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Splitting Boluses on MDI

Discussion in 'Parents of Children with Type 1' started by KHM, Apr 11, 2010.

  1. KHM

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    In another thread, Kim, Arleta and Tammy all gave a little glimpse into new territory for me: splitting boluses for fatty/mixed meals like pizza, fried foods... I didn't want to hijack that thread any further so maybe we could continue the discussion here.

    To summarize, Kim said she had given about half of the supper bolus 15 minutes prior to meal and the second half about one hour after beginning the meal...to my head that should extend the "fast" insulin for another hour to about 5 hours of coverage. Is this correct? It also gave her the flexibility of adding in an additional food item that DS had decided he wanted :) love the flexibility.

    Tammy (I think) said her approach was to split the meal bolus by half, give the first half as usual and give the second half when she could see his bg beginning to rise. This seems to take a lot of vigilance for non-CGMers and I wonder, too, about identifying that rise---wouldn't we expect two distinct increases in bg with such meals?

    Finally, I believe it was Kim who said her experience with split boluses was very good with some types of meals...which types?

    Am I alone in having concerns about giving supper boluses and your long-acting insulin too close together to avoid additive peaks of activity? We are seriously late supper eaters (blame it on growing up in Spain and loving The Lehrer Report...) and I always have this niggling worry about timing of night time Levemir...splitting the bolus would increase those concerns. Does anyone get really specific about the fat:carb ratio when choosing to split the bolus? And what about meal-time corrections?

    So this is why I didn't jump in furter on that other thread :rolleyes:.

    Thanks!
     
  2. saxmaniac

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    Very perceptive. Two syringe boluses are much stronger than the saem amount by pump or one bolus, because of two factors. One is surface area absorption rate, two is the aligned peaks. I would say start with splitting them 2 hours apart, and draw them nearer as needed. We've had some nastly lows until I figured this out.
     
  3. kimmcannally

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    Hi :) That was the first time I had done the split bolus so I can't comment on which meals they work well for. I just wanted to try it for that high fat pizza/chocolate bunny meal :p

    Let me look on my logs....I can't tell you for sure how well it did because he got his first bolus at 10:15, his second at 11:30. I checked at 1:40 and he was 118 but didn't check again until 5:23 - he was 308! But he had potato chips and after the first "free" 15 carbs, kept snacking. So I believe that high was due to the chips, not the split bolus high fat meal.
     
  4. Nancy in VA

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    One thing you can consider is a single bolus of a mix of rapid and medium-acting insulin, like Regular. We used to do a 60/40 Humalog/Regular mix for pizza.

    I woudln't worry about the timing of boluses with the long-acting. The design of the long acting is to keep them steady - it isn't "supposed" to have a peak like rapid. (I put "supposed" in quotes because we were Lantus users that used to have a peak). so, the action of the fast-acting and long-acting regardless of their timing, shouldn't affect each other or result in unexpected lows just because they are near each other.
     
  5. canadianmomto6

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    When Liam was on MDI we would give the first dose before he ate and then because the time of the fat spike would vary from 3-6 hours later we would test him at the 2 hour mark and every hour after to see when his BG was starting to rise. It does mean more BG tests, but it was a great way to head off the fat spikes.
     
  6. KHM

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    This is a very cool thing and Wilf also mentioned it to me. Since you're here in the States, could you comment on OTC availability? Wilf is able to get Regular insulin OTC in Canada...

    ...and we're not opposed to a lot of testing if it keeps us on track. Thanks!
     
  7. saxmaniac

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    Regular is a good idea, too. We fooled around with split boluses for a long time and could never get them quite right. I was looking into using R when we started pumping.
     
  8. Nancy in VA

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    You can get Regular over the counter here, but why don't you ask for a prescription. Our practice readily offered up the mixed bolus concept - they call it the "pizza bolus"

    What practice are you with in the Capital area? We are with Children's in DC and mostly go to the outpatient center in NoVa.
     
  9. Yellow Tulip

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    Yep, that is exactly what we're doing too. It means more pokes, but keeps the nasty highs at bay.
     
  10. KHM

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    I'm trying to interact as little as possible with my current endo because...

    we are ditching her for Children's Endo clinic in DC. We'll be mostly at the outpatient center in Rockville. April 26th, which can't get here soon enough, is our first visit with the Children's group. Our next door neighbor has been in Fran Cogen's care since his dx 10 years ago, when he was the same age our daughter is now. I know they've been very happy with the care they've received there---I've heard very little about the group that wasn't glowing.

    Pizza bolus--love the technical term :)
     
  11. wilf

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    I have a better term.

    In Germany, Regular is called the "party insulin" because you can give a honking big bolus and then it covers 3+ hours of steady grazing.. :cwds:
     
  12. Nancy in VA

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    Well, once you get into the Children's practice, since you are already doing Basal/Bolus, make sure you ask for Regular so you can do the "pizza bolus". They even have a handout - ask if you can get that.

    They'll ask at the beginning of the appointment what prescriptions you need, so have a list. You may need to reissue yours with the new Dr. name on them, so might want to take a comprehensive list.

    Dr. Cogan is who we see - she was our "intake" and then we saw a different one for our next follow-up in 4 months, and the Dr. Cogan from then on since we're pumping and she sees all the pumpers.
     
  13. KHM

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    Funny! The diabetic equivalent of Ecstasy...except without all the brain damage...

    We'll be seeing Cogen--I will indeed be ready :) Thanks for letting me know what I should be prepared for. What was your experience like from your request for a pump until it was approved on the clinic end?
     
  14. Nancy in VA

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    KHM: they do have a process they go through, and they won't let you deviate - but I did push hard to get them to get me through as quickly as possible.

    First event: Pump night. You meet with the pump CDE (There are two of them) and she'll walk through some real basics about pumps and infusion sets and then you'll see all the pumps and infusion sets and get an idea for what you want.

    Second event: Pump paperwork. After you choose, you submit some paperwork that has to be processed. Not a big deal.

    Psych meeting: Both of you and your daughter will have to meet with the psych department. At her age, they probably won't meet with her separately too, but they may. They like to make sure that this decision is what the child wants and isn't just what the parents want (especially important in teens) and that the family appears ready.

    Pump order / Insurance approval: Part of the previous paperwork was all the stuff for insurance. After they get the report from psych, they'll submit to pump company / insurance for approval. They are prepared to have to argue it twice, seems to be typical. I stayed on top of my insurance company and the pump company, asking for the status at each step and calling every other day if I didn't hear.

    Pump training. I think they do this at Children's now. When we started 2 1/2 years ago, the trainer from Animas came to our house. I think the nurses at Children's do it now. You will do a saline start for 5-7 days. At your daughter's age, since she isn't self managing, you and your husband will do a couple of days each on the saline, and then move it to her for a couple of days. During this time, we did all boluses on the pump and then did the syringe injection. Its to get all of you used to pushing the buttons, changing sites, etc.

    Insulin start: You'll go back in and review the pump basics, put in a new site and startup with insulin. After this, you'll be calling / sending in numbers every day and for the first month, you aren't allowed to leave the area. They do not want you to be away from home with a major problem in your first month of pump start (because you aren't as equipped to handle all the potential pump problems out of the gate)

    Follow-up: At the end of 1 month, you go back for some more training and follow-up. You won't do combo boluses, temp basals, etc in the first month - you'll be doing straight carb dosing and correcting but in this session you'll go over some of the the aspects of the pump and you're on your way.

    Most of these activites will be at the facility in DC - I felt like during pump start I was there all the time between July and September. But, I had an appt in July with the Endo and we were pumping on 12 September.
     

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