There’s been a lot of online buzz on the heels of a new study that threatens to topple the long-held assumption that insulin pumps always trump shots when it comes to insulin therapy. It’s the second phase of a trial called DIAMOND. The original study, not too surprisingly, found that taking type 1s who are using shots and fingerstick meters and giving them insulin pumps and CGMs (continuous glucose monitors) improved their glucose control. But Phase 2 took CGM-savvy patients who were using shots and switched them to pumps -- and lo and behold, their control got worse, and their quality of life fell into the toilet.
What’s up with that?
As our correspondent Wil Dubois followed a similar path -- pumping for a long while, then using CGM and shots, trying out the new Tandem pump for two months to write a review, and then returning to the needle -- we asked him to share some perspective here.
On Choosing How to Administer Insulin, by Wil Dubois
Let’s face it, Gang: diabetes therapy is work. Hard work. Nothing short of a cure and a lifetime supply of complimentary Krispy Kream doughnuts is going to change that. For those of us with type 1 diabetes, that hard work includes taking a lot of insulin—and there are two main ways to do that: shots and pumps.
In theory, an insulin pump has a few significant advantages over Multiple Daily Injections (MDI):
- The basal drips, called rates, can be programed to vary throughout the day. This is no small thing, as most people’s bodies require either more or less insulin throughout the 24-hour cycle, something impossible to address with just one or two shots a day.
- Pumpers can also increase or decrease this rate for unusual circumstances. Running the Boston Marathon? Reduce your basal rate. Super Bowl Party? Better increase it.
- You can program them to deliver different insulin-to-carb (IC) ratios based on time of day or what you’re eating, and different correction factors (CF) at different times of the day.
- Pumps can deliver meal insulin in one wallop, like a shot, over a protracted period of time, or a mixture of both. These complex delivery patterns are especially useful for high-fat meals or meals that mix carbs and fat, like, say, pizza.
- Lastly, pumps increasingly offer some level of automation, with two of the three pumps on the market using data from CGM to either limit or limit and increase delivery without the pumper needing to take any action whatsoever.
So why wouldn’t everyone want a pump?
Well, that depends on the person. Remember that Your Diabetes May Vary (YDMV) and what may be a Pro for one person, may be a Con to another.
That’s where the rubber meets the road on the choice of shots vs. pumps. Both take a lot of work, but the work is different, so the trick is to pick a therapy that has the least impact on your non-diabetes life. Yes, I know, sometimes it feels like we don’t have a non-diabetes life. But we do. Or we should have, at any rate.
As mentioned earlier, I have been on pumps and injections, and back and forth again, so this is where my personal experiences come into play in writing this.
Free Time Wanted
To me, this is the biggest difference between pumps and shots, and the most profound difference I felt when transitioning back. Ninety percent of the time, pumps are faster—sucking less time out of my day. On the pump, I didn’t need to take time for a basal shot each morning and at bedtime (a shot I tend to forget, even after doing this for years). Meal and correction insulin were a relative breeze. I say relative because all our current pumps have too many warning and “are you sure” screens that require me to use more button presses to get my insulin than I think I should need, but it’s still faster than getting out a pen and taking a shot that way.
However, for some people, all these little time-savers are overshadowed by the bigger time suck of having to change the insulin cartridge and infusion set, which happens in the mornings for most PWDs every three days, and is a process that takes quite a bit longer than brushing your teeth.
Some of this depends on which device you happen to use -- currently, as of late 2018, there are only three insulin pumps available to buy in the USA: Medtronic's Minimed (with integrated CGM), Tandem's t:slim X2 (which also offers integrated Dexcom CGM), and Insulet's OmniPod tubeless patch pump.
Attached to Your Body
Two of the three pumps still on the U.S. market (Medtronic & Tandem) use an infusion set, with thin plastic tubing running from that spot on your body to the pump to deliver insulin through the skin. The third pump (OmniPod) is tubeless, but still requires you to keep track of its control unit. But either way, this is a huge liberty limit: There’s something attached to your body 24/7. This is one of the things I like least about pumps. They get in the way. Physically.
Infusion set tubing, in particular, doesn’t like to stay tucked in. It catches on passing door knobs, stove buttons, and more. Plus the pump unit sometimes comes loose from belts or pockets, dangling from your body like an old-fashioned computer mouse. Sleeping (and sex) can be a pain with a pump, and frankly, with a tubed pump, going to the bathroom is a more difficult operation than it should be, especially if you have short tubing and like to wear the pump on your waist. And, of course, airport security can be a much bigger hassle with a pump. All of these things, arguably, reduce quality of life.
The Diabetes Gear Load
Speaking of airports, you can’t travel light with diabetes. All insulin-using PWDs should be carrying gear for checking or monitoring blood sugar, some fast-acting glucose, a glucagon kit, and a medical alert of some sort. But, as you’ll see, pumpers need to carry more.
While shot-wielding PWDs can get away with limiting their load to either extra syringes or pen needles, and perhaps a cooling system for the insulin itself, pumpers need spare infusion sets, spare cartridges, spare batteries or a charging cord, and perhaps skin prep products to sterilize the skin and help the sets to stick.
As a pumper, you won’t feel quite like a Marine will a full combat pack hitting the beach, but it’s close.
Less Brain Work
One very nice thing about a pump is that you only need to think about carbs, at least once you’ve taken the time to get the pump set up right. If you have different IC ratios for different times of the day—and pump or shots, you really should—the pump takes care of the math for you. Sure, on shots, you can use something like the excellent RapidCalc app, which is the surgically removed brain of a pump without the pump, but now we’re adding more steps to each bolus, eating up more of our precious time.
Pumps also automatically track IOB, or insulin on board, to reduce the risk of insulin stacking (i.e. overlapping doses), something that apps can also do, if you take the time to use them (there we go with time again), but it’s not something most people’s brains can do.
Sometimes I don’t like people to know I have diabetes. So is a pump or a pen more likely to blow my cover? A tubed pump on the belt, in theory, is a big pointing finger. But in reality, most people are super self-absorbed, or simply have their noses in their smart phones, so 99% of them will never notice the pump. Of course, that last 1% are the annoying loud ones who ask, “What’s that thing on your waist?” At 113 decibels.
They can’t see the pen in my pocket, or if they do, they’ll just think I’m happy to see them ;).
At meals, however, pulling a pump off your waist and commanding an insulin bolus is easily mistaken for a smart phone text or email check, while whipping out an insulin pen and taking an injection tends to get noticed as a medical procedure. Of course, you can always excuse yourself to the bathroom to take your shot, but here we go with time again, plus if the food comes early or late, your food gets cold or your insulin gets ahead of your carbs. Not good.
My Personal Choice
I find that any time I change from one tool to another, I do better. If I changed every two months, I’d probably stay in control. I think it’s because change makes you focus. That, or diabetes is an intelligent alien parasite that can be caught off-guard only for a short time.
To be honest, I did best on the Snap pump, which was unfortunately discontinued in 2015. It had all the advantages of a pump without a lot of the big brother safe guards that wear you down over time when using one. It was fast to use in every regard, from site changes to bolus doses.
I miss it.
But now that Snap is no longer an option available to anyone, I'm going the way of the pen these days and that works just fine for me.
Liberty… In One Form or Another?
No matter what delivery method we choose, the fact remains: without insulin we die. But the choice of pump or shot isn’t really about features and theoretical advantages, if you ask me. It’s about time. And lifestyle. It's about choosing which has the lesser impact on your life, because the therapy that bogs us down the least is the one that we’ll use the most—while we’re likely to take shortcuts with any therapy that monopolizes our lives.
That is why for insulin pumpers, it’s not as simple as saying, “one insulin pump is the same as any other.” These are not interchangeable commodities. While pumps serve the same basic function of delivering insulin, they look and function quite differently – meaning one may feel more usable and less medical compared to another, and as a result one PWD may do better in managing their diabetes with that device. It’s not fair to put them all in the same box. For more on that, see famous CDE Gary Scheiner's article, "16 Reasons Pumps Aren't a Commodity."
And really, that’s the big theme in having a handle on diabetes management or not.
It's all about choosing an option that we’ll actually use, because it best fits the way we live. That’s why any study that proclaims to say one way is good or bad for everyone is not one worth listening to. Each PWD needs to try out the options and see what works and doesn’t, to make the best decision for your own life.