As well as writing your soaraway Shoot Up I read a lot of other diabetic blogs. Generally they’re interesting, insightful and useful; however it really gets my goat when people use their platforms to promote some other service or product that is entirely unrelated to the topic of their blog. Frankly, it’s unprofessional, amateurish and downright dishonest – it cheats dutiful readers.
With this in mind, therefore, I’m not going to use your soaraway Shoot Up to promote my wife’s handbag business stripykat. The fact that each handbag is handmade & unique and that they are incredibly good value for money and ideal for Christmas gifts is neither here nor there.
I also refuse to mention that stripykat has been featured in British Vogue or that Katie is one of only twenty Scottish designers currently displaying their products in the National Museum of Scotland’s renowned “Gifted” exhibition.
Only the shoddiest of blogs would go onto say that stripykat also sells a great selection of unique iPod & MP3 holders and camera cases in addition to hairbands and scarves, which are great accessories that will beautifully set off your favourite outfit.
It would also be deeply unprincipled to say that stripykat ships worldwide (that includes you USA!) and securely accepts payments via PayPal in your local currency.
No, I’m not going to do that – it would be wrong. Move along there, nothing to see.
As I’m having a c-section at 38 weeks, the baby needed to have a shot of steroids before she’s born to make sure her lungs are nice and strong when she arrives. I was surprised by this as I thought 38 weeks was past the date when steroids are required, but according to the latest Royal College of Obstetricians & Gynaecologists guidelines, it’s generally recommended that all babies to be born by c-section before 39 weeks are given steroids. So that’s what we did.
The one advantage of the whole situation was that because everyone was so busy telling me “steroids will play havoc with your diabetes” it did stop them from telling me that all diabetics have massive babies for a short while at least, so that made a pleasant change. Unfortunately I was unable to locate the havoc prevention setting on my pump, so instead I took to the interweb and asked people via Facebook, Twitter and various forums to share their experiences of how steroids impacted their diabetes so I could make a plan.
The general consensus for steroids in pregnancy seemed to be that they make you really high from around 2 hours after you have the first injection up until around 48 hours after the last injection. And the peak insulin resistance seems to be between 9 and 15 hours after the injection. And helpfully, that varies from person to person. Great stuff, just what you need when you’re pregnant. The hospital kindly offered a sliding scale to manage this for me, you’ll be surprised to hear that a diabetic control freak like me declined that option. I decided to manage it myself on pump and CGM.
I find with any form of insulin resistance, once you let BGs get high it’s a mammoth task to get them down again. So I decided on an aggressive strategy of pre-empting BG rises and increasing basal rates well in advance so in theory I should be able to prevent any shocking highs. Overall, I’m very pleased with how it went if I do say so myself. Here’s the detail from day 1:
23.00, BG 5, TBR 110% – increased basal in anticipation of BG rise starting 2 hours post injection
00.30, BG 5.2, TBR 110% – holding steady
02.30, BG 5.8, TBR 120% – CGM shows BGs starting to creep up ever so slightly, gamble that this is the steroids starting to kick and increase temp basal
04.00, BG 6.6, TBR 130% – increased temp basal in anticipation of peak insulin resistance starting in a couple of hours. Also took 1u correction as rate of BG increase was speeding up and I wanted to keep that as flat as possible.
05.00, BG 7.4, TBR 130%
06.00, BG 6.6, TBR 130% – temp basal seems to be holding things steady, stick at 130% and keep a close eye on it
07.30, BG 6.3, TBR 130% – bolus for breakfast 30mins before eating. Increase breakfast bolus by 30% to accommodate steroids (this was a complete stab in the dark, in hindsight I’d probably increase by 50% and bolus about 45mins before)
09.30, BG 11.4, TBR 130% – BG peaks post breakfast at 11.4, give a bit more bolus to try and get that down fast as I’m conscious the second steroids are due at 10.30 and I want to get it down before they start having an impact
10.30, BG 10, TBR 150% – final steroid injection. Increase basal early to 150% in anticipation of them kicking in around 12.30 and my BG already being higher than I’d like
11.30, BG 7.4, TBR 150% – BG coming down gently following aggressive post breakfast corrections
No, I didn’t get much sleep. And so it continued for a further 2 days. I kept monitoring and trying to anticipate the changes. And it seems being brave worked. Over the next 12 hours I increased basal rates to 170% and then eventually started reducing them back down as the resistance started to fade. I returned to normal basal rates about 36 hours after the second injection. I was expecting my aggressive approach to end up in me needing to eat to treat low BGs, but that only happened once when the resistance was starting to fade and I didn’t reduce my basal quick enough.
When I started thinking about how to handle steroids, this is exactly the kind of info I was looking for and I just couldn’t find it, so hopefully this might be of use to some other poor soul in my situation. In summary, I learned:
Try to anticipate the rise and increase basals early – shifting a high once you’re up there is always going to be harder than preventing it
I couldn’t have done this without a pump and CGM – the trend info on the CGM showing me whether I was rising or falling was invaluable. I gambled on basal rate increases based on tiny rising trends on the CGM – you simply couldn’t spot that on BG monitoring alone.
My obstetrician wanted to give me the steroids 2 days before my c-section. After a bit of reading I asked that we did them earlier, so that they’d have time to clear my system before the surgery. He agreed. If you have any choice (ie it doesn’t endanger the baby), I’d recommend getting the steroids out of the way early – otherwise you risk the steroid highs still happening while you’re giving birth and then clashing with the post birth insulin requirement crash. That would be a complete nightmare.
I have a couple of friends who are in various stages of getting themselves insulin pumps (do I really go on about it that much??). Having had similar conversations with each of them about what’s currently on the market in the UK, I thought a quick overview of some interesting recent developments in the UK pump market might be useful.
Bear in mind I’ve only used a Medtronic Paradigm pump, my thoughts below are based on reading reviews and publicity material, playing with samples at conferences and talking to people. This isn’t a scientific, double blind randomised control trial, it’s just my musings.
The Omnipod is a step nearer to the UK
Our friends over the pond have had the tubeless Omnipod for a couple of years now. The overall impression from people who use it seems to be very positive (save for a few reliability problems early on that seem to have now died down).
Personally I like the idea but have reservations on two fronts – firstly the pod is pretty large to have attached to you at all times. On a standard pump when you disconnect to shower or whatever you’re left with an infusion set roughly the size of a 10p. As you don’t remove the Omnipod pod for the entire 3 days until you replace it with the next pod you’re permanently attached to something roughly the size of half a small apple. My other concern is the tubelessness. My pump is attached by a piece of string which does have the unexpected benefit of my not being able to forget it or lose it easily. I don’t have to remember to pick it up before I run out the door as it’s attached to me. As the Omnipod is tubeless, that means you have to remember to carry the remote to do any dosing. Not an insurmountable problem I’m sure, just something that concerns me.
Insulet Corp recently gained a CE mark for the Omnipod, meaning that they can now sell it throughout the European Union. News reports say “the product will be available to a limited extent in selected markets in 2009 with broader availability in 2010“. Always good to see more choice on the market. One interesting issue for Omnipod entering the UK market may be their website – their .co.uk address is currently owned by a company that “specializes in mid-20th century designer furniture and distinctive accessories”!
The Paradigm Veo is already here!
Having had to wait impatiently for the Omnipod to hit the UK shores (and it’s still not here yet), it was a nice surprise to see that we actually got the Medtronic Paradigm Veo in the UK before our American cousins.
The Veo is an upgrade to the existing Medtronic Paradigm Real Time – it has some tweaks to the CGMS but it’s big new feature is that if you fail to respond to the CGMS hypo alarms it will suspend insulin delivery for 2 hours to help reduce the risk of severe hypoglycaemia. Thankfully severe overnight hypos haven’t been an issue for me since I was a teenager struggling with ye olde insulins of Ultratard and Actrapid, but if this had been available back then it would have been life changing for me. For more detailed info try the INPUT blog.
Accu-Chek combo system
New combined approach from Accu-Chek
The AccuChek Combo System is the latest from Accu-Chek, providing an insulin pump combined with what looks to be a fully functional remote and blood glucose meter. It looks interesting and if they could just integrate CGMS I’d be very tempted.
Pumps are very personal things, what suits you depends on what kind of life you lead, what you like, what you don’t like etc. What’s really exciting at the moment is the diversity in the types of pumps and features that are available, we’re really starting to see a market where each supplier has a defining feature whether that’s the lack of a tube, integrated CGMS, great remote functionality or the ability to give really small doses of insulin like the Animas 2020 . The next step has to be to get all the good stuff into one pump. For what it’s worth my wish list includes:
CGMS. This is my “must have” pump feature. I’m not interested in having it as a separate device, that’s just too much stuff to carry. It has to be integrated.
A remote with full functionality would be handy – so I can hide my pump in my bra when I’m wearing a nice dress and not have to fish it out at the table to change my basal rates.
If I’m carrying a remote, it’d be nice for it to have built in glucose meter so that’s one less thing to carry.
I’m surprisingly ambivalent about tubing. If I could get over the fear that I’m going to find myself on a train to London having left the only way of controlling my pump on my bedside table – and they could make the pod smaller – I’d certainly think about going tubeless. It’s not a big deal for me though; the tubing on my pump isn’t something that really bothers me.
Here endeth my thoughts for the day. Comments?
Comatose and rotting toes – the lighter side of insulin dependency