Super Bolus

This is Caleb...

First things first: this approach works for Caleb. It may or may not work for you. I am by no means suggesting that anyone should apply the following theories to their diabetes care. I am only explaining what I do for Caleb.

For weeks, Caleb’s most predictable BG of the day was pre-lunch. Without exception it had been in range. It was sensor change day and we were operating in the blind start-up period. No worries though because this time of day hadn’t posed an issue in quite a while.

It’s approaching lunch time so let’s do a finger stick. 289.


Okay. Oh well. It happens. There was more fiber in his breakfast than usual and he was a little low at the postprandial check. Ah yes, hindsight is 20/20. Moving on. Now back to this 298 and we are getting hungry for lunch.

Super bolus.

John Walsh explains it as follows: “A Super Bolus is created when some of the basal insulin delivery is stopped or partially reduced, and delivered instead as additional bolus insulin on top of a normal carb or correction bolus.”

The intent is to get glucose levels back in range quickly without inducing hypoglycemia. Here is how Caleb’s super bolus went that day:

Correction: 1.50 units, plus

Meal bolus for 50 carbs: 2.00 units, plus

Basal for the next two hours: 0.70 units, equals

Total units delivered: 4.20 units.

Lastly (this is critical) turn basal to “off” for two hours.

The change in the timing of the basal insulin makes all the difference. Front-loading it and delivering it with the meal and correction bolus makes it act faster and all at once, thus bringing glucose levels back in range sooner. If left as basal, the end result will be the same, but it will take more time and hyperglycemia will
last longer. The same amount of insulin is delivered when using a super bolus, it is only the timing that is different.

Back to life, start preparing lunch.

1/2 hour after superbolus: 169

Perfect. Coming down fast and lunch is ready, let’s eat. 50 carbs consumed.

1 hour after superbolus (1/2 hour after eating 50 carbs): 109

Excellent. The first time I tried this, I panicked a little at this point. A 109 an hour after a bolus that large is cause for worry. But his basal had been zero for an hour and he still has food in his system. Plus his basal will be zero for another hour.

DexCom had been calibrated with that lovely 289, which we confirmed after washing hands with a 288. DexCom showed him cruising between 85 and 100 over the next hour.

2 hours after super bolus: 89. Wonderful.

I know a bolus of that size is still hanging around in Caleb’s system beyond the 2 hour insulin duration that we use. However Caleb’s basal insulin has just now resumed. He hasn’t received any basal or
other delivery of insulin for the last two hours. Any tail of insulin duration from that super bolus is required for his basal needs.

And it worked. He continued to hover with a nice flat arrow through the afternoon until dinnertime when a finger stick confirmed a BG of 98.

I invite you to read more of what John Walsh has to say about using a super bolus. He suggests its use for high glycemic foods or large intakes of food in order to avoid blood glucose spikes. I haven’t tried in those situations yet, but I plan to. He also speaks of pumps giving us the option to deliver a super bolus automatically. The thought of it gives me chills.

In what ways have you used the super bolus?

I wonder if after doing the (super bolus) you can do a TBR (Temporary Basal Rate) of 0% for 2hours?.. This was actually a trick I was taught for exercise and the Spirit pump but not sure the Pod can do it? This way after the TBR is complete (in your case the period of no basal rate due to the front loading of the basal)… it will beep and alert you the TBR has ended and you have to confirm it, which makes it a good time to do a quick BG…

Once you understand what it is, Super Bolus makes complete sense and should be an option on all pumps. As John W mentions people could and would use it all the time to correct highs more quickly. Thankfully there is a way to manually set up a Super Bolus despite the typically old feature sets of pumps. It’s high time for pumps to update their bolus options to allow multiple, simultaneous extended boluses, ability to deliver variable amounts over different time segments, and ability to save meal presets that deliver combo/extended.

John - The OmniPod absolutely allows for a temporary basal rate of zero. This is exactly what we do. We have to manually do it, that’s the only trick - remembering. And yes, the Pod (not the PDM) will beep when that period is over and automatically resume the regular basal program established. There is no confirmation necessary with the OmniPod after the temp basal period is complete.

Don - I completely agree. I just love the way that John Walsh thinks and I would really love to see one or all of the pump companies include these features. I really think it could set a company apart from the rest.

I use it when I am high but need to eat on a timeline, not giving my bs time to go down. It seems to work well when I use it.

How to give a SuperBolus as per Walsh…(correct me if im wrong) (of course YMMV)

Take your blood glucose… Its high/much higher than youd like and you want to eat…

Calculate your Correction
Calculate your Meal Bolus… (probably do not want to be doing any square wave/extended funkiness with this)
Calculate what your basal rate will be for the next 2 or 3 hours

Add them all together
BOLUS Correction+Meal+ Total basal youll be in a TBR for
SET YOUR Temp Basal to ZERO! for a time period of 2 or 3 hours

Sit back, and check your bg in 2-3 hours (or more times if you wanna see the results)

Yes sir. I believe that sums it up John. :slight_smile:

Figured id come up with the Cliff notes version to make it a little more routine :wink:

I tried it once and it did not work and then never tried again, which is not the correct option.

I also think it has to do with timing of your postmeal spike…

So is the 2 hour time limit what you should use to calculate for this to determine your basal rate and then suspend for that same time amount?

The few times iv done it is 3 hours worth of bolus 3 hours of TBR… if your bg is usually already dropped in 2 hours then you probably want to do it for 2 hours,

calculate the bolus based on the bolus for the period of time you decide to steal from, and then TBR for that amount of time

If you correct in 2 hours, thats probably the time for you to “steal basal” from…I correct in 3 hours so thats what i use for a guideline… as usual YMMV but try and see, can just keep checking every hour for the 3/4 hours from the time of the superbolus to the end of the insulin action to see what works

Hi Karen. I relate to what you are saying. I don’t use the super bolus too often and there are times when I haven’t gotten the desired results, however, I’ve found that it’s usually something else that affected Caleb’s blood sugars and wasn’t because of the super bolus. It’s hard to go back into the kitchen though once you’ve been burned.

If you are at all inclined to try again, maybe you could do it with a one hour basal to soften the impact (add just one hour to the bolus and turn off basal for just one hour). A dad posted to my blog that he always uses one hour with his daughter’s super bolus.

Hi Schmutz!
Yes. I use 2 hours - I add the next two hours of basal to the bolus amount and turn off basal delivery for the same two hours. That is a variable that is personal to the user. The only thing to keep in mind is whatever duration you pick to add to the bolus, to turn the basal off for the same period so that the total insulin delivery is still the same.

I picked two hours (if you read John Walsh’s discussion he suggests a longer period) because that is the insulin duration I typically use for Caleb and with the exception of very large bolus’. It’s worked so I haven’t changed it. There was a bit of discussion about the duration on Twitter yesterday and it seems that 2 hours is the most popular duration used (at least from my small Twitter sample).

Thanks Danny - likewise :slight_smile:

I’ve heard of people using it for breakfast in general too. Someone posted about using it for donuts because of the big spike that usually results for him, and I read on DiabetesMine a mom using it to allow her child to have a candy cane without worrying about the spike. Sounds like there are lots of opportunities, although they would vary from person to person based upon how their bodies react to different foods.

Thanks for posting this. I’ve never heard of it and plan to try it!

Well it didnt quite work for me last night… But i didn’t go higher, post 4 hours… sorta dropped and then went back up. Nothings ideal in D

I’m sorry John. Do you think there was another issue causing the high? Sometimes, like if Caleb’s cannula gets kinked and thus he is high because he hasn’t been getting his insulin properly, I actually need to give him my self named hyperbolus, which is something like the super bolus but I need to leave his basal on. It’s more like delivering the last 2 hours basal that he didn’t get.

I like what i saw… Don’t think it was a kink but changed the set this morning anyhow… I went to bed and was just a little bit high, corrected and all was good… morning BG was spot on… My solution for a lot of BG issues is 2-3 hours of TBR at 10-20% if i know its not the set… Hey it was an off day… but i liked after eating seeing it drop below 300… just wish it stayed there ;).