I notice there are a lot of MDI members with in the group… this is excellent and exciting! I created this discussion to basically brain storm your thoughts on the best way to handle TAG (extending your bolus) while taking Multiple Daily Injections.
It seems like the best way is to take another injection or two for the fat and protein bolus1-3 hours after your original upfront carbohydrate bolus. Depending on your bodies absorption rate and fat/protein content of the meal.
Who is up for addition shots? Anyone already taking a 2nd phase injection after their meal?
Well, I figure additional shots are one of those “sacrificing” things about being on MDI. I choose to be because it’s most comfortable and convenient for me, so if I have to take additional shots because of it to gain greater control so be it!
A few cents from my doc visit this morning: he suggested not adjusting with insulin post prandial for AT LEAST 2 hours. I have been playing around a lot with dosing of Novolog and low-carbing, and I have led myself to overcorrect and cause lows after just an hour and seeing not much result, so he’s probably right…I should wait at least 2 before deciding I need more insulin or not. I’m a Type 1.
I eat relatively hi-fat, hi-protein and my carbs come from non-starchy veggies and nuts and occasional fruits. I’m usually <50 carbs a day. I’ve been eating this way since December and my A1C dropped from 8.0 to 6.6 so far, and I’ve lost 8 lbs so I am feeling pretty encouraged! (That’s even with holidays and some cheats in there.) Hoping to get below 6 by my next visit in August…the TAG stuff will be good for that, I think!
Thanks, Danny.
No biggie to take additional shots. I’ve been taking a 2nd phase injection about 1 hour after dinner. Haven gotten this down yet because sometimes it works & sometimes it doesn’t. I’ve been taking about 20-30% before meals & 70-80% an hour later. Use Regular, so it’s slower to act & lasts longer.
Low carb is great for those A1Cs!! That’s wonderful news. I’m happy for you.
About the timing…you know what I’m going to say, right? Everyone is different, everyone’s metabolism is different…every food is different. The amount you eat is also a factor. But I’d say this is probably a good rule of thumb - especially starting out. I WISH I had known about TAG when I was MDI.
I’ve also noticed that it didn’t take too long to learn my rhythms - and, of course, I have my personal favorites that I tend to eat over and over so that simplifies as well. I also noticed that for very high protein meals, I have to extend about 3 hours.
I think it really depends on the meal… my breakfasts tend to be mostly carbs…w/ some protein (e.g. 1-2 tbsp of PB)
(based on pre and 1 and 2 hour pp checking but also some CGM confirmation) if I inject enough in advance I don’t really get a huge spike…if I don’t the number spikes but by the next meal and often at 2 hours it’s back w/in range or even on the low side so the insulin was just too slow.
One of the things that interested me in TAG is when I would eat lower carb meals (~15-25 carbs more of which are lower GI) and I tend to inject less in part because in the past when I’ve had similar meals I would crash even if I took the bolus right before the meal… however most times it spiked by the 2 hour post prandial… in this case it would make more sense to do a small bolus which would include any correction factor + enough to cover the carbs and then do a correction/second bolus at about 2-3 hours when more of the bolus’s effect is wearing off, but the proteins and fats are coming in -
For meals that are more balanced between carbs and protein fat… the natural wave of the insulin seems to work to an extent (more of a guess right now though I’ll be verifying with the CGM) but for me anyways Novolog slowly rises, not really seeming to do anything for up to an hour so the carbs are kicking in (or have) so it starts bringing it in…and it seems to have a long tail for me as well…4.5-5 hours… so there is still a bit of an effect at 2-3 hours when the fats/proteins come in…
My problem occurs with not wanting to inject too much when the carb count gets too low so there’s not enough insulin for both the small amount of carbs and the converted fats and proteins…
Hi Geri,
I just saw your post in the pumpers forum asking is it possible to TAG on MDI.
Anything is possible, however, I would say you would have less convenience with MDI and the other issue is the slower onset of regular insulin. Regular also has a longer tail, so your previous meal bolus may still be working when you eat your next meal. This could cause you to stack boluses and go hypo
If you decide to proceed, I see that you already do multiple injections for a meal, so you are already TAGging. The only thing you will have to learn is can you quantify the protein and fats, figure out what percentage you need to bolus for your metabolism and then time the dosing of the second injection to match your metabolism of the proteins and fats.
Since Regular acts so much slower and protein and fat metabolism does not kick in for an hour or 2 after a meal, you possible could take your protein/ fat bolus w/ the carb bolus, especially if your starting BG is above target. When BG is above target, you want to get the insulin on board as fast as possible. If you take the protein/ fat bolus w/ the carb bolus, you want to be careful that you don’t go hypo.
Only trial and error will tell, so start slowly and monitor results.
I used to do it all the time before I got a pump.
Try this (true) story on for ridiculous:
I ordered a medium size pizza from Dominos. For myself. Plowed the WHOLE FREAKING THING DOWN MYSELF! Took about 10units off the bat, and then for the next 2 hours, I took 2unit shots every 30min or so.
Total Insulin: 18 units
Total Injections: 5
This was a couple of years ago, so I don’t remember the exact numbers, but my sugar came out swell! And no rocket to the moon overnight too!
The idea was that I cover SOME of the carbs up front, as they are mostly longer carbs in pizza and not a lot of sugar, and since I ate more carbs than my body can absorb all at once (not a good idea for anyone, nevermind a diabetic) and there was ton of fat, I stacked the insulin doses figuring some of the fat and the carbs will also kick me later.
I know, I know. Stupid. But I just thought I’d throw my two cents in on the topic. And I think I’ll make a new topic: “Stupidest Diabetic Decisions Ever” or something. 
I used to do this (following Dr. Bernstein’s approach) all the time when on MDI (now on the pump as of a couple of months). Here is how I did TAG with MDI: Count carbs, protein, and fat. Use Novolog injected just prior or right at meal time to cover carbs. Use Regular also injected at meal time (yep, I know it won’t start working for a while–that is the point) to cover protein/fat metabolism into glucose. I found Regular at meal time did a nice job for meals. I too eat a very restricted carb diet with an average macronutrient intake per meal of 65% fat, 25% protein, and 10% carb. I try to keep carbs to 30g-50g per day like you as well.
Phishery,
I use Apidra & Regular. I take Regular about an hour after eating & Apidra with meals. Works well most of the time. Just wanted to throw this out there for any others on MDI.
Let me reanimate this discussion:
As some of you might have seen I have developed the first Glucosurfer App for Windows Phone 7. I would like to add a TAGging feature to the App. This feature would allow to switch from Carbohydrate Input to TAG Input.
TAG Input:
Carbs
=>Carb Bolus (inject now)
Protein * Protein factor
Fat * Fat factor
=>TAG Bolus (inject later)
The App would know the Protein and Fat factors from the settings of the user. Now a pumper could choose the best pump program for this. I assume it should be documented too:
Q1: what different types of bolus programs do exist?
Q2: would it be sufficient to just document the bolus program without additional infos? I hope so to keep it simple.
Someone like me on MDI will have to inject for the TAG bolus later. Is 1-3 hours the rule of thumb for this? It would be great if the App could set the internal alarm clock of the phone. This would be a nice way to inform the user about his TAG shot.
Do you have more ideas for my App?
Hi Holger!
Did you see this discussion? I think it might help you - http://www.tudiabetes.org/group/tagers/forum/topics/tag-spreadsheets?commentId=583967%3AComment%3A1578523&xg_source=msg_com_gr_forum
Cheri
Thanks! I have only seen the spreadsheet and not the fruitful discussion that followed.