1. Current And Emerging Technologies In Insulin Pumps & Continuous Monitors
Phoenix, AZ
June 18, 2008
John Walsh, PA, CDE
(619)
Advanced Metabolic Care + Research
700 West El Norte Pkwy
Escondido, CA 92126
(760)

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

3. 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

4. Pump Features

5. 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.

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

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

14. 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

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

16. 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

17. Getting The Big Picture Therapy Effectiveness – Glucose and insulin history

18. Stable and relatively normal glucoses
Your Goal
Stable and relatively normal glucoses

19. 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

20. Therapy Scorecard Screen 1
Monitor control, testing frequency, glucose variability
14 Day Average:
BG mg/dl Tests /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 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.

21. Therapy Scorecard Screen 2
Monitors carb intake, TDD, basal/carb bolus balance, correction bolus%
14 Day Average:
Carbs g TDD u Meal % Corr % Basal %
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 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.

22. 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

23. Example: Correction Boluses Over 8%
10 Day Average:
Carbs g TDD u Meal 36% Corr % 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 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 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

24. 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

25. 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

26. The Long – Glucose Trends And History
Is your A1c between 6% and 7%?
Is your meter average below 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

27. 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

28. 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

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

30. 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.

31. Continuous Monitors

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

33. 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!

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

35. 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

36. 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

37. 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

38. 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

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

40. Turnaround Time A Glucose in Motion Stays in Motion

41. Don’t Stack Insulin

42. 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

43. 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!

44. 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

45. 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, , 2007

46. 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

47. 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

48. Sample Pattern

49. Paradigm RT Meal Breakout

50. 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?

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

52. 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

53. 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.

54. Control Tips Common control problems and what to do about them

55. 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

56. 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!

57. 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

58. 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

59. 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

60. 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

61. 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

62. 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 for higher TDDs may reflect hesitance to lower CF below 10.
Your carb factor X your TDD = your carb factor rule #

63. 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

64. Walsh-Roberts Rules For Optimal BGs
Starting TDD = (TDD X 0.9) + (wt [lbs]/4* X 0.9) **
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

65. 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.

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

67. 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

68. DCA – Duration Of Carb Action
Food Digestion Time
water m
fruit/veg juice m
fruit/veg salad m
melons/oranges m
apples/pears m
broccoli/caulif m
raw carots/beets m
potatoes/yams m
cornmeal/oats m
Food Digestion Time
fish m
milk/cot cheese m
legumes/beans 120 m
egg m
chicken hr
seeds/nuts hr
beef/lamb hr
cheese hr
Take Home: Choose combo foods to lengthen carb digestion time

69. 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!!!

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

71. 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

72. 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

73. 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

74. 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

75. 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

76. 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 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:
13 L Heinemann, et al: Time-action profile of the insulin analogue B28Asp. Diabetic Med 1996;13:

77. 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

78. 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

79. 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!

80. 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)

81. 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

82. 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

83. 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!

84. 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

85. 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 / 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

86. 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

87. 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.

88. 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

89. 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

90. Answers To Your Questions
Available at or