Do you pre-meal bolus?

[Subby]

In my pump orientation I was told that pre-meal bolusing is a thing of the past with pump therapy (except maybe with extremely high BG). The real story seems to be that for some it is useful or even necessary to achieve good bolus results.

What's your practise, are you happy with it and how did you arrive there (eg doctor's suggestion, self testing)?

For the bonus points, what main factor or factors do you suspect are causing the need for your pre-bolusing?

[Subby]

At the moment, a pre-meal bolus between 30 and 40 minutes seems about right for most meals. This seems to minimise my post meal spike and decrease my tail end hypos.

If moderately high (10 to 13 mmol/l) I will generally add another 20 - 30 minutes.

If really quite high (say above 15 mmol/l) I will often bolus for my meal and then test each 30 or 40 min to watch for a dip, as insulin action varies wildly once I am high.

I think the problem may be mainly that I have a range of background resistances, as occasionally with the same site I can drop back to a much better absorption, then return to typically being sluggish to respond.

I wonder if advances in subcutaneous delivery methods may improve things too.

I'd love a faster acting insulin, will hopefully be trialling Apidra soon. I currently use Novorapid.

[xMenace]

When I do controlled testing, I always come to the choice I picked. That's why I picked it. And you can get everything you want at Alice's Restaurant!

[Glucoweb]

I usually pre-bolus, but only by about 5-15 minutes, depending on what I am having, the situation, and remembering to do it before the meal is ready. :D

[Eddy]

Where's the choice for "it really depends"? :)

[notme]

Usually, I try to bolus five minutes before. I'm not always successful. Many times, I think about it while I am eating. I use a pump so it is easy to just forget until you are eating.

[Scratch]

It depends, but I pretty much always bolus at least 5 to 10 minutes prior to eating.

As MDI, I've also been using a split injection idea if my premeal blood sugar is significantly elevated, I will inject half of the bolus into a muscle for more rapid absorption than subcutaneous injection, inject the other half of the bolus into a subcutaneous layer.

[dmbfan_21]

I do the 5-15 minute unless my BG is high. It also depends on the meal, but for most of the meals I eat the 5-15 minutes prevents the spikes. If I am eating a high carb meal I may try to adjust the bolus so that it stretches over an hour or two.

[shabbie]

i have had success pre-bolusing for things like pasta/potatoes. but my problem is remembering to pre-bolus!

so i pretty much just shoot and eat!

[dar917]

I usually bolus afterward, mostly because I'm not always sure how much I'm going to actually eat. Unless I'm unusually high then I'll do it before or mid-way through a meal.

[Alice]

I do a combo of all the above...except the 30 minute prior which would almost always send me low unless I was high to begin with.

More and more, I'm doing an"intro bolus" before restaurant meals. Meaning, I know I will be following up with more, but just want to get a minimum working in me to maybe cover appetizer and such. Restaurant servings are just not predictable. And often, at home, I may eat more or less than planned.

The whole idea of one, solid pre-bolus seems to be a little too "planned" for me. I really prefer to take immediate after eating if I only had one choice. But this is diabetes...and we have lots of choices on how to take that Humalog.

[chaimb7]

Well I think I've learned something from reading all your responses. I have problems with high readings 2 hours after my first meal bolus (usually after a few mouthfulls of food)and then a drop an hour later. I'm going to try and pre meal bolus in future, my difficulty is that I never really know how much I'm going to eat (or what's coming up next when we eat at friends) I've grown acustomed to bolus a number of times during the meal ;)

[solox316]

Depends on many things.

If my sugar is low, or trending down on the CGMS, I will eat and bolus during after after eating. If I am avg. to high I will bolus first, depending on what the reading is.

It will also depend on what foods I am eating, which also changes my type of bolus...

When I use Symlin, I bolus during or after, otherwise I drop WAY to quickly, then spike a bit later... Also with Symlin, I always dual wave bolus 50/50 over 90 minutes, seems to work perfect for me.

I used to always bolus after, but I think my post meal readings/spikes are much better now, doing it before/during.

[Subby]

A real range of replies, lots of info to think about. I'm suprised how much pre-bolusing goes on - I wonder if my team was atypically rigid or conventional in disparaging pre-bolusing for pumping.

Non pumpers are more than welcome to join in the comments but this was intended mainly as feedback on people's pumping strategies.

There is no "mix of all" or "it depends" tick box because then I think most of us would tick that option rather than go for a "typical" trend... if I didn't cover a general category that you are happy with just skip it - your comments about your approach are the most interesting and valuable thing anyway :)

[ant hill]

I genraly have a test and see a high then I bolus and wait half an hour. :)

[weejules83]

with my son its usually after a meal because hes only three and we can never be sure of what hes going to eat but if he was exceptionally high i would do it beforehand his consultant told me that before or after shouldnt really make any difference as long as its within about 15 minutes?

[Scratch]

Non pumpers are more than welcome to join in the comments but this was intended mainly as feedback on people's pumping strategies.



I see the pump as a tool, pumping is a subset of the basal/bolus strategy of insulin treatment.

A pre-meal bolus covers both MDI and pumping, IMO.

[Eddy]

There is no "mix of all" or "it depends" tick box because then I think most of us would tick that option rather than go for a "typical" trend... if I didn't cover a general category that you are happy with just skip it - your comments about your approach are the most interesting and valuable thing anyway :)


I select my insulin mix and timing as a function of what I'm eating, my preprandial BG, anticipated after-meal activity... and the positions of the planets. ;)

Pineapple? 100% rapid, twenty minutes before eating... and eating slowly.

Pancakes? 70% R and 30% rapid, five minutes after I start fixing/eating them.

Dates? 100% rapid, ten minutes after eating them.

Spaghetti? With between 50% and 70% N, and about 20% rapid, the timing just isn't so critical... so before/after depends on how eager I am to eat the first few mouthfuls. :)

If in doubt? Whatever mix looks right, right at the beginning of the meal.

I'm happy with this approach, and arrived at it through much self-testing. My doctor will step in if I get into trouble, refer me to a specialist if needed, et cetera, but lets me do my own thing.

[dar917]

Non pumpers are more than welcome to join in the comments but this was intended mainly as feedback on people's pumping strategies.


Whoops, I didn't notice the category. nevermind then...:/

[Alice]

Sorry, I didn't notice the category either...but a bolus is the same whether on MDI or pump...I split boluses all the time with MDI...I guess the "square" boluses are different...but all-in-all, the two delivery methods are the same on a bolus. And timing also.

[cheryl]

For breakfast....20 minutes..Lunch and dinner....I can eat immediately....or not, it depends...on the bg's.......I have never gone over 30 minutes though ever, cause any kind of bolus I take, my insulin starts it's working within 45 minutes...

Cheryl

[blue eyes]

If I'm low or in range I don't pre-bolus because I never know how much I'll actually eat. On lantus/novorapid I did (pre-bolus 5-10mins before) and there were plenty of times I'd bolus and then find I couldn't eat all that I bolused for.

[Emm]

I'm not a pumper... and I can't answer anyway because mine would go in the missing category, I mostly bolus 10 - 20 minutes before a meal.

Well I try to anyway. I often forget. But even a 5 minute head start is helpful :)

[Subby]

I see the pump as a tool, pumping is a subset of the basal/bolus strategy of insulin treatment.

A pre-meal bolus covers both MDI and pumping, IMO.

Yes of course pre meal bolusing is just as pertinent in MDI, would never doubt that for a second, especially being on MDI for 15 years and having much experience with all sorts of pre-bolusing situations.

But my original context for this poll was in context of what pumpers are up to. This was not an arbitrary thing: as I said in my first post my team said pre-bolusing was a thing of the past for pumping therapy: part of this poll was to get a handle on what other pumpers found they had to do as opposed to what the so called convention said.

Also, absorption "generally" improves or at least "may" become a little more predictable with the same set site, again interested what other pumpers found with this and if it reduced their pre-meal pauses, if coming from MDI.

My downfall came with not framing the question to pumpers more specifically and not realising that the poll was put on the front page, negating the fact it is in the pumping forum. So of course all responded and there are great responses here and since the cat was out of the bag so to speak let this poll enjoy itself as a cross-therapy poll. :)

[Subby]

Whoops, I didn't notice the category. nevermind then...:/

Nope, my bad, I didn't make it clearer at the start. Let us know what you get up to!

[Scratch]

My downfall came with not framing the question to pumpers more specifically and not realising that the poll was put on the front page, negating the fact it is in the pumping forum. So of course all responded and there are great responses here and since the cat was out of the bag so to speak let this poll enjoy itself as a cross-therapy poll. :)

:) Part of the difficulty, at least as I view these boards, is that the board doesn't in a sense correctly frame these discussions. By that I mean this board as it is set up presently has a way of emphasizing the pump in such a way that MDIers may at times feel a bit left out as it were.

Notice that there isn't a forum about the Basal/Bolus Methodology, instead the ideas of basal and bolus are to be covered in this forum, the pumping forum. I suppose the type 1 or general diabetes section would qualify for use about basal/bolus, but I still feel it is unfortunate that there isn't a Basal/Bolus forum perhaps with subforums for pumpers and for those of us who use MDI.

A consequence of this set up is that MDI users are somewhat forced to use the pumping forum. It annoys me some, not enough so that I want to make a big stink about it, and I have one time prior made such a suggestion for an MDI forum. Response wasn't enthusiastic and it was suggested that the pumping forum adequately covered the idea of basal/bolus.

Maybe, maybe not.

I do think a thorough understanding of basal and bolus principles are key for a patient to take full advantage of MDI or insulin pumps.

I apologize for derailing some here, I suppose my annoyance about this issue with the forum structure is annoying me a bit more today.

[Subby]

No worries. My impression, being relatively new, is that the type 1 is a more general purpose forum focusing naturally on MDI, and the pumping forum is in my mind a subset for pumpers to share pump stuff that would simply not interest other type 1ers. Personally I would have put it as a subset of the type 1 forum, but anyway...

I would not have hesistated in putting this poll in the type 1 forum instead if it wasn't originally meant to address pumping. If only MDI, in Type 1. So I guess I think it's reasonably clear where things go at the moment. But for sure there is some messy overlap.

I don't see that a basal/bolus discussion belongs only to one or other forum... there are different factors and dynamics at work with each therapy, and if the discussion is about something unique to that therapy (eg, pump: variable basal settings, or MDI: getting a split lantus dosage right) it would simply go in the respective forum. If general, hopefully in the type 1 but mistakes do happen. And, the territory may move through the discussion to a common ground... ah well. Ces't la vie, perhaps.

[Micha82]

I always do Pre-Bolus, because I don´t know how much I can eat.
Sometime we start eating and my son is finished much to early, so it could be that I eat the rest when he is sleeping. I had many hypos with bolus before eating.

[Alice]

Subby, I'm curious as to the reason you were told that pre-bolusing was a thing of the past...in regards to pumping.

I'm on MDI, but regard the bolus aspect to be almost identical to pumping...the method of delivery is just different. So, I'm curious why they told you pre-bolusing wasn't necessary.

[Subby]

Subby, I'm curious as to the reason you were told that pre-bolusing was a thing of the past...in regards to pumping.

Alice, you and me both. At the time it "just wasn't part of pumping". Being a little more experienced now, I consider the attitude completely inadequate. But, I won't be debating it with the educator again any time soon because there is some attitude problem going on and difficulty with communication which I simply have no time for and which is, all said and done, negative. For my needs, I luckily have a great endo to deal with, she's just not confident with all pump decisions. I need good information: thus this thread, to find out what really goes on out there "in the trenches".

[rzrbks]

Subby, I'm curious as to the reason you were told that pre-bolusing was a thing of the past...in regards to pumping.

1)Me too--- while I am MDI, the CDE I work with is constantly after me to change to pump and when we visit, we always spend much time talking about pumping and I assure you, she's never mentioned any attitude like that

B) The 2nd CDE I work with is, herself, a pumper and she has never mentioned any attitude like this.

Thirdly) I'm confused. It seems to me that a Good team is going to be working with you to find out the system that works Best For You, not whatever Holy Grail they Fandango by.

[MollyM15]

I don't pre-bolus because of sometimes i get stomach aches before i get done eating so I just bolus afterwards...I set alarms on my pump to help me to remember.

[Eddy]

I always do Pre-Bolus, because I don´t know how much I can eat.
Sometime we start eating and my son is finished much to early, so it could be that I eat the rest when he is sleeping. I had many hypos with bolus before eating.

Hallo und Willkommen!

You might try splitting your bolus... having a small pre-bolus that will cover what you know you will eat, then doing more if you eat more.