In case you are utilizing CGM (Steady Glucose Monitor), you already know what number of game-changers this expertise could make relating to diabetes administration.
Getting perception into our historical past of blood sugar, what our blood sugar is for now, the place it’s, and the place it’s, brings peace of thoughts, making managing diabetes a lot simpler, Safer.
However even should you love your CGM, do you utilize trending arrows for insulin changes? If not, you’re really lacking out on the chances of expertise fully.
Being attentive to the arrows in CGM traits permits for extra aggressive and knowledgeable selections concerning insulin dose changes.
The knowledge on this publish is restricted to the Dexcom CGM system. Different CGM methods additionally use pattern arrows, however please notice that if you’re utilizing different methods, we are going to make the most of the knowledge right here.
Open the Dexcom app or have a look at the receiver and you will note that you will note your present blood sugar degree and what’s going to occur in half-hour.
The indicators come within the type of arrows. On the receiver, the arrow is on the appropriate aspect of your present blood glucose degree. The app reveals it as a circle with arrows across the blood sugar degree and circle.
You most likely know that the arrow above signifies that your blood sugar ranges are rising and that it reveals a down arrow that’s falling, however are you aware how a lot and how you can embody it in your insulin adjustment?
In line with the producer, begin with what the arrows point out.
| Pattern Arrows | which means |
| Elevate the 2 arrows straight up | BG can exceed 90 mg/dL (5 mmol/L) in half-hour. |
| Straighten one arrow | BG can enhance as much as 90 mg/dL (5 mmol/L) in half-hour. |
| One arrow is just a little above | BG can enhance 30-60 mg/dL (1.7-3.3 mmol/L) in half-hour. |
| One arrow subsequent to it | There is no such thing as a enhance or lower in BG above 1 mg/dL (0.05 mmol/L) per minute. |
| 1The arrow is barely lowered | BG can cut back 30-60 mg/dL (1.7-3.3 mmol/L) in half-hour. |
| One arrow straight down | BG can lower to as much as 90 mg/dL (5 mmol/L) in half-hour. |
| The 2 arrows are straight down | BG can exceed 90 mg/dL (5 mmol/L) in half-hour. |
sauce: Dexcom G6 Information
Actual life examples
For instance my blood sugar degree is 120 mg/dL (6.7 mmol/L) and Dexcom reveals two arrows straight up.
On this case, we will count on blood glucose ranges to exceed 210 mg/dL (120 + 90) inside the subsequent half-hour.
I attempt to keep under 200 mg/dl, so I am most probably giving myself a correction bolus primarily based on this information (so long as I’ve not eaten a meal and I’ve sufficient lively insulin that is not but on board).
Arrows in CGMS might be very useful in managing your blood sugar ranges, however provided that you know the way to answer these arrows.
A number of well being professionals have provide you with an strategy to assist sufferers administer insulin safely and successfully utilizing CGM arrows. Most significantly, all of them agree that rising or falling charges ought to be considered when adjusting insulin doses. However what they disagree is to just remember to are exactly how you can alter your insulin dose primarily based on these arrows.
The Endocrine Society reviewed 4 printed approaches in 2017 and got here up with its personal pointers. Their pointers have been printed in Journal of the Endocrine Society December 2017 (Notice that the rules defined listed here are adults solely).
I contemplate the Endocrine Society to be the best authority relating to the sort of suggestion, so I intend to share their suggestions with you.
The rules are written for the Dexcom G5, however no adjustments have been made to the arrows on the brand new system, and the suggestions should even be in impact on the Dexcom G6.
The Endocrine Society recommends adjusting insulin primarily based on blood glucose ranges in half-hour, not the present one. Nevertheless, as a substitute of calculating future blood glucose ranges in half-hour, it’s endorsed to regulate the correction issue (CF).
This correction ought to be made on prime of corrections for present blood sugar ranges and carbohydrates consumed.
Your CF is how a lot a unit of quickly performing insulin (similar to Humanlog or Novolog) reduces your blood sugar degree. In case you are utilizing a pump, you possibly can test the CF within the settings. For those who handle your diabetes with injections and do not find out about CF, you possibly can ask your medical group to assist together with your calculations.
Endocrine Society suggestion revision primarily based on Dexcom pattern arrows
| An arrow seems | Correction coefficient (CF) | Corrected Dose (IU) |
| Elevate the 2 arrows straight up | <25 25-50 50-75 > 75 | +4.5 +3.5 +2.5 +1.5 |
| Straighten one arrow | <25 25-50 50-75 > 75 | +3.5 +2.5 +1.5 +1 |
| One arrow is just a little above | <25 25-50 50-75 > 75 | +2.5 +1.5 +1 +0.5 |
| One arrow subsequent to it | <25 25-50 50-75 > 75 | No adjustment No adjustment No adjustment No adjustment |
| 1The arrow is barely lowered | <25 25-50 50-75 > 75 | -2.5 -1.5 -1- 0.5 |
| One arrow straight down | <25 25-50 50-75 > 75 | -3.5 -2.5 -1.5 -1 |
| The 2 arrows are straight down | <25 25-50 50-75 > 75 | -4.5 -3.5 -2.5 -1.5 |
sauce: https://tutorial.oup.com/jes/article/1/12/1445/4642923
Let’s summarize with an instance:
I am away from bed within the morning and attempting to take a seat for a 20 gram carb meal as I wasn’t low in a single day. My blood sugar degree is 120 mg/dL (6.8 mmol/L) and two arrows rise. Because of this it is advisable to do three calculations:
- First, it is advisable to calculate the carbohydrate dose. Assuming my insulin-to-carbohydrate ratio (ICR) is 10, I would like 2 IU of insulin to cowl 20 grams of carbohydrate.
- Second, it is advisable to calculate the corrective dose primarily based in your present blood glucose. If my CF is 25 and my goal blood glucose is 95 mg/dL (5.3 mmol/L), my corrected dose is 1 IU (120-95 = 25 and 25/25 = 1 IU).
- Third, it is advisable to calculate the correction primarily based on the arrows. There are two arrows in response to the advice and the CF is 25, so a 3.5 IU repair is required.
Including all my complete doses offers me 2 iu + 1 iu + 3.5 iu = 6.5 iu.
If I had seen my blood sugar degree decrease than my goal, or I used to be trying on the downward arrow, I might have completed with a decrease really useful dose.
To be sure that is smart, let’s give one other instance.
I am rolling away from bed once more and attempting to take a seat down for a 20 gram carb eating regimen, and now my blood sugar degree is 120 mg/dL (6.8 mmol/L).
What has been modified in comparison with the final instance is the course of the arrow that adjustments calculation #3.
I now have one arrow straight down and my CF is 25. In line with suggestions, a -2.5 IU repair is required.
Including all of it makes my new complete dose 2 iu + 1 iu – 2.5 iu = 0.5 iu
Fau, that is quite a lot of arithmetic. See the subsequent part of how I simplify it.
The endocrine suggestion makes excellent sense to me, but it surely’s quite a lot of arithmetic! You additionally can not take lower than 0.5 IU with correction (which could be a downside if you’re very delicate to insulin).
I might somewhat use a bolus calculator than do all of the maths each time I would like it for a bolus for a meal or a modified dose. If in case you have a pump, it’s doubtless that there’s a built-in bolus calculator. For those who’re doing a number of each day injections (MDIs) like me, it is advisable to see elsewhere.
Prior to now, I used an app referred to as RapidCalc for these calculations. I am at present utilizing Inpen, a SmartPen that has an related app that sends information on to my telephone through Bluetooth, calculates the dose and tracks the IOB.
The Inpen app and RapidCalc mainly do the identical factor as a bolus calc, however give me my dose truly (Please notice that the RapidCalc app is just not FDA authorized).
After finishing the fundamental calculations in Bolus Calculator, you possibly can manually add pattern arrow corrections primarily based on CF.
Do not forget to reply primarily based on what you are doing within the subsequent 1-4 hours, not what you are doing if you’re about to do a bolus.
In case you are planning on exercising or planning extra journey than common (similar to strolling, procuring, cleansing, gardening), it’s possible you’ll not want to reply as aggressively as the rules do.
Normally, it’s endorsed to scale back the bolus earlier than train and probably cut back the basal (if utilizing a pump). Common fast insulin is lively within the physique for as much as 4 hours (some folks might even see the tail as much as 6 hours after injection), so it ought to be thought earlier than the bolus.
There are new, super-acting insulins obtainable now, and endocrine pointers don’t work for these. In case you are utilizing Afrezza or FIASP, know that these insulins peak a lot quicker and making use of the above calculations might be very harmful.
If you don’t use CGM pattern arrows
All publications advocating for utilizing trending arrows to make insulin changes state that there are conditions the place it’s best to by no means use them, or at the least take strict precautions.
For those who plan to begin adjusting your insulin dose utilizing fashionable rows, learn these precautions first.
4-hour meal window
The Endocrine Society recommends that the pattern arrows not be used 4 hours after consuming on a bolus. As an alternative, they suggest:
- 2 hours after meal – Don’t repair hyperglycemia to forestall insulin stacking
- Blood glucose degree 150-250 mg/dl (8.3-13.9 mmol/l) with one or two arrows raised for 2-4 hours after meal – Think about using CF to regulate
- 2-4 hours after meal > 250 mg/dl (13.9 mmol/l) with one or two arrows raised – Test together with your fingertips and repair utilizing ketone take a look at (>300 mg/dl/16.7 mmol/l), injection.
- Blood glucose degree close to 150 mg/dl (8.3 mmol/l) with one arrow barely under, 2-4 hours after measurement – Test once more in half-hour
- Decrease one or two arrows 2-4 hours after blood glucose close to 150 mg/dl (8.3 mmol/l) – Test once more in quarter-hour
- 2-4 hours after blood glucose close to 100 mg/dl (5.6 mmol/l), one arrow is barely under, or one arrow is under – Take into account consuming 15 g of carbohydrates and rechecking in 20 minutes. > For 70 mg/dl (3.9 mmol/l) and downward arrows, test together with your fingertips and contemplate a quicker carb of 15 g
- 2-4 hours of meal, blood sugar close to 100 mg/dl (5.6 mmol/l) – Observe the directions above (f) to eat 30 g of carbohydrates
Blood sugar ranges rise quickly
For those who see two arrows on the receiver or app earlier than meals, it’s best to be keen about pre-bolus and inject 15-20 minutes of insulin earlier than consuming.
Blood sugar ranges drop quickly
If in case you have two right down to the receiver or app earlier than a meal, don’t inject it when beginning a meal or whether it is near 150 mg/dl (8.3 mmol/l) till BGS is leveled.
Fragile / Aged
For susceptible or older adults, the Endocrine Society recommends much less aggressive insulin dose changes to restrict the danger of hypoglycemia.
The rising arrows suggest a 50% discount within the really useful adjustment (1 IU to 0.5 IU to 0.5 IU), whereas the downward arrow recommends a 50% discount (for instance, 1 IU to 2 IU).
Sickness Day Administration and Remedy Issues
Sure drugs, each prescription and OTC, can intrude with CGM readings, and because of this, don’t use pattern arrows to regulate insulin. As an alternative of relying fully on CGM, connect a finger bar to your CGM measurements.
At all times use frequent sense earlier than administering
Like all instruments within the Diabetes Toolkit, we suggest not making use of suggestions blindly.
For those who really feel that the really useful dose might be turned off, it may well depend upon how properly your physique is the trail.
Dexcom G5 and G6 CGMs are authorized for administration by the FDA, however typically they are often inaccurate, so all the time test them together with your fingertips earlier than making large-scale dosing changes.
