Omnipod Insulin Types

[Tom1982]

Sleep is great, its not a setting but the system manages overnight.

Exercise only sets the target lower, which may work for some depends if the aim is to avoid low.
For rugby I never use it unless we are having a cardio heavy session. I am more likely to go high with rugby, especially matches.
I do use it for walking, hovering etc. as its quite good. As I remember the lows could be an issue for her, also pausing the insulin (only in manual mode) is handy too.

How come your levels go up with exercise? Or more accurately how come hers go down!? It’s like watching a battery drain down. Literally 15mmols to 5 in 20 minutes!!

 

[PhoebeC]

How come your levels go up with exercise? Or more accurately how come hers go down!? It’s like watching a battery drain down. Literally 15mmols to 5 in 20 minutes!!

It depends on the type of exercise, cardio only would drop it for me, in most cases.

Again it’s diabetes so it’s all about all the other factors, time of day, food and insulin before, how much sleep etc.

I will try and find something fact based for you. Will take a look at the DAFNE
But my understanding is it’s based on the type of exercise and different hormones joining the party. There’s flexibility, anaerobic and aerobic which all have a different impact on glucose levels.
And there’s 3 hormones linked to exercise - insulin, glucagon and stress hormones (things like adrenaline).

Like adrenaline, which for me (and I believe it’s commonly for t1s) increases glucose levels this can be caused by stress, certain exercise, nervousness. During rugby matches I will be excited and nervous so my levels will raise also once you’ve been smashed or tackled by the opposition then naturally adrenaline joins in. I always have high sugars during matches (as do other t1s I’ve played) then it crashes afterwards.

I don’t think your daughter will be doing any weight lifting, resistance training, contact sport so her going low makes sense.

 

[helli]

How come your levels go up with exercise? Or more accurately how come hers go down!? It’s like watching a battery drain down. Literally 15mmols to 5 in 20 minutes!!

The way I understand it, there are two things that happen during exercise that affect our BG
- our liver dumps more glucose to give us the energy we need
- our body because more efficient at using insulin

The second point takes a bit longer to kick in. So, if we were doing stop-start kind of exercise (like playing a team sport where we have short spurts of running followed by a minute or two of waiting for the ball to come our way), the liver dump happens but the insulin efficiency less so.
And, of course, other things that affect our BG when we are not exercising do not stop. So, the stress of losing or having your team mates relying on you or seeing another rugby player charge at you, will cause more liver dumping.

I don't play competitive sports but I can see the difference when I cycle.
- if I pootle along a flat tow path chatting to my mates, there is little impact to my BG
- if I go flat out at a Spin class for 45 minutes, my BG plummets.
- if I slog up a steep hill against the wind and rain, my BG rockets.

As different exercise has different effects to BG, I struggle to understand the "exercise mode" on HCL. I use my pump in a manual mode so need to make the adjustments to basal myself. I have different temporary basals depending up on what I am going to do (annoyingly I need to make the basal change before I start exercise)
- if I am Spinning, I suspend my basal
- if I am climbing, I increase my basal by 30%
- if I am hiking for 3 to 4 hours, I reduce my basal by 50%
- if I am walking to the shops, gardening, doing the housework, ... I don't change my basal

These basal changes are personal. I know others who need to reduce their basal for the last category.
But, I imagine the exercise a young girl does is more like constant running around which is closer to the Spin class for me.

Edited to add: as insulin is much more efficient when exercising, it is also important to consider Insulin on Board (IOB). I try to avoid bolusing 4 hours before exercise. Or, if I am bolusing for food, I significantly reduce it if I am about to exercise.
If I did a Spin class half hour after lunch with my usual bolus dose, I would not be surprised to see my BG plummet 6 mmol/l in 15 minutes. Not sure if I would expect it to drop from 15 mmol/l but then, I would never trust 15mmol/l on a CGM - they always overegg highs for me so I always check anything higher than 10mmol/l with a finger prick.

 

[Tom1982]

Ah that makes sense! She goes high every time she comes football with me. Diabetes really is fun ain’t it! Oh and it’s made even less fun by Novorapid. How anyone uses this rubbish is beyond me.

 

[Inka]

Ah that makes sense! She goes high every time she comes football with me. Diabetes really is fun ain’t it! Oh and it’s made even less fun by Novorapid. How anyone uses this rubbish is beyond me.

I swapped to Novorapid and think it’s great @Tom1982 It’s a balance and I chose NR for that balance.

I’ve had Type 1 three decades and started off on regular insulin, which you had to inject further in advance than NR. The introduction of the analogues like NR and Humalog was not without controversy, partly because of the hype (they used to say you could inject them right before you ate) and the safety concerns leading on from the introduction of GM ‘human’ insulin. You can Google if you’re interested. IMO there’s a sweet spot between convenience and safety and comfort. Manufacturing very fast insulin like Fiasp comes with its own risks and, as we’ve seen, it too has its annoyances (eg needing extra if blood sugar is very high). You’ve also seen the skin issues it can cause.

We all have our insulin preferences and importantly, it’s crucial a choice of insulin remains. See how upset people are about Levemir being discontinued. The thinking is that Tresiba is ‘better’ because it lasts for 42hrs or whatever it is and only needs to be injected once a day. But, some people don’t give a **** about that because twice daily injections gives them the flexibility they need. Tresiba could never do that.

Bit of a ramble there but Novorapid is NOT ‘rubbish’ and many people are very happy with it and would choose it over Fiasp every time.

 

[Tom1982]

I swapped to Novorapid and think it’s great @Tom1982 It’s a balance and I chose NR for that balance.

I’ve had Type 1 three decades and started off on regular insulin, which you had to inject further in advance than NR. The introduction of the analogues like NR and Humalog was not without controversy, partly because of the hype (they used to say you could inject them right before you ate) and the safety concerns leading on from the introduction of GM ‘human’ insulin. You can Google if you’re interested. IMO there’s a sweet spot between convenience and safety and comfort. Manufacturing very fast insulin like Fiasp comes with its own risks and, as we’ve seen, it too has its annoyances (eg needing extra if blood sugar is very high). You’ve also seen the skin issues it can cause.

We all have our insulin preferences and importantly, it’s crucial a choice of insulin remains. See how upset people are about Levemir being discontinued. The thinking is that Tresiba is ‘better’ because it lasts for 42hrs or whatever it is and only needs to be injected once a day. But, some people don’t give a **** about that because twice daily injections gives them the flexibility they need. Tresiba could never do that.

Bit of a ramble there but Novorapid is NOT ‘rubbish’ and many people are very happy with it and would choose it over Fiasp every time.

I suppose it’s just a case of being a totally different profile. Did you find you needed more on Novorapid? Seem to be using loads more than usual and do you wait 15 minutes or more to eat or is that just us at the moment?

 

[Inka]

I swapped from Humalog and I haven’t found I need more Novorapid @Tom1982 I’d guess that’s more likely to be caused by growth in your daughter’s case. Yes, they have a different profile of action (NR and Fiasp) so it’s worth getting a feel for that.

On NR, assuming my blood sugar is in range, I inject 30mins before breakfast, 10 mins before lunch, and just before eating my evening meal. I don’t find this a hardship. I do stuff while I wait for my breakfast (put my make on, do my hair, pack lunch) so the time passes very quickly.

The truth is, there’s no magic insulin that covers all bases. It’s all a question of balancing things and finding the one that’s best overall. That’s not always the newest, or fastest or one that needs the least number of injections. ‘Fast’ has been a common selling point for bolus insulins, but it’s usually either hype or has some disadvantage they don’t reveal.

 

[Richard F]

Cheers Richard. That’s the exact same problem we had. They were suggesting an allergy to the cannula material and I just assumed that was it. But the more I think about it the less convinced I am. The small bump and levels shooting up, so annoying.

I reckon rather than an allergy to the cannula, it's about the amount of insulin pumped through one site. (only my theory not proven)

So I'm changing my pods based on insulin pumped as much as elapsed time. Around 50u seems optimum, typically 48 hrs. If I'm having a carb heavy, low exertion time, I may reach 50u quicker therefore consider changing earlier and vice-versa.

60-70u on one pod and I'm pushing the boundaries.

 

[Tom1982]

I reckon rather than an allergy to the cannula, it's about the amount of insulin pumped through one site. (only my theory not proven)

So I'm changing my pods based on insulin pumped as much as elapsed time. Around 50u seems optimum, typically 48 hrs. If I'm having a carb heavy, low exertion time, I may reach 50u quicker therefore consider changing earlier and vice-versa.

60-70u on one pod and I'm pushing the boundaries.

Very interesting and not really something we’d considered. In a weird way reassuring to know at least one other person has the same/similar issues we do.

 

[rebrascora]

One of the reasons I don't fancy a pump is the idea of all that insulin going into one spot. I split any dose bigger than 10u and inject into 2 different sites. This may be an unfounded concern but I would rather spread the insulin into smaller pockets for absorption than having it all going into the same place. So for instance my morning dose of Levemir is 22 units so I split it into 2 doses of 11 and inject one into each buttock. That may be overkill on my part but there is potential benefit in more even absorption by splitting it over 2 sites. I think medical professionals have a thing about more injections being a big issue for patients when better results far outweigh the very minor inconvenience of an extra jab or two.

I appreciate that a pump is trickling that basal cover in over a longer period of time so it isn't the same as injecting 22 units at one go or even 11, but I still have reservations about it, especially when you talk about 50 units being about the optimum one site is happy with. I appreciate that that will be different for everyone but it does make you stop and think!

 

[helli]

One of the reasons I don't fancy a pump is the idea of all that insulin going into one spot. I split any dose bigger than 10u and inject into 2 different sites. This may be an unfounded concern but I would rather spread the insulin into smaller pockets for absorption than having it all going into the same place. So for instance my morning dose of Levemir is 22 units so I split it into 2 doses of 11 and inject one into each buttock.

With a pump, you would not have a dose of 22 unit at one time. Your basal is given to you throughout the day at the rate that has been set up for that time of day.
Plus, you have option to split a bolus over longer periods. For example, I avoid giving myself a bolus higher than 4 units in one go. Instead, I request a bolus of 5 units with half of it to be given now and the remainder to be bolused in 0.05 unit "microdoses" over the next 30 minutes.

I think the limit of 50 units total at one site is unusual. Pumps are designed to contain 200 or 300 units and be able to deliver that much insulin between pump changes. I never use that much before changing a pump but restricting the change to 50 units suggests to me (as someone without any medical training) that there is an absorption problem. This may be due to the cannula (one of the problems with a patch pump is that you cannot change the cannula unlike a tubed pump) or the location of the pump.

My team would be concerned by the cost if I was changing my pump every two days. They do not budget for this many pump changes.

 

[Inka]

If it helps @rebrascora , when I was pregnant and had huge insulin resistance, my total daily dose was more than 50 units and I changed my cannula every 3 days like normal.

I do think maintaining good absorption is a big issue and often one that’s overlooked (why can’t they design an insulin that doesn’t cause these problems rather than be obsessed with finding faster and faster insulins?). However, I think it applies to both injections and pumps.

 

[Tom1982]

With a pump, you would not have a dose of 22 unit at one time. Your basal is given to you throughout the day at the rate that has been set up for that time of day.
Plus, you have option to split a bolus over longer periods. For example, I avoid giving myself a bolus higher than 4 units in one go. Instead, I request a bolus of 5 units with half of it to be given now and the remainder to be bolused in 0.05 unit "microdoses" over the next 30 minutes.

I think the limit of 50 units total at one site is unusual. Pumps are designed to contain 200 or 300 units and be able to deliver that much insulin between pump changes. I never use that much before changing a pump but restricting the change to 50 units suggests to me (as someone without any medical training) that there is an absorption problem. This may be due to the cannula (one of the problems with a patch pump is that you cannot change the cannula unlike a tubed pump) or the location of the pump.

My team would be concerned by the cost if I was changing my pump every two days. They do not budget for this many pump changes.

How many time slots do you have in a day with regards to different basal rates?

 

[helli]

How many time slots do you have in a day with regards to different basal rates?

I haven’t counted but about 7 or 8 different basal rates throughout a day.
And then I have three different basal profiles.

 

[PhoebeC]

I have 6 different basal time slots, and 3 carb ratio settings each day.

 

[Richard F]

With a pump, you would not have a dose of 22 unit at one time. Your basal is given to you throughout the day at the rate that has been set up for that time of day.
Plus, you have option to split a bolus over longer periods. For example, I avoid giving myself a bolus higher than 4 units in one go. Instead, I request a bolus of 5 units with half of it to be given now and the remainder to be bolused in 0.05 unit "microdoses" over the next 30 minutes.

I think the limit of 50 units total at one site is unusual. Pumps are designed to contain 200 or 300 units and be able to deliver that much insulin between pump changes. I never use that much before changing a pump but restricting the change to 50 units suggests to me (as someone without any medical training) that there is an absorption problem. This may be due to the cannula (one of the problems with a patch pump is that you cannot change the cannula unlike a tubed pump) or the location of the pump.

My team would be concerned by the cost if I was changing my pump every two days. They do not budget for this many pump changes.

It was me that struggles with over 50u per site. And yes I think I do have an an absorption problem. If I could use more sites (back, abdomen, buttocks and thighs) then the pod lasts longer (as it did with dash)

Due to the HCL connectivity issues with Libre 2+ I can only reliably use one one arm, and therefore not much fatty tissue. I find that if I lose connectivity it often causes a pod failure which means I'm forced into changing early often at random and inconvenient times. This became a real problem for me when I switched to HCL last year.

Top and tailing, below, above, inside, outside I manage to find enough different sites during the 15 day libre life then I change arms.

Not ideal. Sometimes I wonder if Dexcom would give me more flexibility?

I don't know how common this is but I've been authorised by the team and marked as a 'high user' by omnipod. I'm not sure how the funding works, or whether the extra is picked up the NHS or omnipod. (I.E. do the NHS pay per pack or per month?)
It's a known problem, one of the diabetic team suggested it when I was struggling to maintain control on day 3. I notice in the omnipod blurb they state that the pods last 'up to' 3 days.

Does anyone else get this hard red lump (a few mm across) at omnipod canular sites?

 

[Bloden]

Ah that makes sense! She goes high every time she comes football with me. Diabetes really is fun ain’t it! Oh and it’s made even less fun by Novorapid. How anyone uses this rubbish is beyond me.

I agree! Been on it now for 3 years. The only way I can get my favourite - Apidra - is to go back to injections. So annoying!

 

[Bloden]

Sometimes I wonder if Dexcom would give me more flexibility?

I use the Dexcom G6 and Omnipod 5. I've recently started putting the Pod and sensor wherever suits me (ie not next to each other or on the same side of my body, as recommended) and connectivity has not been an issue at all. I was sick of wrecking the skin on my arms!

 

[Tom1982]

I agree! Been on it now for 3 years. The only way I can get my favourite - Apidra - is to go back to injections. So annoying!

She’s been prescribed Lyumjev now. Ever tried it?

 

[Bloden]

She’s been prescribed Lyumjev now. Ever tried it?

No, I haven’t. @Flower switched from Humalog to Ljumjev in her pump and said at the time how much better it was. I hope it works for your daughter too.