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RE: Hypos RE: [IPk] Paradigm 512



Seos,

I just follow the arithmetic of the Wizard and find that superbly 
useful.  It prevents you from banking up insulin and certainly, for 
me, prevents as many lows.  You have to ensure that you have a good 
estimate of the activity period.  I use humalog and an activity time 
of 4 hours.  For my money, this is one of the nicest features of the 
Paradigm 515, which is what I use.



>Hi Jackie
>
>Thanks for this. You really have explained very clearly and, yes, 
>while I'm aware of the difference between the correction bolus and 
>using the Square/Dual Wave function, am pretty hazy about 'insulin 
>on board' (only just come across the term in the Bolus Wizard) and 
>the Diabetes Mall. I did DAFNE a few years back but seem to have 
>lost touch with new developments.
>
>I'm definitely going to check out those sites and that book you 
>mention. Very helpful hearing about your strategy with Sasha and 
>raising temporary basal for high-fat meals is an option I hadnt 
>considered. Although a diabetic for over 30 years, I'm definitely a 
>newcomer to such fine-tuning and thanks for taking the time to 
>clarify it for me.
>
>Seos
>
>>From: "Jackie Jacombs" <email @ redacted>
>>Reply-To: email @ redacted
>>To: <email @ redacted>
>>Subject: RE: Hypos RE: [IPk] Paradigm 512
>>Date: Sat, 17 Jun 2006 21:57:24 +0100
>>
>>Hi Seos
>>
>>
>>  Maybe I didn't explain very well about the difference between a correction
>>bolus
>>and using the Square wave or duel wave functions.
>>
>>The Square wave and duel wave functions are not really anything to do with
>>correcting a high blood glucose reading, but to do with bolusing 
>>for food that
>>may take much longer to have an effect on the blood sugar levels.  Food like
>>pizza or curry and rice or some pasta meals.  In many people, if 
>>they bolus the
>>full number of units calculated for the carbs in that meal they often go hypo
>>and then high again later.  This may be due to the fat slowing down the
>>absorption of the carbs.   However Sasha rarely goes low just after 
>>a meal but
 >> does need a higher basal to cope with a rise around 6 hours later due to the
>>fat
>>or protein.
>>
>>We have tried using the Square wave and Dual bolus feature for various meals,
>>but it didn't work out very well for Sasha.  Most meals, whether they contain
>>fat or protein, seem to need the whole of the insulin amount 
>>immediately and we
>>only see a rise from the fat and or protein after 6 to 8 hours later with the
>>  blood sugars in between being at normal levels. So using a fancy 
>>bolus wouldn't
>>  help Sasha at all. For curry and rice, which always sends the BG 
>>levels up high
>>later, we put on a temporary basal rate at around 6 hours after the meal, to
>>last  for around 3 -4 hours.  We just increase the basal to show 140%.
>>
>>If we are correcting a high BG level then we tend to use the chart on the
>>Diabetes Mall for working out what insulin is still "acting" after the last
>>correction or bolus.  Though John Walsh, one of the writers on Diabetes
>>mall/IPumping Insulin books, previous had a different table which showed the
>>duration of insulin action to finish at around 4 hours and had 
>>almost finished
>>  by 3 hours duration. He has since amended his "Unused Insulin Rule 
>>but we still
>>find the original table works best for us.   His new table is on the diabetes
>>mall here.  I printed it off and laminated it so I have it in the 
>>middle of the
>>night as a reference.
>>
>>Bolus on Board
>> 

>>http://www.diabetesnet.com/diabetes_control_tips/bolus_on_board.php?PHPSESSID=
>>7ce42496460a
>>
>>Try this link if url wraps  http://tinyurl.com/q8kbx
>>
>>
>>
>>Jackie
>>
>>>  ----
>>>
>>
>>>
>>>  Thanks Jackie.
>>>
>>>  That's very interesting. I have found that the Bolus Wizard is completely
>>>  pointless when it comes to very high readings over a sustained 
>>>period. I was
 >>> not aware of the fact that it calculates insulin duration for 8 hour period
>>>  only. That's quite a limitation.
>>>
>>>  This accounts for some recent high readings where I couldnt figure out why
>>>  the BW advised insulin already on board. I had started overriding this but
>>  > was unaware of the rationale behind the BW calculation.
>>>
>>>  Am I right in understanding that when Sasha has a high reading you
>>>  administer the correction bolus spread over a 3-4 hour period using the
>>>  Square Set function - or do you simply administer CBs manually every hour?
>>>
 >>> Thanks very much for this info - something I was completely unaware of, let
>>>  alone the acronyms!
>>>
>>>  Best
>>>
>>>  Seos
>>>
>>>
>>>  >From: "Jackie Jacombs" <email @ redacted>
>>>  >Reply-To: email @ redacted
>>>  >To: <email @ redacted>
>>>  >Subject: RE: Hypos RE: [IPk] Paradigm 512
>>>  >Date: Sat, 17 Jun 2006 18:41:34 +0100
>>>  >
>>>  >Seos
>>>  >
>>>  >
>>>  >
>>>  >
>>>  >  IOB is short for" Insulin On Board". This is referring to the fact that
>>>  >on some
>>>  >pumps they have a system, which on the Medtronic pumps is called 
>>>"The Bolus
>>>  >Wizard, which can help you calculate what bolus to give based on the
>>>  >insulin
>>>  >that is already "active" from the last bolus.     Basically you key in
>>>  >certain
 >>> >figures, what your target blood glucose levels are, your correction factor
>>>  >etc.
>>>  >Then if you have a high blood sugar level which you want to 
>>>correct or want
>>>  >to
>>>  >bolus for a meal, you key in the info into your pump and the bolus wizard
>>>  >will
>>>  >take into account the "active insulin" that is still working from a
>>>  >previous
 >>> >bolus. This is a simplified example of what the bolus wizard is used for.
>>>  >On
>>>  >the 512/712 you cannot adjust the duration of insulin action which is
>>>  >"factory
 >>> >set" to 8 hours duration. This means that if you have recently bolused to
>>>  >  correct a high BG levels and it is still high 2-3 hours later 
>>>the pump is
>>>  >likely
 >>> >to "tell" you than a further correction is not needed because it "assumes"
>>>  >that
>>>  >the insulin action from the previous correct/bolus is still working.
>>>  >Medtronic
 >>> >have newer models available in the US that have an adjustable "duration of
 >>> >Insulin action. Most people, adults and children that I have come across,
>>>  >have
>>>  >their "duration of insulin action" set to between 3.0 hrs to 4.5  hours,
>>>  >the
>>>  >most usually figure seems to be 3.5 hours.   So for Sasha we do 
>>>not use the
 >>> >bolus wizard on the model of the Medtronic pump we have. 712, as the bolus
>>>  >wizard would "tell" us that no correction is needed, whereas 
>>>experience has
>>>  >  shown us that for Sasha, 12 years old, that the duration of insulin
>>>  >action
>>>  >would
>>>  >probably work best if set to about  around 3.5 - 4 hours.  When we do
>>>  >corrections we tend to work them out in our head or use a 
>>>calculator  using
>>>  >3.5 - 4 hours as our basis for the duration of insulin action.
>>>  >
 >>> > There are other pumps in the UK like the Cozmo, Animas and the newly, or
>>>  >soon
>>>  >to
>>>  >be released Medtronic 522 sensor augmented pump that all have adjustable
>>>  >"duration of insulin action" features.
>>>  >
>>>  >The Dual or Square wave functions are a different things.
>>>  >
>>>  >For instance if you were eating a meal with a lot of fat or 
>>>protein you may
 >>> >calculate the total carbs and you might choose to bolus half with the meal
>>>  >but
>>>  >deliver the rest of the bolus over two to three hours.
>>>  >
>>>  >Some more info about IOB here
>>>  >
>>>  >http://www.childrenwithdiabetes.com/sports/iob.htm
>>>  >
>>>  >http://www.diabetesnet.com/diabetes_technology/pump_durinslact_danger.php
>>>  >
>>>  >
>>>  >Jackie mum of Sasha aged 12 years
>>>  >
>>>  > > Hi Melissa
>>>  > >
>>>  > > What's an IOB feature?
>>>  > >
>>>  > > Also, what do you mean about adjusting the duration of 
>>>insulin action? I
>>>  > > thought the Dual Wave and Square Set functions did that - or is there
>>>  > > something smarter available on some of the other pumps?
>>>  > >
>>>  > > Thanks!
>>>  > >
>>>  > > Seos
>>>  > >
>>>  > >
>>>  > > >From: "Melissa P. Ford" <email @ redacted>
>>>  > > >Reply-To: email @ redacted
>>>  > > >To: email @ redacted
>>>  > > >Subject: Hypos RE: [IPk] Paradigm 512
>>>  > > >Date: Sat, 17 Jun 2006 01:11:59 -0500
>>>  > > >
>>>  > > >Hi June,
>>>  > > >
>>>  > > >It sounds to me like you may be a candidate for the old "aim-for-8
>>>  >mmol/L
>>>  > > >for 3 weeks/do everything to prevent going hypo" trick for restoring
>>>  >hypo
>>>  > > >unawareness. The frequent hypos that you have had may mean that your
>>  > >liver
>>>  > > >is basically empty of glycogen (because of the first few bad 
>>>hypos) and
>>>  >you
>>>  > > >need to rebuild the glycogen stores. The new pump definitely won't
>>>  >hurt:
>>>  > > >having the IOB feature, even though you can't adjust the duration of
>>>  > > >insulin action on a 512, may help you prevent hypos too.
>>>  > > >
>>>  > > >If you want references on avoiding hypos for 3 weeks to restore hypo
>>>  > > >awareness, I can find some. But your DSN should know the 
>>>technique too.
>>>  > > >
>>>  > > >Good luck getting this situation sorted. It must be No Fun :[
>>>  > > >
>>>  > > >Melissa
>>>  > > >Type 1 13 years, MiniMed pumper 7.5 years; Animas pumper 2 years 5
>>>  >months
>>>  > > >.
>>>  > >
>>>  > > _________________________________________________________________
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>>>  > > .
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-- 
Tim C.
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