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Posts from the ‘Insulin’ Category

When Good Insulin Goes BAD.

Ninety percent of the time, my high blood sugar has an identifiable reason, and there’s a cluster of common causes.  Did I under-estimate the carbs in a snack and therefore under-bolus?  Did I over-treat a low blood sugar?  Did I eat without bolusing at all (it happens)?  Is there a lot of stress floating around that I’m responding to?

Most of the time, those questions cover the why.  Once in a while, my highs are for rogue reasons, like an air bubble in my pump tubing.  Or when I eat something carb-heavy right after an insulin pump site change (it’s like that first bolus doesn’t “catch” somehow).  Or I forgot to reconnect my pump.  Or if the cat bites through my pump tubing.

But rarely, if ever, is one of my high blood sugars the result of bad insulin.

Except it totally happened last week, when two days of bullshit high numbers had me mitigating every possible variable … other than swapping out the insulin itself.  (And clearly I’m stubborn and/or in denial about the quality of my insulin’s influence on my blood sugars?)  I rage-bolused.  I exercised.  I low-carbed the eff out of an entire day.  I did a site change at midnight to take a bite out of the highs.  Nothing.  The downward-sloping arrow on my Dexcom graph had gone on hiatus.

(Always a punched-in-the-gut feeling to see the word HIGH on a Dexcom graph, accompanied by an up arrow.)

But ditching the bottle of insulin entirely and swapping in a new Humalog vial?  That did the trick in a big way.  For once, it was the insulin.  Next time, it will surely be the cat.

Changing the Set.

Changing out an insulin pump infusion set is a methodical moment for me. I do things in the same order almost every time, with the same mildly frenetic mindset.

  • Remove old set from my body so I can enjoy the “connected to nothing” feeling for as long as possible.
  • Take out a new infusion set and new reservoir.
  • Ferret out the open bottle of insulin from wherever I’ve stashed it last in the bathroom.  (Usually it’s in the medicine cabinet, but during the hotter months of summer, I tend to keep it in our bedroom, where it’s cooler.)
  • Line the insulin set, reservoir, and bottle up on the counter.
  • Unscrew the reservoir cap and remove the old infusion set and reservoir from the pump.  Throw the tangle of tubing into the garbage, making sure said tangle doesn’t dangle over the edge of the garbage can because otherwise Loopy and Siah will find it and drag it all over the house.
  • Open the packaging for the reservoir and take out all the little parts (except that one frigging thing that I don’t know what it’s for and I usually throw it right into the garbage – see below):

  • Rewind the pump.
  • This is the point where I mentally set some kind of timer, challenging myself to race against the time it takes for the pump to rewind.  While the pump is whirring, I rush to fill up the reservoir and connect it to the tubing.  I do this every, single time.  It’s as satisfyingly ritualistic as shaking the bottle of test strips before I check my blood sugar.
  • Thread the tubing through the battery cap and connect the luer lock, then insert the cartridge into the pump.
  • Load the new cartridge.
  • Prime the cartridge, trying to stop the prime before more than a single drop of insulin escapes from the needle in the infusion set.
  • Hold the tubing up to the light and inspect it for bubbles.
  • After the pump is primed, again the mental timer is set.  This time, the challenge is to unpeel the sticky backing from the infusion set and find a place on my body that’s suitable for insertion before the screen on my pump goes blank from inactivity.
  • Insert the new infusion set, prime the cannula (sort of holding my breath while it primes because I’m never certain that the first introduction of insulin won’t burn under my skin).
  • Tuck the tubing out of sight and clip the pump to my clothes.
  • Fin.  (As in “the end.”  There’s no marine life actively involved in this process.)

This process takes less than two minutes to complete, but if it’s interrupted in any way, I’m thrown so far off course that it takes me five minutes to recover.  The method of this madness is that it’s one, fluid mental movement and any upset to the process makes my brain disengage to seek the comfort of something shiny.

It’s an intricate process involving several steps, precision handling, and the safe housing a powerful drug.  And if I have to change the battery at the same time …

 

Pre-Bolusing for Snacks.

“Do you pre-bolus for your meals?”

“I do.”  (I was happy to answer this question because I actually do pre-bolus.  Pre-bolusing is my A1C’s saving grace.)

“Okay, that’s great.”  She made a few notes in my chart.  “How about for snacks?  Do you pre-bolus for those?”

“I … um, nope.  I am horrible at pre-bolusing for snacks.”

Unfortunately, hat is completely and utterly true.

Meals are easier to pre-bolus for because there’s time involved in making them.  If I know I’m cooking chicken and green beans for dinner, I have 25 – 30 minutes to let that bolus sink in before the meal is even ready.  Going out to eat at restaurants is easy, too, because I usually have an idea of what I’d like to eat, so I’ll bolus for the meal once we are seated at the table.  (Pre-bolusing backfires at times, too, but as long as I’m not in the middle of the woods, I’ll take the risk.)  A meal feels like an event, and therefore easier to accommodate.

Snacks feel like an accident.  An unplanned moment.  I don’t take an apple out of the basket and bite into it in a premeditated fashion, but more like a fluid movement without any thought involved.  (A run-by fruiting by any other name …)  It’s not until I’m done with a snack – apple, yogurt, nuts, protein bar … cupcake? – that I realize I haven’t taken any insulin to cover the carbs.  My post-snackial blood sugars aren’t grateful for the misstep.

This would not be a big deal if I wasn’t such a grazer, but when 50% of my caloric intake throughout the day is on a whim, pre-bolusing for snacks matters.  My A1C is currently in my range (under 7%) but I know if I can remember even half the time to pre-bolus for snacks, I bet my standard deviation will tighten up and blah blah blah other numbers as well.

Little, conscious changes will hopefully become habit.

 

Guest Post: The One Diabetes Rule I Always Follow.

Thanks to the magic of the Internet and how words can travel from CA to RI by email faster than a sneeze, I’m happy to be hosting a guest post from friend and fellow PWD, Christopher Angell.  (You may remember him from such glucose tabs as GlucoLift and such guest posts as the one about decAY1c.)  Today, he’s writing about the diabetes rules he’s willing to bend and the one he always follows. 

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When I was first diagnosed and started my testing and insulin regimen, I did everything by the book. I disinfected test and injection sites with alcohol swabs (no longer recommended). I used a fresh lancet for every finger stick, and I always removed and properly disposed of my pen needles after each injection. I was a model patient (except on those nights when I washed down a giant bowl of popcorn and a chocolate bar with a bottle or so of pinot noir…).

Over time, however, my diligence started to show some cracks. After one too many meals out where I fished out my Humalog pen only to realize I was out of needles, I started leaving my last used needle on, and only changing it right before my next injection, so that worst case, I wouldn’t have to skip dinner or run home and force everyone else to wait while I retrieved my supplies. After using that “emergency needle” one or two times with no adverse effect, I got more and more lenient, until I was only changing a needle when it started to hurt (or required noticeably more force to do its job). Then of course I figured that if needles could be treated like that, lancets certainly could too- they were far less delicate to begin with, since they weren’t hollow.

When I started on a Dexcom CGM, it didn’t take me long to realize that those expensive sensors could have their lives prolonged without consequence as well, and I was regularly getting more than 14 days out them (I still do). Unlike reusing the relatively cheap lancets and needles, that had a real financial advantage. I also quickly learned that I could save my skin some wear and tear by using sites other than the FDA-approved abdomen. In fact, now I can’t remember the last time I wore a sensor there.

Even insulin, I discovered, was often (though not always) good well after its expiration date, or its 30-day window after opening, and subjecting it to a life outside the fridge was usually surprisingly benign.

Now that I’m on a pump, I generally change my cartridge and tubing every 6 days. I still take Lantus as well, and use one needle for the life of each pen, and I’m confident that I will never have to buy another lancet as long as I live (even if I were to live for 1000 years). So to say that I play fast and loose with the usage guidelines of my diabetes devices is to put it mildly. I don’t do it to be stubborn, and generally speaking I don’t do it to save money (though that’s a welcome result). I do it because every second not buying, storing, or changing a lancet, needle, sensor, or pump cartridge is a second that diabetes hasn’t stolen from me, a second that can be spent sleeping, talking, eating, ANYTHING but diabetes-ing. And if I’ve learned anything from living with a chronic disease, it’s that ultimately there are no small things – over time they all add up. Those seconds becomes hours and days over a lifetime with diabetes, so they’re precious to me, and I will only surrender them to diabetes if I truly believe I’m getting something better in return.

Which brings me to the one rule I DO always follow: I never leave an infusion set in longer than three days. Why? Limited real estate. I already know that prolonged injection/infusion of insulin changes my body, and I can tell the difference between a site that has been in one or two days and one that has been in three. I know that over time, the ability for certain locations to absorb insulin can be compromised, and I know I only have so many locations. I also believe that the next substantial improvement in my treatment will be some version of a dual hormone closed-loop pump (quite possibly Ed Damiano and Steven Russell’s Bionic Pancreas). This means I will need twice as much serviceable tissue to enjoy the full benefit of that treatment. So I’m doing my best to preserve what I have. Spending that time now correlate to very real potential benefits  in the future.

In the meantime, I’ve found other uses for my lancets.

Don’t Mind Me.

Don’t mind me …

… I’ll just be sitting here with 1 unit of Humalog left in my pump because I went to bed with 9 units left and tried to use my insulin to the very last drop.  I’ll let my dawn phenomenon-induced morning basal rate suck up the rest of this cartridge before swapping it out for a full one.  Insulin isn’t something I take for granted.  It’s precious stuff.

Guest Post: Timesulin, Innovation, and the Sniff Test.

People with diabetes know what people with diabetes want, and John Sjölund is no exception to this rule.  Diagnosed with type 1 diabetes just before he turned four, he has created a simple, streamlined solution to make multiple daily injections easier to manage:  Timesulin. I’ve used his product, and thought of it as “informed MDI’ing.”  Recently, he kicked off an Indiegogo campaign to raise funds to help bring Timesulin to the US market, and today, he’s sharing the how and why of that effort.

*   *   *

If we haven’t yet had the opportunity to meet, you won’t know that diabetes doesn’t define me. Diabetes has, however, given me a platform to speak to amazing people, to ensure I live healthier than most of my non-D friends and it’s put me on a path to try to make life for all of us around the world with diabetes a little easier. In fact, I have made this my mission!

I have lived with type 1 for 28 years, first diagnosed a couple of days before my fourth birthday. I really have never known a different life to one that consists of 6-10 finger pricks a day, 4-6 insulin injections and constantly checking in with my body to check whether my blood glucose levels are high…or that dreaded low. That said, diabetes has never held me back from leading a life that is full, high-paced and filled with excitement! Kickboxing, triathlons, sky diving or traveling off the beaten path (horseback riding in Lesotho??) …I decide what I want to do and then make adjustments to allow me to do whatever I set my mind to, despite my faulty pancreas.

With this life, however, few things are as routine as taking my four daily insulin shots – one before each meal and a slow-acting injection at bedtime. And maybe it’s because I usually have a thousand things on the go, but over the years I have often caught myself feeling unsure of whether or not I had taken my shot. Do you know that feeling? I would step out of the shower, ready to get to bed and then have that sinking feeling, ‘Ugh…Did I take it, or not?’ or sit down for dinner and then have that niggling worry hit me.

Not having a way of knowing for sure was driving me nuts! The best method I had was to ask my then-girlfriend, Susan (now my wife and pregnant with our twin boys, due any day now!) if she had seen me take my insulin. Too often, we had to resort to the Sniff Test.

The ‘Sniff Test?’ Indeed.

Susan has a keen sense of smell and would sniff my belly, legs or arms to see if the smell of insulin was present around the injection site, which was the sign that I had already taken it. After a shower, however, the method was less reliable as the smell of body wash would mask the pungent smell of insulin. The sniff test just wasn’t a fail safe method to see if I had taken my insulin or not, something that 77% of physicians estimate happens as many as six times a month for those of us with diabetes, according to a study done by Novo Nordisk. Also, I tend to take my long-acting insulin in the backside … and Susan often exerted her right to not have to sniff that region in the name of healthy living!

Frustrated with the existing solutions that were available to me from large pharmaceutical brands, I gathered a team, which included my brother Andreas, one of the creators of Skype, to create Timesulin – a smart replacement cap for your existing insulin pen to simply show how much time had passed since the last shot. By having this basic information you can make decisions that will help you avoid an accidental missed or double dose of insulin – which can have very serious effects. Very importantly, we didn’t want Timesulin to incorporate wi-fi, bluetooth or USB plugs or any other mumbo-jumbo that I felt complicated life with diabetes (it’s worth noting that I am a tech junky, know html and CSS, can program, but when it comes to diabetes I believe in the idea of ‘Keeping it simple’). I’m proud to say that we created a product that encompassed all of this – and is today being sold in forty countries around the globe – two years after launching to consumers in February 2012!

As proud as I am on a personal level that our simple solution has helped so many people, I am super frustrated that we haven’t been successful in getting our product to the United States. Why you may ask?

  • Requirements for U.S. regulatory registration (which function well, we are supporters of keeping people safe) on medical devices are lengthy and more expensive than in Europe. It is a big undertaking for my team both in cost, time and resources to get it done, with no 100% guarantee that it will be worthwhile
  • The sheer size of the U.S., which makes distribution and logistics a challenge.
  • The costs of marketing a new brand in a market cluttered with medical advertising from big pharmaceutical brands with enormous budgets.

Most importantly, I realized that patients in the United States are not given the same choices about which devices will help them live their best possible life with diabetes. I want to change this.

We just launched a crowdfunding campaign on Indiegogo to help us raise the funds necessary to file for approval from the FDA and help us get Timesulin approved for distribution in the U.S. I am particularly excited about this as it truly lets those of us living with diabetes the ability to vote and decide for ourselves what tools we need. Is Timesulin going to solve everybody’s challenges with diabetes? Of course not, but it can play one small yet important part in allowing people to not be afraid of taking a double dose. Since I couldn’t find a solution that worked for me, I decided to start Timesulin. I have been super frustrated at not being able to empower other people to make that same decision for themselves, and I think that crowdfunding may just have the potential to help us.

This is just the start, we have lots of other ideas that we want to launch, which may not be blockbusters that cure diabetes, but can go a long way, until a cure is reached, in making life with diabetes a little simpler, less complicated and perhaps less scary.

We need your help to get there, and without the support of other people with diabetes, it will be impossible for us to keep innovating.

I know it has made things much easier for myself – and for Susan! – and importantly, we no longer have any of those awkward restaurant moments when it’s a toss up between pulling my shirt up to have her ‘Sniff Test’ my belly and taking the risk of an accidental double dose when I simply feel unsure of whether or not I had already administered my insulin dose. These days I just glance at Timesulin and know.

And now, so can you! Please help us succeed with this campaign and help everyone who’s ever needed a “Sniffer.”

*   *   *

You can follow the Timesulin efforts through their Twitter account, learn more about the product on their website, and you can help support the campaign by visiting their Indiegogo page.  And if your significant other has ever sniffed your skin for insulin, show them this post; they are not alone.

Guest Post: How the MiniMed 530G Changed My Diabetes Management (Without Ever Even Seeing it in Person)

SUM is being borrowed today by Christopher Angell, fellow PWD and creator of GlucoLift, so that he can share his thoughts on the Minimed 530G … without having ever seen or used the system.  What is he on about?  Find out …

*   *   *

Leading up to the launch of the Medtronic 530G (and what a long lead-up it was) I kept asking myself “What’s the big deal?” It seemed like, apart from a new sensor (which some data had already shown to be a minimal improvement over their previous sensor, and a far cry from the already-extant Dexcom G4 Platinum) the only real innovation was the introduction of the low glucose suspend (LGS) feature, which shuts off insulin delivery after a series of alarms alerting the user about low blood sugar are ignored. “How useful could that possibly be?” I wondered.

We’re constantly told that, because of the action curve of our rapid acting insulins, changes in pump basal delivery should be calculated for events 30-60 minutes in the future. So how does shutting off my basal drip help me if I’m crashing NOW?

Still, my curiosity got the better of me.

Now, I don’t use a Medtronic pump (Tandem t:slim), or a Medtronic CGM (Dexcom G4), and I don’t even get all of my basal insulin from my pump (my current split is about 57% from my pump and 43% from a single bedtime Lantus injection). So my experience is probably in no way directly comparable to what someone using the Medtronic system would experience. Nonetheless, I started experimenting with what I’ll call MLGS (manual low glucose suspend). I didn’t use it for all of my lows, but there are a couple situations where I’ve found it to be rather useful.

The first is where my bolus and my food may be correctly matched, but are out of step. For example, say I bolused for a meal that’s mostly protein, fat, and some slower carbs, like a steak with sides of spinach and broccoli. Then after the meal, I notice a slow dip on my Dexcom, but I KNOW that once the meal starts digesting, there will be plenty of food to give the insulin I have on board something to do.

Previously, I would have eaten one or two proactive glucose tablets to keep the insulin busy while the steak and veggies get over their stage fright. Now, I’ll just unhook my pump, or set a temp rate of 0 units for 15-30 minutes. And as long as I didn’t way over-bolus, that dip tends to reverse on its own, and I’ve managed to avoid unwanted, unnecessary carbs (delicious though they may be). This is especially useful if I’ve eaten a late dinner, and don’t notice the dip until after I’ve brushed my teeth. I can still get into bed, unhook, and read until I see the CGM line flatten out, then hook back up, without re-fouling my pristine pearly whites.

The other situation where I find myself implementing MLGS is with my serious, all-hands-on-deck lows. You know, the ones where every second spared from their depths means less of a hangover, and more of my day returned to my control. There are two caveats to using MLGS with this type of low. The first is that, since I’m not at my most functional when these lows hit, I’m more likely to use the “unhook the pump” method than the “very responsibly set a temp rate” method. This means that it’s very important to remember to re-attach my pump after I turn the corner on the low. The second is that since disconnecting, even for a little while, leaves me more vulnerable to a rebound high, I always treat these lows with glucose tablets, as opposed to my fridge-clearing binges of yore. I know when I’ve eaten enough glucose to right the ship, but I have to be disciplined enough to trust it and not pile another 50g of future disaster carbs on top.

When I do those two things successfully, my bad lows feel less bad, and I seem to recover from them faster. Can I measure/prove this? No. Do I care? Not really. If it feels to me like it’s working, and I believe it’s an improvement, then it kind of is, even without hard data to verify or explain it.

So even though I’ve never used the new Medtronic MiniMed 530G, or even seen one in person (as far as I know), it has nonetheless made a positive contribution to my diabetes management toolkit, which, when you think about it, is pretty impressive.

*   *   *

Christopher Angell is the founder of GlucoLift glucose tabs (I have a stash of them in my cabinet, and they are so much better than your average glucose tab) and a good friend, diagnosed with type 1 diabetes at the age of 30.  He’s contributed here before, exploring the t:slim insulin pump and both travel and dental woes.  For more from Chris, you can check out the GlucoLift company blog.  To taste test GlucoLift glucose tabs for yourself, you can purchase them from their online store, or write to caring@glucolift.com for samples.  Tell ‘em Loopy sent you.

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