Dual Wave Bolus

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Permalink Reply by FatCatAnna on August 30, 2009 at 5:34pm

Hey Danny - on my Animas 2020 pump - we have what is called a Combo bolus - you can set it to give you X% of X amount of insulin over a period of time depending on how insulin works in your body. I generally set the amount of insulin I have to give over a period of 1 hour (have experimented as I'm sure you have) - and I find I don't do spiking of blood sugars like I used to. It all depends on how my BG is at the time - and what I'm eating - and I go from there.

I use this for my main pig trough meals during the day. I used to do the same thing when I was MDI (multiple doseage injecting) as well (pretraining for the pump I guess? ) - giving myself small increments of fast acting insulin as I use/used a pen needle that can inject as small a dose as 1/2 unit.

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Permalink Reply by Danny on August 30, 2009 at 5:42pm

"- and I find I don't do spiking of blood sugars like I used to. " This is exactly what I notice, Anna.

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Permalink Reply by Lorraine on September 30, 2009 at 6:00pm

I haven't tried this method, but am intrigued. I'm having a hard time understanding how extending the duration of insulin delivery could help the spike. Aren't you effectively delaying insulin effect, which in my mind would only contribute to a spike? I would think the only way to avoid the spike would be to deliver the insulin earlier. And perhaps if delivering it earlier and over a period of time, you could then avoid any low from all the insulin hitting at once. Or do I have this all completely backwards?

Lorraine

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Permalink Reply by Kim Moores on October 28, 2009 at 7:52pm

The dual wave bolus works in a way that you get x amount of insulin up front and then over the next 1/2 hour to hour (or what ever you pick as your time) it gives you the remaining dose in very small incriments. Kinda of like your pump giving you your basal through out the day. Hope this makes some sense

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Permalink Reply by Cara Bauer on August 30, 2009 at 5:44pm

I've used dual wave for parties and such, not every day. I've used a square wave in the past, but just got away from the habit. Maybe I'll start again. Interesting idea.

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Permalink Reply by Mike S. on August 30, 2009 at 6:11pm

This is something that I am going to have to look at a little more. This makes perfect sense to me. Think I am going to start playing around with it and see what happens. I am anxious to see if it helps with the spiking that I get. Thanks Danny for the suggestions.

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Permalink Reply by Ray Marino on August 30, 2009 at 6:33pm

Yes, I use the dual wave every time I eat. It really helps me, especially having
Gastroparesis, and all. With Buffets the dual wave works great. The only time
I use a normal bolus is when making a correction.

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Permalink Reply by Sophie on August 30, 2009 at 8:24pm

I'm really loving this idea...but have struggled a bit with the dual wave before. Maybe I've extended it too long...Usually I've felt (and been) very high right after the initial bolus and not felt better until the end of the dual wave (which makes sense, I needed that much insulin). I guess my question is: how long are you extending the dual wave on these "normal" meals? Anna mentioned 1 hour...is this what most people use?

And my second question. Danny, you said, "thus giving myself more units over a longer period of time." How much "more"? I, too, get the spike 1-1.5 hours after bolusing, and am back to normal at 2-2.5 hours. I have been trying to eliminate these spikes, but am worried that since I DO come down at 2-2.5 hours, then if I give more insulin, then I'll ultimately get low, and if I decrease the initial bolus, I'll FEEL high during the duration of the dual wave.

I'm EXTREMELY interested as to how this works with you (and other people too!). The concept is very attractive--but I think I need more information/instructions! I've only been pumping for 2.5 months and was diagnosed 4 months ago, so any and all explanations are very helpful and will be much appreciated!!!

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Permalink Reply by Ruth on December 7, 2009 at 9:48am

I just recently started using the dual wave bolus for all my meals...I dual it over 1/2 hour. I was having serious post-prandial spikes, and since I started doing this, my bg's usually stay below 160 (and more often around 140) two hours post-prandial.

I'd read about this here and on another board and realized that part of my problem was that my esophagus has no motility, so it takes a while for the food to get to my stomach. Dual-waving compensates for that.

Ruth

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Permalink Reply by Ricardo on August 31, 2009 at 6:06am

I wrote about my use of the dual wave/ combo bolus on another forum. I have copied and pasted my post below:

I have been doing something similar for about the last 3 years.

From what I have read in this thread, it sounds like most of you who are using this technique are doing so by calculating a carb bolus based strictly on the carbs in the meal and stretching out some or all of the carb bolus using the square wave/ extended bolus.

I use a bolus calculation technique that is usually referred to as TAG (Total Available Glucose). The premise behind TAG is that a portion of the protein and fat content of the meal will also contribute to carb loading above and beyond the actual carbs in the meal. Whereas 100% of the carbs are accounted for when calculating the bolus, only a percentage of the protein and fats are expected to be eventually converted to glucose. The carb bolus is delivered immediately and the protein and fat bolus is delivered using the square wave/ extended bolus.

I have found through trial and error that for my metabolism, approximately 40% of ingested protein and fats are eventually converted to carbs (my percentages have changed over time as I played with the technique). I total the grams of protein and fat and multiply by 40%. As an example, if the protein and fat total to 80 grams, I would multiply by .40 and come up with 32 grams. With an i:c ratio of 1:10, this 32 grams of protein and fat carb loading would need to be covered by 3.2 units of insulin, in addition to the carbs in the meal. Since proteins and fats are digested more slowly than carbs, the 3.2 units have to be delivered using a square wave/ extended bolus to
prevent a person from dropping too low.

How do I time the square wave/ extended bolus? Again, through much trial and error I find that a delivery rate of approximately 1 - 1.2 units of insulin per hour delivery rate for the square wave/ extended bolus keeps me from dropping too low or spiking too high. So in this example, I would deliver the 3.2 units over a time span of 3 hours (3.2 units per hr/ 3 hrs = delivery rate of 1.06 units per hr, which is within the 1 - 1.2 target delivery rate. The 1 - 1.2 delivery rate is used assuming I was in BG target range to begin with. If my BG is above target, I would use a delivery rate higher than this range or transfer part of the protein/ fat bolus to the carb bolus for immediate delivery. If my BG is below range, I would use a delivery rate which is lower.

As you all have noticed, I also experience a much smaller spike after eating a meal when using this technique. Typically, I see my BG spike as little as 20 - 30 points after eating a pasta meal which will have over 100 grams of carbs. After such meals it is common to see 1 hr post prandials of 100 - 120 and 2 hr post prandials of less than 100. If I delivered the insulin correctly, I will be at or near target several hours after the meal, without ever going low.

TAG is NOT taught or recognized by most medical professionals I have talked with. My TAG percentages are essentially a personalized algorithm for my metabolism of a meal and should not be seen as percentages that anyone else can pick up and run with.

Why does the technique work? Better absorption may be one reason the technique works. My explanation however is that the square wave/ extended bolus on top of a carb bolus simulates secondary phase insulin release, which is how a non-diabetic pancreas would handle a meal. Having once tried Symlin, this technique works better to control my post-meal spikes. However, if you are not sensitive to protein/ fat carb loading, the technique may not work well for you. My understanding is that TAG will work best for someone whose second phase insulin release is less than satisfactory. Unfortunately, most of us are simply given a catch all diagnosis of "diabetes" without any further classification of inadequate first and/ or second phase insulin release.

You can read a lay person's article about second phase insulin release at the following link:

http://www.phlaunt.com/diabetes/14046621.php

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Permalink Reply by Danny on August 31, 2009 at 7:09am

"My explanation however is that the square wave/ extended bolus on top of a carb bolus simulates secondary phase insulin release, which is how a non-diabetic pancreas would handle a meal."

" My TAG percentages are essentially a personalized algorithm for my metabolism of a meal and should not be seen as percentages that anyone else can pick up and run with."

Wow, you touched on many points that I have been feeling the past few weeks, Ricardo. Thank you so much for taking the time to post this information. I hope your reply/comment is seen by many insulin pumpers here at TU.

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Permalink Reply by Ricardo on August 31, 2009 at 7:44am

Thanks Danny,

I should also add that I am a Type 1 diabetic with no endogenous insulin production. This means I have no primary or secondary insulin release and TAG can work well for me.

If someone is a Type 2, they may have adequate secondary phase insulin release, but insufficient primary release. They will spike high after any carb loading, but their body will slowly bring them back into range over several hours using the secondary release. My understanding is in this case the TAG method would supply too much insulin.

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