Abby the Black Lab, who is wise about all things related to diabetes, is celebrating a birthday. Her blogposts are some of the most-read posts at Test Guess and Go. Someday I hope to have half as much wisdom as she does.
Please wish her a Happy #10!
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*** Related Posts ***
Abby the Black Lab Discusses DSMA Live
Abby the Black Lab Discusses Nutrition
Abby the Black Lab Discusses Community
In September I wrote a blogpost about the pros and cons of upgrading from the Dexcom G4 CGM to the Dexcom G5. Since my upgrade was free and I did not have to return the new and still-unused G4 transmitter, the decision to accept the G5 transmitters was a no-brainer.
Two weeks ago my transmitter warranty expired and I was once again faced with the G4/G5 decision. Most of the arguments from my September post are still valid, but probably my biggest concern was whether I liked the positives of the G5 enough to outweigh the increased cost of the transmitters. As most of you know, G4 transmitters are warrantied for 6 months but operate until they die—sometimes as long as a year after initial use. G5 transmitters are sold in pairs with each transmitter programmed to shut-off after 108-112 days (90 days + 18-22 days grace period).
Around the DOC I have seen many CGM users who have chosen to remain with the G4 for various reasons. Read Mike Hoskins’ post at Diabetes Mine for a good description of valid reasons for not changing. Recently on Facebook there have been discussions where some users are considering going back to the G4 as their G5 warranties expire. In most cases the motivation is financial although some users have been dissatisfied with the transmission range and signal reliability of the G5 system.
I have been using the Dexcom G5 since late February. Initially I was quite frustrated by the alert sound options on my iPhone and in typical fashion wrote a rant blogpost. At that point I was too new to the system to evaluate other pros and cons of the G5 platform.
Fast forward a few weeks and when once again faced with the G4/G5 decision, I chose without hesitation to remain with the G5 system. So what changed and why am I totally on board with the G5?
1. Although I never really minded carrying the Dex receiver, I quickly fell in love with not carrying it. I appreciate having one less thing in my pockets and one less expensive device to keep track of. I like how my BG numbers are displayed on the phone and how the G5 app allows me to key in calibration numbers rather than scrolling on the receiver wheel. I like the use of color in the app and the ability to see graphs in landscape mode. I appreciate the new iPhone “complication” that allows me to see my BG number without unlocking my phone.
2. When I use the receiver, I find the screen with the white background easy to read unlike the G4 screen with colored numbers and tracings on a black background. As someone who spends a lot of time hiking in bright sunlight, I found the G4 receiver impossible to read at those times when I needed it the most. (See “Sunlight and the Dex G4: A Bad Mix.”) I will admit that I dislike the glaring spotlight of the G5 screen when checking it in the middle of the night.
3. Although I am still not happy with the sound profiles on the iPhone, it is not bothering me very much. I am experimenting with using the receiver at night and my phone during the day. When I combine the musical Dexcom alerts with my Lantus reminder alarm in the evening, I feel like a digital music box.
4. Because I am a year away from Medicare and no CGM coverage, it is easy to argue that I should be hoarding transmitters and continuing with the extended life of the G4 transmitters. A great idea in theory, but it ignores the probable release of the Dexcom G6 in 2017 or early 2018. The G6 promises improved accuracy and reliability and I suspect it will quickly leave the G4 and G5 platforms in the dust. Because the G5 does not require a receiver, maybe it will be more economical than the G4. Or are you required by the FDA to purchase a new receiver every year?
Right now Medicare is a huge “unknown” in my life and I will soon be writing about my preparations and guesswork as I move closer to April 1, 2017. I hate the idea of hoarding supplies and technology that will become obsolete and possibly unused. But I am not optimistic about a change in Medicare CGM policy and am I crazy not to stock up on G4 transmitters?
5. I have not been bothered by things that could be considered flaws of the G5 system. I have experienced very few dropped data points. I have occasionally lost the signal on my phone, but that also happened periodically with my G4 receiver. The battery of my almost 3-year old iPhone 5 runs down more quickly due to the Dex G5, but not enough to be a real problem. I am still not satisfied with the lack of a robust vibrate alert on my phone, but I’m losing no sleep over it.
Summary: As I am reminded whenever I write technology blogposts, I am indeed one of the “Diabetes Privileged.” I would of course prefer not to have diabetes and it is certainly not a “privilege” to live with this difficult-nagging-frustrating-serious-chronic health condition. But given that I do, I have many things in my favor. I am educated. I have good health insurance and am able to buy insulin and other required medications/supplies. I have a computer, an iPhone, and a connection to the Internet and the Diabetes Online Community. I have access to good food and a safe environment in which to walk and exercise. I am the beneficiary of the newest diabetes technologies and able to debate whether I want to live with the fabulous Dexcom G4 CGM or the newer and fabulous Dexcom G5 CGM.
And today I choose the Dexcom G5.
More than once I have written about using injections of Lantus in combination with an insulin pump. Although I have good results following this regimen, I tend to abandon it after a few weeks because it adds complexity and expense to my already complex and expensive diabetes life.
For those of you not familiar with the idea of using injections of a long-acting insulin along with pump therapy, this strategy is called the Untethered Regimen. It is described in a 2004 article by Dr. Steve Edelman as a plan where the user takes a pre-determined amount of basal insulin by injections of Lantus (or other long-acting insulin) and uses the pump for the rest of the daily basal requirement and for most or all of the required boluses. This approach allows a pumper to disconnect from the pump for long periods of time without worrying about erratic blood sugars and even DKA. The user still benefits from the flexibility of the pump with the ability to precisely dose for meals and corrections and to use temporary basals as needed.
In my previous experiments using the untethered regimen, I had the following pros:
Somehow the cons always won out and I went back to pumping 100% of my required insulin. The disadvantages I experienced were:
So why I am rehashing this topic now? As you can probably guess, I am back using Lantus along with my pump. I have been struggling with overnight BG numbers for months, most noticeably spikes in the middle of the night followed by early morning lows. I have tried multiple changes in basal rates with little success. Similarly reducing evening snacks, changing my dinner menu, and giving up alcohol didn’t reliably fix the problem. My guess is that I have been dealing with a hormonal “dawn phenomenon,” but the pattern has not been reliable enough to make huge and somewhat scary increases to my overnight insulin.
About 10 days ago I decided to add Lantus to the mix. Rather than using two injections for 75% of my basals as I did in the past, I am giving 50% of my basal in one injection of Lantus at about 8:00PM. So far this is working great and I am not experiencing the negatives that I did in my previous Lantus trials. I’ve had night after night with few or no Dexcom alerts. I don’t need a “get-out-of-bed” bolus as I have required for several years to prevent my blood sugar from rising before I eat breakfast. My daytime BG’s have been more stable with fewer corrections required.
Why is it working so well? Magic, maybe. Actually I think that Lantus is providing a more stable foundation than the fluctuating pump rates I was previously using. I wonder if I have been experiencing pooling of insulin while asleep and that is not happening with Lantus. I have definitely been having itchy pump sites and even a few infections in recent months so maybe my insulin absorption has not been good. I suspect that whatever peak Lantus may have is matching up with my need for increased insulin in the early morning. Maybe I am just paying more attention to my diabetes and making better decisions over the things that I can control.
The fact is that although I don’t completely understand why, the untethered approach is working for me right now. When I wrote about this regimen previously, I was either using it temporarily for a beach vacation or calling it an “experiment.” I have a different feeling this time and can see it being a permanent change. Rather than feeling burdened by the scheduled Lantus injection, I feel a weird sort of freedom as BG numbers have been more consistent and less of a bother.
After having had Type 1 diabetes for almost 40 years, you’d think that I would have long ago given up on improving my diabetes care. I guess I’m just hard-headed or stupidly optimistic. Or maybe I just need to try new things to escape the boredom of a relentless day-to-day chronic illness. Whatever. The untethered regimen is working for me right now and that’s my story.
If you’re interested in learning more about the untethered regimen, check out the posts listed below.
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 time to investigate different ways of eating and alternative ways of dosing your insulin. And no matter what, keep testing your blood sugar and always carry glucose tabs:-)
*** Related Posts ***
In September I wrote a blogpost “Considering the Dexcom G5 Upgrade” which continues to be one of my most-read posts ever. My upgrade was free and it was a non-brainer to accept the two G5 transmitters. Because the G4 transmitter that I began using last March was still working fine until now, I have only just begun using a G5 transmitter. I am due to order a new transmitter next week (definitely trying to stock up before I transition to Medicare!)and I am glad to get some experience with the G5 before deciding whether to order a G4 or G5 transmitter.
So far I hate the G5 or at least how it functions on my iPhone 5.*** Maybe one of you can
give me some help. As far as I can tell, there is no way to set Dexcom alerts to vibrate without having my whole phone on Vibrate Only. I find it hard to believe that “Vibrate” isn’t one of the sound choices on the phone as it is on the Dex receiver. But if it’s there, I don’t see it. If I turn off sounds for the Dex app in the phone notification settings, then it doesn’t vibrate either and losing alerts negates the major reason for using a CGM.
I like having a ringtone for my phone and I especially like a ding when I receive texts. So I don’t really want my phone on Vibrate Only. I find the Dexcom alerts incredibly loud and they don’t seem to respond to the volume adjustment of my ringer. I don’t want my day interrupted with diabetes sound blasts and I think that my husband, dog, golfing partners, and hiking friends would agree.
So unless I am missing something, I have 3 choices.
I am not willing to go with Option 1. Diabetes intrudes into almost every moment of my life and I don’t want it accompanied by beeping, dinging, and babies-crying alerts.
I suspect that I can get used to Option 2 and that is what I am using today.
If I am going to use Option 3 then I should definitely just stay with the Dexcom G4 for my next transmitter with the longer battery life and no drop-dead date. Plus, I thought that the purpose of the G5 was to eliminate the receiver and use my smartphone instead!
So am I crazy and missing something obvious? Or is this another instance of “improved” medical devices taking a step backwards?
***Actually I like the Dexcom app on the phone and the ease of reading data and entering calibrations. But the lack of a Vibrate option is a big issue for me.
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