#652 Defining Diabetes: Pump Break

March 29, 2022Scott Benner

Scott and Jenny Smith define diabetes terms

In this Defining Diabetes episode, Scott and Jenny explain Pump Break

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DISCLAIMER: This text is the output of AI based transcribing from an audio recording. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record. Nothing that you read here constitutes advice medical or otherwise. Always consult with a healthcare professional before making changes to a healthcare plan.

Scott Benner 0:00
Hello friends, and welcome to episode 652 of the Juicebox Podcast.

Today on the podcast, Jenny Smith and I are going to find a term from your life with diabetes. In today's defining diabetes, we'll be discussing pump break. While you're listening, please remember that nothing you hear on the Juicebox Podcast should be considered advice, medical or otherwise, always consult a physician before making any changes to your health care plan. We're becoming bold with insulin

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This episode of The Juicebox Podcast is sponsored by two of my longest advertisers, Omni pod makers of the Omni pod dash, head to Omni pod.com forward slash juicebox to get started today and see if you're eligible for a free 30 day trial of the Omni pod dash. The podcast is also sponsored by Dexcom, makers of the Dexcom G six continuous glucose monitor, say hello to dexcom@dexcom.com Ford slash juicebox. You may be eligible for a free 10 day trial of the Dexcom G six, you'll find out the link links to these and all the sponsors are available at juicebox podcast.com. And right there in the show notes of the audio app that you're listening in. Jenny, I'd like to define pump brake. And I have to admit that I don't know enough. I think because I don't have diabetes. This one's lost on me. Right? Okay. From my perspective, I believe that Ardens insulin pump has made Arden's diabetes easier. Sure, because I'm not wearing it. I don't have any reason to want her to stop it. But

Jennifer Smith, CDE 2:50
she's then obviously never voiced a desire to stop it either. Because I think that's a big piece, especially with kids and teens that were parents are really trying to listen to their kid, it's not so much that the parent would for the most part, I don't think 99.9% of parents would ever want to remove the pump, right? I think it comes more from the desire of the child expressing a frustration that they say okay, well, let's try this.

Scott Benner 3:19
So Arden has when she was younger in the past said, you know, I'm going to stop wearing a pump, and I go, okay, that's fine. Here's how this is going to work. From now on, we're going to take a shot of long acid long acting insulin, probably in the morning. Maybe at night, we'll work that out. You're gonna have to do an injection every time you eat. And then she was like, oh, nevermind. It was it was like that. And I wasn't trying to scare. I was just like, that's fine, if that's what you want to do. And she was much younger. She has not mentioned it in many years. I would admit that. But, but I take your point, you know, if the kid wants to take a break from it, I get that I think that's fine. From your perspective, though, as an adult, you've had diabetes forever. Like, have you ever stopped using your pump to take a break?

Jennifer Smith, CDE 4:10
Yes. Um, but not. God, it's been a really, really, really long time since I did that. I mean, it's probably been six to eight years. Okay. And I know that at one point I had done it in the past only because I really just well one in particular was going diving. So I can tell you that I did it for and it was only like a two day because that was just going to be the time period in which we were actually diving where you can't physically like where the pump down. You know it was going to be like a whole pain in the butt to just do it. And since they were on the pad and couldn't just easily disconnect and leave my site connected, I was just, I'm just going to go to injections. So there are some maybe life types of things, too, that people would decide to do that for as well. But another I think, reason in the past that I had done it was just to give it a try and remember what my strategy was like, with MDI. It was more of a learning, not a, I'm really tired of my pump, I just want to be completely disconnected and have nothing on my body. Now, I didn't disconnect completely. Obviously, I kept by my continuous monitor on. So I still had all of that information to use in order to dose with injections and smooth things a lot better. I mean, I, I don't think I've been off of a CGM for maybe more than like, three days because I didn't have enough supplies left maybe. Or I mean, I've been on a CGM consistently for like 16 years. So MDI without a CGM, I don't know that world anymore other than just, I'll just do a heck of a lot of finger sticks. Because I did do that when I was pumping before I had a CGM, right. And I just did. I mean, I think my order for for testers was like, my doctor had written for like 14 test strips a day or something was what back then and I used.

Scott Benner 6:29
We did that with rd. So I would say 10 was like a slow day for us. Yeah. Because you were like, in the morning, before meals after meals, were we at like, basically trying to be a CGM. Before I even knew what one was

Jennifer Smith, CDE 6:45
that time. I mean, I before I had a CGM, I always had a two o'clock in the morning alarm that went off. In fact, many times I was awake just before my alarm went off, because my body was so used to getting up at that time, it was just the norm. Yeah.

Scott Benner 7:00
Do you know back then? Back then, when I was young, if you would have said to me without a clock or a watch, or any way to follow time, if you would have said to me, Scott, right now start and tell me tell me when an hour is, I could almost do 60 minutes to the second because I would think like, alright, Arden just ate in an hour, I'll test her. And yeah, I would set alarms and set alarms to the point where my body knew when an hour and passed, it was right. It was ridiculous. I do not have that skill anymore. And I'm glad glad of it. Well, and

Jennifer Smith, CDE 7:33
I think it's, it's good to bring this all in in terms of going back to just injections coming off of a pump taking a pump vacation, because like I did in the past, it was sort of a trial of do I remember how to do this. So I don't necessarily think it's actually a bad thing to maybe do. If your child is willing, or if that's an adult, you're like, Yeah, I don't I don't know, if all my technology failed, and it was over like a holiday weekend, or I was on some remote island somewhere. And they couldn't overnight me a new pump, you know, what would I do? So it is a good idea to have an idea, you know, to have that back knowledge of where would you go and what would you do? But it also then starts with? How would I go to injections? How would I take what I'm doing on my pump? And transition that into dosing strategy and calculations and everything? To make it work? Well, there's

Scott Benner 8:30
no way with a with an algorithm like there's no way to mimic an algorithm with I guess you could inject yourself 1000 times but even then you couldn't take basil away. You couldn't take yeah, there's no way to do it. I could probably go back to the way before,

Jennifer Smith, CDE 8:45
but just conventional pumping. Yeah,

Scott Benner 8:48
I could get I could probably mimic that with MDI pretty well, but it's a lot of injections. I mean, you're going to be shooting a couple of times in two hours after a meal maybe if something happens, or you're trying to eat something with fat in it, but when you talk to adults who who say I want to take a pump break isn't is that usually a what do you think? Literally? What do you think? What do you see from people? What precipitates the the idea that they want to take a break when it comes from an adult?

Jennifer Smith, CDE 9:21
I think it's a couple of things like I said the one diving that I did it's so it's sometimes it's more like a life thing where they just don't the perceived hassle of pumping part like all of the pieces and whatnot that may be in disruptive to what they're going to be doing or may not just work well with what they're doing. That may be a reason. Another reason that I've had is some people for some reason start to get irritation with the adhesive enough to the point that they just need a break. They just can't imagine putting Another piece of something on their body with, you know, like an outbreak rash that just takes forever to heal as well. So that might be another reason. Usually, for something like that, I say, well, you're using this type of a pump or this type of infusions that let's just without putting it on, let's do the pump vacation. And I'll give you you know, the rules to do that. But let's also at the same time, get a couple extra different kinds of infusion sets, and just kind of pop it on your body. Without it being used. Let's see if it's truly this product, the adhesive? How can we kind of get around it, especially if we work through all of the other under adhesives? With the other product? And nothing seems to be helping enough?

Scott Benner 10:46
It's It's so unfair people who already have an autoimmune issue. You know, it's, it's reasonable that they might have more allergies than other people too. And then you have to stick this stuff on. I probably probably should do an episode at some point about barriers to and how people probably agree. Yeah, cuz I, I'm gonna put that on the list added to the list. Yeah. I'll do it now. Because I think we all know, yes, I'll forget if I don't write it down right now. Okay, so

Jennifer Smith, CDE 11:13
So those are some of the reasons Yes, I

Scott Benner 11:16
would say yeah. Because I think that's, I mean, it's funny because my brain jumps to like, like people being annoyed wearing something. And so they want to take a break. But the medical reasons are, I mean, for the adhesive itself is that that's probably that's probably the biggest one because it's not like you can power through that, like I've seen terrible, like, some people's rashes are terrible yet

Jennifer Smith, CDE 11:40
Correct. I mean, I've got one team that I've worked with for a while now who loved using the pump. But the problems that we saw with use of the pump, he is doing so much better on multiple daily injections than ever was consistent with the pump. And so, you know, in a decision like that, then it's okay, this is how we would take a pump vacation. Will we ever get back to the pump? I don't know, the big thing there was to look at, what kind of management could we get with multiple daily injections versus the issues that the pump was bringing in to the management? And for him, it was a cut and dry. I mean, there was definitely adjustment and stuff once you go back to just injection management. But it's it's better for him,

Scott Benner 12:30
was it sites was he gonna get an absorption,

Jennifer Smith, CDE 12:35
totally inconsistent absorption sites could be fine for three days. And then they could be really bad within 12 hours. Sometimes there was irritation from the adhesive. Sometimes. I mean, it was a host of things that were just, and because of it, like there was no consistency in blood sugar, because we never really could tell how well insulin was really working some days, he'd have these beautiful lines and like the next day be completely sitting at like 300 Like it was it was not doing anything different food wise and this. This guy eats like the same thing. So

Scott Benner 13:12
that's a perfect example of it. Okay, so yeah. Alright, so let's just like high level, you're gonna stop using your pump. Let's see if you made me do this. You stopped me when I'm wrong. Okay, if you said to me, Scott, Arden can't use a pump anymore. I would say I would add up her Basal rates, right and find out what her Basal insulin is over 24 hours. Right? I would probably Hmm. Because she has an algorithm that takes her Phaselis away sometimes. Would I lessen it a little bit? Ooh, interesting question. No, I would probably be aggressive, I would probably add up her Basal insulin and then shoot that much. I would fight with a doctor if they didn't want to give me a more modern Basal insulin. I don't think I'd want to use level mirror or Lantis if I didn't have to like it just because that's anecdotal from what I'm seeing from other people. Correct. You know, like,

Jennifer Smith, CDE 14:06
Yeah, I think you bring up just the point that there are better newer Basal insulins that are definitely much more consistent 24 hour action like a true 100% 24 hours you will get out of this Basal injection,

Scott Benner 14:20
right and I have I have anxiety thinking back on. We didn't use Lantus big. Oh my god, we didn't use Lantus because it burned Arden. Oh, it's not uncommon to hear I did not remember that though. Because she tried to gasp and loom JEV and it burned her to I wonder, Oh, that's interesting. They might not have anything to do with each other. They just never thought of that. It's been so many years. So Arden used Levin

Jennifer Smith, CDE 14:43
and they're made by different companies but who knows what the chemicals in them that might have caused that interesting to be similar.

Scott Benner 14:50
So Arden use levemir we split it and I would hopefully not want to do that. Like this splitting. It's like it's just it's I mean it works but it's a pain. And then from there, I guess I would just, I'd look at her meal ratio, and we'd shoot and Pre-Bolus and see what happens.

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there's lots more to this episode. So let's get right back to J. Me but you know, mostly J

Jennifer Smith, CDE 19:20
I think the biggest thing there is calculation. Yeah, cuz then it's all right. It's all self calculation at that point. So you know, then it becomes a lot of daily equations and a lot of daily calculation or tracking of insulin on board, right. So with the way that you manage in a very, like tight micromanaging way. If you have just a breakfast lunch and dinner Bolus going in, you see a definite finish of the Bolus by the next time you're going to eat. But if you are really heavy handed in managing and keeping and that I'm not saying that badly, it's just that If you're heavy handed and managing and it's working really well, then your your little lingering trickles of the end of active insulin from one Bolus into maybe a correction or a snack came into the picture or something like that, which can be very common with little kids with their snaps next snack kind of breezing through the day, then your timer is almost consistently being restarted and your analysis of insulin on board becomes deeper, because there's more there to consider.

Scott Benner 20:30
Yeah, I You just made me feel like like I was imagining in my head like bands of like bands or rubber bands. No, no, no, like, like, how am I gonna explain this? Timelines? So yes, so there's insulin that's running on a timeline from the Bolus for breakfast. And if you're MDI, you put it in at 9am. And that one timeline ends usually before you'd put in more, so you'd be only working in this one linear line. But but with the algorithm or even pumping, you might Bolus 30 minutes later Bolus, again, that's a new Bolus on a different timeline, the first 9am, the second one's at 9:45am. And then before you know it, you grab a snack at 1015. And that's a third run there are all these overlapping, yes, timelines of insulin running concurrently. And they're all starting peaking and stopping at different times. It's almost like a symphony. Really, when you're doing all that, and you don't, you don't so much control it as you just sort of, I don't know

Jennifer Smith, CDE 21:38
with it. Yeah, right. I mean, it becomes, you know, the old term of stalking, that really is why on MDI, it becomes more beneficial to just have a pretty rigid schedule, like you get up in the morning in a fasting state, I think that's the, if your Basal is really well dialed in, and you're waking in a really healthy range, and you've done enough testing that you can fast into like the mid morning, and you know that your Basal isn't allowing you to drop at least not too much or rise at least too much, then could you test out and say, well, morning isn't really my weird place, I can vary when I wake up in the morning, it might be the next boluses down the line, though, that you really have to keep in a I know my active insulin time is three and a half hours. So I'm going to eat breakfast at eight o'clock today. So maybe by noon, I'll definitely be out of that active insulin window enough that lunch will be its true own effect coming into the afternoon. But like I said, if you're stacking, kind of, because you're eating and snacking, and eating and snacking and grabbing and whatever happens through a day. It's a it's a tracking that you end up having to do.

Scott Benner 22:54
Yeah, it's it's so interesting. Like, I wish I wish I could put it together visually the way I see it in my head, just, you know, layers on top of layers floating in their own timelines. And though yes, all right, yeah. If this is a plan thing, contact the doctor. Make sure you have a pen or needles and you know the insulin that you need. And

Jennifer Smith, CDE 23:17
yep, and that, you know, like you were saying before with basil, everybody on a pump should have a basil sitting in the refrigerator anyway, in case of pump failure. That's a good rule of thumb. That if you are a pumper, even if you have a backup pump, again, all things beautiful. Not all of your systems as backups will fail. But in the time or the day that that does happen, you may have to go back to a Basal injected insulin. And sure if you at least have one on order, could you quickly swing by your pharmacy and grab it and come home? Absolutely. But you know what, if it happens at two o'clock in the morning, it's easier to have a basil sitting in your fridge that you can just take and not have to worry

Scott Benner 24:04
like Jenny's trying to make me feel bad. I don't. About once a year Kelly's like do we have Basal insulin in case Ardens pump has a problem. Am I gonna know what I don't know? But every time there's been a problem, it has been at two o'clock in the morning. I'll tell you that.

Jennifer Smith, CDE 24:20
So the example here is don't be like Scott

Scott Benner 24:23
episode with the word Adele in it somewhere. We went to an Adele concert. Arden's PDM died at the Adele concert. She was still getting basil. And so I remember just it happened. And it was Kelly's birthday present. And so nobody wanted to bake Kelly upset. So I just reached over Arden had popcorn. I took it from her and I was like stop eating. And and because we couldn't Bolus and then we got home. And then I got you know, I got told about not having Basal insulin. It was a lovely woman that every married man understands what I'm saying. And I got I got to explain to me that I was wrong. And then I remembered there was a kid in town that used Omni pods. And we literally woke them up and stole their their

Jennifer Smith, CDE 25:10
extra PBM for PDM. Yeah, yeah. I mean, the good thing in the story is, of course, that the pod didn't fail. It was just the PDM that wasn't working. So it was good to know that your pumps still giving you basil.

Scott Benner 25:21
Yeah, it was the old PDM it just died. And she stuck. She kept getting basil. I was positive. That was right. But in fairness, to my anxiety, there were people I was able to text right from the Adele concert and go, Hey, I'm right about this on a she's still getting basil. And they were like, yes, it was like, yes.

Jennifer Smith, CDE 25:39
Yeah, yeah. So yeah, I mean, it boils down to a Basal insulin in the fridge, as you were kind of doing some figuring or calculations. It's what is your current pump delivering in terms of what is your base basil? Even if you have an algorithm driven pump? What is the bass profile supposed to be delivering for you in a day? Now if you're going to get a little bit more nitpicky about it on average? Could you go and see, well, what is your algorithm algorithm on average kind of taking away? What does it averaging out? Mean? In the moment, you're probably not going to do that, go to your base Basal profile, look at what it would give you over a 24 hour time period. And then because pump sites are supposed to be a little bit better at consistency in absorption. That's the reason that if you're coming from MDI, going to a pump, we usually take the Basal down by about 10 to 20% of what your injected dose would be. So if you're doing the opposite, you'd actually take your base diesel in the pump, and you may dial it up by 10 to 20% as the injected Basal dose, okay.

Scott Benner 26:42
Yeah, I think rd would probably it's interesting article, I would probably start Arden around 26, maybe units. And because she but she's so heavy the other way, like like Arden's meal ratios, and meals really heavy. So we're lighter on basil, but that's just because it works on the algorithm, I guess I would learn

Jennifer Smith, CDE 27:08
conversation makes me want to, I mean, not really want to but makes me kind of want to like, get some of my basil out of the fridge and just play around for a couple of days.

Scott Benner 27:19
I mean, Arden's meal ratio is one to four and a half. So I mean, she gets I'm gonna pull up a caucus, she

Jennifer Smith, CDE 27:25
gets big. I mean, and depending on how much she's eating in a meal, I would expect that her basil versus Bolus is probably well off of the your basil Bolus should be 5050. That's

Scott Benner 27:38
probably I mean, if she ate 50 carbs, divided by 4.5.

Jennifer Smith, CDE 27:45
It's getting about Yeah, I was gonna say 10 to 11 units. Yeah.

Scott Benner 27:50
You some people, I tell you what, like some of her like high fat meals. Y'all have a stroke. If you saw that Bolus going. There's plenty of people would be like, how much are you using? And I'm like 19 units

Jennifer Smith, CDE 28:03
of insulin well, and that I mean, that brings up another point. It's like then on MDI, how do you mirror what you were doing? Even not on a even not an algorithm driven pump, but just an unconventional pump, at least you have things like extended Bolus and temporary basil that you have to your advantage on injections, the best thing that you can do is use your hindsight. Where would you have added more insulin for a meal like this previously, and even if it was an extended Bolus, if you're waiting for a rise to Bolus extra for fat or wherever you figured that you usually would have needed more, you're still gonna need another injection. Now, the question is, how much more now? And are you just gonna have to break that? What would have normally been entered into the pump? Do you have to break it up yourself in multiple injection,

Scott Benner 28:54
you're making me wonder if I increased Arden's basil and decreased her meal ratio made it weaker. If we would call it things we maybe couldn't even find stability by making changes like that. I wonder if we could you know, it's a crapshoot because the algorithm will save you try to save you if if the basil is too heavy to begin with.

Jennifer Smith, CDE 29:15
Correct. And you're you're saving on injections is just food, right? Or extra insulin? I guess it's either or right.

Scott Benner 29:25
The one the one high side I could see is that, you know, big boluses don't tend to absorb as well, like through sites. So maybe that is interesting.

Jennifer Smith, CDE 29:33
Yeah. And for boluses, then I mean, the simple math is really just it's two calculations. You have to have a blood sugar calculation and you have a food calculation, right? So you take a current blood sugar, take away the target that you're aiming for, let's say 100. And then you divide it but what by whatever is your correction factor, your ISF, your insulin sensitivity factor? Let's say it's 50. Right. That gives you how much corrective insulin if any, you might need At this mealtime, the second calculation is just carbs divided by your insulin to carb ratio. And that's just the part for food. And then you add them together.

Scott Benner 30:08
So if Arden's blood sugar was 150, and I wanted it to be 100. Yeah, I would take 50 divided by her correction factor extra factor, which is like 45. Maybe. And I would come up with like, one point something, whatever that would end up being I click Yes. 1.1 1.1. And that would be my injection.

Jennifer Smith, CDE 30:27
That would be your injection just to correct, then she's going to eat 60 grams of carb divided by what 4.5 You said is her ratio. I mean, that's 13 units. So now she's getting 14.1 units or 14 because you can't really do microscopic Bolus via injection.

Scott Benner 30:44
I'll tell you, you just took me right back to the anxiety of when Arden was diagnosed doing that math. Yeah, that feeling is the exact reason this podcast exists because I was like, Well, I can't do that.

Jennifer Smith, CDE 30:56
Too much math, all the law that is too much.

Scott Benner 30:59
All right. Well, Jenny, thank you very much for doing this.

Jennifer Smith, CDE 31:01
Yes, of course.

Scott Benner 31:11
Did you know that Jenny Smith works at a little place called integrated diabetes.com and that you could hire her to help you with your type one. It's true. Alright, guys, another great episode, I want to thank Omni pod and Dexcom for sponsoring this episode of The Juicebox Podcast, please don't forget, you may be eligible for a free 10 day trial of the Dexcom je six, you'll know that if you go to dexcom.com forward slash juicebox, you may be eligible for a free 30 day trial of the Alibhai dash. That little bit of information can be found out about that's not English. But let's keep going@omnipod.com forward slash juicebox.

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