To Pump or Not To Pump

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To Pump or Not To Pump

I have some great questions about Insulin Pumps today.

At this point, I will now take a moment and apologize because I have pumped for 12 years & have the benefits of being covered for insulin pump therapy throughout this time, I assume everyone knows what I know about them. I also assume, if they have the ability to, they would automatically want to be on one. That is very ignorant of me and I’m sorry. I started Diabetes Beyond Borders for this very reason, to educate and give as much information to empower you. Unfortunately I missed the mark on this one.

One more small disclaimer. I worked as a Territory Manager for Medtronic Inc. selling Paradigm Insulin Pumps. This Blog will not sell one pump over another. At this point I am now doing Insulin Pump starts & follow-up for Medtronic and Accu-Chek. As a Health Care Professional, peep living with Type 1 & Mom of a Type 1, my aim now is to give you an unbiased summary about Insulin Pump Therapy so that you can research more to see if pumping is right for you & which one best suits your lifestyle & needs if you decide to.

So…here we go….

SIZE: In general, all pumps are bigger then a pager but smaller than a cell phone. Many people have mistaken mine for a pager or cell. In the picture in my hand is one of the smaller ones. I don’t need a lot of insulin, so I use a smaller pump.

COLOURS: You want colour it, you got it. There is charcoal, clear (like mine), pink, green, purple… You can buy covers & skins to decorate it anyway you see fit. I like the clear one because I wear mine in my bra a lot…I don’t want it to be seen through my shirt. A lot of guys like charcoal because it looks more like a pager.

PARTS OF THE PUMP 101:

1. BUTTONS: Used to navigate the pump.  About 5 buttons on the face/front of it, some pumps have ~1 or 2 on the side as well.

2. REMOTE:  Some pumps have remotes that work also as the glucose meter. Not all have this.

3. CARTRIDGE: Fits in the pump which has Rapid Acting insulin such as NovoRapid, NovoLog, Humalog, Apidra (when on a pump you no longer take Long Acting insulin such as NPH, Levemir or Lantus). The cartridge is plastic.

4. TUBING:  It is attached to the cartridge of insulin which comes in various lengths, as short as 18″ to as long as 43″ & a few lengths in between. The tubing is flexible & durable. There is a new ‘patch’ pump on the market that does not have tubing.

5. INFUSION SET: This is the teflon tube or needle that sits under your skin to deliver the Rapid Acting insulin. The tubing connects to the infusion set. It can be connected & disconnected as needed for showering, activity,or intimate moments. There are a variety of infusion sets to choose so that you have the right one for your lifestyle.

BASIC FUNCTIONS OF THE PUMP:

1. BASAL RATE: I call this the ‘base’ or ‘fasting’ delivery of insulin that your pancreas would be doing for you if you didn’t have diabetes. The Long Acting insulin you are taking tries to do this through 1 or 2 injections per day. On the pump, you can customize your basal rate to meet the different needs your body has throughout the day. You can make these changes on an hourly basis if needed. Most people only need 3 − 5 different basal rates during a 24 hour period. They do not change often after they have been established. BUT, the beauty is, you can change them and the time of day you need to. Basal rates are delivered in very small increments throughout the day, each pump delivers the rate based on its own calculation in which that company feels is best for their product but at the end of the day, the delivery is balanced & tiny enough it provides better balance when you are not eating. It is easier to skip a meal or get off schedule without suffering the consequences of a low blood sugar because of the features of a basal rate.

2. BOLUS: Essentially it is the Rapid Acting insulin you inject with. The beauty? The tube is already under your skin so you don’t have to inject. The other benefit is the pump does all the work to calculate your insulin dose. The increments that can be delivered on a pump can be as small as 0.025 units and as big as 35 units. I imagine now your routine on injections involves adding up your carbs, trying to decide how much extra to adjust for a high or low BG, taking a calculator or phone & crunching the numbers to find how much you will inject with your pen or syringe, which usually has to be rounded up or down to the nearest half or full unit of insulin. The built-in bolus calculator allows you to input your BG (usually remotely through the glucose meter), input your carbohydrates. The pump then shows you the breakdown of why it has decided you need a certain amount of insulin. It considers a correction for your sugar to bring it to target, whether that means adding extra to treat a high or subtracting some off to avoid a low. It also shows the carbs you chose & how much insulin you will get based on that. It also takes into consideration how much insulin you still have in your body. Having bad lows from unaccounted insulin still floating around in your body will be no more. The pump remembers.

3. BG READINGS: The pump stores your readings if you enter them into it, whether manually or through your remote meter.

4. CARBS: The pump keeps a history of the carbs you have eaten, when & how much insulin.

5. INCREMENTS: The increments on the basal rate & bolus can be as small or as large as needed. Some pumps vary, so make sure the one you choose fits your needs. Type 1 & Type 2 peeps do very well on pumps for this reason.

6. DELIVERY: The rate a pump delivers insulin varies from pump to pump. Be aware how comfortable you are with the rate it infuses into you.

7. SENSOR: There are only 2 companies that I am aware that offer Continuous Glucose Sensor technology; Medtronic & DexCom. I will post another Blog about this technology. It is far too complex to include it in this one. Suffice to say, having used the technology personally, I see the impact it has on diabetes management & glycemic control.

RESPONSIBILITIES AS A PUMPER:

1. BG TESTING: At least 4 times per day and more often as necessary.

2. INFUSION SET/CARTRIDGE CHANGE: Infusion sets need to be changed every 2 − 3 days, depending on the set you choose. Some companies are saying to change the cartridge & tubing every 3 days, others support 6 is the way to go.

3. DIABETES KETO-ACIDOSIS PROTOCOL: With only having Rapid Acting insulin in your body, it is only in a matter of hours that you will ‘run out’ of insulin in your body if something doesn’t work with your pump. It is easy to trouble shoot & correction can be quick. The trick is to be acutely aware when you test high & adhere strictly to protocol to treat the high sugar. It is rare it can happen but when it does it is SO important to follow the few simple steps it takes to correct it.

WHERE TO WEAR THE PUMP

There is an assortment of clips, pouches & belts that are available from pump companies & online stores. This allows you to decide whether you want it under your pants on your calf, under your skirt around your thigh, clipped on your belt or around your waist, in your bra, around your arm. Creativity, convenience & comfort are key. I know many with  careers from police officers, construction workers, nurses, teachers etc that find living with their insulin pump provides better quality of life for them. It is trial and error of where to place it at first, but once you get your groove, it’s a no-brainer. You’ll forget it’s there.

PROS OF A PUMP:

1. Less low sugars
2. Less variability
3. More flexibility with lifestyle & scheduling
4. Less needles
5. Ability to pro actively prevent low & high sugars with activities, exercise, work etc.
6. Less calculating

CONS OF A PUMP:

1. Have something attached to you 24-7
2. Remembering to change the infusion site, tubing & cartridge on time. (I developed a system to help me remember, some pumps have a reminder in it)

WHAT TO CONSIDER WHEN BUYING A PUMP

1. Ease of Use
2. Technology available that suits your needs
3. Software available to download the results to manage your diabetes
4. Cartridge size (they come in 1.8 mL, 3.0 mL, 3.15 mL)
5. Insurance Coverage
6. Long term costs
7. Pump Company Customer Support
8. Ease of ordering supplies
9. Features within the pump that meet your needs
10. Basal & Bolus delivery increments that meet your insulin needs
11. Infusion set choice (one pump company’s sets are proprietary so you will need to order their supplies only, make sure they have what you want)
12. Some companies require you replace your battery cap & cartridge cap every 3 months. It will be at a cost to you. Make sure to ask about this.
13. Some pumps are waterproof & some are water tight. I have always put it this way…I wouldn’t swim with my cell so why would I swim with my $7,000 pump. Especially in a lake…if it goes to the bottom of the lake there is no getting it back.

I liken deciding to pump & choosing one to buying a car. It’s a long-term, expensive decision you will live with for 4 − 5 years. Shop wisely & make sure to ask a lot of questions. If you have the option to trial one using saline in the cartridge before buying, I urge you to do it.

Always keep in mind:

1. All companies give a 4 year warranty.
2. You have 90 days after you order your pump to return it. If you decide it’s not the right one & you want a different one OR if pumping just isn’t for you. There is no cost to you to return it.
3. Please, please make sure to add your pump to your house insurance policy. If your pump is stolen (which I know people it has happened to!), you want the reassurance you can get it replaced.

You can email me at tracy@diabetesbeyondborders.com with any questions. I am here for you.

All I Ever Wanted – My First of Two

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All I Ever Wanted -  My First of Two

Pictured is days after Cayla was born on June 18,1991. She looks abnormally fat, doesn’t she? She is in the Newborn Critical Care Unit. That is the look of a Macrosomic baby. She was SO sick. I was very sick as well, but not related to diabetes.

In 1990 when I found out I was pregnant with Cayla, I lived with diabetes for 15 years.

At that time I found out I was pregnant I was in my 3rd year of Nursing in College. I was only in College because my Mom told me I should get a post-secondary education “just in case”. She told me that as a woman it’s always good to have an education for when I ever needed it. I didn’t see the point at the time & so much so I was initially kicked out of my 1st year of Nursing. I cared so little about having a post secondary education. I was in love & I just wanted to get married & have a family. That’s all I cared. Before re-starting back into the last half of my 1st year, I married. That helped me re-focus on achieving the education I ‘should’ have.

In the second year of Nursing I did a rotation in the Labour & Delivery floor. Ultimately I helped with several deliveries. I ached for a baby. I wanted to be a Mom SO bad.

At that point, I had 2 goals.

1. Finish my Nursing with honours. My goal was a result of being ‘told’ I couldn’t do something. That wasn’t true, but I saw it that way. I saw it as “they kicked me out, I’ll show ‘them'” I would finish it & with pizzaz.

2. Get pregnant.

Anyone who knows me understands that when Tracy wants something, Tracy will do all the right things & take all the roads needed to achieve it. It takes some painful learning, but I get there in time.

What resulted?

1. Tracy became pregnant 2 months into the 3rd year of Nursing.

When my classmates told me it would be near impossible to finish my year out (my due date was the 1st week of July) or ask me how was I going to do it with diabetes….it made me dig in my heels deeper. I would do it all!! I would graduate from Nursing with Honours, have my baby, write my Nursing exams, become a R.N. & be the best Mom ever.

The Diabetes Complications & Control Trial had yet to begin. There were no guidelines for pregnancy. I had not seen a Diabetes Specialist in years. Thankfully I went to my Family Physician within 6 weeks of suspecting I was pregnant. Back then, the home tests to decide pregnancy were not reliant so early. By blood test, the physician confirmed I was. He immediately referred me to an Internal Medicine Physician who specialized in diabetes. It was not an easy pregnancy.

The variables:

1. My long-acting insulin therapy consisted of NPH morning & supper (today all nighttime insulin is injected at bedtime to avoid missing the coverage of the Dawn Phenomenon causing sometimes severe low blood sugars in the hours shortly after midnight).

2. My short-acting insulin therapy consisted of regular insulin, once at breakfast, once at supper. Humalog had not been launched yet. I knew by how sleepy I was after meals that the regular insulin was not covering my needs. Sometimes, I would take very small doses of regular at lunch to see if it would help. I look back & see how incredible it was that I knew if I could coordinate my meal insulin to my meal sugars I would feel better. Unfortunately, it just resulted in severe lows as it stacked throughout the day.

3. I began my Clinical Consolidation shortly after I became pregnant. I worked 40 hours/week on shift in the hospital. As well, on the weekends I wasn’t on shift at the hospital, I was working as a cashier at a grocery store to help pay the bills. Weekly hours I put in between consolidation & work until I was hospitalized at 32 weeks was in excess of 45-50 hours, not including assignments & studying.

I remember the wild swings in blood sugars. I remember panicking every time the meter I used since I was 11 showed a high or low. I knew it would hurt my baby. Even then hypoglycemia protocol was not in place. If was low, I panicked as I always did. I would drink juice & then eat & eat. What resulted was a high so high I had to take regular insulin to correct in fear I would hurt my baby. As time progressed with the pregnancy, I learned how to manage certain issues. A low treatment was a couple of mouthfuls of milk. That seemed to keep my sugars more stable then before. I decreased the amount of carbs I ate. This eliminated the wild swings.

Unfortunately, it was too late, it did not save my first-born from the complications of a poorly controlled pregnancy.

1. As soon as Cayla was born, her blood sugar was tested.  She went from 11 mmol/L (198 mg/dl) to 2 mmol/L (40 mg/dl) in a matter of minutes.

2. Throughout my illness in the hospital, not related to my diabetes, I gained 45 lbs of fluid. Cayla gained fluid as well. Upon birth she weighed 9 pounds 11 ounces because of this. When they tried to insert an IV to bring he sugar up, they had difficulties getting a vein.

3. She was very, very ill with jaundice. Not only was she placed under lights, but her body was wrapped in a specialize blanket that emitted extra phototherapy. My baby was SO yellow. They poked her little heel with a razor blade too many times. I cried as she shook & screamed when they did it. My saving grace was I saw she had spunk!!

What I describe are the behaviours & control that lead to what Cayla was born with…Macrosomia. She & I were so fortunate, she did not have any respiratory problems. She was only in CCU for 1 week. Each day they told me I couldn’t have her in my room (I was too sick to go home too) I cried. I just wanted to be a Mom.

I took mental notes of my experience with my pregnancy with Cayla. I used them to my advantage with Kurtis.

Look for my post tomorrow on my pregnancy & birth of Kurtis.

The Latest & Greatest

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The Latest & Greatest

Up front I will post a disclaimer. I worked for Novo Nordisk in Canada for 4 1/2 years. I loved working for the company. I know the clinical studies they provided inside out and backwards. In researching this article I have done my best to be impartial to the information I offer. The pic is a result of the fact Kurtis & I use Novo Nordisk products. I have no other product to showcase in my portfolio. I am presenting this blog as a health care professional & peep & Mom of a peep living with diabetes, not as a sales person.

Here is the ‘low down’ in a nutshell based on current clinical evidence AND practical information for intermediate & long acting insulin…

NPH (Novolin NPH, Humulin N): first created in 1950 by Novo Nordisk – NPH is an  intermediate acting insulin. The onset is 1-2 hours, peak (meaning the insulin is at its highest potency) is in 4-12 hour & it lasts 18 − 24 hours. Upon injection it can cover about 1/2 a day or night. It is a highly variable insulin, it can add to the challenges of achieving goals of long-term metabolic control. To equalize the distribution of crystals within the solution of NPH , it needs to be rotated an excessive number of time. This in itself does not guarantee accurate distribution.

Glargine (Lantus): It is a long acting insulin. I can not find when it was first created or by who, so I won’t show what I know from that perspective. It’s onset is 1 − 1 1/2 hours. On product monograph it claims to have ‘no peak’. Duration of action is 18 − 24 hours. Once injected it cover about 1 full day, 24 hours. It is an acidic solution so upon injection there may be burning & stinging. There are studies being conducted with regards to concerns of carcinogenicity. Results will not be published for a few more years.

Detemir (Levemir): It is a long acting insulin. Unlike any other insulin which is bound to fat, it binds to albumin. When bound to albumin, it is inactive. It is unclear when it was created. At any given time 98% of Levemir is considered inactive because it is bound to albumin providing more predictability. It’s onset is 1 − 2 hours. It’s peak is 6 − 8 hours. Duration of action is up to 24 hours.depending on dose. It is shown that smaller amounts injected offer smaller duration of action. Many people living with T1 need 2 injections per day.

If you look up the impact of NPH vs. long-term analogue it may seem that is a better choice. As a sales rep & practitioner, I have seen this. Clinically, it doesn’t the peeps that do the studies aren’t ready to say so yet.

So regardless of what insulin you are on, here are some tips & tricks to help make the insulin you are taking work better:

1. Label each insulin bottle upon opening.
2. Discard that insulin, whether it is finished or not, 28 days after first date of taking out of the fridge.
3. Keep insulin at room temperature. If it freezes or gets too warm (>28C) THROW IT OUT!!
4. Know your insulin.
5. Know your body.
6. Know how to inject properly. (any needle tip more than 8mm should be changed under your diabetes team watch!!)
7. Don’t switch brands without consulting with your diabetes team.
8. Do not mix Lantus or Levemir with any other insulin!
9. Levemir & Lantus are CLEAR!! Read the label before injecting!!
10. Keep to the same site to rotate your sites. HUH?!? you say….I tell my patients…Long acting legs, short acting stomach. BUT, rotate. It prevents lipohypertrophy (fat deposits) but guarantees more predictability with insulin release.
11. Higher doses of insulin reduce the blood sugar levels more than lower doses.
12. If you have exercised be conscience of where you have injected or are going to inject. Areas that have been exercised & then injected with insulin offer more unpredictability.
13. Do not apply heat (such as bath, shower, heat pack or massage) to the area injected. Heat speeds the insulin along.
14. Keep hydrated. Insulin is not absorbed as readily when there is not as much fluid available because blood isn’t flowing as easily as it should.

I also urge you to Google the brands. Ask your health care team. Read, read, read. That’s how I started on Humalog!!

Insulin is a complicated topic. It’s variables are abounding. But with common sense, getting to know you or your child well & being informed to the choices available as well as asking for the change that may be needed, this enables you & your loved one to live with Diabetes Beyond Borders.

As Exciting As the Discovery of Insulin!

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As Exciting As the Discovery of Insulin!

In 1983 and for the next 10 years, researchers began to study whether intensifying diabetes management among people living with Type 1 made a difference. Up to this point there had not been long term research to provide data to prove this to institute change.

When I was diagnosed in 1975, I started on one injection of NPH and Toronto in the morning.  A Keto-Diastix before & after school & at bedtime was dipped in a urine sample to determine sugar & ketones. Little did we know that it was not an accurate test of glucose control. Every 3 months my blood work was done & thankfully my A1C as well. We would see the Paediatrician shortly after.

In 1981, an extra injection of NPH & Toronto was added at supper time. Around that same time I received my first glucose meter.

This study has changed the way people with Type 1 diabetes are managed. It was & still is exciting!

Here is what the Diabetes & Complications Control Trial is about.

There were 1,441 people from Canada & the U.S from 29 centres living with Type 1 diabetes more than 1 year but less than 15 years. They could not take part if they had too many or severe low blood sugars, severe complications or limited life expectancy. The ages studied ranged between 13 and 39. Young children were not studied. There were 2 groups; 1 had their diabetes managed intensively, the others managed as before.

The main goal was to keep blood sugars as normal as possible through a criteria of intense methods for diabetes management.

Clinical findings & significance:

1. The risk of eye complications were reduced 76%.
2. The risk of complications of the kidney were reduced by 50%.
3. The risk of nerve complications were reduced by 60%.
4. By keeping blood sugar’s as normal as possible, the onset & progression of eye, kidney & nerve damage caused by diabetes slowed.
5. Even those who had a history of poor control who sustained any type of BG lowering showed a difference in the progression of complications.
6. For those who already had eye complications by participating in intensive management of their diabetes, they saw the progression of the complication slow by 54%.

What is Intensive Management?

1. Testing BG 4 or more times a day.
2. Injecting insulin at least 3 times per day or using an insulin pump.
3. Following a diet & exercise plan.
4. Monthly visits to a health care team which consists of a physician, nurse, dietician & behavioural therapist.

Risks involved with participating in an intensive management therapy? Low blood sugars. It was clear that less stringent goals are appropriate for some patients.

This trial has become the pioneer of studies that changed the management of Type 1 diabetes . Since completion of the study in 1993 there has been further work done to answer more questions & give more data. I will continue to post on these.