Review part 2 of the latest automated insulin delivery device: the Medtronic 780G.
Switching diabetes technology is no easy feat. Not only do you have to learn the new mechanics of the device and connect everything, you have to learn new patterns for bolusing, how to review your data and when/how to react to highs and lows. If you are already using an insulin pump it's not as big of a change, but it's a huge change from multiple daily injections (MDI). As a certified pump trainer, I tell clients that the pump will take some time to get used to and to be able to trust the technology. It takes time to learn how the pump interacts with each person's body and we don't necessarily know which tech will work best until we get to try it out.
The Warm Up Period
The switch to Medtronic 780G was not too tricky for me given that I am a pump trainer and I am used to wearing pumps. I used an earlier version of a Medtronic pump (670G) for many years before switching to the Omnipod 5 but I really wasn't sure how the technology would handle my body and my wide fluctuation in BG that seems to happen with stress (yes, both hyper and hypoglycemia). Would this technology be able to adjust fast enough to curb those extreme blood glucose (BG) changes? Or, like the 670G, would I be left wondering why it wouldn't recognize and adjust for certain patterns like the early morning increase in BG (darn dawn phenomenon!).
With AID (automated insulin delivery) systems, aside from Tandem, there is a warmup period where the pump is gathering data about the person's response to insulin and carbs before it is fully automated (Medtronic calls this automated system Smartguard). During this warmup time, I had expected to see a decreased time-in-range (TIR) from the Omnipod 5 but was pleasantly surprised at my stats during the first 2.5 days of warmup. I had been in target range 86% of the previous day which included eating pizza twice!
I was so excited to start that I stayed up until midnight (see Initial Impression blog for more info), tested my BG and voila! I was now in Smartgaurd! As instructed, I adjusted my AIT down to 2 hours and my target BG to 100 mg/dl. Time to start testing out the full functionality of this pump!!
Testing Out The Medtronic 780G Insulin Pump
The biggest questions I had for this insulin delivery device were:
Will I go low with a lower target BG?
If I drop too low, how many treatment carbs will I need to have?
What happens if I don't bolus for a meal?
What happens if I bolus for part of the meal?
When I eat at a restaurant and don't know the carb count, will my BG stay within range?
What if I bolus for my meal but then have dessert and don't bolus for that?
If I go high, what do I need to do to react? Do I do a correction bolus, or let the pump handle it and for how long?
Now, I am someone who has bolused prior to every meal for the last 27 years and it’s not something that I tend to forget to do. With this particular technology, they have what is called "bolus forgiveness." Essentially, the pump will start bolusing (giving a larger chunk of insulin) every 5 minutes once sensor glucose (SG) has gone above 120 mg/dl and is trending up. Compare this to Tandem CIQ which will gave a automatic bolus correction dose once per hour. Omnipod 5 will not give a bolus but will increase the basal dose as it sees SG start to rise. The 780G was designed to be more aggressive in giving correction boluses as a way to reduce the burden of precise carb counting for the patient. The Ilet pump goes 1 step beyond this by asking the user to bolus not with carbs but with stating whether the meal is a "usual," "less than usual" or "more than usual" amount of carb.
Can the Medtronic 780G insulin pump really do better than I can at dosing insulin for meals??
So, while a “meal announcement” is recommended (bolusing for just 10g can be enough to tell the pump to expect an increase in BG), I am not someone who is very comfortable with doing that. Perhaps after 6 years of taking nutrition classes and 27 years of trial and error it's a challenge to switch the mindset to "Just tell the pump that you are eating and it will do the rest!" Can the pump really do better than I can at dosing insulin for meals??
Always one to promote making incremental changes as they feel safe, I gave myself a few days to use the pump as I would normally by trying to accurately carb count and bolus 15 minutes before the meal. Once that proved to work, I would try announcing the meal by entering 15-20g of carb. I even planned to get sushi and only bolus for an initial amount of carbs and allow myself to listen to my body on how hungry I was and how much sushi I ended up wanting to have (what a novel idea, right?).
Preliminary Findings
My first week in Smartguard was amazing! My TIR was 80% with 2% low and average sensor reading of 139 mg/dl, already beating my typical stats on the Omnipod 5 in just a week! During this week, I ate sushi and only bolused for 60g carb beforehand (but probably ate more like 100g). I went to Skamania Lodge for 2 nights and went swimming multiple times and ate food that I didn’t have the carb information for. It felt great not to worry that my BG would go super high and to have to fight for hours to get it back down.
I must say that it was so nice to not worry about accurate carb counting and just allow myself to eat. I also would have dessert or additional helpings without bolusing any additional insulin knowing the pump would help with out. The best time I had with the Medtronic was when we went out to sushi. Each piece of sushi tends to have around 10g of carb so sushi can require quite a lot of insulin to accompany it. Usually I try to get some low-carb options to help fill me up and restrict the number of sushi pieces I am allowed to eat but this time I bolused for some of the meal, sat back, relaxed and enjoyed my food until I felt satisfied. I didn't feel guilty afterward as I watched my SG react and saw the pump doing it's thing!
You can see that I was out of the target range during most of the meal when I had sushi but let's not forget that I ate way more carb then I bolused for. I never went above 250 mg/dl which was about 100 mg/dl from where I started off the meal. Only 100 mg/dl fluctuation with sushi? I was impressed!
When I eat, I typically give myself an allowance of carbs then cut myself off once I think I've reached that amount even if I'm still hungry. This tends to range from 30-45g carb each meal which is less than what would be recommended for me. I don't think that I'm alone in restricting carbs in an attempt to manage BGs but that doesn't allow for intuitive eating or for fully enjoying the experience of food. Perhaps this method of management is a thing of the past with the newest technological devices. A tool that was once one of my most useful techniques may not ever need to be used again! Sorry, Adam Brown (author of Brightspots and Landmines)!
Imagine a world where we don't have to try to control every single factor in our lives in order to be healthy! Some of you are already in this place, but for me, the higher the carb amount, the more guilty I feel about consuming it and the less likely I will bolus for the actual correct carb amount (trauma anyone)?
I must say that it was so nice to not worry about accurate carb counting and just allow myself to eat.
There were a couple other perks that I noticed in this first week. I didn’t have alarms going off all day and night as happened with the 670G and I never had to calibrate the sensor AT ALL. I hardly had to respond to highs or lows because the pump is aggressive with getting the BG down but somehow backs off more aggressively as BG drops. It seemed I needed only about 5-7g of carb to correct a low and I didn't need a snack following the low to prevent another low from happening. The 780G required less action in managing BG than any other device I have used (yay for reducing burden!).
In Summary
As a diabetes educator who has type 1 diabetes, I get the unique experience of trying out different devices. I don't assume that a client will have a similar experience to me with each pump but knowing the ins and outs of what it takes to have successful BG management using tech helps me to understand the person and what they are looking for in a pump. The Medtronic 780G did not disappoint. The algorithm is aggressive but somehow does not create a lot of low BGs. It allowed me to be more flexible with my eating and proved to be able to improve my TIR while letting me relax a bit with carb counting or bolusing for second helpings or dessert.
The Medtronic 780G insulin pump did not disappoint.
Overall, I would recommend continuing to bolus for meals as best one can and utilize the "bolus forgiveness" feature to help correct for the 41 other factors aside from food that impact BG. With this pump, my TIR could be in the 80s and 90s if I continued to bolus as I do now which would reduce the burden of caring for diabetes and I would hope help to increase my energy levels. Because there weren't alarms all through the day and night like the 670G, I wouldn't have to worry so much about BGs during the days or nights (if I could figure out a surefire way of keeping the pump in my pocket or in a comfortable sleeping spot - but more on that later).
I hope this can help inform your next insulin delivery device choice. Schedule an appointment if you want to talk more about what pump system might work best for you!
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