Fiasp Injection_0

The Newest Fast-Acting Insulins – How Fast Is Fast?

I think it’s time for me to send out an update on the new ultra-rapid acting insulins but before I jump into what’s new, let me back up a minute and talk about what’s “old”.  Most of us use a rapid-acting insulin of some kind- mostly either Humalog or NovoLog.  But we all know that these insulins are a FAR cry from rapid acting.  In fact, they are quite the opposite.  How many times have you been high, taken a dose of “rapid” acting insulin, then looked at your CGM 30 minutes later (or tested) and your blood sugar hadn’t moved at all- or even gone UP.  WTF?!  Super frustrating and the number one cause of rage boluses in my personal situation.  Oh, 5 units didn’t budge me at all?  Nothing a 10 unit rage bolus can’t handle.  Annnnnnnndddd now I’m grumpily eating crackers with an apple juice chaser.  And peanut butter for some reason….

Unfortunately the myth of rapid-acting insulin perpetuates our mentality- for both people with diabetes and physicians, that we still think we can take the insulin and eat right away.  This might work if you have significant gastroparesis, but otherwise, you will be WAY behind the eight ball.  That’s one reason Steve and I always push the “pre-bolus” or bolusing a minimum 20-30 minutes before you eat, and longer if the glucose level is really high and/or with trend arrows shooting upward.  This was actually one of my most vivid memories when I was first diagnosed and in the hospital.  They brought me my food and gave me my insulin but made me sit there staring at my food for 20 minutes before they would let me eat!  Nothing like not being able to eat to let a 15 year old kid know that his whole life just got F’d up.

So can these new “ultra-rapid acting insulins” get us away from the pre-bolus and enable us to take insulin when we actually eat?  I’m sorry to say, but I just don’t think so.  Not yet.  I should clarify that I’m NOT talking about Afrezza which you actually CAN (and should) take when you start eating… or even after eating because it is that fast.  I’m talking specifically about the new “faster-acting aspart” or Fiasp.  This is basically the new NovoLog that just hit the shelves about a month or so ago now, and you may start hearing about.  Basically it adds a couple of excipients to the NovoLog we all know and love to make it get absorbed a little bit faster.  So how fast is faster?  Well, a little, but not a ton.  In the first of the clinical trials, Fiasp lowered A1c by about 0.1% compared to regular NovoLog with some small improvements in BGs after a meal.  So not a huge difference, but a difference.

My take on it is really this-

1. Some people seem to notice a difference when switching, but I personally didn’t, nor did Steve.

2. If you are going to switch, I would just go into it with low expectations so you aren’t all devastated if you don’t like it.  This is my approach to movies as well and it works well for me.  Was still disappointed by Pitch Perfect 3 though.

3. Also, and most importantly, I personally would STILL pre-bolus before eating.  Fiasp is a little bit faster, but not enough to make me really believe you can avoid pre-bolusing.  Don’t worry, it’s not super-dooper fast to the point it will make you crash, so you definitely still can give it a run up before eating.  Having a CGM will help you figure it out.

4. It’s supposed to be priced the same as NovoLog, so you might just adopt a “why not” approach to trying it.

5. Even though number 4 is true, it still might be a hassle to get for these early days since it’s new.

6. You will probably have to remind your provider that it exists and you want to try it.  Then sit back and enjoy the moment where they realize you know more than them.

7. It MIGHT have the best benefit in automated insulin systems like the 670g or for you LOOPers out there since it can take care of the basal for you and really highlight any mealtime benefits.

Ultimately I think having a truly fast-acting insulin that you can inject or put into a pump is the single biggest need for insulin therapy in T1D. So for that reason, I’m super super glad to see companies working on this.  Out of the gate with Fiasp, I don’t think we are “there” yet, but I hope it will continue to push insulin therapy in this direction.  With that in mind, numerous other companies are working on their new, faster-acting insulins, so we will have to see just how fast their fast is.

 

This post originally appeared on weareonediabetes.org. If you are a diabetes professional and also have type 1,  sign up for the WeAreOne online diabetes community here!

Diabetic woman preparing for a run

Tips on Glucose Management During and After Exercise
for Type 1s

You may never have heard their names before, but they’re out there and they’re dominating in almost every sport: basketball, football, surfing, car racing, Olympic snowboarding, Taekwon-Do and even ballet. Sean Busby, Zippora Karz, Charlie Kimball and Missy Foy are just a few professional athletes living out their dreams and simultaneously living with type 1 diabetes.

Even though shooting for an Olympic medal is not the norm for most of us when we lace up our running shoes, the success of those who have can bring inspiration to people with diabetes who want to keep fit at any level.

A ton of research is being done in the field of glucose management during and after exercise, and we asked two top researchers who are also athletes living with type 1, to provide insights into their work and to share their personal training regimens.

Dr. Michael Riddell is a Professor in the School of Kinesiology & Health Science at York University in Canada and is considered the international authority on exercise and stress hormones and how they affect diabetes metabolism. He enjoys biking, hiking and trekking, and climbed Mt. Kilimanjaro in 2013 with the World Diabetes Tour.

Dessi Zaharieva is a 3rd year PhD candidate in kinesiology and health science at York University. She earned a bronze medal in Taekwon-Do at the 2013 World Championships and is currently training and competing in mixed martial arts. Her research at York is aimed at improving diabetes management and blood sugar control during exercise in individuals with type 1.

TCOYD: Do you have any advice or tips for someone with type 1 who wants to take their training to the next level or take on a new fitness challenge?

Mike:

Unfortunately there are no magic bullets or magic solutions…what we’ve noticed is that training for an activity with type 1 requires a lot of vigilance around glucose monitoring along with a lot of trial and error.

 Dessi:

General guidelines are difficult because individual variability is so huge. For me, even if I were to do the exact same things today and tomorrow, the exact same training with the exact same adjustments to my sensor-augmented pump, I may not have the exact same response.

Also I have to take my pump off during training because I do mixed martial arts and I fight, so the changes I make to my pump might be very different than what Mike does when he’s cycling, because he doesn’t have to disconnect his pump.

TCOYD: Can you share some things that have worked for you personally with regard to managing glucose levels while working out?

Mike:

For the prolonged endurance exercise that I do that lasts an hour or so, I need to get my insulin down beforehand, so I try to find a time to do that activity when my insulin is already low, and the insulin I’ve taken after a meal is largely gone. This can be four hours after a meal or more, or it can mean exercising in the morning before I have breakfast. That really is the key to my success.

On top of that, I need to lower my basal insulin on my pump well in advance of an endurance activity, so an hour or 90 minutes beforehand, I need to get my basal down to about 20% of my usual basal rate. I also have my CGM on to make sure my blood sugar’s not getting too high.

I can usually get my basal rate down aggressively and then I can go for an hour – two hours even – with a very long run or a long bike ride. My performance improves if I can then start to have a little bit of carbohydrate from either a sport beverage or glucose gels, but I might need to turn my basal back up a little if I notice on my CGM that my glucose is beginning to rise because I’m snacking.

So for me, the secret is starting with low insulin in my body and then consuming carbohydrates for performance at the rate of around a half a gram of carb per kilo of body mass, so around 40 grams an hour or so.

Dessi

With my training there are a lot of similarities to Mike in that we both reduce our basal insulin quite drastically beforehand because I feel like without doing that, too much insulin in the circulation is not going to be a good thing with the amount of training I do. My training sessions are between one and three hours a night and sometimes even longer.

With that amount of exercise, reducing basal insulin becomes very important (or just having less insulin in the circulation if possible). That is one of the times when preplanning is essential. I don’t like to go fully fed into a training session. If I can wait four hours before I train that’s the best situation – to not have a lot of food or insulin in the body in order to try and prevent big spikes and drops in blood sugars.

TCOYD: How often are you checking your blood sugar during a workout?

Mike:

I’m vigilant about monitoring my glucose and constantly using CGM, and I wear my CGM on my watch. I don’t stop and poke my finger and do a blood test – I’m just looking at my outputs on my watch or on my pump, and I look frequently because I know my performance is best if my glucose is near normal or only slightly elevated. In American units I’m talking about 120, 130 milligrams per deciliter. That’s where I want to be, so I’ve got to look at my CGM all the time so I can continue to make changes. I can increase my basal rate if my glucose goes high or I can snack on carbohydrates if it drops below that narrow window of performance for me.

Dessi:

My pump is off when I train so it’s not as easy for me to check my CGM. I have the new Medtronic 630 G pump. I keep it in my bag really close to where I train, and anytime we get a water break I go look at my pump screen and it picks up a signal as long as I’m not too far away. So even if it’s not connected to me I still have an idea as to what’s happening.

TCOYD – Are there challenges in glucose management post exercise?

Dessi

It can be really challenging to maintain blood sugars throughout exercise AND in recovery. That’s one of the biggest challenges right now.

Mike

Some of the research we’re doing is focused on the glucose excursions and the meal after exercise, and if you have your pump off whether that makes glucose go higher. During exercise everything may be okay, but you may suffer a little bit in what to do for the meal after exercise if you’ve had your pump off, you’re hungry and you want to have a big meal, but your insulin might be low at that point.

Recovery is important because if you want to feel good and do it again the next day, you have to treat your body well in recovery. We’re still learning what the best approach is, what the right meal is, when to eat, how much insulin to give for any given meal, etc. You know you use a lot of calories and you burn a lot of carbohydrate when you exercise, and you’ve got to pay it back or you’re going to possibly set yourself up for hypoglycemia overnight. So these are all interesting research questions that we’re working on right now.

TCOYD: What are your thoughts on taking Afrezza if your numbers are high after a workout?

Mike:

We have Fiasp here in Canada. We don’t have Afrezza, but we know athletes who have taken Afrezza after seeing high blood sugar, and it disappears out of the system quite quickly which is nice, and then there’s no prolonged late onset hypoglycemia so I think it holds some promise.

Dessi

We know that if we can get the insulin in our system faster it’s going to help.

Mike

Get it in and get it out!

Dessi

I’m going to have spikes if I don’t take bolus insulin after exercise with my pump disconnected for so long and if that insulin is taking half an hour to actually start kicking in and working it’s already too late, so the Fiasp has been very helpful.

A few final thoughts:

People with type 1 diabetes can achieve basically any dream they have on the exercise front. They can be Olympians, marathon runners, rugby players, basketball players, etc, but each form of exercise has different energy needs and places different demands on their diabetes.

If you are embarking on a new goal or simply focusing on maintaining a current one, remember that it’s process of trial and error, try not to get discouraged, and what’s most important is that you do what works best for you and your body.

 

For more information on exercise with type 1, check out Dr. Riddell’s book:

Getting Pumped- An Insulin Pump Guide for Active Individuals with Type 1 Diabetes
available here.

For more information on their research at York University, please visit Dr. Riddell’s webpage here.  

mini-med

My Detailed Review of the MiniMed 670G from Medtronic

The MiniMed 670G from Medtronic is an insulin pump coupled with a glucose sensor.  It uses a computer program (called an “algorithm”) to automate certain aspects of insulin delivery.  I decided to try 670G partially out of professional interest (everybody and their great aunt has been asking for my opinion on the system), and partially out of personal interest, as my blood glucose control hasn’t been the greatest the past couple of years.

Let me start out by saying this:

Since I started using 670G, my overall blood glucose control is better.

I have to keep reminding myself of this non-consequential fact, because every day I find things about this system that I don’t particularly like.

To continue reading, click here.

Hand writing DIY - Do It Yourself with white chalk on a blackboard. "n

DIY Looping

Steve and I had the pleasure of going to Vienna, Austria together two weeks ago for the diabetes technology meeting, and while there definitely was some cool stuff presented in the artificial pancreas world, my update comes from my own AP world.

As I’ve mentioned before, I started on LOOP about 4 months ago, and I think I’m finally ready to give an update on it.  So first off, what is LOOP?  Basically, it’s an AP system that uses:

  1. An old Medtronic pump
  2. An Iphone
  3. Your CGM (Dexcom or Medtronic)
  4. And a device called a “RileyLink” that connects them all together

The founder of Loop has a daughter with T1D named Riley, and thus, RileyLink!

So what does it do?  Basically, it uses an app to determine what basal rate adjustments should be made on your pump, and uses the RileyLink to hack the pump and tell it what to do.  You still have to bolus as you would for meals, and correct, and all that garbage, but the system does a great job of giving you more or less insulin as a basal rate.  Basically, it does what the 670g system does, but with a lot less hassle.  So what do I like about it?  Well here it is:

THE UPSIDE:

I SLEEP BETTER

I could probably just drop the mic after this one and walk away and I would be fine with that.  I simply don’t get low at night anymore.  And I don’t really get high either.  Nighttime went from my most frustrating time, to my most consistent.  My wife told me the other day, “Hey you don’t sleep with apple juice by your bed anymore.”  And I was like- she’s right.  Now I’m just spending time thinking about what I’m going to do with all this juice money.  Seriously though, I don’t wake up to alarms, and I wake up every day with a really, really good blood sugar.  It took going on LOOP to realize how crappy I was sleeping before…  Low.  Eat.  High.  Insulin.  Repeat.

I’M A LITTLE LAZY WITH MY DIABETES

Yeah that’s right.  Loop lets me slack off a little, and I kinda like that.  I know if I don’t nail my bolus, the basal rate will kick in to help minimize the damage of me drastically underestimating my carbs…. again.  So I think I worry a little less about the fluctuations and my time in range is better.

LESS LOWS

Not a lot to add here.  I get low less.  Less at night, less during the day, and less with exercise.  Less lows means fewer texts from Steve telling me to get my shit together.  I really like that feature a great deal.

SOME TECH FEATURES

The pump is completely controlled from your phone through a pretty slick-looking app.  So if you don’t want to, you never really have to touch your pump.  You can adjust your target to whatever you want- including an exercise target.  It gives you a predicted glucose curve and its fun to see it shift when you enter carbs or insulin.  It’s not always right, but it looks cool.  You can tell the app if you’re eating a high carb meal (lolly pop), a mixed meal (taco), or high fat (pizza).  All well thought out stuff.

THE DOWNSIDE:

So what don’t I like about it?  Well it’s really when it just doesn’t work.  Sometimes it drops the Dexcom signal or isn’t picking up the pump for some reason.  So I do spend a fair amount of time looking at the app to make sure I’m still “looping”.  Carrying the RileyLink around is kinda annoying and I’ve broken 3 of them.  Yes 3.  All water related.  So more “fried” them then broke them.  But this is all minor stuff.

SO HOW DO YOU GET ONE?

How do you or your patients get on the system?  To be honest it’s a little complicated to set up, but I actually did it myself (the second time) without any problems.  There are VERY good instructions here:

https://loopkit.github.io/loopdocs/

I didn’t mention before that this is a complete Do It Yourself (DIY) system so is NOT FDA APPROVED, you won’t find it in any CVS, and your doctor can’t prescribe it for you.  You have to do it your damn self (DIYDS).  And to do that you’ll need all those things I mentioned at the top, several hours to spend, and about 130 bucks to buy a RileyLink.

I didn’t realize how much LOOP had really been helping me until I was in Vienna, and I only packed one European electrical converter and ended up charging my phone more than my RileyLink.  So my LOOP would drop out when the RileyLink didn’t charge, and I was back to the dark ages.  Champagne problems for sure, but hey, it made me realize what a big advance this type of technology is.  So while we are waiting for systems to get better and better, for now, go out and DIYDS.

 

This post originally appeared on weareonediabetes.org. If you are a diabetes professional and also have type 1,  sign up for the WeAreOne online diabetes community here!

tesimonial-cme-g01

The shifting paradigm of a “cure” for type 1 diabetes: Is technology replacing immune-based therapies?

Nearly 50 years after the autoimmune nature of type 1 diabetes was discovered, no therapy has been approved to alter the course of the disease at any stage. However, during that same period, technology has been delivering tools to help patients achieve better glycemic control and reduce the burden of the disease. With the imminent arrival of fully automated artificial pancreas systems that will continue to improve control and quality of life, it appears that we are on the verge of a major technological breakthrough that will significantly impact diabetes care. These devices have such a high degree of potential that they are, at times, mentioned as a virtual cure for the disease—a first for technology in this space. As such, these devices will undoubtedly alter the research landscape in a field that has predominantly been occupied by immunotherapies. This article reviews the history of type 1 diabetes and compares and contrasts the advancements that have come from the world of technology and immunology alike at this important crossroads in care that we are currently in.

View the full article here.

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Raise Awareness for Diabetes with Your Warrior Call!

Join forces with TCOYD during Diabetes Awareness Month and show the WORLD what it means to be a diabetes WARRIOR!

Post your best warrior call to Facebook or Instagram! Your warrior call can be anything you want it to be – a photo, a video, a look, a shout or a song. Tag @Dexcom, use the hashtag #WarriorUp and help us raise diabetes awareness during the month of November!

For every post and share of your photo, Dexcom will donate $2 to be split between five amazing organizations doing amazing things for people with diabetes.

Check out the campaign video from Dexcom!

 

So get those cameras out and let’s see and hear those warrior calls!

Why I’m excited about Tandem’s X2 Dexcom G5 software update

By David Ahn, MD

In late August, the FDA approved Tandem Diabetes’ long-awaited first software update for their X2 Insulin Pump that enables Dexcom G5 integration. With a FREE simple software update performed in the comfort of their own home, thousands of X2 users can now display CGM data (from the Dexcom G5 Mobile System) directly on their Tandem pump screen.

In the world of smartphone apps and hybrid closed loops, viewing CGM data on a pump screen might not appear at first glance to be groundbreaking, but Tandem’s software update will provide meaningful benefits not only for Tandem customers, but for the entire industry of people affected by diabetes.

First time a software update has added a new feature to an insulin pump

“The pump that gets updated, not outdated” is appropriately Tandem’s marketing slogan for their X2 Insulin Pump. A longstanding frustration for pump owners has been that insurance companies will not replace or upgrade most insulin pump hardware until the 4 year warranty period expires.

Therefore, while you might be buying the latest and greatest pump on the market right now, it will likely be outdated within 18 months. By the time your 4 year warranty period expires, you might be two or three generations behind. And as we draw nearer to a fully closed-loop artificial pancreas, those two or three generations might make a huge difference.

However, Tandem’s X2 platform has been built with the future in mind. People who received the very first X2 pumps nearly one year ago now have the same new Dexcom G5 integration available in the latest version shipping today with a simple convenient software update. Adding completely new features via software update has never been done in an insulin pump before.

Tandem X2 is now the only pump that integrates with Dexcom G5

Dexcom integration with Tandem pumps might seem like old news because their T:Slim G4 pump (released in September 2015) similarly displayed CGM data from the Dexcom G4. However, the T:Slim G4 did not include the advanced software 505 algorithm, leading to less accurate readings than on a later Dexcom G4 or G5 model. Second, the T:Slim G4’s lack of bluetooth functionality prevented integration with the Dexcom G5 and its popular ability to transmit CGM data directly to smartphones.

Therefore, prior to this G5 software update, Tandem and Dexcom customers were stuck with a dilemma: purchase the older T:Slim G4 and forego the amazing smartphone feature OR go with an X2 and forego the ability to view CGM data on the pump. With the new G5 software update, this dilemma is solved and the X2 is the only pump that directly integrates with the Dexcom G5. (The Animas OneTouch Vibe Plus was planning to integrate with the G5 but Johnson and Johnson decided to exit the pump market).

Dexcom G5 integration is a godsend for many Android users

While G5 owners with iPhones have long enjoyed the luxury of viewing their CGM data on their phone or Apple Watch, Android users have only been recently granted access. And only Android users that use certain models. For example, owners of the highly-rated Google Pixel smartphone or other non-Samsung Android phones will not find the Dexcom app in their App Store. (Workarounds do exist, but are at your own risk).

Therefore, insulin pump users that own Android phones not supported by Dexcom would previously have to resort to carrying around their insulin pump controller AND their Dexcom receiver. Not fun.

With the latest software update, X2 owners can leave their Dexcom receiver at home AND take advantage of the advanced software algorithm and smartphone-sharing capabilities of the G5 Mobile.

The update points toward even better upgrades in the future

Tandem has already begun the pivotal study for their next significant software update, PLGS (predictive low glucose suspend). PLGS will allow the X2 pump to automatically suspend insulin delivery when its advanced software algorithm predicts that the blood sugar will sink below <80 mg/dL in the next 30 minutes, significantly reducing dangerous hypoglycemia. This feature also aims to reduce hyperglycemia as users will be less fearful of low blood sugars limiting proper bolusing.

Tandem Diabetes has indicated that the PLGS software update will apply to the current X2 pump, so all existing X2 owners will be able to add that feature when the company hopes it will be released in Summer of 2018. (Unlike the free G5 software update, the PLGS software update might require a one-time cost).

Conclusion: Pump competition is good for consumers

Unfortunately, the pump market is currently getting smaller with the exits of Asante, Roche, and Animas in the past several years. No matter which remaining pump company you find yourself rooting for, having options when it comes to insulin pumps is important for several reasons.

First, competition breeds innovation. In the smartphone market, if it weren’t for Google and Samsung, Apple would have very little reason to continue adding new features to the iPhone year after year. In fact, many features such as the “Plus” form factor and the rapid evolution of voice assistants such as “Ok Google,” Alexa, and Siri are likely a direct result of competition in the market.

In the insulin pump market, Medtronic pumps looked largely the same and only added minimal new features until other players in the market came along.

Second, competition brings down costs. The cost of living with Diabetes is already ridiculous as it is, the last thing we need is for a single company to monopolize the pump market. In fact, Tandem Diabetes is offering all owners of their previous T:Slim pump an upgrade pathway, costing $399-$799, which is dramatically lower than Medtronic’s upgrade cost of either $599 or $3100.

Lastly and most importantly, competition brings choice. People with diabetes aren’t all alike and their needs might change over time. When starting a new patient on a pump, I like to present the wide variety of pumps on the market, each with their own strengths and weaknesses. Medtronic has the only hybrid closed loop on the market; Insulet’s Omnipod is the only tubeless patch pump available; Tandem’s X2 has the only touchscreen pump.

With Tandem’s X2 ability to add new features via software update, patients have an option that will remain up-to-date over the next few years.