The ongoing pump vs. MDI debate

Diabetes Technology Insulin Pumps
1

This posting is sort of a follow-up to ones that Kimmy and I have recently made on the topic of pumping vs. MDI. I’m now one week into my “Back-to-MDI” experiment (Levemir + Humalog), after 4 years on a Minimed pump (usually w/CGM). What I’m feeling right now is that both systems have really rotten disadvantages, so I thought I’d make a list of the pluses and minuses and see how they compare. Then I thought I’d post it here, just for the heck of it.

So far, pumping is looking to have the advantage, especially when I figure in the relative importance of the various points (ie. I don’t like being hooked up to a device, but I’m even less happy about heading off to an impromptu soccer practice with an unchangeable dose of Levemir already inside me).

One thing I should note is that, for me, my overall control, as reflected by A1c numbers and frequency of highs/lows, has been no different between my years on the pump and my many years + 1 week on MDI. So while I realize that “better control” is a significant pumping advantage for many people, that hasn’t really been the case for me.

Pump advantages (=MDI disadvantages):

  • no forgetting my insulin at home when I go out
  • no forgetting to take twice daily Levemir
  • bolusing for impromptu snacks or meal add-ons much easier
  • integrated CGM available (when it's working!)
  • much more sensitive basal patterning (also, possibly, a disadvantage — see below)
  • temp basals for physical activity
  • very small bolus amounts possible
  • not committed to an injection taken hours earlier (sort of the internal equivalent to being hooked up to tubing)

Pump disadvantages (=MDI advantages):

  • tubing (Omnipod is not yet available in Canada)
  • scarring, shortage of usable "real estate" for pump and CGM sites
  • 24hr attachment to a device
  • current pump isn't waterproof (makes swimming a challenge; could switch to Animas, but then I'd lose the integrated CGM)
  • amount of non-recyclable garbage generated
  • constant reliance on sometimes unreliable external technology to deliver insulin (cannula crimping and other site failures, pump failures etc.)
  • too much information / too many adjustment possibilities (Sometimes I think I over-adjust and then get discouraged when my efforts prove unsuccessful or even damaging: people aren't computers or robots that can be mathematically programmed and fine-tuned, but sometimes the pump literature makes me feel like this should be possible.)

That's it for now, though I expect these lists will need some tweaking!

2

Honestly I can’t wait to start pumping! I do 2 shots a day sometimes three if I am finishing up one pen and starting another to finish the amount of insulin I need. Plus changing it ever three days is fine by me! Better than poking 14 times a week. Plus the CGM I’ll be using is approved for up to 7 days of wear. So I rather be pumping. Plus no excusing myself to the bathroom to give myself a shot, etc. I can just push the button and boom, I can eat! Again I can not wait

3

Heather, I am with you that pumping doesn’t always mean “better control” for me… what it does ultimately mean is that maintaining good control is less of a hassle.

My pro/con lists are very similar to yours :slight_smile:

4

I have had type one for 41 years and have pumped for seven , No, the control is not necessarily better. I got ,to 5.7 on MDI. but I am a woman, and vain, and the MDI ( sometimes 6-7 shots a day was starting to pock up my already cellulite ridden skin. I know you can vary your shot sites, and I did, but I just hated sticking my self over and over again , even for a little snack… I was raised up diabetic fromthe late 60’s with old school one shot a day and “fageedabout it” ( but make sure you have Candy for the NpH peak) routines, so I really did nto like going from one or tw shots a day to 4 to 6 plus… your pump list of advantages and disadvantages are good. I vote for the pump My lowest a1c on the pump has been 6.0. I am 6.6 at latest test in late August. I now it will be higher in November… I am finishing up a round of steroid injetions for spinal stenosis… “UP the Ladder to the Roof” of high blood sugars ( that by the way, was the tile of first song released by the no-more Diana Ross Supremes in 1971 Just an old-school memory" spiking thru "(LOL)



God Bless,

Brunetta.

5

I could not agree more with you Sarah. I have the pod, so tubing is not an issue. Just a constant reminder that I have something stuck to my body.

Some people prefer MDI. I say do what’s best for the individual. (and of course, financially possible)

6

Since you are so active, pumping seems better overall. I would add that cost can be an advantage of MDI. An advantage of pumping is avoiding lows due to the inherent variability of long-acting insulin from one dose to the next. I suspect a pump would save me from up to 7 lows a month. Usually my Lantus peak is a manageable 30 points but some nights I drop 50 or more. It would be nice to not worry about that anymore. So far, I can’t get motivated to take on the tubing despite 56+ needle jabs a week.

7

I’m a fairly new pumper. :slight_smile: I found the best thing I could do was the CGM. It really helped me tighten the control. The pump has also been great because you can fine tune your insulin boluses. I’m not an athlete by any stretch of the imagination, so I don’t have some of the issues others have about fixatives. My control has improved a lot. But like anything diabetic, YMMV.

8

What’s “YMMV”?? :slight_smile:

9

“people aren’t computers or robots that can be mathematically programmed and fine-tuned, but sometimes the pump literature makes me feel like this should be possible.”

This is an interesting point, Heather B. I think the fact that we can somehow manage our illness leads to headgames like this, no matter the method of insulin delivery.

I’m on MDI and I guess I’ll stay on it unless it seems better for me to be on a pump.

10

Your mileage may vary!

11

Interesting responses! Thanks! and good to know what YMMV means :slight_smile:

I like hearing about what the “deal breaker” points are for people who are choosing between pumps and MDI. It helps to sharpen my own often confused thinking about the issues.

12

Great list. I agree, both have compelling advantages and disadvantages, and at different points in life, one may work better than the other, but later that may switch. The pump was really better when I was pregnant than MDI. I have done both and for years was very happy with MDI. Making the switch to the pump was an adjustment, and not entirely positive, but overall I think it is better for me right now. BUt in the future, who knows!

One advantage to pumping that I would add is fewer needles…when I did MDI I always had the needles/pen tips floating around. It was a problem around cats and kids, disposal seems easier with the pump stuff.

13

There is absolutely no more “flexability” provided by a pump than there is with MDI.

The sole difference is a pump allows microdosing in different (2 ?) methods. Yet disconnect from a pump for any meaningful period of time, have a delivery problem or even brief periods disconnect and sugar typically soars, a DKA nasa rocket. The capasity to microdose has a very serious price.

It is the SHORT acting insulins we are using today which permit so called flexability, the technolgy itself is 100% irrelevent.

If you disbelieve, simply switch out whatever short acting insulin you use in your pump with a long acting insulin and pretend to try “flexability” then.

Its the short acting insulin kids!

You eat something and then do not “cover” for it, it will come back at us 100% guaranteed. Blood sugar must be lowered with insulin. Without it, its gonna be higher than desired period. Which method is irrelevent from that perspective. The fact you cover for it is what matters.

MDI, pump are solely subject to human error. Until we can;t guess wrong about absoption. Until we cannot over estimate the carb count. No matte what you call it, the technology is irrelvent.

Now if you do not test, you will not know where you are at. CGM, pumps, MDI are entirely irrelevent to that issue. Testing is 100% mandatory. Don’t care what tools we use, testing is necessary to correct those numbers.

Now if CGM’s were actually “valid” we would not have to cross verify their readings, calibrate the machines so bloody often, before ever being able to act upon their numbers. “Calibration” would be unimportant, and completely unnecessary.

No thanks, puncture myself quite enough already… you can keep those too…

We can eat or snack at any time what so ever. It is the short acting insulins we are using period which makes that possible, NOT the technology at all. Pen, pump, syringe does not matter at all. Coverage is the point.

===========
There is one disadvantage you touched upon, I believe requires far more discussion. If the latest, newest technologies “do not work” for us, where on earth does that leave any of us??? When the technology does not work as advertised, as we require, as we needed what does that leave prey tell?

Great marketing for sure… amazing advertising… many who love theirs too th and nail. But when it does not work, what does that leave, I ask?

Stuart

14

I agree… I think CGM offers a bigger benefit than pumping can… my control improved by leaps and bounds after I started using a CGM. That improvement isn’t necessarily reflected in a lower A1C though, but it is very obvious by my lower standard deviation.

15

It’s strange that you attribute flexibility to the insulin and not to the way in which it is delivered. I agree 100% that microdosing of fast acting insulin, kinda like what your pancreas does when it is functioning, is what gives us the flexibility.



However, I would absolutely hate to even think about trying to microdose with fast acting insulin using MDI. i would have to say that it’s about as close to an impossibility as you can get without being an impossibility.



Pumps allow effective microdosing using fast acting insulin, period.



I completely understand, and agree with, the point you are trying to make. Still, coming from MDI to the Omnipod in particular is a one way trip until they decide to take it away from me.



The puncturing thing is kinda interesting too. Between both my CGM and my Omnipod, I puncture myself about 138 times less a month, on average, than I did when I was on MDI. Technically, I’m not really puncturing myself because bith devices have automated insertion. Even if I did stop using my Dexcom, which i wouldn’t think of doing, I’d be puncturing myself 140 times less a month instead of 138 times less. Those extra two puntures are well worth it though.

16

It really is terrible that you can’t get the Omnipod in Canada given your list of disadvantages Heather. For me, the basal patterning thing was finally what pushed me over. The constant reliance issue is what probably kept me off for as long as it did.

If Animas ever goes throgh with the Dex integration, that be one item off the disadvantage list.

Great list.

17

Another plus I notice with the OmniPod is that I don’t have to worry about the vagaries of Lantus. Its release is even-ish. Rapid acting insulin was a game changer that’s for sure. Only having to deal with short-acting makes things a lot more predictable.

I do still check the Dexcom a lot with a finger test. It’s accurate a lot of the time, but I rely on the Dexcom to show me in which direction I’m heading more than anything else.

I’m a huge fan of the OmniPod. I can’t see myself ever needing to take a vacation. I never thought I’d hear my internist tell me that my A1C was too low.

18

Many discussions on this topic & you summed it up beautifully. Great job.

Pumpers get a far better education on adjusting doses, ratios & carb counting than those on MDI. My theory is that it’s the training that’s responsible for improvements people experience, not the technology itself. I’m a MDI’er & have learned a lot following pump discussions.

19

I agree with you Gerri as far as the education goes. However, I think that it’s only partially responsible. The ability to precisely meter dosing afforded by the hardware and technology is considerable.

It’s one thing to be able to calculate a dose of, say, 3ish units based on carbs in the meal, IC ratio, and any insulin you may have on board. It’s another thing to punch in some numbers and meter out a dose of precisely 2.75 units using the same available info.

It’s another thing, entirely, to be able to meter out basal rates using fast acting insulin to really smooth out peaks and valleys between meals. I honestly don’t know if there’s any practical crossover between the use of long-acting insulin and fast acting insulin to cover basals, but I know which method has worked the best for me.

20

Yes, I think it’s the basal issue that will ultimately (probably quite soon!) send me back to pumping. I can manage all right with rounding my boluses off to the nearest half unit etc., but having to consume extra carbs during a workout to compensate for the Levemir that I injected several hours earlier is getting me down (not that I don’t ever eat exercise carbs when I’m pumping … I think it’s just the psychology of being under the tyranny of the prior injection … to be a tad hyperbolic ;-).



Great to hear that you’re enjoying your Omni, FHS! I look forward to trying that system out, hopefully in the not-tooo-distant future. An Animas/Dex integration would be great, too. For now, I’m investigating alternative infusion sets as a means of diminishing the “bullet holes” problem. I’ve heard good things about the Orbit Micro.



Thanks, everyone, for the additional comments since I last posted, and for the positive feedback on the list. It’s Thanksgiving up here in Canada, and I’m thankful for the great support and friendship I’ve found here on Tu!