Bolusing for Delayed Spikes

Hi all

I know you pumpers have your dual wave bolus, but I remember hearing some people on MDIs talk about bolusing for delayed spikes. I have a couple meals that leave me absolutely fine after two hours, but then I am high at approximately four hours when I test for bedtime. I tried yesterday bolusing an extra unit at the two hour mark. I know if I bolus more initially I will go low. I still ended up high. Maybe I just needed two extra units (It involved potatoes). But what would be the correct timing to bolus the extra? I would rather head off the high than wait and do a correction later (which is what I ended up doing).



I would think potatoes would hit your BG pretty quick so it might be what you’re eating with the potatoes (they sure do for me). If there’s much fat in the meal, it could delay the absorption of the carbs in the potatoes for a spike later. Experiment. We’re all different.

Thanks, Danny. Very interesting (once I figured out what TAG was!!). For me, I don’t think I want to get into computing for fats and protein (I think way too much about diabetes already!). Also, it is only a couple meals I have this problem with. But it’s interesting to read of other people’s experiences!

I know we are all different, but was hoping to get other people’s take on the timing of their second shot. I’ve gotten to the point where I feel comfortable with corrections; I know my ISF and how to compute IOB. But I’m somewhat at a loss when my numbers are fine both before the meal AND two hours afterward, but I’m anticipating a high coming up at the 3 or 4 hour mark. I think I was probably on track with bolusing (Apidra) at 2 hours but probably needed to bolus two units instead of just one. I ended up at 176 so and my ISF is one unit for about 30 points, so I’m thinking of I bolused two units that would put me in range. I think I will just experiment. But I would like to hear timing and amounts from people who do it.

When I was on MDI i used ultralente for background and humalog. Unless I was eating proteins and fats both of those have always messed with my BG really bad. In that case I used humalog for the simple carbs and regular to cover slower absorbing stuff for e like potatoes, beans, fats and proteins. It worked ok but it was a bit of a task figuring how different foods should be covered. So I might take 2 units humalog and 3 units regular for a burger and fires… no healthy just and example.

Be loved

For meals like that (lots of proteins etc. slowing down absorption of carbs and adding up to result in a rise in bg 3, 4, 5 hours out) good old Regular insulin is actually a very good match.

If you’re only doing that occasionally then an extra unit or two of Humalog, two hours after the meal might be an OK.

But if you’re doing this a lot, you might want to think about Regular.

Thanks, all. No, I don’t do it a lot, not enough to buy a special insulin for it. I just have a couple meals that seem to do that to me. It seems like certain foods, or combinations of foods are just “more than the sum of the parts” where my normal I:C ratios either make me too high after 2 hours, or fine after two hours but too high after 3 or 4. I think I will try just using 2 extra units of Apidra at two hours (I tried with only 1, I was nervous to take insulin after eating and with normal blood sugars).

All I’ve figured out is to write down the amount and timing of the shots, always eat the same meal in the same portions, and keep tweaking. Some meals require a 3rd shot 3 to 4 hours later. The worst is when taking the 3rd shot would require waking up during the night, so it has become common for me to wake up 30-50 pts too high in the morning because I won’t make myself wake up. I adjust the timing and amounts of the 2nd and 3rd as needed to avoid early lows and really late spikes. I can count on a shot’s peak effect to be completed within 90 minutes, so I will test then to see how well it is working initially but usually I have to test 4-6 hours later to figure out when the insulin is dropping off and bg is starting to climb again.

For mexican food (with beans and rice) or pizza, I take a 2nd shot at the 2 hour mark and a (small 0.75 unit) shot at the 5 hour mark. For trail mix (with M&M’s), I take extra shots at 1hr45m and 3hr45m. Chinese food is a complete bomb of fat and protein. I take 3 shots plus a unit of long-acting to cover the 8 hour digestion period.

'Course a pump would make taking 3 boluses for a meal a lot easier especially if I could set an extended bolus to cover the 3rd shot while I sleep. I really should look into how to count the protein/fat content of these meals and there could be a way to quantify their effects.

Thanks, Don. As for counting, Danny posted a link to a great thread above that helps with the whole counting thing; me I just don’t want to go there. Since it’s only a couple meals I have this problem with, I’d rather just, as you say, get the amount and timing down and write it down for next time. Yeah, it does seem as if you did his often and had a busy life that a pump would be a good alternative. Oddly enough, even if I’m high at bedtime due to dinner spiking late, I’m always fine by morning. Thanks for your info.

Let us know how the extra insulin helped.
Did you glucose eventually return to target? If it did, I would be more inclined to think it was a timing issue…(e.g., if you injected at 2 hours, but at 1 hour were still high, but at 3 hours returned to target, then you’d want to inject sooner to better match the insulin with the digestion). However, if it didn’t return to target, it suggests that there was not enough insulin.

This is also assuming that all basals are correct :slight_smile:

I’m a little confused about your post Xanthasun. I’m talking about a situation in which I was in target after two hours, but spiked somewhere between 3 and 4. I’m going to try the leftovers of the “problem meal” tonight so I’ll let you know how I do with bolusing a bit more at the two hour mark. Btw for me it isn’t about protein in this case, as there is no protein, but it’s a potato dish so I think it’s the glycemic index because potatoes cause me late spikes as do beans. I also wonder because the meals that cause me problems are always in the 50s of carbs which is high for me. I wonder if beyond a certain level of carbs if the I:C ratio is not accurate.

I always bolus at least one unit for a delayed spike. I am on MDI too. I won’t bolus until the four hour mark though just in case it is taking time for the insulin to kick in…unless it is at like 250 or something very high.

I always calculate in the Insulin On Board so I can do a correction at the two hour mark. But I was actually trying to figure out how to do an extended bolus so I can prevent it from spiking high altogether, not just correct it once it does.

Sorry for the confusion because my “fast” acting insulin seems to have a long tail (lasting up to 5 hours) so for me I would have rechecked at 5.5 hours to see where I was at and then decide whether I would have used more insulin or if the number had returned to normal I would have tried injecting the second wave at 1.5 hours rather than 2. I’m not sure how Apidra works for you, but if it’s out of your system by 4 hours then it seems like you should just a larger second bolus.
Because the insulin seems to start really slow, I also tend to do the first bolus 15 minutes early if w/in range and then the extra bolus after only 1-1.5 hours so that the peak hits the second round of food’s peak. (like w/ today’s lunch I had a small 20-30pt rise (for the carbs) after the first hour and a second smaller one (probably the fat and protein)at the 3.5ish hour according to the CGM which has leveled off now) It still spiked but all under 130 so I’m happy with it.)

As far as the accuracy of the I:C ratio, since it’s MDI , it may be an insulin absoprtion problem (dual wave/combo boluses are spread out so some people report having better absoprtion).

Good luck with tonight’s testing.

Thanks for the additional info, Xanthasun. I’ll try doing the second bolus tonight at 1.5 and doing 2 units instead of just one and see how it goes! This dual bolus thing is new for me.

Well, partial success to my experiment. I actually ate a larger serving this time (I eyeball divided and the last serving ended up larger). This time I spiked a little high at the two hour mark (147). I tried doing two units more at the 1.5 mark in addition to my original 4. By bedtime (4.5 after dinner) I was at 150. Not as bad as my previous days bedtime of 176 (especially considering the larger serving) Also I tested at the 3 hour mark and I’d spiked up to 165. So not an altogether successful experiment. Maybe a smaller serving next time and the same dosages. I’m not willing to go beyond that amount and the timing seemed right. Sigh. Maybe there are just some meals that don’t work at all.

I have a hard time digesting starchy carbs like potatoes and rice (especially white rice) or pasta. I usually try to steer clear of those all together. But, if I eat even a tablespoon of those kinds of starches, I’ll have to double my insulin/carb ratio to cover… and then two hours later, I’ll still have to do a correction.

So… if you’re having some of the same issues as me, I do the bolus at consumption, then wait 2 hours and do the same bolus dosage again. (which means having to take almost double my normal bolus amount for those kinds of foods)

Maybe you can work yourself up to it. I would hate to see you plummet.

Also, I’m type 1 too, and when I’m going to eat those kinds of foods, I take a Metformin as well. It helps me to absorb the insulin that I inject.

Wow. When you said spike, i thought you meant SPIKE. haha. I guess I’m still a little uncontrolled (after 12 years) bc when I spike 2 hours after a meal, I mean that I’m in the mid to upper 200s.

Just yesterday I had a bean burrito, but at the end of eating it, realized that about a tablespoon of rice was inside the burrito too. So, I popped a Metformin, upped my bolus coverage… then two hours later, I was battling a 344 BG.

thanks, Marps. Yep, I might have to work myself up to higher doses slowly, or just give up on the “offending” meals. Sorry about the burrito. Living in the Mission District of San Francisco for many years, I practically lived on burritos. Now I can have them only at home with low carb tortillas and of course no rice! Black beans are also an important part of my diet and sometimes they work if I watch portion size and sometimes that’s one of the foods that gets me at 3 or 4 hours. Oh well, practice, practice, practice, test, test, test!

What do you all do with extended meals, not just meals that cause you to go high - i.e. - what do you do when you are out and have several courses to eat, all with carbs, - i.e. - rolls, appetizers and then a main meal. Do you take several shots, or do you just do a one time bolus at the main meal? I am a T2 on MDI, and I have been taking multiple injections for these meals (2-3) and don’t know if I am doing the right thing as I am “stacking” insulin doses. Any insight on this?

Have you gotten good results this way? I no longer eat multiple course meals very often because it is way too much carbs for me. Rolls? What are those? LOL. But when I do have a long meal with appetizers I just do one shot to cover what I plan on eating. Fast acting insulin does last 3 hours so it continues working for the duration of a long meal as long as you bolus enough.