Pumps, Pens or Shots? What's Best for Diabetes Control to Lower A1c?
Pumps VS Injections for Diabetes Control
Hello my friends, I hope you are doing well. This article is bit personal because I am attaching my Dexcom CGM reports. Even as a Diabetes Educator and a Registered Dietitian Nutritionist, I still feel pressure as I share my blood sugar reports. I don't think that will ever go away; it's apart of being human.
Everyday we have to work on our diabetes. Everyday we learn something new. Everyday we decide to do the menial tasks to keep our blood sugars in check. I get it. I'm coming up on 25 years of diabetes in a couple short months.
A couple weeks before I was diagnosed with diabetes.
Diabetes is tough, don't get me wrong, and some days, it's REALLY tough, but in a odd way, I am grateful for my diabetes.
Diabetes has shaped me into a very empathetic person and has led me to a career as a health provider and educator where I have been able to interact with many wonderful and empowering individuals (such as yourself).
We as humans, all have hardships. These hardships are what allows us to connect with each other. I may have diabetes, but my neighbor may have high anxiety, depression, or maybe even cancer. We all have hardships, but such hardships can cause us to become more perceptive and caring people because of the level of understanding that comes from having hardships.
I apologize for the tangent, but I do feel it's important to try to see the light when sometimes life appears dim. If you look up diabetes on the internet, you are not going to find people consistently talking about how blissful it is. However, if we can try to see some good from it, it makes life a little brighter.
Okay, back to the reports...
Comparing Blood Sugar: Insulin Pump VS Shots
Below are 2 graphs to compare my blood sugar during times when I was on the Tandem Insulin Pump (first graph) vs times I was using Multiple Daily Injections (second graph), which I am still currently using.
As a T1D who is a Registered Dietitian Nutritionist and a Certified Diabetes Educator, I try to run a pretty tight ship when it comes to my diabetes management. However, that doesn't mean I do not enjoy baking occasional triple chocolate chunk brownies with my 3 year old son or indulging in a big bowl of popcorn with my husband as we watch a movie.
I will say that through a lot of trial and error, education, and experience, I have learned how to dose for such treat times.
It's about balance. Below is my 6 hour Dexcom graph after eating a giant bowl of popcorn with sliced bananas (my favorite odd treat) along with a little chunk of 70% dark chocolate.
It's about eating healthy the majority of the time, exercising as you are able and consistently, but then eating occasional treats, enjoying those treats, and trying your best to dose accordingly.
It's not about being perfect, it's about balance and continually learning from your experiences.😀
When my son and I made snowman cookies. We like to bake treats on the weekends. 😊
Back to the reports ♡♡♡
Reasons to Switch from Insulin Pump to Shots
So, I absolutely LOVE the Basal IQ software with the T-Slim X2 pump. However, I was having a lot of issues with my infusion sets.
During the last days before switching to MDI, I was having to change my site anywhere from 1-3X a day. It was quite frustrating.
I would change a infusion set, it would work well at first, but then I'd find myself always having issues with my insulin absorption, and wondering how long this site was going to last.
At the end of my pump days, I decided to try a new experiment by using Tresiba (long-acting) and Fiasp (ultra short-acting) instead of my pump. I was already using Fiasp in my pump, so that wasn't a change, but to stop using a pump when I had been on a pump for the last 15 years to go back to shots was a BIG change. At this point though, I was frustrated with the number of site changes and ready for something that worked.
I had tried MDI in the recent past, but only for about a week and got frustrated because I wasn't getting a great response with my insulin through the use of pens. However, this time I was planning to go completely old-school... Not pens, but syringes.
Yes, syringes. And guess what, those syringes work pretty well.
Through personal experience I have found...
SYRINGES = Great Absorption, not convenient.
PROS: You take a shot and know that insulin will work (unless your insulin is past expiration).
CONS: It is not convenient because you have to take insulin and your syringes everywhere you go. Also, you can easily misplace your insulin vial and shots. However, most annoying is taking a shot in public (not exactly socially acceptable). You may get a couple stares if you forgo going to the restroom for your injection and whip out a needle and inject while waiting for your food. Been there. Done that. 😅
However, personally I feel the pros outweigh the cons because of how reliable the insulin is when it comes to absorption.
PENS = Less Reliable, may require larger doses to reach target blood sugar. More convenient.
PROS: Pens are easy to shuttle around and they aren't nearly as odd looking compared to the old syringe and vial, especially with pens that actually look like pens.
CONS: With my personal experience, and what I have seen from working at the Endo clinic, those who are more sensitive to insulin may need to increase their insulin doses compared to what they would use on a pump or with syringes. There are many reasons for this. Due to this, I always felt that I was guessing the amount I needed. You already have to guesstimate when calculating total carbs in a meal, I don't want to guesstimate my insulin dose, too!
Guess + Estimate = Guesstimate
I promise it's a word, and it's a very relevant one when it comes to managing diabetes! 🤣
PUMPS = Quite Reliable for most, not all. Very Convenient. Allows for ultra fine-tuning.
PUMP PROS: Pumps are a very convenient way to bolus before a meal via standard, dual-wave, or extended. Also you can greatly fine-tune basals, carb ratios and correction factors throughout the day in order to compensate for dawn phenomenon, your work life, your eating habits which may also change depending on of it it's weekday, weekend, you're stressed at work or stressed from a upcoming family reunion. 😬
With a pump, you can turn off your pump and suspend all insulin, you can set temp basals if you are sick (increased temp basal) or if you have been exercising more than usual (decreased temp basal), etc, etc. If you ate a high fat chicken alfredo pasta meal, you can do a a dual wave bolus, or add a increased temp for the hours following the meal in order to avoid your blood sugar slowly (and stubbornly) rising.
I want to add, I am a certified pump trainer with the major insulin pumps (Tandem, Omnipod, Medtronic). Therefore, I am well-educated and involved in the pump community. I really do love pumps and appreciate the many features that are not accessible through MDI such as personalized basal, temp basals, personalized carb ratios and correction factors, extended boluses, etc. Being a Tandem pump user, I especially appreciate the Basal IQ especially as a mother, however, at this time in my life, I am loving the reliability of MDI by using Tresiba and Fiasp.
Also, there are some really neat software available and coming out soon for all pumps relating to CGMs.
There is the Basal IQ for the Tandem T-Slim X2 pump to decrease low blood sugar, and there will soon be software called Basal Control to decrease high blood sugar with the T-Slim X2 pump.
There is the 670G Medtronic closed loop system which delivers micro-boluses as your basal when you use the 670G pump and the Guardian Medtronic CGM combined. An algorithm is used every 5 minutes to calculate the amount of micro-bolus needed to bring your blood sugar back to 120 mg/dL (the set blood sugar target with this system).
Lastly, the Omnipod is soon releasing a looping system linked with Dexcom which will have a closed loop system somewhat similar to Medtronic. Just recently, the Omnipod has released it's new PDM called the DASH, which contains the Calorie King app. This app allows you to carb count on your PDM, then your DASH PDM uses the total number of carbs from your meal and your personal setting to give you an exact number to bring your back to target.
PUMP CONS: For a select few, you may have infusion set issues which can cause issues with your insulin absorption. You are at higher risk for malabsorption the longer you have been using a pump and if you are not great about rotating your sites.
You can get a bad infusion set or a clog which can suspend insulin and result in high blood sugar, possibly a hospital visit due to Diabetic Ketoacidosis (DKA). Lastly, you have to wear it so it can get in the way, especially during exercise or sleep.
Back in the day before I was educated on a nutritious diet and workout routine, I was taking about 40 - 45 units a day as my total daily dose (TDD).
Due to my nutrition and exercise routine, I dropped that amount down to about 30 units total on my pump, with about 18 units of that as basal.
With MDI, I am down to about 20 - 22 units total, and use about 8.5 units of Tresiba as my long-acting. These amounts are achieved while eating carbohydrates. I absolutely love fruit and popcorn, but I understand that the diet needs to be highly individualized to the person with diabetes.
How to Not Waste Insulin on MDI
Maybe the idea of switching to MDI seems alluring to you because you have issues with your pump sites, but you are concerned because you seem to waste so much insulin.
To combat this, especially since I only use about 10 - 15 units of short acting a day and only 8 - 9 units of long acting, I actually use pens. However, I use pens as vials.
Let me explain.
I take the Fiasp pen around with me, but draw insulin out of the pen as if it was a vial. Since I only use 10 - 15 units of short-acting a day, I would never be able to use a full vial in 28 days because it contains 1000 units. There are only 250 units in a pen, which I can use in 28 days.
My point. This system is a bit odd, but it works well for my blood sugars, it has reduced insulin waste, and it is more affordable.
Now that I have you thinking of the possibilities, what do you think would be the best insulin delivery plan for you?
A pump? Pens? Syringes? Maybe pens, but with syringes. Your insulin delivery plan should be based on your insulin needs, your body's insulin absorption with infusion sets, your nutrition, your exercise routine, etc, etc. It all depends on you!
Years ago, I would take closer to about 45 total units a day, but due to education on proper nutrition and exercise, I have more than cut this amount in half. There is a lot of power in the proper nutrition and exercise routine for everyone, but especially for those with diabetes.
There are 4 major contributors when it comes to managing diabetes.
3. Insulin Delivery (pumps, pens, syringes, medication)
4. Continuous Glucose Monitor
The first three are varied and can be greatly customized to the patient, but a CGM is an absolute game changer. No matter what you do for nutrition, exercise, and your insulin delivery, there is so much power in knowing your blood sugar every 5 min by using a CGM.
There are 3 CGMs on the market. I am not affiliated with any of them, and I respect and appreciate each CGM. However each have their own set of pros and cons. Below is a brief summary of the pros and cons of each CGM.
Abbott Freestyle CGM
($74 x 2) + $93 = $241 (first month)
$148/month after first month
$74 for each 14 Day sensor (= $148 a month)
$93 for a reader, but you only have to purchase once
Freestyle CGMs are great for those with diabetes who are not insulin dependent (AKA: mostly people with Type 2).
Switching over to a system that is easier to share data with providers and to use yourself to see trends
Sensor lasts 14 days
No calibrations needed
No alerts for high or low blood sugar
No Bluetooth capability for sharing
Sensor may pop off
Medtronic Guardian CGM
Medtronic CGM Pros
Allows you to use 670G closed loop system
Comes with Sugar IQ app which allows you to better analyze your trends (only with iPhone)
Has high and low alerts
Medtronic CGM Cons
No Bluetooth capability for sharing (may come out soon though)
Only FDA approved for 7 days
Expensive out-of-pocket (if insurance doesn't help)
Requires 2 calibrations (without 670G pump use)
Can be difficult to access data
Dexcom G6 CGM
Dexcom CGM Pros
No calibrations. Only test if you feel the Dexcom is off
FDA approved for 10 days (less than Abbott but more than Medtronic)
Easy to restart a sensor to get more days
Alerts for high and low blood sugar
Bluetooth sharing (so loved ones can see your blood sugar)
Currently is integrated with T-Slim X2 (Basal IQ)
Easy to share data with providers and to check trends yourself to better manage diabetes through Dexcom Clarity
Dexcom CGM Cons
Expensive out-of-pocket (if insurance doesn't help)
A new implantable CGM that you can use for 90 days by a company called Eversense is coming out soon. Stay tuned!
BOTTOM LINE: There are a lot of options and room for customization when it comes to your nutrition, exercise, and insulin delivery strategy based on your needs, BUT in my experience, using a CGM should be a high priority. It is a total game changer when it comes to better managing your diabetes. A CGM not only gives you a blood glucose every 5 minutes, but a trending arrow to tell you where your blood sugar is projected to go.
It allows you to be proactive. Let's say your blood sugar is 110 mg/dL but with 2 arrows down? You would eat something before you crash.
What if you are 125 mg/dL but 2 arrows up? I would probably do a short aerobic activity to serve as a catalyst for the insulin already in my body.
Knowledge is power my friend.
TAKEAWAY: You need to do what is best for you! Even if it is not the standard protocol. Maybe that's a pump, maybe it's using pens, maybe it's old school syringes. Maybe it's pens, but you use the pens as a vial because you do not need very much insulin.
I do feel strongly about CGMs, but you need a treatment that is individualized to your needs. Every person with diabetes is different, therefore every person with diabetes should have a customized treatment plan.
Finally, I write articles to educate and empower people with diabetes. However, if you feel that you are lost, burnt out, or just want to fine-tune your diabetes management, send me an email. We'll talk through all your questions and concerns regarding your diabetes and health goals.
As a Certified Diabetes Educator, a Registered Dietitian Nutritionist, and a T1D, I have been trained and have the personal experience to help you manage your diabetes and help you find balance.
My goal is to teach you how to eat, exercise, and give insulin so you can have flat-line CGM graphs while empowering you to be able to manage your own diabetes. After working together, you will feel much more confident in making your own adjustments in order to reach your target blood sugar, weight loss, and A1c goals.
If you want to learn about proper nutrition, how to normalize blood sugar during and after workouts, or why your blood sugar is spiking and dropping throughout the day. Don't hesitate. Sign up with me for a Kickstart Call and we will talk for 30 min to figure out a game plan to customize your diabetes treatment plan, or you can go ahead and sign up for a program through my website.
For 5% off any program use Promo: T1D5
Every person with diabetes is different, therefore every treatment plan should be individualized.
I'm here for you and I sincerely care about your health and diabetes. I understand what you are going through and am here to help.
Your fellow T1D,
Ariel Warren, RD, CDE, T1D