Choice of pump (and CGM)

[Jemzor]

I've been T1D for 30 years on MDI's throughout. I recently had 'the chat' with my consultant, have had some structured training and been referred to the pre-assessment clinic for a pump. The clinic is offering a choice of the following:

1. Animas Vibe
2. Insight
3. Medtronic 640G
4. Dana R

The omnipod is not being offered due to high cost - regretably

I am interested in a solution that incorporates CGM as I would look to self-fund this.

It is quite a dynamic time for pump choosers with the more recent introduction of the Insight and 640G. With this said, I have changed my mind more times than I care to count! The Vibe was the choice for a while as it is waterproof and has the integrated CGM receiver, but the safety limitation on bolusing multiple times in short timeframes is making me think twice . I also can't help but feel we are entering a new generation of potentially very useful pump tech (basal suspense & BG predictions) which given the age of the Vibe, is not included - or maybe it just feels new as I've yet to use a pump.

The 640G seems to be ticking all the boxes and being that I am familiar with the Bayer USB Next, the choice of meter is also fitting. My only reservation is with the integrated CGM and its high associated cost. According to some users, the Dexcom sensors appears to be lasting 14 days. The Medtronic seems to last 6 days? Can it be used for longer?

The reason why I have mentioned the choice of pumps in this war of CGM is becausing I feel the choice of CGM is driving this (rather than vice-versa). So whilst the 640G looks great on Youtube and paper, if the CGM is not the most appropriate then I would lkely change my choice of pump back to the Vibe. The clinic has not received the 640G yet, so I will still ned to play with it before deciding.

Going for 2 separate systems (eg. Insight + Dexcom) would be my least favourable option.

I am interested to hear your views on the CGM and particularly if you use the latest Medtronic CGM equipment (or pump!).
.

 

[Spiker]

Like you my pump decision was driven by CGM and that's why I chose the Vibe. What's this bolusing limitation? I've not encountered it, and I've had the Vibe over a year. I've certainly done boluses in rapid succession, many times. There is a total bolus limit per period of time, but the limit is huge, and can be reconfigured by the user.

 

[Jemzor]

I was led to believe there was a safety feature on the Vibe that does not allow you to bolus in succession over a 2 hour period. Is that not the case?

My concern for instance would be if I had lunch, then decided to snack twice after that within 2 hours of eating originally.

Also have you had any problems using th CGM during either intensive or non-intensive exercise?

 

[Spiker]

There is no such limit. I just gave myself 5 boluses in a row to check. There are limits on :

- Max dose per bolus
- Max basal rate
- Max total bolus per 2 hrs
- Max total bolus per 24 hrs

All of the above are user configurable, up to very high levels. The only time I needed to raise them, it was a symptom that the infusion set was not working.

 

[Flowerpot]

Hi Jemzor

I've used the Medtronic Veo and Enlite sensors for 4 years constantly now. I'm starting the 640g in a few weeks when the pumps are delivered to my pump clinic. Sensor wise I haven't had any issues with reliability, they track my blood glucose pretty closely usually spot on or within 0.2/0.3 of my bg.

The sensors stop after 6 days and at that point I restart and get an extra 24 hours out of it. Beyond that the transmitter will need recharging and trying to remove it without disturbing the sensor filament requires skill and luck, I've not managed it so can't say whether you could re attach the fully charged transmitter and whether the sensor would restart again. My first transmitter lasted for 3.5 years with a warranty for 6 months so not bad going.

The alarms for low and high glucose prediction really keep you in target and make you think a lot about when and what you're eating and when best to bolus. You choose the glucose levels for the high and low alarms, the Low Suspend is a life saver if you have lost hypo awareness - basal insulin is suspended for 2 hours if you drop below a chosen preset hypo level. The SmartGuard technology on the 640g is designed as an extra level of protection from hypos and is to prevent you reaching hypo territory by suspending basal for only the amount of time necessary for your bg to stop falling.

The length of time Dexcom users get from their sensors exceeds anything I can reach on my Enlite sensors. It depends how much you need the basal suspend function and the SmartGuard technology provided on the 640g.

 

[Jemzor]

@Spiker thanks for this. Presumably if you're having a main meal after all these snack-based boluses, the calculator in the Vibe will account for all the insulin taken earlier so you don't end up taking a bigger bolus than you need to?

@Flowerpot thanks for your input. Must be an exciting time now waiting for the new pump to arrive That's good news regarding the accuracy of the readings - do you tend to blood test when you're on the flatter parts of the curve? (i.e pre-meals with only basal in effect). Or do you find this level of accuracy generally whenever you test?

Also I received my pump pre-assessment appointment letter from the clinic this afternoon. What should I expect on the day?

 

[Flowerpot]

I calibrate when my bg is stable and always pre meal when just basal insulin is onboard, you are advised to calibrate with a stable bg.. CGM doesn't quite reach the high and low extremes of blood glucose but my sensors are pretty accurate at tracking what is happening. If my blood glucose is rising or falling rapidly then there is more chance of a discrepancy due to the time lag between interstitial and blood glucose. The Contour Link meter asks with each blood test if you want to send that result to the pump to calibrate CGM so you can choose which test to use.

I am very excited about starting a 640g, whoever would have thought a piece of medical technology would make me so pleased

 

[-Artemis-]

The Vibe was the choice for a while as it is waterproof
.

- just wondered if you knew the 640G is also 100% waterproof...?

I also had a choice - and have chosen/am waiting for the 640G - will be another month or so before my hospital gets them in but I'm already super excited!

 

[Spiker]

Yes the IOB calculator on the Vibe is awesome.

 

[Jemzor]

- just wondered if you knew the 640G is also 100% waterproof...?

I also had a choice - and have chosen/am waiting for the 640G - will be another month or so before my hospital gets them in but I'm already super excited!

Indeed I did. I spend a lot of time in water and wet thermal areas so waterproof is important for me

Will you be using the Medtronic CGM with your new pump?

 

[Diamattic]

I am essentially in the same situation here. I am looking between the Medtronic Veo 554, and the Animas Vibe w Dexcom.

They both seem to equal in terms of pump for pump, with the edge i think going to the vibe for being waterproof, and having a colour screen.

But would anyone have more info on the CGM available from Medtronic?

I have heard some people really dislike it, and that the accuracy can be horrible, but at the same time i have t think that if everything is working fine why would the user need to post that online lol The complainers always have the loudest voice eh, so anyone have GOOD things to say about the Veo CGM ?

 

[Flowerpot]

I've used Medtronic sensors for the past 4 years first Sof Sens and then Enlite sensors. I haven't had any issues with accuracy with the Enlite sensors, usually within 0.1 or 0.2 mmol of my blood glucose and tracking and predicting what is happening spot on. I rely on then completely as I have no hypo awareness and if I didn't have faith in them I would request to use something else. That hasn't happened and they have saved me from many hypos along with improving my HbA1c and overall stability. Dexcom users can extend the life of the sensors a lot longer than I can manage with Enlite sensors.

Medtronic have just released the 640g pump in Europe and Australia with added hypo prevention technology and this pump is waterproof with a colour screen but I presume if you are considering the Veo you aren't living in the UK?

 

[Diamattic]

@Flowerpot if that is directed at me - Right, I am in Canada. We have no estimated arrival time of the 640G as i would easily get that, but we tend to get things after the USA which is predicting middle 2016, so i dont expect the 640G until 2017... So as much as i would want it, i don't want to wait 2 years for it.

My largest concern is the CGM, as the pump portion of the Animas and Medtronic systems seem to be fairly level.

I have read lots of issues with the CGM and my own sister has told me that her sensor readings were VERY off to the point where she stopped using the CGM all together. Sadly she is not in Canada so i dont have a chance to actually interact with the system.

I feel like its almost a shot in the dark as to if the Enlite system will work, because some people love it and some people say its very off. Where as Dexcom units dont ever seem to be 'wrong' at least i have never read of anyone stopping the G4 because the readings were to far off.

Why do you think some people are getting very off readings and others (like yourself) are getting things spot on?

 

[Spiker]

@Diammatic, turning it round, what are the features of the Medtronic pump that would make you consider taking the risk with the Medtronic Enlite CGM? Why not go with the Dexcom G4 and Vibe? Will OHIP or whoever cover your sensor costs? If not, sensor stretching means that the Dexcom operating costs are much lower than Enlite.

Also when would you expect Canadian availability of the Dexcom G5?

 

[Spiker]

The complainers always have the loudest voice eh, so anyone have GOOD things to say about the Veo CGM ?

A very fair point.

 

[Diamattic]

In Canada we have the assisted devices program, which essentially will pay for your pump, and its annual supplies, but not the CGM stuff.

So when i run the number the Medtronic annual cost for the first year (because they are offering A LOT of discounts right now) is 1,800$ less then the Dexcom.
After that the Medtronic cost is roughly 500$ cheaper every year as well. SO that really makes me want to like the Medtronic.

However, the Dexcom system tends to get longer sensor life, and better accuracy so if i adjust the numbers to use each dexcom sensor for around 14 days instead of 7, then the dexcom comes in at a cheaper annual cost. With the exception of the 1800$ savings from the first year.

My animas rep told me that the G5 won't be linking with the animas pumps, we will have to wait until the G6 for the next upgrade because the G5 will be a standalone sensor upgrade only for use with the Dexcom receiver and/or other devices (like Apple products). SO that is a couple years off as well.

 

[Spiker]

Averaging 14 days per G4 really should be the minimum expectation. Once you get the hang of stretching the sensors you should be able to consistently average 21-28 days.

 

[Diamattic]

That is awesome to hear.

I would to try and bring the annual cost down and didn't want to budget for 7 days because I know it's not the reality but at the same time budgeting for any higher is not guaranteed.

Glad to hear I should expect at least 14 but will end up closer to 20!

Where as Medtronic seems like 6, but many report an average of 8-10. Which isn't great... Add in the in accuracy. Things lean towards animas now.

 

[Spiker]

Check out this thread

http://www.diabetes.co.uk/forum/index.php?threads/64613/

 

[Jemzor]

Had a very productive conversation with the Animas area rep earlier today. Most of the dialogue was centred around the CGM and the differences between the Dexcom and the Medtronic systems.

I really love the looks of the 640g and the smartguard tech is something no one else is able to offer... yet. With this said, I think it's very difficult to justify the Enlites over the G4 (based on cost and accuracy) and aside from the basal suspense (which Animas do not/will not support due to the liklihood of hyper's occuring after the suspend) I cannot see any other functional benefits of the 640g over the Vibe.

Really is a very tough decision, but the rep has suggested I trial the G4 through my clinic before I make my decision and Animas would be happy to support me on this.