Injections vs insulin pumps

Type 1 and LADA
1

I’m seriously considering switching over to a pump and was hoping to get some insight from those who have. The two main reasons for doing so are I have very tight control (last A1C was 5.4), but in order to do this requires multiple injections daily, even if its 2 or 3 units. The other reason is I have I guess dawn phenomenon. I can run a steady 100 all night but at 4-5 every morning it starts to rise and if I don’t get up and take 3 units of insulin it will be close to 200 by 8am.

I am assuming a pump would solve this issue, but would I be able to keep as tight of control as I am now? Especially using a Tslim with my Dexcom?

To those of you that have switched are you glad you did?

2

You can definitely have tight control with a pump and CGM. Although you may still battle dawn phenomenon, a pump allows you to program higher basal rates at the appropriate time to mostly tame it.

I use a Tandem pump and a Dexcom G6. My old pump was programmed with Control IQ and just went out of warranty. I chose to get the new one with Basal IQ.

I used Control IQ for almost a year and liked many things about it and hated other things. It is superb for preventing lows but not as good at preventing highs although it definitely helps with highs. Sleep Mode when used 24/7 allows you to target a lower target range than regular Control IQ, but that range is 110-120. There are people on Facebook who are getting very low average BG’s while using Control IQ and one guy last week reported an A1c of 4.6. For me that would be impossible because my insulin always suspended when I trended lower and then I would go high later on. I consistently had an average of 120 with Control IQ but my A1c’s were still below 6. My endo was thrilled with those numbers because at age 68, she doesn’t want me having lows.

I have been using the older software Basal IQ which only addresses lows and uses a different algorithm from Control IQ for suspending insulin. I like that my insulin suspensions aren’t as long and I can control my target ranges. But after a couple of weeks I am finding that I miss some of the good things of Control IQ. I can always go back to the old pump and can also upgrade the new pump to Control IQ.

Control IQ is a first generation hybrid artificial pancreas system and in future years we’ll see lots of improvements and more user-controlled settings. Some people love it (especially people with previous higher A1c’s) and others are frustrated by it (especially people with lower A1c’s). My experience was that there was a lot to like and a lot to be frustrated about. For sure it was not less work although at times it enabled me to forget diabetes.

In the end Type 1 diabetes is difficult and my experiences with different technologies and ways of administering insulin just highlight how difficult it is. But I find that the better my tools are, the better I expect to do. So diabetes stays challenging.

I have been pumping for over 15 years and have never considering going back to injections full time. At the same time I believe that most motivated people can get just as good of control with injections.

Given the pumps and CGMs currently on the market, t:slim and Dexcom are all that I would currently consider. I previously had a bad experience with Omnipod although many people love it. I wouldn’t go to Medtronic because I won’t use their sensors. So right now there is not a lot of choice in the pump market.

Good luck with your decision. Chances are you would like pumping a lot. And if you don’t you could always go back to injections.

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3

Many people using pumps enjoy tight control but they do have to work at it. Programming a pump to dose for dawn phenomena is definitely possible but don’t expect to discover a formula that will not require tweaking and adjustments over time. Diabetes remains a moving target that you need to pay attention to and change your settings when it changes.

This squares with my perception of glucose management. For the last four years I’ve used a do-it-yourself hybrid closed-loop system whose performance I’d have a hard time reproducing with injections. It makes dosing decisions while I sleep, something no multiple injections system can do.

The commercial hybrid systems like Tandem’s Control-IQ are reaching toward this performance and, as Laddie points out, their track record is mixed but they will get better over time.

I do believe, however, that the knowledge and dedication of the person with diabetes counts for a lot. There are people who follow Dr. Richard Bernstein’s low carb methods using injections alone who consistently over many years post A1c’s in upper 4% to lower 5% range.

Bernstein is not a fan of insulin pumps and does not use one. He’s in his mid-80s, and has lived with T1D for almost his entire life. He still sees patients in his clinic and currently posts diabetes videos to YouTube.

I’m not quite as dedicated as the most ardent Bernstein followers. My Loop system enables me to deal with the inevitable glucose variability inherent in diabetes. What I’m trying to say is that a person with diabetes can do very well using a pump or on multiple daily injections.

One of the things that I like about pump therapy is that it records your doses and you can always check the size and time of your insulin doses. You don’t have to depend on your memory or record keeping discipline when a question arises.

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4

I know very little about pumps so forgive my ignorance, but I was under the impression that a tandem along with a G6 would automatically start delivering more insulin if your numbers started to rise. Is it not that simple?

5

There are 2 basic triggers.
Increase/decrease basal, or deliver a bolus correction. Sounds simple.

But there are certain parameters that can’t be user set. For example, if trending high, it does not do correction until 160. It will increase basal slowly, but for some, not quick enough.

When trending lower, and predicts low, it will suspend basal. This does result in bg trending back up. But may be more up than you want, especially if targeting A1C in 5s. There are various tweaks to adapt to this that makes it not so simple. There is minimal user options to set the bg settings for the triggers. For some, the “out of the box” solution is great improvement to reduce lows and lower A1C. But if already attaining lower A1C, it may go up.

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6

@Baddog40,

I was on BIQ for a little more than a year. I went on CIQ in January 2020 just before having open heart surgery. Training for CIQ is a mountain in and of itself. The best analogy is learning to supervise the autopilot of a commercial aircraft.

I must vehemently disagree with @Laddie. There are several things left out of the analysis she presented.
1> CIQ has hard coded levels in the software. The levels were researched, juried, and peer reviewed by experts from the American Diabetes Association, American Association of Clinical Endocrinology, & American Association of Diabetes Educators, to name a few. The research and opinions of these and other groups lead to the establishment of the CGM levels set in the CIQ software. Many people have expressed disdain for the values, especially the upper level of 160mg/dL before CIQ increases insulin to decrease the glucose level.

2> @Laddie, mentioned SLEEP ACTIVITY. This is a setting within CIQ for use during sleep. It changes the levels CIQ software is programmed to act on CGM data as well as the manner in which it acts. Using SLEEP ACTIVITY 24/7 is outside the normal usage of the Tandem system. The advocates of SLEEP ACTIVITY are pushing the window of their own diabetes management below the levels diabetic professionals agree upon.

3> When I started CIQ, my training was longer than most any one else shares. Mine was two days. The first day was with my endo’s CDE. Day two, was with the nurse educator from Tandem. She is the regional director for Tandem. We still communicate. The two educators shared the following documents and went over just about everything in them.

Here is that list of documents and their source web links.

Tandem Document Site

CIQ User Guide (350+ pages and is best put on a tablet or computer for easier searching)

https://www.tandemdiabetes.com/docs/default-source/product-documents/t-slim-x2-insulin-pump/käyttöopas-(t-slim-x2--pumppu-control-iq-teknologialla)cf14759775426a79a519ff1100a9fd393f6fb39775426a79a519ff1200a9fd39.pdf?sfvrsn=18a507d7_66

CIQ Technology PDF

Sleep & Exercise PDF

t:Connect USER GUIDE (about 60 pages)

https://www.tandemdiabetes.com/docs/default-source/product-documents/tconnect-application/aw-1002654_e_tconnect_patient_artwork.pdf?sfvrsn=73553bd7_32

Dexcom Document links:

The DEXCOM support site is: Dexcom Support | G6 Customer Service | Dexcom

Dexcom FAQs: Dexcom Help Center | Dexcom

Dexcom Guides: How to Use Dexcom Products User Guide, Quick Start Tutorials | Dexcom

Dexcom Training Resources: Dexcom CGM Training Sessions and Resources | Dexcom

I hope this mountain of information will give you a different perspective on Tandem’s CIQ.

7

I think you misunderstand the principles of Control-IQ and for whom it was designed for. It was designed for doctors treating the “average” type 1 who can barely achieve 50% TIR, let alone the recommended 70%, to bring them into the target zone. It was designed for people who haven’t mastered good bolusing techniques. And it’s really good at doing that. Yet… I dare you to find me a single study that declares 70% TIR is OPTIMAL. That is a minimum target, not the end goal. It’s a balance that was struck because doctors don’t believe the common man can achieve much better without experiencing hypoglycemia. Obviously, gluco-normalcy is optimum, but only if it can be done without increased risk.

The OP is already doing much better than the Control-IQ target audience. Why should they, or any of us, be expected to sacrifice their current level of care to meet a lower standard?

Thankfully, Control-IQ gives me my best chance at gluco-normalcy… Just not in the way the system was intended. I’m one of those people thriving on sleep mode.

Bullcrap. Absolute bullcrap. Sleep mode targets a range of 110-120 mg/dl. Well within the recommended range of 70-180. There’s even a nice cushion built in to avoid hypos. In fact, Tandem themselves put it out there as an option for tighter control. They spoke about it during a Facebook live broadcast while unveiling the new software.

@Baddog40 Back to your original point. Yes, you can achieve great results with a pump. I daresay you might even be able to achieve better control with a pump, because you have delivery options currently unavailable to you, such as: varied basal rates throughout the day including the ability to program extra morning insulin for “dawn phenomenon” and “feet on the floor”, extended boluses for difficult high protein/fat food items, and my personal favorite… Super boluses! Basically, this involves exploiting your pumps ability to prevent hypos by suspending your basal insulin. You can add up to 2 hours worth of basal insulin in to a bolus dose (don’t stack them!). This let’s you take advantage of the early peak insulin action, and instead of waiting out the long tail, that long tail essentially becomes your basal insulin, and your pump suspends everything you don’t need. It’s a miracle. I had lasagna and bread sticks for dinner tonight, and my blood sugar ranged 97-126. Personal victory for me!

But, as much as I love my T:slim X2 w/ Control-IQ, pumping comes at a cost. Literally, because supplies can be expensive… But also mentally, physically, and emotionally. Depending on the pump you choose, you’ll be living your life on a very short leash. A 23-40 inch leash! There’s the burden of more supplies, and traveling with spares and backups. There’s a LOT of new information to learn, and settings to adjust. There’s the emotional burden of alerts and alarms…

I’m only 3.5 years into pumping, so I’m still thrilled to be a cyborg. I’m achieving the best care of my life, while feeling less burdened by my diabetes. Many people feel the need to take a “pump break” and walk away from them for awhile, though, and wind up back on MDI.

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8

As a 20+ year pumper and user of various models of Dexcom CGMs, there are some some facts absent with allusion to their veracity. CIQ software was not designed for doctors, it was designed to integrate data & insulin administration for individuals prescribed insulin therapy and CGM monitoring.

The first set of facts missing from the discussion is the programmed parameters of the CIQ software in a Tandem X2 pump. Yes, @Robyn_H, here is the exact statement taken from the Tandem Control-IQ handout.
Screen Shot 2020-12-19 at 06.18.16

The second set of facts center around a group of insulin pumping individuals who have or desire to have their RANGE measured in the area of 85-110 mg/dL. Members of this group move openly with endocrinologist prescription to the CIQ pump and then bemoan the prevention or inability of changing some parameters within the CIQ algorythm.

Because CIQ has hard coded some settings, like insulin duration, there is a group espousing turning CIQ off and back on to force the pump to perform certain tricks denied them in the CIQ programming. Others want to run SLEEP ACTIVITY 24/7 because its maintains a narrower range. It is time to present the exact CIQ set points in the Tandem pumps.

Screen Shot 2020-12-19 at 06.31.42

The TIR (Time in range) studies have show better clinical outcomes than individuals with tighter control. Some pumpers, prior to using CIQ, have tweaked their settings, watch their own CGM data, and ‘Sugar Surfing’. Sugar Surfing is a metaphor for Dynamic Diabetes Management, also known as “managing the moment”. It’s based on an awareness of one’s blood sugar trends using a continuous glucose monitoring system or by use of frequent blood glucose checks with a handheld meter. By viewing blood glucose trending, a person can make self-care choices earlier and at times more aggressively than with old-style single point in time blood sugar information. Sugar Surfing represents a paradigm shift in how all types of insulin using diabetics can be managed by individuals or involved families to maintain glucose levels at the very lowest of ‘normal levels’ so their TIR values are closer to the 85-110 instead of the WIDE norm of 70-180.

So, @Baddog40, just like faith based establishments, there are converts to different houses of worship, so are the folks using CIQ & BIQ. Some arrived with tighter numbers & A1c values in the 5.x range wanting CIQ to keep them in their lower tighter range. Others arrived with TIR histories resembling buckshot. For them, the CIQ monitoring of HIGHs and LOWs was a blessing, bringing A1Cs from 13-15 down to the 6-7% range and over time to the 5.5-6.5% range (Where I am currently on basic CIQ except sleep times).

@Baddog40, is this technology for you? Do your research, discuss it with your endo, and pump team. Draw your own conclusion about this solution.

Again, I have been on CIQ since January 2020. I have worn my pump thru a three hour cardiac procedure to manage a complication following open heart surgery. As soon as I was awake, CIQ was restarted in the ICU following open heart surgery. I am a believer.

9

This is one of the primary reasons people switch to a pump.

One of the main side effects of a pump is an increase in lows and an increase in the severity of lows. I, personally, couldn’t run a 5.4, but lots of people do.

You will need to do a bunch of work upfront in order to make the switch, so if you feel up for that, now might be a good time. Are you able to maintain good communication with your Doc during this time? I’ve had some difficulty there.

10

Yes, with Control IQ, Tandem will increase your basal rates when using Sleep Mode and will increase your basal rates plus bolus for 60% of the projected rise using standard Control IQ. The limitation of this is that short-acting insulin is still too slow to compensate quickly for many BG rises. But over time, the Tandem pump using Control IQ will deliver more insulin to try to get you back to the target ranges.

But it is not a simple plug-and-play algorithm. It can take work to find settings that work well with Control IQ. It has been a steep learning curve for endocrinologists and CDE’s in the last year just as we patients have worked to optimize settings.

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11

@Jay6 I won’t get into an arguing match with you and lots of what you are saying is very valid. For sure it sounds as though you and your doctor have found Control IQ to be a great tool to help you reach the goals that you and your doctor have agreed on.

But my doctor is on board with my goals and supports my constant work to improve my BG numbers and to lower the burden of my diabetes.

I personally would be disappointed at a 70% time in the range of 70-180 although that would be a vast improvement for many of most people with diabetes. I am not breaking any rules to try to do better.

FYI there were people in the clinical trials for Control IQ who began using Sleep Mode 24/7 and Tandem was okay with that. In fact I learned about that option from a Tandem employee and first learned of the term “Sleeping Beauties” from her.

My understanding is that when the Medtronic 780 system is released, it will allow for more user selected targets. I have read that this system will allow patients to target a BG of 100. I think we will see the option for lower targets in future generations of Control IQ. Do I think we will see the choice to target an average BG of 83 as Dr. Bernstein recommends and some Loopers achieve? No.

So I am glad to know you are doing well with Control IQ but please realize that your experiences and opinions do not speak for all of us.

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12

@Laddie,

If you find CIQ is harmful, you and your endo should be completing a FDA MedWatch report, citing the harm perpetrated by CIQ and what changes should be made to remove the harm.

Happy Holidays.

13

As far as pumping, DP, and hybrid closed-loop pumps go:

  • One of the main reasons I switched to a pump was because I could NOT control my increasingly severe DP with injections. It was easy to get control of using a standard (non-loop) pump simply by setting a higher basal rate starting about 1/2 hr before DP would usually kick in, a time relatively easy to determine with a CGM. @Terry4’s comment notwithstanding, I’ve had no difficulty finding a rate that stops DP flat, and have rarely had to tweak it.
  • One of the main reasons I gave up on the one hybrid pump I’ve tried, the MT 670G, was because it basically ignored my DP, partly because the MT sensor didn’t pick up on it, and partly because the correction was response was so anemic, so I was consistently starting the day far higher than I had on my old, non-hybrid pump, and the 670 corrected so s-l-o-w-l-y that I ended up running a higher A1C than I had before.
  • The Tandem may be much better at this, since it uses the Dexcom CGM, which is more reliably accurate overnight (in my experience) than the MT Guardian 3.
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14

My dawn phenomenon is very well handled by my dex and tandem.
My problem is that my dawn jump doesn’t always happen so some days I would go over 200 other days I would stay around 100. So when upped the basal at 5 am it would sometimes correct and sometimes crash me.
Now I put on my sleep mode after dinner and draw a straight line until breakfast the next day. But you can see my insulin usage move from 0.8 units per hour up to 1.4 units and back down again some days it only goes to 1.1 but my sugar stays pretty flat.

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15

I just dropped from Omnipod to syringe NPH because of slow mail and inability to get PODs in time. Its been about a week. The numbers are OK, but you can see that morning DP (and over-treating overnight lows) are causing some problems. That DP wouldn’t be a problem for me on Omnipod.

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16

My comments above reflect my more recent experience of needing to make a series of adjustments to basal rates and insulin sensitivity factors to counteract a tendency to go low early in my sleep time. This battle has been going on intermittently for the last six months or so. Just when I think I’ve extinguished it for good, it makes another appearance. Last night it interrupted my sleep yet again. More tweaks this morning!

I have enjoyed periods of glucose stability around overnight and dawn phenomena events like you describe. I’ve been successfully treating a morning rise after awakening (so-called feet on the floor syndrome) with one 4-unit Afrezza inhalation but my insurance coverage for that was lost.

That caused me to experiment with an approximate 2-unit pre-emptive pump dose when I get out of bed. This has worked extremely well. Of course, this could be easily done with an injection as well.

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17

Of course I can’t decide for anyone else what therapy is right. My experience was being on MDI for 20 years with good control but overwhelming hypoglycemia. The earliest pumps helped a little since I no longer had the confusion of mixed insulin injections. The introduction of Dexcom CGM was much more helpful in preventing hypoglycemia and I could manage my glucose well during the day but was “on call” to the Dexcom alarms all night. Six months ago I switched to Tandem with Control IQ. I’m 70 years old and not particularly tech savvy but was able to set it up in twenty minutes after watching the you tube videos. The result has been completely satisfactory. I am on a low carb diet and now have an A1C of 5.9 which is about the same as the past 30 years but my time in range is now 94% with no serious hypoglycemia and I get to sleep through the night without any alarms and actually had the alarm go off once because I had not touched the pump for 12 hours. I’m not a low A1c fanatic but have found the Tandem keeps me in range with much less work.

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18

I decided to go ahead and try to get the Tandem, all depends if insurance will cover it. One thing I’m wondering about though, my Dexcom loses signal once or twice a night from laying on it, and I also get compression lows. How big of a problem would this create with the Tandem?

19

I find my phone loses connection often but my pump almost never does. However when it does, it alarms and wakes me up. And then after a while it updates the missing readings.
The control iq software needs glucose readings to operate so if it loses 2 readings, it will alarm and shut off the algorithm, it will default to the standard settings that you gave it when setting it up.

This happens to me maybe once a week, but then I just move my pump and it’s fine.
Also while your sensor is warming up, you won’t have control iq.

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20

If you are using ControlIQ, set the alarm to tell you if the pump does not receive a signal in a period of time, say 20minutes. I have turned off all alarms on the Dexcom app since who needs double alarms. After bedtime I use only the pump as a receiver and iet rarely loses signal for more than a few minutes.