"New" to Omnipod and Pumping: 4 years in and I feel like I'm missing something

Tips, Tech & Gear Pump
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I am new here and still feel new to pumping…but it’s been FOUR years. I felt very capable on MDI and did that for seven years until I ended up pre-DKA in the hospital because my new pharmacy was letting insulin pens sit outside of the fridge for hours/days. So I switched to the pump, betting that pharmacies would do a better job of handling insulin vials instead.

I worked with the awesome team at Integrated Diabetes Services to get my basals set four years ago. I’ve been consulting with them again this year, but I want to start being able to manage my basal adjustments on my own.

Also, site rotation? Adhesive reactions? Scar tissue? So, so many questions. My upper left arm is most reliable. My upper right arm is more persnickety. IDS told me to not use my stomach since I get blood/pooling/bruising there. I’ve ordered dresses (I live in jeans) so that I can start trying my low back and thighs.

In other words…any and all tips and tricks are welcome! My A1C needs help…I’m 2% higher on the pump than what I achieved on MDI. And I feel yucky because of it.

Thanks in advance!!!

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Hi Allison.
There is a lot of difference in pump use. It has benefits and disadvantages. We can discuss that sometime if you think it is worth looking at.

BTW, I don’t think letting pens sit outside the fridge is an issue. (see ==> my car-baked insulin experiment)

A few of the big advantages of pumps are ease of bolusing, records of all the boluses, and adjustable basal rates. One of the big disadvantages are quirks in absorption from sites.

  1. Let’s start with absorption issues. I found that sometimes on day 3, my site didn’t work as well as the first few days. Nobody told me that was a possibility. Just tough learning. So perhaps one of the first thiungs to examine is if you have issues as the site as been in use for a few days. Works great first day, not as well the second day, worse the third day. Just see if that is an issue. Take notes and try to look at that.

  2. Next - what insulin are you using? You may hear from an endo that they all work the same. The reason they say that is because…most endos have never actually used insulin. :smiley: I think Humalog is great for MDI, but I won’t use it in my pump anymore. It wasn’t as stable as NovoLog. But that’s just me. Some people have issues with stability with Apidra. Just something to consider - the type of insulin. (I think @TravelingOn tried Novolog recently for that reason. Testify, Kim!)

  3. Third - the pump trainers always start your basal lower than you should be. Safety concerns and all of that. If you are running higher - 2% is pretty significant - than perhaps your basal numbers need to be figured out. Is your BG higher in the day or night? Are your basal rates the same all of the time? Let’s fix your basal.

  4. Fourth - different sites with the pump. You need enough real estate to be able to rotate. Back? Upper back between neck and shoulder? Chest? Upper thighs (like near your pant pocket? Calves? All over your arm, like near your arm pit, your forearms, etc. 1) You have to be creative. 2) And since different sites may absorb differently, you need to take notes on sites.

Initial things to focus on would be making sure your basal is set correctly, and seeing if you have a “day 3” issue, and possibly trying a different insulin to fix that.

Questions? Fire away.

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Welcome and what a great first post!

My son is a diabetic (currently 15) who was diagnosed about 2.5 years ago during Christmas break from school. What an amazing Christmas present, NOT!

For us, the pump has been amazing because eating in a structured way is a horrible restriction to a growing teenager, so being able to bolus for what you eat, and then bolus for dessert when you are still hungry has been a godsend. Additionally, being able to postpone or skip meals without crashing is really nice.

Anyway, making the best of things. We frequently titrate my son’s basal settings and change some part of them about once per month. The best way to work on basal is to skip a meal once in a while and see what happens. We break the day into three periods - Waking to Lunch; Lunch to Bedtime; and Bedtime to Waking. Sorry about using super scientific terms :wink:

Then skip a meal and see if you stay flat. If you go up, increase your basal, if you go down, decrease your basal. It isn’t much harder than that.

Do you have a CGM? If not, you may want to get one even for just a few months to help with this endeavor. The CGM has changed our life. Sorry about paying off the pilot training, I took the easy way out and got a commercial instrument rotary via the Army plan. Lots of fun and much cheaper, plus 100 touchdown autorotations can’t be beat for actual training.

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This is just a quick reply before I head out to class, but I have lots of experience with adhesive and site reactions (specifically allergic reactions). It takes a lot of trial and error to find out what you react to and what you don’t. But I’ve found a good combination is Cavilon cream under the site, inserting once that dries, metal sets for me because I react horribly to plastic, Hypafix tape on top because I react to others, and putting some Benadryl cream and sometimes Polysporin on the site after removal all help. I also change sites minimum every two days but sooner if I feel any irritation or my blood sugar isn’t responding to a couple pump corrections. I also find taking a daily antihistamine helpful, although I’ve had to stop that for the past few days and have been surprised at how functional I’ve been without it (I thought I’d be barely functional!).

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Thank you to everyone for your input, guidance and ideas.

  1. I’m basal testing like crazy. Every single night acts differently which is frustrating. I’m in the right ballpark overnight, but every night behaves differently. My 4PM - midnight is set well (knock on wood). I think it takes so much insulin in the morning to recover from whichever randomly timed spike that I get in the morning hours that it throws off both breakfast and lunch. I feel like I’m fasting the whole morning waiting for it to come down.
  2. I’ve apparently been waiting out highs so much of the time that I’ve lost 10 badly needed pounds. This is making site issues worse as I’m already a tall beanpole.
  3. I’ve started with the freshest vial of Humalog I have with a site change tonight. I’m calling the endo’s office tomorrow to inquire about a sample of Novolog to try.
  4. I’m a 34 year old female which means that week 1 of my cycle runs low (except lately when everything is high), week 2 is stable, week 3 is insane due to ovulation hormones, and week 4 is just sluggish. I hate carrying an extra 40% basal waiting for my basal needs to go to -10% in a 24 hour timeframe from week 4 to week 1. I’m looking into trying birth control to dampen these swings. These swings make basal testing seem frivolous any week other than in week 2.
  5. I’ve noticed in the last week that which day of the pod determines my effectiveness. My blood sugar binder notes Day of Pod, Day of Cycle, work day or weekend day. You’d think this amount of info and mindfulness would make this solvable??

I’m hungry. I’m exhausted. I’m skinny. I’m trying a new pod tonight with Flonase on the skin first. I tried Benadryl under the last pod and that seemed an improvement.

Is it normal to have liquid in the Omnipod viewing window at pod change? I’m assuming that was insulin due to absorption issues. At least there wasn’t blood in this one!

Do other people have pod issues after sleeping on it? I can’t sleep on the pod on my stomach or else the whole set-up starts bruising and bleeding. And that’s placing it in the fattiest area I have.

Once again, thanks for your help!

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Sweat and condensation can be in there. When you remove a pod, try to look and see if the cannula is still in the skin. If it is, probably not a concern. Also, you should be able to smell if it is insulin.

I am not sure what this means, can you clarify? Are you seeing a difference in day 1 vs day 3? If so, getting the script written for a 2 day change can help.

Can you share your basal profiles? Like what time segments you use? I need more at night, so mine ramps up and gets to the highest amount at 4am, and then comes down until when I wake up. If you are frequently waking high, sounds like more basal at some point in the night would help.

This part is outside of my wheelhouse. @Jen might be able to share some insights.

But as a general comment - it is much easier to fix a problem that comes from too much basal than it is to fix a problem from too little basal. Too much basal can be fixed with a bite of cookie and 15 minutes. Too little basal takes hours to fix. Just a general rule I follow is to be aggressive with the basal amounts. Basal is the foundation of the house, so make it solid and strong.

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When you say waiting it out, are you not eating because you are high? If so, stop this behavior. We don’t eat high carb when we are high, but, a big vegetable and sausage omelet is just fine. We don’t have the luxury of waiting to eat, my high schooler’s schedule is unrelenting. Eating when high, exercising when moderately high all happens. We just don’t have a milkshake when high…

When I say skip a meal, I mean like once or twice a week, followed by a great meal once the waiting is over.

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Hi @T1Allison! Welcome!

My partner EH has T1, and recently switched from Humalog and Lantus/Tujeo/Triseba (we tried them all) to the OmniPod. Lots of stuff to love about it (suspending basal for exercise, for example) but many knobs to fine tune. We are also still trying to figure it out.

We’ve found our endo and CDE to be somewhat useless in the struggle to dial it in, honestly. And EH just goes for it when it comes to making basal adjustments on his own.

@Eric is super helpful (and probably why EH has been willing to try pumping from an adequate run using MDI for 10 years). Switching from Humalog to NovoLog has made the biggest difference with the pump. We used Humalog from November until March and it sucked. Regularly not working well past day 2 with Humalog. Awful, prolonged highs which we didn’t catch as a pump failure because it never threw an occlusion alarm. NovoLog has majorly reduced that issue. Also, we’ve asked for a site change every two days. And we second @Eric’s advice to use plenty of body real estate - I hear his voice in my head chanting “if you can pinch an inch!” all the time (well, about every two or three days when I help EH stick a pod somewhere hard to reach). Also, we’ve recently done heat baked desert backpacking with no insulation on the insulin and it worked fine. It was rather fresh NovoLog but it worked and it was above 86° and stored in a backpack/not refrigerated. YDMV of course.

Great advice has come from here on this forum.

@Chris and @Aaron and @Millz and @Beacher have had great podding suggestions. Two days and change, locations to try, noticing if you skyrocket and being willing to pull it and start again, smelling insulin suggests a leak, bolusing upon application and never bolusing more than 5 or so units at one time. NovoLog! Do it! Also, eat! I agree with @Chris - lower carb can make the results easier. And if you think that the high won’t abate, try brisk exercise if possible (walk fast, vacuum, rake or sweep, all seem to bring EH’s BG back into range when insulin won’t touch it.)

And here’s to feeling better soon!

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My current Work Day basal profile:
12A-1A: 0.5
1A-4A: 0.55
4A-9A: .5
9A-10A: 0.4
10A-1P: 0.3
1P-4P: 0.25
4P-12A: 0.4
Total: 9.9 Units

My theory is that if I base my basal rates on week 2 of my cycle, then the “shape” of it should be accurate, I just theoretically need to change the amplitude (i.e. temp basal increase or decrease) throughout the different hormonal phases of my cycle.

My blood sugar last night (day 1 of pod) was mostly flat. Day 2 of the last pod saw an increase overnight…so would that be decreased pod effectiveness at the site or just a hormonal shift? No idea! :slight_smile:

I had read that you shouldn’t eat until you get at least under 150 bg, so I’m usually waiting for that to happen and on Day 2 and Day 3 that point may never come. I do eat breakfast, lunch and dinner…but now that I think about it, I have been trimming those meals down trying to fit within the bg box. Which isn’t working.

I think a lot of the general wisdom from non-diabetics (i.e. my endo, etc) on the pump just isn’t accurate for me. I think I should theoretically be able to eat more carbs for breakfast on the pump than I could on shots, but empirically that just doesn’t seem to pan out.

Also, I know I am afraid of lows. I have two young children and a husband who travels a lot. I used to be super aggressive with pre-bolusing meals (well, with shots, anyways) and upping my dose so that the spike would be within parameters and then I could tack on a snack without an additional shot two hours later. Now I’m complying with the I:C ratio that “should” work and the reduction for IOB, and I’m not pre-bolusing as aggressively and I just spend most of my insulin trying to dig out from highs. It’s hard for me to get over my concern of runaway lows after having a few on shots and early on with the pump.

I’m trying! I’ll keep on keeping on! Keep it coming and thanks so much!! I really appreciate your support.

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It could be either, but try to find a repeatable and consistent pattern over the course of several weeks with the day of the pod to see if it matters for you.

So where do you run into trouble? Probably good to tackle one time-range at a time and adjust. How often do you wake up with high BG? Is that 4am-9am basal amount sufficient?

Are you able to test once an hour? Can you feel a low BG?

I know they can be scary, but as long as you are awake and can test for it, low BG’s don’t need to be scary. The only time I worry about them is when I am sleeping. And there is a pump trick you can do for that for when you are alone.

I really think a strong and sufficient basal sets the stage for everything you do. If you have a sufficient basal, you won’t be chasing highs and won’t need to pre-bolus as long.

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Just from our personal experience, but breakfast is the worst meal for us to go high carb, because of the dawn effect. It is very hard for us to deal with hormones and high carb food. We go highest carb for lunch, because that gives us the most awake time to deal with the aftermath if we messed up the calculation or phase of the moon. Dinner comes next, and then breakfast with the lowest carb. BTW, sorry for my strong post above, I wasn’t in my “happy place” when I posted.

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Hi, Allison.

There are lots of folks here who will help you work it all out. We all have our own mostly-strong opinions, and they won’t necessarily all point in the same direction. But if you can stick with us, you’ll get there.

So here’s what I think.

First, when it starts to get too confusing, I always go back to the touchstone I got from my CDE early on. She said this: “If your blood glucose is too high, you need more insulin.” The utter simplicity of that helps cut through all the confusion and complexity.

If you BG is too high when you wake in the morning, you need more basal during the night. Starting about 2 hours before the rising trend.

If your BG is too high after breakfast, you need more insulin (or less carb) for that meal. And pre-bolusing or super-bolusing can help.

If you tell the Omnipod to give you more insulin and it doesn’t seem to be working, maybe you are having absorption issues, so switching the pod might fix it, but you don’t have to switch the pod, you can always take out a syringe and vial (or pen) and just take an injection. Some people prefer that for a large meal bolus even if they are pumping, so they help protect the site from an early failure because of too much insulin in one place. An injection can even can be IM if you’re looking for a quicker response.

Now if you need inspiration that you can get this under control, you can look to DaisyMae’s swimming thread. She started out afraid and confused, and now she’s a fearless, independent expert at dosing insulin for her exercise. Daisy Mae’s swimming BG thread

Sam likes MDI, tresiba, and afrezza. He knows how to get great results.

Eric likely will be happy to guide you through the process of figuring out your dosing, step by step. He’s a pumper and an expert in many things, including dosing for distance running and the low-level biological processes underlying diabetes and treatments. I agree with Eric’s comment that “a strong and sufficient basal sets the stage for everything you do. If you have a sufficient basal, you won’t be chasing highs and won’t need to pre-bolus as long.” Figuring out your basals is an excellent starting point.

By the way, I agree with your thinking that if you get the shape of your basal profile right, mostly you can just use percentage temp basals to adjust it up or down for the day’s circumstances; hormones, site age, immune/allergic reactions, and dozens of other factors. You don’t have to figure out and understand all those causes to fix your BG. If your BG is too high, you need more insulin. So if you see a trend (I’m running high today) you can just increase your temp basal percent, and keep turning that knob until it works. Michel and his son do this all the time.

I’m a big fan of Dexcom CGM. You said that you used it in the past. If you can get one, it could protect you from lows so that you can dose enough insulin to solve your high BG without getting into trouble. But you don’t have to use the CGM: DaisyMae figured out her insulin dosing strictly with needlesticks — lots of them; sometimes a couple dozen per day.

You’ll get this figured out. We’ll all help.

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Great post, bkh :arrow_up:

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Welcome @T1Allison! This is the right place to come to figure this out and it’s great to have you here with us!

I just have a couple questions that have already been asked but I haven’t see the answer yet. First, do you alternate sites? If so, what site(s) do you use? For our son (4 years old now, diagnosed at 2), we have 4 main spots that we alternate between: Left and Right “upper” thigh as well as Left and Right “side” thigh. And we alternate cannula directions every other time (one run through all 4 sites, we have cannula facing upward toward the head and the second iteration, we do cannula down facing the feet.) We plan to also use his backside and his abdomen as he grows and these sites are more suitable for PODs being inserted into. Rotating sites is very important to avoid absorption issues as well as scarring and other issues (including sensitivity to adhesives, etc.,…the more you use something on one spot, the more odds you’ll begin adversely reacting to that material.)

The second question is whether or not you use a CGM (Continuous Glucose Monitor)? If not, I would HIGHLY recommend you get one of these ASAP. Having a CGM allows you to visually see when your BG’s are beginning to rise…if you time things correctly there is usually a small curse, but if you don’t time things correctly (the timing of bolusing and eating) OR if you have hormone issues going on (which occur during that time of the money and with kids growing), you’ll see bigger “spikes”. But having a CGM is the first step in recognizing when your sugars are rising, how quickly they’re rising, how they react to specific foods and when you should either bolus more or eat more. The CGM was the single biggest lifesaver for us…before we had it, I slept maybe 1 to 2 hours per night.

Again, very nice to have you here and nice to meet you!

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I’m already SO SO SO glad that I joined this space. You guys are great!

Chris: I think I’ve worked in the dispute resolution field for too long (10 years now), because I didn’t think any of your posts were too strong. I’m still not sure which one you thought was too strongly worded, lol!

So here’s some more…

  1. I do use the Dexcom G5 and adore it.
  2. My anxiety about lows has skyrocketed since I became a mother (7 years ago)…and then switched to the pump (4 years ago).
  3. When I was on MDI, the motivation to avoid additional correction shots for highs was so great that I’d overestimate my meals to ensure no runaway highs, and then I’d get the bonus of getting to eat a snack to feed the impending low 3 hours later.
  4. Bolus calculations via the Omnipod just seem to freak me out. It shows you IOB and calculates precisely for the carbs I plan to eat…but I find that if I still need that IOB then I really shouldn’t be subtracting it out. Not great advice for everyone obviously, but it just screws me up. Also, when I took shots, I’d take the dose and move on with things and parcel out my carbs as my blood sugar allowed. With the pump, seeing the insulin on board calculation just fills me with anxiety like I’ve injected myself with a time-bomb. I know that sounds silly, but the anxiety about “what if” is clearly very real to me right now.
  5. I have re-discovered that I have to bolus completely differently on work days (office job) vs. weekends (11000 steps daily chasing kids/dog/laundry). My bolus difference is in the neighborhood of 40% between those two realms. My weekends go much better (knock on wood).
  6. Sites: I can’t use my abdomen. I’ll spare you the pictures but I get bleeding and bruising and no absorption as soon as I sleep on it one time.
  7. I rotate through 7 spots on the back of each arm. That’s the only place I’ve tried other than my stomach. With my accidental weight loss, my thighs look way too skinny to try. I’m apprehensive about trying my back bc (a) my dexcom lives there and (b) I imagine sleeping on it will cause similar issues to my abdomen with the added issue of not being able to see and monitor it. I know that I need to try, but site rotation seems like an added monster while trying to get up the courage to get back to “proper” pre-bolusing for me.
  8. Pre-bolusing: On shots, I would pre-bolus 10 - 40 minutes depending on the scenario. It seems I just phased that out of my process on the pump to my great detriment.
  9. Post-breakfast highs: My breakfast dose was quite effective when I started pumping. I even had to dial it down after a bit. Now it’s double for the same breakfast but my basal testing showed my rates were correct. Head-scratcher…
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I could be wrong about this, but I believe one or more of our members have indicated that you don’t really need “fatty tissue” in order to place it on a specific site. Even very tone, low body fat individuals use PODs and place them on their body. Some very high-level athletes use the PODs/pumps. You may want to try (just as a test) one or more locations! You just never know if it will work for you until you try all sites. If they don’t work, OK…maybe test one more time just to be sure it wasn’t a fluke but if it doesn’t work at least you can rule it out in an informed and fully tested manner!

We’ve found, at least in our case with our son, apprehension was our worst enemy and was the reason he got too, and stayed at or over 400 at times. When we released our apprehension, we began being much more successful with him. Nights are different for us, though…we’re a bit more apprehensive because we don’t want him to drop low during the nights…so we’ll let him ride higher at nights.

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FWIW, because of lipoatrophy from repeatedly using my thighs for pork insulin injections when I was a kid, there are places where I can’t pinch more than 1/2 inch. It took me nearly a year to try my pods there, and I am AMAZED how comfortable they are. But if you try it and your site is painful or doesn’t absorb well, remember that Omnipod/Insulet is very good about replacing pods you have to remove early.

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A bunch of stuff here to look at. don’t want to overload the info, so jsut a few to start with.

:arrow_up: I tried using the calcs on the pump but quickly abandoned it. Those calcs just seem primitive compared to all the factors that your mind can use. Like carbs - 30 grams of cake carbs don’t work the same as 30 grams of oatmeal. And a BG of 90 that is rising is different than a BG of 90 that is falling. But the pump acts like those are the same! Silly.

I’d encourage you to going back to using the Force. Ask @daisymae about the Force and what it’s done for her in the past year.

:arrow_up: The magic of exercise. :slight_smile:

If you can’t exercise as much during the week because of family commitments, that is understandable. But if you have a job that uses a desk, consider a walking desk or lunchtime walking or anything like that.

:arrow_up: When you say, “My breakfast dose was quite effective when I started pumping” , do you mean when you were doing MDI or actually with the pump they were correct? Did they work with the pump a long time ago and now they don’t? Just trying to clarify that.

This is fixable, for sure.

:arrow_up: Go back to the pre-bolus time! Ideally your BG will be in range and dropping when you start to eat. That helps prevent a spike. If I have enough of a drop coming on, I can eat absolutely anything without a spike.

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You’re not missing anything, the pump is just a fancy syringe that has some awesome features that are difficult to replicate on MDI (variable basal rates, extended boluses, ability to bolus discreetly, etc.). I’m a huge pump advocate but definitely experience some of the problems you describe, and I think the biggest mistake for us diabetics was Medtronic cancelling the MiniMed implantable pump. If MDI was working well for you except for the DKA incident, maybe try it again? There are new basal insulins including Tresiba that many people love. What I’ve learned from using a CGM is that while basal testing and setting ratios as accurate as possible are important, it really is a dynamic disease and what worked for me an hour ago won’t work right now. I have the same issues as you, such as breakfast dose constantly changing and carb ratios different on work vs. non-work days. Have you tried Fiasp? While many people have issues with it, it is much faster-acting than Humalog/Novolog and could give you better control if you are having trouble pre-bolusing. It also has a weaker tail, so if you take too much up front you are less likely to drop as low later on. I can eat things I can’t on the other insulins with Fiasp, such as fruit and cereal, since it works fast right away to cover the rapid spike from these foods and doesn’t drop me low after when the tail exceeds digestion. I’d also recommend keeping glucose tablets on you, watching your CGM as much as possible, taking more insulin when you start to see straight up arrows and eating the tablets when you see you are dropping. I have my Dexcom working on my smartwatch which makes “sugar surfing” a lot easier and discreet. Lastly, I’d recommend trying a tubed pump if you’re able to. With tubed pumps you can try different infusion sets, such as steel, longer/shorter cannulas, etc. and you might find one that works better for you than the one-size-fits-all pod. Don’t be afraid to change things up, I switch to MDI when my pump is annoying me and back to the pump when I start to hate MDI. I would never dream of consulting a doctor or medical team to make changes to my treatment regimen or doses unless I have to, Dexcom gives me all the data I need to make these decisions!

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My breakfast dose was effective when I started on the pump…to the extent that I increased my breakfast from just milk (on shots) to toast and coffee (on the pump). Now the dose needs to double to cover the same breakfast…or a huge pre-bolus time?