Freestyle Libre - Going for the hat-trick?

Abbott have been able to announce a couple of really exciting bits of news in the last few weeks. Just in case you hadn't heard here they are...

Libre approved for use in children
The lovely Lesley Joseph from INPUT was attending ATTD 2016 (Advanced Technologies & Treatments for Diabetes) in Milan last week and was excited to share a glimpse of one of the presentations where Abbott announced that they had achieved a license for Libre in children. This was enthusiastically shared on social media along with another of the slides from the conference with some of the details from the study.

This is really good news for parents of children with diabetes who have been wanting to try the Libre as part of their diabetes management toolkit. It also reassures those who jumped in early before approval and used the Libre 'off license' for their children that they can now contact Abbott with a happy heart if they have any problems or need any advice.

Not to be outdone, Abbott themselves made an official announcement soon afterwards. Unsurprisingly choosing overnight testing as a particularly useful time to have a Libre in use. A lot less hassle to wave a reader through the duvet than to have to get a lancet out at 3am and rouse your slumbering child.

This welcome news came pretty hot on the heels of another long-awaited update in the story of the Libre...

No more waiting list
Following the launch of their new high volume production facility in January, Abbott have been able to clear the UK waiting list and the Libre can now be bought by anyone without having to wait. I heard about this a good few weeks back, but was a little cautious to mention it until I could actually see the results (we have been here before remember). However a week or so ago the news on TwitFace and other Social Bloggings was that, yes, the waiting list is no more. Hurrah!

At the same time, I had also heard from Abbott that they were beginning to roll out an official smartphone app that allows people who have a phone with an NFC chip to dispense with the reader and just use their phone to take Libre readings. I can't say much more than that as it has currently only launched in Sweden, but being able to ditch the separate meter certainly appeals to me. There are a couple of 'home spun' Android apps that attempt to do the same, but an official one from Abbott would reassure users that it has had to be put through all of the regulatory rigours of the handset itself. I will watch this one with interest (though I suspect as it stands no iPhone version will be possible because of the way Apple limits access to the iPhone 6's NFC chip).

I have not heard any more information about plans to launch either the Libre itself, or the app in more countries (though I know the UK is next on the list for app launch), but I have been promised a bit of a catch-up with Abbott in the near future and will keep you posted if I hear anything else.

The next big thing?
What would make this perfect for UK readers, of course, would be the announcement that the Libre was to become available on prescription via the NHS. Rumours and grapevine whisperings suggest that this might be tantalisingly close, but as yet remains elusive.

It seems there was much talk at ATTD about CGM (and other continuous monitoring options) and sensor-augmented pump therapy (Smartguard and other Artificial Pancreas dual or triple hormone technologies) so we will all be watching with interest.

If you hear any juicy gossip or rumours, do share them in the comments below.

Another Non-invasive BG Meter?

Stumbled across this yesterday. I'd heard rumours of this new non-invasive BG monitor a while back, but it looks like they are gradually creeping towards a finished product.

It's not a continuous monitor (so can't offer trend arrows on the device or any kind of automatic alerts) but *is* measuring blood glucose values so, perhaps, might be sufficient for DVLA. Measurements look to take 10s and are made by passing radio waves through thin areas of skin such as your ear lobe, or more likely that stretchy bit between your thumb and fingers.

Results are displayed on the device and can be blue-toothily uploaded via a smartphone/tablet app to a cloud-based software platform. The app promises to use the uploaded data "to calculate and forecast immediate trends in your blood glucose levels, allowing you to adjust your food or medication intake according to your activities or how you are feeling". Sounds promising, but a bit wishy-washy and vague in terms of what that might actually *mean*.

The non-invasive nature means, of course, that you could monitor your BG many more times a day without burning through strips. Ideal when waiting for BGs to come up (or start dropping) and allowing some of those 'sugar surfing' techniques (is it just me whose toes curl every time I hear that phrase?). Also pretty handy for testing on-the-go in situations where fiddling with strips and lancets is impossible, much like Abbott's Libre.

Currently in clinical trials and the website suggests it may be available for pre-order (whatever timescale that means!) at some point in 2016

Another to go on my long list of possible 'ones to watch'.

More details at www.gluco-wise.com/

Disclaimer. I have no relationship with the manufacturers of this device and I've not been paid to write this post or publicise the product in any way.

Collecting third pancreas object (C-3PO)

On Monday this week I popped in to see the lovely LJ the DSN at my Pump Clinic to collect my new pump. We had a nice chat and ran through the set up procedure before I pottered back with a little smile on my face.

You may remember that I posted about collecting my first insulin pump on 1st November 2011. Mostly for my own amusement, I began referring to my little robot counterpart as Artoo almost immediately (R2-P2 - replacement to pancreas #2, with MDI having been replacement to pancreas #1). Insulin pumps generally have a warranty period of 4 years, and my hospital were happy to replace my old pump fairly soon after that period had passed.

I could have chosen pretty much any of the currently available insulin pumps I think, and I have been tempted by the Animas Vibe for some time, though of course, that pump is now getting rather long in the tooth. Animas are well down the road of developing their next pump, but their new offering is not supposed to launch until perhaps 2017. I'm not sure exactly what the new Animas pump will bring to the table, though some sort of insulin-adjusting CGM integration seems to be rumoured. For the Vibe though, despite the attractions of the Dexcom tie-in I was wary of some irritating details of the bolus wizard on the Vibe and was very mindful of the absence of SmartGuard and potential alarm fatigue should funds permit some CGM usage for me.

Medtronic have timelined their new 'hybrid closed loop' MM670G for a similar period, perhaps 2017-2018 (which apparently will have a souped-up version of SmartGuard that aims to counteract highs as well as lows). In the end though, given my very positive experience of the MM640G, I decided to opt for that one. After all, those tantalising shiny, new, possibilities may not actually launch until more than half way through my next pump contract.

Given the almost stifling saturation of hype surrounding the UK launch of the new Star Wars film in 7 days time, I have not been able to resist revisiting that old joke again and so 'threepio' has become my new droid companion. Apparently he has a protocol for dodging hypos as well as communicating with moisture vaporators, but unless I have an unexpected windfall of 'galactic credits', sadly that particular function will remain little more than a futuristic fairytale.

In other, and slightly related news. I have already changed the Threepio's setup so that the homescreen displays as if I were using sensors. Partly this is because I prefer the look of the graph on it (even if the graph has almost no information to display) because of the irritating enormity of the '-.-- we have no fingerstick BG information to show you' dashed line. But also because that way I can use the graph data to track down the timing of my most recent bolus. Either as a visual ready-reckoner with the blue dot beneath the otherwise empty graph, or by drilling in to the graph view and scrolling back to see the exact time. Gathering the information this way takes only five clicks from 'standby' whereas getting the same information in the normal way from the 'status bar' takes seven.

Little things and all that.

64 Days with the Medtronic 640G: Ep 9 Review - the best and worst of the MM640G

Well, this is it. The last of my posts covering my time with the Medtronic MiniMed 640G. Thank you so much for bearing with me over the last few months. Normal wittering will be resumed shortly. However, as seems to be the way of things with blockbuster franchises (HA!) I have split this last episode into two parts. Part (i) covers all the little niggles and irritations I had while using the MM640G, while part (ii) looks at the things I loved, and reviews my results including reductions (if any) in hypoglycaemia and an HbA1c I had done at the end of my time using the pump. HbA1c is the test which measures how much of the glucose in your blood stream has stuck to red blood cells. It is often used as a measure of your likelihood of developing the long term complications of diabetes.

For those who really can't bear wading through all those minutes of video I will summarise the results below. The video gives a lot more detail though, and features a fluffy bunny. What's not to like?!

When it comes to the things I really liked/disliked about the MM640G you will need to bear in mind that I am comparing to a MiniMed Veo. All of the really good stuff about pumps generally - precise basal patterns, advanced dual and square wave bolus options for tricky meals, ease of use, bolus calculator, temporary basal rates, precision of doses and correction factors, blah, blah, blah... are already assumed to be present and correct. Some of the things I loved about the MM640G are precisely because they fixed annoyances I found with the Veo. But more on that later. First:

The worst of the Medtronic MiniMed 640G

Those who have read any of my reviews before will know that I can get unreasonably irritated by the slightest things. It will come as no surprise then, that while I generally loved the MM640G both with and without sensors, there were a few things about it that drove me nuts.

1. Pump lock
   After a few minutes the pump automatically locks and most interactions require you to play an annoying 'press the right button' game. This is no good if you are in a hurry, and is not an option that can be turned off.
   
2. Change of orientation
   It's now 'portrait' not 'landscape'. As someone who wears an insulin pump on my belt this is a bit awkward.
   
3. No small versions
   Medtronic have now abandoned plans to produce a smaller version of the pump. All MM640Gs will now have the little sticky-up bit to accept the larger reservoirs. The smaller reservoirs can still be used, but at present, with approximately 35u/day usage, the 'how full is my reservoir' icon on my status bar is pretty much permanently red.
   
4. Sensor overtape irritation
   The glue used on the sensor overtapes (and also the little patch that holds the sensor down initially) caused a red rash to appear after a couple of days of wear. Initially it was only toward the end of a sensor but in the end it began pretty much at day 2. I used an alternative dressing, but even that was pretty itchy. Weird - because I don't usually react to adhesives at all.
   
5. Sensor swap delays
   From start to finish swapping a sensor takes around 3 hours to begin providing new continuous data. That's a looooooong time!
   
6. Occasional sensor lag
   Mostly I found the sensor accuracy was brilliant. But sometimes, particularly if I treated a low to try to fix a below target BG reading, the sensor was a little slow in responding (perhaps 30 minutes behind reality). Additionally calibrations by BG meter do not necessarily reach up to match sensor glucose and BG fingerstick value, but often end up with some odd half-way house. If the sensor glucose value had drifted a little there were even occasions where calibration triggered an 'alert before high' which was doubly annoying.
   
7. Sensor Glucose Review
   The one-day graphs which allow you to flick back through previous days' results show no indication of SmartGuard interactions or insulin doses. Makes them about 10% as useful as they could have been.
   
8. Home screen without sensors
   For no apparent reason, the icons in the status bar do not align neatly when using the MM640G without sensors. There's a gap where one of the sensor icons(!) would go, which makes it look untidy and poorly considered. The enormous dotted line 'we have no BG information to show you' panel where recent meter BG readings go (when not using sensors) also irritated me more than strictly necessary. Just doesn't feel like the visual look of the home screen for most UK users, who will be using the MM640G without sensors, was given enough finesse.
   

Watch the video

The grumbles, gripes, and irritations - everyone will have their own, I'm sure.

The best of the Medtronic MiniMed 640G

Whether you use the MM640G with sensors or not there is a LOT to like about it. There are all sorts of little, pleasing improvements in the interface and options that make a massive difference. Add the wizardry of SmartGuard into the mix and things are taken to another level - but even without there are lots of tasty treats for non-sensor users.

1. Setting basals and temp basals
   There are now up to five basal patterns on the MM640G, and brilliantly you can copy entire patterns from one 'slot' to another to experiment with and then switch back if you need to later. The patterns also come with helpful names to keep track of which are which: Work Day, Day Off, Sick Day, Pattern 1, Pattern 2. Which pattern is set is not marked on the home screen, but thankfully setting any of them does not cause the 'alert circle' to appear like it did on the Veo.
   
   Temp basals can now be set in 15 minute increments for more precision and alter up and down by 5% at a time making them much quicker and less fiddly to set.
   
2. No TBR 'chime'
   Setting a Temporary Basal Rate no longer causes the pump to issue a useless wittery alert tone every hour, which means you can ACTUALLY USE THEM OVERNIGHT! In even better news - the end of a TBR is now indicated by a single beep. Brilliant!
   
3. Different Alert Tones
   There are now a series of different alert tones to indicate different things. There were a few on the Veo, but so many overlapped with either 'pip-pip-pip' or 'naah-naah-naah' that I find it much easier to work out what is going on on the MM640G without having to check the pump for 'information' alerts and being alerted (ha!) to things that actually require action. The ability to increase volume has also significantly improved.
   
4. No lockout during bolus delivery
   It is possible on the MM640G to do rather more things during the time while a reasonable sized bolus is being delivered - for example you can set a TBR. The Veo made you wait until the bolus had finished before allowing you to do anything (other than stop the bolus!). This meant I could group my pump interactions together and then get on with life, rather than having to wait around tutting.
   
5. Screen visibility in sunlight
   Really, really good - especially compared to some other colour-screen diabetes gadgetry I have tried. Not perfect from every angle, but really easy to turn a little and see very clearly even in direct sunlight.
   
6. Remote boluses from BG meter
   Not a full remote control with bolus wizard, but a really useful standby when digging your pump out from within clothing is impractical or inconvenient.
   
7. Waterproof
   Now rated as IPX8 - up to 12 feet of water for up to 24 hours.
   
8. SmartGuard - overnight hypoglycaemia
   Unsurprising if you have watched my Overnight Hypoglycaemia post, but SmartGuard overnight for me was a real stand-out winner. No readings at all for 9 weeks below 3.5mmol/L overnight, and hardly any below 4.0mmol/L. Some nights almost no basal insulin required, and others requiring my more 'usual' 6-7 units at night. Looking at the results it's hardly surprising I had so many problems and so much Severe Hypoglycaemia during my years on Lantus!
   
9. SmartGuard - results overall
   When compared to averaged results from 10 weeks of Libre sensors (the only other 24 hour data I have) time in hypoglycaemia fell by 90% during my 9 weeks with the MiniMed 640G. At the same time my overall levels, as measured by HbA1c fell by 0.3%. And all this with less effort and very little 'alarm fatigue'.
   

Watch the video

Improvements to the pump (with and without sensors) and the all important results.

Conclusion

It has been a great privilege to experience the MM640G system, and for me the results were spectacularly good. The comparison with Libre data is an interesting one, particularly where hypoglycaemia is concerned. Times wearing a Libre sensor were previously my 'best ever' results-wise. The ability to spot hypos coming during the day and try to head them off (I generally scan a Libre sensor something like 30-40 times a day), plus the ability to spot low levels overnight and make hurried basal rate changes meant that I generally had fewer hypos on a Libre than I would normally. And yet when compared to these data, the MM640G system reduced my time spent in hypoglycaemia by 90%. To be clear, that means that for every 10 minutes I spent below 4.0mmol/L trying my very hardest with a Libre sensor, I would spend only one minute when using SmartGuard. That and my HbA1c dropped over the same period from 6.3% to 6.0%. 0.3% - it's not a huge margin, but those fractions are pretty tricky to shave off once you get down below 7.0 in my experience.

My only hint of melancholy about the whole experience is, of course, the eye-watering cost of full-time sensor coverage (approx £3,500 per year inc transmitter). It's not something we as a family can afford, and full time CGM on the NHS is reserved for those who really need it most - and rightly so.

It feels a little like being given a chance to live in a multi-million pound mansion and drive an Aston Martin for a few weeks to see how I like it. I may think it's brilliant - but the reality is that it's not really an option that is really open to me long-term.

I have a pump clinic coming up in a week or two and will see what they say about the results - particularly my unpredictable and occasionally lengthy periods spent below 4.0 overnight. These do nothing to help my efforts to keep my Imparired Awareness of Hypoglycaemia under control. I may ask about the possibility of part-time sensor coverage. Even a few months in a year would make a massive difference (as long as the transmitter continued to function, of course).

My Veo is nearing the end of its warranty period, so I am looking to the future. I have some thinking and some sums to do after this experience - depending on what my clinic say.

Final verdict (with sensors and SmartGuard): 5/5
Final verdict (without sensors): 4/5
Final verdict (considering self-funding sensors): 4/5*

* because of Dexcom's more 'stretchable' reputation when it comes to sensor life

Disclaimer: I was offered a trial of the Medtronic MiniMed 640G system for 64 Days with full sensor coverage so that I could share my opinion and experience good or bad. I was not paid to write this post, and if I had thought the pump was terrible I would have written that. I was encouraged (not required) to post video blogs about my experience, but Medtronic did not have any control over what I posted.

Abbott Freestyle Libre available to new customers again

There were excited murmerings on Facebook last week and on Friday I received a phone call that confirmed what many, many people have been waiting for over the last few months.

Abbott have begun to take on new customers for the Freestyle Libre again

Wooooo hoooooooo!!!

I think it is probably fair to say that Abbott were a little taken aback by the level of demand for their new toy immediately after launch (the Libre 'flash' glucose not-quite-CGM monitor). It wasn't long before they realised that consumer enthusiasm was going to outstrip their production capabilites and they took a tough decision to stop taking on new customers in order to protect supply to those who had signed up first. Probably the right thing to do, but pretty frustrating for many people - myself included, who hadn't quite got around to registering with their e-shop early on.

Some people have got quite cross about this, but I'm more inclined to give them the benefit of the doubt. This was a completely new piece of technology in a relatively small market place (certainly in the UK). They had to anticipate what sort of level of early take-up there might be, but it's not entirely surprising that they didn't get it spot-on. And deciding to limit supply so that fewer people got better service rather than many people getting rubbish service seems to have quite a consumer-focussed feel to it. They didn't just take everyone's money and not deliver, they concentrated on ensuring that those who signed up early could get full-time sensor coverage if they wanted it.

But for the rest of us, the weeks turned into months... and still we waited.

Until now.

As of last week they have begun to issue emails to people who signed up on the website. They are doing this on a 'first come first served' basis, so those who asked to be told when Libre was available to new customers in October/November 2014 will be hearing first.

Of course they will have to weed out a bunch of dead results from those expressions of interest. People who have changed their minds and so on - so if you recive an email you will need to act on it pretty promptly.

According to what I've been told by Abbott, it works like this:

• People will receive an email alert which (I think!) outlines the process
• People then recive a second email which gives them a relatively short window of opportunity to respond
• They then need to sign up as a new customer
• You also need to place an initial order to activate your account (minimum of one sensor approx £50)
• Thereafter a maximum of 2 sensors can be ordered every 14 days

Looking forward to receiving my email :)

Update: Hurrah! No more waiting list!

25 not out - stick THAT up your nose diabetes!

At some point during the last week (I'm not entirely sure which day) I made my quarter century of living, more or less successfully, with type 1 diabetes. Twenty five years later and I've still got both feet, my eyes are pretty much unscathed and my kidneys still seem able to cope with clearing up after all the stuff I throw at them. Not a bad effort.

Also this week, I stumbled across two interlinked snippets of information that interested me:

We're dooooooooomed!

The first came via a retweet from Dr Pratik Choudary about some research from the T1D Exchange that suggests that the longer you have lived with type 1 diabetes, the more likely you are to experience severe hypoglycaemia (needing assistance of a third party, family member, friend or paramedic to recover). I've come across Pratik's work during my sifting of research for the NICE Guidelines update, and he seems to have his finger on the pulse, so was intrigued - interesting people sharing interesting stuff...

I confess I was slightly surprised at the findings. I suppose in a sense there is a certain logic to them, older people will have any residual 'helping hand' action from their own pancreas long gone, and more opportunity to have succumbed to a degree of hypoglycaemia unawareness. Still a bit odd that incidence of severe hypoglycaemia looks to increase year on year though - I would have expected a good deal of difficulty in managing BG in early childhood (tiny doses... erratic hormones... growth spurts... irregular physical activity) and certainly during teenage years (rebellion... wanting to fit in... more growth spurts and raging hormones). Even during young adulthood and middle years there's a degree of chaos going on with life in general. Particularly if people become parents themselves - when focussing entirely on yourself tends to slip into the background, replaced with sleep deprivation and general exhaustion. By contrast my own life seems to have become slightly more settled post-40. Much more time to sort out my own stuff.

When we began writing our blog it was not at all uncommon for Jane to have to help me out early in the morning from a nasty low (thanks Lantus!). When I look back, I am ashamed that I put everyone through this for so many years and did not sort it out earlier. But thanks to the support, wit and wisdom of the DOC, over the last few years I have gone a long way to reduce my hypoglycaemia in general and severe hypoglycaemia in particular. I can't remember the least time I got so low that someone in the family had to lend me a hand - but it was probably three or four years ago.

I for one have exactly the opposite experience of the T1D Exchange findings. What about you? If you are living with type 1, are you seeing more or less severe hypoglycaemia than before? Should we accept an increase in severe hypoglycaemia as inevitable*?

* The answer, of course, is NO!

Nasal Glucagon

Photo: Mike Hoskins

The second thing that caught my eye came as an email, following a presentation at the Advanced Technologies & Treatments for Diabetes (ATTD) conference in Paris last week, concerning a novel new glucagon treatment that is in development. Glucagon is used as an emergency treatment for severe hypoglycaemia. Currently it involves injecting sterile water into a vial of powder, mixing into solution and injecting into a person who has become so hypoglycaemic that they are either unconscious or otherwise unable to consume any high glucose treatment. Glucagon is a great treatment, but the current delivery method is pretty complex. I first came across the 'nasal puff' concept via Mike Hoskins in the US, who posted on Diabetes Mine following involvement in a trial of the device. It's ingenious! Developed by a tiny private company with parents of T1D children at the helm, it seems driven by passion and practicality.

I know that when I have tried to mention Glucagon kits to anyone among my family and friends they immediately take on a distinctly 'rabbit in the headlights' expression and start mumbling about "erm... yes... or I'd call an ambulance". The idea that at a time of extreme stress, possibly in the middle of the night, someone entirely untrained in giving injections would be able to calmly proceed through a multi-step process of mixing, drawing up, selecting injection site and administering (especially if I were thrashing about) seems crazy.

This new treatment involves simply 'puffing' dry powder up the nose. It doesn't need to be inhaled (designed for people who may be unconscious), simply pushing the base of the container ejects a cloud of dry glucagon into the nasal passages where it is absorbed directly. No needles, no mixing, no faffing about in the dark.

The device is not currently available, but phase 3 clinical trials are currently underway and I will watch the story with interest.

Disclosure: I was not paid to mention Locemia's nasal glucagon device (ha! chance would be a fine thing!). It just sounds like a great idea.

6.5% A1c target - A reply to a comment that got out of hand

I've had a couple of comments on my post about the proposed new HbA1c target in the draft NICE guideline that is currently out for consultation. I was rattling in a 'quick' reply, when I thought - this is *ridiculous*. I can't even see this any more in this tiny box - so I've decided to post it here instead :)

Here are the comments:

Tamer Hassan said...
how do you achieve these numbers?

thanks

Tim said...
These numbers are impossible to reach...
Or at least give me some suggestions on how to reach these levels. Thanks.
Tim

'How to reach these numbers' is a question for your healthcare provider really. Don't just ask some random nutter on the Internet! However (and desperately trying to avoid sounding like Mr Smug of No 22 Smug Gardens, Bigheadshire) I have had a sub 6.5% HbA1c for over 3 years now, so I know that it *is* possible if only perhaps for the lucky few. Plus I've never had fewer hypos in my life with diabetes either - so it's not that I am 'paying' for A1c improvements with the hefty cost of Severe Hypoglycaemia.

I cannot really tell why some people seem to put in so much effort and get such scant rewards, and that is why I think individualised targets are SO important.

But it does seem pretty clear to me that the closer you can get to those standard-issue BG targets (5-7mmol/L waking, 4-7mmol/L pre meals and <9mmol/L by 2 hours after meals) for as many days in the week as you can manage, the closer you will get to these kind of tough, aspirational, borderline non-diabetic A1c targets. My own HbA1c has fallen by around 1.5% in recent years, and I think only around 0.5% of that is attributable to the pump - though Artoo has gone a LONG way to reduce my number of irritating low-level hypoglycaemia dips. When I look back over the changes that I have made in recent years I can see a few things that I think were important. I don't offer these as any kind of guide or advice - it's just what I did.

1. Education. Get access to proper structured education regarding diabetes management. In the UK we have DAFNE which is highly thought of, but other options are available. Things that should be included (in my opinion) are:
   
   1. carbohydrate counting, working out how to check and change insulin:carb ratios for different times of the day
   2. SMBG technique - when to test and what to do with the results *including* basal testing to PROPERLY adjust basal on an ongoing basis
   3. correction factors - when and how to correct (with insulin or fast-acting carbs) to aim bring you back into range without jumping aboard the gluco-coaster
   4. exercise and alcohol
   5. dealing with illness
   If structured education courses are not available in your country/area you can do a lot worse than buying 'Think like a pancreas' (Scheiner), 'Type 1 Diabetes' (Hanas) or 'Pumping Insulin' (Walsh/Roberts) which cover much the same ground. Though the benefit of peer support in group sessions should not be underestimated



2. Test more often AND RECORD THE RESULTS. Find some way of keeping notes daily as you go along. What you are eating, units and timing of doses (how long before... split doses...), exercise, mood, everything! Without a fairly detailed set of records I find it impossible to see what is going on. Personally I still love mySugr for this.



3. Gadgets - seek out new tech that can help you manage your diabetes more easily. It might be a 0.5u pen; a smartphone tracking app, or copy of 'Carbs and Cals'; or it might be a BG meter with a bolus wizard so that you can have properly fine-tuned ratios without having to worry about keeping the maths easy. Additionally, ask your clinic about access to Insulin Pump therapy and CGM.



4. Seek peer support - join a forum or two, join Twitter, read some blogs (thanks!) or even *crazy!* join a local group and meet face to face. Living with diabetes is tough, but it's even harder if you are battling on your own. For everyone there's a little corner of the internet that can provide support, encouragement and shared experiences.

At the end of the day we each have to find our own balance between living a life and managing our diabetes. Somewhere in the middle you'll find your perfect A1c and it won't drain all the joy out of life to reach it.

Good luck :)

Medtronic MiniMed 640G 'SmartGuard' Pump - Preview

The Medtronic 640G launches Feb 2015

I was absolutely made up to receive an email a few weeks back that invited me to go along to the Medtronic UK 'Bloggers and Patient Advocate' meeting in sunny Watford today. It seems that Medtronic are keen to connect a little more with the diabetes online community in the UK, share a little of what they are up to and generally get some grass roots feedback. The group is a mix of MDI and pump users (Medtronic, Animas and Roche, with and without various CGM alternatives all present). It includes both people with diabetes and parents of children or young people with diabetes. It was lovely to meet up with a glittering array of familiar and less familiar faces, Annie (@understudypanc), Lesley (@INPUTdiabetes), Laura (@ninjabetic1 and #ourD), Lindsay (@LwSweetpea88), Sue (@desangsue), Dave (@SowerBee), Chris (@grumpy_pumper), Paul (@TheTeamBG and #GBdoc), Gavin (@Diathlete), Kris (@diabeticbanana), Kyle (of @mysugr), plus @JDRFUK youth ambassador George (and his mum!). We were joined by 6 folks from Medtronic who were very excited by some of their new toys that are just about to launch. I believe that this group has met several times before with more of a 'brain-picking' workshop feel, but today was much more of a full-on sales pitch with a sneak peek of the new MiniMed 640G insulin pump which launches in the UK, Sweden, Denmark and Australia on the 1st 2nd of February (regrettably it looks like FDA approval for the US could take years). We were lucky enough to get a short amount of hands-on time to play with the 640G and I just wanted to share a little of what I saw today. I won't be able to go into too much detail for a full-on review here I'm afraid, because there was LOT of information shared and while I tried to take some notes, all too quickly we had to hand the devices back in. Plus since the official website doesn't launch for another couple of weeks I've nothing to check against. I will try to get someone from Medtronic to glance over the post and set me straight if any of this is complete nonsense. I'll post (and add think about ignore mark) corrections as necessary :)

Those familiar with Medtronic's Veo may have come across the term 'Low Glucose Suspend', the facility where overnight the Veo (when used with Enlite CGM sensors) can automatically stop basal insulin supply if the pump detects a predetermined low glucose threshold has been passed. This has been shown to significantly reduce the severity and duration of overnight hypoglycaemia in clinical trials and was welomed (particularly by parents of T1 children) as a major step forward towards developing the 'artificial pancreas'.

The MiniMed 640G takes this approach to a whole new level with 'SmartGuard', an algorithm that begins to take effect significantly before you have hit your 'low' level, attempting to dodge some of those pesky hypos altogether. The sensors are Enlites again, but with a new (and apparently much improved) 'Guardian Link' transmitter to boost performance.

More on that later, but first a quick overview:

• Colour screen which apparently reads easily in sunlight
• Waterproof (yay!) including swimming
• Reservoirs available in either 180u and 300u
• Up to 5 different basal patterns with up to 48 rates per 24 hours each.
• Pairs with Contour Next Link USB (new 2.4 version)
• Limited bolus options via meter, full bolus wizard on pump
• Completely re-worked interface with many more 'user-friendly' options and updates
• More customisable alarms (and at louder volumes)
• Already licensed for use by children
• Size-wise it's very similar to the Veo, just a few millimeters taller, wider and deeper

SmartGuard
The thing Medtronic were clearly most excited about was obviously 'SmartGuard', so it's probably worth trying to note down what I can remember about how that works. SmartGuard builds significantly on the premise of Low Glucose Suspend by making the whole thing much more predictive. While Low Glucose Suspend only kicks in when you are already registering low, SmartGuard acts earlier trying to head off the low by temporarily stopping basal (in much the same way I started doing while wearing a Libre sensor - see 'new technique'). They had a snazzy graph in the presentation to explain how it works, which I've attempted to recreate here. On the pump you set a 'low' limit that you do not wish to fall below - anywhere between 2.8 and 5.0 in 0.2mmol/L increments. Above that the pump sets additional 1.1mmol/L and 3.9mmol/L guides. SmartGuard is triggered if sensor glucose values fall below that upper line (3.9 above your low limit) AND are falling sharply enough that you are predicted to fall below the 1.1 line within 30 minutes. All insulin is stopped for at least 30 minutes from that point (including basal and any partial dual or square waves still in progress). If your numbers stay down, the insulin stays off for a maximum of 2 hours. Basal delivery (only) automatically resumes once you have risen above the 1.1 line AND are predicted to remain there for the next 30 minutes. Users can, of course, cancel the SmartGuard intervention at any point (eg if they would prefer to treat the impending low with some tasty fast-acting carbs. Rather neatly you can also choose whether or not the 640G alarms or alerts at any of those points and even tailor what times of the day (or night) to switch SmartGuard on or off. Alternatively you can simply run the system as the current Low Glucose Suspend works.

It was claimed that in the 'Pilgrim' study, the same algorithm that powers SmartGuard was able to avoid 80% of potential hypoglycaemic events both day and night. If those results could be reproduced 'in the wild' it would be nothing short of groundbreaking. A handful of people have recently been able to use the 640G on a trial basis at Kings College Hospital and two of them (including @desangsue) shared their experiences. Responses from other hands-on users are also very encouraging and seem to suggest that many found SmartGuard alone was sufficient to cope with moderate exercise. After a short while to build trust, many were also happy to simply let SmartGuard do its thing silently and alarm-free, only realising when checking the pump later that they had been spared a low-level dip here or there by some automated basal jiggery-pokery. The only mandatory alarm that sounds would be if your sensor glucose fell below your 'low limit'. This is a good thing. But the customisability of those alarms, while preventative action is automatically taken without confirmation being required seems to go a long way to prevent CGM 'alarm fatigue'.

Fancy new meter
The 640G pairs with a Bayer meter that looks just like the existing Contour Next USB, but this souped-up '2.4' version has some extra cleverness under the hood. For starters you can use it to deliver a quick manual bolus of any number of units you choose without having to fish the 640G out of your pocket. You can also create up to 8 bolus presets (which can include predetermined square or dual-wave options and doses) on the 640G that can be fired from the meter. Frustratingly you cannot vary the doses of these presets from the meter itself at the point of delivery - which would make this much more useful for me - and neither can the meter act as a fully fledged bolus wizard as it does with Roche pumps. However *some* meter bolus options are certainly better than none, and I can see that these could be very useful for snacks and preset mini-corrections or standard preboluses. The new BG meter also acts as the USB conduit for uploading data to the Carelink software package which (mercifully) is also getting a complete overhaul very soon.

Sensors schmensors
That's all very well you may say, but I'm about as likely to get funding for full time sensors as I am to become the next Pope - is this all about SmartGuard, or is there anything here for non-CGMers?

It is true that Medtronic are putting a lot of emphasis on SmartGuard - they are keen to describe the 640G as a 'system' rather than just a pump. It seems they are trying to work with Healthcare Professionals and NICE, seeking to allow more people to access this sensor augmented, 'virtual pancreas' approach. Swift murmerings were made about price points and volume but no real detail given as to if (and how much) sensor cost may fall if there is a greater uptake.

However even without all that sci-fi automation there is much here to please regular pumpers.

A colour screen is pretty much a given these days, but the layout and icons here are well thought through and in themselves allow quick access to a detailed and drillable overview, similar to but richer than the 'back button' on old MiniMed pumps. Bolus and basal adjustments are available direct from the 'home' screen, and everything is navigated by the 4-way/OK controller plus two other buttons - one for 'menu', the other for 'back'. Pleasingly, pressing and holding the 'back' button takes you directly to the home screen however deeply you are embedded in within menu options, which is a nice touch.

A great deal of attention seems to have been paid to the available options to make the pump more customisable and personalisable for individual users. For many things (such as basal patterns) you can now choose named versions eg 'work day' or 'illness' that make them more self explanatory to use, alternatively you can still opt for the more usual numbered options. You also have the option of setting all sorts of presets, including temporary basal rates of predefined length/intensity (again with named alternatives). Whatever you choose to populate from the available options in setup screens get shown in the selection menus, but you don't have to wade through dozens of items that you never use if you don't want to set them up. So you might choose to set just two of eight available TBR presets one for 'moderate activity' and another for 'light activity', then when setting a TBR you can choose either of those or dial in a custom one. Overall it felt logical, intuitive and that several regular tasks would be faster to achieve. The added complexity might mean an additional button-press here or there for one or two things, but in the hour or so we had to play with the 640G most things I wanted to access within a few presses I could.

Battery life is anticipated to be around 2-4 weeks, depending on use. The 640G needs the slightly larger AA batteries (rather than the Veo's AAAs) to power the colour screen. In the top menu bar the battery (and other) icons re-colour to indicate their status. On the battery front, as well as the usual 'low battery' warnings at 25% and again (if I remember right) at 5% there is also an inbuilt 'get out of jail' rechargeable battery that will allow the pump to limp on for up to 8 hours if you find yourself stranded in a motorway traffic jam or somewhere with no shops over a Bank Holiday having paid no attention to the icons/alerts when you set off. I also unwittingly tested the "what happens if you need to change battery in the middle of things" situation and a trial TBR I had set running happily carried on after I took the battery out to have a look. Another neat trick is that the standard-issue belt clip can be swiftly detached and is moulded in such a way that it can be used instead of a coin to unscrew the battery cap. Just a nice bit of attention to detail which speaks highly of the amount of effort Medtronic have put into the design of things.

Infusion sets and reservoirs are exactly the same ones used in the Veo, but special mention must go to the 'Infusion set change' alarm which you can set as a reminder. This particularly caught the imagination of Paul B who said that as a feature, it was pretty much enough to win him over on its own.

My biggest disappointment on the day was to discover that those infernal (and entirely useless) TBR hourly chimes are still present on the MiniMed 640G and it doesn't look like you can turn them off either. After all the effort that has clearly gone into usability and user-experience... The mind boggles. [EDIT: This turns out not to be the case after all. See the end of my compare/contrast video blog for details.]

To be honest I'm going to have to stop there - it's suddenly got rather late and I had thought I was just jotting down some quick notes. It was a very interesting day and there were other snippets (such as the iPort) that will have to follow later.

In short, I will have had Artoo for 4 years in November this year, at which point the warranty runs out and my robot counterpart begins to live on borrowed time. While I'm not champing at the bit for a new pump, I had absently been wondering what I might look at next. I am still interested to find out more about Roche's Insight pump. Omnipods don't feel right for me, and until today I was fairly certain that the Animas Vibe was my front runner because of Dexcom integration (and longer sensor life if I ever take the plunge to self fund). I know that for many the lack of a fully functioning remote handset on the 640G will be a dealbreaker, but that really doesn't bother me much. Today has given me much to think about and Medtronic's new offering very clearly sets itself apart in the market by doing something that absolutely no other pump can do.

Video blogs now available

Update: I have been given the opportunity of trialling the MiniMed640G for 64 days and will be posting video diaries of my experiences. Watch the videos.

Disclosure. Medtronic generously paid my train fare and laid on a tasty lunch. I was not asked and have not been paid to write this post or publicise their products in any way, but thought you lot might be interested.

Abbott Freestyle Libre results vs BG meter - Review part 2

Last day of 2nd sensor. Complete with crazy-flat overnight graph.

In this update to my initial review of the Abbott Freestyle Libre I wanted to share my experience of what it was like to use and also to provide the promised comparison with results from my regular fingerstick meter (the Contour Next Link USB). If you have been living in a cave and have no idea what I'm on about you can get an introduction to the Libre here.

It is probably worth pointing out at the outset that the Libre WILL NOT give you identical readings to your BG meter all the time. It just won't. They are not even measuring the same things. If that's what you want the Libre to do, you can pretty much stop looking, because it's not going to happen - not with the Libre and not with *any* technology that measures glucose in interstitial fluid and then converts that into an estimate of plasma glucose values (so all current CGM options). More on that later. But first - what is the Abbott Freestyle Libre like to use?

Do the sensors come unstuck?
I found the Libre to be extremely comfortable and unobtrusive to wear and both sensors stayed firmly stuck for the full 14 days. I was almost never aware of the sensor being there, with the exception of one or two times when I leant on it or absent mindedly scratched near it (having forgotten it was there). I did deliberately try to remember it when towelling off after showering to make sure I didn't accidentally dislodge it, but apart from that I barely gave it a second thought. There was very little in the way of itchiness for me and at the end of 14 days the sensor removed to reveal, well... nothing very much. Insertion of the second sensor was as painless as the first. I have seen some comment online where people have found that sensors came loose after just a few days, but that certainly didn't happen to me. With infusion sets I have found that the adhesive seems to need 12-24 hours to get up to full strength. I suspect it is the same for the Libre sensors. If it gets loosened early on you may need to over-tape it with Opsite Flexifix, Tegaderm or something similar. There's not a lot of 'edge' on the sensors and I can see the possibility of the sensor getting 'levered off' if knocked in just slightly the wrong direction.

I wonder what my levels are now?
I think this picture sums up my experience of living with the Libre for 28 days. Since I started attempting to *actively* manage my blood glucose levels four or five years ago I spend quite a lot of time wondering what is going on between my BG checks. I have never really known how often this happened until now - but the Libre released me from any monitoring constraints. So there you go. An average (average!) of 31 checks a day. Something like once every 30 minutes during waking hours. I had expected that my frequency would drop off after the initial excitement, but I remained fairly consistent through the full life of the sensors - checking more frequently when levels were changing more rapidly and leaving hours between checks at times in the day where things are generally more stable. The inconvenience and discomfort of 'traditional' punctured-finger-and-strip-fiddling monitoring means I would never check this often via a BG meter, but for 28 days whenever I wondered what my levels were, I found out. It is easy to underestimate how much of a transformation this is. Any time. Every time. All the time. I could know what my levels were *and* what they had been over the last 8 hours. There was no longer any reason not to look. No 'avoiding' the numbers (whatever they might be!) in between my 'normal' testing routine. Rather than feeling swamped and judged by data I felt completely liberated.

Basal test every day
In my previous post I mentioned how amazing it was to suddenly be able to see what had happened overnight every morning. Overnight basal tests are - as everyone who has undertaken them will know - a real chore. Waking every couple of hours to check blood glucose via fingerstick is a very effective management technique - but it's no fun. But look at what happened when I had 28 consecutive basal tests - the result is at the very top of this post. I couldn't help but tinker with my overnight basal profile gradually moving it from a bit wobbly, to ridiculously level (at least for a short while!). Seeing the patterns every day meant it was easy to spot the general trends and ignore the one-offs. And I made alterations to the 'shape' of my overnight pattern that I would *not* have made without those data.

New technique
After I had been living with the Libre for around 7 days I noticed that I had added a whole new technique to my management armoury. The preventative TBR (temporary basal rate). I've regularly used them since I started with Artoo to cover activity and other things, but this was slightly different. Because of the constant availability of data and the trend arrow that accompanies each check, I found myself setting short sharp TBRs - perhaps 50% for 30 minutes or an hour - to head off an impending dip in glucose levels. I was slightly surprised to realise that the 'level' trend arrow on the Libre doesn't actually mean level as such. It just means not rising/falling fast or very fast. In the first week on sensors I ignored a lowish level because of the 'flat' arrow only to dip below 4.0mmol/L an hour or so later. By using preventative TBRs for flat or more accurately reading-flat-but-slightly-falling readings that were just 'a bit near the edge' I managed to avoid several low level hypos and without bouncing up into double figures. Similarly, micro-boluses of small fractions of units when levels were high-ish (but not yet out of range) allowed me to be bolder in preventing BG drift. WIN!

Data analysis
I really like the simple, clear overview screens on the Libre. They might be a bit simplistic for some, but by dividing the day into four chunks and averaging 7, 14, 30 and 90 days of results in those sections I found it very easy to spot patterns and filter out the ebb and flow of 'diabetes randomness'. I particularly liked the 'Daily Patterns' graph which only appears after 5 days of results are stored and offers an average of daily results along with a 90th and 10th centile shaded area (it's a simplified version of the Ambulatory Glucose Profile graph - see image). It becomes very easy to see which periods in the day are providing the most challenges. You get a similar view (but with many more options, and helpful traffic lights) when you connect the Libre to your PC (or Mac - hooorah!). The Libre software niftily allows you to create smart PDF reports recording all sorts of averages, graphs, low glucose events and mealtime patterns which can really help to understand what has been going on. Additionally any mealtime notes and/or carbs and other details that you may have chosen to record on the libre are transferred for review too. If you have a particular penchant for number crunching you can also download up to 90 days results and details as a 'tab separated' txt file ideal for import into your spreadsheet package of choice. Look for the 'File' menu at the top of the screen, and choose 'Export Data'.

The end result of my 28 days? I had some of my BEST results all year. Lower post-meal spikes, fewer lows, fewer highs. Not bad Abbott! Thank you very much Freestyle Libre.

Ready to insert second Libre sensor

Libre results vs BG meter
Well... this is all very well you say. But if the results the Libre is providing are complete garbage, then it doesn't matter a hoot how nifty the downloaded PDF reports might be.

So how reliable were the results?

It's a good question. And not necessarily an easy one.

As I suggested earlier the Libre is reading glucose levels in interstitial fluid (via factory calibrated sensors) and then interpreting those through an algorithm to present values intended to reflect plasma glucose levels. That's a whole lot of steps in between what the Libre reads and the results you receive. And much as I realise a lot of work will have gone into ensuring that those results will be mostly OK for most people most of the time - clearly it is likely or at least possible that some variation will occur. Not least because the glucose values in interstitial fluid will 'lag' behind blood glucose values (typically 10-15 minutes, though the Libre aims for 5). Things are complicated further by the +/-20% variability which is allowed between BG fingerstick strips (though again these days meters tend to perform more like +/-5% or 10% most of the time).

What matters more to me is not whether results are identical all the time - it is more whether the results I get are useful. Whether any variation is modest enough that the readings, trends and analysis help me manage my diabetes better.

In order to understand what I was getting from the Libre I tested both sensors against my standard BG fingerstick testing routine. This is usually between 6 and 10 fingerstick tests a day, including premeal and post-meal tests as well as those around driving, exercise and activity. Whenever I took a BG fingerstick test on my 'normal' meter (the Contour Next Link USB that works with my pump) I cross-checked with the Libre. At the end of each sensor I then downloaded all the data and compared it on a spreadsheet to see what (if any) differences there had been. I do not for a minute pretend that this is a scrupulously scientific test - or that the results here might apply to anyone else. I took these comparisons purely for my own interest, and share them here in case others find them useful.

Here's a summary table from the first sensor - there were 94 pairs of results (BG meter vs Libre) over the 14 days:

Sensor 1

	BG meter	Libre	Avg +/- % (against BG meter reading)	Avg +/- mmol/L (against BG meter reading)
Average	7.8mmol/L	7.4mmol/L	10.1%	0.7
SD	2.8	3.0	8.9%	0.6
Distribution of readings
Number of readings where Libre higher			18	19%
Number of readings where Libre lower			70	75%
Number of readings equal			6	6%
Number of readings within 0.5mmol/L			43	46%

I don't know about you - but that looks pretty darned good to me. Yes, in amongst that there were some readings which were substantially different. A handful of times around 40% different from the BG meter - to put that into context one was a 4.4mmol/L that read as a 6.1mmol/L - one needs watching the other doesn't. There were also results where the Libre read hypo, but my BG meter confirmed I was in the 5's.

But the vast majority of the data feed is well within usable limits for me. The SD line gives a useful estimate of the range of most of the results. So from an average of 0.7mmol/L difference the most of the results were somewhere between 0.1 and 1.3mmol/L out.

You will notice that in most cases (but not always) the Libre was reading lower than my BG meter - with the result that overall the average of all results for the Libre comes out at 0.4mmol/L lower than my Contour Next Link, but with a slightly wider range (SD of 3.0 vs 2.8). Amazingly though, almost half the time the Libre was reading within 0.5mmol/L of my BG meter - and don't forget that at least some of the differences in readings could be down to the 5-10 minute 'lag' between BGs and interstitial glucose - especially if BGs were moving fairly rapidly at the time.

What I think this means for me in practical terms is that if I was running off results from the Libre more or less full time, with only a few cross-checked results where BG was moving rapidly or if things 'didn't feel right' I would most likely run a little higher most of the time. This would probably do wonders for my avoidance of hypos, but I suppose it may also have a small knock-on effect on my HbA1c.

But.

Isn't there always a 'but'?!

Things get a little more interesting when I switched to Sensor 2. As soon as that sensor started reading the graph 'jumped' down the screen. If the first sensor had tended to read a little lower, this sensor was taking that to new levels. Now Abbott do suggest that the Libre sensors may not read quite so accurately on day 1, but that days 2-14 should be relatively steady. Even on the second day though readings on the Libre were consistently 2mmol/L or more lower. And since there is no calibration option there was absolutely nothing I could do about it.

Here are the results for the first 5 days of that sensor:

Sensor 2 - days 1-5

	BG meter	Libre	Avg +/- % (against BG meter reading)	Avg +/- mmol/L (against BG meter reading)
Average	7.1mmol/L	5.4mmol/L	26.2%	1.7
SD	2.3	2.3	13.7%	0.8
Distribution of readings
Number of readings where Libre higher			1	2%
Number of readings where Libre lower			43	98%
Number of readings equal			0	0%
Number of readings 1.5mmol/L or more out			26	59%

You can see the difference in performance for yourself - over twice as far out. Suddenly almost 60% of the time the readings were 1.5mmol/l or more different and almost always lower. I had a few overnight traces that looked as it I'd been on the verge of a hypoglycaemic coma all night - when in reality I'd just been bobbling along in the low 5's (I know because I panicked and checked). On several occasions the Libre just reported 'LO' - with (allegedly) a level too low for it to record.

After several days of 'waiting to see' I contacted the lovely folks at the Abbott helpline who ran through a few checks to make sure I had the sensor in the right place and generally could tell my Libre from my elbow. I had been given a handful of Freestyle Optium Neo strips with my pack of goodies and the helpline person suggested I tried cross-checking against the Libre's inbuilt BG meter rather than some other technology (interestingly these strips also read a smidge lower than my ususal meter). As it turns out the reading on that occasion was pretty close (typical!) so I left it at that and wished I'd called them earlier.

The plot thickens
A couple of days later I had a call from Fiona who I'd met at the Libre pre-launch meeting called to say that a software glitch had been discovered (and fixed) in some of the very early sensors which was causing some interruptions in data and other concerns. I related the issues I'd been having with the second sensor and while they didn't seem to exactly fit with the software glitch described, Fiona offered to replace the second sensor.

In the meantime, and certainly into the second week, the second sensor seemed to be settling down considerably and behaving much more like the first. Here are the results averaged from days 6 to 14:

Sensor 2 - days 6 to 14

	BG meter	Libre	Avg +/- % (against BG meter reading)	Avg +/- mmol/L (against BG meter reading)
Average	6.9mmol/L	6.5mmol/L	11.7%	0.8
SD	2.2	2.1	10.2%	0.6
Distribution of readings
Number of readings where Libre higher			15	27%
Number of readings where Libre lower			38	69%
Number of readings equal			2	4%
Number of readings within 0.5mmol/L			21	38%

Not exactly back to the performance of the first sensor, but pretty darned close. Of course it did take those 5 days to settle. And if I'd been stumping up hard-earned cash for that sensor I suspect I might have been quite miffed that data from 36% of the life of the sensor was fairly useless to me.

I would have expected that a relatively consistent error would have still yielded useful 'trend' data - but in reality I found it very difficult to detach myself from the uneasy feeling that 'red' (hypo) results gave. However much I knew, or suspected, that my *actual* BG level was 1.5-2.5 points higher it was impossible for me to use the information in the same way when the margin of error was that great.

So in the end I am left with one spare sensor yet to use (which I plan to put into action around Christmas time) and just a very slight sense of unease as to what future sensor(s) might bring. When it worked at the 10% MARD that Abbott promise in the marketing literature I found it an incredibly powerful tool. If it were available on prescription and performed consistently like that I would be banging the table and asking to swap my (fairly generous) fingerstick allowance for Libre sensors - topping up with as many strips as I needed on top of that out of my own pocket.

But.

If other sensors only perform to the accuracy of the first 5 days of Sensor 2 then it's a whole different ball game. I wonder if Abbott may come to regret their decision to go for factory calibration. From a user's perspective I have already seen several posts from people who would find it very useful to have a 'manual override' setting where you could offset Libre readings which are consistently out to bring them more in line with our own fingersticks.

All in all I love the Libre and I am really hoping that future sensors live up to overall positive experience I have had so far.

Now that the online shop has opened I'd be interested to hear your experiences if you have used the Libre yourself.

Final verdict: 4/5.

Update: Freestyle Libre now licensed for use in under-18s

The Big EDUAD Timesulin Giveaway!

I know... I know... You wait weeks for a post then three come along all at once!

Those of you with memories as bad as mine will doubtless have forgotten that I wrote some time ago about Timesulin, an ingenious replacement insulin pen cap. While not a fully equipped dose memory device the Timesulin is brilliant in that it does solve the main challenge of "Did I take my insulin just now or not?".

There are different versions to fit the pens for most popular UK insulins and the device works by displaying how long it has been since the last dose was taken. A quick glance will tell you whether it was 5 minutes or 4 hours and Hey Presto! No more missed-dose vs double-dose conundrums.

Cleverly the device does not need to you interact with it in order to register the injection, it 'knows' when you take the lid off the pen. And even more clever, it allows you to take a quick peek at how much insulin is still in the cartridge without registering that as a dose. Which is a great touch and kinda lets you know that at least some of the people who developed it have T1 themselves.

The lovely folks at Timesulin have offered us three, yes THREE! Timesulin caps to you, dear readers. If you would like a chance of winning one, please just send your name by the end of January to mike[at]everydayupsanddowns.co.uk or leave a comment below. I'll put all the names in a hat and draw the three lucky winners on 1st February 2014, then Timesulin will send you whichever cap suits your insulin free of charge.

Good eh!

So drop me an email and good luck :)

Lantus 0.5 unit pen at last - Pendiq Intelligent Insulin Pen

Lantus 0.5 unit pen at last - Pendiq

I *love* the DOC.

No really.

I absolutely love, love, *love* the DOC.

Just a quick glance at Twitter and I can be cheered, encouraged, supported, made to laugh and occasionally brought to tears all at once. Other times you go looking for some lightweight wit and wisdom, or just to see what folks are up to and suddenly discover some weighty new piece of research, campaign to fight for or better still... everyone's favourite diabetes benefit an exciting-sounding new gadget.

Before Artoo became my constant companion a couple of years ago, I wrote quite a few posts about Lantus basal insulin. I spent quite a bit of time trying to wrestle Lantus into submission, and eventually we got to the stage where we muddled along bearably, but it's fair to say that one of my main motivators for starting pump therapy was to get 'proper' basal coverage, that accurately reflected the ebb and flow of my body's rhythms over a 24 hour period.

Comparing notes with other users it seems I was not the only person to be frustrated by Sanofi's rather less than enthusiastic approach to insulin delivery. Most of the injection pens that fitted Lantus were, frankly, nasty. And none of them offered doses in increments smaller than 1 unit. This might be OK if you are on higher doses, but many T1s are quite sensitive to insulin. I'm not quite sure how small children cope, for example. The minimum dose adjustment could well be a significant percentage of the total.

The other pen-related problem I had fixed around the same time related to my terrible memory. It may be hard to believe it you do not live with diabetes yourself, but after a few thousand injections they can become so automatic that you barely think about them. Sometimes you have absolutely no idea whether you have injected your dose or not. I changed bolus (mealtime) insulin to Humalog to get hold of a pen with a 'dose memory' the Humapen Memoir so that if I was ever unsure I had some means of checking that didn't involve me having to write something down, which I was just as likely to forget to do... Or possibly even to remember to write it down, but then forget the actual injection. See what I mean about my memory? Hopeless! Sadly the Humapen Memoir has since been taken off the market and it looks like its development has been abandoned. So now the only memory-enabled pen available on prescription in the UK is the NovoPen Echo.

But...

Thanks to a Twitter conversation I chanced upon earlier this week, I now know there is an alternative. And a very interesting alternative it looks to be too.

Enter Pendiq, the Intelligent Insulin Pen

Pendiq is a new breed of injection device from Germany initially launched in 2011 and relaunched in 2012. Such is the ruthless efficiency of German engineering that this pen boasts not just 0.5u accuracy but increments of 0.1u (from 0.5u upwards). Delivery is unlike any other pen I am aware of - dial up the dose on the display, press the button and a precision motor delivers the insulin at 2/u per second. The pen stores and displays around 2 months worth of injection doses and timings on an LCD screen and the website boasts all sorts of download opportunities and compatibility with logging software such as SiDiary. The battery is rechargeable and the device seems to be compatible with 'standard' insulin pen needles. The Pendiq is compatible with Lilly and Sanofi-Aventis insulins, which means that both Lantus and Humalog doses are now available on MDI in 0.1u dose increments. Heck you can even choose from five funky colours!

Unfortunately there is a snag. Isn't there always? It seems the Pendiq is not currently available on prescription in the UK. It looks like you can buy it via the website, but with the shipping/delivery it will set you back almost €185 (around £150). So not cheap... by any means. You would also probably be wise to speak to your DSN/hospital/clinic to get there guidance if you were tempted to spring for one before you part with any cash.

If you'd like more information, visit www.pendiq.com

Nano technology, non-invasive BG monitoring and smart insulin

There are some diabetes-tech buzzwords that always attract my attention. Thanks to a tweet from Nick Guerin (@Typeaware) I was treated to a triple-whammy this morning.

We have come painfully close to a 'non-invasive' BG monitor (or even better CGM) once or twice before, but it is good to see that the search continues. To be honest the breathalyser-style BG monitor (which still uses a single-use 'strip') interests me less than Smart Insulin, which I think is probably my most favouritest 'wildest tech fantasy come true' product of all time ever - see here.

"A team at North Carolina State University believes so. Prof Zhen Gu and his team are working on a couple of different systems which may achieve this ideal – effectively creating an artificial replacement to the beta cells in the islets of the pancreas, which would normally release insulin to counter high glucose levels.

"Our overall aim is to create 'smart delivery' systems for insulin provision," says Gu. "What I mean by that is that insulin is delivered at the right time, via a safe approach – avoiding too much or not enough dosage – and in a way which requires only small formulations."

One of the team's ideas in development is an injectable nanoscale sensory network, announcing earlier this year that such a system maintained normal blood sugar levels for up to 10 days in type 1 diabetic mice. The "nano-network" degrades to release insulin when glucose levels are high and the researchers are currently trying to optimise it to respond as quickly as pancreatic islet cells do naturally in the body, and to make it more biocompatible with human tissue."

And wouldn't you know it those pesky diabetic mice have beaten us to it again.

Full article is here:
TheGuardian.com - Nanomedicines set to revolutionise the treatment of diabetes

mySugr Review - The best Diabetes logging app ever?

When we began this blog almost exactly three and a half years ago (crikey!) I had just made two important and, in their own small way, utterly life-changing discoveries.

One was that I wasn't anything like as good at managing my diabetes as I liked to think I was. And the other, and perhaps more important, was the extraordinary power, knowledge, support and cameraderie of the DOC hive mind. At that stage I felt that my control was 'as good as could be expected' and that diabetes was just pretty random every now and again. Years later I now understand both of those statements to be completely true, but in a very different way - and with the benefit of signficantly better control and confidence in handling my diabetes.

One of the main changes I made at that time, and perhaps the one that transformed my self-management more than any other, was to start testing more frequently, and to record the results more systematically. This information then enabled me to spot patterns in the apparent 'randomness' and apply the knowledge & experience of the DOC to experiment with the whole 'pretending to be my pancreas' business. Identify a problem... find out what others do... experiment... try something else... develop a strategy... test... review... adjust. None of that would be possible for me without a decent feed of data to try to keep track of the million and one variables.

At first I used the ever-faithful pen and paper route, which is fine in its way, but doesn't really let you do anything with the information you are so carefully collecting. Shortly afterwards I started using different apps on iPod Touch and later iPhone (other smartphones are available etc...). I must have tried the best part of a dozen apps in quick succession before settling on one which allowed me to log and track everything I wanted to without making me want to chew off my own fingers in the process. A couple of years ago I saw a mention by Mike Young of Diabetes in Spain about an app he was using called mySugr so I had a look. I've been using it ever since. Recently they launched a major upgrade as v2.0 and to my mind mySugr has now become something really rather special.

Overview
Well let's see...

Fast/easy data entry? Yup.
Pretty graphs? Absolutely!
Useful averages over different time frames? All present and correct.
Additional analysis like SD and number of high/low readings? Correctamundo.
Suitable for pump users? Certainly.
Export data in a variety of formats? Of course!
Fun? Yes!

Erm.... what?

This I think was the biggest difference I found when I first started using mySugr. The team behind it (which includes quite a high proportion of T1s) understand that logging, while potentially *very* useful is not the most fun to be had. Underpinning all mySugr's seriousness and analytical clout is a healthy dose of wit and charm. When you first set the app up you choose a name for your diabetes monster and every time you make an entry you go some way to taming it day by day. They turn diabetes logging into a sort of game, scoring points with every entry made. This may not appeal to you from the outside, but there is something inexplicably smile-inducing about the animated gurgling reactions of your monster when you make an entry - especially one that is above or below your ideal range, which is exactly when I need distraction most.

mySugr allows you to log all the things you would expect - BG (in mmol/L or mg/dl), carbs (in exchanges/CPs or grams), meal boluses, exercise/activity, basal dose for those on pens/syringes and temporary basal rates/duration for pumpers. Naturally you can also make copious notes alongside your entries which I find essential in terms of interpreting the data later. In addition you can also capture photos of meals and even add the geographical location at which the entries were made which is a nice touch. Entries can be tagged with one or more predetermined icons which range from the inevitable 'breakfast' and 'sport' to more emotional options like 'stress' or 'chilling' adding further detail to records. A very useful 'search' option allows you to quickly scan back through months worth of entries to find what you last tried for 'pizza' or 'chinese takeaway' then jump to those records to see how it went and what you might try this time.

mySugr operates on a 'freemium' basis. The fundementals of the app are available absolutely free of charge, but full functionality (eg photos with records) requires a 'pro' subscription. When you install the app you get all the bells and whistles for a few weeks. Following that you can just use the (excellent) core functions, pay a small monthly fee to upgrade to pro, or complete motivational 'challenges' to earn days of pro subscription for free by logging several entries per day or exercising. EDIT: As of January 2014 mySugr seem to be moving away from a subscription-for-pro set up towards a single payment model.

The data analysis on offer in mySugr is excellent. The home screen (above) gives you a general overview of how things are faring over the last week/24 hours in different ways. The graph itself recolours to give you instant feedback if things are altogether too high/low (red) or a bit marginal (amber). There is a logbook screen with pleasingly swooshy draggable graph and table of entries that allows you to quickly scan back through previous week/month - the graph dragging side to side as the table of entries scrolls up and down. A separate analysis screen allows you to see 7-day, 14-day and month-by-month changes in average BG and crucially the SD of those entries (how closely grouped or wildly scattered they are). Dig a little deeper and you'll see a summary of numbers of high/low readings, tags, photos and other useful detail to help you work out what has been going on. If you enjoy your own number crunching and/or want to amaze and impress your clinic with how marvellously you are getting on you can choose between different .csv formats for Excel or export your data as a slick PDF report.

mySugr is registered as a 'medical device' and CE marked (I think it is perhaps the only logging app to have achieved this). Data storage is safe and secure and the entries are seamlessly uploaded and synced in the background. I experimented early on with this and if no data connection is available mySugr will just wait patiently without pestering you until a connection becomes available. If you own more than one device you can log from whichever is closest to you at the time and the data will stay in sync on all of them.

What? No niggly complaints?
If you've read a review here before you will no doubt be waiting for the 'but...' followed by a long list of things I really hate about mySugr. Well it surprises me as much as it might you that I can hardly think of *anything* I would change about the app. I would love to be able to edit the preconfigured list of 'tags', either to just hide the ones I'll never use, or preferably to allow me to customise the text myself. The options they have are decent enough, customisation would be perfect - I gather this is on the 'wish list' for future versions. There seems to be a slight glitch with data export for Excel in that dates are coming through as text rather than an Excel-friendly timestamp. This has almost no relevance to any other user I'm sure, but it makes some of my occasional attempts at analysis/graphing in Excel go a bit wonky. I'm going to drop them a line about that, and it's just the sort of thing they fix in one of their version updates. (Edit: as expected, this has now been fixed!)

So I quite like it then?
I noticed something a few weeks ago that really surprised me. The way mySugr helps me keep track of my readings actually helps me improve them in a way no other app has done before. There is a sort of 'sliding scale' of reward and motivation going on that on one level just lets me know if things are slipping a little, but then - even when they are pretty much perfect manages to encourage me to keep trying harder. That's not a bad effort for some lines of code, comedy noises and a sprinkling of funky graphics. In general terms the BG average and SD over 24 hours 7 days, 14 days or month-so-far offer me a ready reckoner of how well (or badly!) any time period is going. I have a tendency to think 'things have been terrible for ages' so it can be encouraging to look back a few days and see that results were not so bad after all and a little basal testing will probably fix things.

Aiming for amber
For about a quarter of this year things were not going well for me diabetes-wise. Looking back it wasn't a disaster (see previous para) but every month I'd hope for a better average, lower SD, fewer highs and fewer hypos only to find that the results would be slightly worse not better than the previous month's. Despite the fact that I felt like I was trying harder. This is not particularly encouraging... But following my annual Pump Clinic at the end of June where I made some small basal and ratio tweaks things all seemed to slot into place. Day after day with bewilderingly good levels. I felt like I was winning. Even when we were away on holiday (a notoriously chaotic experience for my BG in previous years) I pushed to maintain this success*. Why? Well during this period I began to notice the 'high/low' marker on mySugr's home screen (see the big picture above) was no longer it's customary Red. Quite often it was Amber. Once or twice it was even Green! So in a rolling 7-day period I would find myself pushing to avoid a high or low reading that day, because if I could make it with a 'no hitter' then tomorrow the wobbles from this time last week would disappear and I'd be in amber again. I was playing my diabetes like a game.

The fact that my logging app was providing that motivation should make the folks at mySugr very pleased indeed.

mySugr is available for iOS devices in the App store and an Android version is currently in 'beta test'.

Final score: 5/5

* Fear not. Normality is resuming this week... along with some set failures and hilariously jaggedy mySugr graphs that well and truly revoke my #teamsmug membership.

Disclosure: I wasn't paid to write this review and I have no commercial interest in mySugr at all. I was lucky enough to be one of the beta-testing volunteers for 2.0 and have spoken to Frederik a couple of times but that's it.