How useful is the IOB feature on pumps? And other questions...

[Gary_W]

Evening all,

As stated in another thread, I'm hoping to get a trial of a pump soon (though soon varies hugely in its scope and definition). I'm jumping the gun here by a long, long way I suspect but I like to get things sorted so I'll be in a better position to do the right thing when the time comes. It was alluded that I may get a choice between an Accu-Check Spirit, a Minimed (not sure if it's 522 or 722 or if I understand the difference) and an Animas (I think 2020). It's pretty difficult trying to decide between things, but when you don't know all the facts it's harder still.

I've had a good look at all three in terms of the websites and am trying to work out what is going to be important to me in terms of features.

One feature that I really like the sound of is 'Insulin on Board'. However, the implementation of this looks very simplistic on both the Minimed and Animas and the Spirit doesn't do it. From what I can see on both the Minimed and Animas, you tell the pump how long you think a bolus is active for in the setup menu. If you tell it 4 hours, I take it that it does the maths based on using 25% of that insulin per hour? If that's the case, it's a pretty useless feature for me. I use Apidra, and (when it's working) I recon on 70% being gone after 2 hours, then 15% per hour after that so it's all gone after 4 but it's far from an even absorbtion. My correction shots based on this 35/35/15/15 have tended to come right... Would IoB on a pump think that it was 25/25/25/25, and if so is there a work-around?

The only website that has a decent interactive pump is the Animas one, though I've managed to find good info on the Minimed too. The Animas website has kind of put me off the Animas pump as it seems to involve a lot of button pushing to do a bolus. What I couldn't work out was that, when you use the bolus wizard and it calculates that you need, say, 7.2u of insulin, it still makes you dial that in rather than just asking you to press a button to confirm. The Minimed looks like it puts that amount straight in there. Can owners let me know if this is the case?

I don't think I'd use the food database on the Animas; one slice of my brown bread may not equal yours. If I'm at home, I weigh it on my Salter diet scales that do an outstanding job. They strike me as less fiddly than the interface on the pump. Also, it looks rather rife with US foods, so I doubt it would find use in my life. Anyone want to give me a good reason why I could use it?

The Spirit looks most flexible in terms of basal rates; you can set every hour individually from what I can see wheras the others do 4 or so different rates per day? Would anyone need more than 4 basal rates per day? My main reason for wanting to pump is problematic basal rate variations, though I'd be shocked if I couldn't get it right with 4 different basals in a day... It also looks like the software allows Accuchek meters and the pump to download to the same software for profiling which looks very useful. Does this software come with it, and is it any good? I currently use an Ultrasmart meter which I'm very happy with but this looks like one up for the Spirit in this department.

All seem to do several bolus types, and I guess you can do the 'super bolus' on all of them (which sounds good for a carby meal which I do occasionally do :D ) Any particular pros and cons of each?

Do any of the pumps alter the bolus ratio based upon time of day? I'm sure I'll find this out on the websites, but haven't seen it so far. I know the Spirit doesn't as there is no bolus wizard type thing.

If you made it this far, thanks for reading!

Gary

[Funnygrl]

IOB isn't quite as simplistic as you make it sound. They base the amount of insulin it uses on the curve of action of the insulin, not a simple 25% after each hour math.

I find IOB EXTREMELY helpful both in terms of knowing how much I need for a low and in terms of preventing stacking and correcting too soon.

The Spirit is NOT better at basals than the Paradigm or any other pump. On all the other pumps you set the time frame, and the rate for that time frame. You can set it by the half hour. The Cozmo and the Minimed allow up to 48 rates per profile. The Animas allows 12. So the Cozmo and the Minimed are both actually better with basal rates than the Spirit. And you don't have to set it by the hour- you set it by the time frame.

All the pumps allow you to download the pump and a meter.

None of the pumps technically have a super bolus as a feature, but all of them can do a super bolus.

Overall, the Spirit is WAY behind the Paradigm, Animas, or Cozmo in terms of features.

All of the pumps let you alter carb ratio, bg target, and ISF by time of day. The bolus calculators are actually VERY helpful.

[David]

Knowing the IOB is VERY important to me. While I usually use my pump's wizard, I sometimes want to overide it and knowing my IOB helps me make an informed decision.

David

edited to add, I tend to agree with FG about the Spirit

[Gary_W]

Funnygrl and David - thanks for your replies.

Funnygrl - please can you give a little more detail about the IoB feature? How does it know what the response of the insulin is, as you could potentially be pumping Humalog, NovoRapid or Apidra and they all differ. If and when this happens for me, it will be Apidra I would stay with (well, that's my current perception). I just don't see how the pump 'knows' the profile as the only bit I could see to fiddle with was 'how many hours does it last?'

It's good to know about the basal rate abilities of the pumps, and that you can do different ratios and ISF's per time of day. So far, the Spirit is certainly sounding like the most basic of the three though to be fair I'd be delighted by any one of them at the moment. Given the choice, my current one would be the MiniMed. As the MiniMed is the pump they give everyone at the moment, that might even make things easier as the trainer here will be most familiar with that. I don't perceive of any training issues (I was an engineer for 17 odd years before I started selling things) and if anything has buttons and menus I'm typically right at home.

Gary

[w5wjp]

You tell the pump how long the insulin will last. It is done this way because it is different for everyone.

[xMenace]

I think it's very valuable, but I don't use my pump's smarts. I do it all in my head. I suppose this helps me get into trouble, but there are times when IOB doesn't work. When I have a bad set, either the insulin doesn't work at all or it kicks in up to 8 hours later. 30+ years of scar tissue will do this to you.

[Subby]

Just a quick note for Paradigm users: you can get to an IOB reading of sorts this way:

Go into Bolus wizard, dial in any blood sugar and proceed to Estimate Details screen. If you scroll down you will see your current Active Insulin (this is IOB or BOB, to my understanding)

(note: not putting in a BG will give you an n/a)

I'm not sure if the IOB features on the other pumps give more information, but just this figure alone can be very helpful as has been mentioned. Why they couldn't put this very useful figure in the Status screen is absolutely beyond me.

[Funnygrl]

Just a quick note for Paradigm users: you can get to an IOB reading of sorts this way:

Go into Bolus wizard, dial in any blood sugar and proceed to Estimate Details screen. If you scroll down you will see your current Active Insulin (this is IOB or BOB, to my understanding)

(note: not putting in a BG will give you an n/a)

I'm not sure if the IOB features on the other pumps give more information, but just this figure alone can be very helpful as has been mentioned. Why they couldn't put this very useful figure in the Status screen is absolutely beyond me.
Keep in mind though, if you use Carelink, putting in "any bg" will cause "any bg" to show up in Carelink, and will skew your averages in daily totals.

I really wish they would just put it on the status screen already!

[Subby]

Thanks for that info funnygrl, I haven't been using carelink. How about if you cancel the bolus right at that point? It still records the BG you put in?

[Funnygrl]

As soon as you hit "Act" after the bg, it's recorded. If I just tested, know I don't need a bolus, and don't care about knowing IOB at the moment, I pull a B, bg, act, esc manuever to get the bg in there quickly for future reference on Carelink.

[JJM335]

Evening all,

As stated in another thread, I'm hoping to get a trial of a pump soon (though soon varies hugely in its scope and definition).
Gary

Gary:

This is a bit "off topic" but how did you go about getting on the list for a pump? I have always understood that to qualify you need to have shown that you cannot get acceptable control with MDI (i.e. A1c>7.5) or you have other issues (e.g. hypo unawareness + severe hypos).

Like you I am getting frustrated at the limitations of MDI, I can do the boluses fine, but my basal requirements seem to diverge between night and day. Basically, I can get the night-time Lantus perfect. However, I am then going consistently hypo during the day (26 readings of <3.0 in the last month is way too many). If I drop the Lantus even 2U I go sky high at night.

I know that you have decent A1c's and are not making constant trips to the ER so how did you persuade your clinic to let you trial a pump?

Joel

[HollyB]

I think John Walsh has a comparison somewhere of how the different pumps calculate IOB -- anyone got a link?

It's been extremely useful for us with the Animas, which I know calculates along a curve with a peak at 1-2 hours and then a small "tail" or residual effect for the last hour. That would be a better match for Novorapid or Humalog than Apidra, I think.

It gives me a lot of peace of mind, especially when Aaron is sleeping over somewhere, that he can take his BG before bedtime AND factor in how much insulin is still active in his system.

6.9 looks a lot different if you've got 3 units of insulin still working away!

[Gary_W]

HollyB - This might be the link; it's a web address written down on p 50 of 'Pumping Insulin' (4th edition). I've read it twice and still don't quite get it... It references a 'table 2' and seems to think that tells you how to set your own pump for this feature, but table 2 is missing from this page. Anyone help with that? Index of Diabetes Technology pages: Insulin Pumps, Insulin Pump Comparison, Blood Sugar Meters, continuous glucose monitoring devices, noninvasive monitoring, diabetes software. (http://www.diabetesnet.com/diabetes_technology/dia.php)

Joel - I still don't know for certain if they will let me trial a pump. I'm just on the first rung of a ladder, and I'm not sure how tall that ladder is.

The way I got to this rung of said ladder was simply to ask. The most recent two British pumpers I've noticed around these parts have been Sharon (Shabbie) and Shane (Gobbly). At the time of getting the pump, neither had an HBA1c >6.5 (let alone what NICE says) and, if I understand it correctly, neither have disabling hypos. But both have pumps. Sharon and Shane - hope you don't mind me quoting your cases and apologies if I have hold of the wrong end of the stick.

So this said to me that the NICE guidelines have huge variants in how they are interpreted throughout the country, and as such the only way to find out locally is to ask. When I did so, the answer came back that it was possible, but what is 'required' around here is the say-so of the consultant and to have been on the DAPHNE course. You can then borrow a pump and potentially get one though I'm hazy on the details as to how...

I have not been on the DAPHNE course; I argued that I was assessed for DAPHNE last year and that the clinic stated my level of knowledge exceeds the DAPHNE course. For this reason, it would be a waste of my time and their money. For all I know, they could try and hold it up due to this local protocol. NICE says you must have been given education, my argument is that I educated myself here + reading plenty and that my education has lowered my HBA1c to <6 and lost me a whole bunch of weight whereas using their method I was sat firmly outside deaths door (slight exageration, but I generally keep a whole bunch better these days).

Anyway, until I get to see this consultant, all bets are off. Currently, this appointment is not scheduled until July. He may turn around and tell me I must do the DAPHNE course, for which there is now a 10 month wait. So I potentially have a long, long way to go.

The problem I have is that getting the pump is purely down to the LOCAL clinic's interpretation of the guidelines. If they choose to interpret them to the letter then I would have no chance, so I need these guys to be on my side. It is not something where jumping up and down looks like it will work, as it is their potential loosening of the guidelines that is giving me a chance in the first place. But it is incredibly frustrating and I don't really know what to do at the moment...

A little edit for those who don't know - DAPHNE (acronym is actually DAFNE) is Dose Adjustment for Normal Eating. It essentially teaches that 1 CHO is 10g of carbs or 5g of carbs or 15g of carbs (a very crude way of working out your ratio that counts in 5's) and is therefore (A) useless to me and backward compared with the way I do it and (B) completely useless for a pump when you can go in .1 u of insulin...

Gary

[xMenace]

I think John Walsh has a comparison somewhere of how the different pumps calculate IOB -- anyone got a link?




Index of Diabetes Technology pages: Insulin Pumps, Insulin Pump Comparison, Blood Sugar Meters, continuous glucose monitoring devices, noninvasive monitoring, diabetes software. (http://www.diabetesnet.com/diabetes_technology/dia.php)

[Funnygrl]

Ok, I feel bad being the American correcting this, but it's DAFNE- dose adjustment for normal eating.

[Gary_W]

Hi Funnygrl,

If you look at my (long) post, the last sentance acknowledges this; I realised I'd spelt it wrong throughout and thought I'd clarify; guess I didn't do a good job of that :)

[Subby]

It was clear to me :) The possibility of having to wait to do Dafne to prove your knowledge and commitment sounds ridiculous, you have so obviously covered all that and gone beyond it. Here's hoping the doctor recognises that.

You probably know this, but it may serve you well to act very positive about exchange theory when you do talk to the doctor. Whenever I give doctors my personal take on things against the manstream, (even when I think hey! Here's someone who will surely appreciate my initiative and discoveries) more often than not it completely backfires against me, even if presented in the most logical, rational of ways. Given the huge time and stress constraints of an appointment, I've found many doctors, most in my experience, will instead jump to the conclusion that you either don't "get it" or have emotional or rebelious issues, if given half a chance.

[JJM335]

Gary:

Many thanks for the info. In Scotland we are not subject to NICE guidelines, and it's certainly the case that for a number of the more controversial cases involving anti-cancer drugs, Scottish Health Trusts have been much more generous than in England.

That having been said, Scotland (despite having about the highest level of T1D in the world) has even lower pump usage than the rest of the UK. HOWEVER, the last time I talked to my Nurse/Educator at the clinic I attend, she did mention that they were considering starting up a pump group and I might consider it. Unfortunately, the Doctor (not the consultant but his No. 2) then stated that there was no way I would be eligible for a pump. They already think my A1c is "too low" (they think anything below 6.5 is in the danger zone) and that I have too many hypos. I need to persuade them that the hypo problem can't be solved by "relaxing" my targets but is fundamental to my basals.

My plan now is to keep the idea afloat and hope that when they start with pumps, they might consider me. They have consistently used me as a trialist and guinea pig over the 25 years I have attended the clinic and I am about their longest attending (?surviving) patient, which might give me a bit of an "in".

Joel

[Injecto]

Importance of IOB?

The difference between going to bed at 4.6 knowing you have .1 unit left and no more food in you vs going to bed at 4.6 with 3 units left and knowing you have no more food in you, or even if you do, you know you are taken care of.

To me, it's critical to control.

[Gary_W]

Importance of IOB?

The difference between going to bed at 4.6 knowing you have .1 unit left and no more food in you vs going to bed at 4.6 with 3 units left and knowing you have no more food in you, or even if you do, you know you are taken care of.

To me, it's critical to control.

Hi Injecto,

The question was how useful the feature is on a pump. I realise it is critical to control, and at the moment I work it out manually based on my belief of the response curve of Apidra. My concern is that all the pumps out there seem to do the IoB calcs slightly differently (several John Walsh articles are seeming to back that up) and the only parameter I can see that the user can change is 'how long does the insulin last?'. As far as I can see, this only gives the pump half the story as far as doing the maths correctly goes. In me, I believe Apidra lasts for 4 hours, but it is not a linear absorbsion. How does the pump know about the non-linearity of the insulin, as this depends on me and the insulin I take (neither of which the pump is informed of....).

From what I can see, a Paradigm does the maths differently to a Cozmo (e.g.). As this is the case, I am questioning how useful the feature is vs doing the maths yourself.

Gary

[lilituc]

Keep in mind though, if you use Carelink, putting in "any bg" will cause "any bg" to show up in Carelink, and will skew your averages in daily totals.

I really wish they would just put it on the status screen already!

It also shows up in your Daily Totals information on the pump, on the 522 and 722.

[Jenniferpark005]

Joel,

I am going to be starting my insulin pump in scotland on the 6th of May; Finally!

Firstly previous posters are correct: You need to ask.

When I decided that a pump may be a good Idea for me I phoned my clinic and I was told the waiting list was 2 yrs so there was no point getting an earlier appointment than my rountine yearly appointment.

When that finally came around 3months later, I was (un?)lucky enough to get one of the many junior doctors at my large clinic, I told him I wanted to be referred to the pump nurse at my clinic, and didn't stop talking about it until he agreed that he would send a referral letter.

I then phoned the nurses once a week to see if my letter had arrived.

When I met with the nurse 6months after my initial enquiry, we talked about my control, I need to take a lot of insulin and have never been able to get a good HBa1c with out going hypo alot. Even then there were large swings in my readings which are exausting!

I went armed with the guidelines and having already thought about how I fitted them and spoke to the nurse in an informed way. This worked and she recommended my case to the Doc who put me on the waiting list for funding.

4 months later my funding was approved in June 2007 and I reached the top 10 of the waiting list at the beginning of January. I start my pump on the 6th of May.

I even managed (another very long, very fraught story)to got my clinic to agree to an Animas pump! The first prescribed in scotland, because I felt it was the best pump for me.

I have done quite well through the whole process I think because I was informed. I requested pump therapy, I knew why and how I fit the guidelines, and I researched all pumps approved for sale in the UK found the best for me and fought for it.

Knowledge is power here. If you are having problems getting a pump and you feel you are eligable try contacting John at INPUT who specialised in pumping in the UK. He sent me a large amount of information which backed my claim that there were no rules constraining me to the pump brands offered by my clinic.

I am sure I read somewhere that if you are in a PCT which does not have a pump service you can attend one in another PCT and yours has to pay for it. INPUT will defiantly have info on that.

Sorry for the long post, but I have yet to here from another Scot wannabe pumper!:o

Back to the IOB, this is the feature I am most interested in when pumping since I take alot of insulin for little effect I can have a lot floating around my system at any one time. Having that tracked reliably for me I hope will help me finally get my HBa1c down without the many hypos from my previous attempts.

Jen

Joel I forgot to add that Quality Improvement Scotland (our version of NICE) have ruled that the NICE guidelines apply as much in Scotland as in the rest of the UK, so if you meet the Guidelines you should get the same treatment as someone in England

[xMenace]

Welcome Jen. Knowledge definately is power in this game :D

[HollyB]

"From what I can see, a Paradigm does the maths differently to a Cozmo (e.g.). As this is the case, I am questioning how useful the feature is vs doing the maths yourself."

Gary[/QUOTE]

I guess it depends on how good you are at math and at remembering when your last bolus was. It would be very useful for me!

[Gary_W]

Holly - The difficulty I have is that if I don't know how it works it out, I don't know if I can rely on it... I guess it will be a case of trying it and seeing when I finally get one :)

Jen - Welcome to the board. I'm glad that all of your persistance has finally paid off. It is very interesting that you have not been required to take further education in terms of DAFNE; I've had two PM's from British board members who have pumps and neither have had to go through DAFNE. It just seems like different areas make up different hoops to jump through but I guess we all knew that anyway.

I do go hypo a lot and this will be one of the areas I will concentrate on in my pump fight, but I've never yet had a hypo that I couldn't deal with myself. The current NICE guidelines seem to require disabling hypoglycemia, and its definition of disabling is to do with requiring the assistance of another. That's a real catch 22 situation. No-one with a driving licence would cheerfully admit to that as that's your car gone. Again, this bit of the guidelines gets interpreted entirely differently depending where you are and I'm hopeful of that changing. Hypoglycemia does not need to be in the 'unawareness and A+E' category to have a serious negative impact on your life.

I am frequently made late by hypos as one will turn up and require treatment meaning I cannot safely get in a car and drive. As well as feeling bad whilst a hypo goes through its motions, you have the sheer inconvenience of putting your life on hold until you are back in the world of good sense. Night hypos are a delight, as they tend to make me feel really hung-over in the morning after I've had one. Preaching to the choir here I know, but I bet if your average doctor tried a course of scary hypos several times a week they would soon change their minds as to what constitutes a negative impact on a patients life. I had a 2.2 earlier this evening and, whilst I was quite capable of getting my own juice and sorting it out, I feel completely wiped out now. As I'm getting older, the after effects of these just make me feel grim.

Incidentally, what made you go after the 2020 as opposed to the Spirit or the Minimed? It's interesting that you were able to get a week loan from the company; that might be worth looking into as well. As an aside, I emailed Minimed customer services over here with a question on Sunday. I still don't have a reply. I hope their customer service is a little better than this when you actually own a pump...

Gary

[Cyborg]

Unless I've had a high fat or high protein meal, I can usually trust the IOB stated by my pump. In those other situations, I tend to ignore the IOB and bolus as if there were no insulin on board. I tend to check my bg every 2 hours so most of the time I am able to catch it without it going too high or too low.