Late and Missed Meal Boluses with Multiple Daily Insulin Injections
Abstract
Background: Using sensor augmented pump data, late or missed meal boluses have shown a strong correlation with higher A1c levels, particularly in adolescents. With the Type Zero InControl Phone connected to a Dexcom G5 sensor and Novo insulin pens with memory and connectivity it is now possible to evaluate for late and missed meal boluses in MDI users. Methods: For this study 326 days of CGM data were evaluated from 24 subjects (mean age 33, range 15-59 years). Seven days of data were analyzed on starting the system and 7 days 1 month later. Overall 1,173 meals were evaluated. Meals were determined by either the subject manually recording the meal, or if the CGM was >70 mg/dl and there was a >70 mg/dl rise within 2 hours. A late meal bolus was defined when the CGM increased >50 mg/dl from baseline prior to an insulin dose. A missed meal bolus was defined by no insulin dose within 2 hours from the start of the CGM rise. Results: 27% (range 8 to 55%) of meals had either a late or missed meal boluses: 13% (range 2-30%) were late and 14% (range 2 to 38%) were missed. There was no correlation with age or gender. There was a positive correlation with the percentage of missed meal boluses and A1c levels (p=0.019), but no correlation with the percentage of late meal boluses and A1c levels. There were no significant differences in missed or late meal boluses when comparing the first week of use to using the system one month later. Conclusion: The rate of late or missed meal boluses is high for both adults and adolescents using MDI therapy, and missed meal boluses correlated with higher A1c levels. Having this information may provide significant insight to patients and help clinicians provide advice to MDI patients. Disclosure: L.M. Norlander: None. S. Anderson: Research Support; Self; Medtronic. Consultant; Self; Senseonics. C.J. Levy: Advisory Panel; Self; Medtronic MiniMed, Inc.. Research Support; Self; Lexicon Pharmaceuticals, Inc., Dexcom, Inc.. L. Ekhlaspour: None. D.W. Lam: None. L. Hsu: None. S.E. Loebner: None. S.J. Ogyaadu: None. G. O'Malley: None. C.M. Levister: None. M.D. Breton: Stock/Shareholder; Self; TypeZero Technologies, Inc.. Speaker's Bureau; Self; Ascensia Diabetes Care. Consultant; Self; Sanofi. Speaker's Bureau; Self; Roche Diabetes Care Health and Digital Solutions. Research Support; Self; Dexcom, Inc., Ascensia Diabetes Care, Senseonics. B. Buckingham: Advisory Panel; Self; Novo Nordisk Inc., ConvaTec Inc.. Research Support; Self; Medtronic, Insulet Corporation, Dexcom, Inc., Tandem Diabetes Care, Inc.. Consultant; Self; Tandem Diabetes Care, Inc., Becton, Dickinson and Company.
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Research from individuals using multiple daily injection therapy with continuous glucose monitoring and connected insulin pen or cap devices revealed that missed, mistimed, and mismatched insulin bolus doses are common and occur in both older and younger populations with T1D or T2D, and are associated with higher A1C.
“Research from individuals using MDI therapy with CGM and connected insulin pen or cap devices revealed that missed, mistimed, and mismatched insulin bolus doses are common and occur in both older and younger populations with T1D or T2D, and are associated with higher A1C.13–18”
From Shining the Spotlight on Multiple Daily Insulin Therapy: Real-World Evidence of the InPen Smart Insulin Pen (2024) · cites this paper as [15]
Missed bolus insulin doses correlate with higher HbA1c levels in patients with T1D.
“This is consistent with other studies of patients with T1D that have demonstrated that missed bolus insulin doses correlate with higher HbA1c levels.24,25”
From Smart Pen Exposes Missed Basal Insulin Injections and Reveals the Impact on Glycemic Control in Adults With Type 1 Diabetes (2024) · cites this paper as [24]
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“This method aligns with previous studies where the GRID algorithm (6,10,20) or similar methods (26,27) were used.”
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- Authors
- NORLANDER, L. M., ANDERSON, S., LEVY, C. J., EKHLASPOUR, L., LAM, D. W., HSU, L., LOEBNER, S. E., OGYAADU, S. J., O'MALLEY, G., LEVISTER, C. M., BRETON, M. D., & BUCKINGHAM, B.
- Affiliations
- Stanford University (US)
- Palo Alto, CA, Charlottesville, VA, New York, NY, Stanford, CA
- Venue
- Diabetes
- Publisher
- American Diabetes Association
- Published
- 2018-07-01
- Volume
- 67
- Issue
- Supplement_1
- ISSN
- 0012-1797 (ISSN-L)
- 1939-327X
- OpenAlex
- W2808833989
- Cited by
- 19
- References
- 0
- Citations by year
- 2026: 1 · 2025: 3 · 2024: 2 · 2023: 2 · 2022: 4 · 2021: 4 · 2020: 3
- FWCI
- 1.40
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Diabetes (publishedVersion)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Keywords
- multiple daily insulin injections, continuous glucose monitoring, glycemic control, HbA1c, insulin dose, adolescents, adults, diabetes management, glycemic variability, hypoglycemia
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