Replies to This Discussion

Permalink Reply by Jonathan on August 19, 2008 at 2:31pm

Chris: I very much understand. It's that final step that makes it tough -- going from what you know to what you do not know. If you have a good team working with you, the transition should not be difficult. My fear when making the transition was the overnights-- I had a big problem getting low while asleep. My educator recommended starting out with basal rates that were probably a little on the low side, to avoid lows. We then adjusted to get to the right levels. Highs and lows are parts of our lives, as are carb counting and adjustments.
Go for it!! Once you are used to it (a week) and feel that your basals and boluses are moving in the right direction, it will become second nature. Plus, it is going to be a lot easier to take a bolus when you are sitting across from your great date than it is to excuse yourself to go take an injection!! Trust me on that one.
You can always decide that pump therapy is not right for you. It is not irrevocable.

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Permalink Reply by Chris UK on August 20, 2008 at 1:54am

Hi Jonathan

Thanks for response, i think it was the fear of the unknown initially without being sure what to expect during the initial bedding in period. On the induction there was so much talk of the negatives that the positives were easily forgotten. I left feeling some relief but later in day felt really low about choosing the easy way out.....my fears also include night time hypos ar extreme highs but you are right, giving it a go is only way to find out.

Thanks again

Chris

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Permalink Reply by Kristin on August 19, 2008 at 2:32pm

Hi Chris. I won't tell you that you are stupid.

I think that the level of control that I can get with the pump is much better than what I could achieve with shots. BUT I also think that I started on the pump before I was ready. My doctor really pushed it and I decided to go for it. My control got worse on the pump, because I did not figure out how to use it effectively.

I think that you did the right thing. If you feel comfortable on injections and you can find ways to maintain good control, then that's right for now.

I think if I had waited a year longer, I would have had a better start on the pump... so it's good to know that it is still an option... for the future.

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Permalink Reply by Chris UK on August 20, 2008 at 2:01am

Hi Kirstin

Thank you for responding. I think i needed to hear your words of reassurance and affirmation that its ok to work at my pace and not feel rushed into it. Think i just felt like i had let myself down as i am normally a person who gives things ago, so if i am being honest felt a little weak willed.
It also reassured after hearing your experience that you wished you had waited longer before starting pump that its maybe not the `magic pill` therapy for diabetics everywhere.at any time. How do you find the pump now?, do you think you would still use pump even if could achieve good levels with injections?

Chris

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Permalink Reply by Kristin on August 20, 2008 at 3:10am

Hi Chris!

I definitely feel that the pump is a big decision and you should not rush into it. The pump is not a magic pill, but in some ways, it's the closest thing that we have to a magic pill!! So I DO recommend trying it again, when you are ready and I think that you need to stick with it at least six months to know if it works for you.

That said, you are not the first person to decide NOT to pump. So it isn't for everyone...

I LOVE the pump... I recently took a week off from the pump and it had me thinking about that exact question of whether i would someday go back to injections. I might switch back to injections someday just to see if I can keep as tight of control. I am thinking about pregnancy and trying to get my A1c under 6-- I don't think that I could do that with injections. So I will stay on the pump for at least a few more years before trying injections again.

The reasons that I think my control is better on the pump:
- I correct EVERY blood sugar, even when they are just slightly high. It is hard to correct just slightly high blood sugars with injections
- I exercise more with less lows because i can turn my basal rate down to 50% one hour before exercising-- this is amazing!
- I can live with more flexibility, because if I ate, checked my sugar, then want to eat more, my pump can process all that data telling me what to do without going high or low (it remembers how much insulin is active in your system-- something that is hard to keep track of unless you write down every move).
- It's easier for me to give boluses early. You should give your bolus 15-20 minutes before eating. I can often do this while walking to get lunch, while cooking, etc. I think that with injections I would often forget to do this.
- I have different basal needs through the day. In fact, most of us do. So the pump can give me more basal insulin in the late evening than in the early afternoon. You can replicate this by splitting your long- acting insulin dose. With the pump, if I have good blood sugars and do not eat or bolus, they will stay good all day. The basal really works as a background insulin. When I used injections, I could not go 12 hours with eating, which means sometimes I was feeing my long acting insulin.

This LONG answer is to say that I don't think that you are stupid. The pump is a huge commitment that may help you achieve better control when you are ready to try it again. I would definitely recommend trying it again for a longer time... perhaps you can set a time frame for yourself. First trying to improve control without it... but I would not spend your energy beating yourself up about it, but i also wouldn't dismiss the option that the pump might be right for you, in the future.

Keep in touch about how it's going!!!

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Permalink Reply by Jonathan on September 2, 2008 at 12:03am

Kristin: I'm interested in your statement that you correct every blood sugar. I usually do the same, but sometimes run into problems with over-correcting or having too much insulin on board. How long do you give a correction to take effect, and will you still correct even if you may have enough insulin on board to cover the high?

Does anyone else do this too?

Thanks.

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Permalink Reply by Kristin on September 2, 2008 at 12:53am

What I meant above is that I correct even blood sugars that are not high. For example, I correct a blood sugar of 110 (which I would never "correct" on injections) to get it down between 80-100.

But you raised a good question about correcting when you have insulin on board. From the time that I give my "fast-acting" insulin, it takes about 25 minutes to start working. (A good way to test how long this is for you comes from Dr. Bernstein. When you have a blood sugar of over 100, take a common size meal bolus and test every 5 minutes to see when you first drop by more than 5 mg/dl). That means that if I correct and test within an hour, I won't see a lot of the effect. My pump (Cozmo) calculates if I need additional insulin based on my current blood sugar and insulin on board. If I do, of course I give that.

If I have enough insulin on board, sometimes i just wait it out, knowing that my blood sugar will come down. What I usually do is correct and if possible give the bolus for the next meal or snack (even just 10g of carbs if it's too early to eat the next meal) when I give the correction bolus, but I only eat the meal/snack 1-1.5 hours later. You need to be careful that you don't just force yourself to keep eating more, but this can bring down the highs more quickly.

One way that I have prevented many highs is to give my insulin early. I wait 20-30 minutes after giving the bolus to eat (if my blood sugar was above 100, if not then I wait 10 minutes). I also sometimes wait 1.5 hours to eat some of the carbs. For example, I will bolus for a lunch of 30g of carbs by giving a bolus for 36g. I wait 20-30 minutes and then eat my lunch, then an hour later (1.5 hours after the bolus), I eat a 6g chocolate bar. I like working the chocolate into my routine and it makes me less likely to snack at other times. If you are snacking during the day and giving a bolus right when you snack, you are facing a full day of "postprandial" highs.

If you are trying to lose weight, this may not be the best plan, but I find that working my snacks into the routine leads to less spontaneous snacking. I would love to hear what other people do to correct high blood sugars when you have insulin on board.

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Permalink Reply by Jonathan on September 2, 2008 at 7:59pm

Kristen: Thanks. It is all very interesting. I'm not concerned about weight (for once in my life), but this shows how different we all are. I've done the "correction test" to determine insulin sensitivity and reaction times and, for me, Novolog does not start to show an effect for at least an hour after a correction bolus and reaches its peak effectiveness at about 11/2 hours. It also stays in the system for 5-6 hours.

I do the same thing (or at least try to) on taking the bolus before eating. I also separate out the correction bolus before meals -- I'll do the correction about a half hour before I do the meal correction.

I won't correct for just 10 pts, but do it for 30 or more.

I do wish there were a simple formula to make this all work. Because we all are so different, I really do not believe that the closed-loop sysem will ever truly work. Certainly not without an instant-acting insulin. One would think we would have had that step already.

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Permalink Reply by Kristin on September 3, 2008 at 12:37am

Have you tried using Humalog or Apidra? I have heard from some that Novolog acted very slowly for them. The insulins all work a bit differently so it might be worth a try. Acting at 1 HOUR makes it more like regular insulin...

I can see why that would make it so difficult. Correction is slow, but it would be great if you did not need to wait for an hour for any drop...

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Permalink Reply by Jonathan on September 3, 2008 at 9:15am

Humalog was worse (plus, my old endo got lots of funding from the manufacturer). New endo is thinking about Apidra -- perhaps at the next visit.

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Permalink Reply by Lee Ann on August 19, 2008 at 3:13pm

Your anxiety is understandable. I think most of us who lived on injections for a long time can relate. That being said, you have nothing to lose! The worst that will happen is that you'll give it a go for a few weeks or months and decide it's not for you. Then you can always go back to injections. On the other hand, you might love the pump as much as most of us do, and you might kick yourself wishing you'd done it sooner - that's how I've always felt about it :) Either way, you always have options, so trying something new doesn't mean you have to commit to it forever and ever.

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Permalink Reply by Julie on August 20, 2008 at 7:12am

Hi Chirs!
I agree with all the things that Kristen has said about why she loves her pump and how it helps to improve BG control. I love my pump as well and can’t imagine being on shots again, even though I wasn’t on them very long to begin with. I think everyone should move to a pump at their own pace. It might depend on what type of person you are too. The pump does take some work to figure out. I’m the kind of person that likes to plan things and problem-solve, and also likes new technology, so it was a no-brainer for me. I also like to be in control, which was the real motivator 
Some suggestions for easing into it might be:
1. Talk to your Diabetes team and see if there is a way that you could simulate using the pump for a few days to get the feel of it, while still maintaining your BG control with injections. When I first got my Omnipod, I wore a pod filled with Saline for 3 days, just to see what it felt like.
2. Try to plan to minimize factors that you can control when you first start on the pump, so that you can figure out your ratios as quickly and safely as possible. Your Dr. should be able to give you a very good place to start for basals by looking at how much long-acting insulin you currently take. I set my alarm and checked my sugar during the night for the first week but felt comfortable sleeping through after that. The bigger danger for lows I think would be miscalculating on carbs and/or having a carb ratio that doesn’t work for you. My suggestion is to pick something that you like eating, weigh the components, and figure out exactly how many grams of carbs, protein, and fat are in it and use it everyday for a week or so, until you feel comfortable with the ratios you’ve chosen. I would actually pick 3 things I liked, one for every meal. That way, you can take the carb-counting a little bit out of the picture until you’re sure that you have the correct ratios.
Good luck and keep us posted as to what you decide and remember you can always switch back to injections!

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