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Pumping Tips

What this is​
This is how I do my pumping. Some things can be done successfully in more than one way, other ways are fine, as long as they work. With some things relating to pumping, there really is only one right way to do it.
Disclaimer: I make no claim that if you do things my way, you will get numbers as good as mine. I am very fortunate in that my body reacts to insulin in a very predictable way. Have been a Type 2 for 14 years, on insulin for about 2 years, and on a pump for about 18 months. On the other hand, I can't be doing much wrong, or I would not have the numbers I enjoy.

When you are just starting out:

1. Buy "Pumping Insulin", by John Walsh. Ask around, just about every experienced pumper will tell you the same thing!
2. Attitude is very important.
"I'll give it a try" means you have a chance of succeeding.
"I'll do whatever is needed, and learn what I have to for success" almost guarantees success.
3. Have reasonable expectations
Expect that it is work getting it set up. Expect that it will take weeks to get numbers you are hoping for. Expect that things may well get worse before they get better.

There are a whole lot of things to get set right to match the insulin delivery of your pump to your body and lifestyle. That is what makes it such a powerful and flexible tool. With every change you make, you need to go look at the results, and decide if that is an improvement or not, and if you have reached your goal for that particular parameter. I have 9 basal rates, due to Dawn Phenomenon, it took 6 weeks to tweak the settings on my pump to the point where I was happy with the results.

It is well worth the time and effort!

4. Infusion sets
There are many kinds out there. I highly recommend getting free samples, so you can try different types out to see what works for you. When you buy infusion sets, you are usually buying 10 of them, so if you don't like them you will be stuck with them for a month. A few phone calls and e-mails got me a months worth of samples of various kinds.

5. Good carbohydrate counting skill is a must!

6. Lowering your carbohydrate intake will improve your control, because your errors in carbohydrate estimation will be smaller.
An example to illustrate:
An omelet for breakfast, 4 grams of carbohydrate. A 25% error in carbohydrate estimation would mean an error of 1 gram of carbohydrate.
An omelet, toast, juice, and a huge plate of hash browns, 100 grams of carbs. A 25% error in carbohydrate estimation would be 25 grams of carbohydrate.
Your test 2 hrs after eating the second breakfast could be 25 times as far from your target number as it would be from eating the first one.

Some pumping rules I live by:

1. Tell the pump when you disconnect, that way it will remind you if you forget to reconnect!

2. When changing pump settings, make small changes.

3. When changing pump settings, change one thing at time!

4. Verify that the changes are what you intended! Yikes, you could hurt yourself with a mistake. Verify that the changes you made are working! What if you screwed up, and moved a value in the wrong direction, or too far?

5. Double check for user error BEFORE replacing a set.

Forgetting to bolus, or not giving the bolus for the whole meal, or if you take pills, forgetting your pills happens much more often than a problem with the pump or infusion set. Check the log on the pump, it will tell you what the pump was told to do.

6. If you have a problem with glucose that is too high, bad insulin is one of the first things you may think of, but it is the least likely thing to be the problem. Unless you freeze the insulin, or cook it by forgetting it in the car in hot weather, your insulin should be fine.

7. Do not change infusion sets before bed. If something goes wrong, either you will not know about it, or you will be up half the night worrying about it if you do notice there is a problem.

8. Keep a spare battery for the pump with you or in your vehicle.

9. Use insulin that is at room temperature. This prevents air bubbles from forming at a later time, and also cold insulin could be painful.

10. Take the time to get all the bubbles out, when changing insulin.

11. I have my pump set to remind me to test 2 hours after a bolus, including correction boluses. For me, it is safe to do corrections in the evening, but if I forget to tell the pump not to beep 2 hours later and I expect to go to bed before the reminder goes off, I tell the pump to vibrate instead of beep. This is better than disabling the beeping because you will have a vibrating reminder the next morning to reset it back to beeping.

12. I don't try to keep the changing of infusion sets and insulin cartridges synchronized. If you keep them synchronized, you are likely tossing out perfectly good insulin.

13. It is a good idea if you add up all the basal that will be delivered while you are sleeping. That way you know what minimum amount has to be left in the pump before you go to sleep. Add that amount to what the minimum is for the "low insulin" alarm. Who wants to be awakened at 3 AM for pump messages about being low on insulin?

14. Rotate placement of your infusion sites, so they have plenty of time to heal before they get used again.

Shortcuts that work, to save money.
Tubing can be reused at least several times. At the least do this enough to have spare tubing at hand, in case the dreaded doorknob bites you

Insulin will last longer than the 48 hours in a pump that the spec sheets say. I always do at least 3 days, this saves on cartridges. I have never had any problem with the insulin.

Shortcuts that I do not recommend:
Reusing a cartridge
I tried it once, and got delivery errors a few hours into the second use. The rubber seals in the cartridge are fragile, and perhaps easily contaminated. I just decided it was not worth the trouble and risk.

Danger in leaving sets in longer than 3 days.
Some people have problems with scars forming, areas that they can no longer use for infusion sets. When I asked these people how long they leave sets in, most responded 4 days or more. I just can't see taking that risk. After about 3 days, your body starts to react to the infusion site, time to move it. I want to be able to pump for the rest of my life, until something better comes along, or there is a cure, hopefully without having to put the set in a less desirable place than I now use.
 

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Excellent -- Just What I Needed.

Thanks Lloyd.

I might have a little trouble adapting to carb counting. When I started 22 years ago they used the Exchange Method, which I later dropped and just learned how much insulin it took for different foods. For instance, I did not know how many carbs in pizza, but I knew from experience that this particular food required nearly twice the insulin for me.

Domino's anyone? Just put a needle straight on the bottle!!:eek:

reido
 

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Discussion Starter · #5 ·
Wonderful information there Lloyd. I may be needing those tips somewhere's down the road. Thank you for sharing your expertise and experiences. :)


Reido, pizza is processed slowly in the body, as pasta is. I take one shot(Humalog 5u) before I begin eating and another shot(Humalog 3u) about 90minutes later. Chinese food is worse. My first shot I take Humalog 7u. My second shot I take 5u. That stuff is full of sugar and fat. Of course, everyone is different. I don't eat much of those foods.
 

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2 Slices Domino's

Terrie

Dial that dosage up to 25u of Humilog for me and add another bolus of 5-10after a few hours. That shows how different one person's dosage may vary from another's. I go into the hospital for one day, eat only one meal of hospital food, get to go home and test -- wow...450. Told them they were not giving enough, but they said "We use the sliding scale." :eek:

reido
 

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Terrie

Dial that dosage up to 25u of Humilog for me and add another bolus of 5-10after a few hours. That shows how different one person's dosage may vary from another's. I go into the hospital for one day, eat only one meal of hospital food, get to go home and test -- wow...450. Told them they were not giving enough, but they said "We use the sliding scale." :eek:

reido
IMHO,

the only good sliding scale is the one that scoots across the counter when you park your recreational vehicle on a hill.

-Lloyd
 

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You tell em Lloyd!! Grrr! The look on Snoopy's face in your avatar clearly shows that nobody stands a chance messing with him! Lol!

Richard
 

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Discussion Starter · #9 ·
Ugh!! Well, there are many Diabetics that use more units of Insulin than that for the same meal, as you probably know Reido!! Not that that makes you feel any better. That's where counting carbs helps also.

You and your Dietician decide how many carbs you should eat and then how many units of Insulin for carbs that works just for you. Carb to Insulin ratio(C:I). It's determined by how many carbs:Insulin unit it takes to bring/keep your sugar level to a Good area of control.

Generally, 15 carbs to 1 Insulin unit. This ratio does vary from Person to Person and sometimes even if a Diabetic has the same meal another day, since we are such complicated machines. :D Quite often we see however, People with Diabetes who use 1 unit to 5 carbs or 1 unit to 30 carbs. Insulin (IR)Resistance and Insulin Sensitivity can contribute to these ratios.

It is quite simple to learn but it can be a pain in the application of this system. That's where that big box of motivation(that you have hidden in your closet)becomes a necessity. I'm sure you will put you Best foot forward when it is your time since you need it in order to use that pump that you want. Keep us in track with all of that please.
 

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Ugh!! Well, there are many Diabetics that use more units of Insulin than that for the same meal, as you probably know Reido!! Not that that makes you feel any better. That's where counting carbs helps also.
Err yeah right Terrie. :D

You and your Dietician decide how many carbs you should eat and then how many units of Insulin for carbs that works just for you. Carb to Insulin ratio(C:I). It's determined by how many carbs:Insulin unit it takes to bring/keep your sugar level to a Good area of control.
And I would get to learn how to count carbs in november in the D.A.F.N.E. course.

Generally, 15 carbs to 1 Insulin unit. This ratio does vary from Person to Person and sometimes even if a Diabetic has the same meal another day, since we are such complicated machines. :D Quite often we see however, People with Diabetes who use 1 unit to 5 carbs or 1 unit to 30 carbs. Insulin (IR)Resistance and Insulin Sensitivity can contribute to these ratios.
I can just see to use the 1:5U Carb:Insulin ratio for me as I am F F Fat!! :(:(:( May be that's an exaggeration I think. :rolleyes: It's something that I would have to work out. :eek:

It is quite simple to learn but it can be a pain in the application of this system. That's where that big box of motivation(that you have hidden in your closet)becomes a necessity. I'm sure you will put you Best foot forward when it is your time since you need it in order to use that pump that you want. Keep us in track with all of that please.
Pump!! What pump as I cannot afford one. :eek: Gee I can just see lunchtime as I look at the calculator, Scales, And the knowledge of what's is a carb and what's not. :confused: But all jokes aside it is an art to judge what to do as practice makes perfect. ;)
 

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A recent analysis of the records of CGMS and pump users showed that the average improvement in A1C was 0.5 . The average time spent by users to manage these devices was 50% more than with 5x MDI. There were notable increases in episodes of hypoglycemia and weight and no reductions in oter medical costs by by users.

The pump costs 3x vs syringes and CGMS 4x vs syringes and standard metering. When combined with the recalls and product defect reports on the pumps and CGMS systems available today in the US, there's no substantiation yet for the position that either is a significantly superior alternative to MDI by a well-educated person with diabetes.

When these devices are merged into a reliable moderate cost artificial pancreas that doesn't require user intervention they'll merit serious consideration, but until that time the users will be guinea pigs who will continue to drive up the cost of medical care with no improvements in outcome.
 

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Request for references

Dear "psdaengr"

Interesting analysis that you are referring to. Could you please provide the relevant references?

Thanks,
Trine

A recent analysis of the records of CGMS and pump users showed that the average improvement in A1C was 0.5 . The average time spent by users to manage these devices was 50% more than with 5x MDI. There were notable increases in episodes of hypoglycemia and weight and no reductions in oter medical costs by by users.

The pump costs 3x vs syringes and CGMS 4x vs syringes and standard metering. When combined with the recalls and product defect reports on the pumps and CGMS systems available today in the US, there's no substantiation yet for the position that either is a significantly superior alternative to MDI by a well-educated person with diabetes.

When these devices are merged into a reliable moderate cost artificial pancreas that doesn't require user intervention they'll merit serious consideration, but until that time the users will be guinea pigs who will continue to drive up the cost of medical care with no improvements in outcome.
 

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Hello psdaenger, I appreciate your post. It is very interesting but I agree that you should give us a link to show us the source of this information. Does it apply only to your country?
 

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Dear "psdaengr"

Interesting analysis that you are referring to. Could you please provide the relevant references?

Thanks,
Trine
My experience is that if you have to (search) for something, it becomes more valuable to you than if it's spoonfed to you.

The outcomes meta-study extracted the number of patients and claimed improvements from 50 randomly selected studies of the use of patients with type 1 diabetes plus the statistics from their control groups, calculated weighted averages. It did the same with studies that were more than 5 years old on the effects of metering vs non-metering and 10 years old on the effects of intensive MDI vs 1-2 injections per day using NPH and Humalog.

Time figures were based on surveys of 1000+ patients using intensive MDI, Humalog and Lantus with sliding scale, 100+ patients using pumps and 50 using CGMS 90 days after training and adoption of the management method by the patients. These surveys included patients from 15 European counties. The cost figures were calculated using US over-the-counter costs for supplies.

By far, the largest improvement in control came from patients being trained to utilize MDI with sliding scale, a measured diet and exercize plan. When patients who were thus trained were switched to metering and/or CGMS, they experienced a slight improvement in A1C, but a significant reduction in hypoglycemic episodes. When patients were not trained in MDI and sliding scale, they experienced an improvement in A1C but an increase in hypoglycemic episodes.

I realize that a metastudy typically isn't a good sole criteria for choosing a course of disease treatment, because any particular individual may be able to benefit more from it than the average patient.

In light of the health care insurance debate now going on in the US, what I found interesting was that the control gains from utilizing each of the newer technologies, when analyzed on a pure cost basis, were so tiny.

When all my supplies were being provided by my insurance for a small copayment, I didn't realize how high the cost of basic diabetes management was, but when I had to start paying the entire cost myself, I was astonished to discover that the "preferred" products of US companies sold in the US had twice the US retail price of non-US products sold in the US and in widespread use internationally. The sole exception was that each latest generation of insulin, has had a nearly constant price/unit for the last 50 years when adjusted for inflation. Given that the demand has doubled in the last 15 years, and the cost of production hasn't . . .

I guess my point is that if cost were no object, it would make sense to always use the latest technology. But it's not. Someone pays for everything we get, and someone suffers whenever resources are diverted to produce a benefits to society that isn't proportional to the costs.
 

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Richard157:

Obviously you didn't achieve your excellent results after 64 years by being dependent on a pump.

The metastudy outcomes statistics for everything except cost should apply to any country. The costs obviously can only apply to the US, since the US is one of the few countries that has retail prices that aren't subsidided by its government.
______________________________
"Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime." Chinese Proverb.
"Teach a man to think and act and you may not need to feed him at all." psdaengr.

Age 61. Type 1 for 32 years. Using MDI + diet. A1C = 5.6
 

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My A1c had been below 6.0 for several years before I started pumping. It has not been significantly different since I began pumping in June, 2007. The reason I wanted to pump was to reduce the number of highs and lows I was having. It is a well kown fact that a roller coaster type of control can lead to diabetes complications even when the A1c's are consistently good. After adjusting to pumping my BG's are in the range 70-130 (3.9-7.2) about 90% of the time. Before pumping it was in that range about 70% of the time and I had rather frequent highs at 170 (9.4)or greater, and lows below 50 (2.8) that sometimes required my wife to feed me glucose. That has not happened for two years now. My roller coaster has leveled out considerably, it is no longer a bumpy ride. I was having mild retinopathy and some neuropathy before pumping. Those problems have vanished due to my more stable control, even though my A1c's have not improved. My pump has enabled me to be complication free. I know many Americans who are using much less insulin, are losing weight and have considerly lower A1c's than before pumping. I rather doubt that your statistics are valid for pumpers in the USA.
 

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... I rather doubt that your statistics are valid for pumpers in the USA.
I'm happy that you doubt; it's people who accept what they are told without question that prevent progress.

It gives me no pleasure as a US citizen that even though the US spends far more per capita, the US trails most EU countries in quality and access to education and access to medical care for diabetes. Unless you think that US citizens are better educated, better motivated or smarter than citizens of the EU, I don't see how you could conclude the statistics wouldn't apply, or that the US statistics might not be worse.

Being highly motivated, informed and educated is what enables you to apply technology successfully to your personal advantage. I wish that more persons with diabetes were equally competent and had equal access to the technology; but until cost-effective hands-off systems are introduced, (or **** Sapiens Mark II) pump and CGMS technology has to be applied on a case-by-case basis.

The meta-study hasn't been released as it is undergoing review, but its findings aren't surprising; there are many individual studies that have results consistent with the metastudy going all the way back to the early 90's. Three things to consider when looking at an individual study is what was the study trying to prove, how did the control group differed from the intervention group, and who sponsored the study. The majority of studies with manufacturer sponsors have been primarily intended to prove that pumping and CGMS are safe and effective, not that they are more effective, and too often the control group receives no education. Newer studies are addressing these defects.

Here are some studies that are relevant:

Completed Trial
PUMP STUDY MDI Lantus/Lispro vs Continuous Insulin+Lispro
Comparison of a multiple daily insulin injection regimen (basal once-daily glargine plus mealtime lispro) and continuous subcutaneous insulin infusion (lispro) in type 1 diabetes: a randomized open parallel multicenter study.
http://www.ncbi.nlm.nih.gov/pubmed/19389820?dopt=Abstract

Comparison of Insulin Pump and Multiple Daily Injection Regimens in Type 1 Diabetic Patients (Children)
Author(s): Bassam S. Bin-Abbas, Abdullah Al-Fares, Nadia A. Sakati, Abdullah A. Al-Ashwal
Vol. 10, No. 1 (2006-10 - 2006-12)
http://www.indmedica.com/journals.php?journalid=13&issueid=107&articleid=1475&action=article

papers:
http://www.ncbi.nlm.nih.gov/sites/e...kname=pubmed_pubmed&uid=16026370&ordinalpos=1
http://www.insulinpumptherapy.co.uk/diabetes_resources/clinical_research_papers/index.html
http://thejsms.com/744/

This publication from the Undersecretary for Health is interesting. It says flat out that efficacy of using pumps in an adult population was comparable to MDI. It raises the question of cost but it avoids answering it, http://www1.va.gov/VHAPUBLICATIONS/ViewPublication.asp?pub_ID=2054

This site has data on the effective application of pumps to children, one of the best applications, since management of childhood diabetes has been very difficult to manage. Note though, that even with government subsidization and control of pharmaceutical industry profits, the cost is still more than double vs MDI.
http://www.insulinpumptherapy.co.uk/diabetes_resources/clinical_research_papers/index.html

Ongoing Clinical Trials
"Study to Compare Efficacy of the MiniMed Paradigm REAL-Time System Vs. MDI in Subjects Naive to Insulin Pump Therapy"
Study Director: Scott W Lee, MD Medtronic MiniMed
Responsible Party: Medtronic Diabetes ( John Mastrototaro, VP, Global Clinical, Scientific and Health Affairs )
Study ID Numbers: CEP179/Z25
Study First Received: January 2, 2007
Last Updated: January 7, 2009
ClinicalTrials.gov Identifier: NCT00417989
http://clinicaltrials.gov/ct2/show/NCT00417989
 

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Thanks for these links! I am enjoying the topic and discussion.
 

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I'm happy that you doubt; it's people who accept what they are told without question that prevent progress.

It gives me no pleasure as a US citizen that even though the US spends far more per capita, the US trails most EU countries in quality and access to education and access to medical care for diabetes.


psdaengr, I confess that I don't know a lot about the subject of pumps, so I am actually changing the subject a bit. I'm Type 2 and don't take insulin. I do work in the health care system, as a customer service representative for a major insurance company, and I have talked to literally thousands of people this year - a few hundred last week alone. I have heard the same frustrations voiced over and over.

Thus, I would like to make a comment about our health care system in the US. One of the reasons I think our "health care system" and "cost of health insurance" is so high is that in the past 30-40 years we have spent more money and time educating our kids to play basketball and football and play with computers than we have ever done educating them about their body and health, or anything else for that matter. Now it is taking its toll healthwise. Likewise with adults; we are too busy earning a living and raising families to have time for "proper living." No one is pushing "health." Just a "health system" or "insurance." And I think there is a reason for that.
Our government knows what is wrong with the system. I offer the following document as a reference: Citizens' Health Care Working Group: Health Report to the American People
This study was sponsored by the US Government by means of the MEDICARE PRESCRIPTION DRUG, IMPROVEMENT, AND MODERNIZATION ACT OF 2003, Public Law 1080-173, Sec. 1014 c, which I'm sure anyone over 65 is now familiar with. (Citizens' Health Care Working Group) The act did a little more than just make the first ever major change to Medicare.
The study shows that: (page 8)
"In 2004, almost half of all people in the United States had a chronic condition that ranged from mild to severe. That year, 23 million Americans had heart disease, 22 million had asthma, more than 13 million had diabetes [22], 400,000 had multiple sclerosis [31], and more than 750,000 had cerebral palsy [32]." (The bracketed numbers are footnotes found in the report - references for the info).
(page 9) "Health care for people with chronic diseases accounts for 75 percent of the nation’s total health care costs [34]. For example, people with diabetes incurred an average of $13,243 in health care bills in 2002 [35]."
(Page 35)
"Health promotion and disease prevention - One way to reduce the amount of health care we need might be to take better care of ourselves. For many of us, better diets, exercise, or not smoking could reduce the need for some kinds of health care. Nearly two-thirds of American adults are overweight or obese [6]. Unhealthy lifestyles contribute to this statistic. Not everyone is able to exercise regularly, but many of us who are able to don’t. Nearly 40 percent of adults are not physically active during their free time, and 1 in 3 high school students do not get the recommended amount of physical activity [41]. Lack of exercise is just one lifestyle habit that can increase the risk of certain diseases, such as heart disease or stroke."
It seems to me we work very hard in this country trying to cure things after they develop - but not to prevent them. Would there be some $ signs in this equation - would anyone make as much money if people were healthier? But I don't hear one Congressman taking a stand for promoting "health" rather than "health care", although they have the information in the study directly before them. Could there be some $ signs from drug and food lobbyists blocking the legislators eyes?
Food is another thing - how much do we really know about what is being put into our food? What about our water supply - is there a better way than pouring clorine and floride in it?
I'm not saying prevention is the answer to every health problem, but isn't it at least half the answer, at least for future generations?
The only thing I can see is that it will take a huge grass roots effort, and research, to make a change.
I can say this, "lowering the cost of the health care system" by just cutting out waste and fraud, or limiting people's ability to sue drug companies, isn't going to work. Those costs are small compared to the overall costs. Nor is "insuring all Americans" the answer. I hear the pain in people's voices when they get their rate change letters as a birthday or policy anniversary gift, and they are forced by economics to choose a higher deductible or policy with fewer benefits. They don't go to the doctor or get health care checks thinking that is the cause for their premium being raised, but it isn't. They're actually paying for others' medical bills through their "unused" premium if they are healthy. Also, in the last ten years, I believe the health insurance companies have drastically lowered the percentage of total premium they are paying out in claims. So its a money deal, too.
If the government takes insurance over, people will still have to pay the health care through the tax system, and government will have control of access. So, the only thing I can see as being beneficial if to attack the root causes and the symptems.
Sorry to rattle on like this. I'm not siding politically here with either party. However, I do agree with you, psdaengr, we do need to be always asking questions.
Jer
 
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