Learning How To Bolus

Medicines Insulin
, ,
1

Hey diabuddies, been awhile since I’ve posted lately so I figured it’s time for an update!

So upon high blood sugar readings two days in a row, and some fear on my part, I called my Endo for advice because I was uncertain about my choice in split dosing my Lantus. He said a few things I didn’t agree with, but then agreed upon looking over my Dexcom days that I was on too much basal at 18u a night. He then advised me to revisit my bedtime single dose, starting between 10 and 12u, and adjusting up or down every 2-3 days as I noticed levels weren’t in the appropriate range. I looked after myself on my Dexcom, verified with fingersticks, and found that 14u of lantus at bedtime seem to work pretty well for me.

The lowest I go in the morning (in the week or so I’ve adjusted to this regimen) is 85 mg/dl. I’ve even found that with this dose, I have room to start bolusing for my meals! I am still a little newby when it comes to these things, so I am not pre-bolusing for these meals yet. Instead I watch my sugars, double check the range, and will make corrections for my meals.

With a helpful conversation from @Eric I am learning that I need to see how my diabetes works in order to really decide my best plan of treatment, Endo agreeing or not. So I am taking my care into my own hands and I am only holding on to things that pertain to my best possible care.

I’m really just posting here for two reasons:
-To update all of you beautiful diabadasses that have so freely and warmly welcomed & educated me in my journey
-I’m also very curious about everyone’s starting experiences with bolusing. How you came to learn about your body’s needs, how you first adjusted to introducing your bodies to insulin, etc.

Also hoping everyone has a wonderful independence day! I will be enjoying some backyard fireworks later myself. :slightly_smiling_face:

7 Likes
2

Sounds like a great plan!

My first ‘betes mentor (who also coached me to only listen to endos so much) got me onto the “write everything down” method. Basically a chart noting time, food (noting carbs but also noting everything I ate), dose, dose time, and then the starting bg, 90 minute or 120 minute post meal number, and then a four hour post meal number. But this was also preDexcom so take that into account.

It really helped me to slowly sidle up to what I needed to do for in range control.

And I also discovered that in sedentary situations, I have to space out my meal intake over two hours to avoid a stuck high. I don’t have to do that if I’m active (like housework or shopping active).

Basically try and observe and try and observe is what I still do to this day.

5 Likes
3

I struggle with my night dose of Levemir. As I get older and have had D for longer, I have become really sensitive to temperature and activity. @Eric also helped me with that great excel sheet he came up with, to see whether it was stacking or not. It helped me, but I do also think that my endo needs to have a good look at everything, as aside from the initial set of my doses he gave me when I first started seeing him over a decade ago, he hasn’t really looked at it much since and I think I need a complete overhaul.

I wish there were forums like this for when I was first diagnosed. As it was, the internet was still pretty new and I didn’t own a computer. My Mum jumped on her work computer with dial up and printed a heap of info and then snail mailed it to me half a country away!

I think it’s sensational that you’re learning early on how to read your body and to adjust your management @Necroplasm . It took me years to get to the same point.

Keep on being awesome, but also watch for that burnout! Hopefully you can avoid that one!

5 Likes
4

Oh wow! Ironically enough, I started doing that this morning! Guess I’m on the right track with how I’m learning my bolus.

As far as sedentary situations go, I noticed that my insulin fought with my BG for a bit after I injected, but now that I am moving around more since my work shift started… it’s more fiercely lowering me back to a controlled point.

I will continue to try and observe until I feel more comfortable with starting pre-boluses. But it’s nice to know I’m headed in the right direction.

4 Likes
5

Hopefully! Ty for sharing your experience, I hope you have some luck with readjustment! I know that awful feeling when you know your doses aren’t helping you, and even worse when they’re hurting you.

I am very fortunate to have all of this knowledge at my fingertips, and will certainly do my best to utilize it as well as I can.

4 Likes
6

Hi Nec!

I am glad you posted this. It’s very helpful to get this type of conversation started.

A few things to reference from our discussion the other day. First of all, there is no such thing as a perfect system. Every single type of regimen is going to have advantages and disadvantages. And they are different for each of us (which is why none of us do things the same way).

You need to try to figure out which one is the best for you. Or maybe you can think of it as trying to figure out which one sucks the least. :man_shrugging:

I know there are a million other options for you. Different basals, like Levemir or Tresiba. Or a pump.

But for now, just to keep it very simple, we talked about just using Lantus and Humalog. And we talked about 3 different ways of doing it.

  1. Taking Lantus once daily at night (with Humalog as needed)
  2. Taking Lantus once daily in the morning (with Humalog as needed)
  3. Taking Lantus twice daily, morning and night (with Humalog as needed)

Just looking at those 3 different regimens, what I would like you to do is come up with a list of advantages and disadvantages for each of them. By doing that, you will process it better, you can apply your understanding, and you can gain insight from the braintrust at FUD who can also point out some advantages and disadvantages you may not have thought about. So you will learn a lot by doing that.

I think that will help you get a great understanding of how these things can work, and help you gain insight into all the various interactions with timing and food and basal and bolus and…life. Basically everything that goes with it.

So maybe that is kind of a crappy assignment.

Oh no! Stupid Eric wants me to make a pros and cons list.:man_facepalming:

Sorry, tough love. :wink:

5 Likes
7

Pffffft jokes on you. I love making lists. :laughing:

I will definitely work on that while I’m on vacation this upcoming week and see what potential the 3 options ahead of me have, good and bad.

6 Likes
8

Glad to see you taking control @Necroplasm, that is a big step and is to be commended (it is no small feat). It may take longer than you like to get everything dialed in, but you have made the most important step that most everyone here has, which is to understand all of your options, test to ensure you know what works, and change whenever needed. You too will soon be a diabadass extraordinaire!

4 Likes
9

That’s a really hard set of questions, because the answers keep turning into long stories that I have to erase because of TL;DR. It’s still too long, but this is what I have for you.

I was misdiagnosed type 2 but didn’t believe it, got an endo appointment a month later, the endo ordered antibody tests and the day they arrived she turned me over to a type 1 CDE for insulin instruction. The CDE talked to me for about an hour, gave me starting numbers for basal (lantus) and insulin:carb and correction ratio for bolus, and sent me home with prescriptions for Lantus, Novolog, and syringes. I got 8 test strips and 4 syringes per day. I started basal immediately, and on my own adjusted it for a week until I stayed more-or-less level. A few months later I split it to half in the AM and half in the PM just on the theory that it would provide a smoother dose. I kept a log book to record all insulin doses and eating so that I could try to observe cause and effect.

Then it was Thanksgiving day, so I started bolus insulin. I guessed a number of grams of carbs, took the shot, and waited for the meal to arrive.

First lesson learned: I have to know when the food will actually arrive before I take the bolus, because if it’s too late I’ll go low.

Second lesson learned: I have to actually see the food before I guess how many grams of carb will be there, because if it’s a restaurant meal and it turns out to be smaller than I guessed, I’ve just overdosed insulin. Of course at home I weigh the food and multiply by the %carbs of that kind of food, either from the nutrition label in prepared food, or from the USDA nutrient database (a PC program initially, now “Food Nutrients Finder” on iOS.)

Third lesson learned: if I overdose insulin, it’s really easy to fix, just eat a good number of glucose tablets. (a) I have to have glucose tablets with me. (b) I estimate 10mg/dL rise for each glucose tablet, and eat the number that will move me from my current BG to 100; if I’m falling fast I’ll eat a couple extra for safety, if I’m severely low I’ll eat 5 extra to rescue myself before I pass out.

I say third lesson learned because I hadn’t been properly taught that. When I realized I had overdosed for dinner I ate some bread, but it wasn’t enough. When I started shaking violently I was taken for medical help. It appears that I never actually went below 120 mg/dL, but the rapid drop had a dramatic effect on my insulin-naive body.

I tested myself to find the correction ratio (how many mg/dL do I drop after 2 hours when I’m fasting, steady, and I take 1u insulin.)

I adjusted my insulin:carb ratio until I was about as likely to end up too high as I was to end up too low. This was 8 years before CGM, so with a limited number of fingersticks, there was no way to sugar surf.

After a while I realized that it wasn’t just a matter of taking the right amount of insulin, it’s about matching the speed of action of insulin to the speed of digestion, depending on the kind of food. To bolus for especially slow carbs I used a split bolus (partial dose of insulin to start, additional insulin after an hour or two.) To bolus for especially fast carbs, I bolused earlier ahead of eating and took an overbolus, with extra carbs later on to compensate for the overbolus. All this was just trial and error, gaining experience until I mostly did it right. That was a couple years.

Before CGM I also learned a lesson about basal insulin. If I wake up in the middle of the night, and my BG is too high, and I’m sweaty wet, it doesn’t mean I needed more basal. It means I had too much basal, went low in my sleep, my body had a panic and dumped hormones to save me, and that made a BG spike.

8 Likes
10

Here’s what I discovered years ago. I could tell my basal medication needed adjusting. I tried the switch from splitting it or increasing/decreasing, but BG was not responding well. I am not/was not on a pump, so that meant a lot more monitoring especially since this was before BGMs were in the market. Over time, I switched from Levemir to Lantus and eventually discovered a medication that totally works for me: Toujeo by Sanofi. This medication totally made the difference for me. My brother’s doctor recommended this about a year ago and it’s he switched from Lantas too.

4 Likes
11

As I look back I realize that my starting experiences with bolus were while my pancreas was apparently still making some insulin (honeymoon period) so all the ratios I started with years ago have shifted since those early days. I did not have a CGM and was on Lantus basal and Humalog bolus. I tested a lot and wrote everything down (pre meal BG, pre bolus time, meal carbs, fast vs slow carbs, bolus amt, BG a few times after meal). My metric was “Number of BG readings over 150” over the course of each week and to be honest I don’t remember what my goals were. Without a CGM I was just taking snapshots anyway but it was helpful to have a metric to track and improve. Pretty crude but it helped me tune my meals and bolus procedures.

Also, shortly after starting insulin I met with a nutritionist. Although the info I got from her was pretty basic it helped me decide on carbs per meal and carbs per day. I ended up eating exactly the same breakfast and lunch most days for about 6 months, which helped sort things out by taking one variable out of the equation.

There were some bumps along that road but I think it made adjustments easier when things changed with time.

4 Likes
12

For me at least…having a low stress day will reduce insulin needs by about 25%…also, being between 80 and 110 will reduce insulin needs as well, this’ll change the bolus numbers a bit and result in less bolus needed the earlier the dose is taken relative to food or the BG going up for whatever reason.

When I tried a double basal dose it seemed as though I needed to bolus quite a bit more to cover the gaps. That’s when I decided to go back to a single dose (sure this has been said a lot…). I also tried some of the newer longer acting insulins like Toujeo and Tresiba but overall it seemed like I felt kinda off and gained weight.

2 Likes
13

Brief update on my journey into bolusing and understanding my insulin in general:

I have been utilizing my current findings on this regimen: 14 units of lantus at 9:30pm (been trying to go to sleep earlier, so I set my basal back 30 mins. I have not slept earlier, but it’s a start :laughing: )

With 14u of lantus, I have a flat glucose level when fasting, which has made it easier for me to be more confident about using my bolus insulin to cover carbs.

I have learned how to properly calculate the amount of carbs I am having, and this morning I have successfully pre-bolused for my breakfast!

Today feels like a really good day, like I’m getting the right type of control on my numbers. Today I am a hopeful diabadass… and I just wanted to share some good with all of you. I know I’ve shared a lot of frustration and anxiety, so I just wanted to spread my joy today. Lord knows we don’t always feel much of it when it comes to this grappling disease.

10 Likes
14

That is fantastic news! Congrats on successfully navigating the most difficult part of being a diabetic and absolutely killing it. Sure you will get better at it, but look how far you have come in such a short time! So glad for you.

2 Likes
15

Thanks! I started my Omnipod dash last Friday, and as @Eric knows - it’s been a bit of a bumpy ride. I have learned that I’m going to have to save my arms exclusively for my pods, because they don’t really do diddly squat on my abdomen. This was also probably why I struggled with bolusing in general, I’m pretty sure I have very little absorption ability in my abdomen - not sure why. Might have something to do with my dramatic weight loss? If anyone has any insight on that, I’m all ears… errr or eyes? lol.

But I had an issued Tues - Wed this week similar to something @Michel had posted - multiple site issues with my pods. First location was on my stomach (left side), I’m pretty sure I disrupted the cannula on this one while I was cleaning the house on my day off - lots of bending. Before I knew it my blood sugar was up to 281 (YIIIIIIKES). I immediately prepped a new pod, and foolishly I put it on the right side of my stomach this time. Thinking I was not going to be that active again for awhile, I figured it’d be safe there. Set up a correction bolus, and my numbers took a minute but they started going back down. Sweet success. Ordered a carb-y dinner from Red Lobster (My DE is encouraging me to add more carbs back into my diet). I pull out my PDM confidently, I put in the proper carbs and I schedule my bolus. All systems go, I had at least 20 mins between my bolus and my first bite. Fast forward to 2 hours later, my numbers are rising - I ease myself into the thought of it not spiking too high - after all I properly bolused for these carbs… nope. Stuck at 190… then up to 200, 201. I set a correction bolus, I check an hour later… 201 still. :roll_eyes: at this point I’m considering that my stomach may not be an optimal site for my pods, I try to be patient with myself… I let the insulin run it’s course. Except it’s not, not at all. I teeter down to 190 and I remain there for the next 2 hours.

At this point I get a call back from Eric, and we discuss certain things. I decide that I’m going back to my upper arm, for that’s where I had the most success so far and it was the smoothest 3 days of my pod life. I set a correction bolus and I go to sleep. I woke up and my blood sugars were in a good range, around 110-120. I bolus, I breakfast, I spike. Sigh, this is now my 3rd site change and the pod is not working as intended for me. I excuse myself from work to run home and get a new pod, from a different box - all 4 of these were from the same one. I remove the 3rd pod from my body, prep the 4th, and really try to go for a fatty part of my arm. I realize I have blood on my finger, not the one I checked my BG with. So I look at the area I’ve just primed - the cannula site from the pod I had just removed was bleeding… ooooof. That’s new lol. So I carefully and slowly place the new pod onto my arm, just as I so assuringly thought I did the last 3 times… and I set the correction bolus. Almost instantly I notice a fluctuation in my Dexcom reads… and gently the 200-221 readings start to drop down… below 180… below 170… and all the way back down to a nice comfortable 99 mg/dl.

It’s been rough, but I navigated through it. I was under the impression that the box I had taken 4 from may need to be replaced. I was informed that it was most likely site issues in general, but regardless I think I might be most comfortable swapping out that box in hopes I may get a better insulin response out of others like I have been with this current pod and the OG pod I started with.

So far I love the pump life and even though this day was seemingly never-ending, I wouldn’t change my decision to switch from MDI to this.

4 Likes
16

Hi @Necroplasm
I wanted to clarify with you some of our discussion. We may not have been on the same page with our phrasing!

When I was referring to a “bad pod”, I was talking about one that has an occlusion or an electronic error. One where you end up getting an alarm or an error code.

The other thing which you mentioned was a “failed pod”. I guess a “failed pod” is a broader term. Like if a pod is doing what it is supposed to do - pushing out little bits of insulin - but it is not working for the person wearing it. Like the site is not absorbing, or the cannula is loose or something like that.

So when I was saying the pods are okay, I meant that they are doing what they are intended to do, but for whatever reason, that pod is somehow not working well for you. So maybe it is not a “bad” pod, but since it is not working, it is still a “failed” pod.

I recommend getting comfortable with this by checking every single pod you wear. Remove it before deactivating it, and do a bolus. You should see insulin come out of the cannula tip.

Maybe that pod was not working for you, but if you see insulin coming out of it, then you know the pod was doing what is is supposed to do, but there is a different issue to figure out.

If you ever have a pod that is still active, and after removing it you do a bolus and nothing comes out, that’s something that would need to be reported in a big way. Like that is a huge deal for Insulet. That is indeed a major failure. If there is no alarm, but insulin does not come out, that is really huge for them. Sell your stock.

When I first started using them, I was using Humalog. I was ready to quit them. But then after much research, I learned that NovoLog is much more resilient to breakdown in a pump. Switching to NovoLog made a huge difference and I am still on the pump 5 years later.

If you have enough failures, it might be worth trying NovoLog to see if that is more consistent. I can send you some. I have barrels. I am like the OPEC of insulin.

4 Likes
17

I will consider this in the future it I continue to have absorption issues, tysm! I hope that I don’t have future failed pods, but if I do I will keep the next one active and attempt a bolus to see if there’s any occlusions.

It was honestly just such a frustrating day that I just kept deactivating them and slapping new ones on lmao. At least now I am prepared for things to go wrong, silver lining!

1 Like
18

Let’s try to narrow down the cause of the issue.

Categories:

  • Bad pod (it’s not actually delivering)
  • Bad insulin
  • Bad site/absorption
  • Bad insertion (cannula is not in)
  • Air bubbles
  • Incorrect dosing - basal
  • Incorrect dosing - bolus / IC rates

Anyone have any other categories to suggest?

4 Likes
19

So I can say that I did troubleshoot most of these and my conclusions are as follows:

With one pod I can be certain that it was leaking, I made my fiancé smell the site and he could smell insulin - I made him double check the window with a flashlight for me and the cannula was inserted. During these pod changes I was sure to draw insulin from a new pen to rule out the insulin, I made sure that there were no air bubbles (only champagne bubbles, no gloopy ones) before inserting the needles into the pods. I made sure at every insertion site to gently push against the skin before sterilizing to rule out muscle underneath, and I pinched up the skin at the cannula side and gently pushed against the pod during insertion. The basal rate is solid for me - I have a flat rate during fasting, and the I:C rate seems pretty accurate as well, curbs me at 180 at the highest and then works its way down from there - and that’s when I eat a pretty Carby meal, which I’ve began doing being I have the pump and can bolus the carbs accurately.

Definitely need to look out for bad site/absorption, it seems that my abdomen simply can not hold the pods well - idk where the insulin is going when I insert them there, but the response is slim to none from both right and left sides and so inevitably renders the pod useless. Whether or not some of the 4 pods weren’t delivering insulin is a question I can’t answer, but the first pod definitely failed on my stomach because it wasn’t delivering any. I saw a steep climb start out of nowhere - which leads me to believe that in my repeatedly bending at the waist, I disrupted the cannula and it wasn’t delivering anymore. The other 3 I believe just weren’t delivering the full bolus, and that definitely could’ve been due to site placement.

I appreciate any further knowledge on all of this though, as pod life is very new to me and any experience is helpful for me to know for my future on this pump. :slightly_smiling_face:

2 Likes
20

That is a great suggestion!! For some reason, it never occurred to me!!! Thank you!! I’ll try this on my next poor absorption day!!

4 Likes