Starting over with Omnipod 5

Type 1 & LADA
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I had a rough start with Omnipod 5 when it first came out, lots of sticky highs and no cooperation between a needed correction bolus and the “Auto mode”. So I spent about the last 9 months plus using the Omnipod 5 mostly in Manual mode, bolussing for meals with syringe/Lyumjev and using Affrezza for corrections and some meals. Recently I had a chance to review “the numbers” and found that my hybrid method of BG management sort of sucked…A1c had crept up by about a half percent to 6.6. First time I had ever been above 6.5 since diagnosis. And over those 9 months I had my first two lows that knocked me over and required assistance. So I decided to go back to Omnipod 5 Auto mode and see if I can dial things in for more effective BG management.

I started cold turkey, did not mess with any settings. I just hit “Auto” and away we go. I am doing a few things different than my first run in Auto mode. One is using some new fleshy sites to make sure I have good absorption. Another is only going 2 days per pod for the same reason. A third is limiting max bolus to 5 units for a meal prebolus, and delaying the rest of the meal bolus for 30 minutes.

On my second pod and feeling pretty comfortable with the results. I’ve had to use some Afrezza for corrections but hoping that will be reduced as the new TDD hits the pod memory/algorithm.

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Sorry it’s been such a rough go. I wish there was an option to add the Afrezza doses to your TDD! It would probably make a huge improvement.

My experience with the algorithm has totally changed in the last few months. My total daily dose has more than doubled because I believe that I’m coming out of my LADA honeymoon. Now I’m totally in love with the OP5 algorithm. As long as I don’t have anything too crazy for dinner I’m sleeping through the night with a great BG. The first couple of years I was waking up at least once to give a bolus. I haven’t had one low either. Just really happy with it.

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Interesting to read that update, and thank you for it. On the older pods, because of tunneling, for anything more than 3U I had to either inject or extend the bolus. I’d asked here about how injections worked with the algorithm, and your approach was one I’d bookmarked as a practical guide to work with.

Yet from Day 1 I’ve been on Auto, three months now. I only go to Manual to do an extended bolus.

I’ve pretty much exorcised the Curse of Tunneling through a spell involving U200, Tegaderm patches, and splitting or extending boluses. I’ve also found I can bolus as much as 10U with no leaking. (Dinnertime extendeds present a mystery, since whether I extend for 30 minutes or 4 hours, the BG result is basically the same. Leading me to wonder, Is there even an algorithm here?)

I still haven’t nailed that algorithm, though. In the beginning it was hyper-aggressive, driving me down day and night. Then everything evened out and I thought we had a happy marriage. Past few weeks it’s been letting me go super high late at night, and I hate it. Last night I wanted to go back to mama, I mean MDI. This morning I was level after breakfast, so I guess we’ve made up for now.

I don’t expect the basal adjustments in Auto to bring down a high. I see a lot of complaints about this in other forums, people saying “I’m 250, why is it only giving me 0.15 units?!” You still have to correct for highs, just like you still have to treat for lows. I’ve heard rumours of an AutoCorrect feature in some future version of the app, but I won’t hold my breath.

That said, in my experience the algo will eventually bring you down – if you define “eventually” very loosely. If I’m feeling generous towards the algo, I let it do its thing, particularly overnight. If I’m ready to sue for divorce, I do manual corrections, but then I have to watch out for the inevitable lows.

Onward and (not too high) upward.

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Here’s an example of how corrections slowly work for me in Auto mode:

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That high BG at 5 pm was not looking like the algorithm could correct it, so 8u Aftezza and a soft landing 1 hour later. Then today at 170 after breakfast and the algorithm slowly correcting it. Decided to let it go (I was on the golf course so mildly exerting) and 3 hours later a soft landing.

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Lyumjev short acting now not covered by insurance
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Hi John, I’m designing an insulin pump that addresses some of the problems of the Omnipod. One common problem is the absorption deterioration on day 3. Can you help me understand your problem a little better? Would you be willing to talk with me for 15 minutes? I’m interested in things like what happened on day three, how often the problem occurred and how much insulin you use a day.

Thanks,

Russ

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Why do you say that? Perhaps some references?

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I do the same thing, though I only have the 'pod to work with so when I get a sticky high I just shoot bolus. I’m using AAPS not the O5 algorithm and I would say the landing is much softer, albeit it takes more time.

I always come back to trust-the-algo; regardless of my use of AAPS I still trust it up to the point where it doesn’t work then I eat or bolus according to the moment. It still works.

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We’ve been using Omnipod for going on a decade and haven’t ever noticed any absorption issues on the last day.

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That’s great – I hope it keeps up. I wonder if it has anything to do with age and tissue rejuvenation – though I realize I’ve posted here about lingering lipoatrophy from my childhood.

Third-day issues were quite noticeable for me. To combat it on the non-algo pods, I had a “Day 3” basal profile set to 50% higher across the board. Now O5 usually copes with it.

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The O5 does not seem to change the basal at all over 24 hours; it just sets a new one every pod change (based on previous insulin requirements). It does seem to depend quite critically on accurate carb counting and an accurate and invariant insulin sensitivity:

I don’t know how accurate that article is and I’ve never seen a definitive description of the algo in terms that I understand and believe. If the article is correct the O5 would never work for me because my ISF can vary a lot within 3 days and, to make it worse, my carb counting sucks.

Given your experience, with an apparent lowering of insulin sensitivity on day 3, I’m not sure I believe the article I just quoted.

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Technically true, I suppose, but if I’m trending higher on day 3, the “auto events” adjustments are more frequent (versus long stretches of “0”) and may be higher than normal (e.g., 0.25 rather than 0.05). Perhaps there’s something in each of our settings that leads to different responses.

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Mostly from talking to pediatric diabetes nurse educators who say they go to bat with the insurance companies for some patients who have such problems on the third day they the get reimbursed to wear the Omnipod for two days instead of three. It is not everyone though which is why I’m trying to understand it better. There is a lot in the literature about things that could cause problems on later in the wear period. I would have to spend time digging up the white papers but here is one from Journal of Diabetes Science and Technology Volume 4, Issue 4, July 2010 by Volkmar Schmid, Ph.D.,1 et al. It concludes, “Using the catheters for 2 days resulted in a safe and well-tolerated therapy. Clinically relevant adverse events started to occur during the 3rd day and their incidence increased constantly with longer use. This was associated with undesired changes in mean glycemic control. Data support the recommendation by the drug and device manufacturers that insulin pump catheters should only be used for 48–72 hours to avoid adverse events and potential metabolic deterioration.” It is for infusion sets but could relate to the Omnipod as well The paper is called “Pilot Study for Assessment of Optimal Frequency for Changing Catheters in Insulin Pump Therapy—Trouble Starts on Day 3”

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My endo prescribed pods every 2 days from the start, years ago. I was using about 50-60 units per day at the time so 3 days was feasible and I went 3 days per pod for years. I often had temporary painful welts upon removal of the 3 day pods. I suspected poor absorption issues recently (past year or so) but only occasionally found evidence of tunnelling or leakage at the pod site.

Since switching to 2 days per pod I have had zero welts at the catheter site. I won’t have enough data for a few months to comment on glycemic control results from 2 versus 3 day pods.

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They’re called “micro-boluses” by Tandem and “super-micro-boluses” by AAPS, but they work in association with basal rate changes, “temp basals”. If your pod is suffering lowered insulin sensitivity on day 3 then the algos should all catch up with it. Medtronic will, I think, just try to temp basal the problem but Tandem and AAPS will do bigger corrective boluses (the “micro bolus”). This has the same effect as you 50% solution, assuming you also applied it to IC.

Maybe this is what is happening; the O5 is just managing the “day 3” problem better because it is reactive; it’s response is not based on a necessarily hard assumption of how old the pod it but rather it implicitly reacts to lower insulin sensitivity with the micro-boluses.

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Ooh, yes. I didn’t read your post before @Beacher 's but I came to a similar conclusion based on what he said. We have the data; it would show up in a ~3-day cycle on the results of closed loop systems but, with AI help, might even show up in the results from any pump user with a CGM. Excellent opportunity for an up-and-coming medical researcher with access to all the data.

The Omnipod is an infusion set with an integrated pump; so far as site behaviour is concerned the I would expect the Omnipod to be identical to the tubed pumps.

I’ve learned something; I had mistakenly assumed 2-day pod users did it because of the small size of the insulin reservoir (2ml) but now I know to think about the site issues over several days.

EDIT: this is a review paper from 2018 which examines catheter life issues and research:

https://journals.sagepub.com/doi/10.1089/dia.2018.0110

From the abstract (with emphassis added):

Our main findings are: (1) adequately designed and powered studies investigating optimal catheter wearing time are still lacking; (2) increasing catheter wearing time is generally associated with increased frequency of catheter AEs; (3) however, interpatient variability is large, with some individuals needing to change their catheters every 2–3 days, whereas others probably being able to keep them in place for longer periods without problems.

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