Can We Compare Pumping to MDI?

1

I was on a pump about 18 years ago and right now I am on MDI. I would like to start a discussion about how similar these two methods are, and also the differences between the two. Why do people choose one over the other, and what are the the advantages and disadvantages involved in each? What is your personal reason for chosing the method you have chosen?

I hope the MDI is the right term. I am terrible with acronyms--it took me awhile to figure out what a PWD was, and I have been one all this time and didn't know it!

Thanks. Lots

2

My friend I was on MDI for 38 years. Only recently did I decide to go on a pump. My job requires me change my schedule every day of the week. My schedule changed constantly. One day I would go into work at 2:00a.m., another would be at 6:00 a.m. then in the middle of the week I would go in at 1:00 p.m. and work until 10:00 p.m.

When I would discuss my diabetes routine with my CDE. She would ask, What time did I eat?, “What time did I take my Lantus? When did I go low, When did my BS go high? What happens when you are not at work and your energy levels are differant.” All she could do was look at me and my log book with total confusion. My diabetes was stuggling with this constant change every day.

Finally after reading every possible piece of info out there regarding an insulin pump I started in April. Wow, what a vast improvement in my Diabetes and my life with Diabetes. This is the best thing I have ever done. The insulin pump made sense to me and how insulin received and alter throughout the day. I have freedom. I don’t believe that I will every look back to MDI. Eventually I will look forward to learning about the CGMS. That is my next step to better control.

3

Lotofshots,

We were not at all successful with understanding/treating dawn phenomenon with MDI. Add teen growth and activity to the mix and it is amazing, truly amazing, that since starting the pump March break age 14 to now, (just turned 17) that David has achieved an A1c under 6.5. It has taken a lot of work. A lot of reading and researching beyond what one learns at that quick endo visit every three months and the first three months of pump therapy were so up and down and quirky that we were ready to throw in the towel.

We are not at the point yet where most nights we can anticipate zero change. But when we have a night start at 1:00 a.m. with a BG of 75 to find that the waking BG, 11:40 a.m. Sun (lazy kid) is also 75, we know that we are on the right track. We know that the basal settings could not be better… for now…

Cheryl

4

The problem with acronyms is that some of them have so many different meanings. I like to use http://www.acronymfinder.com/ to look up the meaning of acronyms, although sometimes there is so many different meanings it’s hard to pick the right one.

Multiple Daily Injections (MDI) is the term I have always used to describe my basal/bolus program.

I like both pump and MDI equally. I switch from one to the other without any adjustment period. When I lived in Hawaii I spent all my free time at the beach. I didn’t like to be on the pump at the beach. When I went to school I did like to be on the pump. So it was pump 5 days a week MDI on the weekends. During summer vacation I rarely went on the pump unless my father insisted. BTW - my father is a doctor and he has always been my doctor.

When I was on the pumps with the tubes, I hated it. I was very bashful about letting anyone see the pump or tubes. When the OmniPod first came out my father got one as a sample and I was his experimental guinea pig to try it out. I loved the fact that it had no tubes.

Eating out is a time when the pump shines over MDI. It’s much easier to just program in a bolus than use a pen or syringe. Another advantage of pump over MDI is the ability to set different basal programs for different times or activities.

5

MDI is the term (multiple daily injections) has many advantages.

PUMP
Pumping is far more expensive.

Pumping requires obscene “backup” supplies, if something needs to be changed out/goes wrong with yours (eg Skin prep wipes, tubing, tape, infusion sets, a large caliber syringe to prep the line, saline, large CC needle, an infusion set gun, extra batteries, etc.). MDI have none of those save wprst case a vial and syringe (insulin pens reduce that MDI worst case by half…)

Pumping has the risk of causing skin infection at the infusion sites a problem which does not exist with MDI

Taping down the infusion set causes meaningful irrition and tenderness

Mechanical delivery errors by a pump cause severe DKA
Mechanical delibery errors care nothing for textbook correct proceedure by their users, requiring a repetition of the extensive proceedure a second, or third time for no known reason.

Insusion sets for a pump require meaningful taping, skin prep in order to stay attached with many
Infusion sets require placement in body locations which will not get pulled, tugged, amd meaningfully irritated if too close to waistlines, or clothing, underwear of any kind

A PUMP being an external medical device will be caught on things, pulled off, moved and consequently cause the wearer problems, discomfort, pain, embarrassment.
A pump does not work well with heavy physical contact activities. It gets in the way or flys off.

A pump makes some extremely self conscious; where does it get put on a bathing suit, a formal dress, lingerie, etc.

One must love the beeps, meaningful alarms and noises a pump will cause.
Some pumps cannot get wet, requiring detachment from them to shower, bathe, swin

The pump requires severe tweaking, to achieve the “control” it is marketed and its PR they are assured to provide its users. There is NO GUARANTEE said control will ever occur.

There is a SEVERE financial incentive by doctors and CDE’s to get us on a pump. They get paid incentives, bonuses for connecting us to them. MDI does not have that incentive

A pump is never a magic wand which will make diabetic problems simply disapear. A pump requires insane hard work, and even more monitering to make them perform as promised,.

The identical problems which exist with MDI still exist with any pump/ There is nothing a pump removes if for no other reason you & I are still counting the carbs, figuring out when we will be eating, after our workout, how much bolus to use. Until a pump is entirely beyond our interference (ie closed loop) and I cannot interfere, make stupid mistakes, a pump provides nothing special.

Pumps offer an emotional crutch, or a false security for many. It requires extensive monitering

Pro’s
A pump provides insulin in microdoses.
It provides an emotional illusion that "control"is easy/very possible.
Pumps have a formula for delivery which covers high fat foods; chinese, pizza well

MDI
You inject multiple times a day, typically every day of your life
Numerically more injections are required than the number of infusion sets required over the same period.
The more insulin injected at a single time the greater the chance it will be excessive amount over a longer period of time
MDI requires long and short acting insulin, to prevent a gap in coverage while sleeping
Longer acting insulin, can still have a peak to it because of its duration. Therefore longer acting insulin can cause problems which short acting does not solely because it is shorter acting. Whatever shorter acting insulin does it is out of the body in 3-4 hours.

You could not pay me to use the current pumps again, for any reason! Cute marketing, astounding PR, but little substance… IMHE…

6

I can only speak about MDI.

My first endo said all his patients had pumps & pushed this. At that time, I knew one person who pumped. He was constantly adjusting it & this seemed like a lot of work & trouble to me. Later, when I learned more about pump failures, site problems, infections, scar tissue, kinked tubing, etc. & the additional expense of supplies, I lost interest.

I posted a discussion a while ago about the success of pumps in improving BG. I questioned whether it was the pump itself that was responsible for better control, or the training people received when they got pumps that really deserved the credit. I think for many people it’s the latter. They were shooting in the dark prior to pump training. Doctors can’t take the time to educate patients about the action of insulin, dosing accurately, carb counting & all the other things pump training provides. CDEs can teach people, but not everyone on MDI has access to one, or to a good one.

There are areas where pumps have it all over MDI. Being able to deliver increments of doses can’t be duplicated with syringes or pens. Being able to control dawn phenonmenon is a huge plus. I can imitate extended boluses with injections & do. Something I learned here from the pumpers!

To me, MDI is less cumbersome than having something attached 24/7, less expensive & worry free compared to pump problems. Maybe one day I’ll try a pump, but I don’t feel limited by injections & like to keep things simple.

7

I’m new to pumping so I’ve got the most experience with MDI. My first pump is the OmniPod. I was always leery of external tubing in traditional pumps. I understood that the control was excellent. I just knew what kind of a klutz I am and I figured I could do some real damage. I don’t miss the variables of the MDI.

I went on the Dexcom about a month before I got up and running with the OmniPod. Together they are a fantastic combination. I really look forward to their integration. The CGM made MDI a lot easier. Being able to keep an eye on trends is really useful. At this point I’d really hate to do MDI without having the CGM. I got spoiled by having real time feedback on what is going on.

8

I monitor just as much on the pump as I do m d I, also I don’t like the hold lantus had on me. I make pretty much the same mistakes, except this time I font fright my nightly lentos shot. I don’t find the pump or m d I makes a difference in my self consciounrss, then again I don’t care what people think about the same. I wear my omnipod with stickers. Omnipod, or any tubeless pumping, makes life different, and I found it motivated me a lot more then m d I (insulin calc helps a lot). Hard to explain, pump is just nicer happier alternative for mr, plus I no longer forget my nightly dose,no longer at mercy to my LANtus, and I got a nifty P d m.

9

If you select a group of 100 type 1 diabetics the Pump and MDI should result in equal control for more than 70% of the group. But MDI needs a medical team that is willing to invest some time at the beginning. The choice of the basal and bolus insulin is the most important choice here. It has no use when doctors are sticking to the description of insulins. In reality the reaction to insulin is highly individual. It is possible that Lantus will cover 24 hours but it it not guaranteed. Levemir is also very optimistically advertised as up to 24 hours. In reality these are only lab figures. Tests of the basal rate need to be conducted to find out if your needs are truely covered.

My recommendations for basal insulins:
a) Levemir should always be shot twice a day - an experienced medical team will not recommend one shot.
b) Lantus can be applied twice a day - some users had great success with that.

For bolus insulin there are different products on the market. Some insulins will be faster, some have a tail others fade out quickly. But the reaction curve depends on the person. So you need to try different insulins to be sure. It needs one vial to collect information about post prandial numbers (the spike 1 and 2 hours after the meal). This way you will find out if there is an insulin in the market with a very small spike. Hopefully you will find one that is quick enough so you can afford to skip the waiting time between shot and meal.

My recommendations for bolus insulins:
a) Apidra - some people say it is the fastest
b) NovoLog - I use it and I do not want to have any faster insulin (would be dangerous)
c) HumaLog - some people say it is slower than NovoLog (they should be equal)
d) good old regular insulin for people with gastroparesis.

If basal and bolus insulin are determined then you are in a position to truely compare pumping and MDI. Now you can find out:

  • if there is a dawn phenomen you can better handle with the pump.
  • if flexiblity of pumping is worth the investment of catheders and the risk of occlusions.
  • if physical activity with MDI is difficult for you to handle and will be better working with a TBR (reduced temporary basal rate of the pump).
  • if stress causes fluctuations that can be better addressed with a TBR.
  • if the personal freedom of MDI is more valuable than the advantages of the pump you have identified.
  • if there is a higher financial burden of pumping.

I have great success with MDI (more than 20 years now) and I think the potential space should be explored first. Just do not waste too much time in this exploration. The differences between the insulins are very obvious after some days of use. Thus it should not take too long to find out which way to go. If MDI seems less promising then you should pick the pump.

10

For me being able to vary basal rates throughout the day and night makes a HUGE difference in my control. This is the #1 reason I use a pump over MDI.

Also, the pump allows rapid changes to insulin doses. Changes to basal rates kick in after about two hours, compared to about three days with changes made to Lantus. This has made a big difference in my ability to respond to things like hormones, illness, stress, increased activity levels, heat waves, etc.

Personally, I am also just as self-conscious doing injections in public as I am wearing a visible pump. I suppose this will vary for individuals.

11

I did MDI for 26 ½ years and just started pumping towards the end of June. I always resisted pumping because I did not want something attached to me 24/7. After getting a CGMS (first the Navigator and now the Dexcom), I couldn’t say that having something attached to me was an issue so decided to give pumping a try.

I have gastroparesis and people said that would be easier to handle with a pump. I am not doing anything different as far as the bolus portion goes. I can’t see the extended bolus feature working for gastroparesis because sometimes my meals digest in 2 hours and other times it might be 12. I don’t want to take insulin unless I know I have food digesting.

What I do really like is the variable basal programs. I was on Levemir prior to getting the pump. The Levemir only lasted 7 hours for me so I was taking that 3 times a day. If I was tired and wanted to go to bed early, I had an alarm going off at 11 PM to make sure I took my Levemir. I have DP and my BS starts going up at 5. I had an alarm going off at 7 to make sure I took Levemir. The pump allows me to sleep for more than 6 hours without something beeping at me to take a shot.

I agree with Gerri about the lack of education for people on MDI. When I first started having trouble with gastroparesis, doctors had no clue how to help. I was in the hospital for a week and a doctor told me my BS baffled him. When I started talking to other people online and saw that people with normal stomachs did split shots for hard to manage meals, that made sense it would work for gastroparesis. I also learned how to do basal testing - the first endo I saw after I started doing that seemed surprised I knew what it was let alone actually do it. Even my pump trainer was surprised that I actually did basal testing.

My A1cs have been in the fives for several years now so I am not looking for huge improvements in control with a pump. I do want the flexibility of being able to adjust my basals as needed. I don’t’ have to worry about sleeping in and missing a shot or trying to remember what time I took a bolus. I don’t particularly care about what it looks like to have tubes sticking out of my clothes so that doesn’t bother me.

12

This is a great discussion. As someone who was fairly recently diagnosed, I’ve been started on shots. My sister-in-law who is an NP mentioned the pump to me as an eventual alternative from the start. Based on what’s being discussed, it seems the best thing (when I get to that point) is to make up my mind based on experience with both. The good thing is that one has alternatives.