A new year, and more experiments... Lantus + Auto-mode 😱 , metformin

 I'm eligible for the new pump, but haven't pulled the trigger yet. The current model is pretty much the same as my current one, but it allows you to have your CGM/pump data sent to your phone and uploaded to Carelink auto-magically. I like those things, but... it's not that tantalizing. I'm probably going to call on Monday to see what the status of my upagrade is. 

My latest experiment has been combining Lantus with Auto-mode. Most auto-mode believers would say that this is faithless sacrilege. After 2-3 years I'm not a believer, I'm just willing to listen to the potential. I have found that as a low-carb eater, the pump's meddling with basal insulin has a much bigger impact because my TDD insulin can be 60% basal. When it suspends basal while below 120 md/dL (a totally great place to be), I see an impact later... this phenomenon is especially bad if I spend 1-2 hours at 100 mg/dL prior to a meal (which I wish could be all day). Normally, if I can start a meal at 90-100 mg/dL, I'll be much more likely to keep things in check than if I'm starting a meal at 130-140 mg/dL.  The pump also suspends basal while you have a bolus on-board... so if you go without basal for 2 hours, and then take a small bolus to cover the meal, you may end up only breaking even between meal bolus and missing basal. If I bolus for a beer while making dinner, I'm basically starting this period of time with suspended basal even earlier. Then your food hits an hour later and you shoot up to 200 mg/dL. I was having to bolus for 2X the actual meal carbs and sometimes adding protein to that later.

Another issue is that if something goes wrong with the pump (infusion site goes bad, didn't click the connector all the way, run out of insulin while at work) you only have a few hours before you are in bad shape because ALL your insulin is coming from one source. Or... if you don't calibrate your sensor as soon as it asks, you might go into safe-basal which is only .3 units / hour, and you will see a rise pretty quick. 

So.... I was contemplating taking a pump break and using Lantus for a bit to see if I could use less insulin and simplify things a bit. I was planning on continuing with the CGM, and basically turning the pump basal off... and then I realized that if I were to have the pump with me at all times why not use it for boluses? And then, I thought... if the pump could be used for boluses and corrections, maybe Auto-mode could be useful to fill in the gaps if my Lantus dose wasn't dialed in. 

While I was thinking of getting away from the pump, I actually found the convenience of taking boluses and corrections and keepging track of insulin to be pretty helpful. In the end, what I started to do was take 14 units of Lantus in the morning. This is about 40-50% of my basal insulin. I've had really good results. If my pump goes below 120 mg/dL I'm still getting some insulin (.54 units/hour), so there's no blank insulin-less period of time. Additionally, when I take a meal bolus (which are usually small) I don't have a deficit there either. The basal suspend features are meant for safety in case I were to over-bolus or over-correct, but in my daily life that's not my problem with insulin. I usually run high more than low. This method that I've developed is basically taking some control back from the pump. The pump is still able to control about 1/2 my basal, and it seems like the amount it needs to keep my BG stable. 

I've asked some questions on Facebook groups to see if anyone else has tried this. One Medtronic group wouldn't post my question, but two others pump groups let it through. No one responded that they had done it and most commenters were stunned that I would do this without medical guidance, or thinking I don't trust the pump enough. 

Searching the web, I found one lady who has done this with her Tandem pump using auto-basal. I have exchanged emails with her, and she is no longer doing this because she's committed to trying to get the most from the pump's next generation auto settings. 

Endo visit & Metformin

 I met with my endo last Monday and she thought all my data was pretty spot on. My only blood work was an A1c, which was 7.0. My data from CGM showed my time in range at 79%, with an average BG of 154 mg/dL.

I told her that I wanted to use less insulin, lose weight and get tighter control. She said that the targets from the ADA (80% time in range: 70-180 mg/dL) do prevent complications, and that shooting for tighter control isn't necessary, especially if you are getting dangerous lows. 

She's supportive of my interest in better control, however, and she had already prescribed me Lantus for pump breaks. I asked about Metformin and she thought it was a good drug to address insulin resistance, and liver glucose production. I'm taking that in the evenings with dinner now and have seen some reduction in insulin use. I will report more on that as time goes one. I haven't had any of the gastric issues that are possible. 

My total daily insulin for the past several days: 47.5, 46.5, 45, 52.5, 47.5

I had been averaging 53 units when I posted in October 2020, so I think between a commitment to low-carb eating, walking after meals, and taking Metformin I'm seeing reduced insulin requirement.

Manual Mode Experiment Hiatus

I'm back... week before last I was trying to see if I could run with Manual Mode more of the time and keep myself in a better range, but after about 2 days things took a turn and became problematic. While the first day or two I was seeing good results, after a few days it got worse and I felt like I was either insulin resistant or I just wasn't getting enough basal insulin. I might turn my basal up to an average number based on my current basal use, and see how that goes if I try it again.

One advantage that I see in using Manual Mode is that I'm paying more attention and it inspires me to think more about blood sugar in general, which also trickles down in to dietary choices and exercise. When I'm in a normal day of AutoMode I'more likely to miss a meal bolus or not think about blood sugar much at all. I guess paying attention is always helpful for better control. 

 Maybe most days I should pay attention, but then use AutoMode for the days when I can't? Do we always know when those days will be?

I heard from Medtronic that I'm in the pipeline for getting the 770 pump. When they call me, I just have to set up the timing so that I pay my upgrade fee after the 1st of the new year. The new pump isn't groundbreaking, it just gives you the ability to monitor your BG on your phone... but, then there's a software upgrade that sounds like it has a better algorithm with more aggressive auto-corrections.

Aha! Manual Mode was more effective on 11/1

 Yesterday I tried manual mode during the day again, and it gave me quite good results. It was a busy day with quite a bit of activity cooking and doing yardwork. I found I had to eat some pumpkin pie a few times, because the basal rate for manual mode was too much for an active weekend day. However, all said and done... I was in range all day, used less insulin than usual, and didn't have any problems keeping my blood sugars close to normal.

Here are the stats for the day: 

90% in target range, 7% below range (pumpkin pie time), 0% above range, TDD 47.3, Basal 34 units 73%, Bolus 12 units 27%, Total Carbs bolused for 65grams, Correction boluses 2.5 in 3 corrections, Sensor average 124 mg/dL, Standard Deviation 0

See, to me it's interesting that to achieve a real average of 124 mg/dL you have to do something totally different than have a pump trying to keep you at 120 mg/dL. If I had my basal right adjusted for the activity, I probably could have used 40 units of insulin instead of eating pie. But, the pie was delicious, and I rarely eat it when I should, so it worked out well. I also had 2 slices of pizza with dinner, bolused correctly for them and took a walk to help my insulin match up. That was successful as well. I think a day with less carbs could run 37 units, and have me a lot closer to the amount of insulin I was using 10 years ago. 

I have found that switching between Auto Mode and Manual mode is pretty easy. All I have to do is put in a BG reading right when I switch back to AM. At night before I go to bed, I calibrate my sensor and put the pump back into AM. 

Today, I will see if the manual mode basal rate will be right for a day at work. If I bounce along the bottom of the low range, I'll definitely adjust it. Being lowish at work is a little panicky. I'll keep some sweet tarts on hand (just adjusted my manual mode basal rate to 30 units from 34). Right now my basal rate is a flat rate all day. So, there could also be some tweaking of that as well.

Experimenting with Manual Mode during the day

 Almost as quickly as I had pondered the idea, I started trying it. 

Yesterday I took the pump out of auto-mode in the morning and I started correcting toward 90 mg/dL throughout the day. It worked pretty well. My basal was still pretty aggressive and was probably doing most of the work. I stayed in the 90-110 mg/dL range most of the day and things were pretty uneventful. At dinner I had some beer,  soup with pinto beans in it, and then some pumpkin pie, and it was really hard to take enough insulin to keep me in range. I chased it with boluses, and took a walk, and when I went to bed I was at 197 mg/dL and I popped back into AM for bed. During the night my BG came down to 130 mg/dL by 1am. During the night I had a request for calibration or BG (I can't remember) and I entered the last reading it had as a BG and went back to sleep. It's cheating, but being woken up is worse than cheating. 😳 I'm always looking for ways to win against the alerts and alarms on this pump.

Some stats from yesterday: 

Sensor average: 135,  Standard Deviation 49, 6 corrections totaling 7 units, TDD 47.3 units

Questions I have... by not using AM during the day, am I depriving the pump of data that helps it keep me in range better? Or, does it know me well enough by now that it can jump in at any time? The warm-up period for AM is MM with sensor, so maybe I'm just warming it up all day?

Wow... Almost 10 years...

 I'm really glad I have this blog because it gives me metrics to compare as I track my health. I am really interested in seeing how things change over time, and to read back through the 137 posts that I wrote over the course of 3 years, it makes me realize how much attention I was paying to my physical health and my diabetes management. I hadn't realized that I have been using CGMs for over 10 years... I didn't realize that I've been using a pump even longer. I'm not even sure how I found the time to write that much... but, I did. 

I'm going to compare some data from then and now and use it to create some goals for myself. 

October of 2012                                     October 2020

Total cholesterol: 250                            220
HDL: 72                                                53
Triglycerides: 56                                    108
LDL: 167                                                145
CHOL/HDLC ratio: 3.5                           4.1
NON-HDL Cholesterol: 178

A1C: 6.4                                                 7.4

We  can see that my lipids are pretty similar, but the triglycerides are higher. I want to get those lower to support my desire to stay off statins. I think getting better glucose control and eating lower carb will help lower inflammation and also get the triglycerides down. It seems that my total cholesterol and HDL/LDL are about the same, but more exercise might help me raise the HDL for a healthier ratio. 

My current A1C is higher than I'd like, but it's been this way for a while. I noticed that when I started using the 670g pump in auto-mode, my average glucose levels have been higher and my TDD (total daily dose) for insulin also went up. My weight has stuck at 170-180 lbs, and I haven't been able to make much impact on it no matter what I do with diet and exercise.

The 670g pump shoots for a glucose level of 120 mg/dl, and it rarely gets you below that. That being said, my average blood sugars range from 120-180 on a daily basis. This jibes well with my current A1C which is 7.4, or an average BG of 164. I'm wondering if I used manual mode during the day and was more aggressive about correcting to 90 mg/dl if I could get my average down. I would have to get my basal really dialed in to make that work. I think another factor for this current A1C is that I have a transmitter that is on it's way out... and for a few months prior to my AC1 check it was throwing errors and requiring a BG randomly. This would bump me out of auto-mode overnight, etc. I wasn't able to stay in AM for long stretches of time. 

Here are some numbers from the last 14 days: 

82% time in auto-mode, 65% time in target range, 0% below range, 18% above range, TDD 53.8 units, Basal 36.7, Bolus 17, 91 grams of carb bolused for daily,  Sensor Average 149 mg/dL, standard deviation 18.6

The new pump that I'm hoping to get in 2021 is supposed to allow for a target BG of 100 mg/dl. If that works, I think I could improve my glucose control, especially since it also gives auto-boluses to correct when you get really far out of range.

Really catching up...

I just found this blog again. I have been missing long-form writing and having ways to journal about many things in life. 

Since I've lapsed into paying much less attention to my diabetes, I'm thinking it might be a good idea to return to dia-blogging. I don't know if anyone is still reading... but, I plan to try to document my journey again, if only for myself. 

 I'm going to summarize my current situation- before I get started with regular posts. 

I'm still using a Medtronic insulin pump. Currently it is a 670g model with the Guardian sensor. I've been using it for about 2 years, and it has made life a bit easier. I wouldn't say my control is better, but I'm spending less time thinking about my glucose levels. At release, this pump was touted as the closest thing to an artificial pancreas on the market. It is pretty smart, but it's pretty slow to make changes to your blood sugar. It's very safe... I have my eyes on the next generation coming up. 

I stopped using Symlin. I wasn't getting a huge benefit from it, and it was very expensive for my insurance to pay for. Right as I was choosing to discontinue it, my insurance took it off their list of approved drugs. So, all's well that ends well. 

I'm walking for exercise. Over the past several years I have had some foot and back pain that has put a damper on exercise, but I've tried to stay consistent with walking daily. 

I'm re-reading Dr. Bernstein's Diabetes Solution book. I'm trying to get my self psyched up to care more... The fact is, we need a pep-talk once in a while. I've gotten pretty lax about carbs, while still trying to keep my levels pretty good. 

My A1Cs have been in the 7s all along, but I think I could do better. I've recently re-doubled my efforts with low-carb eating. Most days I don't eat significant carbs till dinner, and I'm trying to keep that down to a minimum. I think my real carb downfall might be the pints of homebrewed beer that I like to sip at night. 

 Ok, I have to stop there... this doesn't have to be comprehensive, and I think it's just more important that I get something re-started. Anyone still reading? Anyone still have an RSS feed?