Throwing an idea out there - please feel free to shoot me down if this has been said before

[tim2000s]

I understand that the way that pumps are used is to provide a basal insulin which is set up on an hourly or similarly periodic basis, plus boluses as and when necessary, with the added capability to vary the duration and amount of bolus that is done dependent on food type.

As was quoted in a different topic, pumps are really only an insulin administration device. Thinking about this made me wonder whether there is room for a cross between MDI and pump therapy. A kind of Hybrid Theory if you will (sorry Linkin Park).

I may be totally wrong here, and if I am I apologise, but it seems to me that pump therapy is really an extension of MDI, in as much as you replace the Basal insulin with pump maintained basal rate. Bolusing is more or less the same, and if you are undertaking dynamic management or intensive management, you are probably mimicking pump functions with MDI (multi-wave boluses, etc).

The question I was asking myself was whether there is room for a hybrid model which uses something like Tresiba to deliver a background insulin (potentially at a lower level than if it was your only basal) with the pump providing a level of basal on top, plus the flexibility around bolusing and dealing with things like Dawn Phenomenon.

I know it's not a normal therapy approach, but it struck me that it may provide a level of protection from sudden spikes in BG levels when there are issues with the pump, giving a level of protection (and maybe comfort) against DKA, while retaining the flexibility that a pump provides to cover DP and the unusual reactions to some food types.

Apologies if this is the wrong place to post this, but I thought it quite an interesting thought experiment.

 

[CarbsRok]

I use a pump because I do not have a flat profile, I've never had DKA in my 50 years of diabetes either and in all honesty with the invention of home blood testing it should not happen. It is very rare that a pump issue would cause DKA it's more down to the user not doing the required blood tests.
A pump for me is a God send as it can deliver 0.025u per hour for a basal where as MDI certainly can not.

So for me your idea is a non starter

 

[tim2000s]

I use a pump because I do not have a flat profile, I've never had DKA in my 50 years of diabetes either and in all honesty with the invention of home blood testing it should not happen. It is very rare that a pump issue would cause DKA it's more down to the user not doing the required blood tests.
A pump for me is a God send as it can deliver 0.025u per hour for a basal where as MDI certainly can not.

So for me your idea is a non starter

Fair enough! 0.025u per hour is an amazingly low basal rate! What's your total basal over a 24 hour period?

 

[CarbsRok]

Fair enough! 0.025u per hour is an amazingly low basal rate! What's your total basal over a 24 hour period?

About 19.
I have Addison's disease so have to take steroids all the time so need at the moment about 2.12u for two hours of the day as well.
Four hours is spent at 0.025u/hr (8-midnight)

 

[Diamattic]

I am sure your theory would work, but is it worth it?

The cost of the infusion sets and time they can remain in your body is fixed at 2-4 days depending on the set. If you are injecting a basal on your own then you loose the ability to alter that with its need, but also you would be loading your resevoirs with less insulin, AND still needing pens and needles.

In my eyes, you would be consuming more disposables, have more to keep track of and organize, and have less flexibility all while paying more money because on top of regular pump supplies you would need the extra pens and needles.

It is doable, and i have thought about doing that with my lantus as I have many Lantus pens left over still, but i dont think it is a long term solution for me.

 

[azure]

I'd be nervous about the amount of non-pump basal. It'd have to be enough but not too much. I don't know how that'd be worked out.

Personally, I wouldn't like to use any long acting insulin as my basal needs vary so much during the night, and the pump lets me manage those needs and avoid the awful hypos I used to have. I also think I must have an issue with long acting insulin as I remember it being absorbed very unevenly and causing highs and lows randomly.

 

[phoenix]

Have a look at https://en.wikipedia.org/wiki/Untethered_regimen
Like carbsRok, the whole benefit of the pump to me is being able to reduce basal rates. My basal at the moment is 0.45units an hour. If I were walking then I would set it at 40% ie 0.175units and if it were within 3 hours of eating I would probably lower it to almost nothing for a time(because of the bolus insulin onboard) I still don't always avoid hypos.
It was the reason I went on a pump and though I don't think I go quite as low as I did 8 years ago, I still feel I need that flexibility.

 

[iHs]

My need for a pump is more or less the same as @azure. My basal need does vary a tiny bit from time to time and as soon as I started using a pump, the writing on the wall become fairly clear for me to see.........my bg levels tend to fall naturally between midnight and 4am and the pumps basal rate settings can be adjusted to deal with that whereas using insulin pens, I either needed to make my bg levels go higher before going to bed or eat some carb snack to prevent them dropping very low or set alarms up to wake me up before the hypo started. Now that I use a pump, although there are times when they cause problems, I now sleep a lot better and my OH doesnt worry about me anymore.

 

[noblehead]

No it would be extremely hard to replicate the delivery of basal rates using anything but a pump, plus the delivery of bolus doses using a pump could never be matched on MDI as pumps can deliver doses over several hours.

 

[donnellysdogs]

Why would you want to wear a pump and inject as well?? No way for me.. Blimey the spares to carry for a pump were enough.. I could not see how a long acting insulin could really be effective... As it gives less possibility of being flexible.. And that is the whole point of a pump..

 

[Spiker]

Yes I can kind of see the point of using the pump basal only small variations around a tresiba basal. But all the obvious objections have been made.

I don't need micro-tuning for my basal and I am lucky enough to have a flattish profile that it easily matched by injected (non pump) basal. Before I fell off the pump I was considering a different type of variant therapy which was to use the pump for basal but use pens for bolus. Why? Simply so I wouldn't have to hoik the pump out to do bolus all the time, and so I could wear the pump more discreetly. Because for all the other reasons, the pump is a better bolus device than a pen.

If it's a given you are going to be wearing a pump, I don't actually think it's that big a deal to also carry a bolus pen. So, if some kind of variant therapy has any advantage over just wearing a pump, I don't think the 'necessity' of also carrying bolus pens, let alone doing a once a day basal pen injection, automatically makes it a non starter.

Tim I applaud your continuing efforts to think outside the box, even if this one is not necessarily a winner.

 

[Spiker]

20 years of Type 1 and I had DKA only once and only in the first 1-2 years. Then, first 4 months of using a pump and I had DKA at least 4 times, in hospital twice. There are solid stats showing increased risk of DKA on pumps. It's about the only thing that there are solid stats showing any kind of difference, good or bad, between pumps and MDI.

 

[donnellysdogs]

I also had two horrendous DKA moments of levels at 30 but non hospitalisation due to pump failures...

The high risk of DKA is the reason my hospital do NOT give pumps to patients that have had DKA...

Never had DKA or horrendous levels at all like these on MDI. Never hospitalised due to DKA thankfully at all even when I was diagnosED.

 

[Fayefaye1429]

My machine malfunctioned but didn't tell me so it's not always the human!

 

[tim2000s]

And that's why I started this topic. I'm seriously considering funding my own pump so I can play with some of this stuff. I think the increased risk of DKA is unacceptable, and in using some of the injection ports I can see why it may happen.

Having it once, I don't want to find myself there again and I'm not sure I fully trust the various bits of pumping.

I also want the flexibility on the bolussing side. Anyway, one to think further about!

 

[Fayefaye1429]

Need to state though very rare and I was unlucky

 

[ElyDave]

I've been pumping since December, no DKA yet and no hint of one.

HbA1c in June remained at 41, but I do feel I've had more stable BG and fewer hypos since starting on the pump.

I think it would be hard to match my total basal rate of about 3 units per day any other way as accurately.

 

[ann34+]

20 years of Type 1 and I had DKA only once and only in the first 1-2 years. Then, first 4 months of using a pump and I had DKA at least 4 times, in hospital twice. There are solid stats showing increased risk of DKA on pumps. It's about the only thing that there are solid stats showing any kind of difference, good or bad, between pumps and MDI.

One reason for assessments and strict rules re using the pump is because of these dangers, sometimes people in the early days of pump use did not realise the work involved, and did not test enough, or take enough care. Also, given your experience, it may be that some people have a type of diabetes that is just not suited to the pump ?
For myself, as a pump user, I get more test strips to ward off any possibility of a DKA problem developing, I follow the advice re changing sets etc if the testing reveals problems (in order to exclude the pump as a reason for them) if i do this, and test between 8 to10 times every 24 hrs, and more if more than the usual variations are noticed , and correct as soon as safe to do so, with IOB and any recent exercise/illness/stress/lack of sleep etc et in mind, I personally cannot see how i could get to a serious DKA problem (ketone testers are prescribed for illness times etc). I was diagnosed in a DKA coma, spent days in intensive care, and am very aware of the dangers - when i trialled a pump in 1980 the strict rules were the same, the DKA dangers were impressed on me, and i was given a phone number to ring day or night. I still loved the pump.

 

[CarbsRok]

="Spiker, post: 907737, member: 102150"

20 years of Type 1 and I had DKA only once and only in the first 1-2 years. Then, first 4 months of using a pump and I had DKA at least 4 times, in hospital twice. There are solid stats showing increased risk of DKA on pumps. It's about the only thing that there are solid stats showing any kind of difference, good or bad, between pumps and MDI.

My point is that if you test at the required amount of times then you will catch any rise in blood sugars that need to be addressed..
If a pump bolus doesn't fix it then you inject as per the manual of pumping.

 

[phoenix]

Again I agree, if you keep checking and following the 'rules' then for most people the risk of ketones rising quicker than you can deal with them should be low . Perhaps if you have a raging infection or if you are a young child then they may rise much more quickly (or if you start with significant ketones produced by your normal diet???)

The advice from Medtronic is here, it's more or less what I was told at the start..http://www.medtronicdiabetes.co.in/highbloodglucoselevels

I don't often get high levels but on Saturday I was a bit high on waking and 240 mg/dl after breakfast. I changed everything, checked for ketones (none) corrected with the pump and went out to lunch. I used the bolus wizard to do the calculations for lunch so it would take into account remaining insulin on board and all was fine (a little bit too fine as ended up at 68mg/dl 3 hours after lunch but that was nothing to do with the pump; more my choice of duck. Experience told me my levels would rise slightly after this and sure enough they did

This is what diapedia says about DKA and insulin pumps

In early studies there was a perceived increased risk of diabetic ketoacidosis (DKA) due to either pump failure, or problems with the infusion set as people would be rendered insulin deficient within 2-4 hours after failure of the device. However, the technology has progressed over time and pump failure is an uncommon occurrence. A safety mechanism of multiple alarms alerts the wearer in case of device failure or occlusions. This initial risk of DKA is now thought to have been over-estimated and in fact current experience suggests a reduced incidence of DKA for patients on insulin pump therapy.

Authors are Helen Partridge a consultant at BDEC and Adam Nicholls an ST5 (whatever that means) endocrinology trainee at Southampton.