To Pump or not to Pump?!

[JamesL]

Hi there! My name is James and I am new to the forum .

I was diagnosed T1 five years ago and have managed to maintain a good level of control through MDI (Tresiba & Novo Rapid).

However, I have been struggling significantly over the past 6 months as the maintenance of in-range sugars requires, as I am sure you can all vouch for, a lot of your time and energy!!

I have been working with my DN to try to stop my night hypos which are the biggest issues, I have had 3 nights in the past 6 weeks where I haven’t been woken to the charming noise of my Libre! We’ve reduced my Tresiba down to 14 units but still without success.

I have been offered to apply for a pump (Omnipod Dash) as an alternative by my Nurse in a bid to help with the issues above which sounds great (if I am approved) if it could help free some of my mental bandwidth and also improve my sleep - we have a second little one on the way!

However, I have concerns around using a pump as I exercise fairly frequently 6-8 hours running/cycling per week.

I also wondered whether I would risk possibly sacrificing my current Hba1c (39) with a pump and seeking to address the night hypos?

Any advice, views, feedback would be hugely appreciated.

Lots of love to you all x

 

[SB2015]

Hi @JamesL and welcome to the forum.

I switched to a pump to address my night time hypos, and it certainly worked for me. It was just not possible to match my insulin needs with an injected basal, in spite of switching to Levemir which I was able to split to two separate doses, morning and evening.

With the pump it is possible to have a different rate hour by hour, and the pump trickles in insulin all the time. It is also possible druing the day to make changes to this (temporary basal rates) whilst doing exercise which I found very useful. So when running cycling you could turn the basal down about an hour before, and also keep it reduced so that your muscles can top up. It is so much more reactive than trying to make adjustments to the basal insulin at the start of the day.

You mention that you might sacrifice a low HbA1c that you currently have, but that is an average which includes the frequent hypos that you are having, or nearly having with your alarms going off.

Do they offer any other pumps? The Omnipod is a patch pump and Inwas a past master at knocking off my Libre sensors on doors, so did not want a patch pump. I used a tubed one which has a very flat cannula and then I can put the pump wherever I want depending on what I am doing. For me it gives me more flexibility. However I think @helli use a patch and is also very active so she will have another view on the choice of pump.

There is no best pump. The pump that is best is the one that meets your criteria, and I certainly feel that with the positive impact the switch from injections to pump had, I would have been happy with whichever one I was given at the start.

I use a Medtronic 780G with their own sensors now in a hybrid closed loop which is another story, but one I very much like being part of.

Any questions that you have just ask. There will be someone on here using any of the pumps that you are offered and a wealth of experience to tap into.

 

[Rob Oldfield]

Hi and welcome @JamesL

I'd agree with everything that @SB2015 has put up there but will just add something re pumps and exercise. I do a little bit less exercise than you but again with a mix of running and cycling. I actually tend to take the pump off when I'm running but keep it on when cycling. A lot of it is down to finding exactly what works for you but I've found that it gives me a great deal more flexibility than MDI. The ability to do a quick Libre scan, figure out that I need an extra half a unit and deliver that with a couple of button presses makes life so much easier than injections.

 

[JamesL]

Hi @JamesL and welcome to the forum.

I switched to a pump to address my night time hypos, and it certainly worked for me. It was just not possible to match my insulin needs with an injected basal, in spite of switching to Levemir which I was able to split to two separate doses, morning and evening.

With the pump it is possible to have a different rate hour by hour, and the pump trickles in insulin all the time. It is also possible druing the day to make changes to this (temporary basal rates) whilst doing exercise which I found very useful. So when running cycling you could turn the basal down about an hour before, and also keep it reduced so that your muscles can top up. It is so much more reactive than trying to make adjustments to the basal insulin at the start of the day.

You mention that you might sacrifice a low HbA1c that you currently have, but that is an average which includes the frequent hypos that you are having, or nearly having with your alarms going off.

Do they offer any other pumps? The Omnipod is a patch pump and Inwas a past master at knocking off my Libre sensors on doors, so did not want a patch pump. I used a tubed one which has a very flat cannula and then I can put the pump wherever I want depending on what I am doing. For me it gives me more flexibility. However I think @helli use a patch and is also very active so she will have another view on the choice of pump.

There is no best pump. The pump that is best is the one that meets your criteria, and I certainly feel that with the positive impact the switch from injections to pump had, I would have been happy with whichever one I was given at the start.

I use a Medtronic 780G with their own sensors now in a hybrid closed loop which is another story, but one I very much like being part of.

Any questions that you have just ask. There will be someone on here using any of the pumps that you are offered and a wealth of experience to tap into.

Hi @SB2015 - great to meet you, and thank you for taking the time to reply 🙂.

In my knowledge of pumps, which is not yet in-depth but am learning all the time through online articles and this forum, the huge difference in flexibility and different 'profiles' should hopefully help improve the night hypos significantly. Great to hear that the pump has worked for you! Have you found that you are now relatively hypo free overnight?

My DN presented 2x tethered pump options, however my personal preference currently would be for a patch. Out of irnterest, on the forum, are thethered or patch pumps typically preferred (I appreicate it is a very individual decision, but would be interested to know what is preferred in the community). The DN also mentioned that the dash would hopefully be replaced by Omnipod 5 around June time (although I would fully expect this to move). which would offer a closed loop system I believe? How do you find the closed loop system works for you?

It would be great to get setup and learn how a patch pump operates however before using a closed loop system, more for my peace of mind in case anything was to go wrong I would have the knowledge to operate competently without the sensor.

I am certainly leaning towards a pump, again, if I am approved as there doesn't appear to be any real answer through using the MDIs.

It is an exciting, albeit highly nerve-wracking thought to change from something which feels so familiar!

 

[rebrascora]

Hi and welcome.

Sorry to hear you are struggling with night time hypos. I don't have experience of pumps to give you the input you want but just wanted to mention a couple of things which might help you in the mean time.
Firstly, are you aware that Libre suffers from what we refer to as "Compression Lows"? This is where you turn over i your sleep and lie on the arm with the Libre sensor causing the sensor to apply pressure to the tissue underneath which is sampling glucose. This usually causes it to dip and read low. If the alarm goes off during the night, indicating your levels are dropping, it is always a good idea to double check with a finger prick before treating because often it is one of these "compression lows" rather than an actual hypo. Apologies if you are aware of this but unfortunately many people are not.

Secondly, if they are genuine lows, then have you tried Levemir as an alternative to Tresiba. I would never manage with Tresiba because it provides a fairly uniform amount of basal insulin throughout the day and night and my liver doesn't do uniform. It needs much more insulin in the morning and much less at night and I am certainly not the only one. Levemir allows me to adjust my daytime and night time basal insulin doses independently. It is much more flexible than Tresiba and I can adjust it downwards if I have had more exercise that day or up, if I was more sedentary and it responds more or less in real time. I don't have a structured routine to my days, so Levemir is great for allowing me to tailor my basal insulin to my lifestyle and what my body needs. I absolutely love it! I currently take 22 units in the morning and 0 at night because I am doing a lot of physical activity every day but usually it is about 22-24 in the morning and 3-5 units at night, which as you can see is quite a disparity between my day and night needs. I can also vary the time I take each dose according to what my body needs. At the moment I take it before I get out of bed and when I do to bed, so not a straight 12 hour split, but occasionally I go through spells where I start getting a rise after my evening meal, so I can bring my evening dose forwards and inject it at say 7pm instead of 11pm to help with that. Obviously a pump will fine tune to your basal needs hour by hour, whereas this is just 2 doses morning and night but because it doesn't have a flat profile, adjusting the time you take it can give you a bit of extra adjustment, so that it's spike coincides with when you need it most. It is an option to discuss with your nurse whilst you wait for an answer about a pump if you haven't already tried it.

As regards your HbA1c and maintaining it that low, I think you should be considering that that result is probably unhealthily low if you are suffering genuine hypos almost every night. My consultant is delighted with any reading in the low 50s or high 40s and I believe there is recent evidence which suggests that there is not significant benefit in getting it below 53 I think. Your Libre "Time is Range" is a much better assessment of how good your diabetes management is these days, so don't be sad to potentially relinquish that HbA1c of 39, because it may not be doing you any favours.

Anyway, those are just my thoughts on the info you provided. I wish you lots of luck in getting a pump if that is what you are set on and I hope you find it beneficial in the long run, even if it might be a bit frustrating and even more "band width" required in the short term getting it set up.

 

[Inka]

Hi @JamesL Like everything, there are pros and cons, and what suits one person might not suit another, so it’s an individual decision.

I got a pump almost 20 years ago because of nighttime hypos. My insulin needs vary greatly through the night so a pump allows me to match my basal needs better. It does take more work though, and it needs a fair bit of user input as basal needs often change. A pump is just another insulin delivery system - it’s main benefit IMO is the ability to fine tune basal. It’s also convenient for illness when you can just set a temp basal rate, and for bolusing discreetly (my pump is controlled via my phone so that makes it simple).

I wear it for all exercise except things like skating when I’m worried I’d fall and smash it (!) and swimming (when I don’t really need any basal and don’t want to test it’s waterproofness).

Your HbA1C won’t be too affected. Hopefully you’d cut out the nighttime hypos and that would be a good thing - far better to be in the 40s and safe, then 39 and having hypos.

And - bugbear of mine - all pumps are “tethered”. I hate that word because it implies a ball and chain when actually you gain freedom. I’d choose a tubed pump over a patch pump every time. They’re better quality IMO and have better features @JamesL Also, you don’t have to put up with a pod/patch being in the same place for three days. I like to move my pump round depending on what I’m wearing and doing.

 

[JamesL]

Hi and welcome @JamesL

I'd agree with everything that @SB2015 has put up there but will just add something re pumps and exercise. I do a little bit less exercise than you but again with a mix of running and cycling. I actually tend to take the pump off when I'm running but keep it on when cycling. A lot of it is down to finding exactly what works for you but I've found that it gives me a great deal more flexibility than MDI. The ability to do a quick Libre scan, figure out that I need an extra half a unit and deliver that with a couple of button presses makes life so much easier than injections

Hi and welcome @JamesL

I'd agree with everything that @SB2015 has put up there but will just add something re pumps and exercise. I do a little bit less exercise than you but again with a mix of running and cycling. I actually tend to take the pump off when I'm running but keep it on when cycling. A lot of it is down to finding exactly what works for you but I've found that it gives me a great deal more flexibility than MDI. The ability to do a quick Libre scan, figure out that I need an extra half a unit and deliver that with a couple of button presses makes life so much easier than injections.

Hi @Rob Oldfield - thank you for your message.

I was reading about whether removing the pump could be a good option and this looks to depend on duration and intensity of exercise perhaps? If I were on a longer run (c. 90 mins) - would I be right to say that it is likely that I would need to keep my pump on but adjust the basal rate (as intensity would be lower too)? There is certainly a lot of reading I need to do but exactly as you say - being able to be flexible and reactive to changes through a quick scan of the Libre would really help and hopefully allow me to focus on things other than T1 in my day 🙂

 

[Thebearcametoo]

Tresiba can struggle to deal with exercise as it has such a long profile so is less adaptable. A pump may well give you the flexibility you need but it’s also possible that a different basal would suit you better than tresiba.

Your HBA1C is very good but suggests you have really tight control and are more at risk of hypos. My kid’s lowest HBA1C was 41 and that included so many hypos it was horrible. There is a good argument that lower isn’t better once you get below about 45-46. We were told that the target is 48. Typically on a pump he’s around 43-45. So if your HBA1C is a little higher on a pump that’s not necessarily a bad thing.

 

[Rob Oldfield]

Hi @Rob Oldfield - thank you for your message.

I was reading about whether removing the pump could be a good option and this looks to depend on duration and intensity of exercise perhaps? If I were on a longer run (c. 90 mins) - would I be right to say that it is likely that I would need to keep my pump on but adjust the basal rate (as intensity would be lower too)? There is certainly a lot of reading I need to do but exactly as you say - being able to be flexible and reactive to changes through a quick scan of the Libre would really help and hopefully allow me to focus on things other than T1 in my day 🙂

There's quite a lot of info out there re pumping and running e.g. this thread over in the Exercise/Sport section of this site https://forum.diabetes.org.uk/boards/threads/marathon-training-and-carrying-insulin.103435/

You're certainly right that duration and intensity are key.

One of the things I point at in there is this document https://extod.org/downloads/Narendran-DTN-Exercise.pdf which I was sent by my specialist nurse - think it's definitely a good base to work on.

 

[nonethewiser]

Omnipod Dash user myself, been pumping for last 10 years & could not go back to mdi unless it was necessary.

Big advantage of pump over mdi is basal delivery, pens could never delivery basal in the way that body requires it, where as pumps can as you can use multiple basal rates over 24hrs, even have different basal delivery on active & inactive days. Not only that in times of sickness it works far better than injections, plus of course no needles into skin apart from cannula insertion. Have far less hypos hypers on pump than on mdi, even less now since using libre device.

Seriously mate you go for it, so very few people go back to injections after starting on pumps so that says something, heard that said from own consultant at time.

 

[helli]

The only reason for taking off a pump would be if you think you are likely to fall on it and damage it (or if you are doing serious contact sports such as martial arts).
I have used both a tubed pump and a patch pump. I did feel tethered to the tubed pump which is why I pushed for the patch one. Yes, you can put the cannula where you want and the move the tubed pump around but you need to find somewhere to put it. When I went to the gym it would drive me crazy - if I clipped it to the front of my leggings, it got in the way when I did tricep pull downs. If I clipped it to the side of my leggings, it would get in the way when I did bicep curls. I would try clipping it to my bra but it would get in the way when I did lats. When I went climbing, I was worried it would come unclipped (it did once and was dangling in the tube as I ascended a steep overhang). Plus it was always on display.
I appreciate it is a personal preference but I find the patch pump much more discrete and placing it on my abdomen (below the waist) it never gets in the way when I do weights and doesn't jiggle around when I run. Instead of removing the pump, I just suspend (or reduce the basal).

 

[JamesL]

Hi and welcome.

Sorry to hear you are struggling with night time hypos. I don't have experience of pumps to give you the input you want but just wanted to mention a couple of things which might help you in the mean time.
Firstly, are you aware that Libre suffers from what we refer to as "Compression Lows"? This is where you turn over i your sleep and lie on the arm with the Libre sensor causing the sensor to apply pressure to the tissue underneath which is sampling glucose. This usually causes it to dip and read low. If the alarm goes off during the night, indicating your levels are dropping, it is always a good idea to double check with a finger prick before treating because often it is one of these "compression lows" rather than an actual hypo. Apologies if you are aware of this but unfortunately many people are not.

Secondly, if they are genuine lows, then have you tried Levemir as an alternative to Tresiba. I would never manage with Tresiba because it provides a fairly uniform amount of basal insulin throughout the day and night and my liver doesn't do uniform. It needs much more insulin in the morning and much less at night and I am certainly not the only one. Levemir allows me to adjust my daytime and night time basal insulin doses independently. It is much more flexible than Tresiba and I can adjust it downwards if I have had more exercise that day or up, if I was more sedentary and it responds more or less in real time. I don't have a structured routine to my days, so Levemir is great for allowing me to tailor my basal insulin to my lifestyle and what my body needs. I absolutely love it! I currently take 22 units in the morning and 0 at night because I am doing a lot of physical activity every day but usually it is about 22-24 in the morning and 3-5 units at night, which as you can see is quite a disparity between my day and night needs. I can also vary the time I take each dose according to what my body needs. At the moment I take it before I get out of bed and when I do to bed, so not a straight 12 hour split, but occasionally I go through spells where I start getting a rise after my evening meal, so I can bring my evening dose forwards and inject it at say 7pm instead of 11pm to help with that. Obviously a pump will fine tune to your basal needs hour by hour, whereas this is just 2 doses morning and night but because it doesn't have a flat profile, adjusting the time you take it can give you a bit of extra adjustment, so that it's spike coincides with when you need it most. It is an option to discuss with your nurse whilst you wait for an answer about a pump if you haven't already tried it.

As regards your HbA1c and maintaining it that low, I think you should be considering that that result is probably unhealthily low if you are suffering genuine hypos almost every night. My consultant is delighted with any reading in the low 50s or high 40s and I believe there is recent evidence which suggests that there is not significant benefit in getting it below 53 I think. Your Libre "Time is Range" is a much better assessment of how good your diabetes management is these days, so don't be sad to potentially relinquish that HbA1c of 39, because it may not be doing you any favours.

Anyway, those are just my thoughts on the info you provided. I wish you lots of luck in getting a pump if that is what you are set on and I hope you find it beneficial in the long run, even if it might be a bit frustrating and even more "band width" required in the short term getting it set up.

Hi @rebrascora, thank you for your reply!

I wasn’t initially aware of the compression lows when the night hypos first became a major problem but researched and thought that this could be what is really causing the sensor to detect so many night lows, however it doesn’t appear to be the case as I very rarely sleep on that side.

I have only recently switched to Tresiba from Lantus in a bid to help with the night lows about three months ago but seemingly to no avail. I do think that flexibility in my basal is going to be key to whichever route I do take next - as you say with Levemir for example you do have that additional freedom to react based on your blood sugars at that time.

Definitely noted regards the Hba1c and interesting to hear that <53 the benefits are perhaps not incremental when continuing to work down.

My time in range fluctuates with my 90 day average currently 77%.

Thank you very much for your well wishes, I will be sure to update as my journey continues - wishing you the best

 

[JamesL]

Tresiba can struggle to deal with exercise as it has such a long profile so is less adaptable. A pump may well give you the flexibility you need but it’s also possible that a different basal would suit you better than tresiba.

Your HBA1C is very good but suggests you have really tight control and are more at risk of hypos. My kid’s lowest HBA1C was 41 and that included so many hypos it was horrible. There is a good argument that lower isn’t better once you get below about 45-46. We were told that the target is 48. Typically on a pump he’s around 43-45. So if your HBA1C is a little higher on a pump that’s not necessarily a bad thing.

Hi @Thebearcametoo, thanks for your reply and also very interesting to hear further thoughts on both the Tresiba and Hba1c.

It feels as though perhaps the Tresiba is not the greatest fit for my personal circumstances, based on current feedback which is super useful to know and something I wouldn’t have necessarily known without this forum!

I am going to also mention to my nurse regards Hba1c and what I should be shooting for; based on the hypos I am having currently and whether there are really many benefits for striving to be say <45?

How does your little one find the pump overall? 🙂

 

[JamesL]

Hi @JamesL Like everything, there are pros and cons, and what suits one person might not suit another, so it’s an individual decision.

I got a pump almost 20 years ago because of nighttime hypos. My insulin needs vary greatly through the night so a pump allows me to match my basal needs better. It does take more work though, and it needs a fair bit of user input as basal needs often change. A pump is just another insulin delivery system - it’s main benefit IMO is the ability to fine tune basal. It’s also convenient for illness when you can just set a temp basal rate, and for bolusing discreetly (my pump is controlled via my phone so that makes it simple).

I wear it for all exercise except things like skating when I’m worried I’d fall and smash it (!) and swimming (when I don’t really need any basal and don’t want to test it’s waterproofness).

Your HbA1C won’t be too affected. Hopefully you’d cut out the nighttime hypos and that would be a good thing - far better to be in the 40s and safe, then 39 and having hypos.

And - bugbear of mine - all pumps are “tethered”. I hate that word because it implies a ball and chain when actually you gain freedom. I’d choose a tubed pump over a patch pump every time. They’re better quality IMO and have better features @JamesL Also, you don’t have to put up with a pod/patch being in the same place for three days. I like to move my pump round depending on what I’m wearing and doing.

Hi @Inka, appreciate your reply 🙂.

It sounds as though a pump could well be the best way forward in order to really align my insulin dosing with my bodies specific night time requirements.

I completely agree regards your view on the Hba1c- if I was offered 45 in exchange for running slightly higher and removing night hypos I would certainly take it, especially given everyone’s feedback on the diminishing returns on Hba1c once in mid 40s.

I agree on the term tethered, I don’t like the term - apologies for referencing the tubed pumps as such, a newbie mistake. Certainly more for me to consider regards the tubed options - where is your favoured location for it and how does that affect the tubing and handset? 🙂

 

[JamesL]

There's quite a lot of info out there re pumping and running e.g. this thread over in the Exercise/Sport section of this site https://forum.diabetes.org.uk/boards/threads/marathon-training-and-carrying-insulin.103435/

You're certainly right that duration and intensity are key.

One of the things I point at in there is this document https://extod.org/downloads/Narendran-DTN-Exercise.pdf which I was sent by my specialist nurse - think it's definitely a good base to work on.

Thanks @Rob Oldfield - this looks super helpful, I will deep dive on the information on here if heading down the pump route 🙂

 

[JamesL]

Omnipod Dash user myself, been pumping for last 10 years & could not go back to mdi unless it was necessary.

Big advantage of pump over mdi is basal delivery, pens could never delivery basal in the way that body requires it, where as pumps can as you can use multiple basal rates over 24hrs, even have different basal delivery on active & inactive days. Not only that in times of sickness it works far better than injections, plus of course no needles into skin apart from cannula insertion. Have far less hypos hypers on pump than on mdi, even less now since using libre device.

Seriously mate you go for it, so very few people go back to injections after starting on pumps so that says something, heard that said from own consultant at time.

Hi @nonethewiser - thanks for your feedback 🙂

I think this is what really says a lot about pumps that I find almost no instances of people switching back to MDI after moving across to a pump.

It will be one of the questions that I ask my DN next time I see them and also ask, for those that do switch back, why that typically is.

Would you plan to move across to the Omnipod 5 if that becomes available pal?

 

[JamesL]

The only reason for taking off a pump would be if you think you are likely to fall on it and damage it (or if you are doing serious contact sports such as martial arts).
I have used both a tubed pump and a patch pump. I did feel tethered to the tubed pump which is why I pushed for the patch one. Yes, you can put the cannula where you want and the move the tubed pump around but you need to find somewhere to put it. When I went to the gym it would drive me crazy - if I clipped it to the front of my leggings, it got in the way when I did tricep pull downs. If I clipped it to the side of my leggings, it would get in the way when I did bicep curls. I would try clipping it to my bra but it would get in the way when I did lats. When I went climbing, I was worried it would come unclipped (it did once and was dangling in the tube as I ascended a steep overhang). Plus it was always on display.
I appreciate it is a personal preference but I find the patch pump much more discrete and placing it on my abdomen (below the waist) it never gets in the way when I do weights and doesn't jiggle around when I run. Instead of removing the pump, I just suspend (or reduce the basal).

Thanks @helli - great to hear your thoughts having had both tubed and patch pumps.

There is a bit of a mental thing for me too with regards to preferring the patch in that it can be off display, the tubed option, in my very limited knowledge, seems as though it would be to visible and I, whilst am always open o discuss my T1 with any one who asks, would still prefer to keep the pump as discreet as possible.

Similar to the Libre I try to keep that high on the back of my arm and wear loose sleeves when I can to minimise visual impact 🙂

Maybe I should change my mental approach and embrace it more?!

 

[Proud to be erratic]

Hi @Thebearcametoo, thanks for your reply and also very interesting to hear further thoughts on both the Tresiba and Hba1c.

It feels as though perhaps the Tresiba is not the greatest fit for my personal circumstances, based on current feedback which is super useful to know and something I wouldn’t have necessarily known without this forum!

I am going to also mention to my nurse regards Hba1c and what I should be shooting for; based on the hypos I am having currently and whether there are really many benefits for striving to be say <45?

How does your little one find the pump overall? 🙂

I'm wary about commenting here; my D experience is relatively short. But I wonder if Tresiba is getting a beating here - unfairly.

Yes, Tresiba has a long profile, c.40 hrs and today's dose is topping up yesterday's dose. But its strength is because of that apparent inflexibility - its stability. Once my Tresiba is correct as my basal I can depend on it to give me steady, hypo free nights. Of course, realistically, no basal will be optimum at a fixed dose by day as well as night; we have different basal needs across 24 hrs. So I use my quick acting bolus to regulate my daytime activity. Insulin is insulin and your body doesn't know that some insulin is slow release and other insulin is less so.

So it seems to me that juggling both bolus and shorter life basal is creating an extra layer of complication. I listened carefully during my recent DAFNE course to the daily analysis of our DAFNE diaries and there was regular discussion by the DSN with others about whether to alter their bolus ratios or their Levermir basal; invariably there was no definitive answer. Invariably the DSN said each should make up their own mind - BUT also stressed don't change both at the same time.

I don't have that quandary. If my nights start drifting away from level I review my basal Tresiba; I try to identify why, of course. By day I just correct when high and review my bolus ratios if either activity or certain foods are disrupting my BG. Given that there some 42 known (described) factors that can affect our BG, many of which come from left or right flank with stealth and great camouflage, what caused any one BG variation is often a mystery anyway. Meanwhile, if lowish I must respond regardless: either snack, or possibly stop doing what I was doing and sit snugly in the warm (and hope) while frequently scanning! If going high or already high my options are, broadly, exercise and/or greater activity (same thing really) OR take a bolus correction and anticipate it will be sorted in the next 4 hrs. If not sorted, more activity or bolus.

Tresiba can be very useful for longer term stability with less decision making. NovoRapid is OK, just, for me and I've got used to its response "lag", so haven't changed.

Edited to add: as I understand matters, if I were on a pump, then adjustments of the pump bolus insulin, alone, would be the only option anyway - without coming off the pump. There would be different feed rates for different times, of course, but still only adjusting one type of insulin.

 

[everydayupsanddowns]

Welcome to the forum @JamesL

Sounds like a pump would be a great fit for you, and there really isnt a ‘bad’ first option, as the most significant benefits of more accurate dosing, basal profiles, temporary basal rates, and extended bolus options apply to them all.

Like you I was a bit ‘pump averse‘ to begin with, and in fact it took me several years to come to the point where I was ready to try it for a year or so and see if it was everything everyone else said it was.

I‘m on my 3rd pump now, and like @nonethewiser wouldn’t want to go back to MDI if i can help it.

Regarding your HbA1c, well done on your successes so far, but don’t stress if you find it needs to raise a little. The protective benefits of a low HbA1c are very much levelling off below 52-48mmol/L. and while there are slight risk reductions below that, these are massively offset by the potential harms of repeated mild/moderate hypoglycaemia - including cardiac arrythmia, impaired hypo awareness, severe hypos, and even coma and death.

I spent far too many years preferring to run on the low side, and am paying the price now with needing extra care to keep my hypo warning signs intact.

The expert consensus on Time in Range is very helpful here.

Time In Range - useful for Libre / CGM wearers

I've been meaning to post this for ages, but kept forgetting! At the ADA this year the international consensus paper on TIR (time in range) was published by a panel of experts with a huge amount of knowledge and expertise in supporting people to use continuous data to help manage their...

forum.diabetes.org.uk

You can spend more time than you think above target and still maintain protection against long term nasties 🙂

 

[Thebearcametoo]

I'm wary about commenting here; my D experience is relatively short. But I wonder if Tresiba is getting a beating here - unfairly.

Yes, Tresiba has a long profile, c.40 hrs and today's dose is topping up yesterday's dose. But its strength is because of that apparent inflexibility - its stability. Once my Tresiba is correct as my basal I can depend on it to give me steady, hypo free nights. Of course, realistically, no basal will be optimum at a fixed dose by day as well as night; we have different basal needs across 24 hrs. So I use my quick acting bolus to regulate my daytime activity. Insulin is insulin and your body doesn't know that some insulin is slow release and other insulin is less so.

So it seems to me that juggling both bolus and shorter life basal is creating an extra layer of complication. I listened carefully during my recent DAFNE course to the daily analysis of our DAFNE diaries and there was regular discussion by the DSN with others about whether to alter their bolus ratios or their Levermir basal; invariably there was no definitive answer. Invariably the DSN said each should make up their own mind - BUT also stressed don't change both at the same time.

I don't have that quandary. If my nights start drifting away from level I review my basal Tresiba; I try to identify why, of course. By day I just correct when high and review my bolus ratios if either activity or certain foods are disrupting my BG. Given that there some 42 known (described) factors that can affect our BG, many of which come from left or right flank with stealth and great camouflage, what caused any one BG variation is often a mystery anyway. Meanwhile, if lowish I must respond regardless: either snack, or possibly stop doing what I was doing and sit snugly in the warm (and hope) while frequently scanning! If going high or already high my options are, broadly, exercise and/or greater activity (same thing really) OR take a bolus correction and anticipate it will be sorted in the next 4 hrs. If not sorted, more activity or bolus.

Tresiba can be very useful for longer term stability with less decision making. NovoRapid is OK, just, for me and I've got used to its response "lag", so haven't changed.

Edited to add: as I understand matters, if I were on a pump, then adjustments of the pump bolus insulin, alone, would be the only option anyway - without coming off the pump. There would be different feed rates for different times, of course, but still only adjusting one type of insulin.

Tresiba is great. (My kid preferred it to Lantus.) But it can struggle with exercise so mixing in the amount of exercise can make it tricky

Hi @Thebearcametoo, thanks for your reply and also very interesting to hear further thoughts on both the Tresiba and Hba1c.

It feels as though perhaps the Tresiba is not the greatest fit for my personal circumstances, based on current feedback which is super useful to know and something I wouldn’t have necessarily known without this forum!

I am going to also mention to my nurse regards Hba1c and what I should be shooting for; based on the hypos I am having currently and whether there are really many benefits for striving to be say <45?

How does your little one find the pump overall? 🙂

He loves the pump more than MDI but still finds it a faff to change the cannula etc. He has tslim and dexcom so it’s looped and that helps massively. He takes the pump off for swimming and trampoline but everything else it stays on. He has a waist belt thing with pouches in that can go under his clothes which fits his phone and pump so that it’s snug against his body and not likely to be dropped. Very helpful for riding especially. Usually it’s just clipped to his waistband. He can get his pump out and put his carbs in more easily than doing injections which makes eating in public easier. And the adjustable basal makes a big difference. He still sometimes takes a break for a few weeks and goes back to MDI if the feeling of being reliant on tech gets too much but he’s 12 so everything gets a bit much sometimes.