Back to basics! We’ve started a new monthly series called “Diabetes Connections Extra” where we take a look at the essential facts of diabetes. This time, we take go in-depth on insulin pumps.

Stacey talks to endocrinologist Dr. Jonathan Ownby about what a pump does, how to get the most out of one and what questions to ask. This bonus episode includes the entire, much longer interview you might have heard excerpted in episode 212.

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Interview Transcription:

Stacey: Dr. Ownby, thanks for joining me. I’m really interested to see where this conversation leads. Thanks. 

Oweby: No problem. Thanks for having me.

Stacey: All right, so before we get into the specifics, there’s so much to go over here. When we’re talking about an insulin pump, where do you start with your patients? You know, what’s the first thing? I assume it’s not: you’re diagnosed, let me get you in here and get this pump on you. But where do you start the conversation when you’re talking to people with diabetes? 

Right. First, I’d really just get their basic understanding of the disease by itself. So sometimes my patients come in and they you know, especially because we’re specifically gearing it towards type 1. They don’t know why they’re on a basal insulin. They don’t know why they’re on a mealtime insulin. So the first thing I ask them is do you know why you’re on these specific insulins? And if so, why are you, why are you on a basal? Do you know what a bolus is, because there’s a different degree of education for some folks. Some people already know why they’re on a basal plus bolus. Some people say well my doctor just told me to do this. So they have no idea of the importance of the two insulins. Once I get that information from them, then I can kind of move forward.

You know pump therapy unfortunately isn’t prescribed to type 1s as much as it should. There’s about 60 percent of the U.S. population that are type 1 that do not use insulin pump therapy. And that’s kind of a travesty because if you look at really the statistics, they’re about five or six times less likely to have a major hypoglycemic event that’s you know, having to call an EMS or get a visit to the ER because of a low blood sugar. So five or six times less likely on insulin pump therapy versus the multiple daily injections.

All right, so when you get the basal and the bolus insulin straight – and we did this in depth with my interview with Dr. Bryce Nelson earlier this year. We went through all of the types of insulin, how they work and what they do. Then what do you talk about when it comes to an insulin pump? 

Then, what are you doing with them is really talking about using a pump specifically and correctly. You need to know the carb ratio or how to calculate a carb ratio. So that’s what we go to next. Is, can you calculate a carb ratio? Now, of course, it’s my job to get the right ratio for the patient, but can they first understand why they’re doing that. But basically if a patient is coming and they don’t know and they’re type 1, I say, hey, you don’t have a pancreas. So when you sit down and eat a salad that’s a completely different amount of carb versus eating a chocolate cake.  And most of my type ones are normal weight. So I say, you know, you’re eating in moderation, you know what to do. You’re not overweight, but these carb discrepancies you’re really dependent on the insulin dosing. And we go from there make sure that they know how to calculate a good carb ratio.

Now when you say you don’t have a pancreas, I mean you’re exaggerating a little bit, right? I mean, let’s not…

Yeah, right. They have the exocrine part of it so they can they can digest the food. It’s just their beta cells are going out, but again, that’s why hypoglycemia happens too, because their alpha cells are gone. So again, you just don’t lose beta cells. But you also lose your glucagon which is your first line of defense for a low sugar. So again, that’s why pump therapy is imperative. Because after they can calculate, you know carb ratios, what I tell them is, or what I ask the patient next is, do you like doing the math? And most people don’t. The only patients that do are my engineering students that will get a spreadsheet out and this that and the other. Folks on the day-to-day basis do not like calculating their carb ratio, you know, or using their calculator because you can always make human errors as well.

So, the next thing I tell patients is well, what do you do when you eat breakfast and then two hours later you see a donut that you want to eat. Are you going to do the full amount of carbs for the doughnut because if you do that, you’re probably going to go low, but if don’t give enough you’re going to go high. And then the pump really helps you out with that because the pump will have what we call an active insulin time. It’ll go back X number of hours and actually see how much insulin’s still on board from a few hours ago and subtract that insulin out from the bolus you’re about to give yourself. So it does this fancy area under the curve and will subtract out insulin on board. So you’re less likely to have a low blood sugar when you bolus a few bolus within a certain timeframe. While on a pump versus doing injections on your own.

You know, it’s interesting. All of the math that the pump does and all of the safety calculations like you say, such as insulin on board. Those have to be started, as you mentioned, by a person. Usually your endocrinologist or your diabetes educator. 

Right.

How do you come to those numbers? Is do you start just on weight, activity? Where do you start when you’re putting all those numbers into the pump?

Actually it’s been based on studies. There’s different rules that folks use but it was actually Paul Davidson who actually founded my office who started coming up with some of these rules. And it’s first based on the body weight and it’s weight in kilos and divide it in half and that’s usually what we call your total daily dose. And then for example, some people use 1800 some use 17 or 1600, but generally I use the 1800 rule where you just divide the total daily dose and the 1800 and then that gets our first sensitivity factor, which we can talk about a little later. And then I usually divide the total daily dose and that gives me a carb ratio. Everyone’s a little different that just gives you a jumping off point. So in fact if someone who is coming into me, I’m seeing for the first time I’ll use the standard calculations. But if it’s someone who I’ve seen for a while and I kind of know what their carb ratio is and what their basal rates are, then I’ll calculate what I think they’re, I’ll do what they’re currently using plus their theoretical multiple daily dose and I’ll add them together and take an average. So sometimes I’ll do that as well. So that’s kind of where the art of medicine comes in. There’s not, you know, one-size-fits-all not everyone follows the formulas. The formulas just kind of give you a jumping off point to start up the pump on a patient.

I remember that because you know when my son was starting an insulin pump, gosh, almost 12 years ago. Now, you know, we had to take such careful notes and keep really good logs and check him even more often than we were already doing. So I remember adjusting that of course, you never really stop adjusting with diabetes. But sure it’s got to be the kind of thing where you can you know work with your team to make sure the numbers are right. So let’s talk about, you mentioned a whole bunch of terms there and we talked about basal and bolus in the beginning. Let’s start with basal insulin and how that differs in an insulin pump. 

Sure, right. So in an insulin pump, you’re using all rapid-acting insulin. And the reason why you do that is this is that basal insulin’s in there for 24 plus hours if you’re on basal. So just for a good example, if you inject 24 units it kind of slow releases at one unit an hour. But again, you know, we’re relying really on the pump to be your pancreas and sometimes when you’re exercising you don’t need as much insulin because your muscle tissue is an insulin sensitive organ and a glucose dependent organ. So it’s going to suck up the blood sugar in the bloodstream while you’re exercising. And then there’s other times like when you’re asleep, you’re not as active and your insulin requirements can go down in your sleep, especially teenagers what will happen is they’ll have this massive rush of cortisol right in the morning, right when they wake up and that will make you a little bit more insulin resistant. Cortisol is kind of the hormone that gets you ready for your day. So this is what we call a dawn phenomenon. So it’s different for different folks. Some people start at 2:00 a.m. Some may start at 3 or 4 a.m. But if you do see kind of this rise in the blood sugar and with a pump, because it’s the fast-acting insulin you can actually adjust the insulin rate with the rapid acting insulin every 5 to 10 minutes if you want. So you can actually hit that dawn phenomenon, whereas, you know on just a 24-hour insulin, if you try to address the dawn phenomenon and have a higher basal rate then the rest of the day they’re going to have low sugars. Where and if you lower the basal rate too much then the sugars are going to go high. So really the pump mimics more of a physiologic pancreas.

How does it work though? Does it I guess every pump is a little bit different but is it kind of pushing out that fast acting insulin every couple of minutes in those little doses?

It’s usually a little bit more continuous and every minute. Usually it is a fairly continuous rate depending on the pump. There’s some pumps that have a motor that you know, just kind of pushes it out fairly continuous. There’s others that are kind of like a tube of toothpaste and kind of roll like a tube of toothpaste over time. Those kind of halt more and stop for a little bit. But in general it’s more of a continuous flow.

That’s interesting. Yeah, because we we find that my son actually needs, I don’t mean to make this all about us, but we find our son needs insulin as you say about that dawn phenomenon, but since he hit the teenage years even as soon as his head hits the pillow, I feel like those hormones are all releasing and he needs much more insulin overnight. Which is very much easier to do with an insulin pump.

Yeah, I forgot to tell you previously, you know pump therapy doesn’t really change A1C too much. It might lower it a little bit but actually gets teenagers to go a lot better. So to get a teenager to do anything better as you know, is a feat in of itself. So if the pump can get teenagers to get under better control. But yeah data does that show that teenagers that wear pumps have better control through the teenage years. Just don’t tell them that or they won’t wear it.

But we did skip something as we’re talking about how the insulin comes out of the pump and how it works. We really haven’t talked about how insulin gets into your body from a pump. 

Right.

So let’s talk about that. Almost every pump has some kind of catheter, a tiny little one, when you say catheter it sounds so scary, under the skin.

Right.

So, can you talk about how insulin is infused?

Yeah, so there’s kind of two broad categories there, the standard pump we can talk about first. And basically when you get ready to put a pump on you’ll fill a little reservoir that will go into the pump. And that will store the insulin through the next few days. And generally we recommend only wearing these what we call infusion sets for 2 to 3 days. Then you change it out because as insulin goes through one site for too long, so the subcutaneous skin where the insulin is infusing in can grow as the cells around the site grow, and then it actually impede the flow of insulin into the skin itself. So you fill the reservoir up first, and there’s you what we call infusion set or a connection into the body. And that varies from brand to brand but basically you will have an inserter and it will insert a little small plastic catheter into the subcutaneous space. So you connect that to your reservoir and then your pump’s going. Usually before you put the pump on, because there is tubing, you’ll prime your pump. And there’s a prime feature on most pumps where you’ll actually see insulin dripping through the end of the catheter before you connect it to the infusion set.

And then you mentioned the Omnipod, which is a little different?

Right. So, yeah, so Omnipod’s a little different – it’s tubeless but it does have a little catheter that inserts into you. And basically on the Omni pod, it’s a patch pump. So you put it on and then you say you start a new pod and then it auto inserts the little small piece that injects insulin into you underneath the pod. So it’s a completely tubeless system.

Yeah. And with all of them, as you said the needle goes in, the needle comes out, leaving behind that little plastic catheter, but there are different setups, right? This was something that it took me a while to learn. That there, except for Omnipod, which just has the one because it’s all in one, the other pumps have different systems. So different insets, so you can get one that’s more angled. You can get one that’s steel. You know, there’s different ways that they can go into the body? 

Right.

How do you how do you advise a person which one to go with?

Really, it’s all about comfort. So some people, you know, there’s minimal machinery and they can kind of just push it in on their own. Other people want an inserter to do it. But basically I’ll have my educator sit down with the patient and show them the different infusion sets and whatever they’re more comfortable with. As long as the insulin’s infusing in I really don’t care how they do it. It’s what they feel most comfortable with.

I think it’s important. I’m glad you do that because I’ve had a lot of parents in my local group who say I’m so frustrated, you know, this isn’t working. My kid’s so skinny and then someone will say well, how about an angled inset and they say what I didn’t know there were options.

Right.

It’s so important because that’s the way it goes in makes a huge difference. If that doesn’t work then, you know, you’re not going to really get a good infusion of insulin. And you mentioned that two to three days. Let’s talk about that for a moment because I know the, you know, we’re all looking to cut corners because of cost, but you really can’t push that can you?

No, because again, if you’re thinking about the tubing, especially because insulin is going through the tubing. There are little crystals of insulin that actually deposit into the lumen or the hollow part of the set itself. So then that is eventually going to change the flow rate and you know, the pump motor is good but can’t really sense how much how long that infusion set’s been in so flow rate changes a little bit over time. And then where the catheter is in again, the cells will grow a little bit around where that catheter is because insulin’s a growth factor so that can impede flow little bit too. So if you’re wearing the infusions up for more than three days for sure then the flow rates going to change and then you’ll notice by day four or five for sure that the your blood sugars are different. And it’s because the flow rates going to be start to become completely different from the pump into the skin at that point.

There’s also the fear of an infection as well. I would assume, right? 

There’s also the fear of infection. And you know, that’s one thing that unfortunately insurance companies don’t understand, you know, they’ll approve you for x amount of infusion sets but again, not everyone’s perfect and one’s going to mess up every once in a while. So you really need to have extra, so I always try to write every two days for my patients. So they have backup in case something goes wrong.

That’s great. We appreciated that from our endo as well. Okay. So we’ve got the the way it connects to the body. Let’s go back and cover the bolus of insulin. The bolus is the thing that the person using the pump controls. How do you how do you talk to patients about that? This is the stuff when people say oh that pump is automatic. Right? And you have to say no I have to do this this and this.

Right. Yeah, they’re working on the automatic part, but that’s with an integrated pump sensor which is a ways away. But basically you still have to calculate your carbs so you don’t have to do the math per se but you still need to know how many grams of carbs you’re going to eat in the meal. That’s what I want patients to understand before they start a pump. There’s unfortunately some doctors that say you’ve got to get your A1C to a certain level or your control to a certain level before you go on a pump. But I see this crazy dawn phenomenon where your carbs, your blood sugar is just crazy after eating you’re never going to get to that goal A1c to get on a pump. But where the pump really helps you is again, if you do a carb ratio and you count your carbs correctly, then you bolus and then a couple hours later you can bolus again and the insulin on board or the calculations will subtract out insulin so that you don’t overdose yourself. There’s also the sensitivity factor part. So let’s say you’re just minding your own business and check your sugar and it’s high. Well, the sensitivity factor you will actually just put my blood sugar’s high, let’s say it’s 190 and then the  pump will actually calculate how much insulin to give you for that high sugar to get you to a target.

Yeah, and so insulin sensitivity factor always seems to be the one that trips people up. So let’s talk about that a little bit more. How do you know when you need to change it? And then how do you change it?

What I tell folks is the best example is the exact formula that’s blood sugar minus a hundred which is a normal sugar divided by X numbers. And again, it’s a whole bunch of math. But how I explain to the patient’s is that let’s say your blood sugar is 150 and you want to get your blood sugar to 100 one unit. If the sensitivity factor is 50 that would drop you from 150 to 100. So, that’s how I explain it to patients because they think that increasing the sensitivity factor may give you more insulin, but it’s actually the opposite. Because the sensitivity factor is actually in the divisor of the fraction so to speak. So if you want to give yourself more insulin, you would lower the sensitivity factor. If you want to give less insulin you would increase the sensitivity factor.

Yeah. I’ve missed that up before.

And how you figure it out is it’s, I’ll look at a download from a pump and if a patient, corrects, so let’s say they’re are 200 or 220 and then you know, they give a correction bolus and it’s through the pump and you actually see that they gave correction through the pump if it goes from 200 to 50, then I know that the sensitivity factor is giving too much insulin. So I’ll adjust that for the patient or if they correct the high and then they don’t go to a target that we want it to be, will lower the sensitivity factor and make sure they get a little bit more insulin.

One of the things that I can’t say it bothers me, but one of the things that’s confusing is that carbohydrate counting is not an exact science. I used to think it was when we started out. I was counting everything; I would weigh ketchup and peas. My son was a toddler and I was determined that we were going to be perfect. And then you realize that everybody reacts a little bit differently to different foods and that this hamburger bun is not going to be like this hamburger bun. How do you advise people when they’re trying to get their boluses perfect for carbohydrate counting?

Really to just do their best I guess. It’s pretty easy when you’re at home, right because you can cook and you can measure carbs out and that’s perfect. But at least in a lot of experience, most of us eat the same thing, we don’t, we all like to say we’re different but honestly within a month to month, you kind of start eating the same foods over and over, so you’ll eventually get really good at the foods you normally eat. So that becomes less of a problem. And what’s more of a problem is when you go to a restaurant. Because then you’re, you really don’t know how, you know the carbs because with the carb counting, well, this is a fist, this is a thumb, whatever but you just really don’t know how much extra sugar is added. So what I really see is a lot of the evenings in a lot of my adult patients that are going through the roof and I say how often you got to eat and that’s the problem. So I tell him be a little bit more aggressive with your carb ratio when you go out to eat. There’s also called an extended bolus or a square wave bolus that you can do. And again, the higher fat meals you’re not going to absorb the glucose as quicker so you can actually do a square wave bolus on the pump and it will extend that bolus out a little bit more. So you don’t get a lot of insulin up front and will actually help with that delayed spike so it can work with the sugar with the high fat meals.

Definitely and, as you listen, if you’re using an insulin pump, different brands do call them different things. So extended bolus, combo bolus, square wave bolus, as you said. Can you talk a little bit more about when that works well? Because we have found over the years a couple of different things that I’ll get into in a moment. But as you said the basic understanding is you can give the insulin kind of almost like a time-release, right? 

Exactly and that really helps with high fat meals. So most people will associate that with pizza or with Mexican food or a lot of cheese dip. Sometimes if you have a lot of sausage and bacon in with your meals. Especially in the Southeast people love sausage biscuits and gravy. But a pretty good idea is to do a try out the extended from some of those meals.

And a lot of it. I hate to put it in these terms because I am talking to a doctor here but a lot of this is guessing, you know, how do you know how to set it up because what you’re doing if you’re not familiar, you’re setting it up in the pump saying, okay. I’m going to give myself and counting the carbs. It’s you know, 60 carbs and I’m going to give 50% of that upfront and 50% over the next two hours? I mean, there’s no, as far as I know, there’s no formulation that says biscuits and gravy this. Pizza this. You just have to learn it. 

Right. It’s honestly, it’s just experience. So the big thing is, don’t get frustrated. We can discuss the technicalities, but everyone, as far as it’s in bolusing goes, it’s completely different. So there’s not a formula to follow. It’s really just trial and error.

What do you mean “the technicalities?”

Well, you know just the carb ratios, setting up a square wave, those kinds of things, we can talk to patients about as far as real-world information, you know, they’re counting the carbs. The carbs may be a little different, the square waves for pizza versus Mexican food versus a sausage and biscuit and gravy. It’s going to be different for everyone else. That’s when you really have to understand why your pump works a certain way. So that you can adjust that on your own.

Let’s talk about temporary basal rates because that’s something else that almost every pump has. It’s a terrific feature and the basal rate as you mentioned is how much insulin you’re getting as if you were getting a long-acting shot. So talk to me about temporary basal rates in terms of when you would increase them or decrease them.

Temp basals are great, especially with physical activity. So again, it’s all fast acting insulin going through the pump so we can take advantage of that. Especially when you’re exercising. And it depends on the exercise and again and this is more experiential but weightlifting can be different than cardio, but we do cardio for example, I usually tell my folks to do, set a temp basal and I like to use percentages because that way you don’t have to get into the nitty-gritty of your pump. But most pumps you can set a percentage rate. And say set of 50% temp basal so that means while you’re exercising you’re going to get half the amount of insulin that you normally do if you set a temporary basal 50% and again, that’s really more trial and error. Some people do great with the 50, 50% temp basal. There’s some folks that do exercise, like folks on the team type 1, who you know bike for it professionally and they have temp basals of only 5%. So they’re only getting 5% of their normal basal rate. Those are muscles are really sucking up a lot of glucose.

Again, that’s under-utilized by folks because they either, when you first get a pump there’s a lot of stuff thrown at you at once and the temp basal kind of gets pushed back to make sure you know how to do what a basal rate is and what a carb ratio is. That’s you really need to use it, especially with physical activity. Another time to do it is before a surgery for example, so of course surgeons have no idea what these pumps are. So they’ll tell patients to take it off and I’m like, no you can’t take it off. So usually, again, 50 or 40% temp basal while you’re not eating so you can get through your surgery safely without a major high or low sugar and then resume your insulin pump as usual once you wake up post-op. And then sickness or steroid use. So if you get upper respiratory tract infection, you actually go up to say a 110% of the temp basal rate for a 24-hour period. Or stress. So you’re sick. Again your blood sugars may be higher for two or three days than usual and that’s where you can set a temp basal as well.

Alright, I’m going to tell my embarrassing story. Longtime listeners have heard this. But when Benny got an insulin pump, we’d had it I want to say three to four years. And we were working with it beautifully and he was a toddler. He was probably six then by this point by the time I’m telling the story. And the “Friends for Life” conference – they used to have these regional conferences – and it came through Charlotte. So I went, I didn’t bring the kids. I just went by myself and they were talking about temporary basals and it must have been a pump session or something and I remember thinking this is so complicated and I had wanted to try it. Our CDE had suggested it for travel. We travel a lot in the car. She knew that he needed more insulin he always ran high from sitting around.

Our CDE Linnet was actually next to me and I kind of whispered to her. You know, I’m so embarrassed and so lazy, I just can’t get myself to do that because I don’t want to do all the math. She said what are you talking about? I said, well, you said 25% more insulin, and I don’t want to have to go through every basal rate. We had four or five basal rates and he was getting you know, like 0.025. I mean these tiny little doses of insulin back then. How do you multiply by .025 or whatever – in my head I had made it so complicated. She said Stacey just go in the pump and say 25% more 25% less. It had never occurred to me that it was that simple. And I know you laugh when you hear that, but I tell people all the time now use your pump for six months and then go back and actually read all of the instructions again. Because we don’t know how to use this. We don’t know how to get the most out of it. It’s not anybody’s fault. I’m not I mean, you know, you may disagree as you listen. I’m not a dummy but it just never occurred to me that that would be so simple, you know, do you find that as you talk to people they come back to you that they are not really using all the features because they just kind of didn’t get it? We don’t get enough education, I think.

Right. I think I would agree with that because you know, you went from multiple daily injections and then you’re now on a pump and really the educators for either my office or if my educators are busy, the device company itself. They’re really making sure you don’t do anything that you’re going to kill yourself with on this one.

Oh geez.

Because again, if you give too much or too little you’re going to kill yourself. So the big thing is, let’s get the basics. These are the basal rates, these are why we set the basal rates. This is the carb ratio, the sensitivity factor and targets are where we want the sugar to be you know, usually we said about 100-120 where we if you’re high you would want the sensitivity factor to shoot you to that number. And then the temp basals kind of get by the wayside again, they’ll say they’ll go over it briefly. But again, most of the first visit focus is on the basals, the carb ratio, the sensitivity factor. So yeah, I would agree and most people just get that education up front and then you don’t get any more education unless you ask for it. So again, if you’ve been on the pump for a few months, I would go back either see an educator or go back and read the manual and then if you have questions ask your doctor about it.

And as what we’re talking about while we’re talking about the temp basal, I wanted to just from personal experience and I’ve seen other people talk about this as well. We actually find for my son that a temporary basal rate increase works just as well. If not better for him than a combo or extended bolus for high fat meals. So, I’m not a doctor. This is not medical advice. But what we do is if we know he’s going to have a high fat meal, high carb, high fat is we bolus up front for probably 75% of it and then we increase the basal rate for four hours.

Sure.

So that’s worked well for us and you’re saying “sure,” but this was a revelation to me (laughs)

But no, I mean, as I said, the square wave isn’t for everyone and I think setting a temp basal like that, it is perfectly reasonable. And you kind of get a hybrid of a square wave or extended wave bolus plus the bolus up front. So that totally makes sense to me. But again, if you’ve never played with temporary basals before it’s something that you would never even think about.

It just is amazing to me how much of a difference even a tiny basal rate change can make. You know, I mentioned that I’d love to go back and see what those values really were. I know and when we started when Benny was two his basal rate was .025 per hour because we needed the pump that had the lowest basal rate. And then probably around age six or seven it was maybe up to you know .8 or almost a unit. I mean, he’s a teenager now, we’ve had, he’s up to some hours, he gets like three units an hour. It’s crazy. 

Oh, yeah.

But it’s amazing to me. How much just even a small basal rate change makes. Is that the way that insulin works in the body?

Right. So yeah, so with the rapid acting insulin because it goes in fairly quickly, we can make these exact changes. But yeah physically in the body I mean a person who does not have diabetes makes about 25 units of insulin a day, roughly. But again, it really varies on the time of day. But you know physiologically there is a little bit of resistance on everyone when insulin in everyone when the cortisol rises in the morning. So normally, you know, the pancreas senses it and we’ll shoot out the insulin to negate that effect. But you know, we’re having to use these pumps as you know, your pancreas essentially. I’ve seen some patients like, the best one that comes to memory is a young, say 20, 21-year-old college student. Usually her basal rates are about half a unit an hour and then just from 3:00 to 6:00 a.m. it goes to 3 and 1/2 units an hour. And it goes right back. So again, it’s crazy. And again monitors help us with that too. But just seeing what time of day you need those insulin requirements. And again, that’s why you know pump therapy is so beneficial for type 1s because there’s no way you could have a basal rate do that for you on just a 24 hour insulin.

And I think too, we you know, when we knew my son was, and he’d love that I’m talking about this, but when we knew he was going into puberty, I mean his blood sugar would shoot up to 300 and despite feeling we were pouring buckets of insulin into him, it wouldn’t come down.

Right.

But then you go ahead and you just change the basal rate and not by a dramatic amount, and it doesn’t get that high. Is it it’s just harder to bring them down when they’re that high right? 

Right. And in teenagers, especially they get really insulin resistant in the morning especially. And then they’ll hit an age, it’s different for everyone, he’ll hit his early 20s and then his requirements will plummet.

I’m counting on that. 

Right. So, it just like they kind of lose their mind as a teenager and they don’t want to do anything you’re called to do. Then like they have a come-to-Jesus moment. The same thing happens with their insulin requirements. And it just comes right back to normal and you’re like, well, I was all in outer space and now I’m back to reality. And that’s kind of what the pump does. The pump mirrors what the teenager’s going through essentially.

All right, let’s talk about placement of an insulin pump. Because you know tubed pumps and the Omnipod they all need to be rotated. Can you speak a little bit about putting it on and making sure and why you have to move it around?

Yeah. So again, if you keep putting it in the same place and again the insulin’s a growth factor, so those places will eventually, the subcutaneous tissue will grow the exact, it’s really the fat tissue. So the exact word is lipohypertrophy, which is just means big fat essentially in English from the translation. And that will over time that can actually create some scar tissue as well. So you’ll want to kind of, what usually patients will do is rotate clockwise or counterclockwise around their naval, their belly button. But you can also have an infusion set inserted into your upper arm or in your upper buttock area as well. Now Omnipods are a little bit more, because they are tubeless, are a little bit easier to move around but those are the FDA approved sites. But folks, look if we’re going to talk off label can put an Omnipod almost anywhere on the body. We have some women during beach season that will actually put the Omnipod along their, the top of where a bikini would go so that no one even knows they have diabetes unless they’re really looking where an Omnipod would go.

I’ve seen people with tubed pumps put them everywhere as well, which I don’t know how you do that. I mean, I remember when Benny was little there were a lot of little kids running around with the tubed pumps on their arm. And I was thinking like he would never do that, but they had no issue with it. 

Right. But you got to be careful with the tubed pumps because just the physics of the insulin being infused. Because there is a little bit of a siphoning effect. So if you have a pump, and a lot of women do this, they’ll have their infusion set inserted into her abdomen and they’ll put their pump in their bra. But just like siphoning off gasoline, for example, the insulin itself will siphon down a little bit. So you actually get a little bit more insulin if you put the pump higher than where the infusion set is. And it takes the pump a little bit more to work if you actually have the pump lower than where the infusion set’s inserting. So technically you really should have the pump and the infusion set horizontal with each other. Technically speaking. Now that’s not real world and a lot of women are going to put their pumps in their bra anyway. But you would want that infusion set as horizontal with the pump as possible because of that.

I have never heard that. So everybody that I know who has a pump around their waist, they’ll wear it, you know, like the belly button line let’s say. And then they put their pump in their pocket.

Right. So again, if you’re going to do that just be consistent with how that placement is, because again, it’s not an exact science. But if you’re always, especially women will put their insulin pump in the bra or men like to put the pump in the pocket, then try to keep you know, rotate around the site area, but try to keep that pump as horizontal with the infusion set insertion as much as possible.

And if suddenly you take it out of your bra and put in your pocket, you might realize that your numbers could change and that might be one of the reasons why.

Right. Exactly.

That’s interesting.

And then two, making sure that you wear the pump fairly consistently. Because a lot of people will take their pump off to shower for example, but if you’re in the shower for 30 minutes, that’s 30 minutes of insulin that you’re not wearing or getting. And basically for every minute that you don’t wear the pump your insulin, your blood sugar value will go up by a certain amount. So let’s say you get in the shower and your blood sugar 100 and you take a 30-minute shower, your blood sugar’s going to go to go to 130 that’s just on the average for folks. So we see that sometimes before I make adjustments in the morning and I see blood sugar’s going up, some people don’t turn their pump off. So I actually will ask. Well, I don’t see that there was a suspend on the download. So when do you take a shower and if the blood sugars are going up in their shower you know, I say try to take a shorter shower. And they say well I really like just not wearing it while I’m in the shower or I said well, that’s great, but really connect to yourself right when you get out of the shower to avoid that that peak up in the morning.

Yeah when my son does that occasionally and he’ll just bolus for half of the hour that he missed or whatever.

Right. And that’s a trick to do it.

We’ve also found though, don’t as you listen, don’t bolus right before you get in the shower, to try to avoid that rise. Because the warm water, doesn’t that, that can help make you go low, right?

It can a little bit. Yeah, because again the physics of it. Most insulins all work the same if you gave them IV. It’s all about how the insulin is formulated to go under the skin that really helps it to get into the bloodstream. And all rapid acting insulin gets in the bloodstream a little bit quicker, once it goes under the skin. And if you have a little bit of a warmer water yeah, could go in a little bit quicker. So again, if you bolus, really the big thing is if you bolus that insulin, you get a bigger amount of insulin. So it’s not a basal rate so to speak. So there’s a difference between getting a unit over an hour and bolusing a unit right up front. Because again the pumps going to get that unit through, the through the hour pretty consistently. And if you do a full-blown unit right away, then that’s going to really change the physics of what happens under the skin.

In your professional opinion, and you don’t have to answer this, but I’m curious. Is one pump better than another? Do you see people with better A1Cs do you see people with better usage of one pump brand over another?

It’s kind of yes, and no. You know, there are different pump brands out there. And it really depends if you want the most technologically advanced pump versus can you use this in your real life? And that’s one of the problems and I don’t want to go off on a tangent but United Healthcare right now will only approve the Medtronic pump. And that’s a big problem because again that does have an integration with a sensor and the Medtronic pump works really great for that, for a lot of people. But again, you know being tubeless, especially putting a tubeless pump, like an Omnipod on a three-year-old maybe a lot better option for you because the kids gonna keep ripping off those infusion sets. Or let’s say you have a teenager who’s in high school who plays a contact sport. You don’t want them to be wearing a $2,000 pump out on a football field and that get crushed for example. Whereas an Omnipod, you can actually throw it away. So I give people the options and show them the different pumps and let them decide for them personally which pump is the best for them. Because I don’t want to be paternalistic and tell them you have to wear this, because it’s not my life. I’m not the person living with type 1. I can guide them with what to do, but it’s really their life and I want them to choose the best pump that fits their lifestyle.

Yeah. I’ve always felt that. And again a little editorial here from me. If there was a pump that was great for everybody, we’d know. Right? 

Right.

People would be walking around saying look, my A1C went way down and life is great. And this is the one for everybody! But, it just made me laugh because you know, my son played football with a tubed pump. And my son was a toddler with a tubed pump. So I know people who could never stand the tubing and love their Omnipods. But, it’s all personal preference. So I’m glad to hear you say that. So let’s talk about disconnecting because we haven’t addressed that yet. When you’re taking your pump off, you know, what do you, what do you suggest that patients do? You know a lot of concern about covering the site. I mean we never do anything.

No, I mean if you’re just disconnecting for you know a few minutes to a few hours, then there’s really not much that you need to do as far as disconnecting. But know that if you’re going to be off it for more than say two, three, four hours and you’re not exercising then you would probably want to start considering getting on a basal insulin for the rest of that day. Because you’re eventually going to have high sugars. Because again the rapid acting insulin’s going to be out within three or four hours. So if you don’t have any basal on board by that point you have a risk going into DKA.

We were always told, you know, at the beach let’s say, we would take his insulin pump off, to check every hour when you don’t have a pump on and to make sure to bolus at least every two hours. That was our endo’s advice. Do you recommend something similar?

Something like that or let’s say that they are playing football or you’re going to have a beach day, what you could do for that day is give half of the basal as a basal insulin for you know, let’s say a Lantis or Levamir or and then the rest of the half of the insulin through the day’s a 50% temp basal on your pump. So again, that kind of negates the issue with having to check your blood sugar so much. So we do this with a lot of like football players and stuff folks who really like the advantages of wearing a tubed pump. But then when you’re out there playing football you don’t want to go in DKA but you don’t want your pump to get smashed either. So those folks we kind of do a compromise for those days and do half basal through a standard injection through a 24 hour insulin and then half through a temp basal while they’re wearing the pump. But when they take the pump off, they actually have a little bit of basal go in like a temp 50% temp basal essentially while they’re running around and then you don’t have to worry about checking your sugar’s as much especially if you’re wearing a monitor.

Yeah, we’ve I wasn’t sure if I was going to bring this up, but we started that this fall. And I called that, that’s untethered as you know, a lot people called it untethered or POLI, pumping on long-acting insulin. And it has been amazingly wonderful. 

Right.

I hate that he has to take a shot and we do this every day. We do 50% from the pump now and 50% from we use Tresiba. Obviously talk to your doctor about whatever you want to use. But it has been wonderful because, first of all he’s taking these massive, you know, basal rates and it’s just very difficult on the infusion set. So that has helped. And he’s able to take the pump off more for sports without worrying about missing the dosing. Do you do a lot of untethered is that something that people ask about?

It’s hit or miss. A lot of teenagers do because they’re a bit more physically active and they’re doing more team sports and things like that. Again to your point, yeah, some of our really insulin resistant kids and young adults, we do give a basal along with the pump. Even if they’re not taking it off because again, if you give a little bit of a injection it will help you save insulin in a reservoir and keeps the infusion set in for two three days where otherwise you might be changing infusion set out every one or two, one or one and a half days.

It really is amazing all the different things people come up with. I don’t know if it’s on your own or with experimentation or how everybody figures out how to do this. 

Yeah. I think it’s honestly just experience with the product. And again just really having a good understanding of what they can do what they can’t do. To really key in on you know, how, how can the pump benefit you. But again, especially to prevent lows, I mean because we can change the basal rate so precisely there’s a lot less lows especially overnight.

I don’t know if you know the answer to this one, but when, one of the things that I get asked a lot is, what the heck are those little pitchfork shaped doohickeys that come with the infusion sets? These are things that you’re supposed to put in your inset, your pump site when you’re on the beach or you know you. Is it first of all, do you know what I’m talking about?

I know what you’re talking about. I think it’s to protect the little infusion set. But honestly, I don’t know anyone who uses them.

Okay, because what I was going to say is we only used them when my son was little and we’d go to the beach because there’s nothing that you know, no one attracts sand like a magnet like a toddler. And we hadn’t thought about using it until we found that we couldn’t reconnect the tubing because his inset was full of sand. But you don’t need to protect the inset from dirt and water and things like that. It doesn’t let things in until you click in the tubing right? It’s kind of like the top of an insulin bottle is how it was described to me.

Yeah. I mean, it’s very hard to get stuff in there as being an adult and not shoving sand in your side this is probably safe. Just not to do anything else. But yeah, you know three-year-olds or two year olds, who knows what they’re going to do. They’re going to shove sand up their nose. So you do want to protect the site for them. But for adults you don’t really have to do any protection.

That’s a concern I hear all the time about, you know, I’m taking a shower. I’m going in the pool. Do I need to use this thing? And then half the group says, oh, that’s what that’s for. 

Right.

I have a couple more questions, but I want to make sure I’m not really missing anything obvious that you wanted to talk about.

I don’t think so. I really would like to hit home the overnight basal rate because especially if patients are, so I guess most type 1s would really benefit from wearing a pump because of the features we’ve talked about today. But unfortunately a lot of them aren’t. Most type 1s, I would feel more comfortable unless they’re seeing an internist that’s very well versed in type 1 diabetes, actually seeking out an endocrinologist to take care of their blood sugars. Because as we talked about blood sugar surging overnight, you don’t know if you don’t have much experience with pump therapy or type 1s, whether that blood sugar is going up overnight because they, again like your son he’s having this rush of cortisol, all the sugars are shooting up overnight. Or you’re having lows and what I’ve seen a lot of times with especially some primary cares is they’ll see that the blood sugar is high in the morning and they will tell the patient go up on their basal injection, you know, 10%, 20% because the sugar is high in the morning. Whereas that’s really self-perpetuating the issue with low sugars overnight. And they’re looking at A1Cs in the morning blood sugar but not really asking the patient, what’s your blood sugar when you go to bed? Are you having low blood sugars overnight? What’s the blood sugar in the morning? So all my type 1s where they’re on injections or pumps, one of my first questions is, “Have you had a low blood sugar?” Because most of them are coming in thinking, Oh, my gosh, my A1Cs going to be high and he’s gonna be mad at me.” My biggest concern is have you had a low? And if you have a low, when did it happen? And did you need help from someone or were you able to do it on your own? Because you know low blood sugars can get you today. They can get you overnight and you won’t wake up in the morning. High blood sugars will get you in 15 years and that’s a problem and we’ll fix that. But really want to work on the low sugars and make sure those are minimized.

I want to come back to that thought but you brought up a good point earlier about the pumps that work with sensors. You know, there are more and more of those happening.

Right.

I can’t go in depth on this because they are so new. You know what I think we’re learning a more about that. But what’s your, what are your thoughts on those? I mean, this is a pretty exciting time. We just started with the Basal IQ in the fall; we use the Tandem and the Dexcom together. I know people having great success with the Medtronic 670 system. What are your, you know, what are your thoughts about that?

I think that the integration is key because especially just sensors in and of themselves because wearing a pump and a sensor again, you know, the less lows the better. And patients that wear a sensor at least 50% at a time have their A1C drop by at least a half or one percentage point. So let’s say they’re seven and a half, or six and a half or seven without any increase in low sugars then that’s remarkable. So again, you want as tight control as possible without any major lows. And with sensors what we can see is when’s the blood sugar going up and what how I explain it to patients is, you know, the sensor blood sugar isn’t the same as your finger stick blood sugar. It’s kind of like a roller coaster and the front car is your blood sugar and the back car is the sensor because it’s really measuring what we call interstitial fluid or fluid in between cells. So that’s why we tell people to calibrate these sensors right when they when they wake up and they’ve been fasting and sugar should be stable. When you eat the blood sugar shoots up. So the front car is going to be a little bit higher than the back car. When you correct and the blood sugar is going down, the front car, which is your blood sugar, is going to be a little bit lower than the sensor itself. That’s kind of the sensor a nutshell as far as how I explain the blood sugar’s to them. But we can actually see those sensor tracings 24/7 and in really fine tuned. Well, you know your blood sugar went up above target with breakfast only, let’s change your carb ratio at breakfast. Or your blood sugar is dropping overnight, let’s back off on your basal rate overnight. So those sensor combos are key.

And then yeah the integration so Basal IQ will notice that if your blood sugar goes below a certain point, the sensor pump integration, the pump will send, will get messages from the sensor and say your blood sugar’s too low, turn off. When the blood sugar goes back up to acceptable levels the pump will turn back on. And then you know, with a Medtronic pump when your blood sugars are above even 120, which is the target set; unfortunately they made Medtronic do 120 instead of 100 because the FDA was worried about low sugars. Which virtually never happens unless it’s 70. But again, if the Medtronic pump sees that you’re above target at any time that will micro-bolus you back down to target. And then if the blood sugar’s less than 120, it will hold basal rate until you go back up to target and turn back on. So the future will be when you, and this is kind of you know, what will happen in the future as far as new products is targets will be set a little bit lower, and then let’s say you forget to bolus when you eat, if, that eventually that pump sensor combination will notice the blood sugar rising and that trajectory, and will bolus you without you having to put carbs in your pump. So that will be some of the next kind of generation things. Again right now, you know, the pumps will notice overnight that if your blood sugars starting to trend down, let’s back off on the basal rate a little bit. If sugars are going up overnight, let’s give you some boluses and that’s what the 670 will do on the Medtronic.

Yeah, it’s been wild. I mean, I don’t want to make a commercial here for Basal IQ, but we had an amazing endo appointment recently, it’s probably been almost four and a half months. It was our first full Basal IQ, you know, with A1C and it his A1C came down by half a point, which was great. But interestingly he had virtually no lows below 75 for that three-month period. He doesn’t get a lot of lows, I’ll be honest with you. But it’s never been like that. I mean, it was pretty amazing to see how that’s working.

Right. And that’s kind of the wave of the future with these pumps is eliminate the lows and that’s why that was at first, because again, if you have one really bad low sugar, you’re not coming back tomorrow. So that’s when, it’s actually a lot easier to program into a pump’s sensor combination then fixing the highs for example. Because everyone’s a little bit different as far as carb ratios goes. That’s why the basal suspend, what we call threshold suspend, or stop when your sugar goes low. That’s why that was first integrated with, with the insulin pumps.

I want to address something. You’ve said several times, you know, you’re not coming back from that low or people die from lows.

Right.

I gotta push a little further on this. My son – I know many, many, many, many people who’ve been very low 20s, 15.  I think that sometimes newer diagnosed families, you know, children’s parents, especially feel like well if my son hits this number he will die.

Right.

Or if I don’t jump out of bed, you know, my child is going to die tonight. And that’s not my understanding. And I could be very wrong. You’re the endo.

So I don’t I wouldn’t want folks to freak out that their sugars get below 50 than you know, they’re at a higher risk. It really is more of a frequency issue because your body adjusts. Like you just like people especially type 2s will adjust to having a blood sugar 3- or 400 and say, “Hey, I’m perfectly fine. I don’t need to take insulin.” The same thing can happen with low sugars as well. So it’s over time your body has to have a lower and a lower threshold. So again, like I said earlier, you don’t just lose beta cell function. You lose your glucagon, which is your first line of defense. So your blood sugar has to get maybe 70, 60 and then your growth hormone, your cortisol, your adrenaline levels will go up. But then your body’s like well that wasn’t so bad. I’ve survived that so then the blood sugar has to get the 50 then the 40. There’s some people that walk around and are completely fine until their blood sugar hits 30 or 20 and those people were what we call hypoglycemia or hyperglycemia unaware, hypoglycemic unaware. So they don’t even know their sugar’s low and those are the people that are most at risk because they’re fine one minute and then their sugar gets to a certain level and then they’re out. They’re in a coma because the brain really only uses glucose as energy. So once the blood sugar gets to a certain level the brain just turns off. So it’s a gradual process.

I don’t, I don’t want to scare folks. It’s just I don’t think a lot of folks appreciate the fact that lows are just as bad as the highs. Because a lot of times when I have people come in, they’re focused on their A1C, getting their A1C down. And I agree with that, I think that A1C should come down but we want the lowest blood sugar possible without a major low. So in that major low is an EMS visit, you have to go to the hospital.

I’ll give you the perspective of someone who talks a lot more with parents of young children. It is just the opposite. I think people now are so terrified of their children being low that they’re letting them run higher. And I’ll be honest with you. My research does not bear that out. I mean I had a conversation with my endo. And I frankly said, you know, you’ve been in practice 20 years how many kids have died?

Right.

And he said three. Two committed suicide which is a terrible, terrible thing. I mean, it’s horrible no matter how you look at it and one died because they were drinking alcohol and didn’t factor it in correctly and their type 1 diabetes management, which is also tragic. 

Sure.

But you know, this is someone who’s seen hundreds if not thousands of patients and nobody’s died from a low overnight. 

Right.

So I just – I just go back and forth about how much fear we should be having and how much we should be letting it rule our lives. 

Yeah, it’s more just an instantaneous nature of the low causing a death. We’ve seen a little bit more as far as a low that maybe why I’m more a little bit hypervigilant about lows compared to that. But the lows do really happen. So again, if you just look at national data about 10% of type 1s may have this dead in bed. So it’s not it’s not marginal. I don’t want to do a scare tactic, especially with the newer pumps because you’re less likely to have a low with a Basal IQ or a 670. But that’s always in my mind. And that’s one thing that I do want to talk to patients about is making sure they’re not having lows.

I’m not here to argue with you, but wait a second. 10% of people with type 1 are going to have dead in bed? 

Potentially. It depends on the studies. Now, those are older studies. It’d be interesting to see when Basal IQ and Medtronic throw out their data. Because like a 670 it’s been out for several, you know, two or three years now. There’s virtually no lows on the 670. And I think most of these folks again, that’s why I pump therapy is so important. I think most of these folks aren’t being managed very, very well. They’re probably not seeing endocrinologist and they may be having a primary care that’s just jacking up their basal insulin overnight on the 24-hour insulin and not paying attention to what the sugars are doing overnight.

Got it. Okay, so we’re I mean, I’m just think I was just doing the numbers in my head because I have a group. I have a group in Charlotte we have about 500 kids let’s say. So you’re saying 50 of them could die from low blood sugar?

Statistically. That’s what the old data shows.

Because nobody’s… I mean, I’ve run the group for six years and everybody’s there. 

But again you guys, so the only thing about that is you guys are probably be managed by endocrinologists.

Right. Okay, so now I get it.

So globally, yeah primary care’s, you know, really if you’re if you’re type 1 you should be seeing an endocrinologist. I don’t know what’s going on in primary care world, but sometimes it’s just crazy what’s going on out there. Because again, they’re just, they’re telling patients that, “Your sugar’s high in the morning. Let’s go up on your basal insulin because your sugar’s high in the morning and that’s what happened. That’s what you need to do.” For example, I had a little old lady who her basal rate should have been or she was on a 24-hour insulin when I first met her and calculating her basal dosage should have been 10 units. And when she came to see me, she’s on 75 units of Lantus. And her husband was waking her up every three hours to give her glucose overnight to prevent her from going low.

So scary. 

So again, it depends on, it depends on who you’re being managed. So yeah, I have no doubt if you’re being managed by an endocrinologist, lows overnight, because we’re aware of it, probably isn’t happening too much. But if you’re in rural Georgia and the only person is your family doctor, you’re probably having a lot of lows.

It’s a good reminder for somebody like me, who talks all the time with people who have the latest tech, you know, the best insurance. You know, we live in this bubble. So I do appreciate you letting me kind of argue with you a little bit because I’m always learning.

Good. So yes, I would bet you I don’t have ten percent of my type 1 are going to die from low blood sugar.

You can understand how it sounds.

But just in the United States, in the US in general, because these folks aren’t always being managed by or getting the proper care. Yeah 5-10% depending on the study you read are going to have a low. And that’s why it’s really important if you have type 1 to make sure you have confidence in the doctor that’s taking care of you.

Again, I appreciate you going through it because sometimes I need to be led to the obvious point. But it’s really important to learn more about it. One more point. I’d like you to make before I let you go, people are leaving the hospital now with CGMs. They’re getting diagnosed, at least kids, and again with really great access and insurance and terrific doctors. 

Right.

And you know, it used to be that you had to wait at least six months for an insulin pump. Can you just talk a little bit about, look if you want to get it quickly fine, but you know making sure you understand the fundamentals?

So again, really knowing what a basal insulin is. What does it do? And what does bolus insulin do so really sitting down with either your doctor or the diabetes educator and making sure you have a good understanding of that. And then law to carb ratio. And understanding why the carb ratio is important. Because if you don’t get those then you’re really not going to get the pump very well. But some people are really quick learners and some people it’s depends on the degree of education you have, but some people can get basal and carb ratio within a few weeks. And again, that’s one of my pet peeves, is some insurance companies will make sure, will tell you that you have to have type 1 for six months and that’s just complete baloney. They should get the pump right away. Whenever we feel or as a provider deem that you are good to go on a pump. You should go on a pump. It shouldn’t be dictated by a medical director working at an insurance company.

Absolutely and then just make sure that you keep some insulin, we keep a pen or syringes on hand just in case right? 

Right, right. So always have backup basal. So you never know when that pump’s gonna break. Usually for me, usually patients are calling me my Friday or Saturday night.

Of a holiday weekend. 

Usually it happens, right on a holiday weekend. So always make sure, and you don’t have to really. I mean most endos especially have basal as far as samples go. I’ll either give a vial or a pen. Especially if you’re traveling because you don’t know if it’s in a break when you’re traveling either. So always have a backup basal insulin just so if the pump breaks. The other thing is to really know your pump well. Which again, you know, we’ve kind of talked about that. But know what your basal rates are. Know what your carb ratio is. So if your pump breaks and you get a new pump, if you don’t know that you’ll have to go to the doctor’s office and have them reprogram everything for you. But too you want to know what your basal rate is so, you know how much you better give yourself while your pump is broken.

Yeah quick tip. I always tell people obviously you want to write down all your pump settings, but also go ahead and just take a picture with your phone of all the screens because that way I have to use it all the time when I’m not with my son, especially when he was younger if I was calling the endo. So you have it on your phone. We always have our phones. And then you have it written down somewhere. So you can have it in both places.

 Well Dr. Ownby thank you so much for joining me and going really in depth on this. I really appreciate it. 

No problem.

 

 

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