Edinburgh, encouragement and a call to arms

This week I have been lucky enough to be invited to speak at the 55th St Andrew's Day Symposium, hosted by the Royal College of Physicians in Edinburgh. I was given the topic of 'apps and technology' in relation to managing a long-term condition like diabetes, but obviously - not content with that - I managed to sprinkle in a wafer-thin analogy of what living with type 1 is like, along with all sorts of stuff about the #doc and the transformative potential of online peer support communities.

I tried to cover the infuriatingly fickle nature of type 1 diabetes, mentioned a few 'old favourites' like mySugr and the Accu-Chek Expert which have helped me attempt to tame my own 'diabetes monster' and also just a few of the many other things that I know help others in different ways. Gathering data and then learning to be able to apply it to make small improvements. Not forgetting, of course, the support you can get from those facing the same battles every day, whether in terms of just keeping going when it all falls to pieces (again!), or in people sharing experiences and strategies that work for them that you can consider for your own self-management.

It seemed to go relatively well, and people were very encouraging - but the absolute stand-out for me about the whole experience were the conversations I had with some passionate diabetologists after the session had ended. I had deliberately avoided focussing too much attention on the more obvious technological advances like pumps and CGM, as I had wanted the talk to have as wide a reach as possible, and also perhaps fire the imaginations of clinicians working in other disciplines as to how they might make use of similar apps/peer support resources in their own specialism.

Speaking to those diabetes specialists afterwards was something of a call to arms. Much money is being spent on healthcare in the UK which does *not* have the ongoing quality of life benefit for individuals that sensor augmented pump therapy offers - let alone the extension of life for pump users as shown in recent research. The case was made to me that it is time the diabetes online community stopped being so darned understanding about the lack of funding for sensor-augmented pump therapy. The time for accepting defeat has passed, and as more and more data are made available from increasingly positive trials, we need to start banging the table if we are ever to move pump/CGM into the mainstream in the UK.

I got the distinct feeling that there are many clinicians who feel strongly that this is the way forward for type 1 care, but that patient voices as part of that change are crucial. Certainly the impact of patient support in Scotland's wider adoption of pump therapy in recent years sets an encouraging precedent.

Yes I *know* we go on about it all the time among ourselves (often with a resigned sigh and bit of self-funding) - but perhaps the moment has come to really start ramping up the pressure.

Disclaimer. My travel, and accommodation was paid for, but I was not paid to prepare or deliver my talk. I was also invited to attend a swanky dinner at the end of the Symposium which was lovely.

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.

64 Days with the Medtronic 640G: Ep 8 Fine-Tuning SmartGuard

For all the times when SmartGuard has worked brilliantly for me (and there are - too many to count), there have also been a number of situations in which it seemed to make a bit of a mess of things. Overshooting and leaving my higher than I'd like... kicking in when a hefty carb load was just about to arrive and stopping basal for that 30 minute minimum (during which time I would be having a high glucose alert)... or cancelling various parts of dual and square wave boluses which I then may not spot until slightly too late.

I'm sure each user would have their own list - but these are my own #SmartGuardFails and some of the techniques I have tried to fine-tune the alerts and levels to work around them. It's interesting how irritating these odd occasions can be, and I suspect it is only because, well for me anyway, SmartGuard has worked so *brilliantly* for so much of the time that they really stand out.

If you have any MM640G SmartGuard tips and tricks of your own (or any other comments or questions), please leave a comment below.

64 Days with the Medtronic 640G: Ep 7 Overnight Hypoglycaemia

Those of you who can remember way back when this blog started (if you even exist, you have my undying affection for your extraordinary stickability) may recall that we were prompted to start writing a blog about my diabetes as a family after a particularly nasty overnight hypo. It was the beginning of me realising that I was *nothing* like as good at the whole 'pretending to be my own pancreas' lark as I had managed to convince myself that I was. I began to realise how much I didn't know, and that one event led me to connect with literally thousands of others wrestling their own diabetes into submission every day. My life, and particularly my diabetes management are very much the better for it.

Overnight hypos have been a bit of a recurring theme throughout my 25 years of living with type 1 diabetes. I am lucky in that I have never needed paramedic callouts, but there were many times along the way when Jane had to step in at breakfast time to 'bring me round' in the years before we started writing this blog. I look back at those early posts and am bewildered and ashamed that it took me quite so long to realise how much effect this was having on everybody else in the family. How unfair it was on them. At the time though, I guess I had convinced myself that my management was 'as good as could be expected'. I knew I was having 'A few too many highs... a few too many lows'. But doesn't everyone?

If you are the sort of person who approaches anywhere near 8 hours a night when you live with type 1 diabetes, you are spending fully a third of every day in the land of nod. That is an awful lot of time for things to go wrong - especially if your basal insulin dose is not adjusted correctly* or your requirements have moved since you last checked. You may be lucky enough to get clanging warning signs when you dip below 4.0mmol/L - enough to wake you up and sort yourself out. But you can't rely on them. And the more and longer the periods you spend below 4 during the night, the more of a hammering your hypo awareness will take and the less you will feel them. A classic vicious circle.

I am coming toward the end of my 64 days with the MiniMed 640G now (Medtronic have kindly allowed me to keep hold of their toy for a little while longer as there are a couple more posts I'd like to put together). Today seemed like a good opportunity to gather some of the snippets of video that I've been filming since the beginning and edit them into a 'SmartGuard vs Overnight Hypoglycaemia' post. Has Smartguard made any difference? Has my overnight hypoglycaemia reduced at all?

Watch the video below to find out what has been happening over the last 9 weeks. As always, I'd love to hear your comments or any questions, please leave them below or post on my Youtube channel.



*During the video, I mention how important I have found the concept of basal testing over the last few years, both on MDI (multiple daily injections) and also on a pump. Systematically testing and adjusting my basal insulin on an ongoing basis helps me to keep my meal doses and corrections working more or less as I expect them to (ha!). It was one of the most significant 'new concepts' I discovered when I first started comparing notes with other people with type 1 diabetes online. If you'd like to know more read this post by Gary Scheiner (Think Like a Pancreas) which explains the principle. It is written for pump users, but would be easy to adapt for once- or twice-daily basal insulin injection on MDI.

64 Days with the Medtronic 640G: Ep 6 Ordering supplies online

In some ways one of the nicest additions to my general 'managing diabetes malarky' over the past 12 months or so has not really been anything to do with managing blood glucose levels or complicated diabetes technology at all. It has been a very simple addition to my routine in that Medtronic, as of the middle of last year, became the first and only UK insulin pump company to set up an online 'e-shop' for re-ordering pump supplies. This means I can place an order for new infusion sets, reservoirs and other gubbins 24 hours a day, 7 days a week. Best of all the process is nicely streamlined, so it only takes me a handful of 'clicks' to place an order, which is then usually delivered in approximately 3-5 working days. I never had a real problem with phoning the orderline and speaking to the (always very helpful and lovely) staff at the other end... But the e-shop is just completely effortless and means I can place an order whenever I want to.

I'm not the most organised of people, and can easily get distracted when intending to re-order my supplies, then forget all about it. n fact I try to re-order deliberately early jyst to make sure I don't get caught out. So it's a great help to me that I can go online and place an order whenever I think about it, rather than having to wait until a customer-care phoneline is open and try again.

There are other benefits for registering with Medtronic's e-shop too. Registered users get access to an online e-support newsletters 'MiniMed Care Connect', with hints and tips covering things like sick day rules, sport/exercise, back-to-school suggestions and generally getting the most of your insulin pump. There are also promotions and cost-savings available to registered users including a soon-to-launch 'loyalty scheme' which offers reductions in the cost of Enlite sensors for those who are self-funding. More on that as details emerge...

In the meantime, here's a quick video of the process:


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64 Days with the Medtronic 640G: Ep 5 Changing Infusion Set

I don't know... You wait weeks and there are no turgid video blog posts from me that you need to avoid, and then suddenly two come along within the space of a week.

For this latest episode as part of my 64 days with the MiniMed 640G, I thought I would run through the process of changing infusion set including a walkthrough of the MM640G pump screens. Don't be put off by the hefty 17 minute running time - it's a LOT quicker to do when you aren't waffling on and explaining things as you go.

For what they are worth, I've included some of the little hints and tips I've picked up over the last few years which seem to reduce the number of bubbles I get in the reservior/tubing (everyone's second favourite insulin pump nuisance). This isn't advice you understand, and check with your healthcare providers blah blah blah, but personally I seem to get very few problems with bubbles these days and if any of it gives you some ideas to experiment with for your own set changes then great (but on your own head be it).

The only thing I did not explain very clearly in the video is the importance of using room-temperature insulin. Bizzarely, oxygen is more soluble in colder liquids, so if you fill perfectly and bubble-free with insulin straight from the fridge you can find that you get bubbles emerging from the insulin inside the sealed reservior, after filling, as the insulin warms up. Not helpful.

Anyhow - here it is. Enjoy. And do leave any comments, questions or set-changing tips of your own for me below.

Thanks for watching!


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For an alternative video detailing a set change using Medtronic QuickSets check out this great post by Dave Sowerby.

64 Days with the Medtronic 640G: Ep 4 SmartGuard vs Mountain

We have just returned from a wonderful holiday among the Black Mountains, Brecon Beacons and Cambrian Mountains in the middle of Wales. The weather was as mixed as you might expect, but we did grab the opportunity of one of several gloriously sunny days to walk the popular path up Corn Du and Pen Y Fan which the walking guide proclaims to be 'the highest peaks in southern Britain' (presumably Snowdon counts as ooop North).

It seemed like a reasonable 'test case' for SmartGuard and exercise for me. Things were a little complicated by a fairly active morning with a fairly hefty Temporary Basal Rate which I had slightly overdone so as to be confident to drive, meaning that I approached lunchtime in pretty much double figures (180ish for US readers). Often I would choose to reduce my pre-exercise meal bolus a little, because I tend to get very sensitive to any active insulin once I start moving. I didn't want to do that this time though as I was fairly high to start with and in some dim corner of my mind there is something squirreled away about exercising at high levels being Not The Best Idea.

So there you go... the scene is set, the reality TV style 'manufactured peril' is in place (Solemn face to camera... 'But exercising at those levels, and with all that insulin on board - just what will happen')...

Let the drama unfold.

Oh, and as if that were not enough excitement, you may notice I am sporting an impromptu 'holiday beard' in this video. Feel free to express your opinion, hilarity or horror at this unexpected turn of events by voting #beardyes or #beardno in the comments.

Thanks, as ever, for watching.

Any questions or comments, please leave them below.


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64 Days with the Medtronic 640G: Ep 3 What is SmartGuard?

Here's another little update on my time with the Medtronic MiniMed 640G. This time it's a look at what SmartGuard is and how it works. When someone first tried to explain how SmartGuard worked to me I can remember it felt bewilderingly complicated, with all sorts of levels and numbers flying around. Actually once you have got your head around it, I have found it relatively simple - so I'm trying to explain it here with a little animated diagram that tries to work through an example of how and when Smartguard is activated, and what it does.

It should be remembered, of course, that for all it's magic, SmartGuard is not supposed to replace hypo-treatment entirely. Unfortunately for all the over-enthusiastic media hype about the 'Artificial Pancreas' when the MM640G launched, we are nothing like there yet. SmartGuard is a useful step in the right direction, but a full AP it ain't. For starters, there are many situations in which stopping your basal insulin will simply not act quickly enough, or have enough impact, to head off an impending low. And there are other situations where SmartGuard might be triggered for all the right reasons, but not actually have been needed and you end up higher than you'd like because of it.

I'll cover some of those situations in more detail in another blog - but for now, let's focus on those gentle (or not so gentle) drifts below 4.0 which SmartGuard effortlessly squashes without bothering you with any irritating alarms.

When it works well, it genuinely feels like you have a little 'diabetes helper' by your side, actively looking out for you. Not something I have ever felt about any other piece of diabetes technology.

If you have any questions or comments, please do leave them below. I'd love to hear what you think.


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64 Days with the Medtronic 640G: Ep 2 The first 28 days' results

I wasn't expecting to be posting this blog today (well it seems like it'll be tomorrow by the time it has uploaded, but it's still today as I'm typing this). I had a vague plan that I'd do an introductory blog, and then move on to explain what SmartGuard was and how it worked. But today marks 4 weeks since I have been living with the MiniMed 640G and having looked at the results so far to say I am impressed is an understatement.

Ever since diagnosis, if I'm honest, I have preferred to run on the low side rather than on the high side. Lows were quick to sort out and usually involved eating something sweet and tasty, while highs took much longer to come down and, while they did not make me feel particularly grim like they do for many people, they also carried with them the spectre of all those diabetes nasties waiting in the wings. Blindness, kidney failure and amputation vs fruit pastilles seemed an easy choice to make.

Of course running on the low side and 'preferring' hypos is not a brilliant plan. My hypo awareness began to take rather a dent and I spent many years with significant hypo unawareness and the severe hypos that go with it, especially overnight. Looking back I am ashamed that I did not realise the pressure and stress that this placed on my whole family and especially Jane.

Pretty much since we began writing this blog I began to try to reduce my incidence of hypoglycaemia and regain my warning signs, and generally wrestle my diabetes into behaving itself a little better. I have put quite a bit of work in and learned a lot. Thankfully I have not had an episode of Severe Hypoglycaemia for something like 3 or 4 years now - long enough ago that I can't remember anyway. But for all the success there have remained a stubborn few dips under 4 (which may or may not be hypos depending on your definition) that I have been unable to tame.

This video blog examines what effect SmartGuard has had to my results in these first 4 weeks.


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64 Days with the Medtronic 640G: Ep 1 Introduction. Comparing the MM640G with Paradigm Veo

Following on from my early preview of the MiniMed 640G insulin pump, I have been invited by the fine folks at Medtronic to spend 64 days with their new box of tricks, and to share my experiences through the slightly scary and unfamiliar medium of video blogging.

It's what all the cool kids are up to (apparently).

For this first installment I have tried to do a little compare and contrast between the Medtronic Veo and the new MiniMed 640G. Just a few things that have struck me during my first couple of weeks of use really. I'm not yet going to mention Smartguard and compare that feature to the Veo's Low Glucose Suspend, partly because I think that Smartguard deserves a vlog all of its own, but mostly because I have never used sensors with my Veo so have nothing to usefully compare.

I am hoping to post a video every week or so over the 64 day period, but I have quickly come to realise that this video blogging lark is nothing like as easy as everyone makes it look, so you may have to bear with me on timings. I'll announce any new episodes here and on Twitter, naturally, but if you are really keen I suppose you could always subscribe to what is now laughably described as my YouTube Channel.

In the meantime you can find some more, rather more coherent information on the MiniMed 640G here.

And please do check out the video blogs of other MM640G users too.

Leave any comments or questions here or on YouTube and I'll do my best to answer them.


Watch this video on YouTube.

Possibly one of the most inexplicably stupid things I have ever done diabetes-wise

My blood glucose readings, yesterday.

Well... here's a thing. And I still can't actually quite believe that I did what I seem to have done.

The setup
Last night we had a smallish portion of spaghetti as our evening meal. This I realise for many would be a complete no-no, but pasta has typically not been the nightmare for me that it is for many. After little experimentation and tweaking I have managed to work out a reasonably successful strategy so it no longer fills me with dread - we eat it maybe once a month.

My approach (depending on recent results) usually involves a 2.5 hour dual/combo bolus at 60:40 for the calculated dose plus an extra 1u. Previously I'd also needed an extra unit up front too, but had dropped that about 9 months ago following some post-meal dips.

More recently my previously solid post-meal performance has been *slightly* marred by a smallish rise something like 4-5 hours after eating (when the majority of the bolus was waning) so yesterday I decided to rejig my approach a little since I have a Libre sensor in at the moment and can watch what's happening. So last night I went for the calculated dose+1u as 40:60 over 3.5 hours and added the extra unit up front and watched and waited.

Annoyingly I was starting from 8.3, but spaghetti often takes a while to get going for me so I wasn't unduly worried. Stayed pretty steady for the first hour then rose gradually by about 1.5mmol/L towards hour 2. Stupidly during this time I decided to confuse matters by bolusing and nibbling on some snacks that were circulating. By about 3hrs after eating I was 5.2 with vertical down arrows (and DW still chugging away) so I gulped some precautionary Lucozade. Headed off the hypo fine, but then my BG rose and flattened at 8.5-9.5 for an hour and a half (presumably spaghetti kicking in at this point). Then inexplicably at 4.5hrs post-prandial (10.30pm) I had another unexpected BG 'kick' up to something like 11.5 so, getting a little frustrated, I whacked in another unit despite considerable IOB (insulin on board). Sat and waited until midnight and the Libre trace was pretty flat in the 10s-11s - no sign of the 1u or IOB making any impact. Just after midnight I topped-up my IOB to make it the 2u I had intended to go to bed on to counteract the remaining spaghetti fallout.

Just to recap: Spaghetti is usually pretty predictable and not a problem. Added complication of snacking/bolusing/dose stacking/dipping/(over)treating *and* trying a new system all at the same time.

But we've STILL not got to the stupid thing...

The stupid thing
One of the great things about the Libre for me is the ability to see what's going on overnight. And also that if I happen to wake, even for a moment, I can scan and check levels in a way that I simply *do not* do if it requires me to fingerstick test.

I checked at 4am and had been pretty much flatlining around 9.5 since 1am. No insulin left on board. I consulted Artoo who suggested a correction of just over a unit, but I wanted to err on the side of caution so I went for a manual bolus of 0.9u (about two thirds of the recommendation).

I woke three hours later a little groggy and scanned for the Libre to read 'LO'. Artoo showed nearly 2 units of insulin on board.

Ehhhhh????

Checked downstairs via BG meter which confirmed BG was 2.2mmol/L. Bewildered and glugging Lucozade I tried to make sense of the situation...

Checking my bolus history I read that at 4am I had bolused not a cautious 0.9u, but 6.0u. Six units. SIX! My BGs had, not surprisingly, dropped off a cliff around 5.30am.

I simply cannot understand how I managed to do that. Even though one figure is very like an upside-down version of the other, I can't believe I could have made that error as all the buttons etc would be on the wrong side of my robot counterpart if I was holding the pump upside down.

But however it was that I managed to construct that error, there seems no denying that I did it.

And it's not one I'm wanting to repeat any time soon!

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.

The "I can..." of insulin pumps - Diabetes Week 2014

The theme of this year's Diabetes Week is 'I can...'. Here's a guest post I was invited to write for the Diabetes UK blog.

When I was thinking about this year's theme of 'I can' I was reminded of a conversation I had with someone last week about insulin pumps. It was something that they were being encouraged to consider, but like pretty much everyone else (myself included) their initial reaction was uncertainty. Uncertainty over being connected to something 24 hours a day. Uncertainty about relying on a fragile piece of technology to keep them alive. Uncertainty about how it would make them feel and how others might view them. Uncertainty over whether it would actually improve anything at all. In short, they didn't really think it was for them.

I know those feelings well. I had them all, and many more besides. I was 'pump averse' for many years. My clinic suggested that it might help with my recurrent hypoglycaemia, but could never really articulate how that might happen. All I could see was a big bunch of (what I thought were) downsides.

In the end, for me, it was reading the experiences of pump users online that convinced me to give it a go. The day to day nitty gritty of how it helped them. Now I'm not saying that insulin pumps are for everyone. Some people wouldn't want to touch one with a barge pole, others do just fine on Multiple Daily Injections and are completely happy as they are. But if it is something you are considering, here are a few 'I can's that an insulin pump has given me to add to your thinking:

If I want to go to bed at 5.0mmol/L, I can.
Ahhhhh basal! I have been through quite a few basal insulins in my 25 years of pancreas-impersonation. In the old days we were always advised to have a snack before bed. Why? Well because in all likelihood your basal-du-jour was going to be a bit over-enthusiastic in the early hours and could well plunge you into an overnight hypo. It was many years before I discovered 'basal testing' (systematically adjusting your basal insulin by fasting tests so that it just holds you steady) but try as I might, even with fancy schmancy analogues I could only ever get my basal 'near enough' on MDI. A bit too much here, not quite enough there... make up the differences with meal doses and guesswork. With a pump, the flexibility of multiple basal patterns which can be tweaked and changed with almost infinite precision mean that I can adjust things so that I am actually starting from a level playing field. To my mind, basal is the bedrock of my BG levels. If my basal is out, even by just a little bit, my meal doses and corrections just do not play fair. So I no longer have to worry about stocking up on carbs before bed, because my basal insulin should hold me level and when I need less insulin overnight I get less. Where I need more just before breakfast, I get more.

If I want to give a really accurate dose, I can.
My doses on MDI were often a bit 'ballpark' to be honest. I have always counted carbs and altered my doses based on what I am eating, but I usually rounded up or rounded down to make things easy. Plus I would use insulin:carbohydrate ratios that meant I didn't have to get a calculator out all the time. The Accu-chek Expert was a great tool on MDI for tweaking doses, but I was still using a 'whole unit' pen so there was a degree of rounding even then. Now I can bolus in decimal places. And those tiny tweaks of insulin here or there do seem to make a difference. True enough my carb estimates are still often done by eye, but at least one part of the puzzle is now being calculated and delivered precisely.

If I want to stop here for lunch, I can.
This was the biggest surprise for me. Rediscovering spontaneity. I began pumping with an fairly entrenched anxiety about being hooked up to something 24/7. I know almost no one who has not had that when considering an insulin pump. Many people say that within a few weeks (days for some people) they become completely at one with their new robot pancreas and never give it a second thought. I can't say that it was quite so quick for me, but certainly in less than six months I had stopped noticing being attached at all and my emerging 'unthought' behaviours (like automatically hooking it to a t-shirt when getting changed) meant I never really gave Artoo another thought. If you are newly on an insulin pump and it still feels a bit of a nuisance or 'in the way' hang in there. Where was I? Oh yes... Spontaneity. So I was well prepared to dislike being attached, but I really hadn't expected that attachment would turn out to be such a bonus. Out on a wander on holiday... get a bit distracted and it takes rather longer than anticipated... Oh this pub looks nice, shall we stop for lunch? What would have always previously been "No we can't, I didn't bring my pens with me" has simply become "Yes!". Wherever we are now I always have my 'kit' with me, and while I used to like the idea of being able to leave all this stuff on a table and just walk around 'like a normal person', personally I have come to realise that I feel much more 'normal' if I can eat whatever I fancy whenever I want to, without having to remember to bring a case full of gubbins with me everywhere.

If I want to have 20 boluses/corrections/snacks in a day, I can.
Well strictly speaking I always could have, of course. But in reality I never did. There is something so easy and effortless about push-button dosing that I am far more likely to add in a fraction of a unit here or there during a day when I recognise that I probably wouldn't have bothered to get a pen out, airshot, dial up and inject. This has increased freedom around snacks too. Where I previously found them just to be too much of a hassle on MDI, almost always resulting is a BG wobble in one direction or other (depending on whether I had bothered to bolus or not) I've had much more success with the effortless mini-doses a pump offers. It's easier, so I bother to do it.

If I want to run a marathon (or just vacuum the stairs), I can.
Again, this was something I more or less tamed with MDI, but the additional options available on a pump, like the ability to set a 'temporary basal rate' for several hours, have added considerable 'polish' to many of those day-to-day conundrums of physical activity. I am far less likely to see my BG levels dip below my target range when exercising these days and I'm buying far less Lucozade!


Just a few things of the top of my head. I'm sure most people on pumps could write their own list. Of course diabetes is still annoying and frustrating quite a lot of the time. A pump is not a magic bullet and it still involves a fair bit of faffing about. But for me having a pump has made a tighter set of BG levels more possible, with less effort and far, far fewer nasty lows.

If you are struggling with wrestling your diabetes into some sort of submission and have been offered a pump as a possible way forward I'd suggest giving it a go.

If I can do it... You can.

Splish splash - aquapac insulin pump case

The sun is shining... thoughts turn to Summer holidays.

This year we will be returning to Cornwall, to the very same place we stayed a few years ago. When we were there before the girls and I quite fancied a little gentle sea-kayak pottering in the wide open bay on our doorstep but never quite managed to bump into the kayak hire people who seemed to have a rather relaxed approach to timekeeping (and attendance in general). This year we are hoping to give it another go.

The last time we were there I was on MDI, but this time, of course, I have Artoo to think about.

I don't suppose we will be out for very long so I could just detach and leave the pump on the shore. I suspect there will be enough activity involved in paddling to make hypos more of an issue than raging highs, so the lack of basal for an hour or so would probably not be much of a problem. But... what if something happened. The last thing I'd want if anything untoward were to occur would be to be bobbing about awaiting rescue with the added 'excitement' of being just a few hours from DKA once my last bit of basal runs out.

Having asked around I've had very good reports of the Aquapac waterproof pump case, so I've decided to order one. The case is clear so I will be able to check on how Artoo is doing and it's waterproof enough to cope with anything from a bit of gentle splashing to some full-on dunking - for a short while at least!

All we have to do now is hope the kayak hire people actually turn up!

Running. Battles.

It's been a busy old time recently, and updates on the blog have taken rather a back seat. Sorry about that!

I realised this week (on Monday in fact) that I had not yet even managed to post an update following my Half Marathon shenanigans in Bath exactly two months ago today. Shocking!

Part of the reason for this post is to say an ENORMOUS thank you to everyone who donated so very generously in support of my race charity Diabetes UK, in fact your generosity was so apparent that I was also able to donate to Medical Detection Dogs (the tiny charity that is able to specially train clever pooches to sniff out hypos and hypers). In total you raised the mighty sum of £685.50, you should feel very proud of yourselves, you rock!


Ready for the off at the Bath Half 2013I had a great time on the day itself. It was bitterly cold at the start where everyone stood shivering for about an hour, but the mood was very cheery nevertheless. It was my first distance race of any kind, and I think I had naively underestimated the experience of running among something like 11,000 other people. It took much longer than I'd thought to find space enough to run at my 'own' pace. I was able to finish the 21km (13ish miles) in 1hr 46 mins, which is just about as fast as I ever thought I'd be able to do it.

I think the D fairy must have been having a day off that day, as my levels were bewilderingly good. The race started at 11am, but even so I reduced my breakfast dose to 90% of normal. Thanks to Artoo I was able to set a TBR which took my basal down to 10% an hour before the start and throughout the run. My levels on the day looked a little like this:

3.00am - 7.3
8.00am - 7.5 Breakfast
9.30am - 7.9 waiting to start
1.00pm - 7.0 Finish! I downed a 60g CHO bottle of lucozade on the way round
2.51pm - 6.8 Lunch

To say I was pleased with those is a bit of an understatement! I wondered at the time if perhaps I should run a half marathon every day?

As is the way of things, it has taken me a fair old while to get the last few donations collected, but the cheques are now on their way to the respective charities. Immediately after the race I'd found myself reflecting on the unexpected enjoyment I'd found in the training, but thought I wouldn't hurry to take part in another event. Then a *very* odd thing happened. Last Sunday was the London Marathon, and I actually found myself thinking, "Well... I wonder if I could...". Encouraged by Dave and his tangerine enthusiasm I have unexpectedly put my name forward for the 2014 ballot. The chances of making it into the event are pretty slim - but it would be an interesting challenge!

The rest of March and April have been a bit of a mixed-bag levels wise. March, and Easter in particular involved quite a few family get togethers and celebration meals which are always fraught with guesswork and wild stab-in-the-dark boluses with all the (lack of) success you might expect. April looked to be a little more settled in patches, but by the end of it a few chaotic days had worn me down, wrecked my averages and SD and I ended the month feeling quite grumpy about the whole unrelentingly inconsistent business.

Part of me thinks I am pushing myself too hard and need to learn to be happier with the successes I am seeing rather than contantly reaching for those elusive 'perfect' days. Many people who have lived with Type 1 Diabetes for any length of time will be familiar with that feeling I think.

I've decided it's time to run a few basal tests during the day just to make sure there is nothing obviously wonky on that score. A tiny dip below 4.0 after the gym has put paid to that for today. Ah well.

Enjoy your Bank Holiday everyone!

Bubble, bubble, tubing trouble

Looking at my stats it seems Artoo has been having a bit of a run of form recently. Not without a wobble here and there obviously (let's not be silly) but certainly a decent punt at things on the whole, and far fewer eye watering levels in the 20s than in any of the months since I started on an insulin pump (which were never really part of my MDI experience). According to the funky monthly reports on my current BG logging app of choice (the excellent mySugr - 'making diabetes suck slightly less') my purple patch seems to date back to October. I even seemed to manage Christmas with fewer Quality Street induced gaffes than I would normally expect. Generally average BG in the high 6's low 7's (108-126), with an SD around the mid 2's (36). This makes me happy.

Aside from me taking a *very* long time to get used to the whole pumping business (Artoo was very patient with me) I believe there are a couple of changes which have helped me, so I'm posting this insufferably smug blog entry just in case there are any frustrated insulin pumpers who stumble upon it that are putting in all the effort but not seeing the results they are hoping for.

Firstly, September was the time that I switched infusion sets. I'd been having a fair few failures for some months, but only in amongst a majority of set changes that worked perfectly. At the time it was less obvious, but looking back, a readings/recoveries from mid 20s almost every month were messing things up for me. If you are getting set failures/site issues more than a couple of times a year it could well be worth asking your clinic/DSN/endo what alternative lengths and types of infusion sets are available to you. I've not had *one* site failure in the past four months - and aside from the lack of eye-frying levels, it also makes me feel a lot better about the whole business of diabetes day to day (as hard as I try not to part of me always takes these out of range disasters as a sort of personal failure).

Secondly, and my initial reason for writing this post, I think I have cracked the 'bubbles in the tubing' problem. Maybe not 100%, but pretty darned close. I'm not sure how common this is, but throughout my first year on a pump I was occasionally victim of a 'phantom bubble of doom'™. I'd fill the reservoir with room-temperature insulin as advised, having first moved the plunger up and down to lubricate the inside of the reservoir. I'd flick and jiggle for all I was worth until I was absolutely sure that there were no bubbles in the insulin. Fit the reservoir to the pump, and prime with the pump vertical, tapping all the while to ensure that any rogue bubble-ettes got expelled in the priming, and then connect everything up happy in the knowledge that I had achieved the perfect bubble-free set change. BUT. The next day, look at the reservoir and BAM, there it was a big, fat, lurking, bubble of doom. Ready and waiting to find its way into the tubing at some inconvenient moment and then effectively deprive me of basal for an hour or two. Or mess up a meal bolus. Or both. I do try to check my tubing a few times a day but these suckers are hard to spot. And just as frustrating as the high BGs they caused - was not knowing where they were coming from! I was as sure as I can be that they were not there when I changed the set. They just seemed to be emerging out of nowhere with an evil glint in their eye overnight.

I did discover a suggestion on You Tube, which I won't link here as it was a complete disaster for me. The technique (described as something like 'degassing the reservoir') involved creating a fairly strong vacuum in the insulin vial by repeatedly drawing air out of it until you could do no more. Do not try this! My experience is that reservoirs are just not designed to operate under that kind of pressure. On more than one occasion (and I only tried it about 3 times!) the o-rings failed and insulin began to leak 'behind' the plunger while the reservoir was in use. Complete BG chaos. But it did get me thinking...

If you too suffer from occasional 'phantom bubbles of doom' - here's what seems to be working for me. When you draw up the insulin into the reservoir it is usual to first inject air into the vial, equivalent to the insulin you are about to withdraw, to equalise the pressure. Instead of this only inject half of the air into the vial. Additionally you should make sure that you inject the air with the vial downward, then invert the whole caboodle to draw up the full insulin amount. Then flick and jiggle any bubbles that have crept in as normal. Disconnect the reservoir first, to allow the air pressure in the vial to normalise again. It seems that the very slight vacuum created is not enough to worry the o-rings, but is sufficient to make the insulin less 'aerated' in the reservoir. Or something. Anyhow, it seems to be working!

Obviously... Disclaimer, disclaimer. Not medical advice. Consult a qualified person. Don't try this at home. Read the documentation supplied with your pump. Simply reading this blog post may void your warranty etc etc.

If you have any top tips that you have discovered for yourself - please share them below :)

Ho ho ho-peful

Artoo and I began our little adventure just over a year ago. It has been as steep a learning curve as anyone ever suggested it might be. At times it has felt like I was newly diagnosed all over again, and despite 20ish years of experience with injections, there were weeks when that knowledge seemed to count for almost nothing.

A year ago I noted that in hindsight, perhaps beginning to completely change insulin delivery method immediately before one of the most challenging and notoriously chaotic times if the year foodwise might seem a little foolhardy. But in the current challenging financial climate it would be a brave man who would turn down the offer of NHS funding for an insulin pump without a very good reason.

Last Christmas was, if I'm honest, a bit of a mess BG-wise. Much as I stand by the general assertion among people living with diabetes that there are two days (Christmas and birthdays) on which and any carbs eaten don't count, the perfectionist in me delights in giving myself a kicking whenever dodgy results appear. Even when (and perhaps especially if) I'm sort of expecting them. I didn't get myself into any serious bother last December, but it was certainly not my finest hour. Since the Summer, and especially since changing the sets I use to Silhouettes (with occasional Quickset), Artoo seems to have really got into his stride. I had a pleasant surprise with an A1c improvement at my annual review, and if anything averages and SD have been slightly better since (with the occasional lapse obviously!).

I'm not naive enough to expect a Christmas entirely without an errant reading (or 10), but my trust in Artoo's judgement and general ability to accurately correct my mistakes has never been higher. As long as I can weather the basal-tweaking turbulence when the lack of gym visits kicks-in I am hopeful that I might be able to enjoy a few treats here and there over the festive period (along with the inevitable selection of wildly non-standard meals) and still keep a relatively decent hold of things. I can but hope.

Thanks to everyone who has visited and commented on our blog this year. It has been an eventful and exciting one in many ways and it has been lovely to share it with you all.

Have a brilliant Christmas and here's to unexpectedly good results this festive season and rock-steady BGs for 2013 all round.

A1c apprehension and feeling a little deflated

I have an appointment on Monday to have bloods taken for my annual review a week or so later. As is often the case the mere hint of an A1c on the horizon has been enough to play havoc with my blood glucose levels over the past few weeks. Coming down with a cold hasn't helped either.

This time last year I was at a bit of a turning point. I had tried as hard as I could to improve my levels on MDI, and still felt there was improvement to be made. That review was undertaken at the hospital, and having discussed the ongoing challenges I was trying to tackle, the Registrar agreed that an insulin pump was a good option. I recognise that I am extremely fortunate to attend such a pro-pump clinic and after a few more appointments and a bit more prep, I was pumping before Christmas.

Regular readers (your gritty determination astounds me) will know that my journey towards an insulin pump was not entirely straightforward. I spent a great many years resisting the idea each time it was mentioned. Approaching a year into my pump experience I have just done a d-geek 'compare and contrast' exercise that convinces me more than ever of my position on the OCD spectrum - partly because it annoys me so much to have a key period of MDI results missing due to an *ahem* administrative error (I deleted them from one place before checking the place where I thought I'd copied them). I put together seven months worth of BG results side by side, matching 'tricky' periods like Christmas and holidays. I then examined them for a range of markers - BG average, SD, FBG in range, numbers of highs, numbers of lows and so on.

Without going into the minutiae (I appreciate I have to at least make a gesture towards allowing you to retain your will to live) the truth is I'm a bit deflated by the results. Since moving to the pump they are, in some ways, better than on MDI - but not really by very much. And if I'm honest I was hoping for the same transformations to my results that I'd seen in other people. People whose MDI skills I hugely respect, whose lives are busy and full of nice varied (and occasionally eyebrow raising) meal choices. People whose A1c's fell by a significant margin after a short time on insulin pump.

The trouble is I should be perfectly happy. My meter averages suggest that my A1c will be somewhere in the high 6's. To be disappointed by that seems ridiculous, but my last MDI result was 6.3. It is true that I'm having slightly fewer 'waffy' moments these days (thanks Dave!) but I've also had more readings in the 20s than I can remember thanks to multiple set failures which at one stage seemed to be happening fortnightly.

I still believe the pump is working for me - and having changed to Silhouettes a few weeks back I've not had a failure since - but by now I was hoping to have this whole thing sorted and be cruising along with more stability and less goalpost chasing.

I'll let you know what the result is when the A1c jury comes back in.


UPDATE: #teamsmug

Set changes

Since I started with Artoo, infusion sets have been the weakest link in my pump experience. Around the time of the summer holiday I had noticed that I was getting some sort of set-based upheaval around once every 4-6 weeks, occasionally as much as fortnightly. This was clearly not right, and another 'no delivery' alert with attendant BGs in the 20s (360s) spurred me to contacting my pump DSN to investigate the options. Some of the failures I was getting were clearer than others, involving cannulas kinked at 90 degrees and 'no delivery' alarms. Others were less obvious - rampaging BGs which began to resolve after a set change despite there being no apparent problem with the old one. Still others involved multiple changes of reservoir and/or set in a single evening. Partly I am sure this is down to my own nervousness over the whole set business. One apparent failure, followed by a change which gives a 'no delivery' followed by another change can leave you feeling very unsure until you actually see your numbers begin to drop. Annoyingly, for me this can often take more than an hour - plenty of time to decide to do another full change 'just in case'.

In short I was very keen to experiment with alternative sets and see if I could find one which worked, change after change, for months rather than weeks at a stretch.

My DSN was able to give me several each of the shortest cannula length versions of Silhouette (angled Teflon), Sure-T (straight metal) and Mio (straight Teflon with self-serter).

Having spent most of September experimenting, on Friday I received my first order of Silhouettes which seem to work best for me.

I wasn't keen on the 'double sticky' extra loop business with Sure-Ts and while they were almost pain free to insert I found the 2 day changeover came around very quickly. I didn't get on well with the flimsy feeling Mio serter (though I know many love that feature). The first two Mios I pushed in manually, I actually dropped one which fell apart and deposited the 'sterile' needle part onto the floor (which would not have been ideal if I'd been changing on the run and had only taken one with me). The final nail in the coffin for Mios though was the last one which suffered a 'no delivery' cannula kink.

Silhouettes performed very reliably for the few I had to try, so I'll be interested to see what a whole box brings. I was impressed by the relatively compact box size. I'm undecided about the Silhouette kerplunker and may well try a few manual insertions which I suspect may be a bit more comfortable than spring-loaded ones. I did find that the mark on removal seems to be a little more noticeable than others, which might be to do with the angled nature of the cannula.

Fingers crossed I have a few months of clear space before I have to battle my next set-fail shuffle.