Already Gone

I started pumping on the Tandem t:slim in October 2012, less than six months ago. Let me begin this post by saying that I consider myself extremely fortunate to have access to expensive medical devices like touchscreen insulin pumps. Not everyone is so lucky and not everyone has good insurance.

My endo reminded me today with a smile at my quarterly checkup that I had begged her to let me try this pump. I had high hopes. So it is with frustration, embarrassment, and a heavy heart that I put this pump back on the shelf.

I loved the innovation. Loved the employees with whom I have interfaced. Loved their responsive customer service. I won't tell you not to get this pump. I hope your experience is incredible.

It was not the right choice for me.

I've blogged here regarding the fact that Apidra insulin cannot be used in the t:slim. Cannot. Be. Used.

When I last blogged, I stated that I would be trying Apidra on a 48-hour rotation to see if I could have a functioning pump for that short of a cartridge lifespan. By hour 30, my blood sugar had skyrocketed. By hour 37, my insulin was spoiled. Cloudy. Gray.

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!

T:slim in Action - Correction Bolus

I was disconnected for longer than I intended this morning (forgot to reconnect after my shower), so I checked my blood sugar and took a correction bolus. And I did it all on video. Spooooky.

Okay, not spooky. But it's Halloween and I had to acknowledge it. What will be spooky is my post-trick-or-treating-barbecue-feasting-with-friends blood sugar tonight.

t:slim review

UPDATE: I am no longer using the t:slim pump. It wasn't the right choice for me after all. I had issues as an Apidra user and had concerns about inconsistent basal delivery and worsening control. I understand I'm part of a small but significant group who had trouble, but Tandem is listening to the handful of us with problems and hopes to resolve them. Anyway, here was my initial review.

I started pumping this week with the new t:slim insulin pump from Tandem Diabetes Care. I have been watching and waiting for this pump to come to market for years and can hardly believe it's ticking away on my waistband as I type this.

This is not me typing this.

Many of you have been asking me how the t:slim compares to the pumps I've used in the past.

Here is the t:slim pictured with the three pumps I still have in my possession: the Omnipod first generation PDM, the Omnipod UST200 PDM, and the Deltec Cozmo 1800 (my 3 Medtronic pumps went the way of trade-ins). It's slimmer than any pump I've used before - about half again as thick as my iPhone 4S in its Speck case. Not THAT much slimmer than a Medtronic or Animas pump, but still thinner. (I compared it to my student's Paradigm and it was only barely so.)

I know - he's delicious.

My favorite part so far is that they moved the luer lock connection further down the tubing so that there is no stress on the tubing where it connects to the cartridge. I've had a baby or a toddler on my hip for the last couple years. When wearing a tubed pump, I frequently poke them with the luer lock cartridge port on my Cozmo. Not now. Clearance for those yummy chubby thighs.

Insets, IV prep, Verio IQ, cartridges/syringes/needles
t:slim box, charging cable, adaptors, cartridge remover keyrings,,
and the user guide is a business card thingy w/ USB input - wow.

The supplies take up more room in my meter case than I'd like. Your set change and cartridge implements are essentially in four separately wrapped pieces - 1) whatever infusion set you choose (I'm using the Animas inset, my favorite), 2) a flat black cartridge, 3) a fill syringe, and 4) a capped needle similar to the Omnipod fill needle. They package the latter 3 implements in one small black and white box, so that's nice. I just have to make sure I grab one of each item. Consolidation would have been nice.

I am always critical of pump clips and the t:slim delivers nicely on that point. A swivel belt clip with a soft felt lining to help the cased pump slide in and out. I'm looking forward to the t:clip, too - a case+clip in bright colors being developed by Myabetic.

Charging Cables and Assorted Tech Gear

Charging cables. I have a bone to pick with Tandem about charging cables. The t:slim's revolutionary lithium polymer battery requires a charge once every 7 days and does well if topped off for 10-15min every day. They send you a USB wall charger and a USB car charging adaptor (for a cigarette lighter) - and only one cable. One.

Luckily, I keep a spare micro-USB cable in my car for my husband's Samsung Galaxy series phone and it easily topped the battery off while I was driving today. But why send only one cable? Isn't the point of having the car adaptor in case I need to charge it on the go? Do they really want me lugging a cable around in my supply case or my purse? Have you seen what I do to headphones?

Thank you, Samsung. Apple, why you gotta be so proprietary?

Touchscreen. Oh my heavens, it's lovely. The glass and the colors (which denote different information types and whether or not it's a value that can be changed by the user) are crisp. It's not exactly like using an iPhone, but you can quickly adapt to the required pressure for button pressing. The touchscreen input means that you can pair it with any blood glucose meter you prefer to use. No scrolling up and down to input blood sugar values. Just a quick keypad input for BG and for carbs.

Touch me.

Carb calculator. This was the feature that surprised and stupefied me. There is a calculator for inputting your mealtime carbs. Sandwich was 28 and chips 17? No problem. Press "28 + 17 =" and hit Done. I'll never do addition again.

6th grade math teacher: You're not going to have a calculator
on you everywhere you go. Ah, how far we've come.

I LOVE that they have delivered on a failsafe for insulin overdose. There is essentially a holding chamber that they call a micro-delivery chamber in the cartridge that can hold less than a unit of insulin at a time. You're not ever at risk of a pin or plunger suddenly delivering the entire contents of your 300-unit reservoir into your body. Whew.

Loading the cartridge. There are three little idiosyncrasies about the way you fill the cartridge and tubing for the t:slim. 1) The cartridge is inserted before you fill it with insulin. 2) The fill syringe needle is very long, yet only the very tip of the syringe is inserted into the fill port. You feel a little pressure and stop. How many people will break a needle attempting to jam the whole thing into the fill port? Very odd. 3) When priming insulin into your infusion set tubing of choice, prepare for a wait. I'm a 23" tubing length user myself (short length) and in the time it took to fill the tubing completely, I could have gotten up and made myself a cup of coffee. Or gone to check the mail. It takes that long. Hmph. Update: I timed a prime and it came in just under 02:30. =\

So much makes SENSE about the way this pump works. If you time-out on a screen and go back into the pump, it remembers what screen you were on. It pulled the best features from the Cozmo pump (a site change reminder every three days, a missed meal bolus reminder) and the large reservoir capacity previously offered only by Cozmo and Medtronic.

The best feature, hands down, of the t:slim is the way it presents your settings to you.

With the other pumps currently on the market, the user is able to set multiple basal insulin profiles (for work, for weekends, for differently scheduled school days, etc), but you can't create multiple profiles for your correction factors, your insulin:carb ratios, or your target blood sugars. Those are stuck. When I was preparing to go into the hospital to give birth to Dibbs, I could quickly switch to a post-partum basal profile, but I had to go in by hand and change all of my settings in the other screens.

The other pumps split this data into multiple screens, embedded in different areas in the pump.

Omnipod

Cozmo

On the t:slim, it's all in one place. One place. ONE SCREEN EVEN. I can create (and even duplicate and then edit) profiles that are displayed based on time of day. I can look at a glance and see if my correction factor may be overcompensating for my basal rate being off. It's all in one location.

These settings were set by my Evil Genius CDE in regard to my
personal blood glucose trends. Please do not make adjustments
to your regimen without consulting your physician.

From the lock screen, I can see the time, date, battery life, insulin volume, and my insulin-on-board amount and time remaining.

Easy as 1, 2, 3.

And if I go into my History and click Delivery Summary, I can even get a visual breakdown of my usage for the day or over different specified periods (7 days, 14 days, etc).

Rock me, Amadeus.

This baby seems to have it all. I'm excited to see where this company is headed with their future iterations of the t:slim and I'm thrilled to have another competitor enter the market to push their rival companies to keep innovating for the end user.

I have consistently said two statements over the years when talking to people with diabetes about our available choices in regard to insulin pumps: "There is not a bad pump out there; they all get the job done." And "No one pump has everything I'm looking for."

I'm optimistic that I might be able to stop saying the latter.