Hybrid, closed loop or manual

[Lottieb2613]

Hi guys,
I was having a think over the weekend as the time to renew my pump is getting closer and i had a thought. It seems there is a lot of new tech pushing us into the hybrid close loop. My question is - how is everyone feeling? Some people may feel that the hybrid close lopp is the way to go and others may find that injecting/pumping manually with blood checks is best. At the moment i guess im falling into the close loop system being the best for myself (at the momemnt anyway!) where i use my libre for blood checks and the bolus wizard on my pump (omnipod dash). I love not having to do the math as much and not having to inject/manually check bloods but having the machine do it all is a little out of my comfort zone. How are you guys feeling? Feel free to add any comments or your experiences as well!

 

[Inka]

I turned a loop down a couple of years ago. I prefer to control my pump (Dana i) myself. However, I do have a Dexcom G7 and I find that extremely helpful. My consultant said that if you’re managing 85% TIR then a loop isn’t going to make that much difference. When I read about people having to put an Exercise setting on their loop and fiddle with the settings like target blood sugar, I think why bother? Better to do it myself.

 

[Saoirse]

Can I just say that on HCL you *absolutely* need to carb count and pretty accurately too if you want the loop to work well. Yes it will smooth out some bumps, but is not ‘becoming a new self sufficient pancreas’. A lot of people are going to be very disappointed if they are taking on HCL assuming it does the job of a real pancreas.

 

[SB2015]

I have used HCL for four years now. I agree with @Saoirse You do still need to carb count although the system will iron out errors a bit, but the more accurate the better.

When I was on a pump plus sensor, I needed to fiddle a lot with it in order to do exercise, and timing the changes that I made and then keeping reductions going after I had completed the exercise. I now set a higher target about and hour before I start and run it until the end of my session, when coffee and cake sorts me out for the walk home.

I find that I have long periods where I can basically ignore my diabetes. If I eat later than I would have done before, I am happy to go to bed with a slightly higher BG knowing that I will wake to a flat line on target in the morning. I don’t even bother to check my levels when I go to the loo in the night (it’s an age thing!!), I just know that things will be level. I am also confident that I will get an alarm if there is anything untoward, and then get more involved. It took me a good month to trust the system, but now I would not want to go back. It has transformed my life both physically and mentally and I am firmly in the camp of pro HCL for those that want it, so very pleas3d to see Partha Kar’s report that the switch over to HCL, for those that want it is cost neutral and should be available to any on an appropriate pump with compatible sensor.

 

[Lottieb2613]

Can I just say that on HCL you *absolutely* need to carb count and pretty accurately too if you want the loop to work well. Yes it will smooth out some bumps, but is not ‘becoming a new self sufficient pancreas’. A lot of people are going to be very disappointed if they are taking on HCL assuming it does the job of a real pancreas.

When I spoke to the Medtronic team they told me I don’t need to count as much anymore if at all? Is this not right?

 

[SB2015]

When I spoke to the Medtronic team they told me I don’t need to count as much anymore if at all? Is this not right?

!!!!!!!!!!!!
I have just been reading the manual in preparation for my new pump and switch to the new sensors. It makes very clear that we still need to carb count and bolus. Their training modules also make this clear. The system will iron out slight errors, it it is very clear that we still need to do effective boluses.
I would get back to them and clarify things. I suspect the person you spoke to does not actually use the system!!!

 

[Lottieb2613]

!!!!!!!!!!!!
I have just been reading the manual in preparation for my new pump and switch to the new sensors. It makes very clear that we still need to carb count and bolus. Their training modules also make this clear. The system will iron out slight errors, it it is very clear that we still need to do effective boluses.
I would get back to them and clarify things. I suspect the person you spoke to does not actually use the system!!!

Omg thank you so much for the clarification! I was so excited when they said no more counting. My partner said it sounded too good to be true my apologies for misunderstanding, I’ll correct my statement immediately so no one else gets misinformed

 

[Lottieb2613]

Can I ask those that are using the new hybrid close loop how it actually works? As stated before, my clinic team said it wouldn’t need to be as accurate in carb counting and even suggested that I may not need to carb count at all except for super high meals. If I still need to carb count, what is the difference between it and say a sensor and normal pump? Feel a little embarrassed now at how excited I was

 

[Inka]

Don’t feel embarrassed @Lottieb2613 Lots of media pages have wrongly touted it as an artificial pancreas, and it’s a long way from that. You still have to count your carbs and bolus. The loop adjusts your basal to try to keep you in range, but you have to tell it when you’re exercising so it can ease off on its control (else you’d go hypo), etc.

 

[SB2015]

Can I ask those that are using the new hybrid close loop how it actually works? As stated before, my clinic team said it wouldn’t need to be as accurate in carb counting and even suggested that I may not need to carb count at all except for super high meals. If I still need to carb count, what is the difference between it and say a sensor and normal pump? Feel a little embarrassed now at how excited I was

Don’t feel embarrassed at all.
You could get away with not bolusing for small snacks but it makes things more level if you do the same as on other pumps.

The big difference is that the pump is chatting to the sensor every five minutes and adjusting your basal insulin, applying corrections, suspending or reducing the basal. This will cover minor errors in carb counting and bring you back in range. These adjustments also head off hypos more effectively and does all this without me thinking about it all.

Overnight the pump also makes adjustments and I find that it eliminates dips I used to get overnight in spite of testing basal profiles. It deals with changes day to day without me doing anything.

I do far less and get far better time in range. I am usually in the 90s. Better for me both physically and mentally.

 

[Bruce Stephens]

When I spoke to the Medtronic team they told me I don’t need to count as much anymore if at all? Is this not right?

As I understand it it depends a lot on the algorithm. I'm pretty sure I remember one speaker at a Type 1 diabetes tech thing saying that with one system (I think CamAPS) you could just tell it you were having a small, medium, or large meal. I can also believe that that doesn't give the best results and accurate carb counting is better.

Even if I'm misremembering, I can't see why such a thing wouldn't be possible: HCL is going to correct increased BG, so you just tell it to do that more aggressively for a while (and how much more aggressively, and for how long, depends on roughly the size of what you're eating).

 

[Saoirse]

As I understand it it depends a lot on the algorithm. I'm pretty sure I remember one speaker at a Type 1 diabetes tech thing saying that with one system (I think CamAPS) you could just tell it you were having a small, medium, or large meal. I can also believe that that doesn't give the best results and accurate carb counting is better.

Even if I'm misremembering, I can't see why such a thing wouldn't be possible: HCL is going to correct increased BG, so you just tell it to do that more aggressively for a while (and how much more aggressively, and for how long, depends on roughly the size of what you're eating).

I have CamAPS. This is not accurate- yes there is a option to use a slider which roughly equals different sized meals, but the user needs to input this - usually with a bolus. The system cannot ‘tell’ if you are starting to eat a small medium or big meal. Not inputting carbs (at least into camAPS, which is the only system I am familiar with, and so comment on) will confuse the algorithm and unless it is a small snack or there is exercise involved will likely mean it adds more insulin than is needed and you will have to correct with hypo treatment.

 

[Bruce Stephens]

This is not accurate- yes there is a option to use a slider which roughly equals different sized meals, but the user needs to input this with a bolus.

I think that's all the guy was talking about. So it's just a less precise way of specifying a bolus (which is what I interpreted it as)? I wasn't suggesting it was more automated than that. (One could imagine taking a photo of the meal, obviously, but that feels unnecessarily elaborate. It probably wouldn't work well and at best wouldn't really be worthwhile, I suspect.)

 

[SimonP]

I don't have a pump, I could be tempted though, but also not sure I'd qualify/not sure I want the added appendage (but I'm told that concern goes away and it's a good idea by those with them - having waited many years before moving to MDI, perhaps I ought to listen and go with the crowd more.)

Anyway without derailing the thread too much could I ask a question or two or three about how the closed loop systems work in practice? For example, if I know I'm going to eat a large meal of say 100g CHO, do I decide on a pre-bolus time and on a dosage rate/pattern to deal with the meal, or is this automated (or is it preset for a given type of meal that I select)? E.g. there's a big difference between pastry and pizza for example, how is this dealt with?

How well do the algorithms deal with how spiky your BG response is? Sometimes I can get very fast upward and just as fast downward movements (and I have to be mindful that this is how I'm responding atm, and avoid giving a correction which may well be unneeded and then need carbs), other times it's all much smoother and more easily predictable - is this a thing that the algorithm can deal with?

Lastly, I was interested to read what @SB2015 said about looping and exercise, this would potentially make life much easier (less forward planning needed with MDI basal manipulations) and presumably would also make BG while riding much easier to manage. If you're setting a higher temp target, can that completely cut off the basal? What happens after say 3 (or 5) hours when the last of the basal is gone, I guess if you're still running below target it's ok (I'm fuzzy on my understanding of quite whether any insulin is necessary after long duration exercise, or whether the muscles can do without completely - I've always got a bit of background MDI basal on board which makes it hard to judge.)

Presumably if you eat while in this exercise mode you'll give some bolus (or be given some to auto-correct), I assume the algorithm can be set to reduce the insulin:carb ratio (and/or correction ratio if they are unannounced carbs) to avoid then going low?

Perhaps that would be better carved out into its own thread, I'll let the mods decide. Thanks!

 

[nonethewiser]

When I spoke to the Medtronic team they told me I don’t need to count as much anymore if at all? Is this not right?

Oh dear did they really say that???

Just like on any system, mdi pump hybrid closed loop you still need to carb count, simple reason is even on HCL you still have to manually deliver a bolus dose.

I'm now massive fan of hcl, once set up & running there's no more basal testing & low bg levels are few & far between, it just makes life living with diabetes that little bit easier.

 

[SB2015]

Omg thank you so much for the clarification! I was so excited when they said no more counting. My partner said it sounded too good to be true my apologies for misunderstanding, I’ll correct my statement immediately so no one else gets misinformed

Just re read my reply @Lottieb2613
My astonishment was not at your questions but that someone from Medtronic said you would not need to carb count. My apologies if it came across as a criticism of you. Certainly not intended.

 

[SB2015]

Anyway without derailing the thread too much could I ask a question or two or three about how the closed loop systems work in practice? For example, if I know I'm going to eat a large meal of say 100g CHO, do I decide on a pre-bolus time and on a dosage rate/pattern to deal with the meal, or is this automated (or is it preset for a given type of meal that I select)? E.g. there's a big difference between pastry and pizza for example, how is this dealt with?

I used to avoid large meals, I ate no pizza because it was a fiddle splitting boluses, …
I now eat, count the carbs out it in the wizard and then do a delivery at my pre-bolus time. I do make that a bit later if it is a fatty meal. When just using a pump I used dual wave bolus, but I eat and let the HCl deal with the wobbles, as it makes corrections every 5 minutes if necessary. It works for me. This irons out my spikes that arise without me doing anything at all. I now don’t even bother to check that it is doing the job, because I know that it is. If I have a weird meal, forget to prebolus I may still spike, but it will get sorted out for me. On MDI you are having to ensure that you don’t stack insulin, but on this the pump will deal with that, turning off the basal if you have too much insulin, or increasing it if you underestimated or the fat is doing its stuff of messing up the release of glucose.

 

[SB2015]

Lastly, I was interested to read what @SB2015 said about looping and exercise, this would potentially make life much easier (less forward planning needed with MDI basal manipulations) and presumably would also make BG while riding much easier to manage. If you're setting a higher temp target, can that completely cut off the basal? What happens after say 3 (or 5) hours when the last of the basal is gone, I guess if you're still running below target it's ok (I'm fuzzy on my understanding of quite whether any insulin is necessary after long duration exercise, or whether the muscles can do without completely - I've always got a bit of background MDI basal on board which makes it hard to judge.)

Once you have set the temp target,( set two hours before you start exercising - so still need a bit of planning ) the pump will continue to adjust the basal insulin every 5 minutes. This basal is quick acting insulin which is dribbled out all the time (I found it hard to get my head round this when I first switched to a pump). The pump uses an algorithm to work this out all the time.
Medtronic have changed their advice on this and suggest amounts of glucose to top up with (without a bolus) during the exercise. I don’t do the level of exercise that you do so can’t answer your question fully. Mine works for what I do. On the T-Slim you have the option of changing the profile upon which the basal rate is calculated by their algorithm. @everydayupsanddowns will be able to answer this more. I think that may make that pump better for more active people. I prefer the option of doing a lot less and like ignoring my diabetes for long periods of time. There are useful webinars on different topics and they adapt these using the experience of users.
I listened to Prof Rob Andrew’s who works with elite sports people who have T1. He felt that the camsapp HCL was the best for them. I know nothing about that, and have not found out more as my elite sports days are long gone!!!

 

[everydayupsanddowns]

Anyway without derailing the thread too much could I ask a question or two or three about how the closed loop systems work in practice?

There are a variety of different systems, and each have their own logic, settings, options, and foibles.

My first sensor-augmented pump had ‘predictive low glucose suspend’. It watched sensor glucose values and if the trend indicated that levels would fall below a ‘low limit’ within a certain amount of time it would suspend basal insulin it order to gradually reduce iob, and hopefully steer BG away from the edge.

Hybrid closed loop has the predictive low glucose suspend, but it also adds basal increase, and micro correction boluses into the mix where levels are rising and predicted to be above ‘high limit’ within a given amount of time.

The different algorithms will have different trigger levels, some of which may be user-definable, others not, and different amounts of intervention that they allow themselves at different times.

Some act earlier, some act later. Some act more gently, others act more forcefully. Some base their reactions on a profile you set (and can change / switch between) others continually adjust their running profile on how your levels have been over the past day or two.

But ultimately their aim is to provide a ‘smoothing out’ of glucose levels by semi-automating some adjustments.

tSlim has an ‘exercise mode’ similar to MM780’s ‘temp target’ which affects how the algorithm responds to various sensor glucose situations. You can also (if you wish) establish an ‘exercise’ profile on the tSlim, with different basal / correction factor / carb ratio to adjust the basis on which the algorithm makes adjustments. Then once exercise is finished, you can switch back to your regular profile.

 

[Lottieb2613]

Just re read my reply @Lottieb2613
My astonishment was not at your questions but that someone from Medtronic said you would not need to carb count. My apologies if it came across as a criticism of you. Certainly not intended.

It’s ok! I didn’t think it was criticism at all. I’m very thankful for the clarification. My team where I am currently (I move due to uni) isn’t the best with things like this and can be a nightmare to get a hold of. I guess they also misinterpreted things?? I also attended a webinar which made it all seem to automated and the speakers weren’t really clear on how bolusing and correcting work (just that we didn’t need to worry as the pump does it all). Think I’m going to have to have a good think about it x