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Pumping *and* Levemir?

Discussion in 'Parents of Children with Type 1' started by Dad_in_Canada, Oct 22, 2013.

  1. Dad_in_Canada

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    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. Melissata

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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.
     
  3. hawkeyegirl

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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.
     
  4. MomofSweetOne

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    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.
     
  5. C6H12O6

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    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.
     
  6. Kimby

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    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.
     
  7. Beach bum

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    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.
     
  8. missmakaliasmomma

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    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.
     
  9. nanhsot

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    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.
     
  10. danismom79

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    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.
     
  11. Dad_in_Canada

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    Got it. So "untethered" is what I'll start to research, at least to understand it a bit more.

    It's true that our endo may not like or even approve such an approach, but understanding all of our options is quite important to us at this stage.

    We don't have a lot of access to CGMs. We just trialed the Medtronic Enlite + Guardian for a week. While the sensor was reasonably comfortable for my son, it took about 5 days before the readings were even close to the blood meter. And with a 6 day sensor life, well, not so good. It never caught any of the 4 lows we had (Guardian happily said 5.x mmol/L). The range is quite short as well (a few feet).

    Animas is supposed to be distributing the Dexcom G4 in Canada starting next month, but until I'm actually holding one, I'm not holding my breath.

    Like many have mentioned, a CGM is great. If we had a CGM while we were pumping, I think some my fears on insulin interruption would be reduced.
     
  12. Dave

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    We had a push from our pump rep to go cold turkey on Levimeer and switch to pump for basal. I was fearful of that based on peoples comments here about how tricky it is and the high numbers you see. We dont tolerate numbers over 160, so 300 and above aint going to happen. Sure enough on the first day, blamo..problems. We were out of town and called the endo and he was like 'why not just stay on levimeer?'. So we did - I saw someone else here say 'best of both worlds' about the combination. After that, what we did was compensate for the uneven levimeer profile by putting in small basal rates at different time of day. In particular we attacked the morning rise with a 3AM to 7AM basal rate using the pump. 6 months later we still use the levimeer. Our primary application for the pump is to allow DS to bolus for snacks at school, not do shots, and most importantly fractional corrections throughout the day and night. Love the pump for that. Love love love it.
     
  13. danismom79

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    LOL. Oh, Dave.
     
  14. hawkeyegirl

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    I really, really, really am trying not to be a dick to you, Dave, but the implication that the rest of the board is more "tolerant" of high numbers than you are is really sticking in my craw. You are not some diabetes genius, and you don't have higher standards for your kid's health than the rest of us. Your child is honeymooning. Enjoy it, and let us know when it ends and you start having 300s smack you in the face with zero warning or apparent cause. Your genius Levemir solution (which despite being pretty pleased with yourself about, you didn't invent) isn't going to do crap about it.
     
  15. Mish

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    plus, it's not Levimeer. The least you could do is spell the wonder insulin correctly.

    Otherwise, I'm just going to sit and chuckle. I'm sure you think that it's all about what YOU are doing. :D
     
  16. Megnyc

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    I am just going to caution you to avoid giving your son the notion that blood sugars are "good" or "bad" or worse, that some blood sugars are not to be tolerated (whatever that means). In my personal experience that can result in teens either totally rebelling or misleading parents about meter results (hint: teens are experts at tricking the meter).

    For the record, I have an A1C in the 5 range and for an adult (especially a busy one in college) my doctors are thrilled with my CGM graphs. My blood sugar hits 300 at least once a week and 200 most days. Even using the best technology you are going to eventually start seeing high numbers and overall if treated promptly those have minimal impact on A1C. One of the best things my parents taught me was how to calmly troubleshoot highs, correct, and then move on.
     
  17. Beach bum

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    LOL, what a jokester you are. In a perfect world we wouldn't tolerate them either but they still come knocking. One word. Puberty.
     
  18. Sarah Maddie's Mom

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    Dave - you are a riot!

    7 months in? LOL, you haven't mastered squat. You have barely seen the previews. You're still on line for popcorn as far as I'm concerned. :rolleyes:
     
  19. AliciaM

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    Oh dear...Dave like everyone said 300 and over will happen occasionally..actually surprised your son doesn't have off days where he is high, if he is I hope you don't tell him that his bg being that high is unacceptable? I was feeling horrible today nauseous, coughing, fever last night and hardly any sleep. I forgot to bolus for lunch and on top of that was feeling like crap and checked my bg 2 hours after lunch and was 22.6 ... can I help it..not much. Obviously forgetting to bolus for sure was my fault but everyone has off days that they can't control due to hormones or sometimes for no apparent reason. I think you need to have some more realistic expectations ...
     
  20. Melissata

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    Dave,
    Great advice above! The other thing that can happen that will stay with him forever is feeling like he MUST do something to get that number down asap, because you have taught him that it is not to be tolerated. Believe me, if I had it to do over again with both of my kids, I would, and I was not nearly the mindset that you have. They have both put themselves in danger at times because they were too aggressive with correction doses. My son lives alone, and even with the Dexcom, it worries me. You can talk till them until the cows come home, but if they have gotten the idea from you or the endo that they need to keep in perfect control at all times, you are going to have issues. This is a marathon, not a sprint. The sooner you come to terms with that the better.
     

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