Sunday, January 17, 2021

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.