How to manage hypoglycemia with BG down to 86 on Tslim (insulin pump) with basal rate 1.3, carb ratio 1:8, and ISF 30?

Management of Blood Glucose at 86 mg/dL on Insulin Pump

A blood glucose of 86 mg/dL does not require treatment, as this is above the hypoglycemia threshold of 70 mg/dL and falls within the normal preprandial target range of 80-130 mg/dL. 1

Understanding Your Current Glucose Level

Your blood glucose of 86 mg/dL is not hypoglycemia. The American Diabetes Association defines hypoglycemia as blood glucose <70 mg/dL (3.9 mmol/L), with Level 2 hypoglycemia at <54 mg/dL requiring immediate action 1. Your current reading of 86 mg/dL is actually within the recommended preprandial target range of 80-130 mg/dL 1.

When to Treat vs When to Monitor

• Do not treat glucose levels ≥70 mg/dL with carbohydrates, as this will cause unnecessary hyperglycemia 1
• Begin treatment only when glucose drops below 70 mg/dL with 15-20 grams of fast-acting carbohydrates 1
• Monitor closely if you see downward trending arrows on your CGM, as this may indicate glucose is falling toward the hypoglycemia threshold 1

Evaluating Your Pump Settings

With a basal rate of 1.3 units/hour, carb ratio of 1:8, and ISF of 30, you should assess whether these settings are appropriate:

• Basal rate assessment: If you frequently see glucose levels in the 80s between meals or overnight without active insulin on board, your basal rate may be slightly aggressive 2
• Carb ratio evaluation: A 1:8 ratio means 1 unit covers 8 grams of carbohydrate; if you experience lows after meals, this ratio may need adjustment to 1:9 or 1:10 2
• ISF consideration: An ISF of 30 means 1 unit drops glucose by 30 mg/dL; aggressive correction doses with this factor could contribute to lows 2

Pattern Management Approach

Look for patterns over 3-7 days rather than reacting to single readings 2:

• If fasting glucose is consistently 70-90 mg/dL, consider reducing overnight basal by 10-20% 2
• If pre-meal glucose trends 70-90 mg/dL, reduce the preceding basal segment by 10-20% 2
• If post-meal lows occur 2-4 hours after eating, increase your carb ratio (e.g., from 1:8 to 1:9) 2

Critical Pitfalls to Avoid

• Do not over-treat normal glucose levels: Treating a glucose of 86 mg/dL will cause rebound hyperglycemia and increase glycemic variability 1
• Avoid making pump adjustments based on single readings: Wait for consistent patterns over multiple days before changing settings 2
• Do not ignore trend arrows: If your CGM shows rapidly falling glucose even at 86 mg/dL, consume 10-15 grams of carbohydrate preventively 1
• Recognize hypoglycemia unawareness risk: If you frequently have glucose <70 mg/dL without symptoms, implement a 2-3 week period of scrupulous avoidance of any glucose <70 mg/dL to restore awareness 3

When Actual Hypoglycemia Occurs (<70 mg/dL)

If your glucose does drop below 70 mg/dL 1:

• Consume 15-20 grams of fast-acting carbohydrate (glucose tablets preferred) 1
• Recheck glucose in 15 minutes and repeat treatment if still <70 mg/dL 1
• Once normalized, eat a meal or snack to prevent recurrence 1
• Have glucagon available for severe hypoglycemia, even on basal-only or low-dose insulin regimens 1

Optimizing Your Insulin Pump Therapy

For pump users, approximately 40-60% of total daily insulin should come from basal delivery, with the remainder as meal and correction boluses 2. If your basal rate represents >60% of your total daily dose, this suggests over-basalization and increases hypoglycemia risk 2.