Moving into 2019: Diabetes and Not Diabetes

We’re ten days into 2019 and life is the same. But not really the same. Oh yeah, it’s probably the same but it’s nice to use the reset of a new year to check out where I am. With things related to diabetes. And things not related to diabetes.

Geographical change:

I abandon the cold of Minnesota every year after Christmas and snowbird my way to Arizona for 4 months. I have been here about two weeks and we are finally warming up after super cold temperatures and snow in the mountains. We have had a couple of rainy days but mostly the sun shines and my spirits soar. I don’t have to worry about slipping on the Minnesota ice.

Diabetes Stuff:

In early December I wrote about going back to my Animas Vibe pump due to occlusion alarms and other frustrations with my Tandem X2 pump. I went back to the X2 for my endocrinologist appointment later in December because I want my medical records to show nothing other than Tandem use. Medicare Part B insulin and pump supplies require the serial number of my pump and I don’t want to risk coverage nor do I want to put my endocrinologist in a situation of having to fudge on what pump I am using. Then because I was traveling to Arizona, I wanted to wear my in-warranty pump so that if the second pump in my suitcase was lost because of shenanigans while I was being groped by TSA, it would be the old “worthless” pump.

But very quickly in Arizona, I got frustrated again with occlusion alarms on my Tandem pump. So I ditched it again and am back to my Animas pump. I called Tandem to report that I was having occlusion alarms and indicated that I just wanted that on my record not a pump replacement. Since I have had occlusion alarms with three different Tandem pumps, I am not optimistic that a new pump will make a difference and I don’t want to deal with it until I have access to the Dexcom G6 and Basal IQ. For Medicare users, that is expected to start happening in April. Until then I will continue with my workhorse Animas pump that delivers insulin and never has occlusion alarms or other intrusions into my life. As always, please note that I am a huge fan of Tandem and do not regret my t:slim X2 purchase. I just regret that I am one of the unfortunate souls who has occlusion alarms and struggles to succeed with this pump.

Diabetes, Arthritis, and Lifestyle:

I have previously mentioned that I am giving up extreme hikes of 12+ miles in the mountains to preserve the remaining cartilage in my painful arthritic feet. I don’t want to have foot surgery especially as I am finding that my August hand surgery solved some of my problems but not all of my problems. I have no confidence that foot surgery will turn me into a 25 year old athlete again….

I am finding new activities and am attending fitness classes three times a week. Plus I ride my bike to everything in my community and never use my car or golf cart. So far I have been keeping in touch with my hiking friends and right now for me the social connection is far more important than the athletic connection.

Kinda Broken:

A lot of things in my life kinda work but are kinda broken. This is definitely a #1stWorldProblem section. 

The remote for our main TV does not turn on the tuner or cable box and we must do that manually. If you forget, button pushing randomly turns on some devices and turns off others. When the TV dies, it will require an expensive redo. Until then, we just figure it out and make it work.

My husband broke the battery compartment door of my golf laser gun. To get my distance on the golf course, I push up on the bottom of the gun, push the button, and hope to get the distance. Yeah, it works but is annoying and one more challenge for my arthritic hands. But I don’t play a huge amount of golf and don’t want to invest in a new laser gun. When this one works. Sorta.

The screen lock button on my iPad is stuck. I should get it fixed but right now I added an Accessibility Feature button that allows me to turn off the screen with a few clicks. Annoying but a cheap fix.

The garage door manual close button doesn’t work due to a lightening strike last year. So I have to enter the code which works fine but is an extra kinda-broke step. 

My August hand surgery fixed one of the bad joints in my left hand. But it didn’t fix the joint that hurts when I play golf. And the bad elbow wasn’t even addressed. So a hand brace and an elbow strap make golf possible.

Totally Broken but Fixed:

When I flew into Arizona in late December and picked up my husband’s car at the airport lot, the car screamed brake failure and stranded me in a rocky industrial lot north of the airport. AAA, a loaner car, and an eventual warranty repair got me home in a few hours and the car back in our garage a few days later. Thanks heavens that the brakes failed before I got to the highway.

We have dealt with a quirky HP printer for several years where it always needs to have its network settings re-entered weekly just to print a crossword puzzle. Finally it got an unfixable error message and we now have a new Epson printer that promises to be more reliable. I hope. New printer=$90. Ink for new printer=$70. Argh!

Still Broken:

Yeah. My pancreas is still broken. But what’s new???

Abby the Black Lab is doing okay but is in pain due to arthritis and other health issues. She started laser treatments today and the prognosis is good for easing her symptoms. She is still happy and eats and drinks well. And she looks super cool in the doggie sunglasses required during her laser treatments. But she is an old dog and age is not fixable….

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Happy New Year to all of my readers and may 2019 be a good year for you and your family.

A Tandem Vacation

Is it back to the future or forward to the past? 

I’m not quite sure.

What I do know is that this month is my two-year anniversary using a Tandem insulin pump and I just went back to using my Animas Vibe. I am hoping that an older, simpler pump will ease my navigation through the current dark clouds of my Type 1 diabetes. I wrote a blogpost in late November about my diabetes life as a country music ballad and things haven’t changed much. My elderly dog is recovering well from pneumonia but struggling to move around due to arthritis and an injured foot. The cold and cloudiness of late fall continue to trap me in gloom and icy streets prevent neighborhood walks. I have been in an extended funk where my diabetes doesn’t follow the expectations of “If I do A, then B will happen.” A lot of time I do A and seemingly nothing happens. Is it the pump? Is it the insulin? Is it my behavior? Is it one of Diatribe’s 42 factors that can impact blood sugar? I am burdened by diabetes technology that doesn’t give me sufficient control over intrusive beeps and sirens.

Many of you know that when I get frustrated with my D-Life, I try new tools with the conviction that there is a solution to BG frustrations. I have added Lantus as an adjunct to pump therapy with the Untethered Regimen. I have adopted low carb diets and reset my life with a month of Whole 30. I have changed types of insulin and models of infusion sets. Wil DuBois of Diabetes Mine wrote an article this week titled “To Pump or Not to Pump with Diabetes?” and shared his feelings about the benefits of changing up your D-regimen: 

“I find that any time I change from one tool to another, I do better. If I changed every two months, I’d probably stay in control. I think it’s because change makes you focus. That, or diabetes is an intelligent alien parasite that can be caught off-guard only for a short time.”

But back to the subject of this post. I am using my Animas Vibe in place of my Tandem t:slim X2. I have always relied on the Vibe as a backup pump so it is not a bad idea to road test it after two years in the closet. I figured that I would quickly miss the X2 but have instead discovered that I really like this old pump.

I was concerned that going back to scrolling for carb and BG numbers would be horrible but in many ways it is easier than using a touchscreen and navigating through multiple “Are you sure?” screens. I really appreciate the immediate bolus delivery of the Vibe. With Animas, I program the bolus, it whirrs, and delivers insulin before I can get the pump back in my pocket. With Tandem, I program the bolus, it delays for a while, micro-boluses, and eventually finishes with a confirmatory vibrate a minute or two or three later. The Animas clip is a delight with its easy attachment and actually holds the pump securely on my waistband. Temporary basals are simple to enter and a temp basal of zero does not result in an annoying warning alert several minutes later. The Combo Bolus function remembers my last setting rather than requiring a recreation of the split and duration each time. My arthritic hands are having an easier time with the Vibe buttons than with the increasingly stiff T-button on my X2.

There are lots of wonderful things about Tandem pumps but I have been one of the unlucky people who gets occlusion alarms. Most users don’t get them. The vast majority of the alarms are false. I just hit “Resume Insulin” and go on my way. Lately I have had a couple of alarms that actually required replacement of the infusion set and/or cartridge. I have done extensive troubleshooting with Tandem over the years and am on my 4th pump. Only one of those pumps did not give me occlusion alarms and it unfortunately had a defective T-button. I never had occlusions in 12 years of pumping with Medtronic and Animas.

I am tired of troubleshooting. I sometimes experience one or two occlusion alarms a week and then go a while without them. But after two years of alarms, I think about occlusions almost every time I bolus. I average 8-9 boluses per day and that is a lot of thinking about occlusions. I am tired of holding the pump with the tubing extended post-bolus to prevent occlusions. I am tired of feeling guilty for stubbornly refusing to use the Tandem case and for not changing my cartridge every 3 days. I have a low TDD of insulin and an every 3-day cartridge change results in wasting as much insulin as I use. I do replace my infusion set every 2 days.

Longterm I know that I will eventually be back to Tandem. I am probably just being a pouty and whiny problem child. Despite fewer alarms and intrusions into my life, the Vibe has not cured my diabetes but I am doing better. I am committed to Dexcom and thus don’t envision switching back to Medtronic. I am super excited about getting access to the Dexcom G6 and Basal IQ; as someone on Medicare, that should happen in the spring. Hopefully the benefits of Basal IQ and eventually Control IQ will outweigh the insulin delivery problems. An Animas pump is not a longterm option. Johnson & Johnson abandoned the pump market and there is no customer support for my out-of-warranty Vibe. If it quits working or the case breaks, I am done. Fortunately I have a lot of supplies and was recently given enough reservoirs to last for several years. I can use Tandem infusion sets by substituting the t:lock tubing with luer lock tubing.

I think highly of Tandem and have always had good customer service. Until starting to use the t:slim X2, I was never a problem child with diabetes tech and continue to believe that there is something wrong with an insulin pump that frequently quits delivering insulin. Is it the design of the pump? Is it my low insulin use? Is it random bad luck? Am I at fault? I don’t know and am at a point as Gone with the Wind’s Rhett Butler would say: “Frankly, my dear, I don’t give a damn.”

Lots of I Don’t Know’s

Okay. Let’s talk about Basic Medicare** and the Dexcom G6. Then let’s talk about Basic Medicare** and Tandem Basal IQ. And then let’s just admit that we don’t know the answers to our questions and that we’re not going to get answers in the next 5 minutes.

Who, what, when, where, why? 

Yeah, I don’t have a clue.

As someone on Medicare I’ve felt left out in some of my Facebook groups recently. In the Dexcom D5/G6 Users group and the DEXCOM G6 group, the vast majority of topics are about the G6. Do you like it? What is great? What is terrible? Adhesives, accuracy, and sensor longevity. Insurance and supply issues. The Tandem tSlim Pump group is all about Basal IQ with the majority of users stating that it is fabulous. There are questions about how it works and at what point basal insulin is suspended and then resumed. Stories about climbing Mt. Everest and others wondering about how to coordinate the prescription from their doctor, the training, and the software download. I don’t fit in anymore and I have no advice to give. In fact I am a little bored in these groups and mostly not checking in.

You see—I’m on Medicare. I don’t have the Dexcom G6 and my Tandem X2 t:slim pump is not updated to Basal IQ. I am not whining. Okay, maybe I am–just a little. But mostly I am just stating facts.

After weeks of rumors, it was officially announced on October 16 that Medicare will begin covering the Dexcom G6 for Medicare recipients. The nitty-gritty has not been worked out but it is estimated that April 2019 is a reasonable target date.

For those of us who have been involved in advocacy for CGM coverage by Medicare for years and who have been joyously receiving coverage since the second half of 2017, this announcement is welcomed but generates more questions than answers. I think that the more you know, the more questions you have. Addressing customers on the Dexcom G5, the news release states:

“Once G6 is available, Dexcom will be reaching out to current Medicare G5 customers when their transmitter is eligible to be replaced. Dexcom will also discuss the G6 and the Medicare beneficiary’s eligibility during routine monthly contact.”

That sounds very straight forward but I worry that it is not. The elephant in the room for those of us on G5 is The Receiver. In January 2017 after the initial approval of the Dexcom G5 by Medicare, I wrote a post titled “Medicare and CGM Coverage: Love Your Receiver!” and explained how Medicare justified the approval of the G5 as Durable Medical Equipment (DME) because the receiver had an estimated 3-year life. Therefore for those of us on Medicare, the G5 receiver has a 3-year warranty. Although we are now allowed to use our smart devices to read our G5 data, Medicare regulations still state that the smartphone is used “in conjunction with” the receiver. And FDA approval of both the Dexcom G5 and G6 requires a receiver to be provided as part of the initial bundle.

I have an old-style Dexcom G5 receiver that cannot be updated to G6 in contrast with the newer touchscreen G5 receiver that can be updated remotely to G6. Medicare through stupid regulations that I don’t understand does not allow Medicare recipients to participate in manufacturer upgrade programs. Thus Dexcom cannot give me the option of paying $100 or $25 or whatever to exchange my dated receiver for a touchscreen G5 or G6 receiver. 

Technically my G5 receiver is warrantied for 3 years and I can’t upgrade it. Am I going to be able to switch to the Dexcom G6? Interestingly, the Dexcom press release only addresses the transmitter and makes no mention of the receiver. Without knowing the details of Dexcom/Medicare negotiations, I have no way of knowing my status. Is everyone forgetting the FDA requirement of the G6 receiver? Is Dexcom going to provide G6 receivers to current G5 users at no charge? Will I get a G6 transmitter and sensors without a receiver? IMO there is no way in h*ll that Medicare will pay for another receiver. Because the Medicare/Dexcom relationship is on a subscription basis, will all of the previous rules about upgrades be thrown to the wind?

As I said above, the estimate is that Dexcom G6 products will be provided to Medicare recipients starting in April of 2019. I have neither seen nor heard of specifics regarding this rollout. There are lots of discussions and rumors floating around Facebook but no one really knows. I have been on Medicare long enough to live by the mantra: “When I know, I’ll know. Until then, I won’t.”

If I were not using a Tandem X2 pump, I would not care much about using Dexcom G6. I look forward to an easier insertion and no required calibrations with the G6, but neither is a huge deal for me. But I really look forward to updating my Tandem X2 pump to Basal IQ which automatically shuts off basal with predicted lows. And then the future Control IQ which will function as an early generation artificial pancreas. 

But if things are in the dark with Dexcom and Medicare, they are really in the dark with Tandem and Medicare. The last communication I had from Tandem regarding the use of my pump as a receiver for my Dexcom CGM was in November 2017. The webmail stated:

“Dear Customer: As someone who, according to our records, has a t:slim X2™ Pump and also has Medicare for health insurance benefits, you may be aware that Medicare coverage of continuous glucose monitoring (CGM) is limited to viewing CGM data only on a Dexcom receiver and NOT a smart phone or an insulin pump.”

Since then I have heard nothing.

Frankly I think that the current Tandem policy regarding Medicare is: “Live and let live.” Some people are being told by their Tandem reps that it is okay to use their pump with Dexcom. But I do not think that is true because there has been no official announcement allowing the pump as a Dexcom receiver. At the same time there is no enforcement of the policy and Tandem is not sending reminder emails about Medicare. Although one part of me thinks that it is poor customer policy that Tandem is not communicating with Medicare recipients, the other part is okay with just ignoring the problem.

Unfortunately the problem of Tandem and Medicare will come to a head when the Dexcom G6 is distributed to Medicare users. Will we be allowed to download the Basal IQ software update (which requires G6) to our X2 pumps? Tandem has said nothing and unfortunately IMO it would be a total violation of current Medicare policies to allow the update.

Once again we don’t know the answers.

No answers to who, what, when, where, why.

Just a reminder to be patient and go with the flow…

Of no information…

and…

Fingers crossed for the ability of those on Medicare to benefit from the latest and greatest in diabetes technology.

Until then, just remember the Medicare mantra:

“When I know, I’ll know. Until then, I won’t.”

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** Please note that although Medicare Advantage plans must cover everything covered by Basic Medicare, they may have more flexible policies than Basic Medicare and provide more benefits. Currently some of these plans are already covering the Dexcom G6, but most are in line with Basic Medicare.

Thank-you Tandem: A Replacement Pump

I recently wrote two blogposts (here and here) about false occlusion alarms on my Tandem t:slim X2 pump. I was not shy about sharing my frustrations and I want to update my story with the fingers-crossed!!! resolution of my problem.

I have always had good customer service from Tandem. Despite the long wait times on hold reported by some people on Facebook, I have never had to wait more than a couple of minutes. I have never yelled, cried, or been rude to Tandem tech reps, but lately I have worried that they might start to label me as a “customer from h*ll” as I repeatedly called to report more occlusion alarms.

The problem with false occlusion alarms is that when the pump is not shrieking about the stoppage of insulin, it works fine. Thus my pump passed all the tests that that Tandem support had me go through and in the end the in-house reps did not have the authority to authorize a replacement pump. The issue was referred to my local trainer. 

When my first X2 had weekly occlusion alarms for many months, I met with this trainer to review my technique on reservoir fills and infusion sets. We have a good relationship and when she heard that I had experienced 5 occlusion alarms in 9 days, she arranged for an immediate X2 replacement. The new pump arrived within 24 hours and I have been happily carrying the case-less pump in my pocket. So far there have been no occlusion alarms and I am cautiously optimistic that my problem is solved.

Although I am happy with the new pump, I don’t seem to be able to stay away from Velcro. Maybe it is an addiction…. Or maybe it is just the inability to accept diabetes tech when it doesn’t quite fit into my life. Soon I will be heading to South Carolina for a few days in the ocean and pool with grandkids and family. After that I am having hand surgery. Both occasions require a clip on the pump. 

The Tandem case with a clip would work for the surgery but not for the beach. I want a clip on my pump to attach it to the pants portion of my tankini swimsuit and the case would work for that. But when I am in the water, I want to use my Aquapac pump case (actually a Radio Microphone case) purchased many years ago as a waterproof case for my Medtronic pumps. It is an expensive and somewhat bulky solution that allows me to wear my pump strapped around my waist with guaranteed water protection. The Tandem case is too large to fit into the Aquapac. 

So I am back to a Nite ize Hip clip applied directly to my pump. Rather than using the two-sided tape that comes with the clips, I use Scotch Outdoor Mounting Tape because it is equally strong but much easier to remove. Unfortunately the Nite Ize clip is only marginally better than the Tandem clip when it comes to falling off my waistband and I applied Velcro hook pieces to both sides of the clip interior to provide some grip. People on Facebook have reported using heat shrink on the Tandem clip but I am not sure how that would work with the different design of the Nite Ize clip. And anyway, Velcro is what I know and Velcro is what I have in my junk drawer.

Today I have a new pump that seems to accept living in my pocket without a case. I have a Nite Ize clip applied directly to the pump which allows me to clip the pump to my swimsuit but is small enough to fit into various pockets and the Aquapac pump case. The clip is attached to my pump with a strong tape that is easy to remove when I decide to go clip-less or use the case instead. 

Pump. Clip. Velcro. No occlusions. That just about sums it up.

Tandem Occlusion Alarms: Crying Uncle

Last week I published a blogpost addressing my annoyance with false occlusion alarms on my Tandem X2 insulin pump. Periodically Tandem techs have advised me that using a case might eliminate the alarms and that has actually been my experience. But I hate the case which makes the pump heavy and bulky instead of slim and sleek. Thinking that maybe adding something to the pump to protect the vent holes might mimic the case, I experimented with attaching a black plastic ring to the back of the pump. 

A few hours after publishing the blogpost, I added an update:

7/26 Late Morning: Unfortunately my science experiment is already a FAILURE with an occlusion alarm during basal delivery this morning. I totally jinxed myself by publishing this blogpost. In defeat I have already taken off the black washer. I spent 45 minutes on the phone with Tandem and the pump passed all of the tests. Of course it would because the pump works fine most of the time. I even changed my cartridges every 3 days for the last week and a half and got 4 alarms within the last 8 days. The issue has been sent to the local rep and I guess I can try to work with him to get a replacement pump. But I am not convinced that a replacement pump will matter. Why do I get these alarms and so many people don’t???😩😩😩

In my typical stubborn fashion, I put the case-less and clip-less pump back in my pocket. Fast forward to Saturday where I had another occlusion alarm—the 5th alarm in 9 days. (Please note that these alarms stop insulin delivery so they are a serious problem.) Not only did the blogpost jinx me, one of my Facebook friends who never gets occlusions got an alarm on her X2. Then another friend got an occlusion on his Medtronic pump. Occlusions are spreading like wildfire through the diabetes pumping community!

Maybe the wildfire remark is an overreach, but I cried uncle and put my pump in a t:case vowing to wear it clipped to my waistband. Unfortunately I had previously broken my black case  and was stuck using the pink case which I don’t like. Boy, do I sound like someone with a severe case of #1stWorldPrivilege! In my defense, Amy Tenderich of Diabetes Mine figured out a long time ago that design is important for diabetes devices and her 2007 “Open Letter to Steve Jobs” went viral.

The 24 hours that I wore the pink case reinforced now much I hate it. Both the shade of pink and the amount of black showing through the cutouts bug me. I decided to purchase a new case and was disappointed that black is out of stock in the Tandem Online Store and at Amazon. So it was back to the drawing board. I devised a minor engineering solution to secure the Tandem clip to the broken case by using Velcro in place of the missing plastic anchor strip. So far it is working and my fingers are crossed that the fix will be durable. The Velcro does double duty by adding “grab” to help prevent the pump from sliding off my waistband, an unfortunate common t:case problem. 

So it has been another-day another-adjustment to diabetes tech. If I continue to get occlusion alarms on this pump, I will now be totally justified in battling for a replacement pump. If a case solves the alarm problem, I should be happy. But I will still be frustrated. Frustrated that Tandem promotes the small size of the X2 with photos of the case-less pump. Frustrated that many people use the t:slim successfully without a case and I can’t. And maybe most importantly, frustrated that I still don’t understand why.

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7/30/18 Afternoon: I need to stop publishing blogposts because once again my fix that was successful for two days FAILED. The clip slipped out of place and the pump fell off my waist mid-morning. Ugh! My latest solution to prevent going back to the pink case is to attach a Nite Ize clip to the back of the case using strong outdoor adhesive tape. There are various pieces of Velcro on the inside of the clip to make sure the pump stays put. Although I do not miss my Animas pumps in many ways, I do miss the clip that easily attached to the pump and held it tightly on my waist.

Tandem Occlusion Alarms: An Engineering Experiment

I began using the Tandem t:slim X2 insulin pump in December 2016. Since then I don’t think that I have written a blogpost about the pump without mentioning false occlusion alarms. In my first review of the pump, I wrote:

“I have used the Tandem t:slim X2 for almost 10 weeks. In that time I have had 9 occlusion alarms resulting in an immediate stoppage of insulin delivery. The first couple of times I panicked at the shrieking pump alarm fearing that something was actually wrong. Nope. Not once has there been a problem that did not disappear by working my way through the menu screens and pressing “Resume Insulin.” The vast majority of these alarms have been while delivering meal boluses, but not all.”

Periodically I have thought that I have solved the problem and interestingly I have had completely different experiences with my three X2 pumps. Pump #1 got weekly occlusion alarms during the first four months of use. I eliminated the alarms by either using a case or wearing the pump on my waistband with a Nite Ize Clip. But I hated those solutions and eventually went back to carrying my case-less and clip-less pump in my pocket. For no discernible reason the occlusion problem didn’t reoccur and I only had two or three occlusion alarms in the next 11 months. In February 2018 Pump #1 was replaced due to a battery failure. I only used Pump #2 for a month due to a defective T-button. But in that time I did not have a single occlusion alarm.   

Then I got Pump #3 and immediately returned to weekly occlusion alarms and sometimes two or three a week. I figured these alarms were the price of refusing to use a case or clip and I just lived with them. Then a couple of 2-alarm days convinced me that enough is enough. I dug the case out of my supply box. The pump became heavy and large with the case and would no longer would easily fit into the waistband pockets of my workout pants and pajamas. Total PITA. But I didn’t get occlusion alarms. Hating the case, I went back to the Nite Ize clip with the pump on my waistband. And ugh, I started getting occlusion alarms again.

So now my question became: Why does the case eliminate false occlusion alarms? A Tandem tech rep once told me that the case eliminated temperature fluctuations that occurred when I took the pump out of my pocket to enter a bolus. Seemed kind of far-fetched and if that was the case, why doesn’t everyone who carries the pump in their pocket get occlusion alarms? And when I was wearing the pump on my waistband with a clip, why did I get occlusion alarms because there was no temperature change?

My current hope is that the case works because the cut-out over the pump vent holes stops the vents from being blocked during insulin delivery. How could I replicate that without using a case? On Tuesday I went to the nearby Ace Hardware and wandered down the aisle with screws, washers, nuts, springs, etc. I bought a couple of gizmos including black plastic rings with a hole large enough to protect the 6 vent holes on the back of the pump. (It should be mentioned here that there are constant discussions on Facebook about the purpose of these tiny holes and some people swear that they are only for sound. A Tandem tech rep recently told me that the holes are dual-purpose and function both as vents and speaker holes. So that’s what I am choosing to believe.) I also bought 2-sided adhesive strips. 

Working in my kitchen laboratory, I used a hole puncher to cut a perfect-sized hole in the adhesive and then used scissors for the outer circle. Carefully I attached the ring to the pump. Voila! (It wasn’t quite that simple so if my experiment is a success, I will share more detailed instructions.)

It will take a week or two to see if this MacGyver fix works. I started a new cartridge yesterday and I rarely get occlusion alarms until the cartridge measure 80-120 units. If I make it a week without an occlusion alarm, I will have to see what happens with my next cartridge. And then another. 

Diabetes. A science experiment that sometimes requires engineering solutions.

7/26 Late Morning: Unfortunately my science experiment is already a FAILURE with an occlusion alarm during basal delivery this morning. I totally jinxed myself by publishing this blogpost. In defeat I have already taken off the black washer. I spent 45 minutes on the phone with Tandem and the pump passed all of the tests. Of course it would because the pump works fine most of the time. I even changed my cartridges every 3 days for the last week and a half and got 4 alarms within the last 8 days. The issue has been sent to the local rep and I guess I can try to work with him to get a replacement pump. But I am not convinced that a replacement pump will matter. Why do I get these alarms and so many people don’t??? 😩😩😩

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Other Comments: I truly believe that false occlusion alarms are related to a design flaw in Tandem pumps. I have so many questions. What percentage of Tandem pumpers experience these alarms? It is hard to tell because social media only attracts those having the problem. Are there common characteristics for those of us getting the alarms such as low TDD of insulin and small boluses? Or is it that certain pumps have overly sensitive occlusion sensors? I could go on and on with questions.

At the same time I want Tandem to succeed. I like almost everything about my t:slim X2 and I appreciate the innovation and good customer service that comes from this company.  There are few pump choices these days and my being on Medicare reduces that number even farther. My primary D-tech loyalty is to Dexcom as my CGM and I am unlikely to return to Medtronic although I was previously happy with my Medtronic pumps. At this time Omnipods are not a good financial option for many of us on Medicare and I have always been fine with a tubed pump. I am intrigued by Bigfoot Biomedical using the Freestyle Libre and keep my fingers crossed that it will be a future option for me. 

I do not follow all of the Tandem rules. Because of my low TDD of insulin, I refuse to change my cartridge every 3 days and throw away more insulin than I use. I change it about once a week while replacing my infusion sets every two days. This was how I operated on Medtronic and Animas and it works for me. With my first X2 I tried changing the cartridge every 3 days a few times and still got occlusion alarms.

I have always had superb customer service from Tandem. Although I am continually frustrated by false occlusion alarms, I do not regret my choice of the Tandem t:slim X2. If I had to choose a new pump today, I would probably choose the X2 again.

But false occlusion alarms are a problem.

*****   Relevant Links   *****

A Review of the Tandem t:slim X2

A 5-month Review of the Tandem t:slim X2

Tandem t:slim X2 and Dexcom G5: It Takes Flexibility

Tandem t:slim X2:  Experiments with Clips and Cases

In early August I wrote a review of the newly-released Tandem t:case. My views of the case were mostly favorable but I wrote one sentence that was more significant than I knew at the time: “IMO the clip is slightly too short when wearing the pump vertically and is not as tight on my waistband as I would like.”

A month after the Dexcom G5 software update for my X2 pump, I revisited the case issue and wrote: “Wearing the pump on my waistband has brought back the problem that the clip on the new case is neither tight enough nor long enough to keep the pump secure in the vertical position. Over two days it fell off 5 or 6 times.” I followed that statement with one case hack that failed and one clip option that was successful. I promised to experiment more and share the results in a later post. So here we go.

Three Successful Hacks

Success #1:  Knowing that Velcro is my hack solution, I applied a square of Velcro (hook side) to the back of my pink t:case. In one week of use, the pump did not fall off once. There was a little tugging and scratching of the Velcro as I slid it onto my pants, but it was a solid and reliable solution. The pump mostly stayed vertical but was easy to rotate when I wanted to see the pump screen.

Success #2:  I considered that the scratchiness of the Velcro might cause damage to the front of my pants. (Actually I don’t care because I always have a shirt or sweater covering my waist, but you might.) So my next experiment was to attach Velcro to the inside curve of the clip which would only come in contact with the inside of my slacks. This amazingly worked great and once again the pump did not fall off during the weeklong experiment.

Success #3:  In my September post I mentioned that I was using the Nite Ize Hip Clip attached directly to my pump. I removed the clip in order to do the case experiments described in this post. (To remove the clip, I carefully used an X-Acto knife to cut through the adhesive and peeled off as much of the tape as possible. Then I used a tiny bit of adhesive remover to get the last bit.)

After all of my experiments, I decided that the t:case added unnecessary weight to my pump and I went back to the hip clip applied directly to the pump. As before I had a small piece of Velcro (hook side) on the inside of the clip. Although the pump has never fallen off with this solution, it did spin more than I liked. So I added another piece of Velcro—the loop side this time. Just so you know, the Velcro FAQ calls this side “the softer mate.” Almost pornographic, isn’t it?  This provides enough friction (Stop the pornography!!!) to stop most of the tilting but is still easy to turn when I want to look at the screen.

BTW if you decide to apply a clip to your pump, be careful not to cover the vent holes. To give credit where due, I learned about the Nite Ize Hip Clip several years ago from Kerri at Six Until Me and Sarah at Sugabetic.

The Failures

Failure #1:  In my September post, I indicated that I had tried attaching a piece of Velcro to the curved tip of the clip. The Velcro solved the pump-falling-off problem but unfortunately made it difficult to slide the pump onto my waistband. Ultimately I broke the case by trying to open the clip wide enough to pull onto my pants. A definite user error and because I was given this case for free, I did not try to get a warranty replacement.

Failure #2:  To repair the broken case, my next hack was to attach a Nite Ize Clip directly to the case. It was a previously-used clip and I purchased 3M Scotch Outdoor Mounting tape to attach it to the case. I used a piece of Velcro on the interior of the clip as described above in Success #3. The 3M tape is guaranteed to hold 15 pounds and the clip stayed attached to the case with no problems. The issue was that like the Tandem clip, this clip was not tight enough to keep the pump on my waistband. The Velcro pad was not successful in dealing with the combined weight of the pump and case.

Summary:

I am currently using a Nite Ize clip applied directly to my pump. Two pieces of Velcro keep it secure on my waistband. Before the Dexcom G5 integration, I was content with the pump in my pocket and I used a case which seemingly prevented false occlusion alarms. Now I am wearing the pump on my waistband most of the time because of the convenience of seeing my Dexcom G5 info when I bolus. I have not had any occlusion alarms and I will keep my fingers crossed that they don’t reappear.

If I had to pick my favorite pump clip ever, I would pick the Animas clip which attached directly to the pump and was super tight. Tandem pumps are designed differently and the Animas clip layout wouldn’t work. At the same time I would argue that Tandem could have designed a clip that would keep a t:cased pump secure on users’ waistbands. But they didn’t. So know that Velcro is your friend and don’t be afraid to experiment. If you find a great solution, please share.

*******

Please note that I have not damaged my pump, clips, or cases (except the one I broke!) with these hacks. I suspect that you won’t have damage either, but I can’t guarantee it. So hack at your own risk.

Talking Types with Lloyd Mann

I first met Lloyd Mann four or five years ago at a Saturday diabetes meet-up at a local Panera Bread. He was sitting at the end of the table with a big smile, an iPad, and a copy of his book about diabetes. He was discussing the possibility of being tested for MODY because of insulin signaling problems. A resident of South Dakota at that point, Lloyd was in Minnesota visiting family and had previously hooked up with this group through online friend Scott Johnson.

Fast forward a couple of years and Lloyd now lives in the town next to me. We have begun to supplement the every-couple-of-months group meetings with one-on-one lunches at the Panera Bread near his home. Yes, our relationship is built on Lloyd’s love of tomato soup and “Scott Johnson-esque” grilled cheese sandwiches along with endless cups of Diet Pepsi (definitely not Scott-inspired but Panera doesn’t carry Diet Coke).

Lloyd and I are close in age. In diabetes we are simultaneously far apart and eerily close. Lloyd has Type 2 diabetes and I have Type 1 diabetes. In most ways we are stereotypical depictions of our diabetes types. I was diagnosed with diabetes as a young adult in the mid-1970’s. I was hospitalized in an unquenchable-thirst skeletal state with high blood sugars and large ketones and have never had a day since then without injected insulin. Lloyd was diagnosed with Type 2 diabetes in 1994, took pills for many years, and then started insulin 11 years later. Lloyd’s insulin resistance is off the charts and on a daily basis he uses over 10 times as much insulin as I do. His story personifies the fact that Type 2 diabetes is a progressive disease.

So here you have two Medicare people with diabetes. Lloyd uses a Medtronic 723 pump and changes his 300-unit reservoir every day. When his warranty expires in January, he plans to move to a Tandem t:slim X2 pump and continue to change his cartridge every day. He likes the t:slim platform because unlike his Medtronic pump, it allows him to program a bolus larger than 25 units. I use a Tandem t:slim X2 pump. I change my cartridge once a week and rarely bolus more than 2 units at a time. Because Medicare CGM coverage does not exclude people with Type 2, Lloyd is in the process of obtaining a Dexcom G5 CGM. I use a Dexcom G5 CGM. Currently neither of us is using sensors provided by Medicare and we both wear an Apple Watch and carry iPhones. Lloyd and I are technology twins.

Lloyd and I are students of diabetes. Yeah, we are “Know-It-Alls.” You may like us. You may find us annoying. But we don’t care. We know our stuff and we want to learn more.

I recently asked Lloyd if I could interview him and we met at Panera two weeks ago. I did not record our talk so Lloyd’s answers are in my words with scattered quotations. I also throw in an occasional comment.

Lloyd, I know that your diagnosis story is in your book but please give me a short timeline. I was diagnosed with thyroid disease in 1980. Fourteen years later at age 44 I was diagnosed with Type 2 diabetes. What was your reaction was to the diagnosis?  I just thought “Oh no, one more pill to take!” Do you have a family history of Type 2 diabetes?  Both of my sisters have Type 2 but neither of my parents did.

How long have you had diabetes?  23 years.

How long have you been on insulin?  12 years since 2005.

How long have you been on a pump?  Since 2005. Less than one year after starting insulin, I convinced my doctor to order me a pump. I had used Lantus followed by a mixed insulin and wasn’t having good results. I did my homework and presented my doctor with a list detailing why the Deltec Cozmo was the best fit for me. Rather than specify Type 1 or Type 2 in the letter of medical necessity, he just put “Insulin Dependent” and I was immediately approved for pump therapy.

You indicated that you will be purchasing a new insulin pump in January. What features are important to you as you make that decision?  I need a pump with multiple basal rates. I currently use 8 different rates and my highest hourly rate at 3:00AM is 5 times as high as my lowest rate. Because of high insulin requirements, I require a 300-unit or larger reservoir and the option of taking boluses bigger than 25 units. I also need to be able to set an insulin sensitivity factor of less than 1 unit per 10 points. (As someone with Type 1 who is very sensitive to insulin, I want to put multiple exclamation marks after each of those numbers!)

I am planning to order a Tandem t:slim X2 to replace my current Medtronic pump. Although the  t:flex has a larger reservoir, I prefer the upgrade features, Bluetooth, and CGM capabilities of the X2. I am used to changing my reservoir every day and will continue with that practice. I expect that my total daily dose of insulin will go down using the X2.

Tell me about your decision to order a Dexcom G5 CGM. How do you think it will help you? I plan to use the G5 to help reset basal rates. Although I use more insulin now, the basal patterns are the same as I figured out using the Abbott Navigator over 6 years ago. I rarely get lows (insert another exclamation mark here!) but need a CGM for highs. I have always been forgetful and that is increasing with age. My  insulin mistakes are almost all related to forgetting to bolus and the CGM will alarm when I forget and my BG soars. I’ve been working with Dexcom since earlier in the summer and I am “waiting as fast as I can” for the arrival of my G5.

So Lloyd, what do you think of the Medicare ban on smartphone use with our G5’s?  “You can’t print that.”

What year was your book published and why did you write it?  Successful Diabetes Management was published in 2011 and I wrote it because I was doing well managing my diabetes and wanted to help others. I chose the cover from Amazon’s stock photos and the image spoke to me as “Follow the Path” to good diabetes management.

I had also been one of the many people at Diabetes Daily who knew Richard Vaughn and goaded him to write his book published in 2010–Beating the Odds, 64 Years of Diabetes Health. After Richard’s book was published, he contacted me and said “Your turn, Lloyd”.

Lloyd continues his mission to help others with Type 2 diabetes and his Diabetes Daily forum sticky note titled Type 2 in a Nutshell has over 16,000 views. He was previously a moderator at Diabetes Daily.

As we consider Type 1 and Type 2, Lloyd, how do you think our diabetes lives are similar?  Our daily tasks are the same. We count carbs, we bolus, we deal with highs and lows, we test BG, we change pump sites. And most importantly, we live with fear of complications.

How are our diabetes lives different?  My lows are not nearly as debilitating as yours and my risk of DKA is about 1/20th of yours. I think that people with T1 can eat a bigger variety of foods than a T2 aiming for tight control because they process food more normally and insulin works better. (Like many people with Type 2, Lloyd’s weight issues are intensified by high insulin use.)

What is the hardest part of diabetes for you?  “It’s forever” and “knowing what to do and doing it are two different things.”

What are your thoughts on Type 1 versus Type 2 diabetes?  I think that the naming of Type 1 and Type 2 leaves a lot to be desired. Type 1 and Type 2 are based on how you got to where you are but they don’t always address where you are. Type 2’s need to restrict carbs more than Type 1’s and we also have a problem with our livers. Metformin addresses that and I am still taking it after 23 years of diabetes. I think that my diabetes is more predictable than yours.

As this stage of your diabetes career, do you identify more with people with Type 1 or those with Type 2?  My day-to-day life is like a Type 1. My medical team thinks that I have completely quit producing insulin and that is unusual for Type 2. I have more in common with T1’s than with T2’s on pills.

Conclusion:  I asked Lloyd if he had any questions for me and he wanted my opinions on hiking and exercising. We talked about lows and he indicated that he used to get lows on older Type 2 medications and when he used to walk a lot. But he has rarely gotten lows since moving to insulin 12 years ago. Sometimes I think that my Type 1 diabetes is most defined by 40 years of lows: while driving, while taking care of my children, while mowing the lawn, while wandering lost at the mall, while peering up at concerned policemen and paramedics. Even with improved CGM technology which now mostly protects me from severe lows, my treatment decisions are always influenced by the possibility of lows and I might argue that’s the biggest difference between Lloyd and me.

Do lows make me have the “bad” kind of diabetes compared to him? No, because lows mean that my insulin is working. I can’t imagine the frustration that Lloyd must feel when oral medications in addition to hundreds of units of insulin daily are required to tame his blood sugar. Metabolic syndrome and insulin resistance are powerful opponents and I kind of wonder if my life is easier.

When I look at the differences between the types of diabetes, I mostly end up in the “I don’t know” and “I don’t care” camp. I don’t want to fight about labels, blame, stigma, cost, and who’s got it worse. I just want and need the appropriate care for my diabetes and I think that Lloyd would say the same thing. Diagnose me correctly and treat me correctly. That’s not asking too much.

In summary, I would say that the most fitting end to this blogpost is that no matter how you look at it, Lloyd Mann and I are just friends who both happen to have diabetes. Types don’t matter.

Tandem t:slim X2 and Dexcom G5:  It takes Flexibility

Last Wednesday I received my email from Tandem with the upgrade code to add Dexcom G5 integration to my pump. A great feature of the t:slim X2 is the ability to perform software updates at home rather than need a hardware replacement every time new capabilities are added to the pump. This first X2 software update adds Dexcom G5 receiver functions to the pump in anticipation of future updates adding threshold suspend and other insulin dosing algorithms. Tandem has a catchy slogan for the X2: “The pump that gets updated, not outdated.”

My Upgrade Experience

I followed the instructions for the upgrade and for the most part, it went well. I had one glitch where an error code indicated that my pump was communicating with another device. I restarted the upgrade and everything went fine. I had not been using my Dexcom receiver and I was assured by other X2 users on Facebook that I could leave the G5 app running on my iPhone and Apple Watch. (Note: the Dexcom G5 transmitter can only communicate with one receiver and one smart device. You cannot use the X2 and the G5 receiver at the same time.)

For the first hour I received an unbroken every-5 minute tracing of my Dexcom readings. After that it went haywire and I got only 2 readings in the next hour. I continued to get multiple Out of Range alerts as the day went on.

When you use a tubed pump, your pump is never far away from your CGM transmitter. My Tandem pump was in a pocket. My Dexcom transmitter was on my arm. My iPhone was on the table, in a pocket, in the kitchen, in my purse and not missing a dot. The pump was struggling with 12 inches.

I called Tandem twice over the next couple of hours and with a little troubleshooting it was apparent that I shouldn’t be having such problems. As always, the Tandem reps were helpful and the second rep indicated that many similar problems had been solved by a new transmitter. My current transmitter has been in use for a month and seemingly fine, but I wasn’t going to argue with trying a new transmitter.

I received the new transmitter on Saturday and will begin using it with my next sensor.

Meanwhile I have begun to get better communication with my Dex sensor, but it is not because the pump is better at picking up the signal. It is because I am making changes. I initially kept my pump in my left front pocket with the sensor on my right arm. I am now wearing the pump clipped to my waistband on the right side. I still lose signal when I sit in my normal “easy chair” and my arm is against the back cushion. (My phone does not lose signal in this scenario.) But I am getting better at moving to the right side of the chair and keeping my arm on the armrest so that the transmitter is not obstructed. I prefer my pump in my pocket, but I can get used to the waistband.

Basically I am being flexible to make things work.

Pump Case

Somehow every change I make impacts something else. Wearing the pump on my waistband has brought back the problem that the clip on the new case is neither tight enough nor long enough to keep the pump secure in the vertical position. Over two days it fell off 5 or 6 times and was saved from hitting the floor only by yanking on my infusion set. Miraculously the infusion set never ripped off. I decided to do a hack of adding a piece of Velcro to the tip of the clip. Bad hack. The Velcro made it difficult to slide the pump onto my waistband. Ultimately I broke the clip off the case by trying to open it wide to pull onto my pants. Definitely user error and because I was given the case for free, I will eventually just order another one.

Second hack. I am back to using a Nite Ize Hip Clip that is attached directly to the pump. When I used this clip a few months back, it also tended to fall off my waistband but not as badly as the Tandem case. This time I put a small piece of Velcro on the pump side of the clip and it hasn’t fallen off once. Of course so far it is only a 3-day experiment.

I am not done yet with figuring out a case hack and think it will involve a Nite Ize clip attached to the Tandem case and a small piece of Velcro. Or maybe just Velcro attached to the case using the Tandem clip. Although the Hip Clip attached directly to the pump is working OK, I prefer the protection of a case. My false occlusion alarms were eliminated by using a case and I am hesitant to go without one. I’ll definitely write another blogpost once I decide on an ultimate fix.

Summary

I like having my G5 information on my pump and I will continue to be as flexible as possible to make it work. Although there is some frustration that my relationship with the X2 is a bit temperamental—first due to occlusion alarms and now to CGM reception—I am still very happy with the pump. In general if I go back and look at the  various pumps and CGMs that I have used since 2005, they have all required me to learn, change, and be flexible to ensure success.

Medicare?

Now I get to the nitty-gritty of this newest update. What are the Medicare repercussions??? I’m flexible, but I can’t say the same thing for Medicare.

I have discussed more than once the stupidity of the Medicare ban on smartphone use for Dexcom G5 users. I’m not going there today. However, I have been hoping that because the Tandem X2 is durable medical equipment (DME) and not a smartphone that I will be able to use it as my CGM receiver instead of the Dexcom receiver.

When I read the Noridian Medicare coding and coverage document released in March, I do not believe that the X2 violates the guidelines:

“Coverage of the CGM system supply allowance is limited to those therapeutic CGM systems where the beneficiary ONLY uses a receiver classified as DME to display glucose data.  If a beneficiary uses a non-DME device (smart phone, tablet, etc.) as the display device, either separately or in combination with a receiver classified as DME, the supply allowance is non-covered by Medicare.”

Unfortunately I have heard from several sources that Dexcom is instructing Medicare customers that current Medicare instructions mandate use of the Dexcom receiver. I suppose justification for that comes from the first sentence of the Noridian document: “The Dexcom G5® Mobile CGM System is currently the only FDA-approved device with a “non-adjunctive” indication.” Although my Tandem pump works with the G5 Mobile CGM System, it is technically not part of the system according to Medicare. Some Tandem pumpers have also been told by Tandem that the X2 is currently not approved by Medicare to be used as a Dexcom G5 receiver.

I continue to be optimistic that Medicare regulations regarding the Dexcom G5 will be changed to allow use of a smartphone and use of the Tandem X2. I have no predictions for a timetable for those changes. In the short run I am still using Dexcom supplies purchased before Medicare and continue to use my iPhone, Apple Watch, and Tandem X2 pump. In the long run I will follow Medicare regulations because CGM coverage is too valuable to risk losing that coverage.

As always with diabetes, I will be flexible.

 

My Review of the Tandem t:case

On the surface it seems that designing a case for an insulin pump should be an easy task. The new t:case for Tandem t:slim pumps demonstrates that it is actually more complicated than that and that it might be impossible to design one case that will make everyone happy.

Two weeks ago the news spread like wildfire around the Tandem community that we could finally order the long-awaited t:case. A limited selection of colors was offered at that time, but the full spectrum (Black, Blue, Olive Fatigue, Pink, Purple, and Turquoise) is now available on Amazon. Some colors are in stock with others back-ordered until August 5. The Tandem online store continues to show most colors as “Coming Soon” but keep checking. The introductory price of $19.95 is guaranteed until August 31 after which the price may increase to $24.95.

The previous t:clip case was available in fun mix-and-match colors. It looked great, but had major problems with a top heavy design and the tendency to fall off user waistbands. The clip was too bulky for pocket use although some women liked that it was easy to attach the pump to their bras. Frequent breakages and replacements were common. I personally hated this case. Some users liked the t:slider case and I used the removable part of that case in my pocket.

The t:slider case has not been available through the Tandem online store for many months and the remaining stock of t:clip cases shows availability only in Flash Green and Sunset Orange. Leatherette cases are still offered and include the t:flip, the t:holster, and the t:wallet.

One thing I like about Tandem is the importance of design. The t:slim is a sleek and modern pump and I don’t think that Tandem would be satisfied with a case that wasn’t equally attractive. I also think that after the track record of the flawed t:clip case that it was important to “get it right” this time.

So did they get it right?

Yes and no.

The Yes:

The case is made out of what seems to be a very strong plastic and there is no flimsy clip or hinge to break. I think that the case will be durable and provide excellent protection for my pump.

The cutouts make a lot of sense and allow the user to charge the pump and change cartridges without removing the case. (That is good because it is not easy to remove the pump from the case.) My photo below shows a view of the back of the case with the many cut-outs.

The removable clip allows the pump to be worn in a vertical or horizontal orientation. For those  who carry the pump in their pocket, the clip can easily be removed. However, it is so low profile that you won’t be bothered by just leaving it on. The clip is made of stainless steel and seems unlikely to break or bend.

The No:

In my opinion Tandem made a mistake in how the clip attaches for horizontal wear. Those who wear the pump horizontally usually do not want to remove the pump from their waistband to see the screen or program pump functions. Therefore it makes sense for the pump to be oriented upside down so that when it is lifted up it is right side up for the viewer. The t:case orients the pump so that it is upside down when the user lifts it up. This is a big problem for those who are using the t:slim G4 for their CGM data and for those X2 users who will soon be able to see their Dexcom G5 data. Another annoyance about this clip position is that the tubing comes out at the bottom of the pump which increases the opportunity for tubing to hang down below your clothes and to jump out at doorknobs.

The Meh:

The t:slim screen is turned on and off by pushing the silver T:button at the top of the pump. My guess is that I push that button 30 times a day. For unknown reasons Tandem added a plastic cover over this button on the t:case. Previous cases just have a cutout. Unfortunately I found that the button cover made it difficult to turn on my pump. Sometimes it worked the first time; other times I had to push the button 4-5 times. I have arthritis in my hands and am unwilling to tax my joints just to turn on my pump.

Fortunately this was a problem easily fixed. The photo below shows my X-ACTO knife solution.

I found the clip to be quite secure when wearing the pump horizontally, but as I explained above, lifting up the pump to an upside down view doesn’t work for me. IMO the clip is slightly too short when wearing the pump vertically and is not as tight on my waistband as I would like. But it is okay and I know to be careful.

Tasks like removing the pump from the case and changing the clip orientation are not straightforward and no instructions are provided with the case. Fortunately there are instructions available on the Tandem website but that link is not included with the case.

User Feedback on Facebook:

“After wearing my pump all day in the new case, I have to say, I really like this new style case…ALOT! “

“I love my new (pink) case so much I now also have a black one and a purple one on backorder lol”

“Okay, so I may be the odd person out, but I’m not feeling the new case. I don’t like the clip…”

Addressing the cover on the silver T:button — “I’ve found mine getting easier to press- although it’s possible that it’s just my hand getting stronger”

“I just received the new hard case they have designed. No more plastic clips!! Has a metal clip and you can change the cartridge without taking the pump out of the case. I love it!”

“Anyone else annoyed that the pump is upside down with the new t:case when you look at it?! Why didn’t they put the clip on the other side?!”

Addressing the clip placement for horizontal use — “My understanding is they took in feedback from a lot of pump users so either no one thought of that or there were technical limitations that prevent it or they ignored the user feedback.”

“I love it! It’s way more comfortable to wear, and it doesn’t dig in like the old style did. And best of all…it isn’t top heavy anymore!”

“I really still don’t like it. I can’t put it in the center of my bra, which is where I normally wear it, and it won’t stay on my waistband. Putting it in my pocket makes my pants slide down and/or the tubing hangs out.”

“Just got the new clip for the pump but it didn’t come with any information on how to put it on can anyone help me out with this??”

“How do you flip the metal clip on the new case?”

“It is great. I can use the clip on a pair of shorts or put it in the pocket of my trousers without removing the clip.”

“My new T:case came…. WHEEEEE!”

Summary:

I am happy with my t:case. It is compact, functional, and attractive. Although I think the clip design makes a horizontal orientation an unlikely wear for me, I am satisfied to use it vertically or in my pocket. I have previously written that my problem with false occlusion alarms on my X2 was solved by using a case. Whether it is a temperature issue or the cutout for the vent holes, the cases have completely eliminated my alarm problems.

I think that no one could create a case that would please everyone. We each have unique needs and opinions. The t:case is mostly a win for Tandem, but IMO the horizontal clip position is a big problem—especially for integrated CGM use. I know that Tandem had many customers test drive the case and I wonder why the horizontal wear issue was not fixed. Also, did they consider older and disabled users? If it were not for my X-ACTO knife, I would not be able to use this case because of the difficulty of using the T:button. And I am not really that old or very disabled….

Here is a short instructional video about the t:case. I am currently using a black case but also ordered a pink one. In terms of color, I think that the video depicts the color of the cases much better than the Amazon photos.

 

Please note that this post discusses the t:case for the t:slim, t:slim G4, and t:slim X2 pumps. The t:case 480 is for t:flex pumps and is available in black and purple. The t:case 480 only allows a vertical orientation because of the larger insulin cartridge.