Mastering the temporary basal rate

Temporary basals (TBR) have never been my strong point: it's what you'd call my 'development area'. I gained a little confidence in tweeking them for my needs at the Animas Sports weekend, which went a long way in helping me grasp the TBR reigns, but I am still clumsy, at best.

I now regularly use them for exercise and when I am ill and need an increased amount of insulin to keep me in range.  I sometimes do this successfully and sometimes blindingly badly, but I give it a shot. But there is another time that I have found them to be particularly useful; when warding off an unwelcome overnight blood glucose level drop. 

There are times when I go to bed and my continuous glucose monitor (CGM) trace shows that I am dropping, or that I have been dropping and am now teetering above 'low', but a little too close to it for comfort. At times like these in the past I would feed to raise my BGs just a little. A biscuit, a piece of toast or an apple would often suffice, but in all honesty 11pm isn't a time of night I particularly want to be snacking. That's not also considering how much weight might creep on in a year from several biscuits a week to curb a low blood sugar at night. So in recent weeks when I have seen a drop or a number I'm not too confident about leaving as it is, I've been experimenting with TBRs to restrict the amount of insulin going in, on a temporarily basis, therefore allowing my numbers to level out, or bump up just a touch. 

Last night was a great example of this. At just after midnight Jamie and I crawled into bed. I'd seen a spike after my badly calculated dinner and was all too aware of the insulin I had stacked one bolus on top of another trying to get it down. Finally it was coming down, but at this time of night? C'mon! 

I was 9.1mmol (164mg/do) and showing a downward arrow. Great.  I don't want to eat because 9.1mmol is a little on the high side anyway and I don't particularly want to go up overnight. But I'm also fairly sure the downward trend is going to continue, with just a little insulin on board still burning a hole in my CGM picture. I could ignore, which would no doubt end in a 2am hypo, or I could eat, which I don't really want to do. So I opted for secret option C: reducing my basal rate to 0% for 1.5 hours. It seems a long time to be getting no insulin for, but something seemed instinctively right about it. That's something I believe us PWDs (people with diabetes) have a lot of, instinct.

I awoke two hours later all of a sudden. I don't know why, but after accidentally punching my husband in the back of the head after a bad dream, I figured I must have been low. I turned over, clawed around for my Dexcom receiver and with bleary eyes, squinted at the screen. 

Well I'll be damned. I had nailed it, spot on. The downward trend had continued. It had continued for around two hours, having briefly danced with a 3.9 mmol around 30 minutes ago and was now heading back up, nice and safely within the very respectable 5mmol (90mg/dl) range. And back to sleep I went.

Basal rates are funny things. Something which can take days to fully adjust when you make any strategical changes can also impact your blood glucose within a matter of hours. In this case I hadn't needed to eat and was able to nod off to sleep with the use of a carefully timed basal reduction. 

Game. Set. Match. 

Dexcom G4 vs. Medtronic Enlite: The Low Down

There are many tools in my diabetes arsenal which help me smash diabetes out of the park and continue living my life the way I want.  But there are two above all others to which I credit my current success: Continuous Glucose Monitoring (CGM) and my insulin pump, Lord Pumpington.

CGM has been around now for around a decade and gives us the tools to monitor glucose levels within the tissue beneath the skin, feeding back results around every five minutes with a lag time of between five and 15 minutes.  When I was first diagnosed in 1986, we had to pee on sticks to find out what our bloods were doing four hours ago (useful, maybe, as long as you don't have diabetes mind....).

If you are considering Continuous Glucose Monitoring, you probably have one major question rolling around your brain: which system is best for me?  There are two available in the UK; the Medtronic Enlite and the Dexcom G4.  I had the opportunity to try both systems and know that when deciding, it wasn't the gumph (actual term) spouted by the pharma companies but the experiences of others with T1D which led me to my final decision. So here it is, my breakdown of the major differences/benefits of both systems.

Insertion

For this one, Medtronic win hands down.  The Enlites benefit from an automatic inserter in which the sensor sits and from which it is discharged into the skin at the touch of the button.  This means you don't even need to see the needle, let alone insert or retrieve it.  

Comfort

This one is firmly in camp Dexcom.  When you insert your first sensor and have it camped out on your abdominal landscape you will think of nothing else, for a while.  Eventually however, the sensor will become as much a part of you as the watch on your wrist: you know it's there but it comfortably fits in your life, serving a purpose and earning its place on your person.  When I tried the Enlites even after five weeks and having grown used to having CGM in my life, the sensor adhesion felt 'fragile' on me - as though one good knock would see the sensor come away and £50 down the drain.  The Dexcom however feels 'bomb-proof'.  I have bashed it on walls,  scratched at it, got it caught on clothes and been through many a vigorous gym workout.  Nada. That bad boy stays put

Cost

This is the real nitty gritty and, if we're honest, a major factor if you are thinking of bringing CGM into your life.  It is a long term tool, meaning long term costs.  The options for buying include either purchasing a separate handheld unit (if you don't have a pump which can integrate CGM), or buying the kit which integrates into a pump.  I've included the actual costs on the chart below but again, the Dexcom G4 is the industry's worst-kept secret for lasting far longer than the manufacturer's recommendations, making it the much more affordable system

Insulin Pump integration

Both Dexcom and Enlite can be integrated into pumps so this one would be an even keel.  This means the results are sent wirelessly to the pump screen and are 'with you' at all times.

The Dexcom G4 can be integrated into the Animas Vibe insulin pump and the Medtronic Enlites can be integrated with the Medtronic Paradigm Veo.

The Vibe is a waterproof insulin pump which may be worth considering if you are an active water-baby.

The Paradigm Veo on the other-hand has a feature called 'low-glucose suspend', meaning if glucose levels reach a certain low-point, the pump will suspend until glucose levels rise.  Useful if you have kids or severe night-time hypoglycaemia unawareness.

For that reason, there is no winner here, just different selling point.

Low Glucose Suspend

This is perhaps the greatest feature of the Veo and certainly a consideration between the two systems.  I don't suffer severe hypos; but many do.  The Medtronic Enlite system is the only system currently on the market which has the capability to suspend the pump temporarily (up to 2 hours unless someone interacts with the pump, in which case in turns back on immediately) for the purpose of stopping a hypo from progressing further.  This means the Medtronic is the clear winner in this category

Length of wear

One of the biggest factors in making my final decision on which system I should chose was based on the diabetes community's worst-kept secret; that the Dexcom can be 'tricked' into working for far longer than the seven days it has CE approval for.  I'd heard rumours that people could get up to three weeks or so out of the new fourth generation sensors.  And it has most certainly lived up to expectations.  My shortest sensor lasted eight days; My longest, an impressive 36!  Other than that, each sensor I have used has lasted between 14 and 36 days, with the last four alone going between 22 and 36 days. I've heard of one person getting 12 days out of an Enlite sensor but personally after five weeks trial, I never managed more than 8 days.  Meaning the cost really was £50 per week.  Dexcom wins.

Overall Experience

There is a reason I wear a Dexcom, and not a Medtronic Enlite.  There are numerous reasons, in fact.  Even though I use a Paradigm Veo insulin pump (for now) and could have integrated the CGM much cheaper than by forking out for the stand alone kit, it was the accuracy, length of wear, comfort and overall experience of the Dexcom that made it the system I chose.  Everything the Enlites lacked for me, the Dexcom could offer. While there may be considerations such as the false high readings from paracetamol (personally I just switched to Ibuprofen.  Problem solved), the benefits of CGM - and more specifically, the Dexcom G4/Animas Vibe insulin pump system - mean it was a clear choice for me after having tried them both.  

And the benefits CGM has brought to my life are 100-fold:  No more overnight testing, fewer night -time hypos and continuous results driving my decisions, making working, driving, exercising and living my life, easier.  The improvements in my glucose readings are even so marked that I'm even looking forward to my next HbA1c, confident that it will be my best yet.  And for anyone's who been reading this blog a while you will know those are big words, coming from me.

Here it is, the run-down I hope you find useful:

	Dexcom G4	Medtronic Enlite
Cost	£46.50 per sensor £450 starter kit (for integrated pump.  Four sensors included) £975 for stand alone unit (for those without integration feature on pump)	£52 per sensor £750 for starter kit (for integrated pump.  10 Sensors included) Unknown cost for stand alone unit.
Calibrations needed	2 per day although more results can be entered	2 per day.  No more than 4.
Length of wear (according to manufacturer’s guidance)	7 days (CE approved)	6 days (CE approved)
Actual wear by customer’s choice (not advised)	Personal experience of between eight and 36 days wear before sensors expired	Personal experience of only 8 days before sensors expired
Comfort	Extremely comfortable.  Longest time worn for 36 days ith no irritation and very small entry hole. Extremely secure when in place	Comfortable. Longest worn for 8 days, but aware of the sensor site at this time and reasonably irritated on removal. Not as secure feeling when in place
Integrated into pump	Yes, only with Animas Vibe	Yes, only with Medtronic Paradigm Veo
Low Glucose suspend (safety feature to suspend pump temporarily when hypo)	No	Yes, when integrated with Paradigm Veo pump
Alarms	Very good.  Audible, simple, easy to amend upper and lower limits	Good but less audible when pump under covers.  Somewhat over sensitive (alarms when changing very slightly).
Paracetamol use while wearing sensor?	No. It interacts with the fluid giving a false high	Yes.  No issue with fluid interaction.
Range	20 ft, can work between rooms (with stand alone unit)	6 ft (with standalone unit)
Accuracy (MARD score – the gold standard of glucose testing. The lower the MARD, the more accurate the device is considered)	14%	15.3%

Unleashing the stoopid...

It never fails to amaze me that despite having overall normal diabetes control I still have days when all my diabetes know-how goes out of the window and I make decisions which would realistically be out-smarted by a sock with 3 brain cells.  By 'normal' I of course mean a fair amount of steady days, with the odd bat-crap crazy one the next.

Overall, I maintain an HbA1c of around 7% and don't know any of the staff at Accident and Emergency by name, so I consider myself to be negotiating this sometimes wonky path with reasonable success.  It is usually (and reliably) the times when I am under a touch of stress that I lose my ability to function as a reasonably sensible PWD with the ability to make choices.  Clever ones, anyway.

Today was my driving test at work.  Not the first ever one; I passed that 11 years ago.  This one was compulsory with the new job I have been looking forward to starting so very much.  All I needed was a good blood glucose (BG) to work on so that I didn't either a) have a hypo before the test and not be able to take it (hypos mean no driving for 45 minutes under DVLA rules) or b) having a hypo during the test, which would be embarrassing and again, mean no driving for another 45 minutes.  That's all I needed to do.

I was running between 6.5 and 7 mmol all morning from 7am when I woke until 12.30 when I arrived at the test center.  For me, that's a pretty sexy day and exactly the kind of BGs I needed to make this test a go-go, rather than a no-go.  As I arrived, I felt the pangs of hunger creeping in.  Mistaking these for pangs of a familiar slow-moving low BG, and panicking that a hypo could ruin this chance to take the test - an important landmark in my new career - I glugged down half a bottle of juice, 20g of pure fruit sugar.

I was 13.4 and feeling less than jolly by the time my test came around.  Had I been watching in from the outside I could have told you it would happen; I would have giving myself a gentle kick in the leg to stop myself drinking anymore.  A sip, maybe, to ward off any stealthy hypo.  But half a bottle?

Seriously.  Dumb.

What would almost undoubtedly have remained a 5-6mmol (if anything, going up slightly with the adrenaline), was battered for a BG more than double by the time I had finished unleashing the 'stoopid' on myself.

But hey, I passed the test and lived to tell the tale.  Maybe now and then it's OK to unleash the stoopid, if you can spot it when you do it.

Do you do this kinda stuff, too?  You know, the stoopid kind?

Driving, hypos and coming clean

In 2011 ripples of anger traveled through the diabetic community in the UK when the DVLA announced changes to the driving regulations for diabetics.  As a result of the changes, any hypo needing 'assistance' (ambulance attendance, for example) needed to be reported to the DVLA.  More than 1 serious incident in a calendar year now results in the suspension of your license.  As someone who suffered my own 'serious incident' this year, it is something I have often thought about; would I tell my team if I had another one?

INPUT, the world's favourite patient advocacy service are hosting the worlds quickest online survey to find out how you feel about this issue.  It will literally take 10 seconds of your time, but will help us uncover what YOU think.

Please check it out, here.

Thanks

When others know best

My best friend Lauren and I have known one another now for 18 years. We met at the age of just 11 at school and of course, knew all there was to know about life. Like, what Leonardo DiCaprio's hobbies were and that school was really just about learning how to copy home-work and still make it look like your own.

Almost two decades later on and things have changed. A lot.

For starters, Leonardo DiCaprio never came knocking and judging by his preferences, I'm not sure it would have worked out.....And school was, in fact, for learning how to copy home-work and make it look like your own.

Nowadays we have both grown up, settled down and even got ourselves 'real' jobs.

Amazingly despite hating school and having a diabetic as a friend, Lauren decided not only to branch into the world of teaching, but also to specialise in the care of diabetic children, meaning she is one of the few golden people without diabetes who 'gets it'. I'm lucky in that I have always been blessed with people who sympathised and gave a damn. But in many ways Lauren has the knowledge you could expect only the parent or partner of a diabetic child to have.

Where we once had all the time in the world, finding time to just 'hang-out' these days is a very rare occasion, but this weekend Lauren and I stole a few hours to celebrate, albeit belatedly, her birthday. So we packed a picnic and headed for the hills - literally.

Halfway through our delightful afternoon, my 'spidey-senses' kicked in and I could feel a hypo brewing. I had already eaten and knew that the high fat contents had slowed down the high-sugar treats (oh come on, it was a birthday!) from entering my system. But I was still panicking. The hardest time to be calm, is during a hypo.

Worrying that I had eaten all the food we had and had only just run out of lucozade, I started to freak out, just a little. We were, after all, at the top of the hill with only one roll and half a glass of wine left.

But Lauren, with all her training on diabetes calmly said, "Give it 15 minutes honey,” and carried on telling me a story.

Of course despite nodding and saying 'yeah of course you're totally right', in my head it went more like this:

"ohmygodwehavetogofindsomesugarnowIamgoingtodie!"

Begrudgingly, knowing that she was probably right but so worried I could only half concentrate on what was being said, I held on.

Low and behold after 15 minutes of worrying I had jumped from 3.2 (and very ‘wobbly’) to 5.4 and finally able to concentrate again.

It’s funny how sometimes other people really do know better than you.

For a stubborn old bag like me, that’s a toughie to accept

Unconventional cock-ups

There is a very good reason the insulin pump comes with a low reservoir warning alarm; we need insulin.  It's kind of the point of an insulin pump.  Without it, us pancreatically defective people have a time limit, and a pretty short one at that.  The low-reservoir alarm is our lifeline to making sure the pump is never out of insulin.  But when your pump is alarming for hours upon hours and - like me - you don't want to change the reservoir early wasting what insulin is left, you can lose track of the dwindling units. 

Last night I managed to go to bed without having stocked up on insulin (I blame the wine) and must have run out somewhere between 8mmol (11pm) and 17mmol (4.45am).  So my super-sleuth skills tell me, anyway.

In my fuzzy haze of high BGs I managed to change the reservoir, find a comfy spot in the bed again and return to the land of nod.

But today my slightly unconventional method of basal-testing (checking your background insulin dose is correct) has revealed that I have in fact been having a series of overnight hypos.  How do I know this?  For the last couple of weeks I have been having sugars of 15/16mmol during the day with no explanation of why.  I had put it down to my body not agreeing with the oh-so luxurious lunch of Ryvita and Cottage Cheese (hell on a plate) I have been adopting as a low-carb higher-protein lunch, but today I have barely strayed from 6mmol.  The only difference, tellingly, is the guaranteed lack of hypo.

I wouldn't suggest that attempting to go it alone without insulin (which works out less than unsuccessfully the rest of the time) is the way to carry out some decent hypo-testing, but in a backward and very unconventional way it has sorted out my little predicament.

It has also proven that I am most definitely and unequivocally, still a diabetic  :)

Friday the 13th

I am not a superstitious person. I own two black cats, have walked under countless ladders, I don't wink/wave or clap at magpies and seeing only one doesn't move me in the slightest. I often walk under scaffolding and I never throw salt over my shoulder, that is just plain messy. Dates in the calendar - particularly superstitious ones - mean nothing to me

But on Friday 13th January, I had an extremely unlucky day. After attending the funeral of my grandmother (you could argue that was worse for her than me but nevertheless, it was tough) I found myself having driven for 5 hours and in need of some quick fix food in the evening.

I tested my BGs en route to the shops to buy myself a Pizza and was a comfortable 8.8 mmol (that's pretty good - 4-10mmol is acceptable). I picked out my pizza and knowing how much pizza normally makes my stroppy little condition fly off the handle, injected what I would need for the Pizza nice and early, to give the insulin a chance to work before I bombarded my system with garlic bread and pizza dough.

This was all a good plan and in normal circumstances would probably have been the right way to go. However, after bolusing (delivering insulin through the pump) the amount I needed, I started to complain of how very tired I was from all the driving and asked Jamie, my husband, to take over for me.

It wasn't long before I was sat tucking into my pizza but also being very aware that the overwhelming feelings of tiredness I had been experiencing were actually a nasty hypo which had snuck up behind me without much warning. There was no shaking, nervousness, sweating, nothing. Not until this point, anyway. As my cognitive function began to slow down, leaving me with the last image I had looked at, no matter where I looked, the feelings of panic began to set in. But this wasn't like my usual panic. I usually just worry about where my glucose treatment is, but know that I can cope with it. I downed a huge glass OJ and hoped I would recover quickly.

But this time was different.

I began to convulse (something which I thought was impossible while still awake) and within moments was screaming because my mind could no longer understand what was happening around me. Jamie at this point had managed to lead me to the kitchen to wash my hands for a blood test, but that was the last time I would make any sense. Hearing the TV in the background, my mind had begun to convince me that people were in the flat. I knew for sure they were behind Jamie but he wouldn't turn around. WHY DIDN'T HE TURN AROUND?? I was screaming at him and panicking so much that he stood no hope of getting the Glucagon into me. I could barely see for shaky vision at this point, and the next thing I knew, Jamie was stood above me with the ambulance people on the phone, them asking if I was being violent (what with all the shouting and screaming).

The last thing I remembered was being collapsed on the kitchen floor, screaming and crying because there were people touching me and I couldn't see them (these were the convulsions, only my brain didn't have enough glucose in it to understand that).

As quickly as I slipped into that hypo, I was out again. Two ambulance men arrived within minutes - 3 to be exact, according to Jamie. At this point I was able to talk again, had stopped screaming and the large glass of OJ was taking full effect. As quick as that it was over. It took a while for my glucose levels to return to normal, but even after 2 glasses of orange juice I was still only 2.7mmol (anything below 3 is a serious hypo).

I can only imagine that the 8.8 I had seen only an hour before was on the way down at a drastic rate and that by the time I had taken my insulin for the Pizza I was fueling an already nasty hypo.

I have always been lucky in that hypos come and go for me with never a great deal of excitement. I haven't needed assistance for the last 10 years and expect it will be another 10 before it happens again. But it goes to show that even those diabetics who walk a reasonably stable glucose path can be struck by the odd stealthy hypo.

It also goes to show why even people with 'good' control would benefit from CGM. At the rate that one hit me, I would never have seen it coming even if I hadn't been tired, even if I hadn't eaten the Pizza.

It also goes to show that not everyone gets hypo symptoms all the time. Mine normally hit me like a freight train. This one didn't. This one went all ninja on me!