Combo Bolus Hack Bites Dust

Some examples of how not to bolus from when we thought the combo bolus hack was a slam dunk

Some examples of how not to bolus from when we thought the combo bolus hack was a slam dunk: don’t eat 50g and bolus for it and then keep eating 34g more and bolus for that and then eat 15g more and bolus for that too. And don’t repeat this several times a week and then wonder why you’re low at 1AM.**

Since very beginning attempt utilize Combo Bolus pump feature, Bigfoot/B. Spouse more likely hack combo bolus. E.g. bolus, eat, if eat little more, bolus little more, if eat dessert little bit later, bolus little more that time too. In this family mind, it like supersafe Combo Bolus because more flexible, easy halt extra insulin if Type 1 diner in question change mind re food amount.

But no. Endo say Stop This. Can cause lows. “Stacking.” Familiar that term from insulin pen times. Thought stacking concern pen/syringe user only, because pump calculate IOB. Hmmph. Bigfoot explain why think little bolus + bolus little more 1x, 2x for extended meal experience better for Bubs than Combo Bolus. Because unreliable predict what eat. Actually say this:

Why is giving increments of insulin over time different from a combo bolus? Sometimes I know he will be eating more over time, but don’t want to do a combo bolus because I don’t think I can cancel it or decrease the amount after I enter it.

Endo say no. Better use actual Combo Bolus. This paragraph not medical advice but it email from endo:

I am not sure why there is a difference between frequent bolusing and using the combo but experience has shown us that there is a difference. Even with the combo bolus, we still suggest not to rebolus for at least an hour after the whole bolus has been delivered. It is a difficult balance to decide how often to bolus and each child is different but repeated boluses every hour or so seem to “stack up” and cause lows later on.

    Before diabetes, I DEFINITELY would have had AT LEAST one of each

Before diabetes, I DEFINITELY would have had AT LEAST one of each, and ALL of the white chocolate brownies and linzer squares.

And so this happen: Bigfoot Spouse think ahead, make lowish carb dinner (grilled mustard-y pork tenderloin, one carrot, half apple, water) because aunt bring elaborate homemade Christmas cookie gift. (That not true, it Bigfoot think ahead/tell spouse grill this pork tenderloin from a bagCookie part true.) This cookie delivery major event of ring in holiday season. OK. So. Figure 12g CHO dinner + 25g CHO 2 cookies. Bolus for 37g CHO. Cookie time Jack Wouldn’t some milk be so good with these cookies? It true. Should have thought. Seem impossible deny Bubs milk–this once a year cookie heaven experience!–so break rule, bolus additional 6g CHO. Tiny speck insulin. OK. Hour later hear I’m hungry. Could I have a graham cracker?

BIGFOOT: Sorry, no (<–because try adhere anti-stacking policy, not because controlling bitch)

BUBS: Please?

BFOOT: Nuh-uh. How about a cup of tea?

BUBS: Okay…

BFOOT: How about a piece of cheese?

BUBS: Provo-lohhhne (said with low, drawn-out final syllable to show dejected mood)

JACK: May I have cheese too?

BFOOT: Sure! (feeling peppy now: someone’s making cheese seem like fun)

JACK: Ooh, and a glass of that mango juice?

BF: Uhh…

JACK: Bubs! This mango juice is so good!

BF: shut up (<–say in head only)

BUBS: I’ll just have water

**Obvsly, I am hoping that someone reputable will tell me this is a smart and very fine thing to do–and not just on special cookie occasions

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21 responses to “Combo Bolus Hack Bites Dust

  1. I’m reputable but not in any good way in this arena. But your thinking seems logical to me. Helpful? Not. Encouraging? Hopefully. Does your aunt want an extra very nice niece?

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  2. earthling

    Ooooo Russian Teacakes!!!! Your Q…. Um, ackkkkkkk. Sorry. Earthling not know. How human know?! Need do, try other way, decide? Very Ok do, but not tell MD, is your (son’s) life, right? Earthling on your side here, such as is.

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  3. Kim

    I do the same “stacking” thing, and I can see the endo’s point, but it’s hard to predict how much I’m going to eat sometimes (and I’m 30 years old).

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  4. Mary M

    The ability to change food decisions is part of the reason to have the pump imo. We prebolus 50, then finish the meal and bolus the rest. I don’t think of it as combo, just the reality that altho our endo wants us to prebolus, a 10 yo can’t make those food decisions at the beginning. Who can, really. So if bolus 50, eat 90, bolus 40 is followed by eat 15, bolus 15, that is fine with me.

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    • Yeah! The flexibility w. eating is touted as one of the pump’s major benefits. And the prebolus for a conservative guess with a follow up bolus later is exactly what The Legendary Gary Scheiner says to do: put down a “deposit” before the meal/”pay the balance” at the end. So I know that’s rock solid. I’ll continue to do that for sure. Why is two follow-up payments worse than one? Isn’t it just more precise?

      The mystery here is turning out to be: what is going on in the endocrinologist’s mind? I respect her and want to understand the science/math of this from her point of view.

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  5. Reputable? Not it.
    We do what you do. Main meal bolus, seconds bolus, dessert bolus, etc. Haven’t seen any problems. I can’t quite get my mind around what would be going on with what she is saying – overlapping insulin peak times maybe? However, I also have heard to avoid add’l bolusing during a combo bolus.
    I think I studied that cookie tray for 10 min. Yum.

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  6. Nicole P

    Ok. Not medical advice. Not reputable. But I HATE the combo bolus. I do not like it at all and do something much more like what you do. I bolus as I eat. And for chinese food I bolus 50% up front, then give insulin at 30 minute intervals to cover the tail for three hours. Then, I test at around 5 hours and bolus again if needed. So, um, yeah… Not sure what to say!

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  7. joe

    The endo sounds confused-o

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  8. Julia

    Our endo discourages grazing. And she was pretty strong in her views so we would do three meals and large after school snack. At one point, when she consistently wanted a snack after dinner I would bolus for it at dinner and she would eat it 1 and a half hours after dinner. Snack must then be fruit or vanilla wafers, something quick as the insulin is peaking. I liked this method but she would have to be home, not active and you have to be vigilant. Kept blood sugars from going too high. Endo wants to limit the grazing because their blood sugars go up over 200 every single time they eat. Yes, blood sugars do come down but it takes 1.5 to 3 hours for it to do so. Now our DD is a teen and she eats when she wants, does graze, and we bolus each time. Combos have never worked too well. We usually bolus check at the two hour mark and take it from there. Since we know how much one unit lowers her blood sugar, we use the existing blood sugar and amount of IOB to calculate. At some point, with grazing, we usually do have to feed the insulin. And if they are running around it gets a lot more interesting. I did follow endos guidelines as long as our DD didn’t mind. And for years she didn’t mind. Three meals, one large snack or mini meal and a small dessert or snack after dinner (which endo did not approve). Sounds like Bubs does not like going along with that routine. So I would tailor his diabetes management to suit his lifestyle (though trying to keep the snacks healthy). If he is going to be running around, at a certain point I would not fully cover all of the snacks. Just check BS every few hours after eating. You live with Bubs. You know if his meal plan is working for him or not. Use your own judgment. You are the expert when it comes to your own child. Endos do download the pump, go over the information, so when you see her thee months from now, you are going to have to come clean if she queries you. You may have to tell her you respect her judgment but this does not work for Bubs. Keep a log. Write down everything he eats and show her. Most endos give you log sheets to fill out anyway. Then she can gauge his appetite and may have some other ideas. I use plus temps for a few hours after eating sometimes or minus temp basals to help out high or lower sugars. Never have gotten the hang of the combos. You will try things and find out what works for you. P.S. I have heard of people putting a square wave or high temp basal on for hours if they are grazing at a party. It probably works but I am afraid of giving insulin up front when I am not positive if she will be eating enough.

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    • Wow–this is helpful. My son doesn’t like grazing as much as…he’s just unreliable in predicting how much he will eat. And I hate being in the situation of giving him a bolus, then he doesn’t eat everything he planned to eat, then I have to find something carby that goes down easily into a child who is full: juice? Jelly beans? Ritz crackers? Anyway, thank you so much for all of this information.

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  9. Autumn

    When I do mini boluses over the course of 1-3 hours instead of using a dual wave/combo bolus, I usually end up low about 5 hrs after my 1st mini bolus. My understanding is that the remainder of the combo bolus is given in a more even fashion. (.2 units every 2 min) vs the more haphazard manual mini bolusing I’d do on my own. Plus, if I’m mini bolusing, I’m more likely to over bolus because I use the quick bolus feature on my Minimed and am too lazy to go through the manual bolus screen to refine the dose.
    But if you always go through the manual bolus screen to do the mini boluses, then this might not be an issue for you.

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  10. Susan

    I thought stacking had to do with corrections. Bolusing for carbs eaten, as far as I know, shouldn’t have a bad effect. I’ve never thought of that as stacking.

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  11. Anne

    I’m glad to hear we’re not the only ones who have trouble with fancy types of prolonged bolusing. We tried a square wave bolus about three years ago for a restaurant meal. My kid went so low so fast and was so out of it, I was ready to break out the Glucagon. He had a hard time coming back up. Since then, my son uses the “I’ll bolus my meal 25 carbs at a time” approach for meals that contain a lot of fat, or meals whose carb count he has trouble estimating. He may remain high for a while (unless he is exercising a lot) but at least he doesn’t crash. I should also add that my son is a grazer because he can’t eat much food at one sitting–he feels too full. So he does bolus often, because he eats often–that’s one of the reasons he uses a pump. As for going low after frequent bolusing, that sounds like the carb ratio is too aggressive.

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