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.

64 Days with the Medtronic 640G: Ep 9 Review - the best and worst of the MM640G

Well, this is it. The last of my posts covering my time with the Medtronic MiniMed 640G. Thank you so much for bearing with me over the last few months. Normal wittering will be resumed shortly. However, as seems to be the way of things with blockbuster franchises (HA!) I have split this last episode into two parts. Part (i) covers all the little niggles and irritations I had while using the MM640G, while part (ii) looks at the things I loved, and reviews my results including reductions (if any) in hypoglycaemia and an HbA1c I had done at the end of my time using the pump. HbA1c is the test which measures how much of the glucose in your blood stream has stuck to red blood cells. It is often used as a measure of your likelihood of developing the long term complications of diabetes.

For those who really can't bear wading through all those minutes of video I will summarise the results below. The video gives a lot more detail though, and features a fluffy bunny. What's not to like?!

When it comes to the things I really liked/disliked about the MM640G you will need to bear in mind that I am comparing to a MiniMed Veo. All of the really good stuff about pumps generally - precise basal patterns, advanced dual and square wave bolus options for tricky meals, ease of use, bolus calculator, temporary basal rates, precision of doses and correction factors, blah, blah, blah... are already assumed to be present and correct. Some of the things I loved about the MM640G are precisely because they fixed annoyances I found with the Veo. But more on that later. First:

The worst of the Medtronic MiniMed 640G

Those who have read any of my reviews before will know that I can get unreasonably irritated by the slightest things. It will come as no surprise then, that while I generally loved the MM640G both with and without sensors, there were a few things about it that drove me nuts.

1. Pump lock
   After a few minutes the pump automatically locks and most interactions require you to play an annoying 'press the right button' game. This is no good if you are in a hurry, and is not an option that can be turned off.
   
2. Change of orientation
   It's now 'portrait' not 'landscape'. As someone who wears an insulin pump on my belt this is a bit awkward.
   
3. Belt clip
   As I mentioned in the first of these videos, the new belt clip is hopelessly flippy-floppy and needs a much firmer spring. The inbuilt tool for opening battery cap is cool though.
   
4. No small versions
   Medtronic have now abandoned plans to produce a smaller version of the pump. All MM640Gs will now have the little sticky-up bit to accept the larger reservoirs. The smaller reservoirs can still be used, but at present, with approximately 35u/day usage, the 'how full is my reservoir' icon on my status bar is pretty much permanently red.
   
5. Sensor overtape irritation
   The glue used on the sensor overtapes (and also the little patch that holds the sensor down initially) caused a red rash to appear after a couple of days of wear. Initially it was only toward the end of a sensor but in the end it began pretty much at day 2. I used an alternative dressing, but even that was pretty itchy. Weird - because I don't usually react to adhesives at all.
   
6. Sensor swap delays
   From start to finish swapping a sensor takes around 3 hours to begin providing new continuous data. That's a looooooong time!
   
7. Occasional sensor lag
   Mostly I found the sensor accuracy was brilliant. But sometimes, particularly if I treated a low to try to fix a below target BG reading, the sensor was a little slow in responding (perhaps 30 minutes behind reality). Additionally calibrations by BG meter do not necessarily reach up to match sensor glucose and BG fingerstick value, but often end up with some odd half-way house. If the sensor glucose value had drifted a little there were even occasions where calibration triggered an 'alert before high' which was doubly annoying.
   
8. Sensor Glucose Review
   The one-day graphs which allow you to flick back through previous days' results show no indication of SmartGuard interactions or insulin doses. Makes them about 10% as useful as they could have been.
   
9. Home screen without sensors
   For no apparent reason, the icons in the status bar do not align neatly when using the MM640G without sensors. There's a gap where one of the sensor icons(!) would go, which makes it look untidy and poorly considered. The enormous dotted line 'we have no BG information to show you' panel where recent meter BG readings go (when not using sensors) also irritated me more than strictly necessary. Just doesn't feel like the visual look of the home screen for most UK users, who will be using the MM640G without sensors, was given enough finesse.
   

Watch the video

The grumbles, gripes, and irritations - everyone will have their own, I'm sure.

The best of the Medtronic MiniMed 640G

Whether you use the MM640G with sensors or not there is a LOT to like about it. There are all sorts of little, pleasing improvements in the interface and options that make a massive difference. Add the wizardry of SmartGuard into the mix and things are taken to another level - but even without there are lots of tasty treats for non-sensor users.

1. Setting basals and temp basals
   There are now up to five basal patterns on the MM640G, and brilliantly you can copy entire patterns from one 'slot' to another to experiment with and then switch back if you need to later. The patterns also come with helpful names to keep track of which are which: Work Day, Day Off, Sick Day, Pattern 1, Pattern 2. Which pattern is set is not marked on the home screen, but thankfully setting any of them does not cause the 'alert circle' to appear like it did on the Veo.
   
   Temp basals can now be set in 15 minute increments for more precision and alter up and down by 5% at a time making them much quicker and less fiddly to set.
   
2. No TBR 'chime'
   Setting a Temporary Basal Rate no longer causes the pump to issue a useless wittery alert tone every hour, which means you can ACTUALLY USE THEM OVERNIGHT! In even better news - the end of a TBR is now indicated by a single beep. Brilliant!
   
3. Different Alert Tones
   There are now a series of different alert tones to indicate different things. There were a few on the Veo, but so many overlapped with either 'pip-pip-pip' or 'naah-naah-naah' that I find it much easier to work out what is going on on the MM640G without having to check the pump for 'information' alerts and being alerted (ha!) to things that actually require action. The ability to increase volume has also significantly improved.
   
4. No lockout during bolus delivery
   It is possible on the MM640G to do rather more things during the time while a reasonable sized bolus is being delivered - for example you can set a TBR. The Veo made you wait until the bolus had finished before allowing you to do anything (other than stop the bolus!). This meant I could group my pump interactions together and then get on with life, rather than having to wait around tutting.
   
5. Screen visibility in sunlight
   Really, really good - especially compared to some other colour-screen diabetes gadgetry I have tried. Not perfect from every angle, but really easy to turn a little and see very clearly even in direct sunlight.
   
6. Remote boluses from BG meter
   Not a full remote control with bolus wizard, but a really useful standby when digging your pump out from within clothing is impractical or inconvenient.
   
7. Waterproof
   Now rated as IPX8 - up to 12 feet of water for up to 24 hours.
   
8. SmartGuard - overnight hypoglycaemia
   Unsurprising if you have watched my Overnight Hypoglycaemia post, but SmartGuard overnight for me was a real stand-out winner. No readings at all for 9 weeks below 3.5mmol/L overnight, and hardly any below 4.0mmol/L. Some nights almost no basal insulin required, and others requiring my more 'usual' 6-7 units at night. Looking at the results it's hardly surprising I had so many problems and so much Severe Hypoglycaemia during my years on Lantus!
   
9. SmartGuard - results overall
   When compared to averaged results from 10 weeks of Libre sensors (the only other 24 hour data I have) time in hypoglycaemia fell by 90% during my 9 weeks with the MiniMed 640G. At the same time my overall levels, as measured by HbA1c fell by 0.3%. And all this with less effort and very little 'alarm fatigue'.
   

Watch the video

Improvements to the pump (with and without sensors) and the all important results.

Conclusion

It has been a great privilege to experience the MM640G system, and for me the results were spectacularly good. The comparison with Libre data is an interesting one, particularly where hypoglycaemia is concerned. Times wearing a Libre sensor were previously my 'best ever' results-wise. The ability to spot hypos coming during the day and try to head them off (I generally scan a Libre sensor something like 30-40 times a day), plus the ability to spot low levels overnight and make hurried basal rate changes meant that I generally had fewer hypos on a Libre than I would normally. And yet when compared to these data, the MM640G system reduced my time spent in hypoglycaemia by 90%. To be clear, that means that for every 10 minutes I spent below 4.0mmol/L trying my very hardest with a Libre sensor, I would spend only one minute when using SmartGuard. That and my HbA1c dropped over the same period from 6.3% to 6.0%. 0.3% - it's not a huge margin, but those fractions are pretty tricky to shave off once you get down below 7.0 in my experience.

My only hint of melancholy about the whole experience is, of course, the eye-watering cost of full-time sensor coverage (approx £3,500 per year inc transmitter). It's not something we as a family can afford, and full time CGM on the NHS is reserved for those who really need it most - and rightly so.

It feels a little like being given a chance to live in a multi-million pound mansion and drive an Aston Martin for a few weeks to see how I like it. I may think it's brilliant - but the reality is that it's not really an option that is really open to me long-term.

I have a pump clinic coming up in a week or two and will see what they say about the results - particularly my unpredictable and occasionally lengthy periods spent below 4.0 overnight. These do nothing to help my efforts to keep my Imparired Awareness of Hypoglycaemia under control. I may ask about the possibility of part-time sensor coverage. Even a few months in a year would make a massive difference (as long as the transmitter continued to function, of course).

My Veo is nearing the end of its warranty period, so I am looking to the future. I have some thinking and some sums to do after this experience - depending on what my clinic say.

Final verdict (with sensors and SmartGuard): 5/5
Final verdict (without sensors): 4/5
Final verdict (considering self-funding sensors): 4/5*

* because of Dexcom's more 'stretchable' reputation when it comes to sensor life

Disclaimer: I was offered a trial of the Medtronic MiniMed 640G system for 64 Days with full sensor coverage so that I could share my opinion and experience good or bad. I was not paid to write this post, and if I had thought the pump was terrible I would have written that. I was encouraged (not required) to post video blogs about my experience, but Medtronic did not have any control over what I posted.

6.5% A1c target - A reply to a comment that got out of hand

I've had a couple of comments on my post about the proposed new HbA1c to aim for in the draft NICE guideline that is currently out for consultation. I was rattling in a 'quick' reply, when I thought - this is *ridiculous*. I can't even see this any more in this tiny box - so I've decided to post it here instead :)

Here are the comments:

Tamer Hassan said...
how do you achieve these numbers?

thanks

Tim said...
These numbers are impossible to reach...
Or at least give me some suggestions on how to reach these levels. Thanks.
Tim

'How to reach these numbers' is a question for your healthcare provider really. Don't just ask some random nutter on the Internet! However (and desperately trying to avoid sounding like Mr Smug of No 22 Smug Gardens, Bigheadshire) I have had a sub 6.5% HbA1c for over 3 years now, so I know that it *is* possible if only perhaps for the lucky few. Plus I've never had fewer hypos in my life with diabetes either - so it's not that I am 'paying' for A1c improvements with the hefty cost of Severe Hypoglycaemia.

I cannot really tell why some people seem to put in so much effort and get such scant rewards, and that is why I think individualised targets are SO important.

But it does seem pretty clear to me that the closer you can get to those standard-issue BG targets (5-7mmol/L waking, 4-7mmol/L pre meals and <9mmol/L by 2 hours after meals) for as many days in the week as you can manage, the closer you will get to these kind of tough, aspirational, borderline non-diabetic A1c targets. My own HbA1c has fallen by around 1.5% in recent years, and I think only around 0.5% of that is attributable to the pump - though Artoo has gone a LONG way to reduce my number of irritating low-level hypoglycaemia dips. When I look back over the changes that I have made in recent years I can see a few things that I think were important. I don't offer these as any kind of guide or advice - it's just what I did.

1. Education. Get access to proper structured education regarding diabetes management. In the UK we have DAFNE which is highly thought of, but other options are available. Things that should be included (in my opinion) are:
   
   1. carbohydrate counting, working out how to check and change insulin:carb ratios for different times of the day
   2. SMBG technique - when to test and what to do with the results *including* basal testing to PROPERLY adjust basal on an ongoing basis
   3. correction factors - when and how to correct (with insulin or fast-acting carbs) to aim bring you back into range without jumping aboard the gluco-coaster
   4. exercise and alcohol
   5. dealing with illness
   If structured education courses are not available in your country/area you can do a lot worse than buying 'Think like a pancreas' (Scheiner), 'Type 1 Diabetes' (Hanas) or 'Pumping Insulin' (Walsh/Roberts) which cover much the same ground. Though the benefit of peer support in group sessions should not be underestimated. Alternatively look at the free BERTIE online course.




2. Test more often AND RECORD THE RESULTS. Find some way of keeping notes daily as you go along. What you are eating, units and timing of doses (how long before... split doses...), exercise, mood, everything! Without a fairly detailed set of records I find it impossible to see what is going on. Personally I still love mySugr for this.




3. Gadgets - seek out new tech that can help you manage your diabetes more easily. It might be a 0.5u pen; a smartphone tracking app, or copy of 'Carbs and Cals'; or it might be a BG meter with a bolus wizard so that you can have properly fine-tuned ratios without having to worry about keeping the maths easy. Additionally, ask your clinic about access to Insulin Pump therapy and CGM.




4. Seek peer support - join a forum or two, join Twitter, read some blogs (thanks!) or even *crazy!* join a local group and meet face to face. Living with diabetes is tough, but it's even harder if you are battling on your own. For everyone there's a little corner of the internet that can provide support, encouragement and shared experiences.

At the end of the day we each have to find our own balance between living a life and managing our diabetes. Somewhere in the middle you'll find your perfect A1c and it won't drain all the joy out of life to reach it.

Good luck :)

6.5% - Are they mad?

I haven't really got time to write this today, but I have waited too long with too many blog posts bouncing around in my head so I'm just going to rattle this one in quickly to clear some head space.

The situation has been exacerbated in recent years because of my position as one of the patient members of the NICE Guideline Development Group (GDG) for the update to the Type 1 Diabetes in Adults Guideline. It has been an enormous privilege to be part of creating the guideline. Filtering through all the research and discussions looking for definitive, evidence-based, best-practice approaches to treating and managing type 1 diabetes has been incredibly interesting (and quite hard work!). Part of the NICE process is that members of the GDG are sworn to secrecy until the guideline is published. This is partly to promote a healthy, open dialogue within the group and also because - research being what it is - new stuff emerges all the time and blabbing about what the group thinks about a topic early on, might cause upset, especially if it changes later as new results/research are found or economic models are run.

As a consequence there are all sorts of really interesting things I have come across, or thought, or wanted to comment upon over the last 2 years which I have not been able to. Around the middle of December though, the 'consultation' version of the Guideline was published - you can read it here. The consultation document is the first glimpse the world gets of what we have been working on and it allows stakeholders to comment on the recommendations before they are finally published. So at last it feels like I can pop my head over the parapet.

One of the aspects of the consultation document that immediately prompted some comment on diabetes forums and Twitter was the recommendation regarding aiming for an HbA1c of 48mmol/mol (6.5%).

On the face of it, this sounds like madness. In a world where so many people struggle to meet the existing target of 59mmol/mol (7.5%), which fewer than 30%* of people with type 1 can manage, why on earth would you set the bar at 48mmol/mol (6.5%). Currently (and rather appropriately) achieved by just 6.5% of people with Type 1*. Why on earth would you set a target that almost 95% of people cannot reach?

Why indeed.

The section starts on page 160 and the recommendations are made on page 194.

8.1.2 Review question: In adults with type 1 diabetes, what is the optimum target HbA1c level that should be achieved to reduce the risk of complications?
...
39. Support adults with type 1 diabetes to achieve and maintain a target HbA1c level of 48mmol/mol (6.5%) or lower, to minimise the risk of long - term vascular complications.[new 2015]

Surely the patient reps on the group were up in arms at such lunacy?

Well actually no. If anything I was pushing for that very recommendation. And the real reason is the question. Questions are important. And without them, answers rarely make any sense.

I wasn't interested in knowing whether research said achieving 6.5% was easy. I was more interested in whether it was worth it. And even more importantly - how much it was worth it.

From the papers reviewed there was that familiar 'curvy' shape when complications were plotted against HbA1c values. At higher levels the line is really steep - zooming upwards with frightening menace. As HbA1c values fall down toward 8.5% things are curving off, though it is clear that even small improvements could potentially make a big difference. The argument that I was always given for the target of 7.5% was that below that level the added difficulty outweighed the more modest improvements of the levelling curve. But actually the improvements below 7.5% are far from level and when it comes to all the nasty things diabetes can throw at you - worth having if you can do so safely and with a decent quality of life.

The next recommendation is critical too.

40. Agree an individualised HbA1c target with each adult with type 1 diabetes, taking into account factors such as the person’s daily activities, aspirations, likelihood of complications, co-morbidities, occupation and history of hypoglycaemia. [new 2015]

So far from being a 'failure stick' to beat us with - I hope that this new recommendation (if it makes it to the published version) - becomes a source of support for anyone who has the time, skill, good fortune and technology to aim for a sub-7 A1c. And that the next one promotes a tailored programme of support, strategies and treatment options for everyone to achieve their own perfect balance between diabetes management, results and still having a life.

Mostly I hope no one gets told off again for having an HbA1c that is 'too low' by a clinic that assumes you *must* be having severe hypos all the time.

What did you make of it? Do you think it will help or hinder your efforts?

Follow up: How do you achieve these numbers?

* National Diabetes Audit 2009 - 2012

#teamsmug

One of my favourite diabetes-related hashtags of late has been the coining of #teamsmug (I'm not sure who came up with it, but I suspect it was either Dave or Paul). Part self-congratulation, part self-mockery, membership of #teamsmug can follow as little as a single unexpected good BG result after a tricky meal - even just waking up at a good level is enough. The shiny (and entirely imagined) #teamsmug baton is being passed around between Twitter users who know that a few good levels should be enjoyed, but can't necessarily be expected to last. Oddly enough, pretty much as soon as I had blood taken for my HbA1c I had an unusually prolonged #teamsmug period. Almost as if Artoo was responding to my previous grumpy post with, "Doubting my effectiveness are you... Well we'll see about that!"

It has been a hectic few weeks, and I really meant to post something about my HbA1c results before now. I was delighted (and slightly confused) to get a result of 46mmol/mol (6.4%), pretty much back to the last A1c I had pre pump, but with all the hypo reductions and general quality-of-life improvements that the pump has brought. It was a bit of a surprise to be honest. I'm not quite sure how I got that sort of result, as it certainly doesn't seem to fit with the weekly averages I'd been having in the weeks running up to my appointment. It just goes to underline the imperfect nature of HbA1c as a marker.

You'll be reassured to hear that my #teamsmug membership has been revoked since. Nice while it lasted, but the goalposts have moved again, and I'm still chasing after them with a few basal tests.

A1c apprehension and feeling a little deflated

I have an appointment on Monday to have bloods taken for my annual review a week or so later. As is often the case the mere hint of an A1c on the horizon has been enough to play havoc with my blood glucose levels over the past few weeks. Coming down with a cold hasn't helped either.

This time last year I was at a bit of a turning point. I had tried as hard as I could to improve my levels on MDI, and still felt there was improvement to be made. That review was undertaken at the hospital, and having discussed the ongoing challenges I was trying to tackle, the Registrar agreed that an insulin pump was a good option. I recognise that I am extremely fortunate to attend such a pro-pump clinic and after a few more appointments and a bit more prep, I was pumping before Christmas.

Regular readers (your gritty determination astounds me) will know that my journey towards an insulin pump was not entirely straightforward. I spent a great many years resisting the idea each time it was mentioned. Approaching a year into my pump experience I have just done a d-geek 'compare and contrast' exercise that convinces me more than ever of my position on the OCD spectrum - partly because it annoys me so much to have a key period of MDI results missing due to an *ahem* administrative error (I deleted them from one place before checking the place where I thought I'd copied them). I put together seven months worth of BG results side by side, matching 'tricky' periods like Christmas and holidays. I then examined them for a range of markers - BG average, SD, FBG in range, numbers of highs, numbers of lows and so on.

Without going into the minutiae (I appreciate I have to at least make a gesture towards allowing you to retain your will to live) the truth is I'm a bit deflated by the results. Since moving to the pump they are, in some ways, better than on MDI - but not really by very much. And if I'm honest I was hoping for the same transformations to my results that I'd seen in other people. People whose MDI skills I hugely respect, whose lives are busy and full of nice varied (and occasionally eyebrow raising) meal choices. People whose A1c's fell by a significant margin after a short time on insulin pump.

The trouble is I should be perfectly happy. My meter averages suggest that my A1c will be somewhere in the high 6's. To be disappointed by that seems ridiculous, but my last MDI result was 6.3. It is true that I'm having slightly fewer 'waffy' moments these days (thanks Dave!) but I've also had more readings in the 20s than I can remember thanks to multiple set failures which at one stage seemed to be happening fortnightly.

I still believe the pump is working for me - and having changed to Silhouettes a few weeks back I've not had a failure since - but by now I was hoping to have this whole thing sorted and be cruising along with more stability and less goalpost chasing.

I'll let you know what the result is when the A1c jury comes back in.


UPDATE: #teamsmug

Reviewing my review

So today was the day. My long awaited (and only slightly delayed) annual review. As far as I can tell most, possibly all of the old clinicians have left the hospital I attend, so there were new faces to meet. 

It was great. My appointment started promptly and my discussions with Dr S were unhurried and thorough. A little too thorough, perhaps. Apologies if you were after me, I think I stayed and chatted for a bit longer than I usually would. 'Smile and nod' this wasn't. It felt more like a fruitful exchange of information. And if Dr S was bored senseless and wished I would get lost, she certainly gave nothing away. 

I was pleased to learn that my HbA1c had dropped from 7.1% to 6.3% (45mmol/mol in new money). Dr S pointed out that that was the sort of level at which they get begin to get concerned about the number of hypos that might be involved, but thankfully I'd taken a sheaf of printouts showing that I'm having far fewer these days. Other results showed an unexpected drop in cholesterol to 4.7 (with an improvement in the lipid panel split of 2.1 HDL, 2.3 LDL and 0.7 Trigs - yes I realise that doesn't add up, calculated values sometimes don't it seems). Blood pressure, while occasionally higher than ideal, is generally low enough at either end of the day to pass muster. 

I should take this opportunity to thank the Diabetes Online Community for their amazing support and encouragement over the last year or two. Forums, blog posts and comments left here have had a major impact on the way I am able to manage my diabetes. Things that I had thought impossibly illogical for years have been made much clearer. You guys rock!

And as for the *big question*? Well as I talked through pretty much all the issues I still have with Dr S, we agreed that all of them would be easier to handle on a pump. I have booked an appointment with a DSN to talk pumps, Levemir and other options. 

Watch this space. 

'HbA1c phenomenon' and feeling grumpy

I have an annual review coming up in April. I know this because I called the hospital a while ago to check I was still on their list (I recently transferred back, having been seen at my GPs for a few years).

I also know it because my blood glucose levels have been running stupidly high recently. This seems to happen to me a lot. As soon as I know I'm in the 3 months running up to the test (HbA1c gives an indication of average BG levels over the last 3 months) it all goes to pot. I've come to think of this as 'HbA1c Phenomenon'.

I've been working hard at getting my diabetes under control for around a year now. When I look at monthly average figures during much of that time they are around 6.9 - 7.1 mmol/L. There's a ready reckoner which suggests your HbA1c if you give it an average BG level for 3 months or so, provided the tests include a decent spread of pre- and post-meal results (which mine now are). There are a fair few of these conversion formulae, but the one I use is:

HbA1c = (BG average+2.52)/1.583

Weekly averages recently have been in the mid 8's. I haven't been doing this badly for about 8 months. I was so hoping for a good A1c. Almost as an 'official' affirmation of the work I've been putting in. Secretly I think I was hoping I'd make it into the elusive 5% club (sub-40 in new mmol/mol numbers), but now I think I'll be lucky to match my last one of 7.1%. If I was still pottering along without paying much attention I'd be happy enough with that (as indeed I was), but when you are working much harder at something it's nice to see some sort of results, and a little frustrating to think that you would have seen those results a month or two ago when you didn't have the test scheduled!

In my heart I know that the HbA1c is a pretty poor indicator of control. I've cheated low numbers before by having enough hypos to cancel out all the highs. But it's the badge which defines you as far as the medical profession is concerned. However inaccurate it is, it's still considered the 'gold standard' indicator. I wanted not only to have better control (which I do) but to have a pleasingly low A1c to match.

So I am trying (and largely failing) not to get too grumpy about this. To breathe deeply, take one test at a time and be happy with how far I've come in the last 12 months.

You never know... the test is weighted to the most recent 4 weeks or so. I might still have a chance to knock a bit off if I can keep my head during March.