Pumping Insulin

 

No I’m not just pleased to see you: there is indeed a super-dooper electronic gadget bulging in my trouser pocket. I stuff it down my bra when I’m wearing a skirt. Some people with a lot of free time have sewn extra pockets inside their clothes to keep theirs descrete upon their persons. Mine used to have a big plastic clip (before I sat on it and broke it) for my belt and this used to make me look uber-cool: a mother of four boys once asked me to contradict a rumour they’d heard that I was one of those ‘James Bond People.’

So: what does it do…? Well, lets start with an idea you are familiar with: the syringe. You suck up a certain amount of a drug using a little scale on the side, place the needle carefully in the relevant part of your victi – I mean, patient (you will do this even more carefully if it just happens to be yourself who needs the dose) and press the plunger. Voila!

But what happens if your patient needs the fluid or drug injecting very slowly, over a long period of time?  Well, you could persuade a numpty to stand there for twelve hours and push the plunger a tiny nudge at a time. Or you could use a ‘syringe driver’ which is a motorised device, perhaps a little more steady than the hand of your average numpty, that can be programmed to evenly push the plunger down at a certain speed. When I was at vet-school seven years ago these were the length of a shoebox, heavy and – as we were frequently reminded – very expensive. We students had heard the rumours of what happened to the person in the year above who knocked one off the shelf and broke it.

Anyway, lets think about pancreases (and no, I don’t what the correct plural is either). A pancreas produces tiny amounts of insulin and puts them into the blood-stream all day long. Insulin helps normal cells to take glucose out of the blood and use it. The amount of insulin the body needs varies from hour to hour: if you have just eaten a thousand jelly babies, you will need a lot of insulin to deal with all that glucose.  If you have been sitting behind a desk for five hours and someone else has eaten all the office biscuits, then you will need much less insulin in order to conserve whatever glucose your blood has left for powering your brain. Those who don’t understand what I’m talking about and want to, it’s in a post called Type One Diabetes for Non-Diabetics if you scroll down.

Still reading? Then imagine a single mililitre of liquid. One single mililitre of ‘Insulin’ contains one hundred International Units of insulin (we measure Insulin in ‘Units’). I know that my body typically needs just a third of a Unit each hour between midnight and three in the morning, but this goes up to around 0.35 Units per hour from three until six. Yes, that’s tiny amounts of liquid insulin. And the dose keeps changing throughout the day. It changes with my activity level, changes with my stress level, changes greatly when I’ve eaten carbohydrate.

A year ago, I used to inject my insulin. I had two different ‘speed’ injections. ‘Fast’ insulin starts working very quickly once it gets into your body and I took it at meal and snack-times so that my body could cope with the rise in blood glucose that happens immediately after eating carbohydrate. This would also stop working about four hours later, so would be gone once the meal had been digested. I took the amount I needed to cover the food that I ate (ten grammes of carbs need 0.75 units of insulin when I’m not breastfeeding).

The other was a ‘Long-acting’ insulin, that tried to cover the other times. But of course there’s a snag: you only put it in every 12 or 24 hours, so you can’t change the dose when you have been sitting at your desk for five hours and someone’s eaten all the biscuits: nor can you change the dose should you run up a hill. So I’d take an approximate average dose which might be far too much at jog-o-clock and far too little at sleep-o-clock-in-the-morning. What I really needed was a Numpty to inject fast-acting insulin ALL THE TIME and vary the dose according to my requirements at that second, but such numpties are not widely available on the NHS and even if they were and even if it were practical, the doses involved were so small (that is, 0.003ml an hour at one in the morning) that even the steadiest-handed numpty in all of numptydom would be unable to accurately measure it….

Of course, you know what I am going to say. This thing in my pocket, an ‘insulin pump,’ is a super-dooper-clever-syringe-driver, about the size of a match-box, that very accurately injects tiny amounts of fast-acting insulin all the time!  I can slow it down and speed it up and even programme it to change dose at certain times of day.  It sends the insulin down a little tube which attaches to a cannula under my skin and this is, frankly, a bit freaky becasue it is always attached. I am reminded I am ‘ill’ every time I get undressed; it goes everywhere I go except the swimming pool; the kids pull it out sometimes which hurts a little and is very annoying; on a bad day, it makes me feel extremely unsexy too.

It’s also worth saying that with a pump, I still have to put the work in. I still need to work out roughly what dose of insulin I need at what time in the first place. When I eat, I still have to look at the food and count the carbohydrates and have the appropraite amount of insulin. But now I no longer inject at the table: I can key in the units of insulin and press ‘Go.’ Better still, it knows my insulin : carb ratio so I can just key in the carbs and press ‘Go.’ If I also key in my blood glucose level (it knows what blood glucose level I am aiming for at any particular time of day), it will ‘correct’ the dose it’s putting in to cover any discrepencies. If I use my fancy blood glucose metre it just Blue-Tooths the test result straight to my pump to save me the trouble of keying it in. In fact, sometimes these days my hubby hasn’t got half-way through his meal before I get to start my own and if I’m eating with someone who doesn’t know me, they no longer notice that I’m diabetic. At first glance I could be checking my phone.

Some pumps are even cleverer. Some people wear a continuous test metre that produces a trace of what their blood glucose is doing all the time, rather than just giving a one-off reading when they happen to test. The disadvantage (besides massive financial implications) is that they have to wear it all the time; the advantages include spotting trends, knowing that your ‘perfect’ reading of five is actually ‘five but it was ten half an hour ago so it’s falling fast, eat something now’ and knowing what your blood glucose did overnight without having to set an alarm and test yourself. Those prone to hypos, for example the pregnant and the breast-feeding, can benefit a lot. But more excitingly, pumps and a continuous glucose monitors have been made to talk to one another and a ‘closed loop system’ (i.e. the diabetic person doesn’t need to fiddle with it) is in trials at the moment: an ‘Artificial Pancreas’ might be close to being a reality.

Meanwhile, there are people who’d give their eye-teeth for a pump like mine. Diabetic Internet forums are full of rants from people trying to get one on the NHS: ‘I worked really hard at my glucose control and now my levels are so good that the consultant won’t give me a pump’ is a common complaint. At three thousand a pop (and more for consumables) you can see why.

Actually I am told that the general reluctance to offer pumps in England is because there is no scientific evidence that pumps are better than injections. The trouble is that when diabetics are given a pump, they are sent on a course about diabetes (the DAFNE course, Dose Adjustment for Normal Eating). Sure, their diabetic control is better a few months later but was this down to the pump, or just having been on the course? – that course on its own has been proven to change lives (why they don’t just send all type one diabetics on the course a few months after diagnosis like they do in Germany, I’ll never understand: surely a few days training is cheaper than a lifetime of complications of badly controlled diabetes?)

Anyway, there is a study at the moment called the Repose trial designed to settle the matter. I got my pump because I agreed to be a guinea-pig. ‘Guinea-pigs’ were randomly allocated to one of two groups. My group got a pump and a DAFNE course; the other guys just took the course.

I’m not sure that I like being in the pump group. This is a psycological thing: it feels like a bionic body-part and although it’s not often that I stop by the side of a river, rip my clothes off and jump in, I used to like the feeling that I could if I wanted to (actually I did this last month but it was slightly more of a faff). The sheer presence of the thing detracts from any illusion I ever had that I can survive on my own two feet and wearing a slinky dress is definitely harder.

On the other hand, had I not got pregnant during the trial (which makes it hard to tell), I do believe that my diabetic control would be better for it. Exercise (what little I’ve done) is much easier to control. Not having to get needles out at the dinner-table is definitely a bonus. It even helped me to avoid the unpleasantness of a sugar-controlling drip when I had my c-section.  Logic suggests that it is better: it is, after all, much more like a pancreas than injections are.

And best of all, I look a tiny bit more like someone who might work with James Bond.

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