Remote mountain trek: Would it help to switch from MDI to pump?

Type 1 and LADA
1

Greetings,
I will be very grateful for feedback from those who have used both MDI and pump. Thanks in advance. I have been on MDI Humalog and Lantus since my diagnosis in Aug 2014 and have good BG control. The occasional high BG hiccups so far are all caused by incorrect bolus for poorly predicted meals. Have never gone too low before catching/correcting.

I am planning a 125 mile hiking trip in late summer. This is “hut to hut” hiking in the Alps. The trip is through the mountains at 5,000 to 9,000 feet altitude and sleeping overnight in remote huts that provide dinner, breakfast and brown bag lunch as part of the rate to stay there. I have taken similar trips before (prior to the Type I diagnosis) and believe I can handle the altitude and strenuous long day aspect of BG control by staying on MDI and adjusting my basal as needed.

My concern is the food. When you pull into these mountain huts at the end of day, you end up eating whatever meals they serve. The meals are usually pretty carb heavy. The trip is too long to carry all my own food. I am worried that I will have trouble carb guessing and bolussing and might not be able to solve all those BG problems with only MDI.

My question is: Would it be easier to adjust on the fly, make corrections, etc if I switch to a pump (compared to staying with MDI)? Or would the hassles of a pump up in the mountains outweigh the benefits? I will be many days away from a pharmacy most of the time. I’m pretty confident I can keep my insulin pens from spoiling but have no idea if insulin spoilage would be a hassle with a pump.

Side question: I am planning to get a CGM before the trip (have never used one). Does anybody think that maintaining the CGM will be a problem and not worth the hassle? My endo is skeptical that a CGM will be of much help, she advocates bringing hundreds of test strips and lots of extra testing.

2

Whether you decide to do MDI or a pump for your hike, I would STRONGLY recommend a CGM, and the sooner the better so you can get comfortable with it before the trek. Sure you can replicate that with hundreds of test strips, but that’s kind of the point: you get data every five minutes without having to pull out the strips and lancer, and if you’re ever in doubt, you can always check with a strip.

3

… and by the way … sounds like a great hike – have fun!

4

If it were me, I would do it with a CGM and a pump. With a pump you can dial back on your basal as needed. With MDI, whatever you choose for your basal dose, you’re committed for 12-24 hours. If you go low, all you can do is eat carbs.

With such a strenuous hike every day, you may even be able to completely turn off your basal. Another thing, be very aware of delayed hypoglycemia that can hit during the night after a strenuous day. This is due to all the muscles in your body replenishing their local glycogen supplies during the night as you sleep.

I once woke up in a tent in a campground in the middle of the night after peddling up the flanks of Mt. Hood. I was so low, I couldn’t see straight. I finally found some glucose source at the bottom of one of my bags even though I had some right next to my pillow! Delayed hypoglycemia is a real thing. Hiking at those elevations is taxing just by itself.

I suppose someone with lots of MDI experience could adjust for the strenuous hiking and blood glucose levels. Can you do some simulated hikes beforehand to get a feeling for the insulin dosing?

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5

I find the pump far superior for my daily life. I don’t do any long hikes like you’re doing and never have, it’s just not possible for me to do anything too long with this disease because I crash all over the place without warning often later on and during sometimes. Both the pump and cgm are life saving and life improving for me- they aren’t perfect by any means but they do make everything easier and give me a sense of security. I’m not sure about maintaining a pump on a trip like this, My pump cartridge has to be changed every 3 days or the insulin can degrade. Also freezing or too hot temps can cause the insulin to freeze or to degrade in the pump also. For a dexcom you would just need to bring enough sensors to change them when needed I think. It shouldn’t be a huge problem.

Of course even if you decide to use a pump, you still need your syringes/pens in case the pump fails. If you use a tandem I recommend bringing a small portable charger(ifrog) which you can power your pump off of to recharge the battery and if it fails. I did that when mine failed and then the replacement failed until they sent a brand new one. The top button had broken so I couldn’t get into the menu without plugging it in to charge and couldn’t bolus with it. For a complete insulin delivery failure you will need your injectable equipment of course also. I carry a vial/pen and syringes/pen/pen needles with me everywhere as well as a spare inset/tubing and such. I recommend the stainless steel inset needles because they don’t have issues as do many of the plastic cannulas and they are less likely to cause pain/irritation.

6

Downside of a pump is that if it fails in a remote area like this you’re in a really bad situation— so you’d have to be carrying backup MDI gear anyway… Just in case.
I work in remote environments and that is part of the reasoning why ive never opted for a pump, because I have to have the MDI gear with me at all times anyway in case a pump ever failed…

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Thanks for the quick responses! Keep 'em coming, this is all very helpful.

If I go to a pump (understood I will have to carry MDI supplies for backup) is it everybody’s feeling the pump is easier to use for after-meal corrections compared to MDI correction bolus? I had the impression that was the biggest benefit of pumping insulin, small tweaks are more possible. My biggest worry is the unfamiliar food and screwing up my bolus too much on the high-BG side. Maybe I am overconfident about the possibility of over-bolussing and ending up low after a meal, as that has not been a problem for me.

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The pump does afford much more flexibility for dealing with unexpected circumstances, particularly in that you’ll be exercising steadily and with a pump you can easily back off the basal, whereas with MDI you’re stuck with however much Lantus you’ve already injected.

The downside of the pump for what you’re planning is that there’s a lot more paraphernalia to carry around so you have extras if you rip out an insertion site or have other problems. It just is a more complicated system with a lot more potential failure points.

The clearest message you should be getting here, though, is that your endo is nuts about the CGM not being helpful and just bringing lots of strips. The kind of excursion you’re planning, with lots of unknowns each day in terms of how much exercise you’re going to get, what kind of food you’re going to be having, not to mention a time change of 5-8 hours depending on where you live (I assume US?) makes a CGM exceedingly helpful. I first got one last spring for a trip to France just to make the time change transition easier and it was a huge help. I don’t know what your endo could be thinking…

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Two years ago I walked the West Highland Way in Scotland (ca 100 miles in a week, through the Scottish Highlands). I have done a fair amount of day-walking in the Alps over the years. For the WHW I was using a pump and CGM, some of the Alpine walks were done over 20 years ago, on MDI+ fingersticks, although I have walked more recently whilst pumping.

It is certainly a LOT easier with a pump. The problem with using MDI is not just the boluses. You can deal with this using a pen. However walking those sorts of distances has a considerable effect on basal. In my case, when walking the WHI, I had my basal rates temped down by around 50% all day (whilst I was actually walking), but had to put them back to their “normal” settings overnight. I used my CGM as a guide, so I think the settings were pretty accurate. Although you could achieve an overall reduction in basal with long-acting insulin by reducing the dose, you would not be able to regulate it on an hour-by-hour basis without using a pump.

I did do some considerable day trips whilst on MDI (e.g one particular day involved >1700m of ascent/decent + 20 km map distance). I was basically having to stuff carbs in every hour to keep my levels up. I hasten to add this was 20 years ago, I don’t think I would find it so easy now.

I haven’t found wearing a pump on a mountain causes any sort of “hassle”, and it is much easier to glance at a screen to get a cgm reading than fish out test strips, lancing device and a meter. This could be important as aside from the much better information from a CGM (ability to predict BG trends) there are places where a hypo would be undesirable. I assume that your endo has no experience of standing on a 30 cm wide ridge with 300 m vertical drops on both sides. .

Where are you from and what is the funding provision for a pump and cgm? If you can get both, I would strongly advise that you get both. If you can only get funding for a pump, you might seriously consider self-funding the CGM - I do.

If you are going to go down this route, remember it will take you several months to get enough experience of the pump+Cgm to start to use it properly. You should consider starting now. I wouldn’t want to be on a mountain as a new pumper.

Good luck - have a great trip.

Joel

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Thanks for the info!

I’m not overly worried about the BG drops while hiking as we take a pretty slow pace. It is the “Haute Route” from Chamonix to Zermatt. There are alternate route variants that can reduce the vertical climb on some of the tougher days if we are so inclined. These variants serve the added benefit of dropping us down to a village at a few spots, if needed. The trip is not “high exposure” (my wife has an artificial hip joint) but has some days similar to the long day you described. Food served at breakfast usually includes croissants, bread, fruit etc. that I can carry for high carb snacks plus a lot of Clif bars and glucose tabs.

I might have been a little unfair on my endo with the original post; so far she is not “enthused” about the benefits of switching to a pump (or a CGM for that matter) mainly because I am doing fine with MDI. She has described the “hassles” of fiddling with the injection sites, CGM alarms going off, etc. as bothersome. In her defense, I have only had a preliminary discussion about this and will have an appt. in March to borrow a CGM and test it out and to request a prescription for a pump if I decide to go that route. The trip’s not till August and I plan to take some long day hikes beforehand to calibrate myself and make sure I can use the equipment. I have not figured out yet if my insurance will cover either (I am in Seattle area).

Some more basic questions:

  1. I have experience with a Frio for safeguarding my insulin pens. Does the insulin for a pump require anything different? 2. Does any pumper recommend carrying a total spare pump in case the first one has technical problems, or can recommend a basic list of extra pump supplies that would be good to have (Sorry for the basic question but I have never even seen a pump up close so am pretty clueless at this point)?
  2. My main concern is the unknown dinner food and after dinner/sleeping BG. I am worried that I will eat a plate of high starch high carb dinner and guess wrong on my bolus. If that happens and I have to correct for high BG after dinner, how many hours (with CGM and pump) after dinner does it take before you all are comfortable that you have corrected properly?
  3. Is there a modern alternative to a Glucagon kit?
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I’ve never protected my pump with a Frio, but I live in San Francisco, a relatively mild climate. I used to downhill ski a lot and wearing the pump close to my body heat and layered over by jackets and other clothing was all I ever needed.

If it were me, I’d just carry MDI supplies as your backup. A pump is small and wouldn’t be a burden to carry but I think MDI supplies are needed anyway, so why carry two backups?

[quote=“John58, post:10, topic:51475”]
If that happens and I have to correct for high BG after dinner, how many hours (with CGM and pump) after dinner does it take before you all are comfortable that you have corrected properly?[/quote]

It depends on the duration of insulin action (DIA) number you use in your pump. Most people use a shorter duration than I do. I program 5 hours into my pump for Apidra. Your number is discoverable with testing. The insulin is used up more in the early part of that period, it’s a nonlinear action. I feel safe going to sleep with less than 1.0 units of insulin on board (IOB), that is previously delivered insulin that is yet to act. This situation has enough moving parts, DIA, IOB, and insulin correction factor, that you would be well served wearing a pump for a few months before this excursion.

Not that I’m aware of, but there is a lot of research going into this topic with the work on the artificial pancreas project. I think your best tools will be your constant attention combined with a well calibrated CGM. Make sure you have plenty of emergency glucose. Chewing a glucose tab chased by a healthy swig of water works quickly for me. You might carry some glucose paste that come in tubes; it’s kind of pricey but it’s something someone could squirt in your mouth if you were passed out.

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Slight change of topic. I used to do some strenuous hikes (before arthritis in my knees) and I would always figure out the maximum sugar corrections I might possibly need (I like to use Jelly Bellies for this purpose.) Then I would take about ten times that much. Overkill, maybe. But it would surprise me sometimes just how many carbs I might need to avoid hypoglycemia. Better than having to beg strangers for sugar on the trail or to get helicoptered out. Also, bring plenty of food with carbs (granola bars, cookies, etc.) so if you figure out halfway through the morning you have too much basal on board you can feed your insulin if need be. Sounds like great trip!

13

I use Medtronic pumps and always take a spare with me if I’m going to be out without support. Medtronic rents spare pumps for $50.00 and this includes shipping to/from home. Pumping insulin is the Gold standard. Many of us old timers have a collection of spare pumps. I have also been using a CGM since they where first introduced to the market and it has completely changed the way I mange my BG. I would recommend a CGM and a pump, the sooner the better. Get started now and you can decide what is best for you when the time comes. It will take many years for you to really become proficient at using insulin and learning just how your body is going to react to the infinite combination’s of food + activity + insulin + life = ?. There are people playing pro sports and climbing the highest mountains while wearing pumps…again you will need to figure out what you can manage :slightly_smiling:

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14

With my tandem t slim I can do tiny boluses and basal rates. With all pumps( I believe) you can suspend the insulin completely in one way or another- I do it with 0% basal rates on mine. If you make a mistake in either direction a pump gives you the ability to correct it easily. Your cgm will warn you if you’re going up/down and at what rate so you can catch mistakes more quickly usually. There is no comparison with mdi, you can never adjust your basal rates minute by minute if needed with mdi or at all.

For a trip like this you will need to carry more around but most of it won’t weigh too much. The pump supplies are very light weight, it’s just a matter of having enough with you and your back up. Most of us who use pumps feel much happier with them than with mdi so carrying around mdi and extra pump supplies is worth it. You also need to be more careful of dka since that can happen much more easily with a pump if it fails, if your inset fails or if you’re sick/dehydrated etc.

As for pump failure, you will have your injectable back up and many companies will ship a replacement overnight or two day mail if you contact them with an address to send it to. I would think lows will be more of a problem with all of the activity and delayed need for glucose for muscles while you sleep, if you did this before then you have some idea of how you will react.

I agree about over treating lows, I’m often surprised by how much sugar I need to stop a fast dropping low. One technique someone mentioned here a while back is to swirl a sip of a glucose shot or juice in your mouth for as long as possible- it will go into your brain immediately through mucous membranes- I think that is how it works- it really does stop a dropping low in its tracks for me. That and suspending the basal insulin.

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So I haven’t read through everyone else’s comments, but here’s my two cents (which often runs contrary to the others, given that I’ve gone back and forth between MDI and pump and am generally happy with MDI, so spoiler alert for that!)

Out of order answers…
I am planning to get a CGM before the trip (have never used one). Does anybody think that maintaining the CGM will be a problem and not worth the hassle? My endo is skeptical that a CGM will be of much help, she advocates bringing hundreds of test strips and lots of extra testing.

A CGM is worth its weight in gold, and also worth paying out of pocket for in my experience (which I have done in the past with no regrets). Yes, still bring lots of strips and test as needed as your endo suggests, but a CGM brings so much piece of mind, not just for yourself but also the others around you, that its worth getting tomorrow! I use the Dexcom CGM (because it works lightyears better than the other) and regularly have about… zero problems with it. I use extra tape to help it stick longer, and even swimming laps a few times a week I regularly get 20+ days out of a single sensor, so its a low a hassle thing as any I’ve ever used, and the piece of mind it brings is worth even more than the potential for better control, at least in my opinion.What does your endo think a CGM is to be used for if not for this sort of activity???
**Corrected after the fact… I suppose keeping a CGM receiver charged could be seen as a hassle, but there are several solar chargeable battery packs available that work fine, and I’ve even seen (but not tried yet) a motion-powered charger that would be pretty slick if it worked, so there are options even if your version of “remote” includes no power outlets for weeks on end. (That being said, I regularly get 5-6 days on my receiver between charges, so its not like a phone that needs re-powering every night.)

Would it be easier to adjust on the fly, make corrections, etc if I switch to a pump (compared to staying with MDI)?

If you want daily or hourly basal rate changes, YES to a pump. But, you specifically mentioned concern regarding guessing carb counts on high carb meals and having to correct afterwards, and to that aspect I say MDI and pumps are equal IF YOU USE A BOLUS CALCULATOR. If you do injection math in your head and don’t account for IOB, a pump will give you better answers. However, there are several IOB calculators that do a fabulous job (my favorite is RapidCalc, available via iTunes and runs fine on a iTouch, no wifi/data connection required so good even “out in the woods”). If you don’t account for IOB in your current bolus calculations, shame on your endo for not bringing that up! Correcting by 2 units two hours after a meal is either a quick 30seconds with a pen or syringe, or a 30-second round of button pushing on a pump. While a pump can fine tune and give tinier doses (.05 units in many cases), most adults don’t see a benefit from using such minuscule increments in bolus/correction dosing. For what its worth, I speak of actual experience on this one: my last backpacking trip I did with a CGM and MDI with RapidCalc on my iTouch and was a pretty happy camper (except for the weather, but a pump wouldn’t have helped on that front!).

Or would the hassles of a pump up in the mountains outweigh the benefits? I will be many days away from a pharmacy most of the time. I’m pretty confident I can keep my insulin pens from spoiling but have no idea if insulin spoilage would be a hassle with a pump.

Pens and vials need the same treatment, so if you’d protect one, you should protect the other; but the rest of the pump supplies are not temperature sensitive so that makes that part easy at least. The harder question though, “would the hassles of a pump outweigh the benefits?” My first answer is that if you are happy in your regular life with MDI, then stick with that, but if you’re already considering switching to a pump for various other reasons, go for it with the following thoughts in mind: The decision to pump and ultimate happiness doing so will depend entirely on… well, YOU, with a side note that not all pump trainers are created equal, and your first month or two is largely dependent on your trainers training, and how comfortable you are making changes without orders. (I know people who after 15 years still make a doctor appt to adjust their basal rates, and others who are continuously tweaking on their own; both methods have their pros and cons). A pump comes with a lot of parts and pieces and while they can work wonderfully, they can also fail dramatically. And if you’ve never used one before, I’d caution you that there is a pretty steep learning curve, and I would get at least 2-3 months of pumping under your belt before taking it on a trip. Sure, some of your ability to catch on quick will be due to the training you receive, but I don’t think anyone has ever started pumping and felt like they had it under control in just a few weeks. Also, there are many different makes and models of pumps, and so if you were primarily shopping for one to take “adventuring”, you’d want to make sure to shop for one that would hold up to what you were going to throw at it. Because I have a penchant for water, its more important that I look for one that is at least watertight which might not be as big a concern for others: and whether or not there is tubing will affect where you can put it and you’ll want to make sure that jives with how you wear your backpack. I like my pack’s waistband low around my hips, which means (when wearing a pack) I am generally limited to infusion sites on my upper belly or thighs, but someone who wears a waistband higher up could gain real estate on the lower belly and maybe backside and some of that will be affected by the infusion set of pump you choose. FYI, I have yet to go through a pump training course where they start you out with anything but belly sites, so if you go that route, know that pump trainers are generally a conservative bunch and they have to suggest only FDA-approved sites, which aren’t always where “real life users” put infusion sites (or CGM sites, for that matter). Also to be considered would be the pump’s power source- and for remote adventures the ones that take AAA batteries are probably easier, otherwise you need to bring a power source to keep it charged up.

It sounds like a fun adventure either way though, you will come back and tell us how it worked out?!

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Thanks for all the great and detailed responses! This community is a great resource and it’s comforting to know there are people out there willing to spend the time and mental energy to help.

I’m headed to my endo in 3 weeks and will get a prescription for a CGM at that time. I have not yet decided on the pump. FYI I’m chickening out a little on the Haute Route hike as far as the remoteness and heading to the Dolomites for a trek with more villages and fewer mountain huts. I figure I can limit myself to a max of 2 days distance from civilization at all times. It just seems llike the best approach to build in some rest days and nights close to a grocery store especially considering what I’ve found out about the difficulty of the hike route.

Anyway, some oof the responses got me a little confused about the best way to get started with a pump. Is there an accepted way to get trained for pump use? Is it a CDE, a rep from the pump manufacturer, an online source, or ?? What is the best way to learn about how to use the pump (supplemental to trial and error which is how I usually learn things).

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Knowing what I know now, if I got to design my (first) pump start again here’s what I’d push for:

  1. Initial training with the pump rep, because they are going to be the most experienced in the menus, buttons, and optional setting on the exact pump you are training to use.
  2. Weekly (for the first few weeks) and monthly (for the next few months) follow ups with a CDE to help you fine-tune rates and ratios and help show you how and when to maximize the less commonly used settings on your pump.
  3. The book “Think Like a Pancreas” and “Pumping Insulin” on your bedside table, and regular question asking here!

Things that might make any of those impractical: Your pump company might not have a rep within several hundred miles. Your insurance might not enjoy your continuing visits to a CDE. You might not find a CDE you like. You might have a next door neighbor who is already using the same pump you are looking at, and who would love to help you.

I got my first pump start in 2002, and at the time my doctor had never heard of a pump (I brought him a brochure after I convinced him to sign the prescription), I got two two-hour sessions with a pump rep and CDE (combined, they regularly worked together as a team), and then I floundered on my own for quite some time. To be fair, a lot of my floundering was because I had never even heard of carb counting before, was coming off of Regular and NPH and had never used Humalog before, and had to figure out words like “basal”, “I:C ratio” and “sensitivty factor” all at once. The Bolus Wizard hadn’t been invented yet so I was doing all this math in my head and did a pi$$-p00r job of writing it down and analyzing it (because I didn’t know that was a thing to do!). It was, quite honestly, like being rediagnosed and I think for many reasons I fell through a bunch of cracks and had a lot rougher go of it then others might have.

However, when I switched companies 10 years later, I thought since I was a “pro” at pumping and knew all the vocabulary and already had my rates and ratios worked out, I didn’t need any help, and the company didn’t have a rep within 2,000 miles anyway, so I went for it on my own (after reading the user manual, watching a bunch of Youtube videos, etc, “on my own” does not mean without resources). And I struggled. But this time I had the internet in my house (!!!), I knew of the DOC, had heard of several good books (but hadn’t bought any yet), and proceeded to learn the long slow hard way about how to maximize the new pump. That was… three or four years ago, and I have since moved on to pump #3, but I ran into a pump rep at a recent conference and when I described some of the reason why I ditched pump #2, she had some quick ready tips that could have made my stint with that pump easier even though I already knew all about pumping in general. For pump #2 I should have still gone to training with a pump rep, and probably a follow up with a CDE a few weeks later to fine-tune my settings, but could have skipped a lot of the repeat CDE visits.

Interrupt years of pumping with injections for a year…

By pump #3, I had/have full confidence in myself to manage different treatment regimes deftly and confidently, but each pump has some small quirks and this time I found the local person using the pump to give me a quick lesson on tips and tricks to make life easier, and it was still helpful.

(And yes, I am back on injections for the time being, and doing well with them, so a lot of what I have learned over time is just more diabetes management and not specific to any particular treatment method or pump, but I personally find there’s a lot of things that cross over between pumps and injecting if you can get the right mindset around it.)

So, while that is my own personal rough-and-tumble story of starting and changing pumps in an area not generally serviced by pump reps and with only basic CDE coverage, I have met MANY MANY MANY people who use only the minimal functions on their pump and could potentially benefit greatly from a “touch up” pump training every now and then to remind them of some of the “advanced” options (temp basal, dual/square bolus, different profiles etc).

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18

After reading your post, I looked up the Haute Route. I am familiar with the area around Chamonix, and you should be aware that the daily verticals involved are significant - the website I looked at offering guided and unguided tours described the route as “very strenuous”, so although there will not be a lot of exposure or any technical sections you do need to be very fit. I have walked some of the day sections of the Tour de Mont Blanc which I found fairly tough, and that is described as less strenuous than the Haute Route. The Dolomite routes look fun too!. I am seriously considering the idea but for 2017, as I would want to do at least a few months serious training before attempting the routes.

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How do you adjust insulin for strenuous exercise? You can’t hike fast when BG is high and you can’t hike at all when BG is low. It sounds like a lot of changes at one time. It’s possible to do with CGM and pump. On mdi and blood tests you will have off times. The modern equipment makes it easier to catch going hi or low sooner and making correction. The body responds in ways that aren’t intuitively obvious.

20

I’m pretty comfortable with adjusting my MDI insulin for the hiking as long as I have a decent handle on the carbs in my meals/snacks. My issue is keeping track of the BG so I know where things are headed and can make adjustments on the fly. I’ve tried a few things on some longish strenuous days over the past few weeks to calibrate myself and by lowering both my basal and my I:C things seem to be OK.

I struck out with my health insurance covering a CGM. They have an appeal process but so far I have heard nothing from them to create any optimism that they will change their decision. Red tape has always bothered me, this is looking like more of the same…

Are there any members here using a Dexcom G5 and paying out of pocket for everything? I am trying to get a handle on the up front cost and monthly cost, does Dexcom discount it if they know you’re paying 100% yourself, etc. Would it make sense for me in the long run to try to find different health insurance that covers the CGM?