Does anyone do a pre-bolus of ~ 1h 30m?

[JontyW]

Now that I have a Dexcom fitted, I have been doing trials to see how my pre-bolus time affects the post prandial peak. So I started with a 30m pre-bolus and have slowly increased it to 1h 45m which is about the max if my pre prandial BG is ~ 5 or 6, mainly at breakfast.

I had my annual endo review last week, and so asked her .."when should I be bolusing compared to start meal?", and she replied ..."15m before, because bolus starts to be active within 30m" ... the standard answer. So I told her that I can pre-bolus by up to 1h 30m to 1h 45m with no problems, and she was very surprised. I also mentioned that it is not just the start time that is important, but to reduce spiking it is the "max peak (Usage rate/hr)" that matters ... she just went blank! I have now got a mass of data to show this.

I'm not sure what is causing this but think it may be age related (I'm nearly 74) or related to another autoimmune disease I have (vasculitis). So it makes timing meals rather difficult, but my HbA1c in Feb-16 was 6.1%, and last week it came out as 6.2%.... so thank you Dexcom.

So do any of you find you can pre-bolus by such a long time?

 

[Pumper_Sue]

If you are using a dexcom the reading will lag 20 mins behind an actual finger poke reading. I would also suggest that if you are blousing 1.30 hrs before a meal with a starting point of 5 then there has to be something wrong with your basal as I would need an ambulance with that amount of insulin injected and no food for 1.30 hours.

 

[Northerner]

I usually bolus around 40-60 mins prior to eating in the morning, but I suspect that may be partly due to my being particularly insulin-resistant in the mornings, and also having quite an active liver first thing, so the bolus is working on that rather than anything I eat. What injection sites are you using? Injecting in the buttocks takes MUCH longer to peak than belly for me.

 

[JontyW]

If you are using a dexcom the reading will lag 20 mins behind an actual finger poke reading. I would also suggest that if you are blousing 1.30 hrs before a meal with a starting point of 5 then there has to be something wrong with your basal as I would need an ambulance with that amount of insulin injected and no food for 1.30 hours.

Thanks for the feedback Sue.....

I assume a lag of 15 mins for the Dexcom. I should have mentioned that I stopped using basal back in Jul-13, since I was suffering from intermittent early morning hypos. I did many detailed trials of reducing levels of both Lantus (been on since 2005) and then Levemir (am and pm doses), but even with small doses the hypos continued, so I then stopped all together in Jul-13. I should also add that I was dx with a rare autoimmune disease called vacsulitis (inflammation of the blood vessels) in Apr-13 and this causes the BG to increase variably on a daily basis ... or not.

Anyway, even with no basal over last few years but started serous carb counting using bolus based on ratios, my HbA1c has been the best ever in 47 yrs, so I'm obviously doing something right! The key driver to achieving this has been recording all data on a daily basis in my customised spreadsheet, which contains a Bolus Calculator. Then reviewing each morning (5 mins) the previous day's performance against achieving the BG target after 4 yrs (BG of 5 for breakfast & lunch, and 6 for dinner), and deciding what went wrong (if any) and what to change to overcome that. So it is constant review & change .. to me that is the KEY.

 

[Pumper_Sue]

As a matter of interest what steroids do you use for your Addison's? Also have you ever considered having a pump?

 

[JontyW]

I usually bolus around 40-60 mins prior to eating in the morning, but I suspect that may be partly due to my being particularly insulin-resistant in the mornings, and also having quite an active liver first thing, so the bolus is working on that rather than anything I eat. What injection sites are you using? Injecting in the buttocks takes MUCH longer to peak than belly for me.

Here are my answers to your comments / questions .....

1) "I usually bolus around 40-60 mins prior to eating in the morning".
A: I presume this reduces the post prandial spike? Can you do this large delay at other meals also?

2) "and also having quite an active liver first thing,"
A: how do you know that ... I don't understand how that can be measured?

3) "What injection sites are you using?"
A: I'm using both upper legs (thighs) and rotate regularly and have used these areas almost all my 47 yrs. Never used my buttocks but occasionally use belly, when eating out.

I have got some feedback from a FB Dexcom users group, and about six ppl said they can use a 1h 30m pre-bolus OK. Regarding my age related theory, half were late 50s or 60s, but the rest were two in their 40s and one 12 yr old. So not too sure about age and it may be just varying metabolism.

 

[Northerner]

Here are my answers to your comments / questions .....

1) "I usually bolus around 40-60 mins prior to eating in the morning".
A: I presume this reduces the post prandial spike? Can you do this large delay at other meals also?

2) "and also having quite an active liver first thing,"
A: how do you know that ... I don't understand how that can be measured?

3) "What injection sites are you using?"
A: I'm using both upper legs (thighs) and rotate regularly and have used these areas almost all my 47 yrs. Never used my buttocks but occasionally use belly, when eating out.

I have got some feedback from a FB Dexcom users group, and about six ppl said they can use a 1h 30m pre-bolus OK. Regarding my age related theory, half were late 50s or 60s, but the rest were two in their 40s and one 12 yr old. So not too sure about age and it may be just varying metabolism.

In response Jonty:
1 - Yes, I discovered fairly soon after diagnosis that I was getting a big post-prandial spike at breakfast time, so started pre-bolusing, testing to try and find the point at which the insulin appeared to be starting to peak. I bolus when I get up, then it's usually about 40-60 minutes before I have my second mug of tea and some toast 🙂

2 - The reason I say this is because I need a huge amount of insulin in the morning compared to later in the day. I have been having asingle slice of Burgen toast for breakfast for several years now (not a big eater in the mornings!) and currently need 6 units of novorapid to 'cover' it. In contrast, I need 5 units for lunch, usually something like 5x the amount of carbs, then 3 units for evening meal - again about 40-60g carbs. My pre-bolus time also reduces, usually about 30 mins prior for lunch and immediately before evening meal.

Like you, I stopped needing basal insulin 4 years ago. I'm 57. 🙂

 

[JontyW]

As a matter of interest what steroids do you use for your Addison's? Also have you ever considered having a pump?

I am currently on 15mg Prednisolone for 'both' (Addison's and Vasculitis), but once I taper down to 7.5mg Pred I will then change to just the Addison's treatment which is 25mg Hydrocortisone of 3 doses during the day (8am:10 /2pm:10 / 6pm:5). I've had Addison's since 2008, and apart from one Addisonian crisis soon after dx when chest infection took me to A&E and the doctors didn't know anything about it 🙂, I never experience any symptoms or issues with it. Similarly my vasculitis is a mild severity and luckily hasn't affected any major organs like happens to many, with heart, kidney & lung complications.

Re using a pump, I've never considered this since I have excellent control using no basal and just bolus MDI. I am one of the 10% T1s in England & Wales who meet the NICE target of < 6.5% (48) according to the National Diabetes Audit 2014/15 .....

https://www.diabetes.org.uk/Professionals/Resources/National-Diabetes-Audit/
The attachment shows the Target Achievement Levels ...

 

[Pumper_Sue]

Unfortunately I can not see the attachment as to small.
What you are actually doing though is using your bolus for basal. The reason you are having to wait all that time before you eat is because your pred kicks in at lunch time hence needing all that insulin and the waiting game.
I was diagnosed in 2002 but very unwell for quite a while before that. Only needed one admittance to hospital with a full blown crisis about 7 years ago.

 

[pottersusan]

Its anything from 10 mins upwards for me. i have to eat frequently and I try not to eat until my bg is in the 6s or lower. At times to get to that level it can take 60 mins plus. I have to be careful of stacking insulin. Thank goodness for my cgm.

 

[everydayupsanddowns]

I am similar to Northie in the pre-bolusing stakes. I need to wait far longer at breakfast/lunch 30-60 minutes - and if I apply the same wait at evening meal time I would fall hypo before taking a mouthful.

Breakfast I have always put down to FHTF (feet hit the floor) where I appear to need approx 1u just for getting out of bed. Lunch seems to defy logic, but may be because my lunch choice is more or less exactly the same 5 days a week and has been for years.

Bizarrely basal testing can be relatively stable for breakfast/lunch (with only breakfast having a significant basal boost 60 minutes before rising), and yet add in some carbs and my post-breakfast levels seem to need that extra insulin. I have long since stopped trying to apply the usual 'rules' to this and have just accepted it as something I can more or less manage just be keeping/adjusting a relatively consistent behaviour pattern, rather than trying to worry about what my diabetes is *supposed* to be doing. I don't think mine has bothered to read the text book. 😛

 

[Annette]

I'm opposite. I have to slightly (15mins max) pre bolus my evening meal, but not my breakfast (which I have to multiwave - the pump version of split bolus)) or my lunch (which just goes in as I start to eat), and if I eat in the evening after about 7ish, I have to do the whole lot on an extended bolus. What switch is thrown at 7pm to go from pre bolusing to only extension bolusing I do not know...

 

[JontyW]

Unfortunately I can not see the attachment as to small.
What you are actually doing though is using your bolus for basal. The reason you are having to wait all that time before you eat is because your pred kicks in at lunch time hence needing all that insulin and the waiting game.
I was diagnosed in 2002 but very unwell for quite a while before that. Only needed one admittance to hospital with a full blown crisis about 7 years ago.

Re ... "The reason you are having to wait all that time before you eat is because your pred kicks in at lunch time hence needing all that insulin and the waiting game."

So what about all the other people who have told me, in the FB group & also in this thread, that they also find their bolus doesn't kick in until ~ 1hr or more? They are NOT on prednisolone as far as I'm aware. Here are some examples ....

- "I have to wait at least one hour after bolus, to eat. It's so frustrating, I'm 61years old"
- "I was dx at 42 with T1 and 24 years later I'm seeing the same pattern. Sometimes I have to wait an hour to eat to avoid spikes, which is often difficult"
- "My son is 12. Had t1 for 2 years. We see the same thing. Sometimes and hour b4 he starts to drop"
- "I have the same problem! I need to bolus about an hour before meals. it takes that long for the insulin to start working, I watch it on my dex. It doesn't take "5-15" minutes like it supposedly supposed to. If I take it then eat soon I will absolutely get a horrible spike. Sometimes I can get away with 30 min for lunch and dinner but breakfast is 60+ minutes. I take apidra and tresiba. No pump."
- "I need to wait far longer at breakfast/lunch 30-60 minutes - and if I apply the same wait at evening meal time I would fall hypo before taking a mouthful."

So it appears that many others suffer from similar delayed action bolus, particularly at breakfast.

This morning I've done a 2h pre-bolus and plan to take my steroids after lunch when breakfast bolus should all be used up ... we will see. Thank you all for your inputs .. very interesting.

 

[Northerner]

Here's a larger version of Jonty's spreadsheet:

 

[Pumper_Sue]

@JontyW quite simply you have stated you do not use a basal insulin, so no insulin except your bolus which you are using for both basal and bolus, many people including me have found that basal insulin's do not match my basal pattern ie, 0.025unit for 4 or 5 hours at night yet needing almost 3 units an hour from 10AM - 12 PM. Which is probably why others have to wait to eat like they do. (Basal insulin not matching individual needs) Pred causes the problem for me in that 2 hour bracket and Addison's (lack of cortisol) causes the lack of insulin needed at other times.
Pumps work extremely well in this circumstances. I use no more than 3 units of insulin for my lunch bolus.

 

[JontyW]

Like you, I stopped needing basal insulin 4 years ago. I'm 57. 🙂

So what was the data that showed you no longer needed basal, and what was the response from your diabetes team?

My DSN, who I never have had to consult about anything, responded by saying that is not possible and I might go into DKA, a term of which I had never heard since never got to that state in 43 yrs. So she gave me some Ketone test sticks and told me to check regularly. But at the time of just using bolus (Jul-13), I also started carb counting & using ratios and all HbA1c since then have been < = 6.6%, my best ever, plus elimination of serious hypos.

So I think proper carb counting has totally overcome any 'no basal' disadvantages

 

[JontyW]

What you are actually doing though is using your bolus for basal. The reason you are having to wait all that time before you eat is because your pred kicks in at lunch time hence needing all that insulin and the waiting game.

Hi Sue,
I don't understand what you are saying, so please explain ...

1) Re.."your pred kicks in at lunch time":- I thought that pred takes ~ 2 hrs to start working, so if I take it at say 8am, then it will kick in at ~ 10am won't it?
Ref: "Time to Peak: Oral: Immediate-release tablet: 2 hours" (http://www.drugs.com/ppa/prednisone.html)

2) And if I take it AFTER lunch, like I did yesterday (still trying to figure out what happened!), then it should not affect the bolus delay working?

3) I found this ...."Most of us take our prednisolone as one dose in the morning. The main reason for this is that your body makes its own cortisol in the early morning (2am to 6am) and taking the tablets then mimics the action."
- BUT I'm taking it for both Addison's (to mimic the body's release of cortisol), AND vasculitis (to reduce inflammation of blood vessels)
- so can you explain how this might be working in my body to address my two different diseases?

Many thanks for your expert considerations & feedback.

 

[Northerner]

So what was the data that showed you no longer needed basal, and what was the response from your diabetes team?

My DSN, who I never have had to consult about anything, responded by saying that is not possible and I might go into DKA, a term of which I had never heard since never got to that state in 43 yrs. So she gave me some Ketone test sticks and told me to check regularly. But at the time of just using bolus (Jul-13), I also started carb counting & using ratios and all HbA1c since then have been < = 6.6%, my best ever, plus elimination of serious hypos.

So I think proper carb counting has totally overcome any 'no basal' disadvantages

I was originally on 20 units of lantus at diagnosis (admitted to A&E with DKA!), but found I had to reduce this significantly over the following months and years because I was either having night hypos or waking low (in the low 4s/upper 3s). Eventually, I was down to 2 units of lantus and still waking in the low 4s, so decided to try without - and still woke in the upper 4s/low 5s, so decided I didn't need it any more! 🙂 At my review about a month later I told the consultant and he said that it wouldn't be long before I started needing the lantus again - that was now over 4 years ago 🙂 I use between 16 and 20 units of novorapid a day currently.

 

[JontyW]

I was originally on 20 units of lantus at diagnosis (admitted to A&E with DKA!), but found I had to reduce this significantly over the following months and years because I was either having night hypos or waking low (in the low 4s/upper 3s). Eventually, I was down to 2 units of lantus and still waking in the low 4s, so decided to try without - and still woke in the upper 4s/low 5s, so decided I didn't need it any more! 🙂 At my review about a month later I told the consultant and he said that it wouldn't be long before I started needing the lantus again - that was now over 4 years ago 🙂 I use between 16 and 20 units of novorapid a day currently.

That is almost 'exactly' what happened to me also, although I had been on Lantus since 2005 for ~ 8 yrs prior to stopping. My problem was intermittent early morning hypos (< 2.5) which required my wife to feed me fast carbs. My endo suggested various options, such as change bolus to Apidra (made no diff), Levemir instead of Lantus (made no diff). Then after further detailed data collection in a spreadsheet, it seemed these hypos mainly occurred when bolus for dinner was > 20u. The dose obviously depends on any correction + carbs + ICR, but the ICR was starting to change quite dramatically once the vasculitis started.

So starting very accurate carb counting & ICR checking enabled me to overcome the hypos. My spreadsheet, with bolus calculator, updates the suggested ICR based on how well previous day's ICR met the target of 5 (breakfast & lunch and 6 for dinner), so it is continually updating this value unless I override it. My Humalog total units ~65u whereas it ~45u prior to vasculitis inflammation & starting Prednisolone.

 

[declan88]

I am currently on 15mg Prednisolone for 'both' (Addison's and Vasculitis), but once I taper down to 7.5mg Pred I will then change to just the Addison's treatment which is 25mg Hydrocortisone of 3 doses during the day (8am:10 /2pm:10 / 6pm:5). I've had Addison's since 2008, and apart from one Addisonian crisis soon after dx when chest infection took me to A&E and the doctors didn't know anything about it 🙂, I never experience any symptoms or issues with it. Similarly my vasculitis is a mild severity and luckily hasn't affected any major organs like happens to many, with heart, kidney & lung complications.

Re using a pump, I've never considered this since I have excellent control using no basal and just bolus MDI. I am one of the 10% T1s in England & Wales who meet the NICE target of < 6.5% (48) according to the National Diabetes Audit 2014/15 .....

https://www.diabetes.org.uk/Professionals/Resources/National-Diabetes-Audit/
The attachment shows the Target Achievement Levels ...

Hmmm interesting.
I had a lot of problems with hypos pre pump. And in effect pump and your insulin pattern are similar. Perhaps for the consultants and the training to revisit their advice.
I tried prebolusing before breakfast but as I don't sleep very well, have fallen asleep and then hypo one or too many times. So I don't do anymore.