Here's the technical nitty-gritty
of how my pump break plan came together.
As diabetics, we all feel that heavy weight of the “burden” that comes along as free gift with type one diabetes.
This “burden” shows up in a number of forms, sometimes it’s the constant battle against high blood sugar, sometimes it’s a compound of all the little things, like low a battery alert on a device, or the re-scheduling of an endo visit just to get a new prescription, sometimes a broken vial, sometimes a painful injection.
We can brush these off, usually, but the “weight” of all these things feels relentless, never-ending, and it’s exhausting.
Welcome to the wonderful state of BURNOUT
What's the best way to resolve burnout?
"Mix Things Up"
Before jumping into all the nitty-gritty on “how” I made this pump-free transition happen, I need to mention this little aside on where the inspiration for a pump-break came from.
A few years ago, I had just started to build this “Type One Outdoors” website with a main intent to connect with other type one’s around the LA area.
I started searching around online for T1D groups, and one that popped up in the search was “Type One Run”
I was intrigued to say the least, and was stoked to find out they had a local group here in Los Angeles, and was extra stoked to find out they had a run meet-up coming up on the weekend!
I was like “Oh, I’m going”
Along with meeting about 5 other local type ones, I was introduced to Craig and James, who are the originating founders of Type One Run.
This Sunday morning included a 5k run around the lake, a breakfast at The Bright Spot (a breakfast diner in Echo Park) lots of T1 talk, and new, local type one diabuddies. I was stoked!
You know how this goes. Casual T1 talk, often, and usually without fail dives deep into conversations about insulin, pumps, CGM’s, new tech, old tech, new ideas in treatments, etc, etc, and I asked Craig on the subject of pumps, “Which pump are you using?”He told me that he was currently on a “Pump Break”
I was like “WHAAAATTT???” …. “Tell Me Everything”
I got the low-down on what he was taking
“1 shot in the morning of Toujeo (ultra long acting), and Afrezza (inhalable insulin) for meal bolus and corrections”
Wheels were turning in my head for sure.
This regimen (sans pump) sounded like just the “Mix-Things-Up” solution I was looking for as a means to get off this “brick” in my pocket.
My Pump Break Project had begun:
2 Factors:
The 'LONG' and the 'SHORT''
Insulin pumps complete 2 major parts of insulin delivery:
- The Long Acting, (Basal insulin) or ‘background’ insulin your organs and tissues use for baseline functions.
- The Short Acting, (Bolus insulin) for meals and corrections.
“If I was to go off the pump, I need to find insulin deliveries to handle these 2 insulin parts.”
Part 1
The 'LONG' acting
or, ‘basal’ insulin
Tresiba is a ‘Degludec’ insulin, and works very, very slowly.
Which is what you want in a ‘background’ insulin
It starts working in about 10 hours after injection and has a very mild (if any) peak-action time at around 20-30 hours after injection.
It lasts in the system for anywhere between 48-72 hours after injection.
It can be injected as a 1-shot-per-day, or 2-shot-per-day schedule.
It’s usually administered at a 1:1 TDD ratio (the same as what your pump basal settings would be)
As an example, my pump basal settings had me at 12 units per-day as my “basal” Daily Dose.
(which is different than TDD which would also include all the days “Bolus” deliveries)
Note:
There’s a number of different, long-acting insulins, and not all of them are available in all places.
Talk to your endo about all possible options available to you in starting a long-acting insulin program if you’re planning to go on a pump-break.
Other "Long-Acting" insulins:
These are only a sample of other “Long Acting” insulins.
Click on the image to learn more about them from the manufacturer.
Part 2
The 'SHORT' acting
or, ‘bolus’ insulin
Afrezza is an inhalable insulin.
There are no other forms of inhalable insulins at the time of this post.
It’s ultra-rapid in it’s action, begins working in 5 minutes after inhale.
It has only 3 available doses, 4unit, 8 unit, 12 unit cartridges.
It must be used in conjunction with a ‘Long-Acting’ insulin.
It’s used for meal bolus insulin, and BG corrections.
It exits the system quickly (in about 90 minutes) so it eliminates the lingering lows that sometimes occur.
For this reason, it works well for people with active lifestyles, so a meal before an activity has less chance of resulting in a low due to lingering insulin-on-board (IOB)
There’s a LOT of info on this new insulin including a range of potential side effects, which can be read about HERE
It’s administered differently than you would by an insulin pump.
It does not function as a 1:1 ratio as you’re used to with a pump-bolus.
Usually more is needed.
For example: 6-units of Afrezza, might equal 4 units of Humalog liquid insulin.
The Cartridge “Dose Values” are not the same as the dose vales you might be used to by administering insulin from a pump.
For Example:
-Afrezza 4-unit Cartridge = about 2.75 units of liquid insulin.
-Afrezza 8-unit Cartridge = about 6 units of liquid insulin.
-Afrezza 12-unit Cartridge = about 9 units of liquid insulin.
Knowing these rough dosage ‘strengths’ you can make combinations of the cartridges to get the amount of insulin you need to cover the carbs in meals and make BG corrections.
Since there’s only 3 different doses to choose from, you are not really counting carbs the way you used to on a pump, instead, I’m looking at covering food as a “volume” of carbs, with a “volume” of insulin.
I can also add correction insulin into the equation.
For example: if I’m eating an apple, I would take an 8-unit Afrezza Cartridge, and if my blood sugar was 190mg/dl, I am wanting to add a correction on top of that, so I will take an extra 4-unit Afrezza Cartridge.
You can also make “Dual Bolus” patterns just like you used to on the pump.
For Example:
Say your’e having a meal with carbs plus fats and proteins. You want something quick, up front to handle the carbs, but you want something to pick up the fats and proteins that might metabolize out 4-6 hours later, simply take your “Carbs” dose immediately at the start of the meal, then take a 4-unit cartridge in about 3 hours to pick up the fats and proteins a little later.
I also supplement with a fast-acting liquid insulin for this very scenario. I can also use Humalog or Novolog at the beginning of the meal, since I know the liquid insulin is sort of a “Medium” speed insulin which will pick up the fats and proteins a couple hours later. (just omit the second 4-unit Afrezza later on)
Note:
This insulin is only available in the US, and is a rather specialty form of insulin, and will not be available in all places or carried by all pharmacies.
Talk to your endo about all possible options available to you in starting a short-acting insulin program if you’re planning to go on a pump-break.
Other "Short-Acting" insulins:
These are only a sample of other “Short Acting” insulins.
These samples may not be available in all places,
They may not be viable options for all diabetics.
Click on the image to learn more about them from the manufacturer.
New diabetes stuff
As diabetics, we are all too familiar with that feeling after you leave the doctors office, given the absolute minimum amount of medical training on new devices, products and medications that will save your very life.
Here we go, once again, with all-new-stuff.
Going back on shots... feels like a step back.
- I’ll need my new liquid insulin (in a pen)
- And… if I have liquid insulin in a pen, I’ll need needles for those pens.
New, fast acting insulin (not in liquid anymore)
- My new, fast acting insulin is now in cartridge form.
- Cartridges are used with an inhaler device.
- Well, at least it’s not “More Shots”
DIY Medicine
hand-written on a single note
by my doctor
It's a little overwhelming at first.
Especially, since I was using a technology-crammed plastic brick to do all this medicine for so long,
now I need to do all this, all by myself, in my head.
whew....
...Deep breath...
... Let's Do This
Step 1
Get the Basal Ball Rolling
I'll need to start my new "Basal" program as soon as possible.
Since the Tresiba takes soooooo long to start in it's action
(about 10 hours)
I start with my usual baseline dose (12 units) to get the ball rolling.
Step 2
Basal "Step-Down" Plan
Here's where it gets "Technical"
I'm still functioning on my insulin pump while I wait for the new Basal insulin to start working (10 hours)
The Tresiba doesn't just turn on.
It's more like a "Dimmer Switch" very slowly ramping up, over 10 - 15 hours.
So, I'll need to "Step-Down" by pump basal
While the Tresiba Basal "Steps Up"
This drawing is how I visualised the "Step-Down" / "Step-Up" process happening over time, along with my meal boluses mixed in.
Step-Down the Pump Basal
Slowly
... Part 1 ...
As my new baseline insulin works it's magic inside my cells, slowly breaking down, and slowly becoming more and more effective,
I'll need to slowly decrease the basal insulin my pump is supplying.
To Do this, I'll start a "Temp Basal"
50% over a 6-hour duration
most pumps can do this, but the screens will look different.
Next:
Set a timer on the phone, so I know when to start the next Step-Down rate.
Watch those Blood Sugars
An important part of this "Basal Transition" Is paying very close attention to the blood sugars.
A diabetics blood sugar can go off the rails if there's a disruption to the delivery of basal insulin, and what we're doing here is definitely a disruption in basal delivery.
By doing this delivery transition slowly, and with a methodical step-down program, the hope here is to keep the blood sugars from going wildly off-track.
A CGM is key to this whole process.
It enables a close watch on what's going on inside the body while we take the system off one basal delivery form, and onto another.
While a CGM is a luxury, this process can be done without a CGM, it just requires a lot more frequent finger stick blood tests to keep track while the process finishes.
... Part 2 ...
After 6 hours have passed, I can now reduce my pump's basal delivery with a bit more pressure on the brakes.
This next step in the Step-Down temp basal now pushes the reduction to 75% over the next 4 hours
Blood sugars might rise.
Blood sugars might fall.
rest assured that the basal insulin is working, I just need to correct for highs, and bolus for meals, while the "Step-Down" process finishes.
Expect the "Step-Down" transition to take about 12 hours.
After all, this is a very, very slow acting insulin we're talking about and it's going to take patience.
FINALLY!
After 4 hours
I can disconnect from the pump for the last time.
I am now free!!!
De-Tethered
I'm officially on my Pump Break
What steps did you do to go on a pump break?
Were they similar steps to these ones?
Let me know in the comments section below.
In case you missed it:
Check out Part 1 of this "Pump Break" series:
Pump Break – Part 1
After 21 years of pump therapy, it was time for a break.
Here’s why I needed this break.
