Pumping to MDI and keeping A1C below 7

Type 1 and LADA
1

Hi ya'll,

I have flip flopped a few times between insulin pump and MDI and then ultimately back to insulin pump. I do really miss the flexibility of not having the pump attached all the time. I am wondering if any Type 1s have had success in getting an A1C below 7% on MDI and a CGM. This summer I am attending yoga teacher training in Costa Rica and it'd be really great to get into all of the asanas without worrying about 2 things attached to me. It's so much easier to try to pop into a handstand without that worry that my pump is going to just rip out, lol. I'm pretty obsessed with my Dexcom so I know I want to bring that with me. But I'm also thinking that it would be easier to travel with a bunch of Lantus pens rather than a big bag of Tandem t:slim stuff.

My current A1c is in the mid to low 6s and I'd like to keep it this way. However, I've never had an A1C on MDI that is below 7. Are there any tricks to this? Has anyone been successful on shots/Dexcom alone?

Thank you!

2

Hi Elizabetta, I just started pumping a week ago but my latest A1C was 6.1 on MDI, before that it was 6.4. I have stayed under 7 for quite awhile. I think it had a lot to do with the fact that I eat very low carb which doesn't cause the rollercoaster BGs like you get on MDI while eating a heavy carb diet. I think you'll be able to do it easily with your Dex, you may just have to correct more.
Marilee

3

Hi Marilee,
Thanks so much for this response. I'm also on Metformin, so maybe this will help as well. Maybe I will start the CGM/MDI regimen a month before I go to even things out and have some time to adjust everything.

4

I too always had A1C's in the 6's on MDI. I eat moderate low carb and always have promptly corrected which I agree is a key to good management. I've never had a CGM (and don't want one). I actually resisted getting a pump for awhile because I didn't think I "needed" one. But all the women in my Type 1 Women's Group had one and I felt left out...lol. I'm only partly kidding. When I got one I realized how much it improved my quality of life. But I could see why you would want to go without it for awhile. Though Melitta seems to do well with her devices and yoga! (Hi Melitta!)

5

For the last 10 years I am below 6 for 95% of my A1C tests - without CGM and without pump. To me the key is finding the right type of basal insulin, the right injection pattern and the right dosage for this basal. The rest like carb ratios, insulin sensitivity and IOB adjustments are just fine-tuning as my endo likes to call it. Change brands and do not settle with Lantus alone. Try Levemir (I recommend two shots per day) or even Treshiba. Just for you to know which basal insulin has the biggest impact on your glucose control. Ask you endo / medical team about this. They should have vials of all brands to give away.

But there is more to that: I log all and everything in my project glucosurfer.org. My app will estimate my IOB and this helps me to prevent the stacking of insulin. Most importantly I look at the data from time to time. This sounds silly but confronting yourself regularly with your own mistakes is the key to stay focused. Many pumpers get very lazy to work with their data. It is not their fault alone because most software products are not very convenient to use and try to lock the data in. This is sad because data is everything with t1 diabetes. I want to see negative developments before the A1C will bring this to my attention. This way I can do something proactively about it. For every visit to my endo I try to focus on just three problems I have. I found them by looking at my data before the meeting. This way we focus for 15 min just on these problems. My endo sees thousands of patients regularly. He makes suggestions and proposes solutions to me. Solutions he has learned from his other patients. Thus he is the best information hub I can think of. Every time I leave with the feeling that all patients struggle at times but with some small steps improvements can be found - at least the potential is there. It is a marathon not a sprint. Just keep trying.

Another important pattern in the glucose management is the influence of the menstrual cycle. In general the sensitivity to insulin is reduced one week before the menstruation due to elevated levels of progesterone (the same hormone that will cause insulin resistance some months into pregnancy). Of course every women has a very individual cycle. So again this needs data and observation. My app is not very helpful with these observations but at least you can track your cycle. If you have the hypothesis that the week before the menstruation is critical you can start some experiments like increasing the basal for this week.

What else is there: lowering your carb intake might be very effective (for example to something around 100g), I personally found fish oil from krill (it is expensive I know) very effective to lower the average glucose levels, muscle mass in general is helpful to lower the spikes after meals, last but not least: allow yourself to make mistakes and have some days in the month you are free to make them on purpose. Eat the chocolate, ice or what ever and try to catch it as good as you can. If you fail you have learned something new. Next time it will work better.

1 Like
6

Hi, Elizabetta–

I am on MDI and Metformin (diagnosed last summer in DKA) and am wondering, if it is not too much to ask, how you figured out your sensitivity factor. I am only on 6 units of Lantus–the Metformin compensates for a higher basal dose, I guess.

Thanks, CatLady

PS Costa Rica is lovely and you’ll find lots of fresh fish, fruit, and chicken on the menus there. :slight_smile:

7

The lowest I have ever been able to go is 5.9 with MDI. I have never been on a pump and don’t have a CGM. I just check often and correct when needed. Now, that doesn’t mean that I have been able to stay at 5.9 all the time. Most of the time I hover between 6.0 and 6.4.

8

Hi CatLady:
My sensitivity factor has always been all guessing. It also changes depending on the time of month and if I am exercising that day or not. I'm thinking I may need to completely recalculate it before Costa Rica. The last time I was on Lantus, I was taking 11 units per day- but like you said, now I'm on Metformin so it may be a lower amount now. I was going to use the book Think Like a Pancreas to calc a new sensitivity rate.

9

Hi Zoe,
Thanks for this encouraging reply! I felt that on MDIs I was constantly battling lows, which would then result in soaring highs after I treated them. But perhaps the CGM will help. Appreciate your response. Betta

10

Hi Holger,
Thank you for these suggestions. Wow- A1C under 6 for the last 10 years is something I've never heard of before in the Type 1 community. That's pretty amazing. I've only just started hitting the mid 6s this past year after 26 years living as a Type 1. I really can't even imagine hitting 6 without my CGM. There would just be no way unless maybe I was scrupulously logging everything, like you mention. And yes, I am aware of the changes with the menstrual cycle- more than aware, unfortunately! Regarding using a medication other than Lantus- I'm not sure my insurance covers any of the other meds. It's pretty strict. I was on Novolog for the last 15 years until my insurance suddenly decided they only cover Humalog. I am pretty much at the mercy of whatever they decide to cover. If given the choice, I'd of course love to try something different. Thanks again.

11

Hi Cinderfella- getting to 5.9 on MDI would be great. I'd love to achieve that. I guess I'll just have to ease myself back into it and learn by trial and error. It should be a lot easier with my CGM. Thanks for your input. Betta

12

I have not thought of the restrictions the insurance companies might give you. I still wonder if the results of a test run might help to convince your endo to write a letter of necessity. Typically endos are stocked with different brands by pharma reps. So it should be easy to find out about the difference. Convincing the endo is the obviously harder step to follow. But pumping costs twice as much as MDI. In contrast to that the additional costs for another brand of basal are really neglectable in my opinion. Roughly estimated you save half the costs just by going back to MDI. The other basal brand might reduce this effect by 5%. Still these are 45% cost savings per year. This should convince any insurance company if your claims of better basal coverage are supported by your endo.

13

Hi Holger-
Not sure if you're in the U.S. but there is no "convincing" of insurance companies, not in my experience. My company covers what they cover. I am lucky because they cover 100% of pump and CGM supplies. My only costs lie in medication coverage. For instance, even if my doctor writes a letter of medical necessity for Novolog (which she would do if I asked her), they aren't going to cover it. And Novolog at retail rate would cost me $179 a month. I know, because I went several years without insurance. So for me, MDI with added medications that are not covered by my insurance is going to cost me more than pumping because pumping literally costs me nothing.

14

Hi Holger-
Not sure if you're in the U.S. but there is no "convincing" of insurance companies, not in my experience. My company covers what they cover. I am lucky because they cover 100% of pump and CGM supplies. My only costs lie in medication coverage. For instance, even if my doctor writes a letter of medical necessity for Novolog (which she would do if I asked her), they aren't going to cover it. And Novolog at retail rate would cost me $179 a month. I know, because I went several years without insurance. So for me, MDI with added medications that are not covered by my insurance is going to cost me more than pumping because pumping literally costs me nothing.

15

I am writing this from Germany and I have no idea what you are facing. To me the reduction in costs is still an argument to follow. Can 45% reduction in comparison to the current situation really be ignored?

16
My sensitivity factor has always been all guessing. It also changes depending on the time of month and if I am exercising that day or not.

I would think this is likely to be your main problem moving from the pump to MDI.

With a pump you have the option of a temp basal rate to better match your current insulin sensitivity. But with any basal insulin you choose your basal rate when you inject. If life doesn't happen to follow the plan you had in place when you injected, then you just have to cope with it via food and/or a correction "fast insulin" bolus injection.

The problem I always had with a correction bolus while on MDI was I had absolutely no idea whether or not I still active insulin on board let alone any guess as to how much IOB there might be. With the pump I at least have a better guess about this from the pump's "wizard" software.

The CGM will certainly help you cope better with potential highs/lows due to your body reacting in unplanned ways to your last basal insulin dose. You should be able to see them coming. So CGM could make MDI go a lot smoother for you this time around.

Have you considered what you might do if you switch to MDI and you feel it is not working for you? Do you have a backup "plan B" for that? It seems like something to at least think about before you are in Costa Rica. At the very least consider trying out the switch to MDI for a week or two before traveling just to give you time to settle in and be sure it's working for you.

-iJohn

17

I did it during one 3-month period, the popped back over 7. Since getting the pump 12 years ago, I am almost always in the 6's. I'd give up the CGM before giving up my pump.

18

Get on Lantus with the new inhalable ultra-rapid Afrezza insulin with Dexcom CGM if you're from the U.S. Unfortunately I'm from Canada and Sanofi didn't even apply to get Afrezza into Canada yet, so probably another 2 year wait for me.

19

Good for you! That sounds like a fun and an exciting experience. I had no idea what kind of foods that they serve there(I'm sure you have looked it up), so I was happy to see that you can order healthy, even low carb choices there, if youwish to. Big plus!

Anyways, I've been on MDI a long time and am still happy with the results. I've been through many trial and errors like everyone, especially with increasing Insulin needs for my long term high and low dose Prednisone use. That was maddening for a while especially the higher doses. I'm good with it now. My A1c's have been between 5.3(too many lows) - 7.1(higher Pred use) for many years. Mainly 6.0 to 6.5.

Tud Members have given you many good tips on maintaining the MDI procedure, so not much I can add. That was a great point to get it underway 2 or so weeks before you leave on your trip, if you still decide not to use your pump.

The moderate low carb is also what I do and/or small portion of foods sometimes.
If you don't usually get up during the night to test, drinking fluids during the day or a cup of tea before bed would wake you up to go, so you could be awake to test your bg. I make sure that my basals are on track, so I normally don't need to correct during the night but it's still good to know. I also don't inject more than 7.5 units of Insulin in one area, so that it is absorbed and works good.

I also get distracted doing other things sometimes and forget to check. A timer works well for this and definitely a CGM like you have.

EXERCISE!! Keep track of the amount of exercise that you do. If it is more than you had planned on then be careful of lows at night. Eat enough food before, during and after your exercise especially with all the sight-seeing you'll be doing. The result of too much exercise can stay with you a day or 2, depending on your system.

Enjoy your trip and your training. :)

20

I’m on MDI - Lantus and Humalog, like you, dictated by insurance. I have always (three years since dx) had A1Cs in the low 5’s. I could not have that without changing my diet to very low carb at the beginning and adding in carbs and test, test, test everything. I still keep rice, white potatoes, bread and processed food to a couple times a week. Lots of lower carb veggies to feel full. Lots of low carb and paleo websites/recipes around online. Sub a nice salad for the fries. I make a lot of fries from sweet potatoes and I recently discovered I love squash! I am eating so much better than just salads and meat like I was for a while, but still have an A1C in the low 5’s.

I have figured out how to handle the highs the days before my period and always expect the dramatic lower insulin needs when it starts. I aim to be safely under 100 all the time - when I wake up, after I eat, after exercise. But we need to be safe, so you have to have a good idea of what your body is going to do. After cardio, I know I will probably burn more glucose for a while, but after strength training I am going to rise quite a bit. I correct as needed, and test a lot to be sure. I aim to be a little higher when I’m driving or active. But if I’m going to be watching TV or working at a computer, I am very comfortable hanging out around 85 most days. I do my best not to over correct my highs and lows - I know how much to correct a low so I don’t eat everything in the refrigerator and I ALWAYS have rolls of Smarties or Fun-Size packs of Skittles so I have a few, not a full sized bag. I am not needle phobic, so doing multiple injections over a few hours is not a problem for me to correct highs. We are all so different, but your comfort range is key to being in the 5’s, 6’s or higher. If you are comfortable watching tv for a couple of hours at 180, it will be more difficult to have a lower A1C.

I traveled to South Africa last year and had to change everything! The food is just different - chicken and most other proteins are not raised in factory farms, the produce is very local and there was very little overly processed food. I imagine Costa Rica is similar. So just be prepared for unexpected results. I exercise at home every day, but I was a slug on that trip. I ate pretty much the same way I do at home. No joke - I was ALWAYS low and took half the bolus insulin and 2/3 the basal. I can only explain it by the quality of the food, which was delicious, fresh and well-prepared. I did cook, but nothing extravagant. Grilling was big! I was unexpectedly low so much I was able to have a delicious local ice cream bar almost every day! Just be careful - I was shocked by the changes.

While you are there, check into prices of your meds, strips and supplies. You might find they are either much cheaper or much more expensive. Whenever I travel I go to a couple of pharmacies and ask. I have stocked up on strips when cheaper than what my insurance covers. I have heard that Lantus and some other pens are very inexpensive in CR (no first hand experience) in case you need to buy some. If you need a prescription, it will need to be a local one. You can’t use a U.S. rx outside of the US, generally. Some countries allow pharmacists to fill insulin/strip/meter needs without an rx (makes sense to me!), but going to a clinic is cheap if needed.

Have fun! Sounds great! Please post updates. I’d love to hear about your experiences. Good luck.