1) Managing diabetes well requires comprehending changing glucose levels, adjusting to situations, and frequent assessments like surfing glucose levels with a CGM.
2) Effective CGM use involves wearing it often, checking trends, understanding sensor and insulin lag times, and being willing to experiment to improve skills over time.
3) "Sugar surfing" with a CGM means anticipating glucose level changes and giving small, frequent insulin doses or carbohydrate intake to keep levels in target range despite fluxes, rather than large reactive doses.
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
8. 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)
10. 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”
11. 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
13. 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
14. 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
15. 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
16. 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
17. “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
18. Turnaround Time : glycemic inertia
Corrections may need to be adjusted 10-20% to compensate
19. Goal: Try to stay between the lines
As your skills improve, lower the glucose for the upper alert
22. 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
23. 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
24. 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
25. 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
26. 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
32. 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…
40. 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
46. 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
47. 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 ”
49. 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
50. 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”
57. 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
58. 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
66. 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
67. 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
68. “Fried-food revenge” and correction
Fried food earlier in evening
@ 8PM
BG = 194
6 unit correction @ 7AM
BG = 115 in 3
hours
69. “Revenge of the Ribeye” and “The Insulin Strikes
Back”
BG 167: 4 units
LAG
2-3h
72. Correction at 2:45 AM after slow post
dinner rise with 5 units
5 units
~ 2 hours
73. 3 units lispro
Breakfast
BG 173 mg/dl
5 units lispro
Meeting
A “random rise” in BG during a routine day.
2-3 hours
74. 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
75. 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
76. 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
89. BG 137 mg/dl : dose 5 U lispro
Lag time
Eat breakfast here
Timing insulin and food is like shooting clay pigeons
90. 6 U lispro @ 1:45AM
@ 170 mg/dl
30 min lag
3 hour wait
Taking the drop…
91. “Taking the drop”
BG 160 mg/dl @ 1:47AM
Injected 5 units lispro
Lag time
Drop time 2-3 hrs
perfect bottom turn
froth
92. 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”
93. 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
94. 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!
95. 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
97. 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
98. 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
100. 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
101. 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.
104. 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)
106. “Working down” a rising BG
4 units @
173 mg/dl
2 units @
167 mg/dl
7 units @ 2PM for
Whataburger and rings
107. 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
108. 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
109. 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
115. 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
116. Dislodged insulin pump site…
Picked up early by CGM
Pump site changed, insulin dose given,
carb correction taken…$13,000 saved
117. Penny stock day trading strategyCGM is “sugar surfing” board
Change “Managing “d” well with the words: Sugar Surfing requires the following skills and equipment
Normal tides and swells in non-d humans
It’s all about riding the waves, crests and troughs
Based on the principle of FPM (frequent pattern management)
BG (mg/dl) x 75 ml/kg blood volumes x weight in kg x 1dL/100 ml = mg of BG in TBV
Timing 3 at 6:32 28 GM at 6:52 started at 127 and are at 108
“The Umbrella Effect”I’ve packed a lot of useful teaching points into one image here.While long-acting or basal insulin delivery(insulin glargine, insulin detemir, or the basal delivery rate on a pump) is like having a long roof over your glycemic ‘head’. Injections or boluses of rapid acting insulin have umbrella-likeproperties. Properties of any insulin include 1) time to onset of sugar lowering effect, 2) duration of peak sugar lowering activity, and 3) an effective duration of action. I always include a fourth dimension: day to day inconsistency, which can wobble or vary a bit. It’s not only helpful, but crucial that a person using insulin have a good working understanding of these properties of the insulin being taken. Without this understanding, manipulation of sugar levels as I’m about to describe are not possible. When properly applied, rapid-acting insulin protects the user (like an umbrella) from the ‘shower’ of after meal hyperglycemia that rains down for a certain period of time (a). It does so by disposing of glucose into cells. Extending the metaphor fully, basal insulin acts as a roof with gutters that continually and gradually shunts sugar into cells, but without a great capacity. So, in a sense insulin has umbrella-like qualities as I show here on my CGM sensor plot (a 12 hour display in this case). I ate late on this evening and chose one of my more challenging foods to manage: fried chicken (b). It’s a favorite and I don’t eat it regularly for this reason. Nevertheless it was my choice. Fried meals often take more time to digest into blood sugar. That time can extend well beyond the action of the meal time insulin used to cover the meal (i.e., the umbrella), as it did in this case. As you can see, my CGM device allows me to validate my duration of active insulin time, which for me is 3 hours (a). This is the actual span of my insulin umbrella in this case. After that time, the waning insulin effect is no longer able to contain the steady input of sugar coming into my blood stream from my fried meal and the basal insulin in my body can’t properly “cover” this slow influx of sugar. The end result is a slow accumulation of sugar in my blood stream, registered as the rise on my CGM plot shown here (b).Well, I awoke and looked at my sensor and noted I was at 171 mg/dl (d) but the arrow was straight, meaning a gradual upward trend of under 1 mg/dl/minute. Looking at the trend line, recalling what I ate and knowing my prior responses to fried meals, I decided to correct this trend so I would not wake up in the morning with a BG well over 200 mg/dl. Therefore, I took 6 units of insulin to accomplish this. Normally this would take about 3 units since my correction factor is between 1:25 and 1:33 most of the time. But here is another teaching point: my BG was slowly rising and had a form of “momentum” behind it. Had it been trending straight, or even downward, I would have taken very different actions. But since it was trending up, I knew from experience that I needed a greater insulin “force” to neutralize the rise, turn the BG trend downward, and back to my desired target BG of 100 mg/dl. So…I doubled it (6 units). As illustrated here, there was the customary 20 minute or longer “lag” time before any measureable effect of my correction insulin was seen (c). After the insulin lowering effect was underway, it took a full two hours to arrive and stabilize at my target (e). And by the way, I went back to sleep after I took those 6 units of lispro in the middle of the night. Crazy? I would agree with you 100% if I were not using a CGM device. I would be hesitant to take rapid-acting insulin so aggressively although I would have taken the standard 3 units. The result would have most likely been less than optimal, but it would have blunted the rise. My practice here is the end result of lots of practice and careful observation of my own unique responses. Anyone who attempts these maneuvers must find what best works for them. It’s also wise to discuss with your diabetes doctor. Although I must say that many docs might discourage such self-care independence. This is a look into how I manage the daily ebb and flow of my blood sugars. This is not child’s play and requires the input of an experienced and motivated adult. Parents of children with diabetes can master these skills and many have, but it takes patience, consistency and resilience to achieve the confidence illustrated here. I hope this teaching slide is helpful to many of you. This further demonstrates how tight glycemic control truly exists “in the moment”, as I try to illustrate all the time.
“Playing Chicken” with a CGM, blood sugar and insulinI have a weakness for fried chicken. I try not to indulge myself with it often since it requires some extra work to manage the after effects on my blood sugar. The other night I had two pieces of chicken, a roll, cole slaw and green beans (not shown) around 7PM. By midnight, the slowly digesting meal (lots of fat and carbs) combined with the waning effect of my suppertime insulin, could no longer contain the rising tide of glucose entering my bloodstream and hence the levels began to rise after midnight. I woke up and noticed this rise at 2:06 AM. I of course knew what I had eaten the night before, my typical BG pattern with foods like this (a slow steady rise after my meal insulin wears off), plus I realized that some chicken remained in my stomach and was waiting to get into the gut (fatty foods linger in the stomach longer, not a lot of glucose absorption happens there). Knowing this, plus my response to prior doses of insulin to offset these sorts of rises, I took 5 units of rapid-acting mealtime insulin (lispro), then went back to sleep. If I was still on my insulin pump, I would have taken a combination (dual-wave) bolus, but that is another discussion.Let me say that I would NEVER have taken 5 units of insulin at 132 mg/dl and then gone back to sleep. At least not before I had my Dexcom G4. My graphic shows what would most likely have happened if I had just slept through the night and done nothing. Waking up the next morning my BG would be over 200 mg/dl even though at bedtime I was in range. In fact, it is possible I would have taken a snack at bedtime on top of all this, further driving the reading up overnight. The training and understanding of health care providers has some catching up to do in regards to using dynamic versus static data sets created by CGM technologies. The preference is to have a machine make the call (the artificial pancreas or AP). That makes the most sense for the most people I agree. But cruise control is rarely used in rough terrain. I find that a well practiced working knowledge of one’s own body and responses, combined with experience and judgment, can allow some of us now to benefit from a “manual” version of the AP of our own creation. But I agree this isn’t anything kids are able to do quite yet. But IMO the principles used to do this can help everyone in their daily problem-solving and trouble-shooting situations. Anyway, notice that over the next 2-3 hours, I was able to “bend” the glucose curve back the way I wanted it to go. The waviness in the line might have been the sensor on it’s final day since I changed it the next day, but when I calibrated at 5:30, the sensor said 97 mg/dl and my meter said 102 mg/dl. Thank you, Dexcom G4!The power to safely experiment with otherwise forbidden or dangerous practices like taking a dose of 5 units rapid-acting insulin and then going back to sleep is something that is not discussed enough about CGM’s. This is like practicing a high wire trapeze act with a big safety net underneath me: it’s hard to get hurt too badly. Of course I have ample sources of fast sugar (juice) by my bedside (or car or at work) when I do this. My CGM gives me the ability to see highs or lows coming from a distance, not when they are right upon me. This is a tremendous benefit of these devices. When patients ask me, I tell them that a CGM can serve two functions. One the one hand it can serve as a “burglar alarm” that will buzz or beep at alert me when hypo or hyperglycemia is entering my body. On the other hand, it can also be a surveillance system that scans the horizon for possible intruders, allowing you to pick them off before they get too close. As you can see, I use it very proactively, but I am also still reacting to what is happening to me (the fried chicken on this occasion). But a CGM is also a biodfeedback device. I teaches me what different BG levels FEEL LIKE. I can now reliably predict when my BG is shifting…up or down. What an added benefit indeed. I hope this post teaches a few things about knowing yourself, safely experimenting new approaches, and always looking at diabetes self care as a practicable skill, which in my opinion is exactly what it is. As always, feel free to share this post with others who might benefit. I hope you all turned your clocks BACK last night before going to bed. That includes all your diabetes devices too: pumps, sensors and meters.
FFA Field trip home at 10PM. BG shot up at 2PM. Ate pizza for dinner at 8PM. Unknown insulin dose taken relative to meal Meter says 420 at 379 on sensor. Went to 56 by 10:45AM next AM
At sensor calibration time, sensor read 103 mg/dl and meter read 101 mg/dl. After calibration it reset to 99 mg/dl
Straight line trends need more subtle corrections
Bad pump site…
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Although day trading in penny stocks is probably the quickest profit and loss method in the financial world, patience still comes into play. The best day trading strategies involve often going a week or so without a trade, because you must wait to get the best prices. Impatience immediately negates the effectiveness of the day trading strategy.Finally, you need a strong stomach. You should understand that day trading in penny stocks can result in one week gains that are monumental, or can set you up for a loss. Whether making a big profit or taking an ugly loss, you should be able to handle both the good and bad stress that will come with this method of trading. Otherwise, you may make moves for the wrong reasons and compromise your objectives.What Day Trading IsDay trading is simply an attempt to capitalize on short term fluctuations in stocks. For example, with penny stocks it is possible to buy an issue at $0.12 and sell it the next week, day, or even a few hours later at $0.15, giving you a 25% short-term profit on your investment.If a profit of more than 20% to 25% presents itself, you often take it. Do this a few times and you are looking at a highly successful investment strategy.The downside of day trading comes into play when you buy an issue and it drops in value. At that point you either take a quick loss to keep your money available, or you sit and wait for a profit opportunity that may arise later, in which case your money is tied up until that time. This becomes less of a concern for traders who have more assets at their disposal, because while only a portion of their money is temporarily tied up in a stock that has fallen in value, the rest of their portfolio could be actively used.Now, let me tell you how to take advantage of day trading without significant risk, and with maximum profit potential. If you are going to begin day trading, read this section a few times through and adjust your own investment style accordingly.Goals of Day TradingThis is very important if you intend to be successful at day trading. Your overall goal is to make several hundred of percent on your investments on a year by year basis. However, this is to be done 40% and 30%, even sometimes 10% at a time. That is where most day trading strategies fall apart - investors don’t understand that taking the smaller gains more frequently will actually be more effective than the larger gains less frequently!Your goals for an effective day trading strategy should be as follows:•Keep on top of your open buy and sell orders, and the trading activity of the underlying stocks so that you are rarely surprised by a penny stock’s action.•To take small profits when they present themselves. You will find that you have the opportunity for small 15-25% profits very frequently.You won’t often be in a position to be taking the larger 30%-50% profits, because you already would have sold when your shares first began to rise. Therefore, as backwards as it sounds, if you find that you are taking 50% profits more often than 25% gains, you are probably doing something wrong. In the long run, you would likely make more money by grabbing the 25% gains again and again, instead of holding out for the larger returns.Effective Strategies and ConsiderationsThe first consideration of this trading method compared to others is that you will be taking commissions more frequently. If you are not already with a discount broker, or are paying more than $20 per trade, you probably should switch to a cheaper broker. You can read all about penny stock brokers, and get my list of the top ones earlier in this site.With penny stocks, you may often find that a buy or sell order goes partially filled. For example, you may only get $200 worth of shares and be stuck with a $20 commission. To avoid this, keep track of your orders during the trading day - you may pick up a portion of your order at the price you want, then have to adjust the purchase or sell price to make sure you get the rest of the order filled. Changing an existing order to get all the shares you want on one day, instead of over two or three days, means that you will only be subject to one commission.The beauty of day trading is that company fundamentals and overall market action become less significant. You are playing the day by day fluctuations instead of hoping the market will rise or the company will increase its earnings. Buying at the low end of volatility and selling at the high end equals success, despite monthly trends, company fundamentals, or the market outlook.Therefore, it doesn’t matter if the companies you invest in have a positive future or are bad long-term purchases. What’s important is that you keep an eye on the trading activity of the issue in question, try to pick its higher and lower trading ranges, then execute buy and sell orders accordingly.With day trading you need to realize that most of your buy orders should go unfilled, because your bid price needs to be lower than the going trading price of the stock. Buy on the dips and you will have success - put in orders to acquire shares at or below the current bid price. If you put in ten buy orders over the course of a month, you may wind up only getting one of the buys you had wanted, but those shares will be yours at a great price, making it easier to unload them for a quick profit.When tigers hunt, they only catch a meal one out of ten attempts.Deciding on appropriate buy and sell prices at which to submit your orders is relatively simple. Look at a stock that has both high volume of bid lots, and high volume of ask lots. Many people are trying to buy at one price and many people are attempting to sell at another. Look at the spread between the bid and ask prices. If it is about 15% or more, you may want to put in a buy order at the bid price, and if it gets filled immediately put in a sell order at the ask price.Of great importance is the number of bid lots compared to the number of ask lots. There is a very different stock price outlook if the number of bid shares vastly outnumber the ask shares, or vice-versa. The more bid lots, the greater the buying pressure and price strength at that level. In other words, if there is a large level of demand, the price will likely solidify at that level and begin to climb, unless there are enough shares for sale to meet the demand.When getting a stock price quote, look at the number of bid lots and ask lots to get an idea of the demand and supply. This will give you a relatively accurate indicator of the direction the penny stock price will travel in the day, and perhaps throughout the following few days. Use the bid lot and ask lot volumes to help you come up with a price range that the penny stock will trade within.Day trading will prove most effective when you trade in penny stocks that you have been watching for a long time. You will be able to produce better results since you have developed a feel for the upper and lower price ranges. This is not a requirement for success, but rather an advantage.Hedging and Averaging DownAs a more advanced strategy, you may want to incorporate hedging into your day trading practices. When buying, this involves putting in buy orders for the same stock at different prices.Let's use an example: You put in an order to buy 4000 shares of OCN @ $0.23 and a separate order to buy 4000 shares of OCN @ $0.17. Now consult the chart below to see the possible outcomes of your strategy.Possible Hedging Outcomes•Outcome #1: If the price falls to or below $0.23, your first order gets filled. Now if the price drops further, you may get your second order filled at a lower price, averaging the price of your 8000 shares to $0.20. Profits could be realized now by selling at $0.22 or greater. If the price climbs, you will make a profit. If it continues to fall you will take a paper loss. This becomes an actual loss if you sell the shares, or if the shares never return to their $0.22 levels. However, in all likelihood the price will bounce around and will present an opportunity to profit or at least break even at some point in the future.•Outcome #2: The price falls to or below $0.23 and your first order gets filled. The price then rises, leaving your second order unfilled, but providing you with the ability to profit on the 4000 shares you did buy.•Outcome #3: The price does not fall low enough to fill your buy order. You don’t get the shares, but you are no worse off. You can extend your order, adjust your prices, or move on to a different penny stock. Again we must stress that an unfilled buy order means that you probably have the right idea. It is better to have an unfilled buy order than to get shares at too high of a price.These hedging strategies can also apply in the same manner when selling penny stocks.Of course, you are also getting exposed to extra commissions with this strategy.Day Trading SummaryDay trading penny stocks is as straight forward as it sounds. However, you will need a little luck, a lot of patience, and the ability to take the profits that present themselves. By keeping a close eye on the markets and following a simple strategy such as the one outlined above, day trading becomes a straight-forward technical process that requires little thought, yet can provide impressive penny stock returns.