Current And Emerging Technologies In Insulin Pumps & Continuous Monitors Phoenix, AZ June 18, 2008 John Walsh, PA, CDE jwalsh@diabetesnet.com (619) 497-0900 Advanced Metabolic Care + Research 700 West El Norte Pkwy Escondido, CA 92126 (760) 743-1431

Highlights Background Smart Pump Features Control Tips For Pumps DIA and BOB Super Bolus Continuous Monitors and Tips Wrap Up

Talk The Talk TDD – total daily dose of insulin (all basals and boluses) Basal –background insulin released slowly through the day Bolus – a quick release of insulin Carb bolus – covers carbs Correction bolus – lowers high readings Bolus On Board (BOB) – bolus insulin still active from recent boluses Duration of Insulin Action (DIA) – time that a bolus will lower the BG – used to measure BOB

Pump Features

Pump Features Automatic carb and correction calculations based on: Carb and correction factors Glucose targets DIA avoids insulin stacking Carb and correction boluses adjusted for BOB for accuracy and safety Personal carb database Correction bolus shown as % of TDD Direct glucose entry and detailed glucose history Reminders, alerts, weekly schedule, temp basal rates, etc. Today’s Smart Pumps are leading the way toward intelligent devices. They offer easier carb and correction bolus calculations and can show when excessive amounts of insulin are being used to correct high blood glucoses.

Special Features Feature: Pumps: Cont Monitor readout Paradigm No tether Omnipod Lowest basal rate Animas HypoManager Cozmo Weekly Schedule Cozmo Missed Meal Bolus Cozmo Bolus Not Completed Cozmo Disconnect Bolus Cozmo Food/Carb List Animas, Cozmo Omnipod, Spirit Therapy Effectiveness Cozmo, Paradigm Glucose SD (Variability) Cozmo

HypoManager Shows current insulin OR carb deficit Compares BOB to correction bolus need: When BOB is smaller –> Cozmo recommends a correction bolus When BOB is larger –> Cozmo recommends eating carbs A very helpful feature: Reduces overeating when BG is low Warns when carbs may be needed later even though current BG is OK or high

HypoManager Always test when low – the BG reading triggers what should be an accurate recommendation for carb intake to treat that low Prevents ETRS – “Empty The Refrigerator Syndrome” Do not use with Symlin, gastroparesis

One Touch Ping Ping meter sends BG result directly to new Animas pump Give carb and correction boluses directly from meter – remote bolusing Like other meter–pump combos, provides more accurate history Dexcom

Weekly Schedule User’s profile changes automatically for specific days of the week Allows different basal patterns and missed meal bolus alerts for each day of the week No need to remember to change basal patterns or alerts Great for college, shift work, weekends, exercise, or other regular variations in schedule

Pump As Carb Counter Pump or external controller contains user-selected food list for accurate carb counting for Easy carb calculations More accurate boluses Available in Animas 2020, Deltec Cozmo, Omnipod PDM, and Spirit PDA

Carb Boluses Regular Taken immediately – MOST meals Combo / dual wave Some now, some later – bean burrito, some pastas and pizzas, Symlin, precose Extended / square wave Extended over time – gastroparesis

CDA1: Temporary Basal Rate Used by 33.8% of pumpers Great for: Exercise Illness Testing new basal rates Should it be used by more?

Temp Basal Tips Never suspend pump May forget to restart May restart too late Does not work for treatment of lows Need multistep temp basal reductions Need “temp insulin adjustments” – basal insulin does not live alone

Sample Temp Basal Reduction Max temp basal reduction: 0% for 60 min Start temp basal reduction before exercise if possible

Disconnect Bolus To Cover Basal Disconnect up to 2 hrs for sports, sauna, sex, etc. Useful for “Mini-vacations” User estimates time off and pump gives up to 50% of missed basal as bolus Alarm reminds user to re-connect On reconnecting, pump shows missed basal and offers to supply the missing amount

Getting The Big Picture Therapy Effectiveness – Glucose and insulin history

Stable and relatively normal glucoses Your Goal Stable and relatively normal glucoses

Therapy Effectiveness Scorecard Screen 1: Average BG (over 2 to 30 days) BG tests per day BG standard deviation (SD) Screen 2: Carbs per day TDD % correction boluses % carb boluses % basal rates Available in Cozmo and Paradigm pumps

Therapy Scorecard Screen 1 Monitor control, testing frequency, glucose variability 14 Day Average: BG 146 mg/dl Tests 3.5/day Std Dev 53 mg/dl Overall control Adequacy of testing BG variability – aim for less than 65 mg/dl or less than half of average BG Today’s pumps provide excellent information. For example, the Deltec Cozmo shows how many units are being used for meal boluses, correction boluses, basal rates, and TDD on an “Average Summary” screen in the History menu. This information can be averaged over the last 2 to 30 days on the pump display. In the screen printout above, this person has been using 11.34 units a day or over 20% of their daily insulin intake just to lower high blood sugars. Ideally, this percentage is below 8 to 10% of the TDD (ie, below 5.4 units). Because the amount of insulin used to bring down highs is so large, about 5 units could be added to this person’s basal insulin delivery and carb coverage each day.

Therapy Scorecard Screen 2 Monitors carb intake, TDD, basal/carb bolus balance, correction bolus% 14 Day Average: Carbs 206 g TDD 48.58 u Meal 38.07% Corr 4.95% Basal 56.98% Boluses taken? Low carb diet? Guides therapy – A1c, lows, etc Carb bolus % Correction less than 8% of TDD? Basal at least 40 to 45% of TDD? Today’s pumps provide excellent information. For example, the Deltec Cozmo shows how many units are being used for meal boluses, correction boluses, basal rates, and TDD on an “Average Summary” screen in the History menu. This information can be averaged over the last 2 to 30 days on the pump display. In the screen printout above, this person has been using 11.34 units a day or over 20% of their daily insulin intake just to lower high blood sugars. Ideally, this percentage is below 8 to 10% of the TDD (ie, below 5.4 units). Because the amount of insulin used to bring down highs is so large, about 5 units could be added to this person’s basal insulin delivery and carb coverage each day.

Check Your Correction Bolus % If correction boluses make up more than 8% of the TDD (and lows are NOT a problem): Move at least half of any excess units above 8% into basal rates or carb boluses Raise the basal rates Lower the carb factor Or stop skipping carb boluses

Example: Correction Boluses Over 8% 10 Day Average: Carbs 175 g TDD 54.1 u Meal 36% Corr 21% Basal 43% Over 8% Today’s pumps provide excellent information. For example, the Deltec Cozmo shows how many units are being used for meal boluses, correction boluses, basal rates, and TDD on an “Average Summary” screen in the History menu. This information can be averaged over the last 2 to 30 days on the pump display. In the screen printout above, this person has been using 11.34 units a day or over 20% of their daily insulin intake just to lower high blood sugars. Ideally, this percentage is below 8 to 10% of the TDD (ie, below 5.4 units). Because the amount of insulin used to bring down highs is so large, about 5 units could be added to this person’s basal insulin delivery and carb coverage each day. Move 1/3 to 1/2 of the overage to basals or carb boluses: 21% of 54.1 = 11.3 units, 8% of 54.1 = 4.3 units 11.3 u - 4.3 u = 7 units excess 1/3 to 1/2 of 7 u = 2.3 to 3.5 u to add to basals or carb boluses

Therapy Effectiveness Guides TDD – Raise for frequent highs or high A1c Lower for frequent lows or for frequent lows and highs Basal/Bolus Balance – about 50% of TDD Correction Factor = ~ carb factor X 4.5 (mg/dl) (carb factor / 4 in mmol) Correction Bolus % – if over 8% of TDD, move excess into basals or carb boluses Average BG – < 160 when checking before & after meals, < 140 when checking mainly before meals Standard Deviation – Keep less than 1/2 of avg BG or below 65 mg/dl

Look At The Long And The Short – BG And Insulin Doses Long: trends and history over 14 to 90 days Short: instant analysis via 5 Hr TrackBack

The Long – Glucose Trends And History Is your A1c between 6% and 7%? Is your meter average below 150 mg/dl (8.2 mmol)? Do you have frequent lows? Does BG go below 50 (2.7 mmol)? Do basal doses = ~half your TDD? Does correction factor = 4.5 X carb factor

The Short – Instant Analysis Of Insulin Your insulin level over the last 5 hrs was: If your current BG is: Too High Too Low Starting BG In Target Optimal high, low, or normal Too Low Too High

Instant Analysis – 5 Hr TrackBack Whenever you have a low or high reading, compare: how much basal and how much bolus was active over the previous 5 hours Lows – usually caused by the larger insulin amount Highs – usually caused by the smaller insulin amount Assume that your boluses work for 5 hours! Future Pump Feature

Examples – 5 Hour TrackBack # 1 BG = 54 mg/dl (3 mmol) at 1:00 am In previous 5 hours: Boluses = 9.2 u Basal = 4.6 u # 2 BG = 252 mg/dl (14 mmol) at 4:30 pm In previous 5 hours : Boluses = 6.5 u Basal = 2.4 u bolus basal

After The Instant Analysis Decide on a better plan for the next time Always aim for a normal reading 4 to 5 hours from now.

Continuous Monitors

Trends Or Static Readings? CGM shows the wearer only a few carbs may be needed. Meter reading gives no clue.

Meter or CGM Improves Tracking & Insight Pump + Meter for direct BG entry Deltec Cozmo + Freestyle CoZmonitor Omnipod + Freestyle Paradigm + Lifescan (US)/Bayer (Eur) Animas + One Touch Ping Pump + Cont Mon Medtronic x22 + Paradigm RT Future Pump + Meter/Monitor Combos Animas pump + Dexcom Cozmo + Abbott Navigator Omnipod + Dexcom and Navigator The combination of testing data with insulin delivery puts most of the data needed for management on a single device. Blood sugars, insulin doses, carb counts, and timing are all recorded. Now if they would only incorporate a walker!

CGM–Pump Combos Animas Cosmo Dexcom Omnipod Navigator Medtronic Paradigm RT

CGM Benefits Increased sense of security Immediate feedback – look and learn Control with safety Worth out of pocket cost for many Insurance reimbursement gradually catching on

Continuous Monitor A continuous monitor OR frequent meter checks lets the user see where they stand in relation to optimal energy flow Optimal BG range for energy

Plus Insulin Pump With full BG record, basals and boluses can be adjusted to provide optimal energy flow Optimal BG range for energy flow Better growth, better performance, better grades

CGM Look And Learn Excess night basal or bedtime bolus Breakfast bolus too small or too late Lunch bolus too small or afternoon basal too low

No Two Points Created Equal! Higher Risk Going Down Lower Risk Going Up Level of a BG’s risk depends on its trend

Turnaround Time A Glucose in Motion Stays in Motion

Don’t Stack Insulin

As readings improve, bring the upper glucose target alert line down Stay Between The Lines As readings improve, bring the upper glucose target alert line down

Be Careful In CGM Interpretation CGM wearer said “This showed me where my “problem phases” lie. My post-meal results after breakfast and lunch consistently sucked. So I’m taking action: tofu and scrambled eggs for breakfast; earlier, more aggressive injections….and I’ve tightened my insulin-to-carb ratio a bit.” But the bigger problem starts near midnight when the overnight basal is unable to keep the BG from rising before breakfast. When adjusting insulin, don’t focus on only carb boluses or only basal rates!

Detection Of Hypoglycemia HA Wolert: Use of Continuous Glucose Monitoring in the Detection and Prevention of Hypoglycemia Journal of Diabetes Science and Technology V1, #1, Jan 2007

Continuous Monitor Accuracy Navigator 5 day (shown in graph)1 Median ARD = 9.3% Clark error grid A: 81.7% B: 16.7% C and D: 1.7% Dexcom 7-day (not shown): Median ARD = 17% A: 70% B: 28% C and D: 3% 1 R L Weinstein et al: Diabetes Care, 30, 1125-1130, 2007

CGM Tips Be patient, have realistic expectations Don’t panic when meter and sensor differ Expect some lag time Don’t react too quickly and stack your insulin Look at trends, not just individual values Rapid rises usually mean more insulin is needed Validate your readings with a meter

Check For Patterns Frequent highs Frequent lows High at B/L/D/Bed Low at B/L/D/Bed Low to high High to low Keep: TDDs similar from day to day Basals and boluses balanced Correction bolus below 8% of TDD

Sample Pattern

Paradigm RT Meal Breakout

CGMS Data Disaster What you or your physician have to deal with! Correlation coefficient, MAD%, avg. BG, pie charts, %Hi, %Low, 1-Hr and 3 Hr postprandial averages… What you or your physician have to deal with! Why not bottom line it?

Case Study – Type 1 on Pump A1c = 8.6% Overeating for bedtime lows or low basal Too little carb coverage Excess correction

Case Study – Bottom Line A1c = 8.6% Raise the correction factor for smaller correction boluses Check night basal after stopping bedtime lows Consider raising the TDD to lower A1c once lows are stopped

And demand that all you device companies “bottom line” your data. If your smart pump is not giving you great control, check your pump settings and infusion sets. And demand that all you device companies “bottom line” your data.

Control Tips Common control problems and what to do about them

Bad Infusion Set Or Site? If you have “unexplained” highs: How often do they happen? Do they correct only when you replace your infusion set? If you answer yes: Always use tape to anchor the infusion line Consider changing to a different infusion set The right infusion set and good site technique prevents headaches and improves your A1c

Always Tape The Tubing!!! Put 1” tape on the infusion line to stop Teflon tugs Stops movement of Teflon catheter under the skin Stops “unexplained highs” caused when insulin leaks back to surface Less skin irritation Prevents many pull outs Lose tape not insulin! No anchor!

Lose Tape Not Insulin!!! No tape on infusion line! Most insulin is lost when the Teflon comes loose, not from a complete pullout Photo courtesy of kerri@sixuntilme.com

High BGs? Keep Usual Suspects In Mind Bad infusion set or site Inaccurate carb counts Missed boluses Bad insulin Stress hormone rebound Empty refrigerator syndrome Stress, pain, steroid meds I ate too much

Pump Settings That Affect Control TDD – adjust when having frequent lows or highs Basal % – basal/bolus balance, secure sleep Basal rate variation – large variations are NOT physiologic Carb factor – postmeal control Carb factor variation – may indicate basal problem Correction factor – lower high BGs safely DIA – bolus accuracy, HypoManager

CDA1 Study Carb Factors From Cozmo CDA Study Note how actual carb factors are distributed in blue They are NOT bell-shaped!!! People prefer “magic” numbers – 7, 10, 15, and 20 (grs/unit) – for their carb factors A normal, bell-shaped, physiologic distribution is shown in green MANY “magic” carb factors are inaccurate 10 7 115 20

Carb Factors From CDA1 Sudy Graph shows carb factor versus TDD for 200 pumps with better control (avg BG < 209 mg/dl) Note break in relation (red line) near a TDD of 40 u/day or carb factor of 10 Suggests that people are hesitant to lower carb factors below 10

CDA1 Carb Rule #s Carb Rule #s 450-475 475-630 Avg. carb factors in blue boxes for pumps with better control (Avg BG 209 mg/dl or less). TDDs in the tan box to the left. Rule #s of 500-625 for higher TDDs may reflect hesitance to lower CF below 10. Your carb factor X your TDD = your carb factor rule #

CDA1 Basal/Bolus Balance As TDD rises, avg. basal percentage falls slightly from 51.7% at a TDD of 20 u to 49.4% at 40 u and 48.3% at 80 u Basals vary widely – 27% to 83% of TDD Many basal rates may not be accurate

Walsh-Roberts Rules For Optimal BGs Starting TDD = (TDD X 0.9) + (wt [lbs]/4* X 0.9) ** 2 Keep Basal/Bolus Balance near 50/50 Basal test – rise/fall less than 30 mg/dl (1.7 mmol) over 8 hrs Use 450 Rule for Carb Factor Use 2000 Rule for Correction Factor (110 Rule for mmol) Set DIA at 4 to 6 hrs Keep correction boluses less than 8% of TDD * or kg/1.8 ** If current TDD less than wt/4 with good control, TDD = current TDD X 0.90 Adapted from J Walsh and R Roberts: Pumping Insulin, 2006

Delay Eating When BG Is High Glucose exposure is reduced if eating is delayed when a reading is high. Remember: Test early Don’t forget to eat on time Don’t forget you bolused The A1c level rises higher the more we are exposed to glucose. Here, a pumper finds they have a BG of 300 mg/dl (16.7 mmol) before a meal. Should they eat right away? The “area under the curve” above reveals glucose exposure when a pumper eats right away in red, versus waiting until their glucose reaches 200 mg/dl in green, versus waiting until a smart timer alerts them that the blood glucose has reached 100 mg/dl (5.6 mmol) as shown in blue.

Duration Of Insulin Action (DIA) How long a bolus lowers your glucose Bolus On Board (BOB) Bolus insulin still active from previous boluses

Most Carbs Are Faster Than Insulin One hour after a meal, half a meal’s glucose rise is gone, but 80% of the “rapid” insulin’s activity remains Meal’s impact on BG Time over which a bolus lowers the BG Take Home: Bolus 15 to 30 minutes before meals Use extended boluses sparingly. From Pumping Insulin

DCA – Duration Of Carb Action Food Digestion Time water 0 m fruit/veg juice 5-20 m fruit/veg salad 20-40 m melons/oranges 30 m apples/pears 40 m broccoli/caulif 45 m raw carots/beets 50 m potatoes/yams 60 m cornmeal/oats 90 m Food Digestion Time fish 30-60 m milk/cot cheese 90 m legumes/beans 120 m egg 45 m chicken 1.5-2 hr seeds/nuts 2.5-3 hr beef/lamb 3-4 hr cheese 4-5 hr Take Home: Choose combo foods to lengthen carb digestion time

Best Bolus Timing For Carbs Figure shows rapid insulin injected 0, 30, or 60 min before a meal Normal glucose and insulin profiles shown in the shaded areas Best glucose profile when bolus given 60 min ahead But DO NOT bolus an hour ahead of your meals!!!

Accurate DIA Prevents Lows Accurate DIA Time Accurate BOB Accurate Boluses Accurate HypoManager Prevents Lows

Short DIAs Hide Bolus Insulin Activity A short DIA hides true BOB level and its glucose- lowering activity Leads to “unexplained” lows Leads to incorrect adjustments in basal rates, carb factors, and correction factors Or user starts to ignore “smart” pump’s advice Set DIA based on real insulin action time. Do NOT modify DIA time to fix control problems

Duration Of Insulin Action (DIA) Accurate boluses require an accurate DIA DIA times shorter than 4 to 7 hrs will hide BOB and its glucose lowering activity Glucose-lowering Activity 2 hrs 4 hrs 6 hrs

Apidra product handout, Rev. April 2004a More DIA Regular Large doses (0.3 u/kg = 15 u for 110 lb. person) of “rapid” insulin in 18 non-diabetic, obese people Med. doses (0.2 u/kg = 10 u for 110 lb. person) Apidra product handout, Rev. April 2004a

Does Dose Size Affect Duration Of Action? For a 154 lb or 70 kg person: 0.05 u/kg = 3.5 u 0.1 u/kg = 7 u 0.2 u/kg = 14 u 0.3 u/kg = 21 u Woodworth et al. Diabetes. 1993;42(Suppl. 1):54A

DIA May Be Underestimated In Studies To measure pharmacodynamics, glucose clamp studies are done in healthy individuals SQ doses = 0.05 to 0.3 u/kg Injected insulin dose ALSO SUPPRESSES normal basal release from the pancreas (grey area in figure) Unmeasured basal suppression makes smaller boluses appear to have a shorter DIA When basal suppression is accounted for, true DIA times become longer

How Long Do Boluses Lower Your BG? Novolog claims 3 to 5 hours 10, but numerous studies show rapid insulin lowers the glucose for 5 hours or more. With Novolog (aspart) at 0.2 u/kg (0.091 u/lb), 23% of glucose lowering activity remained after 4 hours.12 Another study found Novolog (0.2 u/kg) lowered the glucose for 5 hours and 43 min. +/- 1 hour.13 After 0.3 u/kg or 0.136 u/lb of Humalog (lispro), peak glucose- lowering activity was seen at 2.4 hours and 30% of activity remained after 4 hours. 11 10 Novolog product labeling information, October 21, 2005. 11 From Table 1 in Humalog Mix50/50 product information, PA 6872AMP, Eli Lilly and Company, issued January 15, 2007. 12 Mudaliar S, et al: Insulin aspart (B28 Asp-insulin): a fast-acting analog of human insulin. Diabetes Care 1999; 22:1501-1506. 13 L Heinemann, et al: Time-action profile of the insulin analogue B28Asp. Diabetic Med 1996;13:683-684.

My Recommended DIA Times Set DIA to 4 hrs to 6 hrs to calculate BOB and bolus doses accurately 4 hr Linear 4 hr Curvilinear From Pumping Insulin, 4th ed., adapted fom Mudaliar et al: Diabetes Care, 22: 1501, 1999

Don’t shorten DIA for temporary factors DIA Time Selection Current research suggests that DIA times are NOT different between children and adults Temporary factors can shorten insulin action time: Activity and exercise Hot weather Don’t shorten DIA for temporary factors

DIA Tips DIA times NOT different between children and adults If your pump does not “give enough bolus insulin”, do NOT shorten the DIA to get larger boluses Look for the real reason: a basal rate too low or carb factor too high Low basal rates and insufficient carb boluses make the DIA appear SHORT!

Bolus On Board (BOB) Glucose-lowering activity that remains from recent boluses An accurate BOB Prevents insulin stacking Improves bolus accuracy Reveals current carb or insulin deficit Basal insulin is NOT measured by BOB! aka: insulin on board, active insulin, unused insulin* * Introduced as Unused Insulin in 1st ed of Pumping Insulin (1989)

BOB Prevents Insulin Stacking Bedtime BG = 173 Is there an insulin or a carb deficit? Bedtime BG = 173 mg/dl Correction Dessert Bolus insulin stacking becomes a problem because boluses are so easy to give. After a bolus for dinner, one for dessert, another for the high blood sugar two hours after dinner, how much active insulin remains at bedtime? Dinner 6 pm 8 pm 10 pm 12 am

BOB Is Present In 65% Of Boluses CDA1 Study Results Of 201,538 boluses, 64.8% were given within 4.5 hrs of a previous bolus An accurate DIA shows that BOB is present for MOST boluses 4.5 hrs Take Home: insulin stacking is a common threat

BOB is measured only when a BG is entered into pump! BOB Is BOB If BOB is present, it doesn’t matter how it got there. Safety requires that BOB be subtracted from BOTH carb and correction boluses to avoid hypoglycemia. BOB is measured only when a BG is entered into pump!

How Different Pumps Handle BOB What’s In the BOB & What Is It Applied Against? BOB Includes This Type Of Bolus BOB Is Subtracted From This Type Of Bolus Carb Correction Animas 2020 Yes No* Deltec Cozmo Insulet Omnipod No Medtronic Paradigm * Except when BG is below target BG

Different Pump Bolus Recommendations BOB = 3.0 u and 30 gr. of carb will be eaten at these glucose levels Carb factor = 1u / 10 gr Corr. Factor = 1 u / 40 mg/dl over 100 Target BG = 100 TDD = ~50 u Bolus recommended by each pump when: units mg/dl Omnipod cannot be determined here - it counts only correction bolus insulin as BOB

A way to safely speed up insulin’s action. Rob Peter to pay Paul The Super Bolus A way to safely speed up insulin’s action. Rob Peter to pay Paul

Temp Basal Reduction For Excess BOB Here a temporary basal reduction is used to compensate for excess BOB at bedtime. This allows the person to go to bed without needing to eat. This is a simple example of how some of today’s pumpers deal with excess Bolus on Board at bedtime. This person has a 2 unit excess of bolus insulin even though their bedtime reading is slightly high at 150 mg/dl (8.3 mmol). To compensate, they use a temporary insulin reduction to remove 2 units from their basal delivery. This eliminates the need for a bedtime snack if the basal has been correctly set. This could be done automatically by today’s pumps. An intelligent device could provide precise estimates about when a basal reduction would work. For instance, in a situation where the BG is 90 mg/dl (5 mmol), but the amount of BOB suggests that the BG will drop too far before a reduction in basal delivery could begin to offset this drop, an intelligent device would not offer a basal reduction as an option for treatment and instead suggest how many carbs will be required to counter the BOB.

Super Bolus For A High GI Meal Super Boluses are useful when eating more than 30 or 40 grams of carb, especially for high GI meals like cereal. The Super Bolus borrows basal to pay bolus. By stacking insulin at the time of a bolus, more insulin becomes available sooner. The corresponding reduction in basal delivery prevents hypoglycemia. A Super Bolus shifts part of the next 2 to 4 hrs of basal insulin into an immediate bolus. This speeds up the action of the insulin for a high GI or a large carb meal with less risk of a low later. Future Pump Feature

Super Bolus For A Postmeal High Shift Basal To Bolus Use of a Super Bolus to lower high blood sugars increases the velocity to goal and reduces glucose exposure greatly. Enables a faster correction of highs with less risk of a low. Future Pump Feature

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