Super Bolus

Super Bolus by John Walsh

Super Bolus by John Walsh

First things first: this approach works for Caleb. It may or may not work for you. I am by no means suggesting that anyone should apply the following theories to their diabetes care. I am only explaining what I do for Caleb.

For weeks, Caleb’s most predictable BG of the day was pre-lunch. Without exception it had been in range. It was sensor change day and we were operating in the blind start-up period. No worries though because this time of day hadn’t posed an issue in quite a while.

It’s approaching lunch time so let’s do a finger stick. 289.

289?

Okay. Oh well. It happens. There was more fiber in his breakfast than usual and he was a little low at the postprandial check. Ah yes, hindsight is 20/20. Moving on.  Now back to this 298 and we are getting hungry for lunch.

Super bolus.

John Walsh explains it as follows: “A Super Bolus is created when some of the basal insulin delivery is stopped or partially reduced, and delivered instead as additional bolus insulin on top of a normal carb or correction bolus.”

The intent is to get glucose levels back in range quickly without inducing hypoglycemia. Here is how Caleb’s super bolus went that day:

Correction: 1.50 units, plus

Meal bolus for 50 carbs: 2.00 units, plus

Basal for the next two hours: 0.70 units, equals

Total units delivered: 4.20 units.

Lastly (this is critical) turn basal to “off” for two hours.

The change in the timing of the basal insulin makes all the difference.  Front-loading it and delivering it with the meal and correction bolus makes it act faster and all at once, thus bringing glucose levels back in range sooner.  If left as basal, the end result will be the same, but it will take more time and hyperglycemia will last longer.  The same amount of insulin is delivered when using a super bolus, it is only the timing that is different.

Back to life, start preparing lunch.

1/2 hour after superbolus: 169

Perfect. Coming down fast and lunch is ready, let’s eat. 50 carbs consumed.

1 hour after superbolus (1/2 hour after eating 50 carbs): 109

Excellent. The first time I tried this, I panicked a little at this point.  A 109 an hour after a bolus that large is cause for worry.  But his basal had been zero for an hour and he still has food in his system.  Plus his basal will be zero for another hour.

DexCom had been calibrated with that lovely 289, which we confirmed after washing hands with a 288. DexCom showed him cruising between 85 and 100 over the next hour.

2 hours after super bolus: 89.  Wonderful.

I know a bolus of that size is still hanging around in Caleb’s system beyond the 2 hour insulin duration that we use. However Caleb’s basal insulin has just now resumed.  He hasn’t received any basal or other delivery of insulin for the last two hours.  Any tail of insulin duration from that super bolus is required for his basal needs.

And it worked.  He continued to hover with a nice flat arrow through the afternoon until dinnertime when a finger stick confirmed a BG of 98.

I invite you to read more of what John Walsh has to say about using a super bolus. He suggests its use for high glycemic foods or large intakes of food in order to avoid blood glucose spikes. I haven’t tried in those situations yet, but I plan to. He also speaks of pumps giving us the option to deliver a super bolus automatically. The thought of it gives me chills.

In what ways have you used the super bolus?

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30 thoughts on “Super Bolus

  1. I had never heard of a super bolus! (I think they might call it a combo bolus with our pump) I am going to have to read more about that. My daughter has only been on the pump for 7 months and I feel like we are still learning. Thanks for the insight. :)

    • Hi Heather! Combo, extended, dual wave and square wave bolus’ are different than a super bolus. They are options a pump offers to deliver insulin over a period of time rather than all immediately. Often people will use them for high fat or low glycemic foods, but they have other uses as well.
      A super bolus is a concept that must be administered manually by the user, but hopefully future pumps will include it as a feature.

  2. Very interesting post! I have actually never used a super bolus…. honestly I didn’t really know what it was. :)

    Your post explains it very well! In your experience… do you only use super bolus when Caleb is high and he’s about to eat? Or do you use a super bolus anytime that he is high?

    You said you shut off the basal for 2 hours… how did you know 2 hours? Was it trial and error and you figure out that for Caleb this is what works?

    This is really interesting…. I will have to try it with Tristan… but I’m a little nervous! LOL :)

    • To be honest, I often forget about the super bolus but most commonly use it when we’re going into a meal and his bg is elevated and the thought of him going higher with food before coming down makes me quiver. I think that little quiver reminds of the super bolus. I have also used it when he gets to 300+ because I get that quiver again. In this case, I am literally going with my gut on when to use it.
      Caleb’s insulin duration is programmed at 2 hours and I have always found that to be pretty accurate with the exception of very large bolus’. I’ve only tried the 2 hours and it’s worked. I think this is one of those things that you need to test the waters with and see what works for you. Below Mike mentions that he’s used 1 hr and John Walsh’s example uses a longer period. It’s a variable that the user needs to decide upon.

    • Thanks Bernard. I watched your video way back when I first started using the super bolus. It’s a great visual of how to implement it. I’m glad to hear that you’ve been able to use it so successfully.

  3. I’ve been thinking about trying this, but have been hesitant. Helpful post!

    My only question echoes Rachel’s – what’s the line between superbolusing or not? Do you have a high-BG threshold? And is it always shutting off the pump for 2 hours? I can see the value for something like a 289 or getting in a lot of functioning insulin right away, but would be nervous about using it for a BG much lower than that.

    • I understand your hesitation, Karen. I was too when I first tried it. I would just suggest lots of bg checking until you get comfortable, or in your case, close watch of DexCom with some bg checks.
      I think the 2 hr element is something that will vary from user to user. I commented above to Rachel’s questions that my gut leads me to when to use it. I think it will be great when it’s part of the pump functionality and it can be used more routinely and thus with greater confidence.

  4. Lorraine –
    Great post. I haven’t had too many opportunities to use a super bolus (thank goodness) but I definitely think it is a great way to correct those nasty highs around meal times. Glad to hear it is successful for Caleb.

  5. I use a Super Bolus from time to time for lunch. I have problems with a big spike after lunch, but then crashing before dinner. SB helped with this. I use the 2 hour time frame time. This came from my Endo.

    Coincidentally, I did a SB for donuts on Monday. With donuts, I tend to get that big spike and then come crashing down quickly. Worked well on Monday.

  6. I have heard about the Super bolus in the past and was intrigued, but sort of afraid to use it. It sounds like it works wonderfully for you and Caleb!

    I think the Deltec Cozmo insulin pump had the feature built in, but now that it’s been discontinued, we have to do it manually. It’s a lot of math … what if I screw it up?

    I’d also like to know how you settled on two hours … is this a standard, or just something that you found through trial and error?

    Thanks for sharing!

  7. You know, I learned about this at camp and completely forgot about it. It is genius. Next time we get a high number before a meal I’m giving it a shot. I’ll make sure to keep a close eye on his sugars afterward. Thank you for the reminder! It is exciting!

  8. wonderful explanation Lo! i always learn from you and i love it!! there is soooo much to this diabetes thing, isn’t there?!

  9. Hi Lorraine,

    We use it all the time. And yes, it does work nicely. We will often do 1 hour worth of basal, less often 2 hours. I also like to check 1 hour after bolusing to make sure that the BG is going down. Sometimes the high is caused by a bad infusion site or illness. It’s easy to check in 1 hour with the CGM. If BG is not going down, you can turn basal back on and correct again.

    One thing that I don’t like about this method is that if a snack is eaten 2 hours after the super bolus, there is a greater chance that BG will initially rise more than with a regular bolus and correction. This is due to the fact that has been no “new” insulin in the last 2 hours with no basal. If you can time the snack with the peak of the super bolus this could likely be avoided.

    thanks for sharing !
    Mike

  10. I know I read about the Super Bolus in Pumping Insulin. Or I think I did. Maybe I learned it from Bernard. In any case, I haven’t tried it – although I did think about it a few nights ago when I was hit with a bad and unexpected high. But I decided right before bed-time was not the time to mess with a new technique. I’m going to give it a try next time I have a bad high though. Thanks for explaining it so well!

  11. Hi Lorraine,
    Thanks for explaining this. We are starting G on the OmniPod on Monday the 26th. I am on the uphill side of the STEEp learning curve, feeling I will never really learn all this. Does it get any better? I am intrigued by the super-bolus. Lots of questions though still.
    Thanks for posting this,
    Penny

  12. Thank you for this post, it was very informative. I have never heard of a superbolus before!! It must be my lesson of the day :)

    I’m so glad that it worked for Caleb! It really sounded like it was pretty perfect!!!

    I’m going to check out the link and read more about this super bolus…

  13. OK…this is a SWEET idea. I am going to start trying it with Joe with his breakfast. Now that we have Dexter I have noticed his post breakfast spike of 300s…AWESOMENESS. I’ll let you know how it turns out. Thanks for sharing.

  14. Thank you so much for sharing this. I hate to admit that I’ve never even heard of this concept before hearing it from you! Which means I’ve never used it before but am definitely going to try it. Especially since when I have highs lately (240+) it seems to take forever to come down.

  15. Great post. I have not heard about Super Bolus before, but it makes perfect sense to me. I will definitely try it.

    I have in the past delayed eating my meal by 10 min after taking the bolus. I was trying to achieve a similar result but this is a lot safer and should be just as affective. Thanks

  16. Pingback: Super Bolus for Breakfast « This is Caleb…

  17. Thank you, thank you for this post! We’ve been struggling with this same issue for months now… High 200s after breakfast followed by 40-50s pre-lunch. No basal/IC ratio changes have helped and there have been plenty! Thanks so much for sharing!

  18. I have been trying to learn how to handle post breakfast spikes. My daughter has been using the omnipod pump for 5 months with very good results but at this time, it seems her blood sugers go high when she does her lunch check. I have adjusted I/C and basal rate many times. The result gets better but BG still at around 170. I have been asking about the “Super Bolus” but no one knows what I am talking about so I am glad i stumbled on your article. When you do a “Super Bolus”, you suspend the basal insulin delivery over the determined time frame, add that amount of insulin to the amount of insulin you will need for your meal and dose. The pump will not automatically resume basal insulin delivery after the designated time so you have to tell it to do so. Is this correct? My daughter is 9 years old and at lunch time she is at school and does not have her PDM on her person to resume Basal insulin delivery. Is there a function I don’t know about?

    Thanks for your help,

    Karyn G

    • Karyn – I just emailed you. The short answer is you can set a temp basal of “off” and it will resume automatically without any intervention necessary!

  19. Pingback: The Super Bolus | Diabetesnet.com | Healthergy.net

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