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Thread: Pumping *and* Levemir?

  1. #1

    Default Pumping *and* Levemir?

    We're still relatively new to T1D (9 months in), and not pumping yet (hopefully that'll start in early 2014).

    From what I've read about pumping, one of the major safety downsides is interrupted insulin flow (kinked canula, tubing, etc). Since only rapid-acting insulin is being used for both bolus & basal insulin, things can start to go very bad in 4-6 hours, ketoacidosis if the insulin interruption is long enough.

    One the other hand, a decent safety feature of long-acting insulin (eg. levemir) is that in a 24-hour period there is almost always some insulin working in the body, and will reduce the chance of ketoacidosis.

    So, what if the insulin regimen combined long-acting insulin (once a day via needle injection) with pumping? The long-acting insulin provides a "baseline" minimum insulin level, and the pump provides bolus insulin and "tops off" the basal insulin needs. You'd get the flexibility benefits of the pump, combined with some of the safety of the long acting insulin.

    With basal increments via pumping being very small (eg. 0.001 units with the T-Slim), it should be possible to get very fine control.

    I know the above might sound a bit crazy, but what's wrong with the logic? Do practical considerations invalidate or outweigh it?

  2. #2

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    If you do a search here for the word untethered, you will find out that some do this for various reasons. A lot of parents consider it when researching pumps, but with the CGM's now as a safety net, I think it is less of a concern. Tubing does not kink, it is the cannula that can kink on occasion.
    Mary,
    Mom to Melissa, 29, using Dexcom, 24/7 since 4/10, and T:slim started March 2014. Michael, 34 using MDI's and Dexcom. Melissa is intellectually challenged and needs a lot of help from us to manage her diabetes.

  3. #3

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    I agree with Melissata. We've pumped almost 6 years now, and not once has any sort of site malfunction resulted in a situation that was dangerous for my son. We do CGM, so we catch everything over 150 basically in real-time. Really, the only way I would consider untethered is if my son was in an activity that required us to remove the pump for longer than 2 hours at a time.
    Mom to J., age 10
    Dx 2007 @ age 3
    Medtronic pump and CGM (4/2008-6/2013)
    Tandem t:slim and Dexcom G4 CGM (current)
    CGM in the Cloud 7/2014

  4. #4

    Default

    Quote Originally Posted by hawkeyegirl View Post
    I agree with Melissata. We've pumped almost 6 years now, and not once has any sort of site malfunction resulted in a situation that was dangerous for my son. We do CGM, so we catch everything over 150 basically in real-time. Really, the only way I would consider untethered is if my son was in an activity that required us to remove the pump for longer than 2 hours at a time.
    I agree with ^^. We had our first site-pull out at night this week, and I caught it before 200. We did Cut-the-Cord last summer rather than consider untethered. My daughter hated the sting of Lantus and will do anything to avoid going back on it.
    8/2010 - 9/2011 MDI, Lantus & Humalog
    9/2011- Medtronic Revel 723 & CGM
    11/2012 - Dexcom G4

    "Life is not waiting for the storms to pass, but learning to DANCE in the rain."

  5. #5
    Join Date
    Sep 2008
    Location
    Ontario, Canada
    Posts
    1,394

    Default

    Keep in mind T Slim is not available in Canada. Untethered regimen is not unheard of in the United States, but I am not sure if your pediatric endo will approve of this practice. I was told untethered is incompatible with the ADP pump program in Ontario.

    There is no specific rule against it, and I imagine the practice will catch on at some point in Canada.
    young adult w. type 1
    Pumping Since Aug 2005
    currently pumping with Medtronic Veo (with CGM as much as possible)

  6. #6
    Join Date
    Jan 2010
    Location
    Madison, AL
    Posts
    262

    Default

    While Andrew was playing football, he took a Levemir shot every evening that covered most of his basal. He wore the pump with a very small basal except for during the three hour daily practices. It was a great solution for the time, because disconnecting for long periods of time was fine. Now that football is over though, we are finished with shots too. He is conditioning now with the baseball team, but he wears his pump for baseball. Andrew is one of those kids who does run ketones easily, but if he has trouble with a site, a site change and shot will have it resolved within a couple hours. It isn't worth it to Andrew to take the shots anymore.
    Kimberly- Mom to 5 great kids - Ryan, age 15, Kaitlyn, 14 & dxd TID 3/12, no insulin yet, Andrew, 12 & dxd T1D 1/08, T-Slim, has used Omnipod and Animas Ping, & using Dexcom, Will, 9, and Ben, 5
    Blog: http://andrewsdiabetesstory.blogspot.com

  7. #7

    Default

    Quote Originally Posted by Dad_in_Canada View Post
    From what I've read about pumping, one of the major safety downsides is interrupted insulin flow (kinked canula, tubing, etc). Since only rapid-acting insulin is being used for both bolus & basal insulin, things can start to go very bad in 4-6 hours, ketoacidosis if the insulin interruption is long enough.

    One the other hand, a decent safety feature of long-acting insulin (eg. levemir) is that in a 24-hour period there is almost always some insulin working in the body, and will reduce the chance of ketoacidosis.
    If I recall, there were one or two families here a while ago who chose to do untethered for various reasons.
    You are right, it is a downside, but honestly it doesn't happen all that often. I know in each event that it happened with us, it was because of something I did wrong. For example, the other day I took the cartridge out to top off the insulin (because I didn't want to waste what was in the cartridge already). I did it in a bit of a hurry and didn't notice a big air bubble. Because it was overnight, it took a while for me to notice that there was a problem. We have the CGM, so about 3 hours in I could see that there was a problem brewing. Another time I created an occlusion because of the way I had put the set on her. We've only had a set ripped off once in 8 years (knock wood).

    We do untethered in the summer, but not because of concern of pump issues/failure. My daughter spends about 80% of the day either swimming or sailing and it just creates too much of a nightmare being off the pump. It would be a constant game of chasing numbers. But the downside is that we don't see the insulin on board from the basal, we only have an idea of the Levimere still working in her system. In addition, the Levimere doesn't last 24 hours for her, so we end up putting the pump on so that she gets some reinforcement basal.
    Diagnosed June '05
    Pumping since Feb '06
    Animas Ping
    Dexcom Study







    My current position:
    CIO...CHIEF INSULIN OFFICER

    "Life is under no obligation to give us what we expect"...Margaret Mitchell

    "Make it work"...Tim Gunn

  8. Default

    Quote Originally Posted by Dad_in_Canada View Post
    We're still relatively new to T1D (9 months in), and not pumping yet (hopefully that'll start in early 2014).

    From what I've read about pumping, one of the major safety downsides is interrupted insulin flow (kinked canula, tubing, etc). Since only rapid-acting insulin is being used for both bolus & basal insulin, things can start to go very bad in 4-6 hours, ketoacidosis if the insulin interruption is long enough.

    One the other hand, a decent safety feature of long-acting insulin (eg. levemir) is that in a 24-hour period there is almost always some insulin working in the body, and will reduce the chance of ketoacidosis.

    So, what if the insulin regimen combined long-acting insulin (once a day via needle injection) with pumping? The long-acting insulin provides a "baseline" minimum insulin level, and the pump provides bolus insulin and "tops off" the basal insulin needs. You'd get the flexibility benefits of the pump, combined with some of the safety of the long acting insulin.

    With basal increments via pumping being very small (eg. 0.001 units with the T-Slim), it should be possible to get very fine control.

    I know the above might sound a bit crazy, but what's wrong with the logic? Do practical considerations invalidate or outweigh it?
    I know of one person that does this on here and there are probably more but I just don't know. I actually think it's a smart idea. We HAVE had sites fail. It happens. And that's a reason I didn't like pumping. It doesn't take long at all for sugars to rise. My daughter needs very little basal so even when it was all dependent on the pump, there was still clogging issues and I believe it's because the pressure from the little amount of insulin coming through wasn't enough.
    Kristen

    Mom to
    DD 5: 10/11/2008- diagnosed 3/31/09 at 1.5 years.
    3/31/09- 01/2012- Humalog and NPH
    01/2012- 04/18/2013- Humalog and Lantus
    04/18/2013- Pumping with a Pink Animas Ping
    09/13- back to MDI with Apidra and Lantus
    Currently pumping with Novolog

    DS born July 29, 2013

  9. #9

    Default

    Quote Originally Posted by Dad_in_Canada View Post
    We're still relatively new to T1D (9 months in), and not pumping yet (hopefully that'll start in early 2014).

    From what I've read about pumping, one of the major safety downsides is interrupted insulin flow (kinked canula, tubing, etc). Since only rapid-acting insulin is being used for both bolus & basal insulin, things can start to go very bad in 4-6 hours, ketoacidosis if the insulin interruption is long enough.

    One the other hand, a decent safety feature of long-acting insulin (eg. levemir) is that in a 24-hour period there is almost always some insulin working in the body, and will reduce the chance of ketoacidosis.

    So, what if the insulin regimen combined long-acting insulin (once a day via needle injection) with pumping? The long-acting insulin provides a "baseline" minimum insulin level, and the pump provides bolus insulin and "tops off" the basal insulin needs. You'd get the flexibility benefits of the pump, combined with some of the safety of the long acting insulin.

    With basal increments via pumping being very small (eg. 0.001 units with the T-Slim), it should be possible to get very fine control.

    I know the above might sound a bit crazy, but what's wrong with the logic? Do practical considerations invalidate or outweigh it?
    My son did this through football season but not regularly. There is nothing wrong with your logic and I don't think it's a crazy idea, but I also don't think it's necessarily true that pump/site failures are common or expected. Do they happen, sure, but not with enough regularity to worry with. I think I personally would try the pump first, and know that this is an option IF you see issues or ketones. I'd try different sites, change up your basal, etc, before I'd jump to an untethered option.

    For my son (teenager) the practical and negative consideration was just pure laziness; he took his lantus at 10p and was often NOT home then, and having to plan for yet another thing didn't sit well with him.

    He did it one football season but not the next. Switching to steel sets was a better fix for him. CGM helps a lot, if there is an issue it is detected. The rapidity of which your T1 throws ketones factors in as well, mine isn't susceptible to them, he's had sites out all night before and not shown ketones. We're definitely lucky there, and if I had a kid who threw ketones quickly it might change things.

    ~Nancy~
    Homeschooling our way through high school, learning with them!
    20 year old son diagnosed T1 2/5/10, pumping Tslim beginning 7/13 ; Dexcom on occasion. Animas Ping 10/10-7/13. College student August 2013.
    16 year old daughter teaching her mom all about patience and grace
    .

  10. #10

    Default

    Quote Originally Posted by Dad_in_Canada View Post
    We're still relatively new to T1D (9 months in), and not pumping yet (hopefully that'll start in early 2014).

    From what I've read about pumping, one of the major safety downsides is interrupted insulin flow (kinked canula, tubing, etc). Since only rapid-acting insulin is being used for both bolus & basal insulin, things can start to go very bad in 4-6 hours, ketoacidosis if the insulin interruption is long enough.

    One the other hand, a decent safety feature of long-acting insulin (eg. levemir) is that in a 24-hour period there is almost always some insulin working in the body, and will reduce the chance of ketoacidosis.

    So, what if the insulin regimen combined long-acting insulin (once a day via needle injection) with pumping? The long-acting insulin provides a "baseline" minimum insulin level, and the pump provides bolus insulin and "tops off" the basal insulin needs. You'd get the flexibility benefits of the pump, combined with some of the safety of the long acting insulin.

    With basal increments via pumping being very small (eg. 0.001 units with the T-Slim), it should be possible to get very fine control.

    I know the above might sound a bit crazy, but what's wrong with the logic? Do practical considerations invalidate or outweigh it?
    That doesn't sound crazy at all. There are (or were) actually quite a few people here who go untethered for various reasons. That's the term you're looking for, and you can do a search to find previous threads about it.

    We've been pumping for over 4 years and haven't had any problems with interrupted insulin, besides high bg. However, my daughter apparently isn't prone to developing high ketones as fast as some others.

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