I have good control with diet, a Dexcom 6, and injectable insulins (Humalog/Tresiba), but I’m wondering if I need to ‘up my game’. I’m retiring at the end of this year and wondering how worthwhile it would be to change to using a closed-loop system, smart pens, or upgrading to a Dexcom 7.
Llet me know what you think!
I already used CGM+pump+hybrid-closed-loop but to keep my options open I made sure I had a C-peptide on record. It’s not clear now for pumps but there was a time when either a C-peptide or the immune test had to be on file to get a pump. I think that has changed in the last couple of years but don’t rely on it 
Apart from this you will need a receiver for your Dexcom G6 (or any CGM); you do not need to get one until you are on MediCare. The CGM supplier will simply provide one on demand. I made the mistake of getting a G7 receiver less than a year before going on to MediCare (since I knew one would be required) and then, two weeks after it turned 1 it died. Dexcom only give a one year warranty to private insurance, so I had to get a new one from my MediCare supplier. That one has a three year warranty! Three times better.
Since you are changing insurance in the US you get freedom of choice over what you do. Once you make the choice you are locked in even if it turns out to be a hopelessly bad choice. That means 3 years with a pump you hate.
So since you are considering a change do it now then if it sort-of works but something sucks, e.g. the G7 or the specific pump, you get a second suck with different kit when you go on MediCare. For example if you tried the G7 with a Medtronic pump or the Omnipod O5 and it didn’t work for you then you can simply go back to the G6 and, maybe, Omnipod Dash pods (if you liked pumping)
You can always go back to MDI, so far as I know, so at least try the G7 now so you can drop back to your current kit.
As to how worthwhile it is I’ve been on a sequence over the last 10 or more years which started with the Omnipod Eros pods (or maybe the ones before) and the Dexcom G4. The G4 just didn’t work but I stuck with the pods for years (no CGM) then tried the G6. That worked ok and I got improved HbA1c results. Some time after a few more years I started looking at the various loop systems. This was about when Insulet were promising the O5 but it took so long that I ended up with AndroidAPS and, at that point, I swapped to the G7. The results of the swap to an AID system were spectacular. HbA1c down from around 7 to around 6.
Depending on how much you carb count (I carb guess) and how much you control your diet (I eat what is on the plate in front of me) you may get less mileage out of a closed loop system but I don’t think you should ever lose out because the things can be turned off.
Moving to a pump gives so much more control. That’s the first thing I did and for me that gave me the ability to manage stacking simply because my pump can deliver 0.05IU - try doing that with a syringe or, indeed, a pen!
Pumps to look at:
Medtronic/Tandem - both basically the same. Metal gismo with tubes sticking out of it. Boring
Omnipod. The only remaining self contained pump. The O5 is a hybrid closed loop system which people seem to love or hate (so a good thing to try now if you are considering it), the Dash is what I use and can only be looped with extra software (TidePool, AndroidAPS). IRC neither, including I believe TidePool, are FDA approved in this application.
Twiist. I think this is the one my endo keeps going on about. Twiist uses TidePool and is fully approved in the US (I think; that’s what their marketing says, so check yourself). There’s a lot of expertise here and on FUD with TidePool so it may be a good choice for that reason.
Pretty open-ended question, but I’d start by saying the root argument in favor of insulin pumps from the start of the technology is basal control. Even pre-closed loop, the idea was that you could set different rates throughout the 24-hr period that would better correspond to your basal patterns than could be achieved with a single- or even two-per-day-shot of long-acting. I was doing all kinds of crazy things to try to get my DP under control before going on a pump; with a pump, I just set a higher rate for 4-7am, problem solved. Flip side of that is that you can pause delivery if you want, say for exercise, which you absolutely can’t do with long-acting injections. Beyond that, a pump has memory, so it’s much easier to keep track of what you’ve been doing, insulin-wise. That moment when you’re in the middle of dinner and suddenly can’t remember how much you bolused or even whether you bolused. The pump keeps all that info for you.
Those are the big chunks.
As regards closed-loop, I’ve been on Medtronic’s older system and currently use Tandem C:IQ. That experience led me to the understanding that there are two rather divergent design philosophies at work. Medtronic and some of the other newer systems coming online are designed around the concept that the pump should try to do everything for you. My experience with the Medtronic was frustrating because it entailed locking me out of settings I might want to tweak it to fit my metabolism and my expectations of what constitutes tight control. But other people love it. I think iLet takes things even further in this direction. I have no experience with it but I see the same mix of reviews. You either love it because it takes all the controls out of your hands and does everything for you, or hate it for more or less the same reason. Tandem seems to be in the minority in pursuing a design that acts more as a smart assistant than a master control system. You program it with basal rates, just like a dumb pump, which the C:IQ uses as a baseline but will increment up or down in real time based on CGM readings. It calculates boluses for you based on your input and current BG readings, but all those fields are editable if you need to—I want a smaller bolus if I know I’m going for a bike ride in an hour, that kind of thing. You can even edit the BG field, which I’ve done if I’ve had to do a CGM calibration but want to bolus before the system updates. With Medtronic that would be a HAL 9000 moment: “I’m sorry Dave, I can’t let you do that.”*
Downside of pumping vs MDI: more failure points, which can make it hard to diagnose problems when things aren’t going as expected. Is it my infusion site? My insulin? Bent canula? Something getting clogged in the insulin cartridge? Air in the tubes? I know plenty of people who take a pump vacation and go back to MDI just because it’s so much more straightforward. As for the data thing, that would be the argument for a smart pen. I don’t have any experience with those, and more critically I’m not sure what kind of coverage the insurers will carry—that would be something to research.
*ETA: important to mention that Medtronic requires their proprietary CGM system, whereas Tandem, Omnipod and iLet use Dexcom, and Tandem also supports Libre.
I have the opposite advice. I retired a couple years ago, and like you was using Tresiba, Novalog, and Dexcom G6. And that is what I am still using today.
I asked the same question of my endo when I was about to start medicare, and he reassured me that there was no reason to get a pump prior to being on medicare because it is easy for a T1 to get a pump on medicare (I have had T1 for 50 years) so I didn’t feel the need to rush into it.
I talk with my endo about whether it is time to go on a pump most visits, but he said that my control is so good using injections that it would be worse and not better with an AID pump. Personally I like the freedom of not being connected to a pump which would necessitate dealing with infusion sets and tubing or pods which need to be changed every three days. And I like the simplicity of MDI compared to pumps. It is easier to pack up and go and there is less uncertainty (is my set blocked, did it come loose when I bumped it, etc). When I inject insulin, I know it is in my body starting to do its work.
If Tresiba did not work so well and I was still on Lantus or Levemir then I probably would already be on a pump. And I assume that at some point either the AID pumps will have improved enough to make a compelling case for using one; or that I will be old enough to want to just turn control of my BG over to an algorithm, imperfect as it may be.
The only justification I can see for rushing to get on a pump prior to joining medicare is the absurd law that makes insulin free when it is to go into a tubed pump. That law is an abomination due to intense lobbying by the medical tech companies. When insulin was hundreds of dollars per vial it could have pushed someone into using a pump when they preferred MDI. But luckily the democrats were able to pass the law for $35 insulin on Medicare, so if you choose the right Part D prescription plan then you will not have to pay more than $70 per month for insulin, potentially less if you use your vials to the end. I probably pay only $300 per year for all my insulin.
And one other benefit of staying on MDI with your CGM is that you only need to see your endo/nurse twice a year instead of four times a year. This is a Medicare requirement that you can’t get around.
I started on Medicare 3 years ago and was pleasantly surprised at how easy it became to obtain Omnipod refills and Dexcom G6 and now G7 supplies. I don’t think anyone needs to base their timing or start of adopting new tech on before or after starting Medicare (such as going from MDI to pump, etc). As long as you have up to date doctor notes the DME coverage seems fine. Omnipod 5 is covered via Part D so you must choose a Part D plan that covers it. The question of using a Dexcom receiver vs an iphone never came up, DME coverage seems pretty straightforward especially with a decent Medigap plan to cover the copay.
The only adjustment I had to make with Medicare was switching from Fiasp to Lyumjev for fast acting, based on Part D formulary issues. I use 3 insulins (Lyumjev, Humalog and Affrezza) and I have a prescription for Lantus in case I need a long acting. Have never had any push back on keeping up with insulin refills and now with the $2000 oop max for Part D plans the spare insulin refills became very affordable.
Do it, absolutely. I’m using CamAPS which is loop software, it learns and leaves (forgets) exponentially, it learns on a daily, and hourly basis, and can predict at mind boggling certainty, you can go to sleep and it will bring you (me in this case) into flat and smooth bg. Usually there’s a two to three week period where they learn about how insulin affects you but after this you can largely let go of the control. This is probably the hardest thing, letting it control. If you’re into really tight control this is probably the hardest part, with these systems, but learning what to control and how to work with it is enjoyable, and you can can get amazing results. I can’t recommend them enough, and it is at least at this point ‘the future’ of diabetes control, it’s truly the best thing to happen to diabetes apart from the discovery of insulin.
Congrats on being able to retire! What are you planning to do for the next 10-30 years because that’ll be a big part of your decision to try new things. My experience with a desk job like yours is you have a lot of control over the variables affecting blood sugar. Depending on how big a change your retirement plans are from your current daily routine and how you did managing your blood sugar last time you took time off to have a big adventure a pump may be helpful enough to make the downsides worth it. I do MDI now and last time I traveled to another country I saw how a pump would be useful. Super long term I expect to have to get booked into senior jail and I definitely want to be on a pump before that happens. Preferably before I’m too curmudgeonly to learn how to use it.
For the other things any time is a good time to try a bluetooth enabled pen to make logging easier. The battery in my Novopen Echo just died so I’m looking forward to trying Medtronic Minimed’s Inpen and comparing the reports to Dexcom’s.
During the last few years, I’ve given a lot of thought to the inevitable later senior years. The piece of the puzzle that is proving most challenging to me is dealing with the reality that most, or possibly almost all, of the credentialed professionals and the lower level caretakers are nowhere near the current competency I have managing my glucose with insulin. They are stretched thin and primarily motivated by avoiding hypoglycemia at all costs. Extended hyperglycemia is totally acceptable to the credentialed class and related caregivers, hospital acquired infections and lost healing opportunities be darned!
I’m now in my 10th year using an automated dosing system with superb results and very few episodes of metabolic drama. For more than five years my A1c has ranged from 4.8% to 5.4%, insulin usage only averages 0.39 units per day/kg of body weight, and TIR is 90%+, 65-120 (3.6-6.7). I can’t reasonably expect any institution can even come close to replicating these results.
I believe it highly likely that diabetic seniors who lose the cognitive and/or physical ability to dose insulin and end up in an institution will be moved to MDI if they’re on a pump. I checked with the hospital I would likely end up in and their formulary basal insulin is Lantus. I’ve read that many people do not get a full 24 hour coverage from this.
I worry that my CGM will be discontinued, thereby eliminating a valuable data source even if someone wanted to pay attention to this data stream. I also worry that as a T1D, an institution could lose sight of the fact that I need basal insulin each and every day regardless of whether I’m eating or not.
I’m currently researching a rarely used tool that might be useful to my future self: an Advanced Directive Diabetes Addendum that could have some useful effect as this can be integrated into the active controlling medical record.
Sorry if I’ve veered too far off of the OP’s original question. I suggest that he keep his time horizon a bit shorter/less complicated and make plans for his early Medicare life when his cognitive and physical abilities are intact. In the meantime he can construct a plan to address the more complicated time when he may end up in senior jail!
Hi James. I am on shots using pens, and I am using the same insulins that you use. I am 74 and I was dx in 1959. I try to not go under 65 and try not to go over 140. I have had only 1 A1c over 5.3 in 20 yrs.
I have thought about using a pump thinking it might be easier, but I don’t really know if it would be. I don’t understand how a pump works with a CGM which can be 30 points off. I love having a CGM but I don’t trust its accuracy. I still do quite a few blood tests and sometimes the CGM results are very accurate, but certainly not always.
I am reading about new pumps but I have never wanted the work of using a pump. I have gone 66 yrs without a pump, and I will probably stay with MDI. Good luck deciding what to do.
Terry, I have worried about how well I would be taken care of in assisted living, but I have decided that if i could not give myself insulin, because of mental insufficiency than I probably wouldn’t be very interested in staying alive. I helped take care of my mom and dad when they were in assisted living, and I saw many people who were mentally challenged and their lives were not good. I don’t want to stay alive if my life has lost its meaning.
If I was physically and mentally fit, I wouldn’t be able to keep my insulin needs low because my diet would have to change so much. The future continues to be scary.
Yes, Marilyn, it scares me, too. Your position to remain on MDI instead of using a pump is completely rational. Even though I choose to remain on an algorithm based pump/CGM system, I know I’ll likely be switched to MDI if I can no longer competently execute metabolic decisions.
We’ve each chosen different paths for the time being and we understand the ultimate irony of handing over control to a system that hasn’t demonstrated competence.
The best we can do is enjoy the precious now and make every day count. Let’s hope that we can stretch this last bit on for many more years!
Come to Australia Terry, I’ll look after you mate, at least for the next 20 years! Now I think about it, looking after an elderly person with diabetes, I’d say an AID system and a few sugarmate clocks round the house would make it so much easier to look after an elderly person especially if you get them into a routine, you could lock their blood sugar down nice and steady and probably the only fuss would be just changing sets and sensors, there’s nothing like routine to help keep blood sugars low and even . Now, I’m only half joking here, if you did live in the same country I couldn’t leave someone that was family or a friend go into the hands of the system, and it worries me greatly that yourself and others are frightened, it’s so wrong on many levels I find it hard to deal with, no one should have to worry about what you guys are concerned at, but the reality of it, is frightful.
Thanks for the positive feedback, Shaun. The sentiment you express buoys my spirit. It’s ironic that personal adoption of an AID pump with its connected CGM every five minutes displaying BG on an iPhone and Apple Watch that actually cuts the usual burden on managing diabetes burden is a situation that befuddles the medical mainstream! If they just relaxed and went with the flow, it would be so much easier on the care administration and better for the aging diabetic senior.
I could only dream of the kind of assistance that you envision. If I could clone myself, it would be done for both me and people like @Marilyn6. We all must face reality and deal with situations that can frighten. It’s the human condition. But having to face a reality that doesn’t have to be makes it difficult for me. It’s possibly just an emphatic “life isn’t fair” lesson that I must accept.
I remain hopeful. I’ve been surprised by many positive developments in diabetes care in the last 10 years. None of us can know the future. For the time being, life is good!
I would wait for updated and new versions of pumps. I have 780g and would not recommend. Current sensor awful and they have been promising new one forever. Theirs is a generation behind others. Pump was always reliable. 780G system is a pain. Since it was purched by Medicare I have to wait 4 and 1/2 years to get another on Part B. Waiting to try Twiist. Try Diabetech and other sources for info on current and coming pumps.
Diabetech 
Thanks @John_Bowler. I’ve reached out to my endo and team, but they haven’t gotten back to me yet, which is surprising. Maybe it was too complicated a question.
I’ve seen studies for less-well-controlled diabetics, and the pump improvements are marginal, but that could be because those people didn’t have the methods/habits to make it work better. They had to be poorly controlled to begin with.
As for diet, I eat a controlled diet, striving for 300-400 calories per meal, good mix of protein and low-glycemic carbs, but family dinners out and ‘gifts’ from the spouse make that variable.
Thanks @DrBB. I have a learned dislike of Medtronic, and it seems like I should still avoid them. My endo hasn’t pushed me to get a pump, since I seem to have done a decent job of controlling things over the years. I am fairly techie, but appreciate simplicity, so having fewer moving parts could be better from a peace of mind perspective.
The smart pen sounds less complicated and less essential, so it might be easier to add to my current regimen and would allow me to tie back insulin njections to my blood sugar numbers. As to this last part, I’m the kind of person that can program Python to analyze my numbers, looking for trends and correlations.
Thanks @Jag1. Staying the course is certainly worth considering. It sounds like I have a similar regimen to yours. I didn’t see you mentioning a watch, but I find seeing my numbers on my watch essential, as without it my numbers creep up.
Thanks @Terry4. As always, an informative and interesting response. Long term, I have concerns about one’s mental abilities - it’s almost inevitable if one lives long enough - but not a current consideration.
As for avoiding lows, I am fine, my blood sugar rarely dips into troubling territory, but yes, my current endo and team seem more concerned about lows, sometimes in the range that is not severe.
Thank you @Marilyn6. As always, a thoughtful response. With your level of control, it does not seem like a pump would be of any use. I’m technical, so getting it to work wouldn’t be a problem, and the variation is tolerable to me, but I would want to avoid the complexity. But even then, I avoided pumps 20 years ago because I didn’t want to have to deal with tubes, but now that tubeless systems are here, I’m avoiding complexity. Who knows, I still might try them. At the gym, young diabetics I’ve met have always used pumps and swear by them.