¶ Welcome and introduction
Welcome to Think Like a Pancreas, the podcast where our goal is to keep you informed, inspired, and a little entertained on all things diabetes. The information contained in this program is based on the experience and opinions of the Integrated Diabetes Services clinical team. Please discuss any changes to your treatment plan with your personal healthcare provider before implementing. I'm your host Gary Scheiner and today we're gonna be discussing the how and why of MDI.
And for those of you who don't know, MDI stands for multiple daily injections or inhalations. I guess the I can stand for multiple things. But before we jump in, make sure you that you like, follow or subscribe on your favorite podcast app so that you never miss an episode. And for expert diabetes support beyond this podcast, please visit integrateddiabetes.com. So now we're ready to get started.
I am thrilled to be joined today by two friends and colleagues, Miss Ginger Vieira and Dr. Egils Bogdanovich.
¶ Introduction to Ginger Vieira and Dr. Egils Bogdanovich
Give you wanna give each of you a chance to say a little bit about yourselves and Ginger? Why? Why don't you go first.
Hello Gary. Thank you for having me. I have lived with Type one for 25 years. I've been creating videos, articEgils, and books on type one for about 20 years. Please forgive the earlier ones. I was 20, but um, yeah, uh, I am a huge fan. Well fan, putting it lightly, but I'm a big fan of MDI. Uh, but more, 'cause I'm not a fan of insulin pumps, but I'm sure we'll get into that a little later.
But you can find my books on Amazon, on exercise, pregnancy burnout, low blood sugars, and find me at diabetesnerd.com.
You co-authored one of those books with, uh, one of our team members. Jenny.
Jenny, and we have a second edition coming out, hopefully next month. New and improved. It's 10 years. 10 years. Uh, a lot's changed since we published that book 10 years ago.
There has, and I, I remember. When I first met you, you were a fairly accomplished power lifter.
I was definitely having fun power lifting. I fell into that by accident and because I was just trying to take better care of my own health, I started lifting weights and then it turned out I was really good at it. I got really strong really quickly, and that really is what led me into learning diabetes science on my own. 'cause there were so little. He's got something back there.
No, I, I was going through some old the archives and things in my office, so we used to have an organization called the Diabetes Exercise and Sports Association, and I, I was proud to edit our journal called The Challenge and find that addition there is... Anyway, while I'm looking for that, Egils, tell us a little about this. Egils Bogdanovics, MD: Yeah, sure, sure, sure.
Egils Bogdanovich. I'm, uh, I've had diabetes for about 42 years and this, uh, this is plan B. I, I started after school going through officer candidate school, and I wanted to fly fighter planes. And literally a month before Pensacola, I lost 30 pounds in a couple weeks. Was diagnosed with type one. You know, plan B was to become an endocrinologist, and that's what I do now, and been doing this for a number of years and loving, uh, loving seeing type ones.
I, I learned something from, from every single one that I see. And just like Ginger, I, I am big, big MDI as long as you're using CGM I'm a big MDI proponent, although, you know, all honesty, I've tried everything. Usually it's like a pump that says, not for human use, that I get off the reps. But, you know, try, I, I do have tried everything.
Yeah, for sure. I,
I found the, the,
oh, geez, how funny.
Raising the bar with Ginger Vieira,
Man, yeah, that is 20 years ago I was having fun, actually.
You look younger now.
I'm a lot slimmer. There's nothing, there's no better weight loss plan than not power lifting anymore. I lost 30 pounds in like one year, not even doing anything but walking my dog.
Okay. So I, I think a good first thing to ask you both about, I mean, I, I'm a big advocate of pump therapy for a multitude of reasons. Why? I mean, you're obviously intelligent people. You have access to a lot of resources. The latest, the greatest.
¶ Why did you choose MDI?
Why did you opt to go the MDI route? Ginger tell us.
I really love that started with your obviously intelligent people. I'm gonna start my next, every next time I see you in real life, Gary, I'm gonna start our conversation with that. You know, I used a pump for maybe five, seven years, something like that. I loved it for a little while and it really start to started to break my trust and I started to really hate it. What it does to my skin and really hate pump site failures and having it attached to me.
I did try again many years later, in my late twenties for pregnancy, I put on an Omnipod and I remember my husband being like, wow, you really like this? And within about three and a half weeks I was like, I am ripping this thing off. There's no way. And it's no offense, Omnipod, it could have been any pump. And I would've felt the same way. And he was like, yeah, that seemed too good to be true, that you were really gonna stick with this. And, um, yeah, I've been MDI ever since.
I just, if I think about it right now, having a pump attached to me all the time, I, it's like claustrophobia for me. Egils Bogdanovics, MD: I've got a, I've got a little bit of that robot, uh, feeling also when, whenever I'm, uh, pumping insulin. I, I, as I mentioned earlier, you know, CGM for everybody. That's, I've always been a CGM first. Even if you're, if you're gonna be pumping, but you know, you really, it comes down to simplicity.
You know, it's, I can go out with, with a pen in my bike, uh, you know, kit and, and ride for five hours and not worry about anything. Um, not worrying about a sight loss or, or a kink or whatever it might be. And, and you know, it, I mean, as far I've, as you know, that's personally, as far as professionally, I have no opposition to having patients on pumps. In fact, I, I encourage them if they, they wanna use it, but I, I've never had a call at 2:00 AM saying my pen broke.
And, um, so once you inject, you know it's in there. You're not worried about air bubbles, you're not worried about a kink catheter, you're not worried about any of that stuff.
You know you just cursed yourself. You are gonna get a call tonight.
Well, can I tell you, I think this podcast actually cursed me because I am not sure if I took my Lantus last night and I, I was high when I woke up, but it corrected so easily that I thought, and I don't think I've ever forgotten to take my Lantus injection in 25 years, and I, so I think you cursed me, Gary. And then I hung steady this morning, so I thought, okay, I must have taken it. Then I ate my apple and peanut butter. I took my insulin.
I spiked so quickly that I'm thinking, okay, maybe I didn't take it, but I would think I'd have ketones by now. And be 300.
My Ginger voodoo doll worked perfectly then.
Yeah, so the, the timing of this is hilarious. And then I took a little bit of Lantus right before this. I could have just created a whole disaster. That's never happened to me in 25 years though. Egils Bogdanovics, MD: So you take half the dose the next morning if you forgot it, that's your best. That's what I took was half the dose. Yeah. But yeah, we'll see. Egils Bogdanovics, MD: And you're always, yeah, it's gonna have some basal on board there.
It's not like you're pumping insulin and you just lost it three hours later. Your, your beta hydroxybutyrate is through the roof already. Yeah, it's still lingering. I know, but it then it's also Lantus, right? So it already has a shorter lifespan and like Tresiba. So yeah, I'm pretty sure I forgot. But thank you for that encouragement and that I won't die later today.
So everybody with type one needs a basal bolus type of a regimen. The basal insulin can be administered in a lot of different ways. On a pump. We have the ability to adjust the basal by time of day. It's not as easy to do that on injection therapy. So, Ginger, why did you choose Lantus as your basal, or was that thrust upon you?
¶ What made you choose your basal insulin?
I've tried the other ones. I, I've tried the other ones and I liked them at first, and then like Tresiba just became wild for me after the first month, it was so unpredictable. Lantus is the most steady for me and I know exactly when it peaks. I know that 3:00 AM is that tricky time for me.
I actually, I I have a little, um, quirky thing I do now where I take 20% of my dose at 2:30 in the afternoon and it helps me cover the evening where I was having some really stubborn highs, which someone told me they had the same thing happened during perimenopause.
I have no research to back that up, but it was really weird starting only a few months ago and, and then that allowed me to re, to only be taking 80% of my dose before bed, which eliminates for me that three to 5:00 AM risk of lows when Lantus is peaking po, you know, five hours-ish post injection. And so I know with Lantus and how I compensate for not being able to tweak basal is, I know between 8:30 and 9:30 I, if I was on a pump, I'd need a little basal boost. I am not getting that.
So I take a little, I, I fast, I practice intermittent fasting and I know that triggers for me a release of liver glucose around 8:30. So I take a tiny bolus around then.
So the, the names of the insulins you, you mentioned, we have a lot of international listeners to our podcast. Glargine is sort of the generic name for the Lantus. And the other two options are detemir and Degludec. Degludec is the most long-acting of the long-acting basal injectable insulins and Devimere believe that, that, that's Levemere, that's Novo's product was. Are, are they discontinuing it or have they... Egils Bogdanovics, MD: Yeah. They not making that anymore.
They're not making that anymore? Yeah. Yeah,
That was like water for me. Levimir was like saline for me. It did almost nothing. Egils Bogdanovics, MD: Interesting. Maybe you forgot to take it. Yeah. I was on it for about two weeks. I actually fired my healthcare team over it. This was like 15 years ago. They didn't believe me. It wasn't working, and I was like, please put me back on Lantus. And they, they fired me because I was telling them how to do their job, I guess.
So Egils, I see patients quite a bit, uh, who are on MDI and experience a significant dawn effect where their glucose rises in the early morning hours. And then with kids, we often see that rise in the evening when they're making growth hormone. So what are some of the ways you can work around that if Egils Bogdanovics, MD: Yeah. There's, there's no doubt about it.
I, you know, I was gonna say the one, one time when you really, really need a pump and MDI is not gonna do it, is to compensate for dawn phenomenon. And, you know, you could say, well, I'm going to take a little bit of this, a little bit of that. I have some patients that I, I take Tresiba as a basal, and I like it because if I, if I miss my morning dose, I could take it at nighttime that night. And go back to morning the next day and it's like keeping a bicycle wheel spinning.
It's, it's pretty smooth. But yeah, I have patients that, that aren't just even take a little bit of Lantus at bedtime. You know, sort of a funny combination to compensate for that Dawn phenomenon. But the thing about Dawn is it's not the same every day. So you really need an automated insulin delivery device to compensate for that. We've actually had some success using NPH at bedtime. I know it's kind of taboo.
Get, get away. Egils Bogdanovics, MD: No, no. But Egils Bogdanovics, MD: you know, in, in general, uh, you know, with, with insulin therapy, if you understand. You know, the pharmacokinetics and pharmacodynamics of, of a particular insulin. You could use anything. You know, I used to use NPH and regular three times a day, a reverse mix, you know, 70% regular, 30% NPH.
So even though NPH varies from day to day, like a ton, if you just got small doses a few times a day, you almost overlapping have a, have a nice basal so you know, you can make it work as long as you. As long as you are a smart diabetic.
Yeah. You know what I take to, um, not deal with down phenomenon anymore. I take metformin right before bed. It has eliminated my down phenomenon problems at 5:00 AM
So it's, it's blunting your liver's output of glucose in those early morning hours
and awesome because I exercise first thing in the morning and it was very tedious because dawn phenomenon, dawn phenomenon isn't, you know, exactly the same impact every morning, right? So I would try to get ahead of it and prevent it. And so I was playing this guessing game on top of cardio exercise and metformin has completely eliminated that for me.
The other half of the MDI is the, the bolus, the insulin to cover meals and to correct highs.
¶ What insulin do you use to bolus?
And with a pump, we do it by touching some buttons on MDI, again, the eye can stand for injection or inhalation. So what are you, what are your preferred methods for bolusing?
Want me to. Go ahead. Go ahead. Yeah, I mean, I'm talking too much, Egils Bogdanovics, MD: so, so, so I will bolus you pretty much, you know, NovoLog, Fiasp, Humalog, Lyumjev, you know, everybody makes a big deal about, you know, this is faster. This is faster. You got a few minutes here, a few minutes there. They're all. To me, they're all the same. It's just a matter of taking it early enough.
Um, but I also like to, and you've alluded to inhaled, I love using, you know, a hit of inhaled insulin to, to really correct those highs because I, I mean, I see those arrows going down pretty rapidly and you know, it's. Again, you know, it's not the plain as the pilot.
I think that, uh, you know, if you bolus early enough and, and pay attention to the trend arrows on your CGM and pay attention to what you're about to be doing, you know, the bolus, you know, with MDI can be as good as it is with, with an AID and, uh, Ginger. You have experience with the Afrezza. I'm huge fan of Afrezza, but I don't, I just got a question about this on Instagram this morning, saying how much? Yeah. 'cause I posted a photo of this really yummy gluten-free pizza I had last night.
Oh, Gary. All right. And someone messaged me and said, well, how much do you take, um, how much inhaled insulin do you take for that? And I was like, I would never rely just on inhaled insulin to cover pizza. It's. It's strong for a big like punch. Right, but pizza requires like, like a flood or something?
Yeah. You have to triple dose over time.
Oh, I mean, yeah. Egils Bogdanovics, MD: But you could take it every, you could take it every hour. I mean, it would work if you took it every hour. That's really tedious though, and would be like chasing a, trying to run with a train or something. So I do a combination for a lot of my meals, unless it's pretty simple of NovoLog and inhaled insulin and I love inhaled insulin.
It's definitely a game changer, even though I still also use NovoLog, but it just gives me more flexibility and fewer injections for sure.
Yeah. Uh, even though though I'm on a pump, I use Afrezza every Sunday morning before I play basketball. Because if I dose for breakfast with normal rapid, or ultra rapid, exactly, it's gonna make me crash while I'm playing ball. Yeah, the Afrezza is in and out so quickly I don't have to worry about it.
That's one of my favorite things about it is the, I spend a lot less time on dog walks. I walk my dogs several times a day, and I spend a lot less time preventing low's from meal boluses on board. Because of Afrezza Egils Bogdanovics, MD: The Great, the great thing about Afrezza is it almost doesn't matter how much you take because it's gonna be gone. Yeah. You know? Yeah. You, you got an hour, hour, you know, hour and a half later you're, you're, you're back to normal.
So, so it's, it's, uh, a lot less, um, detail, uh, requiring than, than, than subq. But I agree. I, I do the same thing. I do both at the same time.
How do you guys calculate your doses?
You don't have to. That's what's so great about it. I was just gonna say, you don't have to meticulously carb count with afrezza. It's more they, I think they did it themselves a real disservice by putting a number on these things, because everybody wants to know how that translates to NovoLog or Humalog. Right. And it, it doesn't. It doesn't translate. And like they say that a four is technically two and a half units of injectable insulin.
Now I would take a four for a relatively very low carb salad. I would never take two and a half units of NovoLog for a low carb salad. It doesn't translate. So instead, I think they should, I think of them as small, medium, and large. Egils Bogdanovics, MD: Yeah, blue. Blue is snack. Uh, green is sandwich, and yellow is pizza. Yellow is bam, right?
Pasta, potato, big potato. Yeah.
Plus I mean.
If you're doing Egils Bogdanovics, MD: Gary, Devil's advocate, you know, Gary, you're using Afrezza and you're, I assume you're on, on an automated insulin delivery device. Uh, you know, I mean, every time you use Afrezza you're sort of screwing up your, your pump's brain. You ever think about that? I turn off the automated part for a little while. Egils Bogdanovics, MD: All right. Okay.
Okay. I know a few people on a I systems that use it for correcting highs,
kill the brain for a few hours so it doesn't mess things up. Egils Bogdanovics, MD: Mm-hmm.
Nice. Good.
Yeah. Um, the new connected pens are another popular option for people on MDI because
¶ Have you used a connected insulin pen as part of your MDI regimen?
it offers some features of pump therapy along with, you know, the convenience and the ease of, of the injection. Either of you have experience using a connected pen. Egils Bogdanovics, MD: Yeah, well, I personally use both the InPen, uh, and the Tempo. And you know, I, I agree. I mean, if you think about it, you know, 1% of insulin users in the planet are in a pump, and the rest 99% aren't.
So, you know, we should, or they should, have the option of having all those advantages of, of, of pumping and you're, you're getting about as close as you can. You know, you've got, you forget, you, you know, I, I often like Ginger, you know, forget if I took my insulin or not. And if I look down on my Tempo and I see that I just took insulin 10 minutes ago, then I confirms that I did take my insulin. Whereas if I'm not using it, I don't know. Now a word from our sponsor.
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Yeah, so we were talking about the pens and the connected pens, but Ginger, uh, have you used a, uh, connected pen?
I haven't, because I don't like using pen needles. I don't tell anybody, Gary, but I stick a syringe.
How old do you have with pen?
I know, I think I'm just an old, old lady. I'm like, I resisted CDs. I was like, no way. I am listening to tapes forever. So that's my problem really at the core.
Fleetwood Mac and fog hat c uh, cassettes.
It was, it was a rocky. Rocky III soundtrack I had, Eye of the tiger. I wrote down all the lyrics by hand while listening. So anyway, I um, don't like pen needles. They leak and I don't trust them and I don't like having to prime them. It's all about trust for me or a lack thereof with all the tech.
I hear about the leaking 'cause the drops that come out after the needles removed, you always wonder how much was lost. I
don't that, and I don't like priming it. That's a waste. And so,
Um,, yours is held together with a rubber band. You got your syringe and your pen.
Pretty.
I love the rubber band. You know, years ago, the meter companies were all looking for ways to make out an all in one meter with the lancet, the strips, the meter, and it ended up with these big, bulky devices. I came up with my own idea using a rubber band just to link it all together. So I was thinking I'd market this. I'll sell these all in one meter adapters for $19.99. Brilliant. If you order today, I'll give you an extra one for no extra charge. Just pay the additional shipping.
Shipping fee. Egils Bogdanovics, MD: Yeah. Or get it off your cauliflower when you get it in the refrigerator. In the, uh, at store. Yeah. Yeah. Hey, Ginger, I saw that you have your pen without the cap on. Without the cap on it. Why?
Yeah, I tossed that as soon as I open it. Egils Bogdanovics, MD: Why? Why? I mean, I know some people they come in and they have the, the big cap on it and you can't fit it on there. So if you just have the little needle with the little cap on it, this still fits. And that would disrupt my rubber band system though, doctor. Egils Bogdanovics, MD: But you could still put the band around here and you only have one needle for the whole pen.
I mean, I, I go through one needle for the whole pen unless you get a tissue clot. At that point, you just change. That's interesting to hear from a doctor not changing that pen. Egils Bogdanovics, MD: Again. I do, as I say, not as I do. I appreciate you acknowledging that though, and being honest about it. I do change my syringe. Hopefully once a day, but, or when it starts to hurt, I guess.
Yeah. I've always taught people change the needle daily. Yeah. The pen, needle. How long does a, how many days does a pen needle last you, Egils? Egils Bogdanovics, MD: Well, you know, I, it, I say that I use it for the whole pen, but it never lasts the whole pen. You know, I'd say, you know, somewhere around a week and, and, you know, once in a while patients will call, they say, my pen doesn't work. I said, it works. Change the needle. And they called back and they said, yes, it works.
I mean, you know, I, I, I collect old diabetes stuff. I have a little museum of diabetes and in the old days they had the glass syringe. Of course the metal needle, you boiled both. And they had this little thing called a reamer, where after each injection it was like a little paperclip, tiny. You put it through the needle part of it to actually get that skin clot out of it. 'cause otherwise, even though you boil it would still clog it up. My Yale syringe came with a little sharpening rock.
Egils Bogdanovics, MD: Oh yeah, yeah. Sharpening stone. Absolutely right. Absolutely right. So I've got a lot of those. If you guys want to go old school and you really want to go back, really old school. Ginger, this might be for you since you don't, like...
I like to start around 1999. That's my old school.
Yeah. Well, you know the smart pens like the, like the InPen, you know, they'll do dose calculations, they'll adjust insulin on board and. They'll document the doses that are taken by, you know, there's a Bluetooth communication, so it has a lot of the benefits of, of pump therapy without having to use the pump. Egils Bogdanovics, MD: Absolutely. And the reports.
I think that technology, yeah, the reports. I think that technology is so valuable for people who need the support and the further education. Right? Like, I, like both of you. I love to study the heck outta my insulin doses. I'm not gonna let a device tell me how much to take, but, a large majority of people will learn and, and get a lot of support from that. Should I use one? Yes.
I, I may, I've been making a list of what all the potential advantages are to
¶ The Pros of using a MDI
being on MDI as opposed to pump therapy. So let me run this list by you. You can tell me what I missed. Egils Bogdanovics, MD: Really, it's the same list at all as all the disadvantages of pump therapy. We'll, we'll get to those next, but the advantages, so convenience and Egils, you, you emphasize this, just the convenience, just quick. You carry it, it's portable, it's easy. Cost is also an enormous difference.
Way more affordable.
From an insurance standpoint, you know, if you get coverage for your pump and supplies, you might still have deductibles to meet and copays, et cetera.
You know, that's actually a big part of what continued my MDI therapy in my early twenties is 'cause I did not have health insurance for about four years and there's no way I could have maintained a pump. Egils Bogdanovics, MD: Yeah. Yeah. I used to, I used to take chem strips and cut 'em into quarters, you know, quarters without insurance.
Quarter, yeah. Wow. Egils Bogdanovics, MD: But NPH was like 13 bucks a bottle back then. So you were that good with a scissor, or did you use a scalp? Egils Bogdanovics, MD: Well, you could, you could tell if it was like less than 40 or over 400, and everything in between was about the same color. It's all kind of a, you know, Moish blue. Yeah, yeah, yeah, yeah, yeah. Simplicity's another thing, you know, pump therapy is, you know, it's much more complex.
You know, you gotta learn programming and site changes and all that good stuff. Injections are just that there, or inhalations are a lot simpler. Uh, the portability, it's uh, it's easier. It's probably less stuff you have to lug with you when you travel. Yeah. The absence of adhesives and Ginger, you pointed this out as this was an issue for you when you were on a pump. You gotta use some kind of adhesive to either keep the pump or the infusion set in place.
And you don't need that when you're on an MDI plan. And then the less, fewer technical issues there is the potential if you, you know, take your needle out too soon, it's still dripping. But otherwise you don't really have technical issues with pumps and pens, whereas with syringes and pens. But with pumps, you can have all kinds of technical issues that arise. And we've known for years that the DKA risk is lower for people on injections.
'cause like you said, Egils, once you inject the long-acting insulin, even if you forget it the next day, you still have a trace of it working for quite some time. So it offers some protection against ketosis and ketoacidosis. So now anything I missed? Anything else about MDI?
That cannula pushing fluid into your body 24/7. The skin damage beyond the adhesive, right. Just the cannula sitting there. I could not stand it. It would get, so I have really sensitive skin. I have a diagnosed, like I have like the driest skin in the land kind of diagnosis. I don't even know the name of the skin type, but that's really what it means and I just can't handle it. It's so itchy all the time for me and just the damage it does.
Yeah, so lipodystrophy is another potential problem we see with pump use if the sites are not rotated properly. But the same thing can happen on injections. You know, it's not really the
It's just sitting, there sitting there for days pushing food fluid.
That's, that's in your head, that's in your brain. Ginger.
I guess so. It's one of my nightmare.
It's typically not causing damage unless it kinks cause damage.
Alright. I think it's so yucky. Egils Bogdanovics, MD: Yeah. I mean, lipo hypertrophy is a huge, well, it's not, as you mentioned, it's not just pumps, it's injections. I mean, I've got people coming in, you know, after years I finally look at their belly and I see that there's a softball to the left of the umbilicus and it's like, oh no. Yeah, and, and it, you know, because it doesn't hurt to inject there, so you just keep going back to the same, same place.
And the absorption is terrible at that point. Right? Egils Bogdanovics, MD: Oh yeah.
Yeah, yeah, yeah. I call it the candy machine effect when that happens. 'cause you, you give insulin, it doesn't absorb right away. You go high and you give more insulin and then all of it kicks in at once. It's like that candy machine where you, the wheel turns, but your candy doesn't quite fall so you hit the machine.
Is it it gets in delayed? Egils Bogdanovics, MD: Delayed.
It's delayed. And sometimes by the time the old insulin absorbs, it's not at full strength anymore.
Okay. Yeah. And you know any other, that's actually a big part of getting insurance approval for inhaled insulin is you have to tell your doctor to put in your notes that you have lipotrophy. Okay. That's like critical.
Any other advantages of MDI that I missed?
Flexibility around exercise. I think, I mean, once you figure out your AID system for exercise, but I find it way simpler to exercise without a pump.
So now I'm gonna throw at you all the reasons, I prefer pump therapy and see how you would counter these with your MDI-- the frequency
¶ Why Gary prefers pump therapy—Ginger and Egils’ responses.
of injections and inhalations. Egils Bogdanovics, MD: Hell, I mean, look at the frequency of site changes. That's the the first thing that happens when I put, I mean Omnipod or t some the use, both of 'em, you know, three days later it's like, didn't I just do this? I mean, it seems like two minutes ago I changed my pod and now it's three, three days again. So, I mean...
and the, and the tech failures, right? It's like even if you, if you don't make it three days, I feel like my pumping friends just are always having technical issues, right?
You can't deny, even if you're having to change every 48 hours. The number of needle sticks with MDI is... Egils Bogdanovics, MD: it's much, much more than that. And, and even if you, and, and sort of, you know, to, to make the argument for pumping insulin, if you're correcting highs with what I recently used in Omnipod, I might do that 11 times a day. You know, hit use CGM. I'm not gonna take out my pen and take one unit.
I'm not gonna take out my pen and take two units, you know, 11 times a day to correct those highs. So, sure. I mean, yes, we are pink cushions and acknowledging that I, I think that pump will give you better control with frequent corrections.
I mean, also I would argue personality type though, like I did, I did MDI through pregnancies and I still maintain that A1C below six without a pump and I, I will, you know, I'm, it takes me a month to go through a pen, right? You said it takes you a week. So just the difference in insulin, because I'm five foot two woman, you're a man. I will take out and take an injection of a quarter unit that I micromanage from this for the syringe.
Another reason why I like using syringes is I can pull back just a smidge. It's not even, oh...
That's and, it actually was my next item was dosing precision on a pump. I can give a 20th of a unit. Yeah. I can give 0.35, 4.1.
I can on this too. I just don't quite know if it's 0.35 or if it's
0.1. We're gonna get a molecular scale and see how much you're actually...
I have figured out that if I pull it back where it actually looks like there's nothing in it, that for me is like
almost nothing equals one quarter.
Yeah.
One knee equals two feet. You know you got all these translations you use.
I do it all the time. If I was,
but you, you gotta admit...
blood sugar in the two right before exercising, I would take what is basically a drop. Doing exactly that.
For young kids and anyone who's really sensitive to small doses, you can't beat a pump. Egils Bogdanovics, MD: You know, years ago, years ago, they showed that moms could drop up one unit accurately for their kids. Uh, yeah, that's Ginger's a mom. Yeah. Uh, with a pump, we have the opportunity to sync with an automated insulin delivery algorithm. It'll raise and lower the, the delivery if glucoses are trending out a range. We don't have that capability with MDI. How do you counter that?
I don't trust any CGM technology to be accurate enough to be dosing my insulin. Egils Bogdanovics, MD: I believe CGMs good enough for, for AID and good enough for, for using it in a non-ad adjunctive fashion. In, in MDI, I mean it sort of, sort of, yeah. As, as far as advantage of, of, of pump, we alluded to, you know, using CGM right. And for years I was telling patients that it doesn't matter how you get your insulin as long as you use a CGM.
In fact, there was a study the commissary where injection with CGM or pump with CGM was a lot better than injection with finger stick and in pump with finger stick.
But the AID folks did that. Egils Bogdanovics, MD: You're you're absolutely right. I mean, I was, I was showing pictures of this to patients and to docs saying, it doesn't matter how you get your insulin, as long as you're using a CGM. And then six years into that study, they changed the protocol to use AID and all of a sudden AID went boom right down. So that whole argument is shot. Now you, you're gonna do a lot better with an AID and CGM than injection. Ginger.
Your opinion is, is shared by a lot of people.
Yeah, but I, I think it comes down to the same thing I mentioned earlier is that there's a larger majority of people who do need AID to reach their targets. And it's like a invaluable thing for those people. And
yeah, what it allows though,
likes to micromanage everything.
They, well, they can reach that target with less micromanagement.
No, no. That's what I mean is it's necessary,
right?
For a lot of people.
People with a pump. If, since I have such a healthy diet and I'm eating junk all the time,
That's what I've heard.
I have the ability to extend my bolus delivery. So that I don't drop after the meal and then rise a few hours later. How do you deal with that on injections?
Oh, no problem. I take, I spread out my doses. Egils Bogdanovics, MD: Yeah,
That'll work. Take multiple doses over time.
Yeah. Okay.
It'll work. But it's, it'll, but it's work it.
It's more work, right. It's, I mean, it's a trade off. People ask me all the time why I'm not on a pump. It's a trade off of what kind of work and tedious things you wanna deal with. I don't wanna deal with the cost and the tech and the tech failures and the site stuff. Mm-hmm. And you know, all of that. Versus, sure. I'll take two more shots.
What about social stigma? There's a lot of people who are hesitant to give themself insulin around other people because of just the way it looks. The social stigma associated with taking shots.
Those people need to go somewhere else.,
How do you address that? Egils Bogdanovics, MD: I tell patients just it might be a, a teaching moment for everybody else. Yeah, go ahead and do it. I tell 'em to inject through their pants if they'd like, and it's been shown it doesn't increase infection rate or pull up their shirt a little bit to go into the belly or in the summer, go into the triceps region.
But if somebody, if somebody wants you to go to the bathroom and sit in a stall and take insulin that way, tell 'em, uh, take a hike and be happy you're not taking insulin. Yeah. Punch 'em in the face and then Egils Bogdanovics, MD: Yeah. That'll work though. That'll work too. I'll bail you out, gary. The vast majority of MDI folks are taking injections, not inhalations, and they do need to figure out doses for corrections and carbs and whatnot.
My pump does those calculations for me automatically, and it's only a suggestion. I mean, I can adjust it if I want, but I like the calculation and the insulin on board adjustment. So how do people on MDI deal with that?
Egils Bogdanovics, MD: Well, you use one of those smart pens then if you really, really want to know what your insulin on board, uh, is influencing your bolus and you know, for patients that are, are stacking on a regular basis, you know, taking these rage boluses because they can't wait for a couple of hours, it's probably a pretty good idea to use an app.
And to get inhaled insulin so that you don't feel the urge. Egils Bogdanovics, MD: Yeah. Yeah.
The basal, we talked a little bit about, but I, I consider the variable basal delivery to be a key benefit of pump therapy, even without automated adjustment. Being able to program in lower basal in the middle of the day for people who need less and higher in the early morning or the evening when they need more on injections. You know, there, there's some creative things we can do, but most people are just taking that flat basal rate.
24, we talked about that already, so I don't think we need to get into it much.
I mean, i, I have a little note on that is that I really, you compensate in other ways. So I believe, you know, I, I try to get my basal dose as low as I can. So that I'm never dropping during a fasted dog walk. That's kind of my gauge for I have too much basal, and again, because I'm one unit too much is a make or break for me. So there's times of the month where I go up 10% or down 10% in my dose. Um, based on...
In your case though, when you adjust your basal, it's 24 hours of adjustment for a dog walk. On a pump, we can, we can make,
It's not for the dog walk. It's not for the dog walk. The dog walk is just the indicator to me that I have a little too much basal on board. So, but then when I say you have to compensate in other ways, if I'm going down to my lower dose of nine units a day, I know I might need a little bit more insulin with some of my meals or a little bit more insulin, you know, and I mean, like, you know, the smidge on my little syringe versus. If I go up, I'm gonna need a little less, so I'm May.
I'm compensating for the lack of flexibility in my boluses. Egils Bogdanovics, MD: My, my, my approach to to, to adjusting that basal is my bedtime and my morning. You know, if I'm dropping from bedtime to morning excessively, you know, pick a number, 30, 50, whatever it might be, then, then I want to, you know, drop, drop back on, on my basal and yeah, I agreed. Ginger, you know, you know. I, I like to use, you know, people used to say 70% basal, 30% bolus.
I like to use about, you know, 60, 70% bolus and, and a, a large, a smaller amount of, of basal As little as possible.
The pumps let us make temporary adjustments to the basal for things like sports and exercise, lack of activity, illness. If you adjust the basal on injections, you're making a 24 hour plus change in your basal delivery and not just a few hours. So how do you deal with...
I have a whole book that teaches how to do it on MDI and there's notes in there on, on pumps too, but
Convenient that you had that ready.
How convenient. Hey, there's a shelf back there. It's just where it lives. Okay. But it's so doable. You just have to first get your basal insulin dose fine tuned. So again, that it's low enough. You're not dropping during fasted exercise. If you're dropping during fasted exercise. I believe you have too much basal on board. And then like I said, you compensate with boluses.
Now if I was going to eat a meal and then exercise, I need to obviously adjust the meal bolus just like I would if I was on a pump as well. And you don't have to monkey with the long acting dose once you've got it fine tuned properly.
Do you have any patients who use both a pump and MDI who alternate?
¶ Exploring the untethered insulin pump regimen
Egils Bogdanovics, MD: Yeah, you're looking at one. Um, yeah, it's, uh, every couple months, uh, and it, and, uh, you know, having said that, there's no doubt about it. You know, I give, uh, I do better when I'm on a ID um, even though I do really, really, really well on MDI, because, you know, I. Believe it or not, I think like a pancreas, Gary, you know, it, uh, you know it. If, if I'm going up, if I even, I, if I even see a trend arrow going up, I'll hit it. Exercise.
Yeah. That's, that's one thing that my church is going for a five, five hour bike ride. Uh, you know, I think that I could never figure out exactly what to do as far as insulin, Ginger, but even people without diabetes need to fuel. So my rule is 25 grams of carbs every 30 minutes. So I go through a pile of gel. Do the ride, but it, it would be easier with, uh, with a pump. But again, I'm gonna have a backpack full of pump gear supplies if I'm gonna do that.
Yeah. Endurance, endurance exercise. A a pump becomes a big game changer for sure. It's harder with, on MDI.
Yeah. Um, we have quite a few patients who will alternate between pump and they'll go on injections, let's say if they're on a, at the beach for the weekend or doing some kind of adventure outing where the cons of pump therapy just outweigh the pros. Being able to transition back and forth is great, and a lot of people don't realize that you can do that. As soon as you wake up, you can just give yourself an injection of your long-acting insulin. Stop using the pump and do boluses at meal times.
There's also an option called an untethered plan where you can combine pump and injection on the same day. Where you get enough basal to meet your low, you inject enough basal to meet your lowest basal need, and then you wear the pump perhaps at night while you need more basal. And then you, you can connect to the pump for bolusing purposes, but you can be disconnected from the pump all day on a plan like that. So I guess it's safe to say MDI, whether it's with afrezza or injected insulin.
¶ Closing thoughts
Pump therapy-- AID Automated systems. These are all tools at our disposal. And everyone's gonna have their own unique advantages and disadvantages associated with these different tools, and it's in everyone's best interest to learn how they can benefit from these. If your healthcare team isn't teaching you about them or sharing information about them, seek it out on your own. 'cause clearly different systems work best for different people.
I'm a, I'm a big fan of pump therapy and, and the AID systems. I think work great, but they're not at, they're not advantageous for everybody. Some people do better on MDI for a variety of reasons and encourage 'em to do that if that's gonna meet their needs. The best. Uh, either of you have like a closing summary statement you want... Egils Bogdanovics, MD: You just, you just used people like five times and, and that's the key.
People with diabetes are people, and there's an amount of technology for everybody, and what works for one person may not work for the other. But as far as you know, last words, I I, I, I tell my patients now, I don't know if I'm jumping the gun, but I tell 'em, you know, take care of those kidneys, take care of those eyes because we're gonna have a cure in your lifetime.
I echo the same, I do a lot of writing about cure research for a few places, and I feel very hopeful about the same thing. It's definitely, I will say, so I've, I have. Jokingly, but I'm not joking, said that I'll sign up for an insulin pump when it is implantable and I'm actually getting an the implantable ever since next month. I just got insurance approval, had to fight for it for a couple months, but I'm excited about that.
It has interoperability designation now, so we may see it in an AID system before too long.
Yeah, I hope.
All right. Well, I wanna thank both of you for joining in today. I, I hope I didn't insult you or lose your friendships over this now. I respect what you're, I believe me, I respect what you're doing. You got good reasons behind what you do, and, and I, I respect that. So thanks again. Thanks for tuning in to Think Like a Pancreas, the podcast. If you enjoyed today's episode, don't forget to like, follow, or subscribe on your favorite podcast app. Think like a pancreas.
The podcast is brought to you by Integrated Diabetes Services where experience meets expertise, passion meets compassion, and diabetes care is personal because we live it too. Our team of clinicians all living with type one diabetes understands the challenges firsthand. We're here to help no matter where you are in the world. From glucose management to self-care strategies, the latest tech, sports, and exercise, weight loss, type one pregnancy and emotional well-being. We've got you covered.
We offer consultations in English and Spanish via phone, video, chat, email and text. Wanna learn more? Visit integrateddiabetes.com or email info@integrateddiabetes.com to schedule a consultation. On behalf of Think Like a Pancreas, the podcast. I'm Gary Scheiner, wishing you a fantastic week ahead. And don't forget to think like a pancreas.