# which type of bolus...



## curlygirl (Apr 28, 2015)

Hi,
When i started on the pump last monday the pump rep said to put all boluses on a multiwave setting. She said to split it somewhere between 30/70 and 50/50 in terms of upfront/delayed.
Obviously as i have not had the pump long and i am still in the early stages, which, at present, often feels akin to trying to nail jelly to a wall, i am not sure whether this is good advice, or whether it is something that everyone starts off doing etc.
Having read about multiwave bolus uses i am aware there are certain types of food that  this will be incredibly useful with, but, as yet, i am sticking to the most straightforward meals i can think of. 
Therefore is a multiwave bolus good to use? I am finding that my bg is rising very significantly after meals and am wondering if this could, in part at least, be due to not having all the insulin upfront? It could of course be being caused by my carb ratio not yet being correct, likewise the insulin sensitivity factor, or my basal rates not yet being correct...
Anyway if anyone has any thoughts on this they would be appreciated. Thanks
Curlygirl


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## everydayupsanddowns (Apr 28, 2015)

Short answer: I think you are right and she was being over-cautious.

The last thing they want is for people transitioning to pumps to be having crashing hypos right left and centre and needing the paramedics out, so (in my experience) they err on the side of lower doses and correction factors. I've not heard 'everything as dual wave' advice from anyone else, but it sounds like the same sort of thing.

You are likely to be a *bit* more sensitive to insulin delivered by a pump because of the way it is absorbed more effectively... but if you would not have split the dose on MDI you *probably* don't need to dual wave those meals.

The early days are tricky... because everything is so new, but trust your instincts and the knowledge you have already built up - just be on the lookout for some surprises along the way


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## HOBIE (Apr 28, 2015)

Hi if it were me I would not get into that much till you get more sorted. It is great feature which can work very good. It prob takes a while to get some results from pump to dsn. Good luck


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## Pumper_Sue (Apr 28, 2015)

Stay at the basic upfront bolus until you know what you are doing  As your basal wont be correct I can not see why using different bolus options are helpful.
In 8 years of pumping I have never used the multi or any other form of bolus except the normal upfront bolus


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## Sally71 (Apr 28, 2015)

We did all standard boluses to start with while we were still getting used to the whole pumping idea.  You need to get comfortable with the basics before you start to experiment with all the tricks it can do!  We found standard boluses worked perfectly well to start with, it was only a year or so in that we started to be a lot of hypos fairly soon after meals and then started to experiment with multiwave.  And it is an experiment - even if you have identified a good use for the multiwave it's all a bit of trial and error to work out how much up front and how long to spread the rest over.

Don't try to do too much too soon or you'll get confused - one step at a time


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## curlygirl (Apr 28, 2015)

Thanks for your replies. 

If the rep hadn't specifically told me to always use the multiwave settings then i'm fairly sure that i would have stuck to the standard bolus, initially at least, but i have just been trying to do as i was told to. It just struck me today that using the multiwave as instructed was perhaps complicating things even more for me right now.

Thanks for your thoughts on this matter.

Curlygirl


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## Phil65 (Apr 28, 2015)

Ha Curlygirl, got my new pump today and the pump rep said the same thing to me! For 4 years I have standard bolused most of the time, however she told me today if over 6 units I should extend or multi wave. Tried that tonight and my 2 hours post prandial was 11.9! Grrrrr! Now confused, do I continue with her advice or risk an absorption problem with a big standard bolus?


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## Pumper_Sue (Apr 28, 2015)

Phil65 said:


> Ha Curlygirl, got my new pump today and the pump rep said the same thing to me! For 4 years I have standard bolused most of the time, however she told me today if over 6 units I should extend or multi wave. Tried that tonight and my 2 hours post prandial was 11.9! Grrrrr! Now confused, do I continue with her advice or risk an absorption problem with a big standard bolus?



How big a gap between the extended bolus did you give?
Can you just do a 15 minute extend?


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## Phil65 (Apr 28, 2015)

Pumper_Sue said:


> How big a gap between the extended bolus did you give?
> Can you just do a 15 minute extend?



Yes 15 mins is what I did Sue, strangely it advised I took a correction of 4.5


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## curlygirl (Apr 29, 2015)

That is interesting Phil65, although i was told to use multiwave for ALL boluses regardless of size so not sure it is to do with absorbtion that i was told to do it - most of my boluses so far are between 2 & 3 units.

I had a reading of 7.1 before tea yesterday and was 12.1 at the 2 hour mark (these are not great figures long-term, but given where i am in learning to use a pump i wasn't too upset with that.) HOWEVER - after a further hour and a bit i was at 15.7! 

Anyone know if this indicates an issue with the bolus or the basal or something else?

It feels like all the things i knew about my diabetes have been put in a washing machine and jumbled about since i started on the pump and i am finding it harder to interpret the results i am getting and also harder to attribute them to something that i can then change and improve... I know others have said i is a bit like being diagnosed again when you start on a pump and that is kind of how i am feeling right now.
Curlygirl


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## everydayupsanddowns (Apr 29, 2015)

How far in advance of the meal are you bolusing Phil? 

If you want to continue to experiment with the technique and give it a decent run (just because you changed one thing, doesn't mean that it was the cause of the 11.9 of course, that could have happened anyway)... Could you move the bolus back be 15-30 minutes or so? That way all the insulin will be 'in' when the meal starts just as you are used to, but it will have gone in over a longer time.


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## Phil65 (Apr 29, 2015)

everydayupsanddowns said:


> How far in advance of the meal are you bolusing Phil?
> 
> If you want to continue to experiment with the technique and give it a decent run (just because you changed one thing, doesn't mean that it was the cause of the 11.9 of course, that could have happened anyway)... Could you move the bolus back be 15-30 minutes or so? That way all the insulin will be 'in' when the meal starts just as you are used to, but it will have gone in over a longer time.



Hi Mike,
I didn't really get a spike from my previous standard boluses often 25U taken 5 or 10 mins before dinner, so last night I tried what the rep suggested. I had a starter of pate, toast, couple of salad leaves and a sliced tomato at 19.23 bg 5.1 carbs 50, multi waved 12.5 over 15 mins 6 up front, then had chilli and brown rice at 19.53, carbs 90, multi waved 22.5 over 30 mins 6 up front. At 21.24 bg 11.9, correction of 4.15, at 22.20 bg 13.5 correction 3.35, at 23.13 bg 9.5.....went to bed, at 03.40 I was 4.4, 07.59 bg 3.5! 
So, I think I might try and multi wave 15 mins before eating and probably increase the upfront amount. .....trial and error!


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## Sally71 (Apr 29, 2015)

curlygirl said:


> That is interesting Phil65, although i was told to use multiwave for ALL boluses regardless of size so not sure it is to do with absorbtion that i was told to do it - most of my boluses so far are between 2 & 3 units.
> 
> I had a reading of 7.1 before tea yesterday and was 12.1 at the 2 hour mark (these are not great figures long-term, but given where i am in learning to use a pump i wasn't too upset with that.) HOWEVER - after a further hour and a bit i was at 15.7!
> 
> ...



That sounds like you might just not have had enough of a bolus!  It's a bit hard to tell just from one though, random highs happen sometimes for no obvious reason.  I would have corrected the 15, then tested again an hour later and if it still hadn't come down at all then change your cannula - can happen sometimes that the cannula fails (or more likely, the bit of skin it's sticking in decides it doesn't want to absorb any more insulin today thank you)

Then see what happens for the next few days!


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## Phil65 (Apr 29, 2015)

Sally71 said:


> That sounds like you might just not have had enough of a bolus!  It's a bit hard to tell just from one though, random highs happen sometimes for no obvious reason.  I would have corrected the 15, then tested again an hour later and if it still hadn't come down at all then change your cannula - can happen sometimes that the cannula fails (or more likely, the bit of skin it's sticking in decides it doesn't want to absorb any more insulin today thank you)
> 
> Then see what happens for the next few days!



Good advice Sally, that has ticked my boxes a few times over the past 4 years or so of pumping!


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## curlygirl (Apr 29, 2015)

Thanks Sally71 for your reply. It is always difficult to make assessments based on one thing yes. I just really would like to get some consistancy somewhere so i can begin to feel a bit more like i am in control and not just reacting to what is happening. The cannula seems fine as my blood came down overnight - which i know means that my basal rate can't be right  yet as that shouldn't bring blood sugars down - oh, it is all very overwhelming at the moment. I'll just have to keep trying and making small changes etc.
Thanks again.
Curlygirl


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## everydayupsanddowns (Apr 29, 2015)

That points the finger pretty firmly at the meal ratio to me (assuming you corrected the 15.7).

Keep going! You'll get there


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## curlygirl (Apr 29, 2015)

Thanks everydayupsanddowns for your reply and your encouragment.
I actually didn't correct the 15.7 at bedtime no - i was aware that i perhaps should be doing, but as i have never done a correction that is not at the same time as a carbs bolus ie at meal time, i really didn't feel confident to do my first one ever last thing at night. Instead what i did is wake myself up a couple of hours later to see how things were and as they were coming down i left it and checked it after another couple of hours etc. 
It is possible that there are 2 issues - the basal is not right overnight yet for sure and perhaps the carb ratio for teatime also needs tweaking. Maybe some more small changes will help things...
Curlygirl


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## Aoife (Apr 29, 2015)

work on one thing at a time, either bolus or basal.  Too many changes confuse matters far more and you'll have little idea on which change is making the difference!  Once you get one sorted then the other is much easier, don't worry if your levels run higher for a bit, short term it wont cause problems, if you can get stability (even if high and stable!) then you can slowly increase your insulin until you get the numbers closer to what you would like


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## HOBIE (Apr 29, 2015)

Aoife said:


> work on one thing at a time, either bolus or basal.  Too many changes confuse matters far more and you'll have little idea on which change is making the difference!  Once you get one sorted then the other is much easier, don't worry if your levels run higher for a bit, short term it wont cause problems, if you can get stability (even if high and stable!) then you can slowly increase your insulin until you get the numbers closer to what you would like



Agree, one step at a time. Pumps are great at what they do but its how you & it work together. We are all different


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## Sally71 (Apr 29, 2015)

I agree with everyone else - it looks like your ratio probably needs changing at tea time but get your basal sorted first before you worry about that.  It's very early days for you - things will start to settle soon!


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## Pumper_Sue (Apr 29, 2015)

curlygirl said:


> Thanks everydayupsanddowns for your reply and your encouragment.
> I actually didn't correct the 15.7 at bedtime no - i was aware that i perhaps should be doing, but as i have never done a correction that is not at the same time as a carbs bolus ie at meal time, i really didn't feel confident to do my first one ever last thing at night. Instead what i did is wake myself up a couple of hours later to see how things were and as they were coming down i left it and checked it after another couple of hours etc.
> It is possible that there are 2 issues - the basal is not right overnight yet for sure and perhaps the carb ratio for teatime also needs tweaking. Maybe some more small changes will help things...
> Curlygirl



The easiest way to sort things is set amount of carbs for each meal simple carbs, no pasta rice pizza etc, sort you basal first. There is no point in changing other things until basal is sorted. 
Rome wasn't built in a day, small steps will get better results


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## curlygirl (Apr 29, 2015)

Thanks Aoife, HOBIE and Sally 71 for your replies. I am trying to take it one step at a time, it just feels like there are lots of things jostling for attention! 
I will concentrate on the overnight basal and hope things start to slot in to place a bit more then. 

Can i just ask - if my blood is, say, 11 or 12 at bedtime, can i still basal test from there, because presumably i'd be looking to see how far it strayed from the starting figure? Or would it be better to wait until i hit on a better bedtime figure to basal test? I know that my basal's not right overnight yet because i wake up quite a bit lower than i was when i went to bed.

Thanks for peoples' time.

Curlygirl


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## curlygirl (Apr 29, 2015)

Thanks Pumper_Sue. I have been sticking with the same meals in the hope this would simplify things a little and will continue to do so until i at least make some progress with my basal rate.
Curlygirl


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## Sally71 (Apr 29, 2015)

curlygirl said:


> Thanks Aoife, HOBIE and Sally 71 for your replies. I am trying to take it one step at a time, it just feels like there are lots of things jostling for attention!
> I will concentrate on the overnight basal and hope things start to slot in to place a bit more then.
> 
> Can i just ask - if my blood is, say, 11 or 12 at bedtime, can i still basal test from there, because presumably i'd be looking to see how far it strayed from the starting figure? Or would it be better to wait until i hit on a better bedtime figure to basal test? I know that my basal's not right overnight yet because i wake up quite a bit lower than i was when i went to bed.
> ...



Yes if you are 11 at the start of the basal test then you should also be 11 at the end, so as long as you are not scarily high you can basal test at any level!  You are aiming to stay steadily at the same level all night with no more than 2mmol deviation up or down at any point.  Obviously if you go either sky high or hypo you have to abandon the test, deal with the problem and then try again another night.  Good luck


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## trophywench (Apr 29, 2015)

Curly

You feel exactly how I felt -instantly transported back to 1972and feeling lost alone and unloved.

It isn't a nice feeling, is it? {{{Hugs}}}}

But - it gets better ! - just grit your teeth and refuse to  be beaten, hun!


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## curlygirl (Apr 29, 2015)

Thanks trophywench - your words are very much appreciated. It helps just knowing others have felt similarly overwhelmed when starting on a pump.
I am determined to get the hang of it though...
Curlygirl


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## trophywench (Apr 30, 2015)

Well it's quite clear to me that you have a perfectly logical brain but I also recognise your need /desire to check first before you do something that unbeknown to you might be 'wrong'.

However - the only way to really find out about whether you can trust yourself is to try doing it your way really - and of course, if it works - it will give you confidence.

If it doesn't work, keep quiet and just revert to Plan A  !!

All these things we did on auto pilot on MDI .... will soon be on auto-pilot on the pump.

You are much less likely to become a 999 jobbie on a pump, if you think about it, than on MDI - for the simple reason you have not got a day's-worth of long-acting insulin floating about waiting to send you mega hypo, have you?

And of course - since it's new you'll be doing this anyway I would hope - Test, Test, Test !!


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