Un-tethered pump regimen

Charly Coughran said:

The attached is from our local pump club's monthy news
letter. Steve Edelman is a local endo with both a full
patient practice and a heavy involvement in research. He
is also the founder of the Taking Care of Your Diabetes
conference series which I highly recommend if it comes to
your city. tcoyd.orgtcoyd.orgOpen ↗ Steve is a firm believer
in the first law of diabetic control, find what works for
you and do it.
******************************************************-
********

Quoted message said:

Quoted message said:

The "Un-Tethered" Regimen

By Steve Edelman

The Un-tethered regimen refers to the therapeutic
combination of simultaneously using an insulin pump and
insulin glargine (Lantus) to help improve glycemic
excursions and overall control in a flexible and user
friendly manner.

Why in the world would you be on an insulin pump and a
long acting insulin at the same time? Why would you need
an injection of Lantus if you have the basal rate of
your insulin pump set correctly? Although the Un-
tethered regimen is not for everyone, it does offer
several advantages that many people with diabetes may
benefit from.

I have been living with type 1 diabetes since 1970

i'm betting pure pork insulin from '70 thru '82

(where's the beef?)

i wonder if it was pork-NPH or pork-L or pork-UL?

i'm betting on pork-NPH (which is the worst of the 3,
but was "in" at that time with many docs (my own
included (80's)))

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and I
have
been on
every
possible
insulin
regimen
known to
man. In
additio-
n, being
a diabe-
tes spe-
cialist
I know
that one
shoe
does not
fit eve-
ryone
and it
is
crucial
for long
term
success
that an
insulin
regimen
be tail-
ored to
the ind-
ividual
needs
and lif-
estyle
of the
person
with di-
abetes
and not
be rigid
and inf-
lexible.
After
being on
an
insulin
pump for
almost
20
years, I
switched
to
Lantus a
few
years
ago when
if first
came
out.
When I
was on
my
insulin
pump, my
basal
require-
ment was
~20
units a
day. My
pump was
set at
.8 unit-
s/hour
between
7 AM and
3AM and
1.0 uni-
ts/hour
between
3 AM and
7 AM to
cover my
dawn ph-
enomeno-
n.

a perfect candidate for 1x of beef-L, with all of it taken
1x at bedtime or maybe a few hours earlier (sometime in
the evening)

fwiw, when i was pumping my basal requirement was 8 units.
my fine-tuned basal was about 7 units (i'm 6'1"/170 lb.)

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When I
switched to Lantus I did extremely well on one injection at bedtime of
20 units. I did not seem to have any problems with my awakening
numbers on this dose and had excellent control. I took the same
premeal bolus dose with my fast acting analog insulin pen.

Quoted message said:

Quoted message said:

I decided to switch to Lantus for several reasons. After
being tethered to my pump for 20 years I wanted a break.
I am very active on the weekends and like to swim, go to
the beach, play ìNFLî basketball with my buddies and soak
in our Jacuzzi at home. The pump seemed to always get in
the way and it really caused havoc with my blood sugars
whenever I took it off for more than 45 minutes. This is
the only down side with having fast acting analogs in the
pump in that the disconnection time must be brief.

slow buffered beef-R in the pump is the solution to
that problem.
i.e. together with carrying 2 30 unit syringes of backup
insulin. i'd suggest pork-R as the backup insulin coz
it's long acting enough to conveniently be used 3x/day
by itself (when there's a pump/user failure), and
almost as fast as "human"-R

(as opposed to the even faster lispro or aspart, of which
i've used lispro (ugh!) for a year)

buffered beef-R can be gotten from: cppharma.co.ukcppharma.co.ukOpen ↗

(CP's "normal" beef-R (a.k.a. soluble/neutral) is buffered;
afaik CP does not have an unbuffered R insulin)

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When ever I tried to
compensate for long
disruptions I would
have to test a lot and
take several small
boluses of Humalog or
Novolog and it was a
rare event when I did
it just right avoiding
hyper or hypoglycemia.
I was also continuing
to experience sudden,
unexpected, and
aggravating episodes of
severe hyperglycemia
and pre-DKA (diabetic
ketoacidosis) because
of infusion line
disruptions usually at
the site of insertion
and defective insertion
sets, where the insulin
was leaking out of the
set and not being
delivered properly.

refreshing to see a pumper give insight into some of the
downside(s) of pumping

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I am also to blame with some of
these episodes caused by letting
my pump go empty or ignoring the
low battery alert. Murphyís Law
was always true to form as I was
usually in a location away from
extra batteries or insulin.

Although I did great on Lantus, I missed certain features
of the pump. I missed the ease of bolusing throughout the
day before meals and for catch up doses. I sometimes use
the square wave bolus feature for certain meals that
consisted of more protein and fat. Because I have no time
to exercise during the week and eat at sporadic times at
work, I liked having the pump on Monday through Friday.

I decided to try a new approach that I recommended to one
of my patients with type 1 diabetes who loved her pump
but got "all messed up" when she went scuba diving every
weekend. She would disconnect her pump and use multiple
injections of NPH and fast acting insulin in an effort to
control her sugars, however it was a real rollercoaster
ride with every attempt. I have now termed the regimen
described below the "Un-tethered" regimen.

I now take 75% of my basal requirements (75% of 20 units
= 15 units) as Lantus at bedtime and set the basal rate
of my pump at 0.2 units/hour, which makes up the
remaining 25% of my basal requirements (.2 for 24 hours =
~5.0 units).

it might be better to basal at least 10 units/day

when i tried using my pump only for my basal needs (8
units/day), i ran into occlusion problems at the 3rd day
(my prefence has long been for 5 day site times). of
course, i was using an unbuffered R at that time, so i'm
guessing that a buffered R would not have that severity of
occlusion problem

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Quoted message said:

I continue to use my pump for
boluses

moving more insulin thru the tubing/day helps to prevent
occlusion problems

with an unbeffered insulin and 5 day site times i had to
move at least 15 units thru the pump/day and put band aids
on my skin (between the skin and tubing) in order to keep
the temp of the insulin in the tube down a bit (5 F less?)

(occlusion: i.e. where the insulin becomes cloudy from
the heat exposure of being in the tubing too long)

bill t1 since '57, ex 8-yr pumper pork-beef-L 2x,
simple MDI/DAFNE

Quoted message said:

Quoted message said:

and have the continued flexibility of square and dual
wave bolusing and having alternate basal rates. I can
take off my pump for extended periods of exercise and
have my built in reduced basal rate (the Lantus I took
the night before). I do not have to worry about hooking
up my pump within 45 minutes or taking frequent
injections of insulin to avoid hyperglycemia. I do not
have to worry about sudden and unexpected extreme
elevations of my blood sugar values if I have disruption
of insulin delivery from my pump for any reason. I can
now easily just disconnect my pump and exercise or do
whatever for hours without missing a beat.

My personal regimen in the summer time consists of
wearing the pump Monday through Friday and on Friday
night I take 20 units of Lantus and remove my pump for
the weekend using my insulin pen for meal boluses. On
Sunday night I take 15 units of Lantus and hook up my
pump before I go to bed.

This regimen has worked well for many of my young adult
and teenage patients who are on sport teams and must
disconnect for hours and for a handful of elderly people
on pumps who are not too computer or mechanically savvy
with their pumps. The Un-tethered regimen offers a real
buffer safety zone to avoid ketoacidosis for new pumpers
or anyone who disconnects frequently.

Like I tell my kids every night, I AM A GENIOUS!

-- Steve Edelman, MD

*******************

Thanks. very helpful. I've been a pumper for about 2 1/2
yrs. I'm currently on the Minmed 712.

--
Steve

I love life...Yeah, I'm sad, but at the same time, I'm
really happy that something could make me feel that sad.
It's like...It makes me feel alive, you know. It makes me
feel human. The only way I could feel this sad now is if I
felt something really good before. So I have to take the bad
with the good. So I guess what I'm feeling is like a
beautiful sadness.

Trey Parker and Matt Stone, South Park, Raisins, 2003

"Charly Coughran" <[email hidden]>
wrote in message
"]news:[email hidden]...

Quoted message said:

The attached is from our local pump club's monthy news
letter. Steve Edelman is a local endo with both a full
patient practice and a heavy involvement in research. He
is also the founder of the Taking Care of Your Diabetes
conference series which I highly recommend if it comes to
your city. tcoyd.orgtcoyd.orgOpen ↗ Steve is a firm believer
in the first law of diabetic control, find what works for
you and do it.

--
-------
Charly Coughran [email hidden]

******************************************************-
********

The "Un-Tethered" Regimen

By Steve Edelman

The Un-tethered regimen refers to the therapeutic
combination of simultaneously using an insulin pump and
insulin glargine (Lantus) to help improve glycemic
excursions and overall control in a flexible and user
friendly manner.

Why in the world would you be on an insulin pump and a
long acting insulin at the same time? Why would you need
an injection of Lantus if you have the basal rate of
your insulin pump set correctly? Although the Un-
tethered regimen is not for everyone, it does offer
several advantages that many people with diabetes may
benefit from.

I have been living with type 1 diabetes since 1970 and I
have been on every possible insulin regimen known to man.
In addition, being a diabetes specialist I know that one
shoe does not fit everyone and it is crucial for long term
success that an insulin regimen be tailored to the
individual needs and lifestyle of the person with diabetes
and not be rigid and inflexible. After being on an insulin
pump for almost 20 years, I switched to Lantus a few years
ago when if first came out. When I was on my insulin pump,
my basal requirement was ~20 units a day. My pump was set
at .8 units/hour between 7 AM and 3AM and 1.0 units/hour
between 3 AM and 7 AM to cover my dawn phenomenon. When I
switched to Lantus I did extremely well on one injection
at bedtime of 20 units. I did not seem to have any
problems with my awakening numbers on this dose and had
excellent control. I took the same premeal bolus dose with
my fast acting analog insulin pen.

I decided to switch to Lantus for several reasons. After
being tethered to my pump for 20 years I wanted a break. I
am very active on the weekends and like to swim, go to the
beach, play ìNFLî basketball with my buddies and soak in
our Jacuzzi at home. The pump seemed to always get in the
way and it really caused havoc with my blood sugars
whenever I took it off for more than 45 minutes. This is
the only down side with having fast acting analogs in the
pump in that the disconnection time must be brief. When
ever I tried to compensate for long disruptions I would
have to test a lot and take several small boluses of
Humalog or Novolog and it was a rare event when I did it
just right avoiding hyper or hypoglycemia. I was also
continuing to experience sudden, unexpected, and
aggravating episodes of severe hyperglycemia and pre-DKA
(diabetic ketoacidosis) because of infusion line
disruptions usually at the site of insertion and defective
insertion sets, where the insulin was leaking out of the
set and not being delivered properly. I am also to blame
with some of these episodes caused by letting my pump go
empty or ignoring the low battery alert. Murphyís Law was
always true to form as I was usually in a location away
from extra batteries or insulin.

Although I did great on Lantus, I missed certain features
of the pump. I missed the ease of bolusing throughout the
day before meals and for catch up doses. I sometimes use
the square wave bolus feature for certain meals that
consisted of more protein and fat. Because I have no time
to exercise during the week and eat at sporadic times at
work, I liked having the pump on Monday through Friday.

I decided to try a new approach that I recommended to one
of my patients with type 1 diabetes who loved her pump but
got "all messed up" when she went scuba diving every
weekend. She would disconnect her pump and use multiple
injections of NPH and fast acting insulin in an effort to
control her sugars, however it was a real rollercoaster
ride with every attempt. I have now termed the regimen
described below the "Un-tethered" regimen.

I now take 75% of my basal requirements (75% of 20 units =
15 units) as Lantus at bedtime and set the basal rate of
my pump at 0.2 units/hour, which makes up the remaining
25% of my basal requirements (.2 for 24 hours = ~5.0
units). I continue to use my pump for boluses and have the
continued flexibility of square and dual wave bolusing and
having alternate basal rates. I can take off my pump for
extended periods of exercise and have my built in reduced
basal rate (the Lantus I took the night before). I do not
have to worry about hooking up my pump within 45 minutes
or taking frequent injections of insulin to avoid
hyperglycemia. I do not have to worry about sudden and
unexpected extreme elevations of my blood sugar values if
I have disruption of insulin delivery from my pump for any
reason. I can now easily just disconnect my pump and
exercise or do whatever for hours without missing a beat.

My personal regimen in the summer time consists of
wearing the pump Monday through Friday and on Friday
night I take 20 units of Lantus and remove my pump for
the weekend using my insulin pen for meal boluses. On
Sunday night I take 15 units of Lantus and hook up my
pump before I go to bed.

This regimen has worked well for many of my young adult
and teenage patients who are on sport teams and must
disconnect for hours and for a handful of elderly people
on pumps who are not too computer or mechanically savvy
with their pumps. The Un-tethered regimen offers a real
buffer safety zone to avoid ketoacidosis for new pumpers
or anyone who disconnects frequently.

Like I tell my kids every night, I AM A GENIOUS!

-- Steve Edelman, MD

*******************