Should you use a CGM (Steady Glucose Monitor), you in all probability already understand how a lot of a game-changer this expertise could be in relation to managing your diabetes.
Having perception into our blood glucose historical past, the place what our blood sugar is true now, and the place it’s headed brings peace of thoughts and makes managing diabetes lots simpler and safer.
However even in the event you love your CGM, do you make the most of the pattern arrows for insulin changes? If not, you’re really lacking out on the total potential of the expertise.
By being attentive to the CGM pattern arrows, you’ll have the ability to make extra proactive and knowledgeable selections in relation to adjusting your insulin doses.
The data on this put up is restricted to the Dexcom CGM system. Different CGM techniques use pattern arrows as properly, however they could have totally different meanings so please watch out using the knowledge right here in the event you use one other system.
Once you open your Dexcom app or have a look at your receiver, you’ll see your present blood sugar in addition to a sign of what your blood sugar shall be in half-hour.
That indication comes within the type of arrows. On the receiver, the arrows are to the appropriate of your present blood sugar. Within the app, it’s proven as a circle along with your blood sugar and the arrows across the circle.
You in all probability know that an up arrow signifies that your blood sugar is rising and a down arrow that it’s falling, however have you learnt by how a lot and find out how to embody it in your insulin changes?
Let’s begin with what the arrows point out in accordance with the producer:
| Pattern Arrows | That means |
| 2 arrows straight up | BG may enhance greater than 90 mg/dL (5 mmol/L) in 30 min. |
| 1 arrow straight up | BG may enhance as much as 90 mg/dL (5 mmol/L) in 30 min. |
| 1 arrow barely up | BG may enhance 30-60 mg/dL (1.7-3.3 mmol/L) in 30 min. |
| 1 arrow to the facet | No BG enhance or lower of greater than 1 mg/dL (0.05 mmol/L) per min. |
| 1 arrow barely down | BG may lower 30-60 mg/dL (1.7-3.3 mmol/L) in 30 min. |
| 1 arrow straight down | BG may lower as much as 90 mg/dL (5 mmol/L) in 30 min. |
| 2 arrows straight down | BG may lower greater than 90 mg/dL (5 mmol/L) in 30 min. |
Supply: Dexcom G6 information
Actual-life instance
Let’s say my blood sugar is 120 mg/dL (6.7 mmol/l) and my Dexcom is exhibiting 2 arrows straight up.
On this case, I can count on my blood sugar to probably enhance to above 210 mg/dL (120 + 90) inside the subsequent 30 min.
I attempt to keep under 200 mg/dL so I’d most certainly give myself a correction bolus primarily based on this information (so long as I didn’t simply eat a meal or have already got sufficient lively insulin on board that simply hasn’t kicked in but).
Your CGMs arrows could be extremely useful for blood sugar administration — however provided that you understand how to answer these arrows.
A number of medical professionals have provide you with approaches for utilizing CGM arrows to assist sufferers dose insulin safely and successfully. Most significantly, all of them agree that we must always take the rise or fall charge into consideration when adjusting our insulin doses. What they disagree on, nevertheless, is strictly how insulin doses ought to be adjusted primarily based on these arrows.
The Endocrine Society reviewed 4 printed approaches in 2017 and got here up with their very own pointers. Their pointers had been printed within the Journal of the Endocrine Society in December 2017 (please notice that the rules mentioned listed below are for adults solely).
Since I contemplate the Endocrine Society the best authority in relation to the sort of suggestion, I’m going to share their suggestion with you.
Though the rules had been written for Dexcom G5, no modifications have been made to the arrows for the newer techniques and the suggestions ought to be legitimate for Dexcom G6 as properly.
The Endocrine Society recommends that you simply modify your insulin primarily based on what your blood sugar shall be in half-hour, quite than what it’s proper now. However as an alternative of calculating what your future blood sugar shall be in half-hour, they suggest that you simply modify your correction issue (CF).
This correction ought to be made on prime of any correction in your present blood sugar in addition to any carbohydrates consumed.
Your CF is how a lot one unit of rapid-acting insulin (like Humalog or Novolog) will lower your blood sugar. Should you use a pump, you may see your CF in your settings. Should you handle your diabetes with injections and don’t know your CF, you may ask your medical crew that can assist you calculate it.
Endocrine Society’s really helpful correction primarily based on Dexcom pattern arrows
| Arrows exhibiting | Correction Issue (CF) | Correction dose (IU) |
| 2 arrows straight up | <25 25-50 50-75 >75 |
+4.5 +3.5 +2.5 +1.5 |
| 1 arrow straight up | <25 25-50 50-75 >75 |
+3.5 +2.5 +1.5 +1 |
| 1 arrow barely up | <25 25-50 50-75 >75 |
+2.5 +1.5 +1 +0.5 |
| 1 arrow to the facet | <25 25-50 50-75 >75 |
No adjustment No adjustment No adjustment No adjustment |
| 1 arrow barely down | <25 25-50 50-75 >75 |
-2.5 -1.5 -1- 0.5 |
| 1 arrow straight down | <25 25-50 50-75 >75 |
-3.5 -2.5 -1.5 -1 |
| 2 arrows straight down | <25 25-50 50-75 >75 |
-4.5 -3.5 -2.5 -1.5 |
Supply: https://educational.oup.com/jes/article/1/12/1445/4642923
Let’s sum it up with an instance:
I’ve simply rolled away from bed within the morning, had no lows in a single day, and I’m about to sit down down for a meal of 20 grams of carbohydrates. My blood sugar is 120 mg/dL (6.8 mmol/l) with two arrows up. Because of this I’ll must do three calculations:
- First, I’ve to calculate the dose for my carbs. Assuming my Insulin to Carb Ratio (ICR) is 10, I’d want 2 IU of insulin to cowl my 20 grams of carbs.
- Secondly, I’ll must calculate my correction dose primarily based on my present blood sugar. If my CF is 25 and my goal blood sugar is 95 mg/dl (5.3 mmol/l), my correction dose is 1 IU (120-95 = 25 and 25/25 = 1 IU).
- Thirdly, I’d must calculate the correction primarily based on the arrows. Since I’ve two arrows up and my CF is 25 in accordance with the suggestions, I’ll want a 3.5 IU correction.
Including all that up my whole dose could be 2 IU + 1 IU + 3.5 IU = 6.5 IU.
Had my blood sugar been decrease than my goal or had I seen downwards arrows, I might have ended up with a decrease really helpful dose.
Simply to make it possible for is sensible, let’s do one other instance:
I once more simply rolled away from bed and am about to sit down down for a meal of 20 grams of carbohydrates, however now my blood sugar is 120 mg/dL (6.8 mmol/l) with one arrow straight down.
All that modified in comparison with the final instance is the course of the arrow, which modifications calculation #3.
Since I now have one arrow straight down and my CF is 25, in accordance with the suggestions I’ll want a -2.5 IU correction.
Including all that up, my new whole dose could be 2 IU + 1 IU – 2.5 IU = 0.5 IU
Phew, that’s loads of math. Try the following part on how I’d simplify it.
The endocrine suggestions make full sense to me, however it’s loads of math! Additionally they don’t permit you to take lower than 0.5 IU in correction (which could be a difficulty in the event you’re very insulin delicate).
I might quite use a bolus calculator than do all that math each time I have to bolus for a meal or a correction dose. When you’ve got a pump, you almost certainly have a built-in bolus calculator. If you’re on a number of day by day injections (MDI) like me, you’ll must look elsewhere.
Previously, I’ve used an app known as RapidCalc for these calculations. I now use InPen, a SmartPen that sends knowledge on to my telephone by way of Bluetooth and has an related app that calculates doses and retains observe of IOB.
The InPen app and RapidCalc principally do the identical as a bolus calculator, aside from truly giving me my dose (please notice that the RapidCalc app isn’t FDA-approved).
After ending the bottom calculation in your bolus calculator, you may then manually add within the pattern arrow correction primarily based in your CF.
Bear in mind to react primarily based on what you’ll be doing the following 1 to 4 hours, not on what you’re doing once you’re about to bolus.
Should you’re planning to train or simply transfer greater than typical (like go for a stroll, buying, cleansing, gardening, and so forth.) you won’t have to react as aggressively as the rules state.
Typically, it’s really helpful that you simply cut back your bolus and probably additionally your basal (in the event you use a pump) earlier than train. As a result of common speedy insulin is lively within the physique for as much as 4 hours (some even see a tail as much as 6 hours after injection), you have to assume earlier than you bolus.
There are new ultra-fast-acting insulins accessible now and the endocrine pointers don’t work for these. Should you use Afrezza or Fiasp, please know that these insulins peak a lot sooner, and making use of the calculations proven above may probably be extraordinarily harmful.
When to NOT use the CGM pattern arrows
All of the publications advocating for utilizing the pattern arrows for making insulin changes additionally state that there are some conditions the place you must completely NOT use them or at the very least take extreme precautions.
Should you plan on beginning to make changes to your insulin dose utilizing pattern arrows, please learn these precautions first.
4-hour consuming window
The Endocrine Society recommends that the pattern arrows are usually not used in the course of the 4 hours after having a meal with a bolus. As an alternative, they suggest the next:
- 2 hours post-meal – Don’t right excessive blood sugars to stop insulin stacking
- 2-4 hours post-meal, blood sugar 150-250 mg/dL (8.3-13.9 mmol/l) with one or two arrows up – Think about using CF to regulate
- 2-4 hours post-meal, blood sugar >250 mg/dL (13.9 mmol/l) with one or two arrows up – Verify with a fingerstick, take a look at for ketones (if >300 mg/dL/16.7 mmol/l), right utilizing injections, if after 1 hour you continue to see two arrows up, repeat
- 2-4 hours post-meal, blood sugar close to 150 mg/dL (8.3 mmol/l) with one arrow barely down – Verify once more in 30-min
- 2-4 hours post-meal, blood sugar close to 150 mg/dL (8.3 mmol/l) with one or two arrows down – Verify once more in 15-min
- 2-4 hours post-meal, blood sugar close to 100 mg/dL (5.6 mmol/l) with one arrow barely down OR one arrow down – Think about consuming 15 g of carbs, recheck in 20-min. If >70 mg/dL (3.9 mmol/l) and downward arrows, affirm with a fingerstick and contemplate one other 15 g of fast-acting carbs
- 2-4 hours post-meal, blood sugar close to 100 mg/dL (5.6 mmol/l) with two arrows down – Observe the directions above (f) however eat 30 g carbs
Quickly rising blood sugar
Should you see 2 arrows up in your receiver or app earlier than a meal, it’s really helpful that you’re diligent along with your pre-bolus and inject your insulin 15 to twenty min earlier than consuming.
Quickly lowering blood sugar
Should you see 2 down in your receiver or app earlier than a meal, it’s really helpful that you simply wait and inject your insulin once you begin consuming, or in the event you’re near 150 mg/dL (8.3 mmol/l) maintain off and don’t inject till you see your BGs leveling off.
Fragile / older adults
For fragile or older adults, the Endocrine Society recommends a much less aggressive insulin dose adjustment to restrict the danger of hypoglycemia.
For upward-rising arrows, they suggest a 50% discount of the urged adjustment (e.g. from 1 IU to 0.5 IU), and for downward arrows, they suggest a 50% enhance in discount (e.g. from 1 IU to 2 IU).
Sick day administration and medicine issues
Sure drugs, each prescription and OTC, can intervene along with your CGM readings, and pattern arrows ought to consequently not be used for insulin changes. Fairly than relying utterly in your CGM, accompany your CGM readings with finger sticks.
All the time use widespread sense earlier than dosing
As with all device in our diabetes device equipment, I’d encourage you to by no means simply apply the suggestions blindly.
When you’ve got a sense that the really helpful dose is perhaps off, typically counting on how properly you realize your physique is the way in which to go.
Though the Dexcom G5 and G6 CGMs are accepted for dosing by the FDA, they’ll typically be inaccurate, so I’ll all the time affirm with a fingerstick earlier than making any massive dosing changes.
