Cozmo users: basal testing and IOB

[BrendaK]

I feel like we're back to square one. We are now using the Cozmonitor after 3 years of not using it. And it's just making me more confused than ever.

So here's my question -- when you check blood sugar and it's automatically entered into the pump, how do you handle the "hypo manager" feature? Today Carson was 138 with some IOB, and needed a LITTLE snack, but not the 18 grams of fast acting it was suggesting. We gave 2 glucotabs, 8 carbs, and then about an hour later right before dinner he was 121 -- that was great. But the pump was still wanting us to "treat the low" because he has still some IOB and it thought he would go low. So I just ignored "treat the low" and bolused for the meal only.

This also brings up the IOB question that has been widely debated on this forum. The Cozmo's hypo feature is all based on how much IOB is left. Does this work for you? Because for us it always suggests WAY too many carbs. (Our Duration of Insulin is set at 3 1/2 hours.)

And again, how often do you add a correction bolus? Carson's ISF is 100. Here's a scenerio. He has 4 units for a meal bolus. Then 2 hours later the Cozmo will say he has for example 1.5 units left on board. That will theorecially lower him 150 points according to his ISF. BUT, he would need to be at 270, 2 hours later to have him lowered to 120 (I'm subtracting that 150 points). But 270 is not a good post meal number. Do you see my point/question? I have never understood how ISF and IOB correlate. Can someone help with this? So if Carson, in this example, is at 180 2 hours post meal, then the Cozmo will say he is going to go low. This is the main pump function question I have never been able to wrap my brain around.

Wish me luck tonight. I'm going to use the Cozmo "basal testing" feature for the first time tonight. Carson is sleeping with me and I'm testing every 2 hours. I'm thinking it might take several nights of this to get it right. But it's kind of like making your toddler "cry it out" at night so you can sleep through the night. A few difficult nights of basal testing, then my hope is we can sleep a little better with better numbers.

[mollysmom]

Hi

We use the cozmonitor. We have the hypo manager turned off. It too would suggest too many carbs for us. We have our duration of insulin set at 3 hours. It seems to me that if I did what the pump recommended Molly's numbers would be crazier. If I'm giving a meal bolus I'll let it take out the insulin on board for a correction(for a high).
Also,
If Molly's 230 and I give her a snack 2 hours after her last bolus, the pump will suggest no correction(insulin) to bring her down. However since I do not have the hypo feature turned on it won't suggest giving a certain amount of carbs based on the IOB either. So, she gets the amount of insulin just to cover her carbs.

Well, I think I may have made this more confusing:confused:

[twodoor2]

I feel like we're back to square one. We are now using the Cozmonitor after 3 years of not using it. And it's just making me more confused than ever.

So here's my question -- when you check blood sugar and it's automatically entered into the pump, how do you handle the "hypo manager" feature? Today Carson was 138 with some IOB, and needed a LITTLE snack, but not the 18 grams of fast acting it was suggesting. We gave 2 glucotabs, 8 carbs, and then about an hour later right before dinner he was 121 -- that was great. But the pump was still wanting us to "treat the low" because he has still some IOB and it thought he would go low. So I just ignored "treat the low" and bolused for the meal only.

This also brings up the IOB question that has been widely debated on this forum. The Cozmo's hypo feature is all based on how much IOB is left. Does this work for you? Because for us it always suggests WAY too many carbs. (Our Duration of Insulin is set at 3 1/2 hours.)

And again, how often do you add a correction bolus? Carson's ISF is 100. Here's a scenerio. He has 4 units for a meal bolus. Then 2 hours later the Cozmo will say he has for example 1.5 units left on board. That will theorecially lower him 150 points according to his ISF. BUT, he would need to be at 270, 2 hours later to have him lowered to 120 (I'm subtracting that 150 points). But 270 is not a good post meal number. Do you see my point/question? I have never understood how ISF and IOB correlate. Can someone help with this? So if Carson, in this example, is at 180 2 hours post meal, then the Cozmo will say he is going to go low. This is the main pump function question I have never been able to wrap my brain around.

Wish me luck tonight. I'm going to use the Cozmo "basal testing" feature for the first time tonight. Carson is sleeping with me and I'm testing every 2 hours. I'm thinking it might take several nights of this to get it right. But it's kind of like making your toddler "cry it out" at night so you can sleep through the night. A few difficult nights of basal testing, then my hope is we can sleep a little better with better numbers.

Wow, first of all I didn't know such a feature existed on a pump!! I was actually touting that the MM should come up with such a feature in another thread. I'm glad that this company thought that out, that's a good feature to have!!

In your example, if he has 1.5 units left on board, that will not necessarily lower him 150 points because that IOB amount is still being used to process the food carbs. The ISF is most accurate in a correction that does not involve any food, and that's also the best way to test the ISF. For example, if you have to give a correction at 2:00 am (no IOB left at this time) and he was, say 250, then a correction of 1 unit would lower him to somewhere near 150. However, you may know this already, just wanted to reiterate for people that do not.

I think the "hypo manager" as you call it, just tries to give a warning when it sees too much IOB left during a specific point in the duration of insulin action (DIA). Again, the MM does not have this feature, but I always make it a habit to check her IOB at any time during her DIA, and compare it with the current BG reading at that time. If the BG seems too low for the amount of IOB left, then I may give some carbs to correct, and avoid a potential low later.

I do this quite a bit, especially at night. I need to go to bed by 11:00, and she has her bedtime snack around 8:00 PM. She has a 4 hour DIA, so at 11:00 PM, she only has 1 hour of DIA left, and that calculates to X amount of IOB. If that IOB is too high for the blood glucose value at that time, I give some carbs, or if it isn't, I happily go to sleep.

Here's some examples,

#1) At 11:00PM if she has a BG value of 100 and 0.6 units left of IOB, I worry. The most she can go down is .6*130 (her ISF is 130) or 78 points. However, I know some of that IOB is still processing food carbs, so it won't be 78 points, but it may still be enough to get me concerned.

#2) At 11:00PM if she has a BG value of 180 and 0.2 units left of IOB, I go to bed!! The reason is because the most she can possibly drop from that is .2*130 or 26 points. I am very happy when I see 11:00PM readings like that.:)

I hope that answers your question. The Cozmo probably does some estimation based on the ISF, IOB and the blood sugar at the current time to generate a conservative warning. Usually, if you are at your low to medium target range half way into your DIA, there is a potential of going low. If you're at your low to medium target range one hour into your DIA, then there is a very high chance you will go low.

[BrendaK]

The part that really confuses me on the Cozmo is entering the bs reading on the pump when there is still IOB. The Cozmo calls this the "correction bolus." The endo and the Cozmo people both say if your pump setting are correct, you should be able to enter the bs at any time on the pump, regardless of when you last ate, and it will calculate the correct dosage for your next meal or a correction that's needed.

For example, if you want a snack 2 hours after your last meal... let's say there is still 1.5 units of IOB from the last meal. And bs is 150. The Cozmo pump will subtract 1.5 units from your total bolus because there is 1.5 already on board. That's a problem because 1.5 units is a lot. Carson gets 1 unit for 25 carbs -- 1.5 units would bolus for 37 carbs. If he has a 37g and a bs of 150 2 hours after previous meal, the pump would give little or no insulin for that 37 gram carb snack, and would even suggest probably 30 grams for a snack for the hypo manager feature. And his blood sugar would go sky high. Do you see what I'm getting at? I think that's what mollysmom is saying they have issues with, too. He would have to be in the high 200-300's after meals for the pump to "think" he's okay based on his ISF of 100.

Now, on the Cozmo, you can bypass this "correction" feature and give the entire 1.5 units for the food bolus. But I don't know when to do that and when not to. Or if there's an in between I just need to guess at. It's also confusing because when asked if you want to add the correction bolus (for the pump to calculate the bs and IOB), it will always default to no if there is IOB. If you want a snack 3 hours after your last meal (DIA is 3.5 hours), then the pump would default to "no" correction, even if your blood sugar was 350. (I should also say that the Cozmo does not have a target range like MM does, you just have a target number, ours is 120).

I think I get more of the picture at bedtime -- it's the "in between meals time" which is basically the rest of the day :rolleyes:

We are going to a new endo and they are really really big into analyzing numbers based on your logging data. We've been pumping for so long, I just do a lot of things by "intuition" and I want to be able to "trust" the pump more. And I want to be able to analyze what is happening better. Carson's A1C has gone up by 1.5%.

[BrendaK]

I should also say that the reason I'm suddenly struggling with this after 3 years is because our endo wants us to use the Cozmonitor, so we can log better. I agree - but now the pump "knows" every blood sugar reading! Can't keep the numbers a secret anymore! So now that it knows all the readings, it's making me so confused on the IOB factor, which is a really big deal when you have a 7 1/2 year old boy that is hungry 20 minutes after every meal!!!

[twodoor2]

The part that really confuses me on the Cozmo is entering the bs reading on the pump when there is still IOB. The Cozmo calls this the "correction bolus." The endo and the Cozmo people both say if your pump setting are correct, you should be able to enter the bs at any time on the pump, regardless of when you last ate, and it will calculate the correct dosage for your next meal or a correction that's needed.

For example, if you want a snack 2 hours after your last meal... let's say there is still 1.5 units of IOB from the last meal. And bs is 150. The Cozmo pump will subtract 1.5 units from your total bolus because there is 1.5 already on board. That's a problem because 1.5 units is a lot. Carson gets 1 unit for 25 carbs -- 1.5 units would bolus for 37 carbs. If he has a 37g and a bs of 150 2 hours after previous meal, the pump would give little or no insulin for that 37 gram carb snack, and would even suggest probably 30 grams for a snack for the hypo manager feature. And his blood sugar would go sky high. Do you see what I'm getting at? I think that's what mollysmom is saying they have issues with, too. He would have to be in the high 200-300's after meals for the pump to "think" he's okay based on his ISF of 100.

Now, on the Cozmo, you can bypass this "correction" feature and give the entire 1.5 units for the food bolus. But I don't know when to do that and when not to. Or if there's an in between I just need to guess at. It's also confusing because when asked if you want to add the correction bolus (for the pump to calculate the bs and IOB), it will always default to no if there is IOB. If you want a snack 3 hours after your last meal (DIA is 3.5 hours), then the pump would default to "no" correction, even if your blood sugar was 350. (I should also say that the Cozmo does not have a target range like MM does, you just have a target number, ours is 120).

I think I get more of the picture at bedtime -- it's the "in between meals time" which is basically the rest of the day :rolleyes:

We are going to a new endo and they are really really big into analyzing numbers based on your logging data. We've been pumping for so long, I just do a lot of things by "intuition" and I want to be able to "trust" the pump more. And I want to be able to analyze what is happening better. Carson's A1C has gone up by 1.5%.

I totally understand your frustration and that's why I've mentioned before, that the most accurate correction dose is the one where there is zero IOB left. I do happen to think this correction feature of subtracting IOB can cause highs, but it's better than stacking the corrections.

There are three ways to give corrections

1) A full correction during the DIA (this will cause stacking and a high probability of a low)
2) A correction that subtracts the IOB if given during the DIA (this will avoid stacking, but may not be an accurate correction)
3) A full correction after all IOB is gone from the last dose (this is the best option and will give the most accurate correction)

I also think because the Cozmo uses a linear DIA model for it's correction algorithm, this adds to the inaccuracy. Fast acting insulin is not depleted in a linear form, but a curvelinear form. The MM uses the curvelinear model, so it seems to give corrections during the DIA that I tend to agree with more.

I have to give you much credit though because you're actually thinking about how the pump makes these calculations, and why. It sounds like you are going to a great endo as well (may I ask who since you live a stone throw away from me).

[Twinklet]

The one thing I DON'T like about the Cozmore (and believe me, they KNOW I don't like it ;)) is that they take both carbs AND IOB off when correcting for a low in combination with a meal bolus. They also account for too much IOB when correcting highs in combination with a meal bolus. They think it's a hypoglycemic safety issue, I tell them it's a complication risk because using it will raise my daughter's A1C as she'll be higher than target from their incorrect dosing. :p MamaBelle and I had a long discussion about this several months back.

For that reason, we do not do a correction in combination with a meal bolus. We correct first, then bolus for the meal.

Our CDE has actually flown to MN to discuss this with them. She thinks that eventually this will be an optional feature on future updates. I hope so! I'm gonna ride their butts on this one, too, because I love every other feature of this pump.

We do use Hypomanager and the Cozmonitor. We have it locked out for 3 hours after a meal. It is usually pretty accurate for us this way during school when she typically doesn't have a lot of high-fat foods or combination bolus running. I like it for that reason--she can look at the screen and know exactly how much to take.

When it alerts during a combination bolus, we know we front-loaded too much insulin and will just give enough to bring her up to 100, ignoring the Hypomanager which will suggest a ton of carbs as it accounts for IOB.

Regarding the default to no on the correction screen--you can use the up and down arrows to make it "yes". You can also turn this default feature off.

[funnygrl]

When I used the Cozmo 1800 extending the hypo manager time-out period to like 1.5 hours and lowering the target to like 90 prevented it from over recommending carbs mostly. I still used my own judgment though.

If I used the Cozmonitor and I didn't think I needed any action, I just pressed the return to home option.

[twodoor2]

The one thing I DON'T like about the Cozmore (and believe me, they KNOW I don't like it ;)) is that they take both carbs AND IOB off when correcting for a low in combination with a meal bolus. They also account for too much IOB when correcting highs in combination with a meal bolus. They think it's a hypoglycemic safety issue, I tell them it's a complication risk because using it will raise my daughter's A1C as she'll be higher than target from their incorrect dosing.

The real reason they're taking too much IOB into account when correcting is the linear IOB.

For example, my DD has a 4 hour DIA, and at 2 hours, she has 40% of her IOB left with the MM. With the Cozmo, it would be 50%. The MM pump that Elizabeth uses has a DIA chart that was obtained from studies done by the insulin manufacturer. Does the Cozmo have that, or do they even care?? The point I'm making is that it's very easy to take a period of time and break it down in linear percentages (ie: after 1 hour, 75% is gone, 2 hours, 50%, 3 hours, 25%, 4 hours, 0%). The MM has a more scientific approach to the DIA by using a chart based on actual studies and scientific papers about the actual kinetic absorption of fast acting insulins. I don't know if the Cozmo manufacturer took the time or inclination to do that, so instead they chalk it up to "avoiding hypoglycemia."

There are several nuances in the MM that try to avoid hypoglycemia, and the algorithms are carefully planned and thought out to do this. Every pump manufacturer has their own set of algorithms. Animas also uses a curvelinear chart. That's why I wondered if some A1C's are better with some pumps vs others.

[Twinklet]

I do wish Cozmore would use a curvilinear IOB algorithm, but honestly the corrections work perfectly for us despite this. Her A1C has been between 6.4 and 7.0 (last week was 6.7) since pumping. Our DIA is set to 4 hours.

We correct whenever she tests--even if her BG is 105 she hits "correction". We have never had an issue stacking with corrections at all--never any lows from that.

I know they've received a lot of feedback (and Cozmore users--let Smiths know you DO NOT LIKE that they take off carbs AND IOB for a low--choose one, not both! And they take off too much IOB for highs), and I'm hoping they'll consider this for the next upgrade.

[funnygrl]

I use a Minimed now and used to use a Cozmo. I pretty much follow the wizards to a T and really haven't noticed a huge difference in bgs. My DIA was 3.5 hours on Cozmo and is 4 hours on my Paradigm now.

[twodoor2]

I apologize if I keep bringing up the MM again, but I think it's good to compare the algorithm characteristics. It's something that can be overlooked when pump shopping.

The MM does subtract food carbs for a correction if and only if the BG is below the minimum target blood glucose. For example, if Elizabeth was 90, it would subract a correction of (90-110)/130 or .15, but it chops off the 5 hudredth place, and this would calculate to .1.

One thing about the MM that sometimes bothers me, but I understand why they do this, is that it will chop off the hundredth place of a calculation. It will not round up or down, but chop it off like a decapitation!!! What bothers me is that even though that hundredth place doesn't seem like a lot, it can add up to a tenth of a unit in a very insulin sensitive child who may need it.

For example, if you have a food correction of .89, it will calculate to .8 on the MM. That drives me crazy sometimes, but I also think they do this to avoid hypoglycemia. I wish the accuracy would be to the hundredth, but it is not.

I apologize for hijacking the thread, but I just wanted to note this. Thank you.

[twodoor2]

I use a Minimed now and used to use a Cozmo. I pretty much follow the wizards to a T and really haven't noticed a huge difference in bgs. My DIA was 3.5 hours on Cozmo and is 4 hours on my Paradigm now.

John Walsh said it's safer to use shorter DIA's on the Omnipod and Cozmo due to the linear IOB. However, that still bothers me because it's not your TRUE DIA. What happens when you try to do a correction after the DIA is over? Your blood sugar is still dropping.

Maybe I'm nitpicking, but those are just the things I look for.

[kiwikid]

Does the Cozmo have that, or do they even care?? I don't know if the Cozmo manufacturer took the time or inclination to do that, so instead they chalk it up to "avoiding hypoglycemia."


Marsha - you seem very 'negative' towards the Cozmo :confused: I have no problems at all with our IOB and corrections BUT we don't use Cozmonitor (not available in NZ) so our default with IOB is always 'NO'

Heres an excerpt from Diabetes Mall
Boluses Recommended By The Pump May Occasionally Be Excessive

Some pumps, such as the Deltec Cozmo, balance any active bolus insulin against both carb and correction boluses. In contrast, the Paradigm series pumps (x11 through x22), as well as the current Omnipod pump, ignore active insulin or Bolus on Board for all carb boluses. In some situations, such as when carb boluses are given within 2 or 3 hours of each other, as occurs in children and adults who like to snack, the Paradigm pump may recommend carb boluses that are too large and cause unnecessary hypoglycemia.

For example, a pumper has given an earlier bolus that was too large and happens to have 5 units of active insulin on board a couple of hours after their last bolus. If their blood sugar is 108 mg/dl (6 mmol) and they eat a snack that requires 3 units to cover it, the Paradigm and Omnipod pumps will recommend giving 3 additional units. In the same situation, the Cozmo pump will recommend that no bolus be given or that some additional free carbs may be needed to offset the remaining bolus insulin. The Animas pump, meanwhile, will discount for active bolus insulin if the person's blood sugar is below their selected target, but give the full calculated carb bolus of 3 units if their blood sugar is above target.

A Paradigm user can double check the recommended bolus if they hit the down arrow three times to scroll down on the screen where the bolus recommendation is given. They will see entries for the meal bolus, correction bolus, and active insulin. They can then decide whether to subtract the active insulin amount from both the carb and correction bolus amounts to reduce the risk of a low blood sugar.

For pumpers who have frequent highs because their basal rates and bolus doses are too low, some excess bolus insulin may not be much of a problem. However, in situations like that discussed above, a pumper might go low if they follow the pump's recommended bolus dose. Some pumpers who have gone low in this situation have mistakenly blamed the lows caused when the Paradigm does not account for all of their active insulin as being caused by excess basal insulin and have unnecessarily lowered their daytime basal rates to solve the problem.

Medtronic administration and engineering personnel are aware of this situation. Whether they will remedy this in software upgrades is unknown. The cost of recalling pumps, the time required to retrain users, and an adamant demand by some pumpers that this approach not be changed may be causing a lack of action. Omnipod administrators discussed the issue prior to release of the Omnipod and decided upon a Medtronic approach to their bolus recommendations. They are aware of the pitfalls and are currently considering whether to change bolus recommendations in their next generation Omnipod.

[funnygrl]

The way any of the pumps calculate IOB is still better than I did when I was doing it by hand. Eh...guess it's ok to correct now...eh...2 units sounds good.

[Twinklet]

I apologize if I keep bringing up the MM again, but I think it's good to compare the algorithm characteristics. It's something that can be overlooked when pump shopping.

The MM does subtract food carbs for a correction if and only if the BG is below the minimum target blood glucose. For example, if Elizabeth was 90, it would subract a correction of (90-110)/130 or .15, but it chops off the 5 hudredth place, and this would calculate to .1.

One thing about the MM that sometimes bothers me, but I understand why they do this, is that it will chop off the hundredth place of a calculation. It will not round up or down, but chop it off like a decapitation!!! What bothers me is that even though that hundredth place doesn't seem like a lot, it can add up to a tenth of a unit in a very insulin sensitive child who may need it.

For example, if you have a food correction of .89, it will calculate to .8 on the MM. That drives me crazy sometimes, but I also think they do this to avoid hypoglycemia. I wish the accuracy would be to the hundredth, but it is not.

I apologize for hijacking the thread, but I just wanted to note this. Thank you.

I used a Minimed here for a month and didn't note that. :confused: It's been awhile, so maybe my memory is fuzzy. I only recall an insulin subtraction for a low BG in combination with a meal bolus, not both a carb AND insulin correction. That was one thing I liked about the Minimed.

On the Cozmore, it assumes if you're even one number below your target, all the remaining IOB is bad. In other words, it's not there to digest fat or long-acting carbs. If you're about to enter a meal bolus with this it will not only subtract all the IOB, it will also subtract enough insulin from your meal bolus to bring you up to target.

[twodoor2]

Marsha - you seem very 'negative' towards the Cozmo :confused:

No, not at all, just trying to understand how and why this pump does certain calculations (because it does frustrate other people), and have an intelligent discussion about it. Thanks for the clarification on how the different pumps work.

I think it's very important not to just discuss how wonderful the pumps are, but to also discuss what their issues are as well. I am by no means trying to tell people not to use pumps (although I'm sure everyone thinks I am). :rolleyes:

[Twinklet]

John Walsh said it's safer to use shorter DIA's on the Omnipod and Cozmo due to the linear IOB. However, that still bothers me because it's not your TRUE DIA. What happens when you try to do a correction after the DIA is over? Your blood sugar is still dropping.

Maybe I'm nitpicking, but those are just the things I look for.

Again, we have never had an issue with this at all. We have her DIA set to 4 hours because that's when it truly expires. We hit "correct" for any number over 100 and have never experienced hypoglycemia with this.

[twodoor2]

Again, we have never had an issue with this at all. We have her DIA set to 4 hours because that's when it truly expires. We hit "correct" for any number over 100 and have never experienced hypoglycemia with this.

My issue I guess is that John Walsh suggests shorter DIA times for the Omnipod and Cozmo because they use a linear DIA for their IOB algorithm. What happens if you really have a 5 hour DIA, but choose 4 hours because it's deemed safer, and then you give a bolus in that fifth hour, and there is no IOB in that calcuation.

That's my issue, but if no one has a problem with this, then that's great. I'm just one of those people that tries dissecting everything and finding all the bugs and defects with any type of product. I work in such a field as well. I feel it is my responsibility to understand the calculations the pump does because this is my child we're talking about. The pumps are wonderful machines, don't get me wrong, but there are the issues of corrections, and bolus calculation that can cause hypo/hyperglycemia it seems.

I'm also unhappy to know that MM does not take into account active insulin when you are getting a carb bolus. I knew about this for a long time, and it was one of my biggest gripes. That being said, I'm happy to hear that the Cozmo and other pumps do take this into account.

Again, I want to clarify just so I don't make anyone hate me: I think all the pumps are wonderful pieces of modern technology, I just think that there are some things with some of the algorithms that can be improved. If your pump gives you absolutely no problems whatsoever, I think that's great. Maybe I'm just nitpicking.

[BrendaK]

We correct whenever she tests--even if her BG is 105 she hits "correction". We have never had an issue stacking with corrections at all--never any lows from that.

I know they've received a lot of feedback (and Cozmore users--let Smiths know you DO NOT LIKE that they take off carbs AND IOB for a low--choose one, not both! And they take off too much IOB for highs), and I'm hoping they'll consider this for the next upgrade.


So what is her target bs? Is it 100?

This morning Carson was 105 when he woke up and the screen gave "correction bolus" option. So I hit it out of curiosity (because his target is 120) and it just said no insulin needed. So you do this with every bs check? Then the meal bolus seperately?

What would happen differently if you did the meal bolus, then selected "yes" for correction if she is below target, say 80 instead of 100? I'm thinking out loud -- guessing that the pump would subtract insulin for the lower blood sugar and if there is IOB it would subtract for that too. If you did it the other way, correction seperately from the meal bolus, it might say no insulin needed for the "correction" then give a straight meal bolus without subtracting for the low bs? I might have to try it this way and change some settings on the hypo manager.

If the hypo manager is locked out for 3 hours, then what if your low at 2 hours? It won't suggest anything? Can someone explain the hypo manager and the locked out feature? I haven't understood that either so much.

I had the hypo manager set at target of 100 and locked out until 2 hours. But now I just changed it to target of 80 and locked out after 3 hours. Maybe that will help with it not suggesting too many carbs.

I mentioned the Cozmo linear DIA to the CDE on Friday and she said for the Cozmo it should be set to no more than 3 1/2 hours (I know, YDMV), but it really should work well if your other settings are correct -- like your basal, bolus and ISF factors.

I think I am going to try doing correction and meal bolus seperately...

And I am nitpicking also on this issue, for some reason, if I can't understand how everything works together, then NOTHING makes sense to me, it's just how my brain works.

Thanks for all the responses, let's keep a healthy discussion going.

And FYI, the basal testing went HORRIBLE last night. He started at 10pm in the 300's, so scrap the testing and I gave a full correction. Then at 12am he was 340!!! WTH??? (I used a new pancake mix for dinner and he had a ton of eggs, so maybe that was it??) So I gave an injection with a syringe and checked every 2 hours the rest of the night. He came down nicely and now we're basal testing this morning. (The site looks totally fine.) He only wanted a couple bite of eggs for breakfast. And I looked like an idiot last night, I had to find the pump in the covers to test him on the cozmonitor, there was no nightlight (he was sleeping with me), I turned on a flashlight and Carson started fussing about that, so then I opened up my cell phone for a light and laid it on his stomach to shine on his finger while I was trying my hardest to get the blood on the darn strip! I sure liked the light on the flash!!!

[twodoor2]

I used a Minimed here for a month and didn't note that. :confused: It's been awhile, so maybe my memory is fuzzy. I only recall an insulin subtraction for a low BG in combination with a meal bolus, not both a carb AND insulin correction. That was one thing I liked about the Minimed.

On the Cozmore, it assumes if you're even one number below your target, all the remaining IOB is bad. In other words, it's not there to digest fat or long-acting carbs. If you're about to enter a meal bolus with this it will not only subtract all the IOB, it will also subtract enough insulin from your meal bolus to bring you up to target.

Yes, the MM just chops off the hudredth place, it doesn't even round, nothing. I think there is better accuracy when taking the hudredth place into account. I know this because I do the same exact calcuations as the pump, and I can see the hundredth place, and I can see what the MM is doing as far as it's calculations. The pump trainer also corroborated this to me. However, they probably don't care about the hundredth place, because for most people, a tenth of a unit difference isn't a big deal. My gripe is that it can be a big deal in some very insulin sensitive individuals.

. . . and if it does a correction and a food bolus, and doesn't round either value to the nearest hundredth, you can really be off. For example, if you have a food bolus that is 1.89 and a correction that is .59, I would add both of those and get 2.48, or 2.5. The MM will come up with 1.8 + .5 or 2.3. That's a fifth of a unit difference, and can mean either a high or low in some children.

[Mama Belle]

As Andie mentioned, we've had lengthy conversations about this. At our house we do not use hypomanager typically (or if we do we usually take their recommendation and adjust either direction based upon the information at hand). There have been several times it has suggested too many carbs. I also always do a correction bolus separate from a meal bolus (correction first, then meal for obvious reasons). I think there is certainly a very valid reason that Cozmo has their IOB set up the way they do. I just know that more times than not it doesn't seem to work for us if we lump the correction and meal bolus into one bolus. Out DIA is also 3 1/2 hrs and seems to work well. Our ISF is significantly lower though, 70 at night 75 during the day. Our correction boluses are always right on the money, we have never had any problems with over/under bolusing with correction once we switched the way we bolus.

There have certainly been times when Sam was say 108 and getting ready to eat and still had say 2 units of insulin on board. IF we were using the correction/meal bolus combo in that scenario, it would most definitely save us a low BG later. However, this rarely happens during times of normal activity (tho it does happen a bit in the summertime). So Again, I can see why they designed this feature this way, but I choose not to use it because more times than not we will end up out of range.

[Rick]

Only having the choice of 2-3-4-5-6-7 or 8 hours for DIA settings prevents most users from being able to select a "TRUE DIA". Like everything else with diabetes I would expect DIA to fluctuate hour to hour, day to day. I assume Medtronic's research has shown 1 hour increments to be accurate enough for good control.

[Twinklet]

So what is her target bs? Is it 100?

This morning Carson was 105 when he woke up and the screen gave "correction bolus" option. So I hit it out of curiosity (because his target is 120) and it just said no insulin needed. So you do this with every bs check? Then the meal bolus seperately?

If the hypo manager is locked out for 3 hours, then what if your low at 2 hours? It won't suggest anything? Can someone explain the hypo manager and the locked out feature? I haven't understood that either so much.

I had the hypo manager set at target of 100 and locked out until 2 hours. But now I just changed it to target of 80 and locked out after 3 hours. Maybe that will help with it not suggesting too many carbs.



Her target BG is 100, ISF is 90. So if she's 105 with no IOB, the pump will give her .05 units.

We lock Hypomanager out 3 hours after meals because by that time, most of what she's eaten will hopefully have been digested (unless it's high fat) and much of the insulin needed for that meal is gone. If she's low 2 hours post-meal, the Hypomanager simply doesn't show up, but we know we overbolused for her food and treat accordingly. The main reason we have Hypomanager turned on is for her to use at school. She's pretty good at treating lows, but this can help her by giving her a guideline.

Regarding DIA--we have ours set to 4 hours and it works perfectly. Go figure. We've never had an issue with this and we keep pretty tight control.

What would happen differently if you did the meal bolus, then selected "yes" for correction if she is below target, say 80 instead of 100? I'm thinking out loud -- guessing that the pump would subtract insulin for the lower blood sugar and if there is IOB it would subtract for that too. If you did it the other way, correction seperately from the meal bolus, it might say no insulin needed for the "correction" then give a straight meal bolus without subtracting for the low bs? I might have to try it this way and change some settings on the hypo manager

If you're doing a meal bolus and hit "yes" for a correction when he's low, the Cozmore will not only take off the entire remaining amount of IOB (when she could still have carbs on board, too), it will also subtract insulin from the meal bolus. I think this is overkill--Emily would be sky-high if we followed this suggestion.

This is why we do it separately. We first correct if she's over 100, THEN we bolus for the meal. If she's really low, we treat the low first. If she's mildly low we subtract carbs. I suppose if you have no IOB it will administer the right amount.

Sorry your basal testing went poorly last night. :( Hopefully today will go better! Oh, and I agree about the light on the flash. Something to suggest for upgrades!!

[twodoor2]

Only having the choice of 2-3-4-5-6-7 or 8 hours for DIA settings prevents most users from being able to select a "TRUE DIA". Like everything else with diabetes I would expect DIA to fluctuate hour to hour, day to day. I assume Medtronic's research has shown 1 hour increments to be accurate enough for good control.

I totally agree, that's another thing that bugs me about MM. I was afraid to mention it. I think the DIA should be set in half hour increments.

Did they conduct their research on small children? I would like to find that out, because those are the people that would benefit the most from half hour incremental DIA's, and also the rounding to the hundredths, lower basal rates (like the Animas), etc. . . I would also like an option to choose more than one DIA, because as you said, even those fluctuate.

Sorry again to hijack the thread, this is about the Coszmore.

[BrendaK]

Thank you so much everyone for your help and replies. You should have seen the conversation with DH this morning as I'm trying to explain the concepts and the math over sunday morning coffee. A little to complex of a topic for Sunday morning coffee!!! Anyways, we are all on the same page. We are going to be doing meal bolusing and corrections seperately from now on. (And hitting "correct" every time we check bs.) I'm finally understading how if you do it together you are "double dipping" so to speak -- which is why we've had so much trouble with what the pump recommends. If we do it seperately, I think we will be able to "trust" the pump more. I also have to be consistant on how we do things so the school can do the same thing as well. I will keep you posted!!

So many changes over the weekend. We switched from the flash to the cozmonitor, from the cleos to angled sets and we are totally changing the way we're bolusing, and oh yeah, we're finding that basals are way off!! My brain is FRIED.

[BrendaK]

Update -- we actually had a successful basal test last night!! I changed all his basal rates yesterday and he stayed between 195-213 the entire night. That's a little high, but good enough to run the test. We also had a good basal test yesterday morning, so we're getting somewhere.

We're also getting used to the Cozmonitor and I am really really liking doing correction boluses and meal boluses seperately. I wish I knew to do this sooner!

Okay, I'm off to train the school on the cozmonitor this morning!

[Charmed7]

I'm sorry if this was already mentioned...I don't have enough time to read it all through now, but I will when I get home since I'm interested in learning more.

In regards to the hypo manager and the IOB, I think there's a spot you can put how long the insulin lasts in your child, since YDMV. That way, if your IOB is going for 3 hours, but your child's is only 2 hours, it will change the way the hypo manager (and hyper) alerts you.

Like I said, I'll read through all the posts, and if this wasn't brought up before, I will go into our manager and find where to make the change.

Charmed

[Tamara Gamble]

Okay, I'm not so technical. Shut the hypomanager off. Set your insulin duration for whatever you think. Ours is at three hours. Enter in your bg and correct prior to entering carbs for food. The correction for a low subtracts from the insulin on board. We don't use this one it doesn't work for us. We only correct with a high.

Tami

[BrendaK]

Okay, I'm not so technical. Shut the hypomanager off. Set your insulin duration for whatever you think. Ours is at three hours. Enter in your bg and correct prior to entering carbs for food. The correction for a low subtracts from the insulin on board. We don't use this one it doesn't work for us. We only correct with a high.

Tami

I think we are finally getting better at this after a LONG weekend!! We almost always used the "correction" feature when entering a meal bolus and that was TOTALLY screwing us up. I am amazed at how much easier everything is by making them seperate.

As for the hypo manager, well, I don't quite have that figured out yet. If you "lock it out" after 3 hours, then what's the point? You IOB is almost gone and you know by testing if you're low or not. BUT, if you have it ON before 3 hours, it will almost always suggest WAY too many carbs. I think, like you Tamara, I'll just have to shut the darn thing off :rolleyes:

I think all of our huge changes are for the better, though. After switching infusion sets, consistantly prebolusing before every single meal/snack, using the cozmonitor, and doing some intensive basal testing, we are starting to see some much better and more consistant numbers. Last night Carson went to be at 150 and woke up at 135. We checked 2 times last night and he stayed at 140. WOW, that's the best numbers we've seen in a long time. Thanks for everyone's help!

[Traci]

I had the hardest time wrapping my brain around all these factors when we first started with the Cozmo. We currently do not have the hypo manager turned on. If ds is below 70, we treat with 15 carbs and retest. Our DIA is set to 4 hours. When I was trying to type up a concise instruction sheet for the school nurse, the one basic concept the endo and I put was to bolus to cover the carbs. If ds6 was over his target but still had insulin on board, we let the pump figure out the bolus both with and without a correction and we give the higher amount. Does my simplistic approach help any??? :o