What adjustments can be made to a tandem pump to prevent hypoglycemic (low blood sugar) episodes and hyperglycemic (high blood sugar) episodes, particularly overnight, in a patient who is not tech-savvy and occasionally delays bolus (bolus insulin) administration?

From the Guidelines

To effectively manage the patient's glucose levels and prevent overnight highs and morning lows, I strongly recommend adjusting the basal rate settings, specifically increasing the overnight basal rate, and simplifying the pump settings to ensure consistency and ease of use. The patient's experience of overnight highs followed by morning decreases suggests a need to reassess her basal pattern, as indicated by the 2025 standards of care in diabetes 1. This adjustment can help mitigate the dawn phenomenon or the Somogyi effect, which may be contributing to her glucose fluctuations.

Key considerations for adjustment include:

• Reviewing and adjusting the insulin-to-carbohydrate ratio (ICR) if glucose after meals consistently falls out of target, as suggested by the 2025 standards of care in diabetes 1
• Adjusting the correction insulin factor (ISF) and/or target glucose if corrections do not bring glucose into range, in line with the recommendations from the same standards 1
• Simplifying pump settings and focusing on consistent carbohydrate counting to make management more accessible for someone who isn't tech-savvy
• Considering the use of automated technologies, like Control-IQ, if available, to help adjust insulin delivery based on continuous glucose monitor readings, although the primary focus should be on optimizing basal rates and insulin-to-carbohydrate ratios based on the patient's specific needs and glucose patterns.

Given the patient's challenges with timely bolusing and her lack of tech savviness, working with a diabetes educator to review pump data and make targeted adjustments is crucial. This collaborative approach will help optimize her glucose management while keeping the technology manageable for her comfort level, ultimately improving her quality of life and reducing morbidity and mortality associated with poorly controlled diabetes.

From the Research

Tandem Pump Settings and Insulin Dosing

• The user's tandem pump settings are being adjusted to prevent low blood sugar levels, but she still experiences overnight highs and sometimes trends down in the morning 2.
• The user's bolus timing can be late, and she may not be tech-savvy, which could impact her ability to manage her insulin dosing effectively.
• Studies have shown that insulin dosing estimation formulas can be complex and may not always provide accurate estimates of total basal insulin dosage, insulin to carbohydrate ratio, and correction factor 2, 3.

Insulin Dosing Formulas and Guidelines

• Research has led to the development of guidelines for basal-bolus insulin dosing, including the accurate insulin management (AIM) system, which provides a consistent and convenient means of estimating insulin-dosing variables for patients with type 1 diabetes 3.
• The AIM system uses formulas such as total daily dose (TDD) = 0.24 * body weight in pounds, basal insulin = 0.47 * TDD, correction factor (CF) = 1,700/TDD, and carbohydrate-to-insulin ratio (CIR) = 2.8 * body weight in pounds/TDD 3.
• Other studies have examined the relationship between total basal insulin dosage, insulin to carbohydrate ratio, and correction factor, and have provided estimation formulas such as TBD = 0.2 x weight (kg) or 0.4 x TDD, ICR = 300 / TDD, and CF = 1500 / TDD 2.

Switching Basal Insulins and Monitoring

• When switching basal insulins, it is essential to closely monitor glycemic control and risk of hypoglycemia, and to individualize insulin therapy based on patient preferences, lifestyle, and health insurance plan formularies 4.
• The user's situation may require adjustments to her basal insulin and bolus dosing, as well as closer monitoring of her blood glucose levels to prevent overnight highs and morning trends down.