CGM data summary Average BG = 103 mg/dl Standard deviation = 34 mg/dl Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value
  107. 107. Day vs. Night: any thoughts about why?
  108. 108. Interpret these two images Hint: sensor is over two weeks old
  109. 109. What is it a good time for and why?
  110. 110. Straight line trend Straight line trend = 10 grams carbs 60 mg/dl 90 mg/dl
  111. 111. 6 U 4 U 4 U 4 U 5 U 6 U 28 GM 90+ GM 1. Stacked insulin + delayed eating 2. “Hyper-treated” severe low 3. Fought “rebound” high BG all night 4. Took the drop and timed meal
  112. 112. Dislodged insulin pump site… Picked up early by CGM Pump site changed, insulin dose given, carb correction taken…$13,000 saved
  113. 113. Penny stock day trading strategyCGM is “sugar surfing” board
  114. 114. © “Kickin’ D’s Butt”

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