Medtronic Hybrid Closed Loop System: Extra Bang For Your Buck
Gary Scheiner MS, CDE, Jennifer Smith RD, LD, CDE, Alicia Downs RN, MSN, CDE, Annette Valle RN, CDE
The Medtronic 670G "hybrid bar loop" system has been round for a yr and a half since we began using and educating patients. And we've discovered lots. We’ve discovered that 670G is beneficial for some, but it’s clearly not for everyone. Sure, for a mean individual with diabetes, it could actually improve glucose management while decreasing the danger of dangerous hypoglycemia. But there are limitations to the level of glucose control that may be achieved, and there are lots of hassles and additional tasks related to using the system.
There are other hybrid-closed loop methods which are already in use, although they don’t seem to be in the "FDA-approved" system record.
- Loop and OpenAPS techniques are extremely effective in enhancing glucose control but require particular gear and
- Tandem T: Slim and Basal IQ are straightforward to use, nevertheless it solely breaks down the basal insulin to help decrease it.
- Other techniques coming available on the market soon: Tandemin Management IQ, OmniPod's Horizon, Tidepool Loop and BigFoot Biomedical techniques are all automated primary settings (comparable to Medtronic's 670G, however much less with the consumer), however ready to boot earlier than FDA logs off All we will do is describe them in our day by day fantasies.
So for those that need a 24-hour auto-default, which is now authorised by the FDA, it leaves only one choice: 670G.
Medtronic has taken steps to scale back a number of the poor high quality of life. similar to repeated calibration requests with a brand new and improved transmitter. Still, there are numerous different drawbacks that don't seem to go away soon.
The question then is:
How can we squeeze better performance from the 670G hybrid-closed loop System?
I feel most of us would really like to tolerate small disadvantages if it means a lot better glucose management, not just a bit enchancment over time.
This question, Built-in Diabetes Providers medical employees put the collective brain collectively and put forward the next options:
- Prepare the settings BEFORE starting automated mode (AM).
It is true that if you end up in automated mode, the system does not give horrible issues about what the basal settings have been earlier than. It smooths every thing and adapts to the state of affairs. Nevertheless, you are not all the time in automated mode and you don’t want your management to endure if you use guide mode. Because of this you get your primary shift to maintain you secure when you’re fasting, non-bolusing, non-training. Additionally setting Carbon Effectivity so that you are shut to your BG for Three-4 hours after eating, and understanding how lengthy the bolus really lasts – which may best be determined by analyzing CGM knowledge after the correction bolus  Carb ratio and lively insulin time are the one parameters which are transferred immediately from the guide mode to the AutoMode (AM) mode, so it is sensible that these settings are chosen before AM is began.
Making the fallacious settings whenever you start AM produces a rocky start in the first few days / weeks. Yes, AM makes adjustments to the essential service to clean things up, however these adjustments are short-term and delicate, so don't anticipate them to clear up every thing.
- Understand how AM works.
AM updates its algorithm (formulation used to decide primary settings and correction doses) at midnight every night time based mostly on insulin use during the last six days. Because of this, it is best to use the pump in MANUAL mode for the complete six days before beginning to use AM.
Because AM adjusts its algorithm during the last six days of insulin use, watch out after steep rise insulin necessities akin to sickness, steroid use, consuming or extended stress. AM could also be more aggressive than standard after these durations of time, so think about using the use (150) for a minimum of a couple of days for momentary durations of use of insulin.
When in AM, there are solely two settings which might be "moved" from the guide mode to carbonic and lively insulin time. It only recommends reversed correction (reduction of meal consumption)) if glucose is lower than 100.
There are limitations on how much AM will increase basal insulin, which varies personally. Based mostly on our expertise, it seems to be about 2.5 occasions the "average" primary course, so AM can't repair the excessive readings shortly, as an alternative use the correction plugs. Decreasing or extinguishing produces a gradual improve in glucose one hour or two hours later. still have to cope with fast appearing carbohydrates
- Do all the things you possibly can to make sure that your insulin is absorbed evenly. Issues with insulin perform or dosing intrude with AM's capability to management blood sugar ranges.
- Change your infusion set often – every 2-3 days
- Rotate your website appropriately (don't use the identical level twice a month)
- Change your infusion set for the first sign of irritation or inefficiency  Hold your insulin nicely and don't use the final one use date
- Take away air bubbles from tank and hoses before use
- Know when to take your self out of automated mode.
There are conditions where the automated mode has the potential … we say… to get optimal glucose control. For instance:
- When utilizing a sluggish melting meal, a traditional bolus can peak and cease working too early. Because the expanded (square / double) bolus function just isn’t out there once you use AM, it might be best to briefly change to guide mode and bolus utilizing a sq. or double pack. b. Short-term Basal
- Turning Off Auto Mode permits you to set short-term baseline values for, for instance, sick days, stress, long-term exercise, alcohol use, and fatty meals.
- Steroids, resembling cortisone or prednisone, can considerably improve blood sugar for several days. AM will not be in a position to keep up with the increased want for insulin. Altering to guide mode when the temperature has risen or a secondary base mannequin tends to work better.
- On days of intense or prolonged physical exercise, both basal and bolus insulin requirements might be significantly decreased. AM limits the period of time allowed for a very low primary dose, and bolus doses calculated during AM counting are possible to be too high when used.
- If in case you have high blood sugar due to an infusion drawback, it’s best to change to guide mode, change the infusion set and let the bolus inject a high BG. When BG is on the best way again, go back to AM
* Oh, by the best way: Don't overlook to activate "pause before trip" if you turn off AM as a result of this function is disabled every time AM is on.
- Do not cover things from AM
After disconnecting, set the pump to a halt to let you realize that you do not get any insulin. If the system believes that it’ll receive AM-controlled basal insulin whenever you really don’t, it often lowers the dose for you within the subsequent few hours for elevated or rising sugar levels. Similarly, in case you give yourself an insulin dose or in case you use inhaled insulin (Afrezza), stop AM for the subsequent 2-4 hours. In any other case, the system might switch insulin an excessive amount of, considering that you’ve much less insulin (lively insulin) than you really do.
In case you eat, enter carbohydrates and bolus accordingly. AM is just not designed to cover most meals and snacks. The exception could also be small, slow-melting snacks.
By no means do you have to give a glucose (bolus or correction) worth that isn’t a real worth based mostly on a meter or CGM. This could cause AM to change insulin supply patterns for a number of hours, and the distinction between glucose labeling and sensor value might drive you to carry out further calibrations.
Some individuals want to feed "ghost carbs" (carbohydrates that they don't really eat) so that the pump provides the bolus to repair elevated readings. Although this apply is definitely better than feeding fictitious blood glucose, it is often discouraged by the effect it has on AM over the subsequent hours
- Make the sensor work as well as attainable.
AM (and your peace of thoughts) rely upon reliable sensor knowledge. Calibrate the sensor 3 to 4 occasions a day, preferably when the glucose ranges are secure, to keep away from unevenness related to the delay time. If attainable, use the Contour Next meter provided with the pump. This is probably the most correct indicator of the market, and it offers probably the most correct readings for calibration purposes.
Comply with the principles for setting the sensor, including any taping methods. A protected / secure sensor works higher than the one that always comes off.
Each time there is a vital difference between the sensor and the calibration values, you could be asked to recalibrate immediately. Don’t do it. Wait a minimum of 30 minutes for extra correct values. This enables you to avoid sensor error or AM error.
- Design an Train.
Don't overlook that fast-acting insulin often takes Three-4 hours. The essential modifications made by AM a couple of hours ago will continue to affect your blood sugar ranges. In case your exercise is causing your blood sugar to fall, set the momentary goal (150) a minimum of one hour before beginning the exercise. Hold Your Aim Targeted After Train If You Are Susceptible To Drop After Workouts
If your 150-item is just not sufficient to forestall low blood sugar ranges, think about using fast-acting carbohydrates before coaching without bolusing. And, as mentioned earlier, once you disconnect the pump during exercise, set the pump to droop mode.
- Assume again about how to treat hypos
When glucose ranges are approaching a low degree, AM often reduces considerably insulin. This reduction can continue until the glucose ranges return to a protected degree. In consequence, LESS carbohydrates are required for the remedy of low or low low remedy. A mixture of regular carbon remedy and a decreased basal may cause high blood sugar ranges.
Be careful additionally when trusting the sensor when creating a low. In lots of instances, the sensor will take at the least 30 minutes to detect a rise in blood sugar after remedy. For those who trust the sensor beneath these circumstances, you will discover an excessive amount of. It’s best to verify your glucose together with your finger for 10-15 minutes after low remedy to make sure that your blood sugar degree (or not) has risen to a protected degree.
- Adjusting the Pump Settings
Changing to AM might require modifications to regular pump settings. If the pump settings have not been fine-tuned earlier than utilizing AM, you will in all probability find that your carbon dioxide ratio was too conservative and that the standard primary settings of the pump have been too aggressive. If You Change Your Carbon Relationship After analyzing your knowledge from AM, think about adjusting the essential pump settings on the similar time. On this method, glucose is unlikely to go excessive or low once you return to guide mode.
Though it’s recognized that lively insulin has an lively time of about Three-5 hours, it might be useful to set a shorter time (2 to 2.5 hours) in AM mode. This causes AM to think about less lively insulin when calculating correction doses. This may be helpful for those who want to make the algorithm more aggressive.
- Avoid Grazing!
Eating and bolusing too typically may end up in optimal system performance. AM allows a extra aggressive primary setting when there isn’t any lively bolus insulin in any respect. Grazing makes the system less aggressive and leads more to AM launches due to extended maximum or minimum delivery.
- Analyzing Your Knowledge
If a tree drops and nobody hears it, does it make a sound? In case your blood sugar is chronically irregular and no one does anything good about it? Obtain the pump and examine your knowledge frequently;
Carelink is Medtronic's designated info system. It might be a bit complicated and it doesn’t supply all of the features you want (for instance, sensor protection notification), however it offers helpful insights. Verify the Meal Bolus Wizard report, particularly, if you’d like to examine whether or not carbon dioxide is required, or when you want a bolus earlier (spikes instantly after consuming are often an indication of bolus too late). Physical exercise and different way of life occasions don’t seem in Carelink, so comply with them yourself and see how glucose responded within the Weekly Report.
One other various for checking / analyzing knowledge is a network-based program referred to as Tidepool. In contrast to Carelink, Tidepool permits taking notes and downloading them into stories. It additionally allows you to see what the essential velocity was when AM had marked it up and down all day lengthy, and particular person day by day studies have been extra simply interpreted.
So what can realistically be achieved with 670G?
Medtronic's key research a number of years in the past confirmed that 670G users reached a mean of about 6.9% (common glucose of about 150 mg / dl) and about 70% of the time within the 70-180 range.
The sufferers with whom we’ve got labored with the above methods have succeeded in attaining the following:
- Average Blood Sugar 130-145. Lower averages will not be practical with AM's current target settings and correction parameters. Customers who’re accustomed to utilizing decrease targets should set a guide mode target to 120 earlier than starting to use AM to get used to pending modifications. This corresponds to a mean of A1c 6.5%
- Time vary (70-180) about 80-90% of the time
- Less than three hypoglycemic events per week.
Not too shabby! 19659005] It isn’t meant to promote you any specific product. We are proud to give our sufferers a fair scam of every part out there so that they will make an educated selection. But if you already have a Medtronic 670G or have given it a robust judgment, hopefully these strategies will provide help to get the best value from it
. We are joyful to work with everyone over the telephone and over the Web to get the best out of any system.
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