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Calculating Insulin

How To Calculate Insulin Dosing For Type 1 Diabetes (including Protein And Fibre)

How To Calculate Insulin Dosing For Type 1 Diabetes (including Protein And Fibre)

This article reviews a range of approaches to calculating insulin requirements for people with type 1 diabetes. The simplest approach is standard carbohydrate counting, which may be ideal for someone whose diet is dominated by carbohydrates. Bernstein recommends standardised meals for which the insulin dose is refined based on ongoing testing and refinement. Stephen Ponder’s ‘sugar surfing’ builds on carbohydrate counting, with correcting insulin given when blood glucose levels rise above a threshold due to gluconeogenesis. The food insulin index approach predicts insulin requirements based testing in healthy people of the insulin response to popular foods. The total available glucose (TAG) advocates a ‘dual wave bolus’ where insulin for the carbohydrates is given with the meal, with a second square wave bolus given for the protein which is typically slower to digest and metabolise. In the article Standing on the Shoulders of Giants, we met a handful of people who have achieved excellent blood sugar control in spite of having type 1 diabetes. Common elements of their success include: keeping carbohydrates low to prevent the blood sugar roller coaster, accurately dosing for a controlled amount of dietary carbohydrate, targeting normal blood sugar ranges (i.e. 83mg/dL or 4.6mmol/L) with regular correcting doses, regular exercise and / or intermittent fasting to improve insulin sensitivity, and having a reliable method to account for the insulinogenic effect of protein. Everyone’s diabetes management regimen is going to be different. There will be a degree of trial and error to find what will work best for you. This article reviews a number of approaches that you can learn from to see what suits you. In the 1970s Dr Richard Bernstein got hold of a blood glucose Continue reading >>

Insulin Dosing Worksheet €” Correction Formula Insulin To Carbohydrate Ratio

Insulin Dosing Worksheet €” Correction Formula Insulin To Carbohydrate Ratio

Calculate insulin dose to correct a high blood sugar • If pre-meal blood sugar is high, take the blood sugar reading and subtract target blood sugar. • Divide what remains by the correction factor. • The result is the amount of insulin needed to correct high blood sugar. (blood sugar – target) ÷ correction factor = units of insulin needed 1 unit : _________ grams carbohydrate Correction formula (Blood sugar – target blood sugar) ÷ correction factor Target blood sugar ________ Correction factor ____________ Calculate insulin dose for food • Add up all the carbohydrates in your meal. • Divide the total carbohydrates by the insulin to carbohydrate ratio. • The result is the amount of insulin units needed. Total carbs ÷ insulin to carb ratio = units of insulin needed Visit choa.org/diabetes for additional copies. ©2017 Children’s Healthcare of Atlanta Inc. All rights reserved. MED 966873.rb.02/17 Time Correction insulinInsulin for food Total insulin (units) Meal Breakfast Morning snack Afternoon snack Lunch Dinner Bedtime Time Food + correction insulin (units) BS*: - _________ - _________ - _________ - _________ *BS required BS*: *BS required BS*: *BS required BS*: *BS required Blood sugar (BS) level Correction formula (BS-target/ correction factor) Correction insulin calculated (units) Total carbohydrates (g) Food formula (carb count/ carb ratio) Food insulin calculated (units) -------- -------- -------- -------- -------- -------- Daily plan: Calculate total insulin dose • Add the number of units needed for food to the number of units needed to correct blood sugar to get your total dose of insulin (Humalog/Novolog/Apidra). Food insulin + correction insulin = total insulin 1. Wash and dry hands thoro Continue reading >>

Weight-based Insulin Dosing Safe At Recommended Doses

Weight-based Insulin Dosing Safe At Recommended Doses

Weight-based insulin doses up to 0.6 units per kilogram are associated with a low risk of hypoglycemia, according to a new report…. Dr. Daniel J. Rubin from Temple University School of Medicine in Philadelphia writes that, "Our study provides evidence for the safety of daily insulin doses up to 0.6 units/kg." "I hope this will encourage more physicians to be comfortable using weight-based insulin dosing." Dr. Rubin and colleagues investigated the relationship between insulin dose and hypoglycemia in a retrospective, case-control study of 1,990 diabetic patients admitted to hospital wards. The report appears online June 23 in Diabetes Care. The unadjusted odds of hypoglycemia increased with insulin doses above 0.2 units/kg, and patients who received insulin doses of 0.6 units/kg or more faced increased odds of hypoglycemia. The adjusted odds of hypoglycemia were not higher among patients who received 0.2 to 0.6 units/kg. The adjusted odds of hypoglycemia were 3 times higher among patients who didn’t receive sliding scale insulin than among those who did, and there was a trend toward higher odds among patients who received NPH compared with patients who received glargine or short-acting insulin. Hypoglycemia was not more common among patients given insulin with an oral diabetes medication than among those given insulin alone. "0.6 units/kg seems to be a threshold below which the odds of hypoglycemia are relatively low," the researchers note. "Some patients, however, require more than 0.6 units/kg to treat hyperglycemia and do not experience any hypoglycemia," Dr. Rubin said. "If there is any concern for hypoglycemia, it is reasonable to use doses <0.6 unit/kg. Insulin dosing for individual patients must be done on a case-by-case basis." "Our data are consistent with t Continue reading >>

Insulin Dose Calculation Definitions Ï‚§carbohydrate Ratio

Insulin Dose Calculation Definitions Ï‚§carbohydrate Ratio

Information Needed to Get Started How many grams of carbs the child is eating Blood glucose (BG) taken before eating Important numbers from primary caregiver: – Carbohydrate Ratio – Correction Target – Correction Factor How many grams of carbohydrates will be covered by one unit of insulin Correction Target Target blood glucose value used for insulin dose calculations when the blood glucose is high Correction Factor How many points (mg/dL) one unit of insulin will lower the blood glucose over several hours Bolus Insulin Calculation Worksheet Insulin for carbs Insulin for high blood glucose Add insulin for carbs to insulin for high blood glucose Bolus Insulin Calculation Worksheet Place the example numbers on the worksheet. Carbohydrate Ratio: 15 Correction Target: 120 Correction Factor: 30 15 30120 Bolus Insulin Calculation Worksheet Place the example numbers on the worksheet. Carbohydrate Ratio: 15 Correction Target: 120 Correction Factor: 30 15 30120 Bolus Insulin Calculation Worksheet Place total carbs and blood glucose on the worksheet. Carb Grams: 68 Blood Glucose: 214 15 30120 68 214 Bolus Insulin Calculation Worksheet Calculate carb bolus: 68 ÷ 15 = 4.533 Round answer to nearest tenths 15 30120 68 214 For example: 4.533 rounds to 4.5 4.555 rounds to 4.6 Bolus Insulin Calculation Worksheet Calculate Correction Bolus: 214–120 = 94 ÷ 30 = 3.133 Round answer to nearest tenths 15 30120 68 214 4.5 94 3.1 For example: 3.133 rounds to 3.1 3.155 rounds to 3.2 Bolus Insulin Calculation Worksheet Add the carb bolus to the correction bolus: 4.5 + 3.1 = 7.6 15 30120 68 214 4.5 94 3.1 4.5 3.1 7.6 Bolus Insulin Calculation Worksheet The final Rounded Total Insulin Bolus depends if the child uses half units or Continue reading >>

New Apps Calculate Your Insulin Doses

New Apps Calculate Your Insulin Doses

Trying to calculate your insulin doses for injections, without the help of an insulin pump "wizard"? There's an app for that! (of course) First came basic insulin dose calculators like RapidCalc. But providing more personalized recommendations in a so-called "insulin titration app" was something of a challenge, because these provide real medical treatment decision support and therefore require FDA approval -- as opposed to so many diabetes logging apps that do not. The first regulatory breakthrough for a "mobile prescription therapy aid" that analyzes users' past data trends to deliver personalized recommendations came with WellDoc's BlueStar app in 2013. That was followed in 2015 by the Accu-Chek Connect app, that also calculates and recommends insulin amounts. WellDoc just recently snagged an expanded label for its BlueStar app that allows patients to use it without a doctor's prescription -- adding to the accessibility of this mobile tech tool. The FDA's decision last year to allow a dosing claim for the Dexcom G5 CGM system seems to have helped pave the way for even more smartphone-based decision therapy tools. And now, two new apps have snagged FDA clearance and are almost ready for prime time: Lilly's Go Dose In December, Eli Lilly got FDA clearance on its new mobile app called Go Dose, which can be used for the Lilly-branded Humalog insulin to titrate doses. This is the company's first class II ("moderate-risk") mobile app approved by the FDA. This one is designed for adults with type 2 diabetes, and is focused on meal-time insulin use for Humalog U-100 only. There is a Go Dose version for patients to use at home, and the Go Dose Pro clinical version for use by healthcare professionals. As of now, it's only compatible with iOS devices (iPads and iPhones), but hop Continue reading >>

Potential Formula For The Calculation Of Starting And Incremental Insulin Glargine Doses: Aloha Subanalysis

Potential Formula For The Calculation Of Starting And Incremental Insulin Glargine Doses: Aloha Subanalysis

Abstract Pragmatic methods for dose optimization are required for the successful basal management in daily clinical practice. To derive a useful formula for calculating recommended glargine doses, we analyzed data from the Add-on Lantus® to Oral Hypoglycemic Agents (ALOHA) study, a 24-week observation of Japanese type 2 diabetes patients. Methodology/Principal Findings The patients who initiated insulin glargine in basal-supported oral therapy (BOT) regimen (n = 3506) were analyzed. The correlations between average changes in glargine dose and HbA1c were calculated, and its regression formula was estimated from grouped data categorized by baseline HbA1c levels. Starting doses of the background-subgroup achieving the HbA1c target with a last-observed dose above the average were compared to an assumed optimal starting dose of 0.15 U/kg/day. The difference in regression lines between background-subgroups was examined. A formula for determining the optimal starting and titration doses was thereby derived. The correlation coefficient between changes in dose and HbA1c was −0.9043. The estimated regression line formula was −0.964 × change in HbA1c+2.000. A starting dose of 0.15 U/kg/day was applicable to all background-subgroups except for patients with retinopathy (0.120 U/kg/day) and/or with eGFR<60 mL/min/1.73 m2 (0.114 U/kg/day). Additionally, women (0.135 U/kg/day) and patients with sulfonylureas (0.132 U/kg/day) received a slightly decreased starting dose. We suggest a simplified and pragmatic dose calculation formula for type 2 diabetes patients starting glargine BOT optimal daily dose at 24 weeks = starting dose (0.15×weight) + incremental dose (baseline HbA1c − target HbA1c+2). This formula should be further validated using other samples in a prospective foll Continue reading >>

Sanofi Gets Fda Clearance For Insulin Dose Calculator App

Sanofi Gets Fda Clearance For Insulin Dose Calculator App

Following in the footsteps of Eli Lilly and Roche, Sanofi has quietly received FDA clearance for a smartphone app with a built-in insulin dose calculator. According to FDA documents, the app, cleared at the end of March, is called My Dose Coach. A pending trademark application gives a more in-depth description of the app, describing it as "downloadable software in the nature of a mobile application for use by patients with diabetes, for calculating and monitoring insulin dosages". The trademark application also suggests the app will contain some kind of database of diabetes information. We've reached out to Sanofi for comment and will update this story if they reply. While there are a number of insulin dosage calculator apps available, not many are FDA-cleared despite clear guidance from the FDA that insulin dosage apps require premarket approval. A 2015 study found 46 such apps on iOS and Android stores and reported that "none of the apps included in this study appear to have completed registration, labeling, or other general controls which are the minimal requirements for products in both regimes". A few pharma companies have bucked the trend recently though. Eli Lilly recieved FDA 510K clearance in January for a new mobile app called Go Dose, a diabetes management and insulin dosing app for users of Humalog, Lilly's rapid-acting insulin. The clearance is for prescription use, but includes two versions of the app: Go Dose, for patients, and Go Dose Pro, for healthcare providers. Diabetes management app mySugr offers a bolus calculator to European customers but hasn't introduced it to the US because of the regulatory burden. And Eli Lilly's choice of predicate devices in its January clearance -- desktop and Palm Pilot software -- further suggest very few if any FDA cle Continue reading >>

Insulin Sensitivity Factor

Insulin Sensitivity Factor

The drop in blood glucose level, measured in milligrams per deciliter (mg/dl), caused by each unit of insulin taken. Knowing their insulin sensitivity factor can help people with Type 1 diabetes to determine the dose of short-acting or rapid-acting insulin to take. Health-care professionals use the “1500 rule” to calculate insulin sensitivity factor for people who use Regular (short-acting) insulin. The 1500 rule works as follows: Divide 1500 by the total daily dose of Regular insulin, in units. For example, if a person’s total daily dose is 30 units of Regular insulin, his insulin sensitivity factor would be 50 (1500 ÷ 30). So one unit of Regular insulin would be estimated to lower his blood glucose by 50 mg/dl. Health-care professionals use the “1800 rule” to calculate insulin sensitivity factor for people who use the rapid-acting insulin analogs lispro (brand name Humalog), aspart (NovoLog), and glulisine (Apidra). This is done by dividing 1800 by the total daily dose of rapid-acting insulin. If the total daily insulin dose is 40 units, the insulin sensitivity factor would be 1800 divided by 40, or 45. Insulin sensitivity factor can be calculated only for people with Type 1 diabetes. It cannot be calculated reliably for people with Type 2 diabetes, whose pancreases often still make some insulin and who have varying degrees of insulin resistance. Continue reading >>

Guidelines For Temporary Removal Of The Insulin Pump

Guidelines For Temporary Removal Of The Insulin Pump

correction factor (insulin sensitivity factor) is 4.0 the basal rate is 0.60 units/hr until noon correction bolus: 14.8 – 6.0/4.0 = 2.2 units Total dose: 2.4 + 2.7 + 2.2 = 7.3 units, rounded off to 7.0 2- Long term off pump (24 hrs or more): There are 3 options Give long-acting insulin (Lantus or Levemir) as basal, and rapid insulin for boluses Give intermediate-acting insulin (NPH or N) ** call the doctor on-call for this dose Give rapid-acting insulin every 4 hours including overnight, as per the “short term” example Calculate the total daily basal amount of insulin and give as a single dose of Lantus or Levemir. It can be given as soon as convenient. Then continue every 24 hours thereafter. These insulins cannot be mixed with other insulins in a syringe Take rapid insulin for meal, snack and correction boluses The carb ratio’s and correction factors remain the same as for the pump Children who are too young to give their own insulin may need to have a parent go to school to give the lunchtime dose. The basal rate is 0.50 units from midnight to 6:00 a.m., and 0.40 units for the rest of the day until midnight. The total basal is 10.2 units. The dose of Lantus or Levemir will be rounded off to 10.0 units, given once every 24 hours until the insulin pump is resumed. Since Lantus and Levemir are basal insulins, you cannot have a basal rate running when you restart the pump or severe hypoglycemia may result! Restart your basal approximately 18 hours after the last Levemir dose; 22 hours after the last Lantus dose.    If you want to re-start the pump earlier, set the basal rate at 0.00 units/hr until all the Lantus or Levemir has worn off. Extra blood sugar checks will be needed to see how your adjustments are working, especially after the first inj Continue reading >>

The Bolus On Board (bob Or Unused Insulin)

The Bolus On Board (bob Or Unused Insulin)

Visit our BOB on a Pump page for more info about managing your BOB while on an insulin pump. A great advantage of frequent injections and insulin pumps is the convenience of giving additional insulin any time a need arises. A bolus can be given for dinner then again more for an unplanned dessert and more for the high blood sugar that follows. However, when boluses begin to overlap, a problem surfaces. How much insulin is still working from these recent injections or boluses? Humalog and Novolog continue to lower the blood sugar for four to five hours after they are given. Only by allowing for the long action time of rapid insulins can bolus stacking and hypoglycemia be avoided. Determining BOB is especially important at bedtime. When several doses of rapid insulin are given during the evening hours, the bedtime blood sugar has to be interpreted in light of how much insulin is still left to work. A normal blood sugar at bedtime may be dangerous if a large residual insulin dose has yet to work. Likewise, a high reading at bedtime may require no additional bolus if sufficient BOB remains to take care of it. Newer smart pumps have a Bolus On Board feature that can help solve this problem. Enter your blood sugar and the correction bolus you want to take. The pump will tell you how much unused or residual insulin you have left to act and will recommend an appropriate bolus that will not cause a low. What Is Bolus on Board? The Bolus on Board (also referred to as Insulin on Board or Active Insulin) tells how many units of rapid insulin are still working. This helps in deciding whether more insulin or more carbohydrate is needed. Never assume you need more insulin simply because your blood sugar is high at the moment. Always determine how much bolus is on board before taking mo Continue reading >>

Calculation Of The Initial Insulin Dosage

Calculation Of The Initial Insulin Dosage

The dose of Caninsulin and the interval between injections has to be tailored to suit each individual diabetic dog. Hypoglycemia Hypoglycemia is a major concern. To help avoid hypoglycemia: The dog's body weight should be rounded down to the nearest whole kilogram The calculated dose of insulin rounded down to the nearest whole or half unit This helps to avoid overdosing particularly during initial stabilization. Starting insulin dose for dogs In diabetic dogs the dose of Caninsulin can be given once daily or twice daily. After calculation of the starting insulin dose, subsequent adjustments to establish the maintenance dose may be required. For more information see product leaflet or dose adjustment. Once daily administration The once daily Caninsulin starting dose of 0.5 IU/kg (label may vary - for guidance see the product leaflet) was established and confirmed in dogs, based primarily on clinical response. Remember to round the dog’s bodyweight down to the nearest whole kilogram and the calculated dose down to the nearest whole or half unit. Twice daily administration Many specialists recommend that intermediate acting insulins be administered twice daily to dogs. Starting dose in the range of: 0.4-0.7 IU/kg twice daily is usually used, with larger bodyweight dogs started at the lower end of the range. (Ref: Broussard JD, Wallace, MS. Insulin treatment of diabetes mellitus in the dog and cat. In Kirk's Current Veterinary Therapy XII Small Animal Practice. Bonagura J ed. Saunders, Philadelphia, 1995. p. 393-8.) 0.25-0.5 IU/kg twice daily (Ref: Fleeman LM, Rand JS. (2001) Management of canine diabetes. Veterinary Clinics of North America: Small Animal Practice 31, 855-80.) The starting insulin dose range is thus taken as: 0.25-0.7 IU/kg twice daily - larger bodyweigh Continue reading >>

Calculating For Smooth-sailing With Insulin

Calculating For Smooth-sailing With Insulin

T1 sailor Erin Spineto shares the longform math she does to get through a day on the water without a low. In her book Islands and Insulin: A Diabetic Sailor’s Memoir, T1 author Erin Spineto chronicles her quest to sail solo around the Florida Keys and lose her fear of her diabetes. This excerpt from that memoir takes place as she is training for the journey: 24 November 2009 Seal Beach, CA If you have ever had the unusual pleasure of spending time with a diabetic, you might have noticed a moment when they look off to the left and appear absorbed by thoughts somehow not entirely related to the current conversation. If you wondered what was running around in their head, here is a glimpse into the things they think about on an almost constant basis: I am heading out to Catalina Island today for my shakedown cruise with Frank and three of his other students. It will be my opportunity to prepare more for my Florida trip. At 05:30 my blood sugar is elevated to 241. My formula for correcting this is to use 1 unit of Apidra insulin for every 50 mg/dl that my blood sugar is above 100. So 240 minus 100=140. Divide that by 50 and you get 2.8 units. I push the insulin and continue calculating. I have been battling bronchitis for 5 days. The extra bacteria will send my sugars higher than usual. I haven’t worked out in 5 days, so my body will not be as sensitive to the insulin until I get in 2 to 3 good workouts. Driving in the morning will also send my blood sugars higher because I will be inactive at a time that is hardest for me to control my blood sugars. All of this means higher insulin needs. My basal rate needs to be raised. It’s programmed into the insulin pump with different rates for different time periods during the day. It has a program that will increase or decreas Continue reading >>

How To Interpret Blood Glucose Monitoring Charts And Adjust Insulin Doses

How To Interpret Blood Glucose Monitoring Charts And Adjust Insulin Doses

Interpreting blood glucose results and being able to adjust insulin doses are useful skills for pharmacists to possess.The key to acquiring these skills is in understanding: The insulin regimen and the onset, peak and duration of action for the insulins used The glucose levels to aim for How to titrate insulin doses How all of the above relates to patients’ lifestyles and eating habits Understanding the regimen Insulin may be given alone or, for those with type 2 diabetes, with oral antidiabetic drugs (OADs), often metformin. Although this article focuses on adjusting insulin doses, readers should bear in mind that oral doses may also need to be adjusted. The three most commonly used insulin regimens are: Once daily intermediate-acting or long-acting insulin — normally given at bedtime or during the day, usually with an OAD Twice-daily pre-mixed insulin — one injection before breakfast, one before the evening meal (pre-mixed insulins contain fixed ratios of short- and long-acting insulins) Basal-bolus insulin — three daily injections of rapid- or short-acting insulin with meals and one or two injections of intermediate- or long-acting (basal) insulin The onset, peak and duration profiles of insulin products currentlyavailable in the UK are in the table. These should be used wheninterpreting a blood glucose result, to determine which insulin wasexerting its effect at the time of glucose measurement. Insulin preparations and their onset, peak and duration of action Preparation Onset (hr) Peak (hr) Duration (hr) Soluble insulin Human Actrapid 0.5 2–5 8 Humulin S 0.5 1–3 5–7 Hypurin Bovine Neutral 0.5/1 2–5 6–8 Apidra (Insulin glulisine) 0.25 1 3–4 Humalog (Insulin lispro) 0.25 1–1.5 2–5 Novorapid (Insulin aspart) 0.25 1–3 3–5 Hypurin Porcine Neu Continue reading >>

Transitioning Safely From Intravenous To Subcutaneous Insulin

Transitioning Safely From Intravenous To Subcutaneous Insulin

Current Diabetes Reports Authors Kathryn Evans Kreider, Lillian F. Lien Abstract The transition from intravenous (IV) to subcutaneous (SQ) insulin in the hospitalized patient with diabetes or hyperglycemia is a key step in patient care. This review article suggests a stepwise approach to the transition in order to promote safety and euglycemia. Important components of the transition include evaluating the patient and clinical situation for appropriateness, recognizing factors that influence a safe transition, calculation of proper SQ insulin doses, and deciding the appropriate type of SQ insulin. This article addresses other clinical situations including the management of patients previously on insulin pumps and recommendations for patients requiring glucocorticoids and enteral tube feedings. The use of institutional and computerized protocols is discussed. Further research is needed regarding the transition management of subgroups of patients such as those with type 1 diabetes and end-stage renal disease. Introduction Intravenous (IV) insulin is used in the hospitalized patient to control blood sugars for patients with and without diabetes who may exhibit uncontrolled hyperglycemia or for those who need close glycemic attention. Common hospital uses for IV insulin include the perioperative setting, during the use of high-risk medications (such as corticosteroids), or during crises such as diabetic ketoacidosis (DKA) [1,2]. Other conditions such as hyperglycemic hyperosmolar state (HHS) and trauma frequently require IV insulin, as well as specific hospital units such as the cardiothoracic intensive care unit [3,4]. The correlation between hyperglycemia and poor inpatient outcomes has been well described in the literature [5,6]. The treatment of hyperglycemia using an IV Continue reading >>

Calculating Insulin For Fats And Protein.

Calculating Insulin For Fats And Protein.

Diabetes Forum The Global Diabetes Community This site uses cookies. By continuing to use this site, you are agreeing to our use of cookies. Learn More. Get the Diabetes Forum App for your phone - available on iOS and Android . Find support, ask questions and share your experiences. Join the community Calculating insulin for fats and protein. do you know website to learn how to calculate insulin dosage in the meals that contains only protein and fats ?? You may find some information and a spreadsheet if you search for TAG as this relates to calculation including total available glucose - including from protein and fats. I will see what I can find when I get a moment. Personally I bolus for 1/2 proteins. It is said roughly 58% protein turns to bs and roughly 10% fat. Timing on injecting insulin will matter too as protein is slow and fat slows it more. I find I have to inject either right before or during the meal or infill go low 1st before my food gets there. I try to eat just a few veg to fill in the gap. A very approximate starting point seems to be to bolus 50% of your carb ratio for protein, and 10% for fat (i.e. if you'd normally bolus 1 unit for 10g carbs, then you'd bolus 0.5 units per 10g protein and 0.1 units per 10g fat). However, this will vary from person to person and depending how carb heavy your diet is. If you eat a fairly high carb diet you may not have to worry too much about fats and proteins, but as I for example eat fairly low carb, I am more sensitive to protein. However, I don't personally have to worry about fats, they barely affect my sugars at all. Also I'd be careful with the timing of doses. If I'm only eating protein and fat, I'll work out the dose, and either bolus just after the meal or use an extended bolus on my pump to prevent a low an Continue reading >>

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