Happy Snappy

After a 30-day trial and a talk with my endocrinologist, I've decided to start pumping officially with the Asante Snap insulin pump.

I'm frequently asked how I have the opportunity to try so many insulin pumps. The answers, briefly, are (1) having an endo who trusts me enough to allow me to experiment, (2) having a husband who will financially support and encourage an "early adopter" mentality, and (3) paying for some of it out-of-pocket so as not to tempt fate with my insurance company.

In this particular case, Asante actually approached me about their 30-day trial in mid-2013 and I had the opportunity to start the trial in November. Because they were soliciting my feedback, they also offered to let me keep the controller portion of the product if I wanted to start using their system. What worked to my benefit was that my insurance covers the monthly supplies and that my endocrinologist was happy to write me the prescriptions I needed. I am Asante's first customer in Texas.

Somewhat related to my decision was that I am being forced onto Humalog in 2014 by Express Scripts International (my insurance plan's Pharmacy Benefit Manager) and Snap is currently Humalog-only (with plans to design a Novolog version), so this was something I felt I could move forward with.

I always have anxiety about switching to a new pump. What if I don't like it? Asante is so confident about their product that they will let you try it for 4 weeks. That really piqued my interest. I tried it and I liked it. And the startup price is so low that, even if they hadn't offered to let me keep a controller, I would have been able to manage the low out-of-pocket costs to switch to the device.

I don't have much more to report about the device than what I reported in my initial review after my first week on it. I felt the same at the end of my trial as then. I really appreciate how little I have to think about the pump itself.

I will echo what Kim said about Snap's lackluster accessories. Much like the Dexcom G4 leather belt holster, I am certain they were designed by and for men. I don't like the options for a case or clip that Snap came with, but I don't usually like belt clips or leather holsters on my pumps (or my phone either). Maybe it's because I don't wear a belt and I often have a kid on my hip that knock those things off.

I prefer drop clip cases that hang from a beltloop and stay out of my way - like the Clip n Go that I used with my Cozmo and the Tallygear G4 case I use for my Dexcom. Fortunately, however, the Tallygear Dexcom case (of which I own three) is perfect for the Snap and I'm loving that I can see the full pump face and control all the buttons without fishing it out (though I do have to remove it to use the handy flashlight). The pump is visible, accessible, yet protected.

I love how quickly I can change out my site and that I don't have to change the tubing unless I'm changing the whole pump body. I just change the site every three days.

And on Day 6, I can change the insulin cartridge and pump body and tubing in under 2 minutes and did it in the dark the other night when I got the low insulin alert before bed.

I love how little I have to carry around with me. I'm carrying a tiny purse that holds my wallet, phone, keys, glucose tabs, meter/strips/lancet, syringe, 3mL pre-filled cartridge, slim pump body, and site. I love tiny purses and women with diabetes never get to carry them! (I was the only 5th grader in my class with an old lady handbag.) And now I have an itty bitty zippered barrel bag.

I don't love being back on Humalog. I'm not going to lie. My highs do seem to drag on for longer. It's not as peppy as Apidra, but it's a battle I was willing to fight only so hard (more on that later). If I'm going to be on an insulin I'm not thrilled about though, I love that I get to use these awesome little 3mL vials and I don't have to worry about compromised insulin or air bubbles and that I get the whole 300+ units from it. I can continue pumping on Snap down to the very final .05u of the vial.

I do like Omnipod still, but it's just never going to be my favorite pump. Its idiosyncrasies are often maddening. I didn't ever experience the frequent pod errors people complain about - on the old or the new versions of the systems, but my occlusion rate was always very high. Maybe once a week. And pods would fall off. Occupational hazard of having little feet climbing all over me, I guess. And the PDM was so often still in my purse or on the kitchen counter when I'd be in bed with a sleeping toddler on my arm and want to bolus. I do like wearing the controls on my person. That's probably the best testimonial for a tubed device. I want it right there with me.

I am optimistic about Snap. I think Asante is a confident and capable new challenger to the existing pump market and I love how responsive they've been to me. I am 10 days in with my new RED controller (thank you for allowing me to exchange for the color I wanted, Asante) and, knock on wood, I'm problem-free.

Well...at least as far as my insulin pump is concerned.

Where No D Has Gone G4

Though I know of people who were lucky enough to be guinea pigs for the Dexcom G4 Platinum CGM system, I think I am one of the first D-bloggers to start using it officially. I've been operational for 12 hours now. Yeah, yeah, shut up and get to the photos.

I ordered their Ocean Blue. I think it looks darker than the photo on their website. Considerably. Still, I love blue. I'll take it.

Ocean Blue

Product Image from Dexcom.com's webpage - I like their blue better

What Came in My Shipment

Transmitter

The transmitter has a six month lifespan and apparently they are fairly serious about this. The box comes with instructions (I also received these instructions from my local Dexcom clinical rep) that removing the transmitter from its position in the box immediately begins its life (aka warranty) and that I should wait to remove it until I was ready to begin my first sensor.

Dex 7+ transmitter next to G4 transmitter

The transmitter is roughly the same size in length and width, but much thicker/taller. Matte finish, too.

What's in the Receiver Box

The box with the receiver comes with a tutorial CD, a user's guide, a wall adapter, a charging/syncing cable, and a leather belt clip case that snaps shut (designed with a man in mind, I think, as it includes a snap loop to go around a belt - Hubster had to explain that one).

Receiver

With 7+ and Verio

You slide the little port cover closed when not charging.

Super Skinny

With t:slim. Will the real Slim Shady please stand up?

Slim enough for back pocket carrying.

Sensor

60% smaller sensor than the 7+ (image emailed to me from my clinical rep)

(image emailed to me from my clinical rep)

Start Up

Symbols: In range, full battery, no reading yet, and - uh-oh ???.
But it worked itself out by the 2 hour calibration time.
In other news, I was their first tech support call.

Up and Running

After calibrating to a 123 and a 133, I got my first reading immediately.

The alert screen for the low threshold I've initially set (YDMV)

The alert screen for the high threshold I've initially set (YDMV)

Accuracy

I think 12 hours is too soon to say. Before I went to bed, it said I was 108 and rising, but my fingerstick revealed I was over 200. I recalibrated and, a few minutes later, it asked me for another calibration. Then it seemed to stay right on track through the night.

It's alarms? Customizable to a degree. I have it set on the loudest, most annoying setting. It woke us in the night to say that I was below 55 and I corrected with a juice box. Woke at 74 this morning (fingerstick) and G4 said I was 76. Not bad, G4. Keep up the good work. I think I'm "falling" for you.

A Belt Full of Sugar

Hubster has been out of town all week.

I'm used to being alone with my little ones all day, running around with the two mommy groups I'm in, prepping meals, teaching voice lessons, etc.

But I'm not used to being alone with my diabetes overnight. It's been a long time.

I've lived all by myself twice in my life - once my junior year of college in a dormitory and then for five months in my mid-twenties between roommates in an apartment. I remember the panic of a middle of the night low blood sugar. The wake in a sweat and hope you can crawl to the cupboard kind of panic that used to grip me. I used to keep a basket of snacks next to my bed before I had a toddler who'd eat them all.

Now I sleep sandwiched between my two precious charges. And I have to admit that I worry.

The first night he was gone, I put my Dexcom in my Spibelt (a small personal item belt meant for runners) and filled the extra space in the pouch with glucose Quick Sticks.

It was the closest I could get to sleeping with handfuls of sugar.

And sure enough...

Dibbs stirred at 5am and I checked my Dexcom sleepily. 82--->. Hmm. Probably dropping, should probably...zZzzzZzzz...

I went back to sleep. Hubster texted.

I slept on.

Dibbs made another noise at 7:25am and my eyes popped open.

Dexcom read 44--->. I reached over for my Verio meter. 60 mg/dL. I unzipped my spibelt and started downing glucose.

I'm ready for my Diabetic Alert Spouse to get home.

So how did we do?

That's a great question.

Pre-Operation:

My Blood Sugar: flatlined for 12 hours between 108-117 leading up to c-section (see 6 hr graph above). Perfection!

My Pump: removed just before surgery and replaced with an IV insulin drip

My Insulin: They put me on a Novolin R drip of 1 unit/hour. (Really? R?) They also started a D5 (dextrose) drip. Yin and Yang!

My Blood Pressure: All over the place - the systolic would be too high, then just the diastolic. Then it would normalize. Nervous much? My blood pressure never had a problem during either pregnancy, but before both surgeries, this happened.

Epidural went in easily, but before they pushed any Fentanyl through it, I was struggling with horrible nausea. My nurse and anesthesiologist determined it was from being flat on my back under the unusually large weight of my uterus. Once they dosed the Fentanyl, I got the shakes something fierce. (This is one of many reasons why I don't regularly do opioids.)

During the Operation:

My Blood Sugar: I lay with my arms out to each side, BP cuff on right arm and Dexcom receiver in my left hand where I could check it as I liked. My BG immediately started climbing. Before the incision was made, I was 134 and climbing. As they sewed me up, 169.

My Pump: I was missing it.

My Insulin: R is a joke. I should have put some of my own insulin on board before disconnect. If Apidra/Humalog/Novolog are jet airplanes, R is a kid on a bicycle.

My Blood Pressure: It was normal throughout.

The nausea from the weight of my belly as I lay on my back was so overwhelming that I requested a vomit bag and had to use it. They pushed some Zofran through my IV and that helped, but honestly, I just needed the kid and all his fluid OUT. This time the epidural knocked out any sensation from my ribs down. I felt even less than I remembered feeling during Sweetie's birth. The catheter didn't tug or hurt like before. It was just...easy, quick, painless. There was immediate relief when they removed my 10 1/2 pound son and they couldn't stop talking about the large volume of fluid in there with him.

Post-Op:

He was born at 8:23 and, by 8:51, he was skin to skin with me being wheeled into post-op where we were encouraged (!) to immediately start breastfeeding.

He seemed a little jittery, so I was curious about his BG, but when they finally tested it, it was 50. Totally newborn normal. (Sweetie had been 54 at birth.)

We were held up in post-op for a couple of hours while they got a room ready.

Because of my recent MRSA infection, there were lots of "contact isolation" procedures they had to follow as far as our room was concerned. Throughout the week, every hospital employee who entered had to wear a plastic gown and rubber gloves. Infectious Diseases says I can be retested a year after my infection, and after three negative tests, I'll be scarlet letter free, so to speak. Until then, plaguesville, population me.

My Blood Sugar: By 9am, I was 196. 10am, 236. 11am, 224.

My Insulin: I took an injection of 5u Apidra (secretly) to correct the 235. But as I continued to hold there over the next hour, it was clear to me that I needed to trash the dumb bag of R and get my own Apidra going.

My Pump: At 11am, I filled a pod and kick-started my Omnipod PDM at my new basal rate. I also bolused another 2u of correction. By the time we got to our room around noon, I was 183. Better.

I could give you all a lot more details about my management through my stay (see log below), but the long and the short of it is that, once I brought the post-op high down, my blood sugars stayed between 68 and 173 the whole hospital stay. My goal was between 80 and 200, so I feel great about that.

The nurses ranged from curious to impressed to downright marveled in response to my continuous glucose monitor (Dexcom Seven+). My L&D nurse wanted it right by me throughout surgery rather than have my husband hang on to it, and my postpartum nurses would bring other nurses in to see it.

They were a little unsure what to make of my self-monitoring and pumping though. They all wanted to stay abreast of my most recent BG reading, but some nurses bugged me about how much I was bolusing and when. I felt less comfortable sharing that - probably because I regularly 'adjust' suggested dosages based on my CGM graph trends, how I feel at the moment, or whether or not I trust the aggressiveness of a particular correction factor. And I was also tweaking basal insulin rates as necessary each day on the advice of my endo (who stopped by my room daily).

The only nurse who drove me CRAZY was Nurse Chattypants. She was so insistent that I touch my incision scar that she grabbed my fingers and forcibly jammed them along my pubic line - um, thanks, but NOT cool. Anyway, she comes in for her first shift with me and rolls me on my side saying she needs to inspect my pump dressing (pod was on my lower back). I was like "what the HELL??!!" and then she kept asking if I needed her to tape it up for my shower. She's so lucky that I don't punch people in the face as a general rule. I told her that my diabetes care was my concern and that I trusted my nurses to be there to care for my postpartum needs. Didn't stop her though. I was in her care twice during my stay for 12 hrs each time. She. Never. Shut. Up.

When I called to place my first dinner order to the Dining Services desk and asked about meal delivery times so that I could time my insulin, the dining crew asked if my doctor meant to order me the "diabetic diet." I skipped the teaching opportunity, rolled my eyes and laughed. "No, I'm breastfeeding. Thanks. The regular menu order is correct." It was skimpy to begin with - can't imagine what their idea of "diabetic diet" was.

Everyone but me and my endocrinologist seemed concerned about whether my diabetes was "stable" after having the baby. Even despite blood sugar values that were almost non-diabetic. When I asked when the earliest I could be discharged was, even my OB said it depended on what Dr. M thought. When I told Dr. M that, she laughed. My numbers were boringly stable (um...no highs AND no lows - practically cured) and, as usual, there was nothing to indicate I couldn't roll with it if they weren't. I had less swelling in my feet than anyone else on my recovery floor. I was lucid, responsive, wearing regular clothes. I was walking the halls and to the nurses' desk, even when my epidural had fallen out and I didn't realize it.

Come ON, freaking hospital people. Stop micromanaging shit you have no more than a cursory textbook understanding of and watch a HOSS living it.

We eat like you, we usually test our blood sugars WAY more often than you think we should, and I resent your help. It's much more complicated than "Oh, you're on insulin? What's your dose?" Asked of me twice. Ummm...how much time have you got? I'll explain my four basal rates, my four variable insulin:carb ratios, my three target glucose levels by time of day, and the four different correction sensitivity factors. Then we'll take my average total daily dosage and discuss the average bolus/basal breakdown by percentage, factoring in the difference between correction bolus and meal bolus. After that, we will talk about how my faster acting analog that none of you have ever heard of peaks differently than the insulin you're used to dosing here and at no point will I allow you to even touch my pump. Got it? Now ask me again how much insulin I take as though it's a pill I swallow before meals.

Anyway, the staff at Dallas Presby really did take excellent care of me. The surgery was quick and painless, the recovery is going well, and I'm home with my 1-week-old and Hubster and Sweetie where I belong.

My Current Blood Sugar: 73 and steady for the last hour with an anticipated low in another 1-2hrs due to recent breastfeeding session. Snack is imminent.

My Pump: pluggin' away

My Insulin: currently running a basal of .90u per hour, which I lowered 10% from where it was two days ago due to going through half a bottle of glucose tablets in a day

My Blood Pressure: eh, feels okay to me

Tired of Betting on the Underdog

Like a die-hard Betamax fan, my status in the world of CGMS users has been one of being the weird outsider, talking about a product that no one else is using.

I've been sporting the Freestyle Navigator CGMS since November of 2008 - over two and a half years. It blows the other CGM systems away for:

Accuracy - It's usually within 0-4 mg/dL of my Omnipod PDM or my Flash or my Cozmo.

Comfort - You wouldn't believe how much tinier and more comfortable (and not wire-like) the sensor is if I showed you. Here. I'll show you next to Sweetie's pacifier.---->

Ease of Use - When the Dexcom 7 (pre-plus) was still showing you only the last few hours, Navigator had onboard range and standard deviation stats for 1, 3, 7, 14, 21, and 28 days, an endless history of graphs, etc. Not to mention only 4 calibrations every 5 days. It uploaded to CoPilot, just like the Freestyle meters, Cozmo pump, and Omnipod pump, and integrated all of your data into one seamless line graph and logbook.

And the single biggest arena in which it bested the competition…

RANGE. I can be anywhere on my property (upstairs, downstairs, outside) and my receiver will pick me up, faithfully noting my per minute (not every 5min) changes. For parents, that means they can sit comfortably on the sidelines of the basketball game and watch Susie's blood sugar. That means they can keep the receiver by their alarm clock in the master bedroom and Jimmy can sleep upstairs in his room without Mom and Dad straining to hear the low alarms.

For adult patients, it means you can leave the receiver in your purse under your desk, walk to the bathroom, and not lose a signal. You can be upstairs, passed out in the shower, and your husband will hear the low alarm downstairs and run up to check on you (actually happened to a patient of my CDE's).

And herein lies the problem. Abbott never sold you on the range. They didn't even train their meter people to know the details of their CGMS. I have taken over the Freestyle booth at many a vendor fair and run the half of the table talking about their product when it was clear the rep just wanted to tell people about their non-coding meters. A failure in marketing. Bullshit. Out of touch with the consumer.

In a meeting with some of their engineers in April of 2010, when we were first discussing the indefinite backorder and production freeze of their device (and how it was all red-tape legal mumbo-jumbo regarding the production rights when Abbott bought the Freestyle brand from Therasense), I was asked as a patient representative if I would trade range for a smaller transmitter.

What? Really? Okay, well, the Dex transmitter is half the size (though the wire below is longer). It's sleek and sexy. But I hated having to carry the big old Dex receiver on my body. I wear a pump already. At what point do I need Batman's toolbelt to hold all my gear?

But I don't think I can stay in this relationship any longer. I'm not going down with their ship. And after talking to both my CDE and my friend who used to work for Abbott today, I've made up my mind.

The backorder on my barely broken (and still usable) transmitter has now persisted to the 18 month mark…and it is rumored that at least another year will pass before it's lifted. I have three sensors left. And Abbott will give their customers $2,000 to stop complaining and just go buy a Dexcom already.

It's time for me to shut up and do it.

With only a few reservations, I'm taking the payoff and switching to Dexcom - a company that will eventually release their next gen (come on, FDA) and eventually integrate with my pump (COME ON, FDA). A company that knows how to treat their customers.

But a part of me will always resent that the rest of the DOC didn't know what they missed out on. I was the crazy chick crying out in the desert about the Nav while others complained about inaccuracy or harpoon needles (looking at you, Minimed), or the Dexcom's ???'s and quirky relationship to acetominophen (not an issue with the Nav).

In the end, just like when I bought a Cozmo 9 months before that company went belly up, perhaps it would have been better 'never to have loved at all.' It only makes me irritably cranky that I got a peek at something great that wasn't meant to be.