Hi ho! Hi ho! It’s back to Medtronic I go

Medtronic MM780G and Simplera Sensors
(Apple watch not included)

Hello. It’s been a while!

The embryonic posts I had in my mind about living with the Tandem tSlim never seemed to manage to make it to the top of the ‘to do’ pile, and remain unwritten - which I'm sure was a relief all round. But there’s nothing quite like a deadline to spur a (largely ex-) graphic designer into action. And tomorrow I am awaiting the delivery of my new insulin pump, as the warranty on my Tandem tSlim has elapsed. So it felt like a long overdue blog post could no longer be avoided.

Interestingly the ‘new’ pump isn’t particularly new at all. It’s the pump I rejected in favour of the tSlim 4 years ago. This might surprise some people. So why am I not sticking with the tSlim? Or joining the ever-growing horde of podders? But no, for me it’s the venerable MM780G, but with the fancy new Simplera sensors.

So Long tSlim

Confusion about my choice of ‘new’ (old) pump might be even more confusing because I have repeatedly said that I’ve never had better results than with the tSlim. My overnight readings in particular have been spectacularly good, very stable, and never required the alarm/calibration acrobatics that plagued my last days with my MM640G. Automated night mode suited me brilliantly, and I just expect to wake between 5.5-6.5mmol/L every day.

Non-shabby 90 Day Results

Control IQ added approximately 10-15% to my average ‘time in range’ which I choose to set 3.9-9.0mmol/L. My previous general 70-80% has become more like 80-95% most days. This is pretty spectacular with something as fickle, contrary, and annoying as Type 1 Diabetes.

Dexcom G6 mostly tracks my BG levels brilliantly. While I was self-funding (for approx 3 out of my 4 tSlim years) I was able to stretch most sensors to run for 20 days with a viable and solid flow of data, that I was confident to use for most corrections, alerts, and bolus calculations.

So in many ways, I am really happy with the system, and have certainly seen significant improvements from running a hybrid closed loop system. I’d really not want to go back to a pump which isn’t integrated with a sensor and making adjustments.

If anyone is considering the tSlim, I’d say go for it. It’s a very smart-looking and smart-behaving insulin pump. And it might really suit you well.

So why the switch?

Good question! With diabetes gadgets and gizmos over the years I’ve found that the devil is very much in the teeny tiny details. And that even something that’s brilliant, and well regarded, can somehow just not ‘click’ with you and your particular diabetes’ foibles.

This seems to be doubly true with algorithms.

An algorithm is based on a way they expect a person’s diabetes to behave. And how much of an adjustment that person might need to steer things in the right direction in any given set of circumstances. Your own individual diabetes may, of course, have other ideas. But commercial systems being what they are, they don’t really want to offer you much in the way of adjustment or personalisation. It is what it is.

Pretty soon after starting in the tSlim (with only Basal IQ at that stage) I observed that their predictive low-glucose suspend acted much later, and switched off much earlier than the one I’d been using on the MM640G for several years. There were a gradually phased series of basal reductions before a full suspend (really my body needs a full shut-off from the start), and the insulin resumed very soon after an up-tick in sensor values was seen. This was good in the sense that I didn’t have any of those occasional teeth-grindingly frustrating high BG alerts following an over-long suspend. But it was a bit rubbish, on balance, because only the most gentle downward-drifts were caught in time for me. Even when I activated ‘Exercise Mode’ for such strenuous exertion as wandering round to the shops.

In the old days I’d have set a Temporary Basal Rate to start things off early. But Hybrid Closed Loops don’t let your set TBRs, because... well... they are supposed to be doing all that stuff for you.

I experimented with setting essentially a fake TBR basal profile of 0.1u/hr for the 24 hours and activating that at the start of dog walks and such... But then, inevitably, I’d forget to switch back when I got home, because TBRs had always just cancelled themselves after a set time. Following an update of the Control IQ software I was able to completely suspend the pump for a defined number of minutes after which it alerts to restart. This was OK, but for reasons I cannot really understand this also silences any alarms of impending hypo/dropping BGs the pump might helpfully provide if basal-suspend isn’t enough on its own, and levels are getting a bit close to the edge.

Dex lag and alarm fatigue

Initially I was blown away by how well the Dexcom G6 tracked my BG levels. Whenever I did a ‘how are things going’ cross-check the results between fingerstick (Contour XT) and Dexcom G6 were only ever a few tenths of a mmol/L out. This gave me huge confidence. But at some stage in the first year I observed that the problems I was having with the late action of tSlim’s predictive low-glucose suspend were being compounded by a distinct lag between capillary glucose and sensor glucose. This isn’t news to me, and I understand exactly why this lag exists, but Dexcom seemed more reluctant to respond to changing values than any other sensor I had used. Almost as if part of it’s ability to match capillary glucose so well when things were stable was bound up in taking extra values and only updating sensor glucose every 5 minutes - perhaps it just waits until it's sure? For me Dexcom G6 is almost always a whole 10 minutes behind moving glucose. And when a ‘this hasn’t worked’ Control IQ alert is happening only 15 minutes before levels dip below 4.0 (and that ’15 minutes’ is what was happening 10 minutes ago) well... some of my increased number of low-level hypos were easily explained. From 1% below 4.0mmol/L to frequently more like 3 - 3.5% - still on target, but I've worked hard to restore flagging hypo awareness and this really can't help.

When is a 4.2 not a 4.2? When it's 10 minutes later

Added to that there were challenges at the other end too. I’d get told that the basal suspend wasn’t enough and to take preventative action after I was already low, and then 10-15 minutes later be told that levels hadn’t recovered, which prompted me to re-treat. Only to then discover that actually that hypo-treatment had been enough, and that the double-treatment was now gleefully pushing me into the teens. Maybe 5-minute updates 10 minutes behind reality are OK for some people - but when I really need to know how things are moving at the sharp end of hypo-dodging, they were causing me frustration and treatment errors.

The upshot was that pretty early-on I had to take the up reins of hypo-dodging myself again. I set my ‘low alert’ at 5.2mmol/L because (10 minutes behind), that gave me enough time to take action if necessary - with a sensor reading 5.2 and dropping I could easily be low 4s when the alarm sounded and need some rapid glucose to steer away from the 3s. I had the alarm repeat at 30 minute intervals, so that I’d get a reminder to recheck to see any action I’d taken had worked.

But of course it might be that I was just pootling along in the 5s. Getting little warbly nags every 30 minutes. Which was quite annoying.

Even more annoying

But nothing like as annoying as the tSlim’s attempts to actively sabotage my hypo-dodging efforts. Alongside a rapid resumption of the basal profile, the tSlim has, on multiple occasions, delivered a mini-bolus just as my levels were returning to safety after a hypo treatment(!). For meal mis-calculations, or dose-timing errors it never seemed quite so enthusiastic, or effective, at turning around a rising BG, but getting another low alert in the high-4s on a dog walk or while gardening, having successfully treated the last one - and then finding out that it was the tSlim that had caused it with a completely unnecessary mini-bolus, was the inspiration behind some particularly florid and lively outpourings of language over the past 4 years. I asked my consultant whether they knew of workaround/setting to prevent this. Alas none was available. So I had to hugely down-grade my correction factor during the likely hours of evening dog walk, which of course means Control IQ can’t work ‘properly’ during those times when dog walks have happened at other times. And again, setting or not setting ‘Exercise’ mode doesn’t seem to be the fix.

The hollow squares are tSlim autoboluses

 

Better results, but more effort

So yes, I have had better results, and the tSlim has handled many things really well for me. But the alarm fatigue has been pretty tough going. I’ve had a much higher numbers of non-severe hypos than I was used to on the MM640G, and I really miss the discovery that my pump has fixed something for me after the fact, quietly, in the background, with no alarms or notifications required.

Hopes for the MM780G

It was the memory of weeks and weeks with no sub-4 numbers that got me wondering about returning to Medtronic, and giving their hybrid closed loop a try. The pump is the same format, and the chassis is still as clunky and grim as ever (though I’ll be glad to have a screen that’s visible in sunlight again - the tSlim is awful in daylight), but they have updated the software, so it's not exactly like going back in time 4 years.

Medtronic G3 sensors never worked well for me and needed frequent calibration, including overnight. I gather the G4s were significantly better, and I have high hopes for the new Simplera sensors that I’ll be starting on.

I know quite a few people on the MM780G, and almost without exception they seem to get on very well with it. I know there will be frustrations and annoyances - there always are. But I’m hopeful I may be able to experience some of the “spending less lime thinking about diabetes” that others mention. On the tSlim I think I’ve had to think more - constantly checking up on what it’s doing, and fixing some very silly decisions it was making from time to time.

I’ll let you know how I get on.

World Diabetes Day 2023 - the road travelled

Hey there! How have you been. It's been a while eh? Sorry about that! Life, the universe, and everything. You know how it goes.

So this isn't the blog post I've been meaning to write about TBR hacks for the tSlim running Control IQ. It's not even the one about seeing if I can get funding for sensors, which I seem to be being promised, but which hasn't quite happened yet.

If those are of any interest, do let me know and I will try to get around to them. Honest!

No. Instead this is a little unexpected ponder I had earlier, when realising that it was WDD once again, as I saw lots of other more capable awareness-raising diabetes types sharing stuff on their social feeds. It came unbidden. And rather surprised me - so here it is...

"Wow. Diabetes has really changed since we started the blog!"

There. That's it. Groundbreakingly insightful as always.

But much as diabetes is still Very Annoying (TM), a bit of a drag, occasionally utterly terrifying, frequently exhausting, but on the whole relatively manageable most of the time... there have been some pretty big changes in the decade or more that I've been rambling semi-coherently on here.

Back then, Twitter (for diabetes types) was a sort of a cosy coffee shop. A place to connect with a few like-minded folk who were also, coincidentally pancreatically challenged (thanks ShootUp), and chat about something and nothing. Now it's not even Twitter any more!

Once 'low carb' to help managing T2 was viewed as some sort of crazy, lunatic idea and positively discouraged by pretty much all healthcare professionals. Now it's seen as a fairly mainstream management approach that works really well for some people, and is often mentioned by practice nurses from the very beginning. This was once unthinkable on the forums I was frequenting when I first started comparing notes with other people with diabetes. There are now whole NHS GP practices championing the approach, and even established NHS programmes to help people who want to give it a go.

When we started writing this blog, as far as the scientific and medical world was concerned T2 diabetes was an inevitably progressive condition (hardly a phrase that encourages self management!). You got it, and then it gradually got worse and worse, and needed more and more meds, until you expired either from it or from something related to it. Now thanks to the DIRECT trial, there is high quality evidence that many with T2 can get their diabetes in remission (keeping HbA1c below 48mmol/mol with no medication) though significant weight loss. And many folks who choose a low carb approach can achieve the same remission criteria too. And this that remission can be maintained for many years.

There are a bunch of fancy new insulins and meds available now too. Including some that could potentially prove complete transformative for people who struggle with overweight and obesity.

Way back in 2010, CGM was almost unheard of outside of the US. I was even invited to a thing where the company developing a product wanted to know whether or not many people in the UK had even heard of the idea. At the time the chance of getting a CGM funded in the UK was vanishingly small. But a torrent of advocacy effort, an expectation defying Prof, and a flurry of new technologies and options later, and now over 90% of people with T1 in the UK have access to funded full time CGM.

They are now embarking on the same transformation for Hybrid Closed Loops (where an insulin pump and CGM talk to each other and are able to make some gentle adjustments to help us out).

The pace of change is extraordinary. And it doesn't seem to be slowing down.

Plus in the background really quite staggering progress is being made with stem cell research and other avenues, edging ever closer to a possible cure.

I'm really hoping that some progress can be made around reducing diabetes stigma. And especially in increasing access to appropriate monitoring technology for those people with T2 who would value it and benefit from it. Possibly even a little sub-division of the T2 umbrella, so that more appropriate options can be offered to the different sub-types, rather than a blanket 'No' to so many people.

So cheers to old Fred Banting. And Charlie Best, and all the others. There really has never been a better time to have diabetes.

And maybe, just maybe, someday soon, nobody will.

Hybrid Closed Loop Insulin Pumps (Artificial Pancreas) - The Basics

Hello!

It's been a while eh?!

Sorry about that. Truth be told, it's all got rather busy for me, and actually since my last post in my early months on the Tandem tSlim x2, my diabetes has mercifully faded into the background a little, and while still very annoying, hasn't really given me all that much to write about.

But this week has seen the release of something really quite exciting, that I hadn't even realised was happening. It seems those smart cookies at NICE have been munching the clinical trial data and developing a Technology Appraisal for Hybrid Closed Loop insulin pumps (which is the latest bit of tech to be enthusiastically called 'the artificial pancreas', none of which so far are much like having an actual artificial pancreas, but I digress...).

NICE TA10845 is now out for consultation so that stakeholders can review it and make suggestions or ask some pointy questions before publication. It's the same process that the 2015 NICE Guidelines for Adults with T1 which I worked on went through. But what's potentially exciting about a Technology Appraisal, is that while NICE Guidelines are just that - an indication of what the evidence shows to be the better approaches - TAs potentially have more clout, and if the clinician decides that the TA recommends a treatment option for a particular person the funding has to be provided. If the draft is published in its current form it has the potential to open the door to the previously hen's teeth elusive pump-and-CGM combination to around 25% of people living with type 1 diabetes in the UK.

Of course some of these people may have little knowledge of this combination of technologies which has been around for a while, but access to which (certainly with funded CGM) has been notoriously difficult to obtain. And there's quite a bit to get your head around, because it's a combination of several different bits of diabetes kit all working together, but not completely automatically. For all the claims of 'artificial pancreas', there are still quite a few things that you need to do to as the wearer.

From my own experience, having some of my diabetes kit actively helping me out, and looking out for me has been a huge help and a massive leap forward. A hybrid closed loop can't do everything, but it really helps me smooth off the edges of my blood glucose guesswork. It gives me much more confidence, and my results have never been better. I'd find it very difficult to go back, even if (as seems likely from the draft criteria) I still need to self-fund my CGM sensors.

A year or two ago Diabetes UK were putting together an introduction to Hybrid Closed Loops, for which I recorded a bit of video. However in the end it was far too waffly for Diabetes UK to use, so they interviewed me for a few comments instead. But this recent announcement has seemed like the perfect opportunity to inflict it on the world. Sorry about that.

So here is a basic overview of what a Hybrid Closed Loop insulin pump is, how it works, and what it's actually like to live with.

Watch this a little larger on my YouTube channel.

Hype or Hope? Dexcom, Tandem tSlim review and 2020 round-up

Wait... hang on... December 31st? That can't be right! Have we actually had a year this year? And how come any of the things that happened this year seem to have happened at least 18 months ago? No time has passed. But it has passed at a snail's pace. And at the same time we've all become accustomed to living completely different lives.

Doing a sort of round-up post for the year that never happened doesn't seem worthwhile. There are only so many times I can talk about avoiding a Zoom-based diabetes thing before I'm going to run out of waffle. Yes even me.

tldr; 2020 was a bit pants. But I really like the tSlim and Dex.

Tandem tSlim with Dexcom G6

Out with the old
I've been meaning to write a post or three about my experiences of the Dexcom G6 and my switch to the Tandem tSlim:x2 (and subsequent upgrade from Basal IQ to Control IQ) since the Summer, but for all sorts of reasons that series of posts never arrived. I have lots of pics of pump and graph cluttering up my phone that were apparently going to eloquently show something or other, but it's all so long ago now that I can't really remember what it was I was going to say.

I am self-funding Dexcom G6 sensors, and it was the first time I had used Dexcom. Such is the relentlessness of the positivity around Dex, that I think secretly I might have been hoping that I wouldn't find it all that special. 

I sprung for the 'starter pack' which gives an official 30-day's worth of coverage before I committed to going for the tSlim, so that if my body chemistry didn't get on with the Dex I could opt for Medtronic's MM670G (or similar) with self-funded Guardian G3 sensors. I had always got on well with Enlites and to some extent G3s too, and I was pretty sure that I would have got on well with the MM670G if that was what I'd gone for.

Inserting the Dexcom sensors was really straightforward, and initially I ran the sensors with my iPhone (not yet having taken the plunge on the pump). They restarted easily, and I didn't even have to faff about with unpeeling tapes and removing the transmitter thanks to these instructions. What really struck me though, was how well the factory calibrated G6 tracked fingerstick results from my Contour Next Link 2.4 meter (still my go-to BG meter). The first few days were uncanny. Spooky even. It didn't appear to be hype at all - generally Dexcom was reading only a few decimal points away from any fingerstick I took.

Even a Dexcom G6 lags a little now and then

Reassuringly though, I did see a characteristic post-hypo-sensor-lag on about the 3rd day, where the Dex stubbornly continued bleating about low BG for 5-10 minutes after I was back above 4. So it was a regular CGM and not witchcraft after all. It was just that it was a really good CGM for me.

Joking aside, those early excellent matched pairs (against fingerstick checks) really helped me trust it as a new bit of kit though. 

And even better, while the factory calibration is excellent for me, and I've all but given up cross-checking with fingersticks, if I *need* to recalibrate the Dexcom G6 because it has drifted a little... I can! 

After a few weeks with the Dexcom I was confident to put in my request to switch to the Tandem tSlim when the warranty ran out on Threepio.

Switching to the Tandem tSlim:x2

I affectionately called my first insulin pump robot counterpart 'Artoo' (R2P2 - replacement to my pancreas #2), and kept with the Star Wars theme with my MM640G as 'Threepio'.  This bit of kit promised to be wiser and much more autonymous though, so I've taken to calling it HAL (hybrid automated loop), though of course it would be much funnier if a certain tangerine diabetic had made that joke, [affects creepily calm synthetic robot voice] "What are you doing Dave? I'm afraid I can't let you eat that biscuit..." etc.

Staying in its box until I was trained up.

As all this was happening while the healthcare system was in some degree of chaos, and all those buzzwords like 'social distancing' were in full flow I wasn't sure how any kind of switchover was going to be able to happen - but in the end, in classic 2020 style I did my pump training via a video call having had the box of goodies delivered direct to my house.

I had a few weeks with Basal IQ before switching to the smarter Control IQ. Both worked well for me, and each have their own idiosyncracies. I have tried to do as little fiddling as possible, taking an initial 7 days to see how each got on when left to their own devices to try to learn what they are good at, and where they struggle. Also learning how to give them the right information to get the best results.

For those outside the Tandem bubble (seriously 2020? another word you've mangled?!), Basal IQ is Tandem's 'predictive low glucose suspend' algorithm, which stops basal insulin in order to try to reduce risk of hypos. Basal IQ is a little more responsive I feel than Smartguard on my MM640G. In that it can turn on and off more quickly, and doesn't have a minumim duration or enforced gap after it has completed. There was a major irritation for me when running the Basal IQ algorithm in that the tSlim moaned at you if you set a 0% TBR, though ot was more than happy to set one itself. Indeed, the tSlim got very grumpy if a TBR was set that was less than 50% of your lowest basal rate. A degree of warbling which was as unwanted as it was unnecessary.

This irritation was short lived though, as I soon upgraded to Control IQ. One of the nice things about the tSlim is that you can plug it into a computer and upgrade the software on the pump. Which means that if they release fancier, smarter, or even just mildly less irritating versions of the pump software, then you don't have to wait until 4 years have passed to take advantage. All I need now is to find the email address of the person to send my Helpful Suggestions to, for inclusion in the next release 😉

Conclusions

I guess I've been on the tSlim a little short of 6 months now, and I can honestly say that I am really glad I made the switch. I loved the MM640G, but the clunkiness of the Medtronic chassis, and some of the million-presses-UX-interface-tedium was wearing me down. Plus the newer G3 sensors were a bit more flaky and prone to overnight calibration requests for me. There are things about the tSlim I would hope would improve - not least the reservoir filling, which is every bit as fiddly as people say. Their reservoirs really need re-engineering so that the 'white dot' behaves more reliably (tSlim users will know what I mean). 

And what of results? Well I've not really that the nerd-energy for much actual data comparison, but going on gut feeling I would estimate that the tSlim has bumped my TIR (time spent between 4.0 and 9mmol/L) by somewhere between 5% and 15%. What used to be a really good week of results is rapidly becoming pretty normal. Control IQ still needs watching as it often responds a little later than I need, and it's not perhaps as 'hands off' as I was hoping it might be, but Control IQ really nails the little adjustments for me. It struggles with circumstances which are a bit wobblier, but it seems very good at optimising gentle drifts. Overnight with Sleep Mode has been spectacularly good. Almost no alarms, and almost always waking in the 5s to 7s.

Gotta be happy with 28/30 days above 80% TIR

It will be really interesting to see if this has had any kind of effect on my HbA1c, but to be honest, I increasingly find A1c a poor proxy for how I feel my diabetes management is going from month to month. It may still be seen as an important stat as far as research goes, but I'd far rather focus on the ebb, flow, and varying proportions of BG values that lie behind it. But that's another post I'll probably never get around to writing...

Here's hoping for a peaceful, healthy, happy and significantly more stable 2021 for us all.

Diabetes days off

As we transition into holiday season, with the traditional exponential increase in holiday accommodation costs everywhere, many thoughts turn to sandy beaches and the chance to take a break from the incessant whirlwind of life for some well-earned rest and relaxation.

Except for diabetes, of course... that never gives you a day off.

Well almost never.

I was thinking about this the other day, and even tweeted my exasperation and the more-than-usually-fickleness of my diabetes of late.

I had an annual review recently, and since my pump is soon out of warranty I am casting a casual eye over the current crop. I've been very lucky to be able to run sensors with my MM640G more regularly recently and there is no doubt that the semi-automation of SmartGuard helps improve my 'time in range' stats (more on that in another post). But recently, although occasionally Threepio acts autonomously and silently to dodge some hypos, more often than not I am having to use warbling alarms to check that SmartGuard isn't just mangling a carefully judged prebolus timing, or I'm getting a notification of a 'suspend' when I've already set a 0% TBR an hour before to cope with such extreme exertions as 'walking round the corner to the shops'.

I currently seem to be extra sensitive to carbs, very sensitive to 'stacked' insulin (overlapping doses acting together), highly sensitive to any form of activity AT ALL when I have any insulin on board, and generally insulin seems to be delighting in a nothing... nothing... nothing... EVERYTHING activity curve. Or not. Depending on the day.

Without sensors I would have been completely lost.

It reminded me of previous phases in my diabetes life when my diabetes would occasionally give me a week or two off.

Let me explain...

There were times when *all* I had to do was estimate carbs in whatever I was eating and deliver the dose to my insulin:carb ratio alongside my basal pattern (and correction factor). And the doses would work. Reliably. For. A. Whole. Week!!

And if I made a small error of judgement in terms of carbs in a meal I could administer the suggested correction dose... and that would bring me to mid-range within about 3-4 hours.

Bliss!

Of course, there's still quite a lot of effort going on there. Carefully tweaked and tested insulin doses, and dose timings. Meal and activity strategies that have been tested, and food choices that have been tailored to try to reduce the bewildering number of variables that life with type 1 diabetes involves.

But when that effort actually works. For whole days, or a whole week on the trot, it genuinely felt like a holiday.

The carb counting and dosing... the fingersticks and correction factors? For me those are the easy bit. They are absorbed into the rhythm of my life so that I barely notice them any more.

What I DO notice, what I find really tough, is the constant faff of putting in all that effort. Of playing my part as carefully as I can... only to get chaotic and unpredictable results back in return. Constantly feeling like I've got it 'wrong'. That I could (should?) have done better. The silent condemnation of BG readings from doses that didn't absorb properly, misjudged exercise, or insulin requirements that seem to change at the drop of a hat.

The 'that didn't happen yesterday's

The 'what on earth went on there's

If T1D was only a bit more predictable, if it would only stick to its own rules, it would be an awful lot easier to live with.

Happy holidays everyone.

Guest Post: From Dx to X2 (Tandem T:Slim) by Robert S

This is a guest post by Robert S who dropped me a line via FaceTwit as he had been  writing down his 'diabetes story' but didn't have a blog to share it on. Apparently he has been good enough (or mad enough?) to read my ramblings in the past and offered it as a guest post for sharing here. His story echoes much of my own, and I am very interested to read that he has chosen the Tandem T:slim X2 insulin pump out of the current offerings, as that is one I have quietly got my eye on too. Here is Robert's story. Enjoy!

Tandem T:slim X2

My Diabetes Story, by Robert S

I was diagnosed in 1994 at the age of 38, about 10 years after my older sister who had (eventually) been diagnosed at a similar age. I was given a number of very vague, unhelpful leaflets & sent on my way.

I spent the next few years religiously taking insulin as instructed but with pretty poor results.

Diabetes clinics were a trial for me, with many 'must do betters' but precious little advice on how to achieve this. Several times I was mistaken for type 2 & had some very odd conversations. I probably presented as typical type 2, middle aged and overweight, and most people at the clinic were type 2. However they clearly hadn't read my notes which didn't inspire confidence.

I was divorced during this period so I was very much dealing with it on my own.

The internet arrived & eventually I discovered diabetes forums. Wow, what a revelation! There were other people having the same problems as me. A LOT of people! Bad news for them but a great relief that it wasn't just me.

Importantly some of these people were working to improve their diabetes & describing how.

At the time of my diagnosis carbohydrate 'exchanges' seemed to be going out of favour but for me, at least, carb counting was a very vague concept.

The forums prompted me to do the online carb counting course set up by Bournemouth Diabetes & Endocrinology Centre (BDEC). It didn't solve all my problems but for the first time I felt I had a method for moving forward.

By this time I had moved from 'Humulin I' & 'Humulin S' to a basal/bolus regime, which also helped.

My GP surgery contacted me suggesting that they monitor my diabetes now they had a Diabetes Nurse. Being rather disillusioned by my experiences in the clinic system I accepted.

I enjoy programming & wrote software for my phone to record everything & do some basic dosage computations. My HbA1c had never been really terrible, usually in the low 8s (8% or 64mmol/mol, Ed), but I honestly don't know how. Some hard work got it down to the mid 7s (7.5% or 59mmol/mol, Ed).

So the situation had improved somewhat & I felt more in control.

Sadly, another event encouraged my efforts, as my sister died from diabetic complications at the age of 64.

From the beginning hypos were an almost daily event. The worst being overnight. I've always had good hypo warnings, but at night hypos tend to progress further & I would wake up soaked in sweat.

By 2013 though, the overnight hypos seemed to be worse. I discussed it with the diabetes nurse at my GP practice but the best advice was always eat some supper & don't go to bed below 8mmol/L. I was already doing this.

I'd read about Continuous Glucose Monitors (CGMs) which looked very interesting, but were way too expensive for me and, I noted, you still needed to do finger sticks.

Things came to a head on Boxing Day night 2013. I was away staying (alone) in a hotel & I woke up with a hypo around 1:30. Dragged myself out of bed managed to force a some glucose tablets & a biscuit down me & fell asleep. The next thing I knew I was waking curled up in a ball under the duvet, sweating yet shivering to the point where my teeth were chattering continuously. The worst thing was that I couldn't move to do anything about it. Eventually I fell asleep wondering if I'd wake up.

I decided to self fund a Dexcom G4, at least for a while. By the end of January 2014 I was wearing my first CGM. I watched it obsessively. On the second day I attended a graduation ceremony and was offered a glass of Bucks Fizz & a blueberry muffin. I thought I was being sensible & only ate about a third of the muffin & bolused for it. The effect on my blood sugars was fascinating. I watched as the graph went up, & up & up. I don't remember how high but it was an eye opener.

Initially it was more about the alarms which warned me in time to stop low blood sugars. Still annoying at night but I no longer woke up sweating.

I began to learn from the readings. The first big thing I noticed was a fairly consistent dip in my blood sugars around 1:30 to 2:30 in the morning. This made it difficult get my overnight average to a sensible level & went some way to explaining the nocturnal hypos. I tried varying the time that I was injecting my basal (Lantus) moving it from evening to morning, or splitting the dose. Nothing was really satisfactory.

Someone in the DOC (Diabetes Online Community) suggested changing my basal insulin. After chatting to my GP I moved to Levemir. I had a lot of trouble sorting out the dose, being quite worried that I had to take so much more than I had of Lantus. It was a split dosage & gradual adjustments left morning/evening doses very different, but, it was working. I saw some fairly horizontal overnight graphs, something I'd never ever seen before.

This encouraged me & I also made other adjustments; splitting boluses for some meals, not being afraid to do corrections between meals & so on.

Nothing was perfect but I did feel more 'in control'. Things still went wrong but when they did I was confident I could put it right. My HbA1c went below 7% (53mmol/mol) for the first time.

Using online instructions I built a box of electronics which allowed my Dexcom sensor data to be transmitted to my mobile phone. Thanks to #WeAreNotWaiting I set up a NightScout website to display my data.

This was all great, but hard work. I was doing a lot of injections, up to 12 a day. Also absorption of my basal injections was rather erratic, sometimes as I would expect, sometimes not. The best location was my thigh, but despite rotating sites there were problems.

By this time I'd been reading about hybrid closed loop (artificial pancreas) systems. First the DIY systems OpenAPS, Loop, and AndroidAPS, then the first commercial system the Medtronic 670G. This was exciting stuff but it was clear that first you needed to have an insulin pump. I had in fact been offered one about 15 years before but was then horrified at the thought of being permanently connected to the thing.

I decided I would now like to try one. It was not something my GP surgery could sort out so I had to be referred back to the hospital. This proved to be a long process, several months. I still don't know why. Eventually it went through just before Christmas.

By the time I met up with the DSN at the hospital a month or so later I had all but convinced myself I was wasting my time as control was simply too good?

Sure enough the DSN was impressed with my readings but it didn't help my case. I pointed out that I was doing a lot of injections each day. Not relevant.

"How many hypos do you have?"
"Hardly any."
"Yes, but that's with the Dexcom you are funding?" This wonderful lady was on my side & looking to find a way.
"Lots, nasty ones, that's why I bought it"
"That's it! Now let's have a look at the pumps you could have."

What! Really! To be honest I would have accepted some dusty old pump from the back of a drawer..

But when I focused on what she was saying I could barely believe my ears. I'd done a lot of homework on pumps & she was mentioning the Medtronic MM640G & the most advanced, the 'Artificial Pancreas' MM670G.

Then she added the Tandem T:slim X2 to the list. Again I'd read about it but thought it was only available in the USA. Positively it would soon be linked to the Dexcom G6 I was already using. I love my G6 & it seems to compare favourably with the Medtronic sensors. (Not that I had any personal experience of them).

Uniquely the software (firmware) of the X2 can be updated & in the UK will soon include Basal-IQ, a system which automatically suspends insulin if it thinks you will go low. There is also the promise of a full hybrid closed loop option similar to the Medtronic 670G - again an over the internet update.

I made my decision; the T:slim X2. By mid March after a couple of training sessions, I walked out of the hospital attached to my pump. Very exciting & not a little nerve racking!

We had agreed a 30% reduction in the basal dosage compared to my Levemir. A profile was set up.

During the evening it became clear to me that this was still too much & changed to an 80% temporary basal rate (TBR).

My Dexcom woke me about 1:30. I dropped the temporary basal to 75% and had a small snack. Readings got 'stuck' in the low 4s & eventually I ate again and reduced to a 60% TBR.

So not much sleep but at least I was closer to the required dosage. One thing that I kept thinking that night was "How does anyone do this without a CGM??" Presumably they start with a much more conservative dosage.

I had worried about what to do with the pump at night, and it was a problem. Clipping it on my waistband sort of worked but it would slide along to an uncomfortable place or slip off completely. I now have a 'Spibelt' with a pocket for the pump which is much better.

A week in now & I'm doing remarkably well, some days over 90% of my readings have been 'in range' - between 3.9 & 9.9mmol/L. I know this is probably just a 'honeymoon period', having had type 1 for over 20 years I find I'm waiting for reality to reassert itself & everything to go wrong...

The pump itself is a very neat device. It is small & has a nice clear touch screen. If you are used to smartphones then it is easy to use. It seems well made, time will tell.

I've had some practice with temporary basal rates as mentioned but I've also been playing with 'Extended Boluses' a new concept to me, promising, but I need to experiment.

As with all pumps the big advantage is the same as the big disadvantage - namely that it is always connected to you. It's great that I don't have to remember my pens & I won't miss those injections - I stopped counting at about 50,000 several years ago.

A big advantage is that you have a record of every dose. No longer do I have to wonder 'Did I do that or not?'

There's also the precision of boluses & the in built Bolus Wizard (Calculator). I am learning to trust the IOB (Insulin On Board) figure on the pump. Previously I had tended to intervene too soon when blood sugars rose quickly.

I'm told that changing infusion sets on the X2 is slow, but it seems OK to me having never used anything else.

I'm looking forward to improving my settings & the upgrades mentioned above.

For the first time in my diabetic life I feel as though I am 'ahead of the game', and yes, I know I am lucky.

Diabetes has never been so interesting!

By Robert S.

Libre Limbo

As of the beginning of April the new national NHS England criteria for obtaining Freestyle Libre on prescription came into effect. This is who it says should have access to Libre on the NHS:

1. People with Type 1 diabetes OR with any form of diabetes on hemodialysis and on insulin treatment who, in either of the above, are clinically indicated as requiring intensive monitoring >8 times daily, as demonstrated on a meter download/review over the past 3 months OR with diabetes associated with cystic fibrosis on insulin treatment
2. Pregnant women with Type 1 Diabetes -12 months in total inclusive of post-delivery period.
3. People with Type 1 diabetes unable to routinely self-monitor blood glucose due to disability who require carers to support glucose monitoring and insulin management. 
4. People with Type 1 diabetes for whom the specialist diabetes MDT determines have occupational (e.g. working in insufficiently hygienic conditions to safely facilitate finger-prick testing) or psychosocial circumstances that warrant a 6-month trial of Libre with appropriate adjunct support. 
5. Previous self-funders of Flash Glucose Monitors with Type 1 diabetes where those with clinical responsibility for their diabetes care are satisfied that their clinical history suggests that they would have satisfied one or more of these criteria prior to them commencing use of Flash Glucose Monitoring had these criteria been in place prior to April 2019 AND has shown improvement in HbA1c since self-funding.
6. For those with Type 1 diabetes and recurrent severe hypoglycemia or impaired awareness of hypoglycemia, NICE suggests that Continuous Glucose Monitoring with an alarm is the standard. Other evidence-based alternatives with NICE guidance or NICE TA support are pump therapy, psychological support, structured education, islet transplantation and whole pancreas transplantation.However, if the person with diabetes and their clinician consider that a Flash Glucose Monitoring system would be more appropriate for the individual’s specific situation, then this can be considered.

Other requirements:

1. Education on Flash Glucose Monitoring has been provided (online or in person)
2. Agree to scan glucose levels no less than 8 times per day and use the sensor >70% of the time.
   
3. Agree to regular reviews with the local clinical team.
4. Previous attendance, or due consideration given to future attendance, at a Type 1 diabetes structured education programme (DAFNE or equivalent if available locally)

Well this all sounds very promising for my perforated fingers... but unfortunately I find myself somewhat in Libre limbo.

I had my annual toe-tickling / BP / weight check appointment at my GP surgery towards the end of March, and mentioned these new criteria and asked about Libre. The nurse who runs the diabetes reviews at my surgery is also one of the DSNs at the hospital pump clinic that I attend, and was able to tell me that all Libre requests in my area were going to be handled in 'secondary care' (that's 'at the hospital' for those that don't speak fluent Healthcare Professional). The suggestion made to me was that since there was not really time in people's regular clinic appointments to deal with all this stuff, that special extra sessions would be being arranged for anyone who was interested in Libre.

At some point fairly soon I'm pretty sure I'll be contacted for my annual* pump clinic appointment (last one was over a year ago). So now I don't know whether to wait and see whether I get an appointment and ask the same nurse I saw a few weeks back (but sat at a different desk) whether I can get another appointment at one of the Libre sessions. Or whether I should try to work my way through the labyrinthine appointment telephone system to try to speak to someone and ask a) if they've ever heard of these extra clinics and b) whether I can come. Then wait for that appointment to come through and see what they say.

* actual timings may vary

Frankly the very thought of it all is exhausting, and I am unable to even summon the energy to decide which of those options is the least teeth grinding, let alone make any of the necessary phone calls.

EDIT: The day after I posted this, I got the letter to book my appointment for pump clinic, so it looks like I'll be rolling with option 1. Next available appointment was mid July, so I've a little while to wait yet I think.

In other Libre news, as part of my position as one of the PWD representatives on the Diabetes Technology Network (DTN) I was involved in reviewing and contributing to a set of excellent video resources to help both people with diabetes and their families, along with nurses and clinicans get the most out of the Freestyle Libre. As part of the project I offered my own meandering thoughts on living with Libre, and took part in a live 'webcast' of the videos. If you missed it you can catch up with the videos and also a recording of the Q&A session on the Association of British Clinical Diabetologists website. The full set of videos and further webcasts will be added as the weeks go by and in all should provide an excellent source of information and guidance as more and more people get access to Freestyle Libre.

Disclaimer. DTN/ABCD paid my train fare to get to the initial meeting to discuss/review the course content, and then to the video recordings. They also gave me a thank-you card with an entirely unexpected voucher in it which was very lovely of them. I was not paid to take part or write this post, and all opinions shared are entirely my own. I mean... who else would want them?

T1D Rise of the Machines 2 - February 2019

Not the machines you are looking for... Public art near TechUK.

This time last week my mind was well and truly boggled by this point in the day by a torrent of information and the potential of shiny new things just around the corner (or already here). I was attending Type 1 Diabetes: Rise of the Machines #2 as a +1 of Kev Winchcombe, the #GBdoc's second favourite Nightscout Genius and holder of the Self Deprecating Diabetes Dad of the Year Award for the 9th consecutive year.

I'd heard a bit about the first Rise of the Machines last year and it sounded really interesting. The opportunity to go was actually very timely for me, because almost unbelievably this year sees the 4-year warranty expire on Threepio, my trusty and occasionally SmartGuarding MM640G insulin pump. As a result I am beginning to consider what options might present themselves for me to try next. The pace of change in diabetes technology seems so rapid at the moment that it's very hard to keep up with what has launched, versus what is being massively plugged but is still confined to the drawing board, versus what has technically launched but remains unavailable to anyone as no clinics either have them or are trained and equipped to dish them out. As an additional complication there are now various grassroots home grown combinations of different technologies that allow a degree of automation of insulin delivery (things like Loop, OpenAPS and AAPS). If you've never heard of any of this stuff prepare yourself for an impenetrable minefield of jargon, abbreviations and acronyms. Luckily for you Kev has put together a very handy dictionary of terms as part of T1resources.uk.

The main opportunities for improving T1 diabetes care are:
1. Improving the ability of a person to self-manage
2. Encouraging peer support
Everything else, whether technology, clinical, education or whatever falls into those categories

Partha Kar

After introductions from Ben Moody of TechUK and Dr Partha Kar, a packed programme of fascinating presentations followed. I took copious notes thinking I might write a detailed account, but in reality there was simply too much to cover here so you will be relieved to hear that you are only going to have to wade through what struck me as highlights.

Chris Bright

Chris Bright, semi-pro footballer and futsal supremo kicked things off with an engaging and inspiring PWD perspective. How different pieces of technology had formed part of his story with T1D, and supported him in exercise, activity and sport over the last 20 years, including the establishment of the Diabetes Football Community.

Next up were industry presentations by some familiar, and not-so-familiar names. Roche/Eversense, Abbott (Libre), Dexcom, then later Medtronic, Diabeloop and Tidepool. It was very interesting that many of the speakers from the companies lived with T1D themselves. The stories from the companies shared much in common. Technology is improving and continuing to improve. The more information (data) people have, generally the better they are able to manage their T1D. Some were able to talk about semi-automated insulin delivery and 'hybrid closed loops' which have either launched or are in the works.

Interoperability - buzz word of the day

One nice feature of the day was the round table discussions that took place after the presentation slots. The first of these involved the device manufacterer speakers who got something of a roasting from an audience which included several people who are actively trying to push the available technology to work harder, and are often frustrated by incompatibility and sandboxing where different devices are locked into their own predefined arrangements or are designed only to work within their own 'ecosystems'.

Interoperability (the ability of one device or technology to speak to a number of others) was certainly one of the buzz words of the day. The device manufacturers mentioned it, including the JDRF 'open protocol' iCGM standard which in development. But they were asked pointy questions about their 'bilateral agreements' for products in the works which will be designed to only work with devices from an agreed (and presumably negotiatied) partner manufacturer.

This is certainly well in evidence in the current market place and is all too often part of announcements about future tech. So Dexcom works with x and y, while Libre are collaborating with z, meanwhile Medtronic devices mostly try not to talk to any other devices if at all possible. While this almost certainly makes sense from a company perspective, it was a source of tangible frustration from users who might find a more open mix-and-match arrangement much more empowering.

The company speakers were clearly a bit nervy and uncomfortable committing to anything, preferring warm noises about 'taking steps' and 'working towards'. Abbott's decision to encrypt the data from its new Libre2 raised quite a few eyebrows, and when the explanation offered was that it was 'for safety reasons' one audience member described such a notion as abhorrent, "It's MY data! Give it to me."

The presentations by Medtronic, Diabeloop and Tidepool also shared many similar themes. Semi-automation of insulin delivery by smart systems that learn and continually adapt to the user's insulin needs as they ebb and flow. CGM data used to make minute-by-minute adjustments to reduce risk and severity of both hypos and highs, with the user only really needing to input carb count estimates for meals. All of these systems using their own algorithms and set-ups to attempt to increase the two emerging holy grails of T1 management 'time in range' and 'quality of life'. A technology which is both extremely easy to use day to day, but which gives improved outcomes. It was fascinating to hear the few snippets of detail that were sprinkled into the presentations - as always, I suspect the devil would be in the details, and whether or not it was possible to make any of these systems adapt to your own diabetes quirks. Tidepool's significant ongoing work to get a version of the 'open source' APS code approved for use by the FDA is very exciting - initially they appear to be partnering Omnipod as a delivery system. As for Diabeloop - the large Brexit-shaped elephant in the room was acknowledged in the subsequent discussion as they will not be able to launch in all European countries at once, and we could find ourselves rather on the back burner.

3 of the best
Clinical research and HCP perspective was offered in a round-table discussion jointly chaired by Diabetes UK and JDRF. Roman Hovorka (Cambridge), Pratik Choudhary (Kings College) and Lala Leelarathne (Manchester) shared their views on the current state of diabetes research and ongoing clinical trials from Loop and APS, to islet cell transplantation and encapsulation. The significant pace of change was clearly evident. In general the move from fingersticks to more continuous data and thereafter towards more automated insulin delivery. One of the challenges ahead would be to improve access to the emerging technologies and make that access more equitable. Additionally the challenges of accurately recording and monitoring 'quality of life' in health economic terms would become increasingly important in the future. Technology that you cannot access is little use. As is technology that is so onerous to use that it makes life miserable.

A brief break for a slightly delayed lunch allowed us all to catch up and compare notes from the morning's sessions.

Unfortunately I was not able to stay for the very last session of the day, but I was able to catch the first session after lunch which involved an overview of the currently available open source options chaired by Tim Street. One of the most emotionally charged and powerful moments of the day was presented by Jacob and his mum who had struggled through the required self-build steps in order to give her sporty teenage son the option to use a closed loop insulin pump. The brief video of Jacob's birthday morning and the look on his face where he unwrapped a box containing pump, reservoir, set, Android phone and CGM sensor caused more than one person in the room to wonder if it hadn't perhaps just got very dusty in there. Jacob's mum shared that it had been on leaving the first T1DRoM conference a year before that they had decided to take the plunge.

HBA1c graph showing the moment James starting with AAPS

James Woodman's encouraging presentation detailing his own journey towards looping left many people wondering if looping might be right for them too. While acknowledging that it looks scary and formidable from the outside, both of these stories had at their heart the sense that, "If I can do it, so can you". In James's opinion, the barrier is less about technical difficulty and more about self belief. And also, I would suggest, in securing the components and consumables needed to run the various systems.

All in all it was a very interesting day, and certainly gave me a lot to think about between now and December. But I will save those ponderings for another time.

If you'd like to watch the presentations, a video of the day has been posted on YouTube here.

European Launch of the MiniMed 670G - Switzerland

The Medtronic Mothership poised for takeoff

I was chuffed to be invited to join bloggers and diabetes advocates from Belgium, the Netherlands, Switzerland, Sweden, Finland, the UK and other places I have almost certainly forgotten for the Medtronic Diabetes Community Exchange 2018 at Medtronic's European HQ in Tolochenaz, Switzerland.

I was particularly pleased to be invited to walk in the footsteps of the legendary Alison and Tim from Shoot Up or Put Up and to needlessly and completely unnecessarily rekindle the rumours that Medtronic have an entire department dedicated to the drowning of puppies in their relentless pursuit of evil. Rumours which are, of course, entirely untrue. And completely made up by Tim. Or are they?

We arrived on Thursday afternoon and were swiftly transported to the impossibly quaint, beautiful and strangely fragrant 'Chalet Suisse' restaurant where we were treated to a slap-up meal composed of cold meats, pickles and industrial quanities of gently bubbling cheese into which we enthusiastically dunked hunks of white bread. Fluffy white bread, a vat of cheese and a little alcohol. What easier meal could there possibly be for a tableful of pancreas impersonators to contend with? As inevitably happens at these events, people with diabetes quickly feel at ease with each other and conversation flowed to a burbling soundtrack of bleeps and buzzes from various bits of diabetes kit. It was a very lovely evening. Thanks Medtronic!

All those friendly faces and barely a functioning pancreas between them.

European Launch of the MM670G
It was perhaps no surprise that Medtronic had invited us during this particular week - in which their latest hybrid closed-loop insulin pump system launched in Europe. The launch begins with the UK, the Netherlands, Belgium, Sweden, Italy and Slovenia as of 10th October, with Finland and Denmark following hot on our heels next week. I have been using Medtronic pumps for the past 7 years or so, but others around the table used other brands, pods or MDI injections.

Inevitable device timeline pic. No future dates, naturally.

The MiniMed 670G launched in the US in June 2017, and the version launching in Europe is almost exactly the same. If you are new to the snazzy concept of 'sensor augmented pumps' (and why wouldn't you be?) the basic idea is that you combine an insulin pump and CGM (continuous glucose monitor) into one device. At it's simplest, the pump acts as a receiver for the sensor glucose and allows display of current glucose values and can alert the wearer if levels are rising, falling or generally going off kilter. The really clever stuff starts to happen though, when the pump uses an algorithm to act independently on the basis of the received sensor glucose values. On my MM640G I allow Threepio to silently and automatically take action and cut off my basal insulin if my BG is predicted to fall below 3.9 within 30 minutes. This has saved me countless low level hypos whenever I have been able to afford a sensor. If you're interested in the details there's a little animation explaining how this works here.

The MiniMed 670G adds extra oomph to the mix by also having the ability to increase basal insulin where sensor glucose is rising. Gary Scheiner, who wrote 'Think Like a Pancreas' wrote a review of the MM670G after it launched in the US which has a good deal of detail if you are interested, but which also prompted several questions for me.

What I thought I knew
The MiniMed 670G uses two main targets, neither of which can be changed by the user. Overall it aims to direct your glucose value towards 120mg/dl (6.6mmol/L). Where it is taking corrective action for elevated sensor glucose, it aims towards a target of 150mg/dl (8.3mmol/L). These were the launch values in the US, and will be exactly the same for the UK version.

A number of options that experienced pump users might expect to be able to use (temporary basal rates, dual (combo) wave, and square (extended) wave boluses are unavailable in auto mode.

From what I can tell, things like differing basal patterns for weekdays/weekends do not apply in auto mode either.  Nor can you alert the system that you are about to undertake exercise in advance.

In fact there seems to be very little you can adjust and tweak in auto mode aside from insulin:carbohydrate ratios and Duration of Insulin Action. If you are planning to exercise you can temporarily set the pump to aim for the higher target, but that's about it.

All of this may fill you with dread and impending frustration. Or it may elate you with gratitude of being able to hand over responsibility almost entirely.

Users can, of course, use the pump in 'manual' mode whenever they wish. This would give them effectively the same choices/options as the MM640G, but doesn't take advantage of the additional automation on offer.

Is there anything else like this?
No. Well... not regulated, approved and currently commercially available no. But of course the MM670G is not being released into a vacuum. There are other emerging sensor augmented pumps (eg Tandem T:slim) which incorporate predictive low glucose suspend (rather like the MM640G). Alongside which there is a growing community of enthusiastic loopers who have decided #wearenotwaiting and use a variety of homespun, and significantly more tweakable, options. Of course not everyone has the confidence to build their own diabetes device - I am assured that these are no longer cobbled together from bits of string and paperclips, but nevertheless still do require careful configuration, software and in some cases additional DIY hardware. Additionally many loop solutions currently require older out of warranty insulin pumps. This may not be the case for long, nor might OpenAPS and Loop's unregulated status continue, now that Tidepool have committed to developing Loop as a supported, regulated app available for users on a range of in-warranty devices.

What I found out
It's fair to say that I was very enthusiastic about the prospect of the MiniMed 670G about a year ago. But things are moving so fast these days, that this is already beginning to feel like an older model. And as an inveterate fiddler the idea of so few settings being settable by me is a bit... well... unsettling.

What I found very interesting, was the observations Medtronic have made from 3.2 million days of data since its launch in the US. Essentially, they suggest the MiniMed 670G tends to work better in people who don't fiddle and try to come up with their own ways of working around not being able to alter settings. Often people who are new to an insulin pump, who have not already built up a library of hacks, tricks and strategies to bully their pump into doing what they want it to. People who simply give the MM670G the information it requests and heed the alarms, who keep the sensors well calibrated, and who count and supply carb information of meals and then let the pump do its thing, are the ones who tend to get the better results.

I am aware from my own relentless tweakery that at least some of it is frequently down to constant changes in insulin sensitivity and insulin need (and working around times when my pump settings aren't quite right).  I suspect that one of the main reasons behind the lack of tweakability on the MM670G is the closely guarded algorithm. This updates up to 17 different parameters at midnight every single day, based on the previous 24 hour's worth of data along with a rolling average of the previous 5-6 days. Essentially the pump is continually adapting and tailoring itself to you. So those unmovable targets may not seem to be what you have chosen, but the intention of the MiniMed 670G is to keep your BGs as stable as possible to increase your time in range, to reduce glucose variability and to reduce hypoglycaemia to almost nothing. At least... that's the idea. Medtronic are quite upfront that this is the first iteration of this algorithm, based on dozens and dozens of research papers, and that it is intentionally cautious. Other more 'aggressive' versions with greater user control are being strongly hinted at.

A consequence of the 'machine learning' of the pump adapting to you as an individual though, is that it does take a few days of sensor wear for auto mode to become available (48 hours from midnight following sensor start). I'm not exactly sure how that would impact occasional-sensor-users like me, who cannot afford full-time coverage, but it's clear that only a portion of each sensor for me would be auto-able. In theory sensors can be restarted just as they can on earlier enlite-using pumps (sorry Medtronic!), but this newer pump uses Guardian 3 sensor technology, and because the MiniMed 670G has more control over insulin delivery it makes more checks that the sensor data being received is of high enough quality. Without having used it, it's impossible to tell whether it would get twitchy and drop restarted sensors earlier than I am used to.

Case study
It was a delight to meet Rob Howe a Texan ex-pro basketball player and MiniMed 670G user. Tall, slim, athletic, and with that easy, effortless charm that seems to be the gift of so many Americans. He shared his experiences and took part in a Facebook Live broadcast after which we were able to ask more questions.

Rob was an enthusiastic MM670G poster-boy, and having moved from MDI/CGM to an insulin pump with an impressive HbA1c of around 6.2% (44mmol/mol) he was obviously no slouch when it comes to BG juggling.

When asked about changes he had noticed during his year on the pump, one of the most striking was that his regular weekly order of two 1 gallon containers of orange juice he kept in his fridge to treat overnight hypos started to go off before he could use them. They simply weren't needed any more. As a basketball player and all around active type, he also seems to have put the MM670G through its paces exercise-wise, from high intensity BG boosting sprints/weights to longer distance runs of 6-10 miles. Rob was able to keep the pump connected throughout exercise and allowed it to manage his activity, with great success it would seem. Initially Rob said his HbA1c rose a little, perhaps up to the mid 6's (48mmol/mol), but seems to have settled back to the low 6s since. So while the fixed settings on the MM670G algorigthm seem to target an HbA1c of approx 6.7% (50mmol/mol), it looks as though, once again, Your Diabetes May Vary.

What next?
It will be fascinating to see more accounts from real users 'in the wild' across Europe. Several people in the group were about to start with MM670G in November. There was an extended discussion during the end of the afternoon where bloggers raised concerns and questions. There are plans to subtly alter the materials and structure of the MM6xx cases to help avoid those battery compartment cracks (which in turn will mean Medtronic don't have to replace those pumps), plus small alterations to clips, and clip rails. Medtronic are planning a version of the MiniMed 670G which will be able to communicate to phone via Bluetooth. It is notoriously difficult to predict how long it might take to get devices through regulatory approval (and goodness knows what additional chaos Brexit might add to the mix for us in the UK), but reading between the carefully veiled lines it seemed that they were hoping it might be in the next year or two. No promises etc etc. Perhaps even more interestingly... this version of the MM6xx series would have the ability to receive updated software/firmware after distribution. This is something that Medtronic have been inching towards for some time, and could significantly accelerate the takeup of new and better pump versions where the hardware is essentially identical, and it is only the algorithm which needs updating.

One thing is for certain. The rate of change in diabetes devices doesn't look to be slowing down any time soon.

Disclaimer. Medtronic Diabetes invited me to attend the MiniMed 670G European launch in Switzerland. They paid for my economy travel, transfers, accommodation, the welcome meal and lunch at their offices. I wasn't asked or paid to write this blog post or any other social media posts connected to the event. They also included a nifty little Medtronic branded battery power pack thing in a 'welcome' bag. Oh and a pen too.