Life with a First Generation Artificial PancreasFriday, November 25, 2011
Anna Presswell has been using Medtronic’s MiniMed Paradigm Veo insulin pump system for almost two years, and she attributes the Veo’s usage in helping her avoid hypoglycemic episodes, improving her average A1c readings, and giving her a better overall quality of life.
By: John Parkinson, Clinical Content Coordinator, DiabetesCare.net
Possibly one of the most important concepts within the artificial pancreas research realm is the idea that patients using this technology will be able to stay within an acceptable glucose range and not suffer hypo- or hyperglycemic episodes as frequently and having to contend with neither acute health safety issues in the near-term or be as concerned about developing complications in the long-term.
Aaron Kowalski, PhD, assistant vice president of treatment therapies at JDRF, has said that findings thus far show an insulin pump and continuous glucose monitor (CGM) used in concert outperform people with the best management plans in place and who are fastidious about their diabetes care. For example, he points to teens who are self-monitoring their glucose and using some of the best clinics in the U.S., and yet, they still spend several hours every single day outside acceptable glucose ranges. Read the article here where Dr. Kowalski talks about studies related to glucose control and people versus technology in montioring.
Dr. Kowalski says the first phase or generation of the artificial pancreas already exists in the marketplace, and that this first generation artificial pancreas technology addresses these highs and lows with a low glucose suspend (LGS) feature.
Specifically, Dr. Kowalski is speaking of Medtronic`s MiniMed Paradigm Veo, the world’s first LGS insulin pump system, which works with CGMs. The Veo has the ability to suspend insulin upon reaching a predetermined threshold set up by the individual person for up to two hours--if needed--for a PWD who is unresponsive to alerts, whether he or she is hypounaware, is disoriented due to a hypoglycemic episode, or has nocturnal hypogylcemia and sleeps through the alerts.
Although the Veo (a closeup, pictured lower right) is not available in the United States, Medtronic, an international medical device company with a business unit that specializes in diabetes-related technologies, was recently granted approval by the U.S. Food and Drug Administration for an in-home study using its LGS feature in its Paradigm insulin pump system. As such, DiabetesCare.net wanted to speak with a person with first-hand knowledge of the product as an enduser.
Anna Presswell (pictured, above) has been using the Veo for nearly two years. While she is a youthful 29 years old, she is a hardened diabetes veteran too. Presswell has had type 1 diabetes for 25 years. She has withstood the battles and dealt with all the anxieties associated with the condition, including taking multiple daily injections, constant vigilance, and perpetual worries about eating the right things and exercising. Presswell blogs about her diabetes experiences and her blog site can found here.
Presswell lives in Great Britain, and serendipitous timing led to her being eligible for both Medtronic’s Veo as well as the company`s Enlite CGM. Presswell notes that the insulin pump technology, and even more so, CGMs, are rarely used there. Presswell had never used any insulin pump before the Veo, despite having diabetes for so many years. She says there is a process to securing these technologies, even with socialized medicine being practiced there.
DiabetesCare.net spoke with Presswell about securing the Veo, the benefits of having an LGS feature, and how it has affected her diabetes self-care management.
DiabetesCare.net: Why did you and your physician decide to start using the Veo?
Presswell: We decided to use an insulin pump since I had a raised A1c for quite a few years, and no matter what type of insulin I had used or eating and diets I tried, I could never get my A1c into target range. Obviously having had diabetes for so many years, I was coming into a time with the disease where I was at risk for serious complications, so we decided to try using a pump.
I’m not sure if I would have had a choice of pumps. Things are slightly different here in the U.K. The National Health Service (NHS) is the government’s arm of taking care of medicine here, and you don’t just get a pump because you want one; you have to fit into various categories. One of those categories is that you have to have a high A1c. I happened to be given the Veo purely by chance.
However, what interested me about the Veo before I was actually going to get one, was the ability to link it to continuous glucose monitoring. That is something we rarely have here; it is difficult to get funding from the NHS. The CGM was not something I had come across before, and I was taken aback by it that you could even think about monitoring your blood glucose.
DiabetesCare.net: So in Great Britain, CGMs are a rarity?
Presswell: Very much so, and insulin pumps are as well. We have about 3.5 percent of people here with type 1 diabetes who are using them. They are getting more popular now and people are starting to really push it for their children.
With insulin pumps, even though not a lot of people are on them, you can get them funded by the National Health Service--if you fit the criteria. Whereas, with the continuous glucose monitoring, there are no loopholes in the system at all. A very few select people have been lucky to apply for CGMs with their practitioners, while most other people have received a flat out no response for them. I am in the process of trying to get funding for one now.
DiabetesCare.net: Are you using a CGM with your insulin pump?
Presswell: I was very lucky because I write a blog and Medtronic had picked up on something I wrote about them. Medtronic contacted me and invited me to participate in their trial using the Enlite sensor they had. This was right around the time I had hit my target A1c, and that is why I’m such a fan of CGM. I appreciate the value of it.
DiabetesCare.net: You had mentioned one of the reasons for starting on the insulin pump was because you could not get into a target range for your glucose. What was your average A1c prior to using the Veo and subsequently after you went on the pump?
Presswell: Prior to getting the pump, my best A1c that I had achieved in my adult life with regular monitoring and multiple injections was 9.6. It was not as bad as some you might hear about, but when you are trying your absolute best, and you are still 2.6 behind the upper bracket where you should be, it was very frustrating.
Within five months of getting the pump, I had decreased to 8.2. My last A1c which was done about five months ago was 7. It was the first time in my adult life I had reached my target. You can imagine that was a pretty good day.
I have also been able to relax a bit more in my diabetes management, including eating more like a normal person.
I will be interested to see what my next A1c will be because I was involved in a trial using the CGM. I managed to make the sensors last a little bit longer each time about 7 or 8 weeks. I was doing everything in conjunction with each other in order to get the best results.
DiabetesCare.net: One of the benefits is the decreased average A1c. What are some of the other benefits of having the Veo and a LGS feature?
Presswell: One of the other main benefits is that I found exercise to be a lot simpler to manage. When I was on daily multiple injections, I would swing from high to very low quickly. Now I know a lot more about why that is occurring, but even when you know with multiple daily injections you can’t manage that quite as easily.
With the insulin pump, when you know you are doing a really strenuous bout of exercise, you can take a couple of extra units beforehand; if you know they are going to drop, you can decrease your basal rates. You feel like you are more in control. You feel like you are managing much more effectively, particularly when you are in target range.
It has also just allowed me to relax about my own condition. I don’t worry about complications anymore because I have daily consistency, which I never had before.
I’m also able to spot when something is going wrong like when I`m getting sick or if I need to change cannulas because my blood sugars are so well-managed the rest of the time. I now can tell if I’m high for a few days, then something is going on. When I was on injections, I had no idea, because I would be swinging from 450 down to 30 or 40. Just having that consistency has done a lot for my attitude of dealing with this condition and thinking about it and made me feel more like I have a normal life.
DiabetesCare.net: Have you experienced any specific issues with hypoglycemia?
Presswell: I have had it and it has been much, much more rare now. I can remember waking up in the middle of the night and remember thinking I couldn’t believe how high or low my blood sugar was. I still do get hypoglycemia and hyperglycemia occasionally, but a lot of that can be if I have done something that messes with my calculations like going out to dinner with friends.
Overall, I seem to get less hypos, and when I do get them, I catch them a lot earlier like when I’m in the 70s and I’m just dipping below where I should be. They used to catch me by surprise and they used to get much lower than that.
I don’t have children myself, but from the perspective of a parent, when a child goes low and the pump system is able to suspend glucose, that is hugely reassuring or the same could be applied for anyone who is hypounaware.
DiabetesCare.net: What are the considerations for people when weighing to using this system versus another system?
Presswell: In talking to people who have used other pumps, it is the really small things when you using an insulin pump. Some of the other pumps give the bolus very quickly, and I have seen people do it and could not believe how fast it is delivered. After about a day or so, they say it gets quite painful.
The Veo delivers insulin very slowly. If I measure about 6 units, it will take approximately 2 to 3 minutes for it to be delivered, and I don’t even notice it going in. My injection sites never get painful.
One of the drawbacks has been the lift screen and if you happen to use it in the middle of the night, and press a certain button, you get trapped in the menu and you have to wait about 20 seconds and then the menu counsels itself to try and get the right button. It might be good to have a button light up the screen to see what you are doing. For anyone who has suffered visual damage from having diabetes for so long, having a screen which is a bit difficult to see, might be a challenge.
Still, if I had the option of using a different pump, I would stick with the Veo every time.
DiabetesCare.net: How has this system improved your quality of life?
Presswell: It has done so dramatically because of the A1c. I was someone who was very, very concerned about the damage that was going on in my body and I felt out of control as well. For me, getting my blood sugar range within target, with what felt like less effort, has been a huge thing. And it is not just me, for my husband, family, and friends--people saw me worrying all the time. We can just enjoy social situations without me testing or worrying about my blood sugars going high or feeling awful because of them.
Being able to go out and eat food with my friends is another. There used to be certain types of foods that while on injections, I could never master the right balance and within a couple of months being on the pump, I was able to enjoy going out again. The Veo offers another way of delivering the insulin, I was able to give a bigger bolus over a longer period of time. It sounds so silly but being able to go out and drinking and eating with friends without worrying about what is going on all the time is fantastic. It has given me a much more normal life.