Bolus after meals

So, I'm having way too many lows, still. some getting bad, 40's. I'm down to 3u am + 3u pm levemir and I'll probably end up at 4 - 5 total units as I just keep dropping. What the heck? This, of course, is effecting my I:CR and ISF. my endo now wants me to bolus after my meals until I (we) can figure basal out before attempting pumping again. Has anyone done this...does it workout about the same?

I thought I'd try some oatmeal yesterday morning (prepackaged stuff with nuts and cranberries); went from 97 to 317 in 1/2 an hour. yuck, yuck, yuck. it tasted terrible and wasn't even worth it..*sighs*

Hi Sarah,

I often bolus directly after meals, sometimes 10-20 minutes into them now and it works a lot of the time although at other times I will spike. Sometimes I bolus when I see a rise start on dex or bolus more if I have already. Today I was dropping after teaching my first class so I ate my whole dinner and then bolused and took my basal right before I left to teach my second class.. I also reduced the bolus and I was ok, no spike but then started to go hypo again, not bad though. I have been raking leaves for two days so that may have caused a low day, who knows. Now I'm spiking a bit but not from my dinner so I'm going to have a snack because food plus bolus is often the only thing that will stabilize me. No oatmeal for me though, I have pretty much given up on grains/potatoes etc. I would not wait to bolus if you're going to eat the oatmeal, maybe just bolus when you eat and see what happens.

It will depend entirely on what you eat. With super-processed ultra fast carbs like instant oatmeal, it’s a recipe for disaster. With higher fat higher protein meals with more complex carbohydrates that haven’t been ground into a powder, cooked once, had sugar added, dehydrated, and then cooked again it may work quite well.

Your physical activity level will play a large role in how fast insulin is absorbed. If you’re sitting on the couch it will take much longer than if you’re running around full speed.

I’d also suggest that if you’re only taking a few units of levemir and having lows in the 40s that aren’t from overdoing bolus doses, you may not need any basal at this point.

Basal and bolus are two complicated subjects. But I truly think, and I know its been suggested before, that keeping them separate in your mind will help you a lot. Once your basal doses are dialed in to prevent random spikes that aren’t related to eating meals… then its time to worry about bolus. With bolus, timing is absolutely as important as amount. Once you “figure basal out” and start working on bolus, keep in mind that timing is critical. For me, I would bolus for instant oatmeal (which I wouldn’t actually eat) about 40 minutes early, just before the insulin would make me crash if I didn’t eat it… because I know instant oatmeal would unload almost instantly. For, say, pizza or chili, I wouldn’t hesitate to bolus right before I started eating, because in 1 the carbs are much slower, and in the other they are slowed down by protein and fat.

thanks ellie and sam. so question,please if i take 3 u levemir at night, have a slight drop 3 hours after shot, stay steady around 120 but then side arrow UP at 4am to 169, how do I know if that's DP or just not enough levemir? if I take .5 - 1/2 unit of novolog to correct that 4am high and wake up at 7:30am at 88, does that mean I need a total PM Levemir of 3.5 (3 u levemir + .5 u novolog correction)? would that mean, too that I need 3.5 u am levemir dose? thanks!

Don't know if this will be helpful, because there is certainly more risk involved.

That said, when I have to bolus post-prandial for some reason, I use a syringe with a long (12mm) needle and give and intramuscular injection in my thigh. I then go out and walk for 15 minutes.

The IM injection infuses faster to begin with, and the walking REALLY speeds it up. This can make the difference between spiking into the 200-300 range vs. staying under 200, eating exactly the same meal.

I do the same for corrections when I'm over 200 (unless it's not convenient, which is too often the case -- then I just deliver a dose via my pump).

Managing IOB with this sort of mixed administration technique is complicated. I use Holger's Glucosurfer to track and manage all insulin dosing -- syringe or pump -- on those infrequent occasions when I do inject, and ignore the pump's IOB and bolus caculations until Glucosurfer clears and indicates 0 IOB. Then I can get back on board with letting the pump handle everything.

It's not as crazy as it sounds... Usually when facing this situation, it's only one injection, no more that day (or probably many days). IA is 4 hours. So the whole "special case" usually clears out in 4 hours, and the pump is back in full control again.

That’s not how I would figure it myself. It’s key to only make adjustments after you identify a pattern… Not after just 1 or 2 events. I would say that if you are consistently spiking at night, whether from dp or from not enough levemir, you should slowly increase your pm levemir dose, 1 or 2 full units at a time… Then observe the trend again for at least 3 days before making another adjustment…

You will not see the same effect from 3.5u levemir as you do from 3u levemir +.5u novolog

Sounds fairly close, but you need to talk to your doctor about any dosing changes.
And the rise around 4am is called Dawn Phenomenon. The bg naturally rises around that time to a degree in everyone.

Interesting you would say that. You never adjust your insulin on your own? I'd go crazy if I had to check with my endo every time I made a change.

well, thanks. i'm a type 1, a very small woman with very little fat, no way I could use a 12mm needle or inject into my muscle. my issue is with lows and being so insulin sensitive. thanks!

thanks, sam. as you suggested, i'm going to just stay a 3u am & 3u pm for three+ days, i'm staying flat at 85 right now, with no food or insulin for over 7 hours, which still is a bit too low of fasting BG for me...but I'll see how I do overnight too. one CD told me to just add up what I need basal-bolus for DP to get me waking to a good number and take that calculation as my PM levemir dose...but I think you're correct as fast acting and levemir don't act the same.

I didn't even know they still made 12 mm needles ouch ! Managing this is too complicated to begin with, start adding in IM shots and glucosurfing and I would have no time to actually work for a living and pay for all my expensive gadgets. I'll just let my pod do the work and Dex keep track of it for me.

Do you keep in mind that even fast working insulin's don't work like the "real deal" and take much more then 1\2 to work?
I try to take at least some of my insulin BEFORE eating. and the real readings are the ones after 2 hours and 3 hour mark. '

I do all my own adjustments now but still always let my Endo know about them and provide logs to show why I made the changes I did.

Before, I would only make small changes after hearing back from my Endo, but that was prior to having a solid understanding of the changes I was making and how they would affect me.

I phrased it as I did because I am not a doctor and am not qualified to give medical advice. So yes, always ask your doctor.

As Sam says below me here, it is supremely important to do Basal testing to identify patterns and trends throughout a specified time period before making any alterations.

DITTO Mario - it is supremely important to do Basal testing to identify patterns and trends throughout a specified time period before making any alterations. Testing and figuring basal has been suggested to Sarah forever. It never seems to happen. Willy Nilly adjustments and reactive methods are no way to manage this thing but that is how some folks prefer to operate. I don't ask my doc about dosing or adjustments, but then I also don't ask strangers for dose and adjustment advice.

Think Like a Pancreas, Pumping Insulin and the IDS have all been recommended as resources for issues discussed in the past. Sarah has even offered that I should get some advice from the esteemed Gary Scheiner MS, CDE blogs and interviews. So I will return the same advice.

so weird!

What works for other people most likely will not work for you as I'm sure you know by now. As I have said many times my bg swings around a lot. I did basal testing twice and it didn't change my timing of basal at all or the dosing, it just basically told me what I already knew, that I have dp most of the time( I can also crash like crazy in the early am too though, lol, thanks D for that!) and I spike up a lot when basal runs out. I also tried changing the basal time according to my cde advice and that was a disaster with my bg spiking and swinging around even more, my body doesn't like big changes. I don't think there is any way to manage things perfectly period.

If I bolused and waited 40 minutes I would end up crashing most of time even with a high starting bg. If my bg is low and I feel I’m going to drop I eat first and bolus later, most of the time this is working very well for me so I’m glad I tried that, I read about various people doing this.What I would do is try the higher basal dose and just see if you still need the novolog. I almost always need novolog as I’m waking up or getting up as dp is really kicking in then and if I don’t stop it then I have no hope of eating and not spiking like crazy. I will be starting the t slim soon so hopefully that will be better. For oatmeal what I would do if there is a large drop with prebolus is to bolus at your meal and then again a little bolus when you start to rise/spike, all depending on your starting bg and general patterns.

Well, the difference is mainly in the absorption rate, being administered interstitially in subcutaneous fat tissue.

Direct venous injections of fast-acting analogs work very fast.

I'd never try it myself, but people do. Search google if you're interested.

thanks, ellie..did you get my v/mail? i know we all swing around a lot. i saw my endo this morning, we're trying all over again. levemir just won't work and i too am going to restart on pump again, my DP too is so bad, although, like you, sometimes I'll just keep dropping all through the night and rise only when I actually wake up. Endo tends to think it's more my incorrect basal doses then my actual body (and YES, incorrect basal 100% effects I:CR and ISF). we 'basal test' every night, obviously...but if one can't get through the night without rising or dropping significantly, something is going on. I've read all the books too, they mean nothing, as they're just references and can't possibly factor in anyone's individual needs. i'm really surprised you're going on a pump, was surprised too you got a dex (although I'm glad you did). at some point, it seems the only way. I don't ever wake up to a normal number, ever and feel like crap all the time. I only tried oatmeal this one time. Typically I have just an egg and coffee. THANKS!

I understand, Sarah. However, IM injections, and everything about them, has no connection to T1, T2, etc. Also, you could use an 8mm needle. Insulin sensitivity just means use a small quantity syringe.

To be clear, I'm not pushing this. It's not for everyone. I brought it up specifically to address the post-meal bolus question, and what adjustments could be made to better control BG in such situations. In such cases, speed is more important than otherwise in order to avoid a really serious spike -- and that's of more concern to T1's than T2's generally because of the higher risk of DKA.

Having adopted the IM strategy for correcting large (>200), persistent highs, I can say that for me at least, they're no more painful or problematic than SC injections, and I do get about 2x the speed of onset and clearance if I exercise the muscle I inject into (usually my thigh, then I go for a 15 minute walk).

Good luck!

You're welcome :-) I'm surprised too! lol- but I never ruled it out absolutely in my mind if I got to the point where I was running super high all the time and or to the point when my fluctuations became too difficult to live with and I think I'm finally at that point(fluctuations and trying to manage on long acting basal which has never worked well for me, It is just too exhausting even with a dexcom. Hopefully this will work better for me- it is worth a try at the least. I did get your vmail I'm sorry I haven't had time to call you yet, it's end of the semester! Please text me your number again and I will call soon!