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** Meals with higher carb intake would magnify these sample glucose changes
Orig. CF CF step 1 g/u CF step 0.5 g/u CF step 0.2 g/u CF step 0.1 g/u CF step 0.05 g/u
20 5.26% 2.63% 1.05% 0.53% 0.26%
19 5.56% 2.78% 1.11% 0.56% 0.28%
18 5.88% 2.94% 1.18% 0.59% 0.29%
17 6.25% 3.13% 1.25% 0.63% 0.31%
16 6.67% 3.33% 1.33% 0.67% 0.33%
15 7.14% 3.57% 1.43% 0.71% 0.36%
14 7.69% 3.85% 1.54% 0.77% 0.38%
13 8.33% 4.17% 1.67% 0.83% 0.42%
12 9.09% 4.55% 1.82% 0.91% 0.45%
11 10.00% 5.00% 2.00% 1.00% 0.50%
10 11.11% 5.56% 2.22% 1.11% 0.56%
9 12.50% 6.25% 2.50% 1.25% 0.63%
8 14.29% 7.14% 2.86% 1.43% 0.71%
7 16.67% 8.33% 3.33% 1.67% 0.83%
6 20.00% 10.00% 4.00% 2.00% 1.00%
5 25.00% 12.50% 5.00% 2.50% 1.25%
4 33.33% 16.67% 6.67% 3.33% 1.67%
3 50.00% 25.00% 10.00% 5.00% 2.50%
2 100.00% 50.00% 20.00% 10.00% 5.00%
2
1 J. Walsh, D. Wroblewsk i, and TS Bailey: Insulin Pump Settings A Major Sourc e For Insulin Dose Errors ,
Diabe tes Technology Meeting 2007
Review 3
Carb Factors In Use 1
20
1 J. Walsh, D. Wroblewsk i, and TS Bailey: Insulin Pump Settings A Major Sourc e For Insulin Dose Errors ,
Diabe tes Technology Meeting 2007
4
1 J. Walsh, D. Wroblewsk i, and TS Bailey: Insulin Pump Settings A Major Sourc e For Insulin Dose Errors ,
Diabe tes Technology Meeting 2007
5
Accurate bolus
estimates require
Glucose-lowering
an accurate DIA.
DIA times shorter
Activity
Handling Of BOB
Bedtime BG
Correction = 173 mg/dl
Dessert
Dinner
6 pm 8 pm 10 pm 12 am
Review 7
Frequency Of Insulin Stacking
CDA1 Study Results
Of 201,538 boluses, 64.8% were
given within 4.5 hrs of a
previous bolus
J. Walsh, D. Wroblewski, and TS Bailey: Dispar ate Bolus Rec ommendations In Insulin Pump Therap y.
AACE Meeting 2007
Review 7
Bolus On Board (BOB)
An accurate measurement of the glucose-lowering activity
that remains from recent boluses:
• Prevents insulin stacking
• Improves bolus accuracy
• Allows the current carb or insulin deficit to be
determined
* Except when BG
* “Yes” is generally safer is below target BG
Example 7
Unsafe BOB1 Handling
If a pump user gets frustrated with a high BG and they
overdose to speed its fall, or they exercise longer or
more intensely than anticipated, they can acquire a
significant excess in BOB.
In this situation, most current pumps recommend that a
bolus be given for all carb intake regardless of how
much BOB is actually present.
If BOB is greater than the correction bolus requirement at
the time, the pump’s bolus recommendation may
introduce a risk for hypoglycemia.
1
Pumping Insulin, 1st ed, 1989, Chap 12, pgs 70-73: The Unused Insulin Rule
Example 7
Differences In Bolus Recommendations
The graphic shows how widely bolus recommendations vary from one
pump to another for the same situation.
Situation:
units BOB = 3.0 u and 30 gr.
of carb will be eaten
4
at these glucose levels
3
2 Carb factor = 1u / 10 gr
Corr. Factor = 1 u / 40
1 mg/dl over 100
Target BG = 100
0
60 90 120 150 180 210 240 mg/dl TDD = ~50 u
Deltec Cozmo Animas 1250 Medtronic 522
Omnipod bolus cannot be determined - it counts only correction bolus insulin as BOB
Review 7
Track BOB Or Carb Digestion?
For safety after meal and correction boluses, tracking the glucose-
lowering action of BOB is more important than accounting for the
glucose-raising action of digesting meal carbs:
When a BG is taken after a meal, the BOB times the correction factor
ideally represents the maximum fall in glucose expected.
Accounting for the impact of the BOB on the current glucose provides
the safest approach in the determination of bolus recommendations.
Low glycemic index meals, gastroparesis, Symlin, and other issues may
counteract a predicted fall in glucose based on BOB, but the user can
more easily judge and remedy this situation than dealing with an
unknown excess of insulin.
7
Exceptions To Usual Handling Of BOB
When a second bolus is taken for an unplanned carb
intake or a desert that is consumed within 60 minutes*
or so of a meal bolus, BOB should not be taken into
account for the second bolus because the impact of the
first bolus cannot be accurately determined.
Given that, it is wise to account for BOB as soon after a
meal as possible, such as within 60 to 90 minutes,* to
provide early warning if the bolus given was excessive
or inadequate.
Accounting for all BOB and applying it to subsequent boluses
is generally safer, although not always more accurate.
From Pumping Insulin, 4th ed., adapted fom Mudaliar et al: Diabetes Care, 22: 1501, 1999
Example 8
A Multi-Linear DIA
Use of a multi-linear method to measure DIA
improves accuracy. The next page shows a
triple-linear example for measurement of BOB.
Example 8
A Triple-Linear Approximation Of DIA
A triple-linear line in red
can more closely
5 hr Triple Linear approximate a
curvilinear DIA.
For a 5 hr DIA*:
1st 10%** – no change
Mid 65%** – fall 75%**
Last 25%** – fall 25%**
(** adjustable as
needed in device)
* % modification
suggested by Gary
Scheiner, MS, CDE
9
Hypoglycemia Alert
9
Standards For:
Hypoglycemia Alert
• Insulin pumps that store glucose and insulin dosing data
shall present this glucose control data in a readily
accessible form on the pump or controller.
• The pump shall alert the user when the glucose data
from their glucose monitor or continuous monitor
suggests they are experiencing frequent* or severe*
patterns of hypoglycemia.
# BGs/week 23 25 28 32
Hyperglycemia Alert
10
Standards For:
Hyperglycemia Alert
• Insulin pumps that store glucose and insulin dosing data
shall present this glucose control data in a readily
accessible form on the pump or controller.
• The pump shall alert the user when the glucose data
from their glucose monitor or continuous monitor
suggests they are experiencing patterns of frequent* or
severe* hyperglycemia.
Avg BGs/week 23 25 28 32
This individual would be alerted when they do not check their glucose
and want to give a bolus but have 0.5 u or more of BOB present.
No tape!
Review 14
Infusion Set Monitor
Many pump wearers experience random
erratic readings until they change to a
different infusion set or start to anchor their
infusion lines with tape to stop line tugging.
However, insulin pumps offer no mechanism
for clinicians or pump users to detect who
may be having problems with their infusion
sets.
Tool 14
Infusion Set Monitor
Insulin pumps with direct BG entry can identify those
who may be having intermittent loss of glucose
control secondary to infusion set failure. The pump:
Shows the average time and variation in time of use
between reservoir loads or use of the priming function.
Shows average BGs for each full or partial 24* hour time
interval following set changes (indicated by the prime
function) over a various number of set changes* or as
soon as statistical significance is reached.