Got labs back, incredible A1C! Wondering if pumping and looping is still worth pursuing though


#1

So I’m clearly a LADA, since T1 started at ~35 years old (early this year). I do still have some endogenous insulin production, which is noticeable in my low Tresiba dosage (11 units daily).

Still, I have to diligently bolus for carbs, or I can easily spike well beyond 150. And, well, I did that, in addition to carb reduction, regular exercise (cardio on stationary bike + resistance training at the gym).

Time in range these last 3 months was 99% … with 1% below because of exercise related BG adjustments. And labs results are: HbA1C 4.9% !!!

I was also worried a bit about the increased fat and protein consumption, but the Albumin/Creatinine ratio is great (2.1 mg/g , threshold is 30), LDL is at 62, HDL at 52, triglycerides at 39!

So my BG control really is awesome now. Thanks to the exercise, the Humalog works crazy fast. I have very modest spikes these days, and in fact sometimes have to split the injections because the Humalog acts TOO fast.

Which brings me to pumps: In the past I was considering pumps, because the BG control is much more fine grained with them. Basal adjustments are quick and easy, you have more options regarding bolusing (for example, spread over a certain time, often called “square wave”), only one insertion every 3 days etc.

But, I am concerned about the downsides: Pump failures, stuff sticking on your skin, costs. In particular, with this HbA1c, I have become skeptical about the cost/benefit ratio. I also currently have no dawn phenomenon, only a modest “waking-up” phenomenon (on some days, the BG rises by 10-20 mg/dL after waking up; dawn phenomenon happens even in your sleep, at a certain time in the morning).

The pumps covered by health care here are the Ypsomed Ypsopump, the Omnipod, the Medtronic 640G, and the Accu-Check Insight. I avoid Medtronic like the plague, given the bad things I’ve heard about them. As for the rest, eventual compatibility with looping systems is a must have for me, since in my opinion, it truly unlocks the potential of pumps. This rules out the Ypsopump and the Insight, leaving only the Omnipod (AndroidAPS support is WIP, and cooperation with Tidepool seems to be ongoing).

However, I keep hearing about frequent pod failures. And, I am concerned about such a large area covered with an adhesive. I don’t want to provoke skin reactions that may eventually not only make Omnipod use impossible, but CGM use as well.

Thoughts? Opinions?


#2

If it ain’t broke, don’t fix it…

But the thing about OmniPod is that it is has a much cheaper startup cost than the other pumps. $200 for the PDM, and $300 for a box of pods (a 1 month supply at your dosing amount.)

So for a total of only $500, you could try the OmniPods for a month. That lets you know if it is something you want to continue. If you want to stick with it, you can get it insured.


#3

The OP’s statement of, “The pumps covered by health care here…” makes me think they are may not be in the US. In which case, if it’s like Canada, the startup cost of the OmniPod is the same as the startup cost of any other pump, and the ongoing costs are also about the same. From what I have read, the US seems to be the only place where the startup cost of the OmniPod is significantly cheaper than other pumps.

But I tend to agree, if it’s working for you, I wouldn’t complicate things. You can always add a pump and CGM in if control gets harder down the road…and by then, most pumps may be at least partial closed-loop systems.


#4

Yep, I live in Austria. Health care is state funded here. As for CGMs, I already use a Libre together with the Miaomiao transmitter and xDrip, which is one big reason for my HbA1c, though I have become very curious about the Dexcom G6.


#5

Yep, good call Jen. You are right. The costs in the U.S. are much cheaper for that pump than in other countries.


#6

I think continuing with your multiple daily injections is appropriate for your case. Insulin pumps do bring with them a whole host of performance difficulties that must be managed by the wearer. If your exogenous insulin needs were greater and your basal needs more varied, the insulin pump option becomes more desirable. A 99% time in range is magnificent!

I like that you report using the Libre flash glucose monitor. That means that you’ll be able to watch your glucose metabolism closely and respond in a timely way when your endogenous insulin starts to fade. I hope that it lasts for many years for you but many report that it does indeed diminish over time.

You could even consider only using the Libre intermittently, like 14 days/month or every other month. Or you could back off to fingerstick monitoring but I like the convenience of a simple scan giving you an immediate answer.

While I use all the diabetes gadgets and gizmos, I do believe low-tech can sometimes offer excellent solutions. My hypo-alert dog is an example of that.

Congrats on discovering the good-news details of your robust native insulin secretions. You have the opportunity, with your carb-reduced diet and exercise, to gently treat your glucose metabolism and hopefully keep your home-grown insulin alive for many years.

Good luck and keep up the great work!


#7

Well, there is one big argument in favor of pumps, and that is the ability to quickly adjust basal. Since I exercise regularly, the swings in insulin sensitivity can be noticeable. For example, based on Libre readings (backed by fingerstick measurements) and the carb count I ate today, my I:C ratio today is something like 1:15, even though typically it is 1:12. Also, basal seems to be too high today. I did do an hour of resistance training yesterday, and 2 days ago I did cardio for an hour, so I am strongly suspecting that this is an aftereffect. With a pump, I can just temporarily decrease basal, and increase it again when the effect faded (well, until the next training, that is). Also, in case of sickness, I can crank up the insulin quickly. Both kinds of adjustments - decrease during/after exercise, increase during sickness - are more difficult to do with Tresiba.

Still, workarounds for these problems exist. I can use a different I:C ratio the day after intense exercise for example. Fixing basal is more difficult, but I could correct with a few carbs. Any other ideas? Because, I think to fully leverage the benefits of a pump, closed loop is a must, precisely because it can handle such shifts in insulin sensitivity automatically and much better than any human could. So, a pump without a loop is much less beneficial for such cases I think, so I guess I should rather try to stick to pens and these tricks and not jump on pumps yet in spite of their ability to adjust basal.


#8

You make a good point. One of the biggest lessons I’ve learned in the last several years is the notion that diabetes is a dynamic condition. Insulin to carb ratios (I:C), basal rate profiles, and insulin sensitivity factors (ISF) are not the set-it-and-forget-it settings we once thought they were. Exercise, like you cite, losing sleep, crossing time zones when traveling, and a host of other things can and do affect blood glucose.

You seem like a person who could understand and make good use of a pump. The performance obstacles I mentioned in my previous answer can all be solved with knowledge, persistence, and common sense. I think your personal preference, at this point, makes a large difference in how you weigh the various factors in this decision. Pump therapy will offer you greater ability to change your basal profile on-the-fly to respond to things like exercise variability.

Even without pairing with a closed loop system, current pump therapy does still offer some flexibility that MDI cannot. I use a hybrid closed-loop system called Loop. It is, by far, superior to any treatment method I have used before. It dispassionately, using math, makes an insulin dosing decision every five minutes. I would never willingly go back to my prior modes of treatment.

Having said that, Loop is a do-it-yourself (DIY) project that requires finding an older compatible pump. Since you live in Austria, I suggest looking into whether you could purchase a new pump from the South Korean manufacturer, SOOIL. They make the Dana models R and RS. These pumps, as I understand it, are compatible with closed-loop apps running on a smart phone. I believe they fall under the category of “AndroidAPS” or Android artificial pancreas system DIY project. If you can access and use this technology, I think that would be ideal.


#9

Yeah. It is a difficult decision. I’ll have to discuss this with my endo as well. She would have to be involved in any pump decision anyway. I also have some more time to think about this.

Thanks for the input!


#10

Great A1C and other results!

All of the members who replied above have good points, and as pointed out, your Austrian location is ultimately what determines what pump(s) and technology you could use for DIY looping.

I’ve also had recent conversations with @Terry4 with respect to my Looping options in Canada, and they come down to locating (older) pumps that can be hacked.

Unless you’ve heard something I’m missing, it was my impression that Looping the Omnipod pump(s) was still “ongoing”, hence the only pumps I can work with in Canada are the older Medtronic pumps (please correct me if I’m wrong)

If your Austrian healthcare will fund a month of trying a (non-looped) Omnipod I’d try it for a month or 2 to see how you pumping. There is a learning curve but it appears you’re exactly the type of person pumps are made for.
Jim


#11

I agree with Eddie - if it ain’t broken don’t fix it. Pumps require somewhat high maintainance so if you have good A1c numbers, it’s not worth the extra maintenance involved.


#12

My opinion (since you asked) is that you will find your basal needs going up in the next year or so, and when that happens you might find the positive aspects of being on a pump far outweigh the negatives you mentioned. And when your insulin needs do go up don’t get discouraged. I think it’s where a lot of us LADA people fall into the trap of living this great diabetes life the first year or two, and then when the bottom falls out it can be very easy to get very discouraged rather quickly. Speaking from 9 years of experience here, and I’ve had the privilege of communicating with others since their LADA diagnosis. The first two years of my diagnosis I could eat pizza no problem. I could do a lot of things and I thought I was so great at managing and then a couple of years in everything went all kinds of crazy and it was hard. So just keep in mind when you do reach the point where you might find managing is not as easy as in the beginning just know that the pump is a GREAT option. And seriously, there are lots of not so great things about MDI as well. I don’t think there is any reason to rush to a pump if you feel in control, but personally I feel the pump is a far better way to manage bs- it’s closer to what a pancreases does. The technology is getting better all the time!


#13

You do make some good points here, though I can tell you from experience that eating a pizza is not easy for me. (Neither is Lasagna.) I have to constantly check the blood sugars and bolus multiple times for hours afterwards. I also do notice some degree of feet-on-floor phenomenon as well as a dusk phenomenon, so the residual endogenous insulin production isn’t that helpful bolus wise. I also cannot eat carrots for example without bolusing. Furthermore, I need to pre-bolus always otherwise I spike very easily. So I am hoping that I am actually not having a strong honeymoon and that my current BG is relatively close to how it will look like years down the road.

That said, you make a good case about the pump. I’ll have my meeting with the doc soon. There are also studies that indicate Verapamil is able to protect the remaining beta cells, at least for a while. I’ll mention that too.

I am discouraged about the frequent Omnipod failures though. This sounds like a really big problem.

EDIT: I am also now somewhat terrified about what hellish BG swings, impossible BG control, terrible HbA1Cs, and exhausting rollercoasters and neuropathies await me :frowning:


#14

Every technology works differently for everybody. I call it the “amazon review” dilemma. You can get a review of the same thing from several different people and some love it and others hate it. You will even find whole facebook/social media groups devoted to the love and admiration of one brand and another that detests the very same thing. I’ve never been on Omnipod but I have friends who love it and swear it is the only way to go and think I’m crazy for my tubbed pump. My tubbed pump works for me though.
One that frustrates me is the huge expense and the very long commitment to these devices. I have to wait 4 years before I upgrade my pump or switch to another brand as per my insurance. And while most of the pump companies have a period of time where you can return the pump if it doesn’t work for you it’s usually short- 30 days. That’s not exactly a huge amount of time to try out and decide if that’s going to work for your lifestyle.
Are you on a CGM? To me that would be the first thing I would add. I didn’t know how badly I needed it until I got it! If it’s in your budget get one. The whole invention and development of Continuous Glucose Monitoring is the number one reason why we have and will have success managing diabetes- even if you don’t have one yourself (and you should eventually get one). What the medical field has learned from the constant reading of blood sugars on diabetics and non-diabetics is changing how diabetes is managed. I hear you on the fears- diabetes is a crap disease. But we now have ways that previous generations never had to understand what happens with our blood glucose and how to better manage it. The leaps and bounds in the last few years are exciting, and I have hope for the future.
I’m sorry you didn’t have much of a honeymoon. I kind of miss the days where my body could run on little insulin and eating certain foods was no problem. It sounds like you manage your carbs well and have a good understanding of the disease. Your insulin needs will be changing. That’s part of diabetes. So as long as you understand (which is sounds like you do) this is not a static disease and the management cannot be static either I think ultimately you will find what works best for you.


#15

For what it’s worth, I was on the 630G from Medtronic and switched recently to the Omnipod on a competitive trial where they gave me the PDM and 10pk of pods. Initially about 1/2 of them failed for one reason or another, but Omnipod is great at replacing failed pods for whatever reason, even if your fault (ie snagging on clothing). They are really easy to fill and I love that the PDM is not permanently attached like the 630G was. You can also wear them while bathing, swimming or whatever, so you get truly continuous insulin delivery that you can’t get from any other pump. Just my 2 cents worth.


#16

I also am Lada and use a low amount of insulin after many years. I usually need to adjust my basal every 6 months so yes it can be disheartening to see your body producing less of its own. When I didn’t use the pump I would use a reusable pen that used vials of insulin. I was told it was often used for children. It allows dosages in half increments that is useful when your carb ratios are where they are.


#17

Update: I talked to my endo, and we agreed to not go with pumps for now. Given my current BG control, a pump would not yield enough benefits to warrant the costs and the efforts (a switch to pumps is not trivial, after all, especially for somebody like me who has never used one). We’ll closely observe the behavior of the BG in the future, and decide later if the pump becomes necessary. Since I’m a LADA, I’ll be honeymooning for quite a while longer, so by the time the pump truly becomes necessary, closed loop controls will hopefully be quite established in the market.