2 Pump Settings to Evaluate Basal ratesInsulin to Carbohydrate Ratio (I:C)Insulin Sensitivity Factor (ISF)Pump Download and HistoryInfusion site issuesCombo BolusCase Studies
3 Basal RatesBasal rates that are set correctly should keep your BG relatively stable in the absence of food, exercise or extra insulinBasal rates should be evaluated when there is variability in BG readings, change of season, significant weight changes or change in physical status
4 Basal Testing TipsDivide day into 4 time frames and evaluate one time frame at a time.Evaluations begin 4-5 hours after the last bolus dose and food consumption.Starting bg should be around mg/dlTesting is stopped if bg goes above 150 or below 90.Repeat test 2-3 times before making adjustments.
5 Basal Rate Test: Overnight What to doWhen to testEat dinner (low fat, known carbohydrate content meal)Bolus for dinnerNothing to eat until breakfast4 hours after dinnerAt bedtimeAt midnightAt 2-3 amEvery 3 hours when awakeBG must be in target range four hours after dinner to start this test.
6 Basal Rate Test: Daytime What to doWhen to testMorningSkip breakfastNo food until lunchTest every 1-2 hours until lunchAfternoonSkip lunchNo food until dinnerStart to test 4 hours after breakfastTest every 1-2 hours until dinnerEveningSkip dinnerNo food until bedtimeStart to test 4 hours after lunchTest every 1-2 hours until bedtimeBG must be in target range four hours after meal to start test. Each daytime segment should be tested on a different day.
7 Looking at the DataBG swings of more than 30 mg/dl indicates the need for basal adjustmentsIt is best to see repeating trends before making changesBasal rate should be increased or decreased 1-2 hours before the BG begins to rise or fall.Make one change at a time
8 Suggested Guidelines for Basal Adjustments Basal of 2.0 units per hour or moreMake adjustments in unit incrementsBasal of units per hourMake adjustments in unit incrementsBasal of units per hourMake adjustments in unit incrementsBasal less than 0.3 units per hourMake adjustments in unit increments
9 What should we do? Time 10 pm 12 am 3 am 6 am BG test #1 149 130 86 61 1311197759BG test #31221107355Basal0.550
10 Suggested ChangesDecrease basal at 12 am to 0.450
11 Calculating I:C RatioI:C indicates how many grams of carbohydrate 1 unit of rapid-acting insulin will coverDetermine starting point for I:C ratio 500 ÷ TDD (Total Daily Dose) = I:C Example: 500 ÷ 50 U = 10 (I:C= 1:10)May have more than one I:C for different meals or times of day
12 Insulin to Carbohydrate (I:C) Ratio After basal settings have been confirmed, you can evaluate bolus dosagesIf the BG consistently returns to target range about 4 hours after meals, you can be confident that the I:C ratio is working wellIf the BG does not return to target range 4 hours after meals, you should evaluate the I:C ratio
13 Checking I:C Ratio What to do When to test Start before meal Assure BG in target range ( mg/dl)Assure known amount of carbohydrate and low fat mealBolus for mealTest BG hourly for 5 hoursRecommended Goals1 hour after mealBG mg/dL higher than pre-meal4 hours after mealBG within 30 mg/dL of pre-meal
14 Adjusting I:C Ratio 4-5 hours after CHO bolus: Result Adjustment BG more than 30 mg/dL below pre-mealRe-check ratio another time using a higher I:C (higher I:C will reduce size of bolus)BG within 30 mg/dL of startCarbohydrate ratio is correctBG more than 30 mg/dL above startRe-check ratio another time using a lower I:C (lower I:C will increase the size of the bolus)
15 Suggested Guidelines for I:C Ratio Adjustments If I:C is less than 1:5Make changes in 1 gram incrementsIf I:C is between 1:5- 1:20Make changes in 2 gram incrementsIf I:C is between 1:20- 1:50Make changes in 5 gram incrementsIf I:C is more than 1:50Make changes in 10 gram increments
16 What should we do? BG Before Meal 1 hr pp 2 hr pp 3 hr pp 4 hr pp Day 199220181176153151Day 2121277205188185Day 31 07256230194183Breakfast I:C1:15
17 Suggested Changes Change I:C to 1:13 Or bolus for breakfast 20 to 30 minutes before breakfast
18 Insulin Sensitivity Factor (ISF) Once you have confirmed basal settings and bolus dosages for carbohydrate, you can evaluate ISFThe goal is for the ISF to return from a BG above target to the target range within 4 hrs of a correction bolus
19 Calculating ISFISF indicates how much (mg/dL) 1 unit of rapid-acting insulin will lower BGDetermine starting point: or 1800 ÷ TDD (Total Daily Dose) = ISF Example: ÷ 40 U = 45 ISFMay have more than one ISF for different times of day
20 Evaluating ISF What to do When to test Give a correction dose of insulin for high BGTest BG hourly for 4 hoursRecommended Goals4 hours after bolusBG in target3.5 hours after bolusBG should decrease within 30 mg/dL of target at 3.5 hours for rapid-acting insulin
21 Suggested Guidelines for ISF Ratio Adjustments If ISF is less than 20Make adjustments in 5 mg/dl incrementsIf ISF is betweenMake adjustments in 10 mg/dl incrementsIf ISF is greater than 100Make adjustments in 20 mg/dl increments
22 What should we do? ISF 1:50 High before correction 1 hour post correction2 hour post correction3 hour post correction4hour post correctionCorrection #1350322230199201Correction #2375335301275242Correction #3250180165150155
24 Do You Download? Look for BG trends Number of BG readings Average BG Site changes – cannula fillBolus frequencyCarbsBolus vs. basalFrequent alarms (empty cartridge, suspend)Current Pump Settings
25 Look in the History of the Pump BolusAmountsFrequencyTypeBasal vs Bolus50:50How much insulin need for a prescriptionAlarmsPrimeSuspend
26 What else do we assess? Infusion site Bolus timing and type Change frequencyRotationAdherencePain or DiscomfortBent Cannula FrequencyLook for signs of overuseBolus timing and typeCombo bolus
27 Combo Bolus Also known as a square or dual wave bolus Used as a bolus to cover slower absorbed meals that contain higher protein and fat contentSuch as with meals that include buffets, restaurant dining, and pizzaNeed to decide duration and ratio when using
28 When to use a Combo Bolus? FoodDurationRatioFast Food, Movie Popcorn,And high fat desserts1 hour50:50Mexican, Chinese, Italian, Steak dinner, Buffets2 hourPizza3 hour*These are suggested starting points
29 Evaluating a Combo Bolus Do Premeal BG – start trial if BG within normal range ( mg/dl)Determine carbs give and program combo bolusMonitor BG hourly to evaluate for up to 6 hoursDid the BG return to within 30 mg/dl of the target range within 6 hours?
30 The 2 hour BG checkThe purpose of the 2 hour check is to determine if the first portion of the bolus was the correct amount to maintain normal BG 2 hours after the mealIf the 2 hour BG is high try a 60:40 split next time continue to make adjustments until the right combination is reached.If the 2 hour BG is low try 40:60 split next time.
31 The 4 hour BG checkThe purpose of the 4 hour check is to determine if the 2nd portion of the bolus was the correct amount to maintain normal BG 4 hours after the mealIf the 4 hour BG is high increase the amount of insulin given over the extended portion of the bolus
32 The 6 hour BG checkThe purpose of the 6 hour check is to see if the second portion of the bolus was the correct amount of insulin and the right length of timeIf the BG was normal at the 4 hour check but high a the 6 hour check the extended portion of the bolus may need to be increased.
34 12 year old male – A1c 10.5%HCP sends pt to the educator for carb counting reviewHas been on pump for 2 yearsPatient comes in with both parentsParents express concerns and frustrations accusing child of sneaking food and not bolusingPatient is quiet and pouty
35 What things should we assess? Have orders from HCP that allows you to make dosage adjustmentsReview Daily routine – assess carb counting ability.Download pump or look in historyBolus, bg testing results, site change frequencyOther
36 Results of AssessmentFound carb counting ability to be adequate, but often guessing amountsAfter reviewing pump data we find that the patient has been bolusing for meals and snacksBG logs reveal that pt is testing frequently as most results are above target rangeBasal vs. Bolus reveals that patient is constantly trying to correct bg. Basal is only 30% 0f Total Daily Dose
37 Plan for 12 year old maleImprove Carb Counting accuracy by measuring portions, reading food labels, and using the smart features on the pump to calculate bolus dosesPraise patient for bolusing and testing frequencyLet him know that he is growing and he just needs more insulin.Do a 10% increase on basal immediatelyInstruct family on basal testing and ask them to send in results in 1 week for needed basal adjustments or make 1 week f/u appointment.
38 32 yo Female – A1c 8.8% She works full time and has 3 young children Both the HCP and patient are frustrated with the poor bg controlShe is fearful of lows - hx of severe hypoglycemic event 3 years agoHas been on pump for 6 years
39 What things should we assess? Have orders from HCP that allows you to make dosage adjustmentsReview Daily routineDownload pump or look in historyBolus – frequency and timing, bg testing frequency and results, site change frequency and rotationother
40 Results of AssessmentDaily routine reveals that life is chaotic and lacks a consistent schedule and as a mom she puts herself lastDine out frequentlyPump download revealsboluses and bg testing infrequent often only 1-2 per dayNot using the pump bolus calculator features or combo bolus when dining outChanging site every 4-5 days when cartridge runs outHas only used abdomen for infusion site area
41 Plan for 32 yo female Set reminders on pump to bolus Discuss and instruct pt on benefits of using the bolus calculating features on the insulin pump including the combo bolus (for dining out)Discuss the importance of site change frequency and rotation. Suggest she only fill her cartridge with a 3 day supply of insulin. Have pt use a alternate infusion site area and leave abdomen area alone for at least 3 months.Discuss benefits of a CGM