Musical Chairs

There's a phrase in German for when you can't pick between two people you love - "zwischen zwei Stülen" or between two chairs, meaning that you have to pick a seat if you're going to sit down.

I'm in a room of empty chairs.

I love my old, use-it-when-I'm-frustrated-with-everything-else-in-my-life, 100% dependable, out of warranty Cozmo insulin pump. They're out of business now. I have been wanting to move on. She's been there for me. When I first got my A1c into the 6s. At the end of two pregnancies when my Omnipod couldn't hold enough insulin. She's my ugly little workhorse and I love her, but being out of warranty, I'd really prefer her to be my safety school. Not my primary path.

Apidra and the t:slim

UPDATE: Please see updated information at the end of this post. I think that I misunderstood the tubing interior. While what I state here about Apidra being the cause of my occlusions is likely still true,  as I've not had a single occlusion in the 2 months I've now used a different insulin (Humalog), I do not believe now that what I pulled out of my tubing was solidified insulin...

I started on the Tandem t:slim insulin pump in October, a little over 8 weeks ago. In that time, I've experienced an alarmingly unusual number of occlusions - blockages somewhere in the insulin delivery that causes the pump to alert the user with an alarm. From my third cartridge to now, I would say it has been 1-2 out of every 3 cartridges that I've had to change early.

All of these occlusions have resulted in extremely high blood sugars for a number of hours while I troubleshoot the problem, change everything out, and take a manual injection of insulin.

Two of these occlusions have happened while I was sleeping. The alarm did not wake me. I woke up a couple hours after the pump detected the problem, so several hours after the problem probably began, and only because I was feeling very sick. A high blood sugar makes me feel nauseous, sluggish, sleepy, unreasonably angry (rage hormones, cortisol), and very thirsty.

Anyway, like a good PWD, I've attempted to isolate the problem. I have spoken with the same two people in Tandem's (impressive) customer service on at least a weekly basis. I've spoken with my diabetes educator over the phone.

I changed cartridge and infusion set lots. It wasn't the cartridges or the infusion sets.

Tandem offered to send a new pump. I accepted. Three cartridges of insulin later, two of those three had occluded. It wasn't a faulty pump.

Tandem Tandems

That leaves one possibility - the insulin. It couldn't be the insulin, I thought. I've used Apidra fast-acting insulin since 2005. I've used it in pumps from Medtronic, Cozmo, and Omnipod. It couldn't be the insulin.

Now, there are plenty of anecdotal reports that Apidra seems to become ineffective on the third day in a pump. And any insulin begins to break down after it's removed from the glass vial. Apidra has never been problematic for me. Or at least I've never been able to blame any third day highs on bad Apidra. Apidra is technically contraindicated in pumps for over 48 hours, yet I've always gotten 72-80 hours out of a reservoir. Most people report no issues, so I've always just proceeded with cautious optimism.

from http://www.apidra.com/faqs.aspx

The representative from Tandem's Customer Service told me that the t:slim was tested and approved specifically for use with Humalog and Novolog, and, while preliminary testing with Apidra showed no concerns, the majority of calls he personally was receiving regarding frequent occlusions all seemed to involve Apidra users. And diabetes blogger Sarah from Sugabetic mentioned to me on Twitter that she had heard people reporting Apidra turning to gel in the t:slim.

So, I had to get a-cutting. I split my occluded tubing from yesterday with a pair of scissors to find this crystalline substance inside it.

That's not part of the tubing. That's Apidra.* - please see update below

Alas, something about the t:slim cartridge and micro delivery chamber seems to age my Apidra to the point of a hardened substance. Like a pliable thread.

A piece of split, unused tubing looks like this:

sliced in half

My tubing looked like this, with an interior thread:

I've bent the tubing halves down like on an ear of corn.

So is this a piece of insulin in my hand? A PIECE OF INSULIN?*

I took great relish in taking a hammer to the opaque cartridge to get a glimpse at the interior reservoir bag. Upon impact, liquid insulin splashed all over my hands. This is what the bag looks like:

t:slim cartridge interior

The bag still has liquid in it, which at least verifies that it's a process occurring - insulin slowly turning to crystal as it moves through the system.* Perhaps it's aged by the materials with which it has come into contact. Perhaps it experiences some kind of catalyst from pressure in the microchamber. I don't know. I'm a shoddy scientist.

At the urging of Tandem customer service, I am switching to another insulin effective immediately. My CDE (diabetes educator) gave me a bottle of Humalog and a bottle of Novolog to try. I started with Humalog (an insulin I took from 1998 through 2005 and am familiar with). I've never tried Novolog, but I'll give it a go next. I don't expect them to differ.

The 3 Fast-Acting Insulins

I am just still in shock. I didn't think it could be the Apidra.

UPDATE: I have some facts wrong and need to issue a retraction. After cutting through additional tubing - both empty and with Humalog insulin inside it, I can state that the thread I saw is NOT crystallized Apidra as I originally believed. Inset tubing DOES INDEED seem to have an interior tubing piece that may be what I was seeing and pulling out. I had originally believed that inset tubing wasn't double-walled, but other pieces of tubing have proven that it depends on how one cuts the tubing. I apologize for the confusion I caused!