Insulin Pumps

Minimise The Lows. Minimise The Lows.

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“Are you alright?”

“What’s wrong?”

“You seem quiet today.”

I knew why my work mates were asking. Diabetes has been affecting me so much at work lately, to the extent that my feelings could be read off my face with ease.

“I’m fine. It’s nothing.”

It wasn’t nothing. But the last thing I felt like doing was talking about it.

Going to work with the insulin pump has really tested my patience. I’m on my feet and moving around for much of the day, which makes insulin a lot more sensitive than normal. My work day is a prolonged period of physical activity, and not simply an hour of exercise. I guess what makes the insulin sensitivity more of a big deal with the pump, is that my basal insulin is being delivered to me live and continuously as I’m working, unlike Lantus. 

For a few days last week, the hypos were relentless. I recall having at least three on one day, in particular, last week. Three. Every time I crack open a fresh canister of skittles, I hear my diabetes educator’s voice ringing loud and clear in my head.

Minimise the lows. The first thing we need to do is to minimise the lows.

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Hypo unawareness is my biggest fear. With every passing hypo, all I think about is was whether I can feel it or not. I think about how much longer I will be able to feel them. At the end of it, all I really want to do is succumb to the defeating exhaustion that follows.

I had talked over my work day with my diabetes educator in the beginning. On a scale of 1 to 5, I’d rated my level of physical activity at around a 3. We’d anticipated a reduction in basal insulin requirements while I was working. I just never anticipated that the taps would take so long to turn down. I’ve now reduced my basal rates to about one seventh of my normal rate, and it finally seems to be holding me steady through the mornings.

The other factor that I am also starting to consider is the insulin I take to cover my meals at work. I’ve been plummeting quite quickly after my lunchtime insulin dose, and I’m starting to think that I might need to reduce my bolus by a certain percentage.

I’m hardly a role model for physical activity. I’d never have guessed that it would be such a significant issue for me on the pump. Not in a million years did I expect to be here, writing about physical activity and diabetes!

But I’m close. I’m really close to nailing this.

Troubleshooting

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A few days ago, I had settled into a certain level of comfort with my insulin pump settings. After a week of relentless hypos, I was close to nailing my basal rates at work. I successfully rocked a temp basal rate on Saturday while I was in the kitchen cooking lunch, and on Sunday when I was gardening.

On Sunday evening, I went out for dinner. I thought I had been fairly sensible – two slices of pizza for entree and a steak with steamed veggies on the side for main. I was bolusing insulin under the table as I was going – thank you for your convenience, Mr. Pump. I’d estimated 30g for the pizza and another 10g for the veggies on the main dish. All was good.

When I returned home, I was 14.2. No problem. I entered my reading into the pump, and administered the recommended correction bolus.

By the time I was ready for bed, my glucose had jumped to 18.8 (insert your favourite swear word here!). I gave another correction bolus. It was nearing 10.30pm, and my lower overnight basal rate was about to kick in. I decided to set a +30% temporary basal rate for 2 hours to help get things moving along.

I was trying to be cautious with the use of my temporary basal rates, not wanting to overdo it and go low. The rest of my night was spent checking my blood sugar level, swearing at the result, correcting, setting another temporary basal rate and setting the alarm on my phone to wake myself in another hour to check.

After trialling an hour without a temporary basal rate, I woke up at 4am to discover my BGLs had skyrocketed. I finally decided that I could safely go to sleep with a temporary basal rate switched on for the remainder of the night.

When nothing had changed 24 hours later, I began freaking out. I’d changed a perfectly good looking site, suspecting possible insulin absorption issues because it was too high up on my stomach. I’d checked my temperature, which was a perfectly normal 37 degrees. I checked for ketones that weren’t there. Stressed? Not that I was aware of. Sick? I felt fine. Change in activity? Nothing out of the ordinary.

I was correcting with very little effect, and temporary basal rates were creeping up to very abnormal levels. In a moment of anxiety, I reached out to the Twitterverse to find out if there was anything that I could have missed.

The first one was dehydration. It has been absolutely freezing cold this week. When I think about it, I don’t think I’ve drank a lot of fluids that didn’t contain caffeine these past few days.

The second one is that perhaps I’m coming down with a virus, and my glucose levels are responding before I am.

The final one was lack of physical activity, but I ruled that one out because my job is quite an active one. 

Today, not a lot has changed symptoms-wise. But I’m confident that a 30% temporary basal rate across my entire day is enough to keep me somewhat stable. I’m trying to drink lots of water, and pre bolus as much as possible to avoid blood sugar levels from going out of control after meals. I’ve talked it over with my diabetes educator over the phone, and I feel somewhat reassured in my thought processes.

I hope I’m not going to have to start all over again with basal testing. But for the time being, I’ll just have to wait it out and see what happens…

If only all the problems of the world could be solved with coffee.


Back To Work With An Insulin Pump!

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I felt a lot more comfortable adjusting to the insulin pump at home, despite the enormous patience and mental strength it required. I didn’t have the added stress or pressure of being at work, or anywhere, at a given time. By the end of week one, my overnight basal rates were holding me steady through the night, and my diabetes educator was confident in my ability to justify the decisions I’d made around my basal rates. I saw out the week with a greater level of confidence in the device that was attached to me.

Going back to work, however, threw a curveball into the mix. It was a great relief to be able to pull out the pump and show everyone that it wasn’t a surgery, or a great big computer strapped to my back. But suddenly, my pump workload had doubled. I had two very different days, with very different activity and insulin requirements to consider. 

My job is quite a physical one. I am on my feet for much of the day. Some days I am simply standing around the table where my team breaks down deliveries. Other days I am climbing ladders, lifting things intensively, or furiously unblocking the cardboard chute. The intensity of my activity often varies throughout my work day.

My biggest setback in those first few days was hyper programming my pump settings, without being patient enough to see them through the day before making changes.

I had initially set my basal rate to drop back a notch at 7.30am, half an hour into my work day. In response to a 17.0 on my FreeStyle Libre on Thursday morning, I gave a 2.5 unit correction that my pump suggested.

The ease of access to glucose data through my FreeStyle Libre tested my patience that morning. I was compulsively scanning. Scanning, scanning, scanning, way too frequently. Upward trend arrows, hitting glucose levels of 18, 20 and 22 within minutes. I was impatient, and set a temporary basal insulin rate of +10%.

Within half an hour, my levels were starting to fall. Feeling satisfied, I cancelled the temporary basal rate.

Half an hour later, I was still falling. I kicked my basal rate down again.

Half an hour later, and I found myself hypo. I set a temporary basal rate of -50%, and treated it.

My biggest mistake in those first few days at work was trying to micro manage data after meals, before the insulin had finished doing its work. My diabetes educator had told me that the first thing we needed to do was to minimise the lows. Yet I couldn’t get that stupid high off my mind.

I know damn well that insulin takes time to kick in, but I ignored my better judgement. I probably upped my basal rates unnecessarily, which was essentially extra rapid acting insulin in my system in the hours that followed.

I paid for my compulsion throughout those first few days with some very exhausting lows.

This week, I am trying not to hyper program my pump. I am setting basal rates the night before, and sticking with them through the day before making changes. 

I am trying to remember that what goes up, must eventually come down again.

First Site Change

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I had it under good authority that first site changes are a mess, and boy did I learn my lesson last Thursday morning when I did mine.

I left the old site on my stomach in place, until I was sure that the new one was a success. I opened the insertion device, unwound the cannula, unwound the paper from the adhesive, and pulled back on the inner white plastic. I squeezed on the edges of my insertion device until it “clicked” into place onto my stomach, directly above the old one.

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I pressed down to ensure the adhesive had stuck, and then pulled the insertion device up. This is what was left on my stomach.

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I could feel uncomfortable pinching underneath. My first site certainly didn’t feel like this. I looked at my site, and I knew straight away that I’d gone too far left, and too far up on my stomach. There was hardly enough body fat underneath the site to cushion it. I had to rip it out, and start all over again.

After connecting the other end of the tubing to the insulin cartridge inside my pump, I went to prime it. Insulin wasn’t coming out. I primed again. I still couldn’t see any insulin coming out.

By this point, I had been disconnected from my insulin for at least half an hour. My desk, my bed and my dresser were strewn with diabetes junk. Fucking diabetes. Fucking diabetes, I cursed out load as I searched around frantically for my workbooks. Not to mention I had the live Survivor finale on timeshift that morning, which I’d planned to be watching by this point. After finding the page that talked me through refilling and replacing an insulin cartridge, I primed again. There wasn’t a single drop of insulin coming out of the cannula.

With all avenues exhausted, I decided to give the AMSL diabetes helpline a call and see if they could help.

Guess what? You know how when you start a new insulin pen, you have to prime 10 or so units until the insulin comes out? That’s all I had to do with the pump. Hold down the prime button until insulin came out. I felt so stupid.

On the bright side, my second site change on Saturday was a piece of cake. I think I’ve got this…

FreeStyle Libre: First Observations!

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With the life of my FreeStyle Libre sensor coming to an end in a few days, I thought I’d better write some observations while they are fresh in my mind.

I first put my Libre sensor on during Diabetes Exchange in Sydney (disclosures are at the bottom of this post). We were advised that the best place to wear the sensor was on the underside of the upper arm. In similar fashion to an insulin pump infusion site, the sensor came packaged in what looked like an insertion device. It simply “clicked” into place on the arm.

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I’m the kind of person who easily gets annoyed by things. I fiddle with my watch, my medic alert bracelet presses too hard on my skin, and I am always picking at scabs. So I was pleasantly surprised that I have hardly noticed the Libre sensor. So far, the sensor has held nicely on my arm. I had one bath where the sensor was submerged in water for some of the time. I’ve had showers and changed my clothes every day, where the sensor is inevitably subject to some bumps and friction. The sensor is starting to look a little grubby around the edges, though, as it heads towards the end of its life.

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Being Winter, my sensor often sits under warm clothes and I notice it less. It is likely exposed to lesser impact and outdoor activity compared to the warmer months of the year. I’m also not sure how comfortable I’d feel wearing this $95 sensor to the beach under some rough waves.

Some of the other bloggers raised the issue of the Libre not having alarms to alert them of high and low blood glucose readings, which is a very valid point. I am not particularly concerned by this. Just as with finger pricks, I check often enough to be able to catch any impending highs or lows. I’m all for something simple, and that minimises the diabetes junk that I have to carry around with me. The Libre fits the bill nicely. As with anything, more features will mean an even higher price tag.

A great deal of my Libre use has been checking my glucose levels after meals. This has given me an insight into where my levels are heading after I eat, and in evaluating the need to readjust settings and ratios on my new insulin pump. We were told that data may be less accurate than a finger prick when glucose levels are rapidly changing, so please bear this in mind around my observations. 

My Libre reader has typically run around 1-2 mmol higher than the reading on my meter. I have also noticed a more significant difference where my Libre presents a reading greater than 15mmol. I have found greater accuracy where my levels are in single digits, and where there is no active meal bolus in my system.

That being said, the Libre has been super convenient to have while I’m transitioning to the insulin pump. It’s been a huge relief on my fingers at a time where I would likely be using test strips like water. Every morning, I plug it into the computer and upload the data to Diasend. It gives me access to detailed graphs that have tracked the movement of my levels through the night, which is extremely helpful in making decisions around my overnight basal insulin rate.

I walked around without my meter and test strips while I was in Sydney quite comfortably, too. The reader was quite easy to carry around, and fitted nicely into a t-shirt or jeans pocket. It was a really convenient tool to evaluate my blood sugar levels after some big Sydney meals, and a reliable indicator of glucose trends. I would definitely consider buying a sensor next time I plan on travelling.

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After a week and a half with my sensor, I am also feeling extremely challenged not to micromanage data. It’s extremely challenging to look at those annoying trend arrows after meals and not respond to them. It’s for the same reason that I’m not particularly interested in using a Continuous Glucose Monitor (not to mention the price!). I will definitely miss the convenience and the detail of my Libre data when my sensor shuts down on Thursday, but I am also very much looking forward to a break.

You can find out more about the upcoming Australian launch of the FreeStyle Libre at freestylelibre.com.au.

Disclosure: Abbott paid for my travel and accommodation expenses to and from Sydney. I received a FreeStyle Libre reader and 2 sensors free of charge. There was no expectation that I would blog about the Libre. All opinions expressed here remain my own.