# Extended bolus - am I the only one?



## MaryPlain (Aug 23, 2012)

I often read of people using the extended bolus feature of their pump to cope with meals which release their carbs slowly.

Am I the only one for whom the opposite is the typical problem? I mean that I find that for 99% of what I eat, the problem is that the carbs get into my blood far quicker than the insulin works. 

I use Apidra, having tried all the other short acting insulins and finding that this acts the quickest, but I still get frustrating spikes two hours after eating moderate amounts of low GI carbs.

In four years of pumping, the only food that made me think an extended bolus would be useful is Dreamfields pasta, which left me high later, but I've only used the extended bolus once and gave myself a nasty hypo so I'm reluctant to go there again!


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## Phil65 (Aug 24, 2012)

MaryPlain said:


> I often read of people using the extended bolus feature of their pump to cope with meals which release their carbs slowly.
> 
> Am I the only one for whom the opposite is the typical problem? I mean that I find that for 99% of what I eat, the problem is that the carbs get into my blood far quicker than the insulin works.
> 
> ...



This is an interesting one, I think you are using the same pump as me? I have never used the extended bolus, for the same reason as you; I know that I would be spiking 2 hours post prandial. I do use the multi-wave bolus often though ...always for pasta,rice and very high carb meals and I have to say it works really well, for me I spread the delivery over 3 hours but you can adjust the delivery ratio and duration to suit.....only thing I don't like is that I sometimes go to bed whilst the multi-wave is still bolusing.


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## everydayupsanddowns (Aug 24, 2012)

I guess it's one of those things where only your meter can tell you whether or not things are working, or need looking at/experimenting with.

I'd spent quite a bit of time working on post meal levels in my last years of MDI, so had that information to recheck on a pump. Many things stayed very much the same, but there were some slightly surprising changes.

Broadly speaking for me:
Correction doses are unlikely to have much if any significant BG lowering effect before 1 hour at most times of the day.

Levels are much improved after breakfast and lunch by waiting 30-45 minutes after bolusing before eating anything.

Weekends are weird and generally I seem to need less insulin.

Evening meals often benefit from dual/square (extended) wave boluses, and boluses are given at the time of eating.

It may be that my basal isn't quite right in the evening (it's the time of day I hate basal testing most), but things are also complicated by the fact that evening meal is by far the most varied food-wise. It also usually has the highest carb load in the day, and the largest meals. 

Meals over 70-80g CHO especially those with lots of veg 'padding' and/or fat often benefit from an extended bolus pattern. 

Sometimes a short square (extended) wave is surprisingly effective at 'easing' an evening meal bolus in preventing a dip at 1.5 hours

There are some notable (and utterly illogical) exceptions in my 'cheat sheet':
60g CHO (100g dry weight) wholemeal pasta  = square wave over 30 minutes
70g CHO (100g dry weight) *white* spaghetti or tagliatelle = 40:60 dual wave over 4.5 hours!

The usual suspects (pasta, buffets, bbqs, chippie blowouts etc) are others where DW comes in very handy for me.

At the end of the day we all just have to work out what works (most of the time) - if you never find your BG dipping 1-2hours after eating then rising steeply at 4 hours then dual/multi waves aren't going to help you, but I *love* them


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## MaryPlain (Aug 24, 2012)

everydayupsanddowns said:


> I guess it's one of those things where only your meter can tell you whether or not things are working, or need looking at/experimenting with.
> 
> I'd spent quite a bit of time working on post meal levels in my last years of MDI, so had that information to recheck on a pump. Many things stayed very much the same, but there were some slightly surprising changes.
> 
> ...



Fascinating, thanks both. I don't really eat high carb meals these days - I tend to do this when I'm not really paying much attention to my diabetes and so I wouldn't really be fully aware of the impact. However I don't think I've ever suffered a two hour low except perhaps when exercising and having overdosed. Also although I do sometimes eat more than 70g carbs in an evening, I don't do it all at once, it tends to sneak up by me having unexpected snacks after the meal, so it would be too late to do an extended bolus by then (it is extended in a way in that I dose for each separate carb).


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## Hanmillmum (Aug 24, 2012)

Hi,

I tend to use dual wave most days with my daughter, never bother with the square wave as when tried has poor effect even if on the low side to begin with - she seems to need at least 50% up front.

Some examples:

If lunch is a sandwich with wholemeal bread i will extend for just an hour. White bread all up front.
Pasta especially the fresh stuff needs a couple of hours as does pizza, occassional fish and chips needs a good 3 hrs. Potato dishes are normal bolus unless quite fatty with protein too then will extend 1-2 hrs depending on fat/protein content.
Not sure if it is her immature digestive system that requires this extended regime, not especially high carb meals ( 40g seems about average) but all relative with body size I suppose.


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## Ellie Jones (Aug 25, 2012)

I very rarely use the extended bolus..  About the only time I use it, is when I'm eating a high fat very low carb meal, such as a fry up and my starting BG is just above 4mmol/l

Most of my bolus are multi-wave bolus's, and if I snack then these tend to be a standard bolus.

Mary if you'll spiking, perhaps pull the time you start the bolus before you start eating.

Personally if I was looking to do this, I would use a multi-wave, using a smaller first wave split though...


@phil

Mary's got the older Blue Spirit pump, which isn't quite the same as our Combo pumps in the main it hasn't quite got the same fine tuning ability...  Which on paper doesn't seem a lot of difference but when you'll using them it really does, as I found out when I up-graded to the Combo.


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## MaryPlain (Aug 25, 2012)

I've recently got out of the habit of bolusing in advance of eating, but as I'm on holiday at the moment decided to try it yesterday with very mixed results, none of them very good! I'm coming to the end of my holiday in a week so won't have the same freedom to experiment - but will try that this week.

On average how long ahead of a meal do people tend to bolus? (I'm using Apidra which is meant to be the fastest I think).


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## Ellie Jones (Aug 25, 2012)

Apidra isn't exactly faster,  

The kick in time is the same as Humalog/Novorapid, it just peaks earlier and burns out the system quicker..  So theoretically better at hitting the spikes and then doesn't continue to lower the BG's for several hours after the peak.

I use humalog, and pretty lucky I can generally bolus just before eating without too much trouble, with spike being dealt with by the first wave of my multi-wave.

A lot is trial and error, though getting the timing, splits etc correct, but they won't be perfect all the time, as different factors will always hit, so it's a case of  finding what works most of the time best...


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## Pumper_Sue (Aug 25, 2012)

Hi Mary,
from reading other posts and forums the time of bolus seems to be about 15 mins before eating.
Hope that helps.


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## Northerner (Aug 25, 2012)

I bolus 15-30 minutes before eating, it has helped lower my post-meal spikes a great deal. Only drawback is when I forget to eat, like last week when I was lucky to make it quite frankly - certainly taught me to take more care!


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## MaryPlain (Aug 25, 2012)

Ellie Jones said:


> Apidra isn't exactly faster,
> 
> The kick in time is the same as Humalog/Novorapid, it just peaks earlier and burns out the system quicker..  So theoretically better at hitting the spikes and then doesn't continue to lower the BG's for several hours after the peak.
> 
> ...



I think that's what I meant - that's certainly been my experience. On Humalog and Novorapid I found that I had hypos 6 hours after eating sometimes.


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## HOBIE (Aug 25, 2012)

In the last couple of years or so i have used the "duel wave" feature on pump & it works for me.


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## heasandford (Aug 25, 2012)

I am not (yet!) a pumper, but found the basis of this thread fascinating. I think my profile is very similar to yours MaryPlain, and I was starting to think I was just going to have to give up some things completely, a HUGE disappointment to me as I love variation in my food! (I also love rice - does no-one with diabetes eat risotto, one of my all-time favourites, oops, separate thread I think!)
I would love to hear how you get on with giving an early bolus, I struggle with timing but have started setting a timer!


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## everydayupsanddowns (Aug 25, 2012)

heasandford said:


> I am not (yet!) a pumper, but found the basis of this thread fascinating. I think my profile is very similar to yours MaryPlain, and I was starting to think I was just going to have to give up some things completely, a HUGE disappointment to me as I love variation in my food! (I also love rice - does no-one with diabetes eat risotto, one of my all-time favourites, oops, separate thread I think!)
> I would love to hear how you get on with giving an early bolus, I struggle with timing but have started setting a timer!



Risotto (from basmati) and other rice-heavy dishes are fine for me Heasandford - like other foods, including what are usually thought of as 'problem' ones, if I'm not prepared to give them up I carry on experimenting until I find a system that sort of works 

Other foods that I'm not so bothered about I am happy to just avoid.


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## MaryPlain (Aug 26, 2012)

I think the bolusing before eating thing is never going to be something I can do all the time. Even when using Actrapid in the dim and distant past, which you were meant to inject 30 minutes before eating, it didn't always work out that way. In a restaurant the risk was always too great to inject before seeing the food, similar when eating out, and when I am cooking myself I am so busy I forget! About the only time I can do this is when I already have my food prepared in advance or it's a standard sort of meal which requires minimal preparation, so breakfast and a packed lunch will be fine, but dinner will always be a bit hit and miss, I think. 

Still, if I manage it 50% of the time, hopefully it will be better than not at all.

I've noticed that my HbA1c does not seem to be affected at all by spikes - in the past I've had some regular and very large spikes with an HbA1c of less than 6, so if I followed the rules I was given on DAFNE I would never know about the spikes!


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## everydayupsanddowns (Aug 26, 2012)

To be honest, that is one of the biggest issues I have with the DAFNE framework (never done it, only heard second hand). That and only ever correcting at the next meal. I can understand the cautious logic, but pre meal only corrections would not work well for me.


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## heasandford (Aug 26, 2012)

MaryPlain said:


> I've noticed that my HbA1c does not seem to be affected at all by spikes - in the past I've had some regular and very large spikes with an HbA1c of less than 6, so if I followed the rules I was given on DAFNE I would never know about the spikes!



Sadly I appear to be the exact opposite, my HbA1c is disproportionately high compared to my pre-meal readings so clearly something is affecting it - my problem seems to be just the huge variation in results, which no-one from the medical side (even those I think know what they're talking about!) has ever taken any notice of. I can eat the same food with no spike some of the time, but a spike at other times. I am keeping serious readings at the moment but I've done it in the past without success. I really want CGM (broken record again!) for someone to see and believe! Although a pump clinic may also take more notice?


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## MaryPlain (Aug 26, 2012)

Hi Heasandford, I have managed to persuade my team to let me borrow a CGM on a couple of occasions. The one they have is out of the arc: it doesn't give you any real time information at all, just sits there logging levels for three days until they are downloaded onto the computer. The second time I did it, the nurse had set the time wrong so it was 12 hours out. When she looked at the results, it was very confusing as what she was reading as the middle of the night was actually early afternoon.

She didn't let me have the results electronically, just printed out, and the scales were so small I could't make sense of them. 

I didn't find the experience very helpful. I followed all the rules I was given about entering blood tests to calibrate it, but I struggled with the one about only calibrating when blood sugars are stable, mainly because mine rarely were, and there was also a rule about taking at least 4 calibrating tests in each 24 hour period! 

The first time this made some of the results completely unreliable!

I hope one day the clinic will catch up and get a CGM that gives real time results, as I would find this infinitely more useful.

Good luck!


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## heasandford (Aug 26, 2012)

Thank you - as I said, I found this thread very useful and interesting, you do seem to share some of the same symptoms as me especially the wide variations! Has the pump helped with that?


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## MaryPlain (Aug 26, 2012)

heasandford said:


> Thank you - as I said, I found this thread very useful and interesting, you do seem to share some of the same symptoms as me especially the wide variations! Has the pump helped with that?



Most definitely - I had real problems with Multiple Daily Injections with erratic absorption of the long acting insulin, which are completely removed by the pump since it only uses short acting. I also have several different basal rates during the course of a day, for example most of the afternoon and evening I have 0.3 units per hour, but in the morning due to dawn phenomenon have up to 0.7. This kind of fine tuning is very difficult on MDI.

My post meal spikes on MDI were so high that I stopped testing after 2 hours. It's a measure of how much more confident I feel that I am now monitoring what's happening in the 2 hour period, and I'm getting levels which I'm quite happy with two thirds of the time.


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## heasandford (Aug 27, 2012)

Great -  I am due to see the diabetes consultant in a couple of weeks so am hoping for news since I have been told I am on a pump trial of Cellnovo. Most pumpers do seem to get a handle on their problems, so I will keep my hopes up!


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## everydayupsanddowns (Aug 27, 2012)

Hope it goes really well for you Heasandford, but don't be surprised/disappointed if it takes a while to settle. Some seem to click right away, but it took me a good 6 months to start to feel fully confident/comfortable.


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## MaryPlain (Aug 27, 2012)

Good luck Heasandford, I hope you get your pump and that you and it get on as well as I have with mine.


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