Artificial Pancreas? Say what now?!

***Note, I’m not a tech guru.  I panic when I have to update my iPhone and can’t find my apps on the correct screen.  My husband manages the DVR because I don’t understand why we can’t record 200 shows at once and having to pick only two overwhelms me.  And, as always, I’m not a doctor so this isn’t medical advice and all that stuff.***

In case you haven’t heard the news, Medtronic has developed an artificial pancreas.  AND, even better, the FDA has approved it!  HUZZAH!  So this means that I can slap on a pump and CGM sensor, leave it there, and not have to think about diabetes for a few days until it’s time to change my site?  Right?  Like, that’s it?!?!  The days of finger pricks, bolusing, temp basaling are over?  Freakin’ awesome, man.

Scrreeeeeeech.  Wait a hot second.  According to this article by The Wall Street Journal, “the U.S. Food and Drug Administration has approved a pump designed to automatically stop insulin delivery in diabetes patients when blood-sugar levels are too low, the first “artificial pancreas” to be approved in the U.S.”.  Heh?  I mean, that’s cool and all, but is that an artificial pancreas?

“Medtronic’s MiniMed 530G, which includes a sensor, sends out an alert if (blood sugar) levels are too low, and if the individual is sleeping, unconscious or unable to react, the pump will shut off for two hours.”  Oooook.  But what does it do if my blood sugar is creeping up?  Does it automatically bolus insulin or set a temp basal?  What about if I eat a bowl of pasta?  Will it sense my blood sugar rising and do what needs to be done to keep me in that 100-130 zone?

To me, this sounds like a pump with a shut-off feature.  Definitely an added security measure that I am sure many people will be happy to have for themselves, their spouses, their children.  Hell, I dropped to 40 the other night and didn’t hear my CGM beeping at me.  (Thank you to the husband for waking me up so I could treat and clip coupons!)  A shutoff feature would’ve been great in this situation!

Another thing that concerns me is that according to the interwebs and other rumor mills, the Medtronic CGM isn’t quite as accurate as the Dexcom.  I wonder how many false shutoffs occur?  And if they do and your body is getting zero insulin for two hours while you’re blissfully unaware in dreamland…well, that’s not really a good thing.

Also, I don’t know about anyone else, but when I have those pesky middle-of-the-night lows, I’m not quite fully awake.  I stumble to the kitchen, pretend I’m only consuming 15g carbs, wait (half-asleep) for 15 minutes, test again, and stumble back to bed.  I can guarantee that I’d forget to turn my pump back on and would not be getting insulin to cover all those carbs (Because we all know, it’s more than 15g) I just consumed.  Of course from the sound of it, this device is geared more towards when the wearer is incapable of treating their low, but still.  I’m forgetful.

So while I think that this new device is a step in the right direction towards the artificial pancreas, I think it’s more of a baby step than the giant leap it’s being made out to be.  Artificial, to me, means I don’t have to think about it.  I want a device that I just wear on my hip and it does all the work for me – it knows when I’m exercising and to give me less insulin, when I’m stressed to give me more insulin, or when I’m indulging in a plate of nachos and may need an extended bolus.  Sure, I’ll change out my insulin/glucagon and change the site every few days, check my sugar for calibration purposes, but, other than that, I want something that is mindless.  To me, artificial pancreas does not = pump with a shutoff feature.

I confess…

I’ve been cheating on the DOC with Reddit.  Does anyone else read the Diabetes sub-reddit?  I really enjoy it.  Check it out!

After my awesome A1c results last week I, of course, had to share with my Reddit friends.  One person asked me to list 10 changes I’ve made to make such an improvement in my A1c (I went from 7.9 in April to 6.8 now, however a year ago, I was 8.7!)  Of course the first thing I thought when this person asked was: “Blog Post!”  I love to make lists.  If you ask the hubs, I make them for him pretty frequently – 10 Reasons why I miss him while he’s away (there’s no one around to kill spiders!), 10 reasons why I am excited for the weekend (Sitting on my butt is better than working, duh!), etc.  The lists.  I make them.

So, without further ado, here are 10 changes I made to improve my A1c:

1. I switched to sugar-free flavored creamer. When I first got my CGM I noticed that I was spiking big time after breakfast, even if I was bolusing to cover the carbs. Not willing to give up coffee, I switched to SF creamer and that has helped a lot.

2. I also gave up cereal. I eat a bagel and cream cheese for breakfast most mornings. I should have more protein but so far I’m doing OK, blood sugar-wise.

3. Getting the CGM period. It’s been amazing to know what my BG is doing at any given moment. I’ve been very attentive to it and adjusting my insulin when needed to keep me in range.

4. Baby-stepping my high alert on the CGM down. It started at 200 and I’ve gradually gotten it down to 160.  I think if I started with a high alert of 160 right out of the gate, I would have gotten frustrated with all the beeping.  If Bob can do it, so can I.

5. Communicating with my CDE a lot! I’m lucky in that she is very receptive to emails. I send her my reports every couple of weeks and she makes small tweaks. She’s noticed patterns I never would have noticed before.  She has quickly become my diabetes care BFF.

6. Getting back on the pump, in general.  For me, it’s much easier to correct those pesky high numbers with a couple mini boluses or temp basal.  A little more difficult and time-consuming to do on MDI.

7. Pre-bolusing for meals. It takes me about 30 minutes to get ready in the morning and halfway through I bolus for breakfast. Since I eat the same thing every day, it makes it easy.  I also pre-bolus for lunch and dinner too and I think it really helps prevent those after meal spikes.

8. Using combo boluses when I eat high fat meals.  I will master you, pizza.  I will.

9. Trying (although not always successful) to cut back on processed foods.

10. Really paying attention to the 15-15-15 rule when I’m low. Although this doesn’t always work (especially over night!).

It honestly hasn’t been a huge lifestyle adjustment or anything. I’ve just made diabetes a priority.  I know that I feel better physically and emotionally when I’m in better control of my blood sugars.

Wordless-ish Wednesday – 8/7 My Bug-Out Bag!

Inspired by my husband’s guest post about prepping with diabetes, I have made a Bug-Out Bag.  OK, fine.  I traveled last weekend and left all my supplies packed to be my B.O.B. This bag is something that has enough supplies to get me through a few days with Type 1, should there be a fire or other emergency which makes us have to escape our home quickly.  In it I have:

  • 100 test strips
  • Glucose Tabs
  • 4 infusion sets/reservoirs for pump site changes
  • Alcohol swabs
  • 2 CGM sensors
  • Syringes
  • Old box of insulin with Rx info

So should there ever be an emergency, all I really need to grab is insulin.  I used packaging that sheets came in and I really like that it’s clear so I can see what is in there, has a zipper so stuff won’t fall out, and is plastic so at least water-resistant.  And it has a handle.  Woohoo!  It would be great to also throw in a Rx for Lantus, extra battery, and glucagon.  But, this is a start and with the addition of insulin, would be enough to get me through a week or so until we received help from outside sources like the Red Cross.

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Going to the Carnival…

The DSMA Blog Carnival, that is.  The prompt for July (OK, so I’m waiting until the last minute!) reads:

Blood glucose.  It’s front and center when it comes to diabetes.  It is how we get diagnosed and it is what we are trying to manage.  An important tool we use to manage our blood glucose is our meter and its strips.  But what happens if our meters aren’t giving reliable information?  Let’s explore that this month as we discuss a topic from the June 26th chat Fill in the Blank.  Weigh in on the following statement:

Test strip accuracy is important to me because______.

As type 1 diabetics we rely so much on numbers.  Our a1c, how many units of insulin we take, insulin sensitivity factor, Insulin to Carb ratio, but the number we rely on the most is our current blood glucose level.  This number is instrumental in telling us how we are going to proceed with our next diabetes decision – do I need a snack?  Insulin?  Should I wait a bit to eat dinner?  Am I at a safe level to exercise?

We test our blood glucose 4, 5, 10 or more times per day.  It is a constant “tattle tale” of how we are managing our diabetes.  Yes, our a1c gives us our overall diabetes “grade” for the past 3 months, but our blood glucose…that is the number we rely on to make these multiple daily decisions which, in turn, account the most for our overall care and management.

There has been a lot of talk lately about test strip accuracy (or inaccuracy if you want to look at it that way).  Our trusty little meters aren’t quite as great as we thought.  Some may read too high, some too low.  The general rule is that a meter is within about 20% accuracy.  This is a big deal.  Say my meter tells me my average BG is about 140.  I think I’m doing pretty darn good at this whole diabetes thing – this would translate to an a1c of about 6.5, not too shabby.  But what if my actual average is closer to 168 (an increase of 20%)?  That brings my a1c up to 7.5, which, not as great as 6.5, especially when you are planning a pregnancy and trying really, really hard to get your a1c to 7.0 or lower.

A person without diabetes may think, “What’s the big deal?  The difference between 140 and 168 isn’t THAT huge.”  But over time, as you can see above, it makes a pretty big difference.  If my meter is telling me 140, I’m giving myself less insulin than if I’m 168, thus remaining a little elevated.  And vice versa.  If my meter tells me I’m 168 but I’m actually 140, I may give myself too much insulin and thus cause a blood glucose drop later on.

Luckily, with the advent of CGMs, we have yet another tool to make our treatment decisions.  However, not every person with diabetes is able to benefit from this technology due to various reasons, so the core issue remains the same.  We need accurate meters and test strips.  Diabetes management is a series of small decisions that lead to an overall result.  Shouldn’t we have the best tools available to make the best decisions possible?

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Doomsday Preppers – Type 1 Diabetes Style

The other day my husband was poking around on the interwebs and came across a forum where someone was discussing “Prepping” with Type 1.  This prompted him to ask me if I had ever thought about it, which lead me to say I’d be screwed and he has permission to eat me should he ever need to.  We used to live in a hurricane prone area, so one would think that I’d be prepared but the great thing about hurricanes is…you usually know they are coming.  Of course, since the husband kinda digs me, he decided to come up with a plan should the crap hit the fan due to a fire, blizzard, alien invasion.  So, without further ado, here it is…

A Guest Post by Laura’s Husband

The funny title and all joking aside, I wanted to try to make an informative guest post about “prepping” – an often sensationalized topic in this day and age.  I wouldn’t say that Laura and I are “preppers” in the sense of the pop culture stigma.  However, I was a Boy Scout when I was a kid and as the motto goes – I like to “Be Prepared”.

In case you’ve seen it, please know that I don’t like the TV show “Doomsday Preppers”.  I think they highlight more of the eccentric personalities of prepping more than providing any useful real world education.  I am however a big fan of TV shows like “Lost, “Revolution” and movies like “Castaway”.   So I ask – What have you done to help prepare yourself or your loved ones for any real life emergencies related to the treatment of diabetes?  How about a situation like one that may come up on TV or in the movies?  Those are obviously the extreme and if you think about everything up to that extreme – you’ll be prepared for anything in between.

Preppers often organize their preparedness into a number of different “bags”.  I thought it would be good to create a quick primer on these different types of bags and some of the situations where you might like to have them with you.

Day Bag
This is most often your purse, a small backpack, or a laptop case – something that you have with you at all times.  Men – this is not a “man purse”, it’s a satchel.  Indiana Jones wears one.

Most T1 diabetics are already great at keeping their “Day Bag” stocked out of necessity.  Obviously you’d keep your daily insulin, meter & test strips, syringes, alcohol swabs, pens, tips, and glucose tablets here.  Laura likes to keep some small snack foods in her purse, such as a granola bar or a rice crispy treat.  Maybe some small candies like Smarties.  Not ideal ways to treat lows, but there if you need them.

Get Home Bag

I like to think of this bag as the bag that gets you through the 12 hours you get trapped in your car on the interstate during an ice storm.  This isn’t something that happens often where we live, but when it does happen every few years it is crippling.  This is a bag that is kept in the trunk of your car.

Related to the D, this bag might have a reservoir, an infusion set, more syringes, lancets, more pens and tips, some extra pump batteries, maybe a spare meter and test strips.  If you’re not carrying your Glucagon in your Day Bag, one would be here and you would tell everyone that its there.  This would also be a good place to have more snacks and maybe a few bottles of Coca-Cola and obviously bottled water.  This is an area where some extra care is needed, especially in the dog days of summer where a soda might explode due to the intense heat.  I don’t care what Mythbusters said, it is totally possible.

Since folks may not be used to having a bag like this in their car, this bag might also have some things like comfortable shoes, extra layers of clothes, gloves, hat, sunscreen, headlamp / flashlight, knife / multitool, dust mask / handkerchiefs, matches / lighter, extra money (around $100 recommended), etc, etc, etc.  Laura currently works about 9 miles from our house.  This bag should have the supplies needed to literally walk those 9 miles home if needed.

Bug Out Bag
The one that gets made fun of the most… but be honest – if your house caught fire, do you have a bag ready to go at a moments notice that will help you survive the next 48 to 72 hours related to T1D?

One of the best things you can have in this bag is a copy of all your prescriptions and a thumb USB drive with your health insurance and medical information.  Next is some cash and a credit card to begin replacing anything you might need, refilling those prescriptions, etc.  In this bag are also more infusion sets, extra sensors for your CGM, an extra charger for your CGM if you have one, more batteries, more Glucose tablets, more syringes and most importantly – Insulin.  Unfortunately insulin is the biggest challenge with prepping for someone with T1D.  It’s recommended to stay cold, has an expiration date, and once opened needs to be used in a month or so.  This bag should have a small cooler or something like an insulated lunch box for your insulin.

The exit plan from your house is completely dependent on the situation at hand, but if time allows there are 3 stops that are made and all can be done in less than a few seconds.

1) Grab the B.O.B. (obviously the bag, not the fun times B.O.B., but hey, I’m not one to judge your priorities)

2) Grab insulin from the fridge and ice packs from freezer.

3) Grab important papers from the safe such as passports / birth certificates.

In a fire, I might be able to make those 3 stops… maybe not.  Obviously, get yourself and loved ones out if the situation is dire.  But if I didn’t have that bag prepared, there would be many more than 3 stops and probably no chance at making them.

Long Term / Permanency
It’s obviously not likely that something like “Revolution” will ever really develop… but if it did, there would be some significant challenges related to T1D.  Test strips run out, there is no way to keep insulin cool, it also runs out, etc.  Unfortunately, we don’t have the means to buy a ~1 year supply of T1D treatment supplies to keep a stockpile… but it might make sense to try to stockpile expired insulin or those old test strips and meters from the brands you didn’t like or the insurance company stopped covering.  If you find an expired vial, don’t throw it away… clearly mark it and save it.  It may not be as potent as fresh stuff, but if you’re at the end of the rope and your life depended on it – wouldn’t it be better to try than nothing?

For many reasons, I used to think about getting Laura a diabetes alert dog.  Though now that she has a CGM, I don’t really think about it.  Again – it’s extreme from a prepping perspective, but without test strips an alert dog might be a way to help monitor blood sugar.  Unfortunately, you then run into the challenge of needing to prep for your dog!  This won’t be something we really explore as we don’t have the funds to properly train a service animal and with the price and availability of CGM it simply doesn’t make much sense financially.

We’ll save the discussion of burying a cache of insulin somewhere out in the woods for next time.  Just kidding about that last part, but as you can see – being prepared never ends.  You don’t need to be a Doomsday Prepper, but any step you can take to make sure you can take care of yourself in an emergency is a positive step to being prepared!

If anyone has suggestions on better T1D preps, please leave a comment below.  Insulin is by far the area where more thought and consideration is needed.

Until next time…

Laura’s Husband

So, as you can see, my husband is definitely the planner in the relationship.  I even ran out of insulin the other day, so should the crap hit the fan, I’d likely panic or forget something of major importance.  I think it’s a great idea to have a bag ready to go with a week’s worth of supplies that you can just grab and go.  This is something I’ll be organizing in the coming weeks.

Rookie Mistake.

The other day I made a rookie diabetes mistake.  I woke up in the morning, checked my pump and realized I had 22 units left to last me until I got home from work.  My daytime basal rates vary from 1.0 to 1.275, so quick, just awake math…8 hours = 10ish units.  And, there’s no way I’ll bolus more than 8 units for lunch, since my average lunchtime bolus is about 5.5 – 6.0 units.  Breakfast is usually about 3-4 units, so, I’ll be just fine until I get home from work!

Mistake number one: A wise diabetic would’ve thrown a vial of insulin in her purse, along with a new cartridge and inset.  I never claimed to be wise.  

Off to work I go, excited for the D-girls gathering that evening and I notice that my morning numbers are running a little higher than normal.  I try to limit my rage boluses to when I’m 200+, instead I rock a temp basal.  So I set my temp basal at +50% for 90 minutes.  Mistake number two.  (Although, D-friends, it’s never a mistake to try to lower your blood sugar, amiright?)

Lunch time rolls around and I have my standard I’m-too-lazy-to-make-lunch Lean Cuisine.  Attempting to be healthy-ish, I had grabbed a banana to have along with it, rather than the Sunchips I have in my desk drawer.  My Ping tells me to bolus 7.55 units so I do because it is way better at math than me.

Literally as my bolus is being administered at warp-Animas-Speed, I remember that I’m low on insulin.  However, the Ping delivers it’s bolus in like, 0.00004 seconds so by the time I realized, it was too late.  Mistake number three – should have checked the amount of insulin I had in my pump before bolusing and deciding to eat that banana!

At this point I had 3 units left.  I thought about setting a temp basal of 60-70% so that even though I’d probably run a little high, it was better than getting no insulin at all.  However, I decided that this wasn’t that dire of a situation.  I work 20 minutes from home and I have a decent amount of sick time.  So, I figured I’d leave when I got down to 1 unit (to spare my coworkers the annoying “You’re out of Insulin!” song) and take a couple of hours of sick time.  I told my supervisor that I miscalculated my insulin in my pump and she, I think, thought death was imminent.  “Ohmygod, LEAVE!” was her reaction.  I told her I still had a couple hour’s worth of insulin in my pump and I’d leave when needed, which was about 2 hours later.

Rookie mistake(s).  Lessons learned – if you are borderline making it through the day, bring your supplies to work.  Better safe than sorry.  Check the amount of remaining units in your pump before deciding to eat the banana/bolus/set an increased temp basal.

And most importantly, don’t attempt to do math before having your coffee.

Not a week goes by….

… without fighting with my insurance company.

Warning: this post is rather venty and may contain some adult language.  Parental Guidance Suggested.

For the past few months I’ve been in one battle after another with my insurance and/or pharmacy benefits company.  Luckily, everything went smoothly with obtaining my insulin pump and CGM.  However, there have been a few headaches that I’ve had to deal with that are really starting to piss me off.  As if we PWDs don’t have enough to deal with, but insurance makes us jump through hoops (of fire, it seems) to get things done.

Test Strips – My blood sugar meter “talks” to my pump.  Yay, Animas!  It’s a One touch meter, not some fancy unique brand that no one has ever heard of.  Well, my strips cost $95/month.  I’ve reached my out-of-pocket max for this benefits year (a perk to making major cyborg-living purchases!) so since they are classified as Durable Medical Equipment, they should be covered 100% for the rest of my benefit year.  Of course they weren’t so I called and was told they aren’t the preferred brand so if I want them covered 100%, I need to switch meters.  Pisses me off.  My pump supplies (remember, my meter “talks” to my pump) are covered, no questions asked.  So, fine.  I’ll switch meters and only use my meter remote when I will need to bolus from it (wearing a dress).  Worth it to save $$ and not a huge deal since I bolus from my Ping 99.7% of the time anyway.  I call to order my new meter (Verio IQ) and they are back ordered/recalled/they don’t like me so they won’t send me one/something.  So, guess who is on her last pack of strips and has to order more at $95 for a month?  THIS GIRL.  I am tempted to call and argue that they should cover this month’s worth of strips since it’s not exactly my fault that I don’t have my new meter yet.  But, I really doubt I’ll win that fight and frankly, I’m tired and don’t even feel like putting forth the effort.
Insulin – Previously, I used Humalog.  Was always covered with no problems.  Well, my doc switched me to  Apidra.  However, when I first got back on pump therapy, my pharmacy didn’t have any Apidra in stock so I used a vial of Humalog that I had to get started.  Worked fabulously.  But, my Endo wanted me to try Apidra so once the vial of Humalog was empty, I switched to it.  I feel like I’m not reacting to it as well as I did with the Humalog, so I asked to be switched back to see if this is the case.  This is all within the last 6 months.  Endo says, no problem, writes me a script for a 90 day supply of Humalog.  I mail it in to my mail order pharmacy and now my pharmacy benefits people are saying it’s not covered.  Something about the “formulary changed”.  Oh, I can get it, I just have to pay out-of-pocket.  So now I have to use a sub-par (for me) insulin because some higher up in some office decided that they weren’t going to cover my insulin.   Granted, it’s not like my control with Apidra is all over the place (if it was I’d be sure to appeal!), but I wanted to see if I’d do better with Humalog, like I think I would.
Dealing with insurance shit makes me rage.  I don’t expect anything to be free, but I’d at least like reasonable options when it comes to my diabetes management.  $1200/year just to test my blood sugar is outrageous.  Telling me what insulin I can and cannot use??  What the French is up with that?!
I don’t often get diabetes burnout.  Sure I’ll have a day here or there where I’m temper-tantruming against the disease.  But, man.  Insurance company burnout?  I have that 24/7.  I just don’t understand why it has to be so hard to make dealing with diabetes or any other chronic illness just a little bit easier with maybe a few more choices so we can make the best decisions for ourselves to manage this disease that we live with every day.
Maybe some day, this will be me.
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Is it time to say goodbye to coffee?

I love coffee.  Coffee, however, does not seem to love me.  I have noticed in the 2 and a half weeks that I’ve been wearing my Dexcom that I seem to have a very high blood sugar spike after breakfast.  Despite taking my BG, Insulin to Carb ratio, and Insulin Sensitivity factor into account when I bolus, I am always spiking about 2-3 hours after breakfast, which I eat around 7:30 am.  Breakfast is usually a bowl of cereal (measured, 1 cup of multi grain Cheerios or corn flakes) and skim milk (3/4 cup), and my to-go coffee with flavored creamer (3 Tbs  – hey I drink a BIG cup!).  I usually drink my coffee over the course of 2 hours, finishing it around 9:30 am.  My blood sugar spikes seem to hit between 9:30 and 10:30 am.  However without taking a correction dose, I’m almost always back in normal range by lunchtime.  Take this morning for example:

  • Woke up with BG of 204
  • My new Ping told me to take 6.6 units for my BG, amount of carbs I was consuming, and correction factor.  My CDE wants me to do what the Ping says for the next few days as we figure out my basal rates and fine tune my Insulin:Carb ratio.
  • I spiked at about 9:30 am with a BG of 320.  Blech.  However, on the direction of my CDE, I did not take a correction dose and am now coming down, about 45 minutes before lunch.
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Who wants to go skiing on that peak?

 

This leads me to wonder if I need a different Insulin:Carb ratio or a higher basal rate.  Or, dare I say it, I should knock it off with the coffee.  I have read on the interwebs that caffeine can cause blood sugars to rise by blocking insulin or something medical like that.  But, it’s my coffeeeeee.  What is worse?  Blood sugar spike or crazy, cranky, half-asleep Laura?  My coworkers probably have a different answer than I do.

My thoughts are that perhaps I should increase my basal in the mornings to account for my coffee.  Or maybe set a square bolus (Or a “Combo Bolus” in Ping-speak) to account for my 2 hour long coffee drinkage.  Or change my Insulin:Carb ratio for breakfast so my bolus is higher, although this concerns me that I will drop by lunchtime.  Maybe next week I will try sugar-free creamer to see if that helps.  Perhaps all the sugars in the creamer are hitting me in a different way than other carbs?  Maybe I need a higher protein, lower carb breakfast in general?  Who wants to be my personal omelette chef?

I really don’t want to have to surrender my coffee to the D.  It’s warm.  It’s tasty.  It wakes me up and it makes me (and my coworkers) happy.

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This diabetes stuff is a tricky thing.