In a recent blogpost I wrote about my plans to experiment with using Lantus along with my pump. Although unusual, this is not a novel idea and is described by Dr. Steve Edelman in a 2004 article as the untethered regimen.
Starting in late November I used Lantus in tandem with my pump for two weeks. Although there were measurable benefits to injecting part of my basal, there were some definite negatives that were specific to my insulin requirements and the type of pump that I use. There were also a few things such as ease of use and expense that demanded consideration.
I started the trial by giving about 75% of my total basal split between two injections of Lantus: one at 7:00AM and the other at 8:30PM. There was nothing scientific about that except those were convenient times and I wanted any Lantus overlap to be first thing in the morning which is a problematic time for me. The balance of my basal was programmed into my pump with a little less through the night and a little more in the morning and evenings.
Let’s start with the positives. For the first couple of days I felt that my blood sugar between meals and overnight was more stable than it had been in ages. The most noticeable effect was in the mornings before breakfast. I often struggle with my BG starting to rise the second I get out of bed. It is not an easy basal fix because I tend to go low in the dawn hours before getting up. Sometimes I take a bolus right after getting up and that helps. But sometimes that bolus makes me go low. And other times I have already started to go high and struggle to get back on track even with boatloads of insulin. With the slight overlap of Lantus at this time, my BG remained stable almost every day until I chose to eat. It was a wonderful result.
The addition of Lantus also minimized BG rises after changing infusion sets. Set changes tend to be a problem for me even though I’ve tried lots of the tricks of the trade to avoid that: extra prime, never change sets in the morning, leave old site in, put new site in a few hours before using, and increase basal rates for several hours. I have never found anything that works every time. Of course nothing works every time with diabetes….
Now for some negatives.
At this stage in my life my basal rates are extremely low. After taking 75% of my basal by injection, I was left with only an average of 0.1 units per hour to be delivered by pump. The total of Lantus and Novolog ended up being a slight basal increase for me and maybe that is the reason I felt as though my BG levels were more stable.
The first problem I had with the untethered regimen was with temporary basal rates which I use on a regular basis. Unlike my previous Medtronic pumps where you can set temp basals either to a specific amount or by a percentage change, the Animas Ping only allows percentage adjustments. With a 0.1 hourly rate, it was difficult to make meaningful changes to my total basal. As I thought of insulin adjustments for my winter hiking excursions, even if I set my pump basal to Off, a reduction of 0.1 per hour might not be sufficient.
Another result of the extremely low basal rates on the pump was that it lost prime three times during the two week period. (Losing prime is an extremely annoying problem with Animas pumps and results in no insulin delivery until you correct the problem.) If you are in the middle of Target, you don’t really want to reach down your pants to unhook your tubing to re-prime the pump. And that is if you’re lucky enough to hear the musical chime that the pump is no longer delivering insulin. Technically some children use basal rates as low as 0.1/hour and the pump shouldn’t have lost its prime. But it did with both of the reservoirs that I used.
After a few days I began to have daytime lows probably because of the increased basals. So I reduced the Lantus by one unit. Then a few days later I tried another reduction and decided to take it all at night and none in the morning. I increased my pump rates to compensate for the reduction in Lantus. Very quickly I lost the benefits that had been provided by two injections of Lantus. Frankly that means that I didn’t have a clue what was going on anymore.
Although I do not have insurance problems buying both Lantus and pump supplies, it is certainly a more expensive regimen and could be considered to be “double dipping.” Many people justify a pump purchase by indicating that long-acting insulin can’t be customized to fit their basal needs. So here I am saying that the pump by itself isn’t doing the job and I need to add Lantus to the mix….
I also got to the point that the addition of two Lantus injections and the corresponding cell phone alarms added too much complexity and regimentation to my life. Diabetes takes up a huge chunk of my brain power already and I don’t need more nagging demands from it.
So I decided to go back on the pump full-time after the 2-week experiment. I was back to where I was before the experiment. But not exactly. I suspect that increased basal rates were part of the reason I benefited early on and my basal rates are set slightly higher than before. But not a lot because I am trying to avoid lows.
Try not to go too high. Try not to go too low. That’s Type 1 diabetes in a nutshell. Not much has changed, I guess….
This should be the end of the story, but it is not. Please stay tuned for the next installment of the Lantus experiment.
Disclaimer: Nothing I say here should be construed as medical advice and please do not change your insulin regimen without consulting your medical team. At the same time remember that diabetes is a life-long science experiment (Thank-you Ginger Viera!). When things aren’t going well, take some time to investigate different diet plans and alternative ways of dosing your insulin. And no matter what, test your blood sugar often and always carry glucose tabs:-)
This makes my head hurt. I don’t think most people have a clue as to how complicated T1 is, with all the calculations etc. I applaud your tenacity and look forward to hearing more.
That’s why only people who are good at math get Type 1….
This is so so so interesting to me. I had never considered Lantus AND a pump. Quite honestly, for me right now, I don’t think it’s a need. But for others, if it works better then YAY!! So thanks for sharing and I can’t wait to read Part 2.
Interesting experiment. Reducing the burden of diabetes is always the best option. But how to get there is the big question that needs to be answered. Thanks for sharing, and I look forward to part 2!
Okay, Laddie, first off- I love the chalkboards! I wish every pros and cons list in my head looked like that!
Thank you for this post. I hope you don’t mind, but I printed it out and plan on discussing it with my doctors when the time comes. You highlight so many great concepts here.
After a month on Lantus, I can totally see how it would help with the post-infusion-site-change-highs. Many of us experience that aggravation, and having injectable insulin helping to mitigate that spike is a creative way to do so.
As for the cons, insurance stuff really stands out to me, and I consider myself to be very fortunate with the insurance coverage offered through my job. Even with optimal coverage, there are still headaches when using multiple courses of diabetes management. For example, right now I’m still testing out whether I want to use pens, manual injections, pump + injections, etc. After refilling a syringe prescription, we then decided to try pens, and I had to negotiate to get that order filled since they had technically “covered” my needle supply for the month with the syringes. Now, the pen needle size is wrong, and it will definitely be a fight to switch to a new type. I can foresee some insurance companies arguing against a Lantus and pump combo, as you discussed, although sometimes I like to hope that they don’t have a clue what is what and won’t end up fighting it!
It’s definitely a hassle taking two injections, but sometimes that makes the Lantus management better. I agree with you that the overall interference with everyday life is a bit amplified on shots, and the level of complexity with pump + shots is “PhD level” stuff that most people would never imagine goes into managing diabetes. Kudos to you for trying this out and I’m so happy you shared this information.
My next post will probably discuss some of the things you mentioned. So far I have been using a vial of Lantus with syringes and keeping it in the refrigerator to maximize it’s life. My insulin doses are pretty small so the idea of throwing away an almost full vial of Lantus at the end of the month is unconscionable. So long term I think pens are the way to go. Or even using pen cartridges with syringes.
Good luck to you as you continue figuring out what will work for you. If all of this stuff weren’t happening to us, it would actually be an interesting science experiment….
Very interesting — and I do agree that the pump/Lantus method is safer when it comes to possible DKA/pump failures. I know someone who does this and is fairly athletic – she often needs to disconnect for competitions (for over an hour at a time) and this certainly is a “safety” from that perspective. With that said, I use temporary basals all the time (often set to zero-basal) and you can’t really do that with the split regimin.
As for morning BGs, something I’ve learned lately is that my fingersticks aren’t always accurate as soon as I wake up (meaning I’m lying in bed and reaching on the nightstand for the meter). Usually it reads a bit high, then treating it brings me too low. If I wait about 30-45 minutes til I’m up and about and fresh blood is circulating through my fingertips, it’s better. (How do I know this? My CGM tends to lead my fingersticks overnight. If I calibrate my CGM while still in bed, it throws the calibration off for the rest of the day. If I calibrate it after an hour or so, it’s good)
That’s interesting, Scott. I always test my BG within 5 minutes of getting up, but I do not keep a meter on my bedside table. In general my meter tends to read lower than my Dexcom first thing in the morning. I hate to admit that some of that is my BG responding to overnight corrections and the Dex hasn’t quite kept up with my meter.
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