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Post by peppy on Mar 1, 2019 10:44:22 GMT -5
... Here is my question. what am I looking at? Am I looking at a continuous glucose monitor sensor and a graph to the Monitor/phone/bluetooth? OR, am I looking at a continuous glucose monitor sensor and a pump in one? What are they selling where? as in where on the body, how many mechanisms? am I asking correctly? I haven't ever looked at pump technology, word is it started with the auto syringe. I am that old. You are looking the CGM unit and the pump all combined into one unit. In the case of the Tandem the insulin lives in that unit and is pushed down a tube to the catheter under the skin. The pump decides what to send based on what it sees from the CGM, and on what you tell it you are doing. A pump is a miniaturized auto syringe, nothing more, nothing less. Tell it how you want the drug delivered and it does it. The newer pumps have the smarts to dynamically change the delivery based on what it sees. You have that exactly right. exact me more please. where in this unit? with a Subq Catheter, for insulin delivery, insulin stored in the unit shown, does the unit get the venous mg/dl CMG value? Specifically, can a subq Cather delivering insulin also have components to obtain a venous glucose value with out the vicinity of the insulin delivered affecting the glucose/mg/dl value?
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Post by agedhippie on Mar 1, 2019 10:46:35 GMT -5
I have not read up on the closed loop systems but apparently they use CGM data and run algos to determine IOB, glucose trends and other inputs to come up with dosing. For many, Afrezza will be much easier. Realistically a informed and disciplined Type 1 who also has a bit of luck on their side could have very good control with a closed loop system but the majority of Type 1s would not fall under this characterization. In the world of Rx (and healthcare in general) patient compliance is a challenge and many times, asking the patient to do the most simple of things is an exercise in futility and Liane can likely speak to this extensively. Ask a pharmacist how many of the diabetic patients that come in for insulin know which one they need - you would be shocked how many have not a clue. Easy to dose, very forgiving and less patient judgement required make Afrezza a winner for the PWD and in their very complicated lives, making compliance easier with better outcomes is a winning formula. Your description of the components of a closed loop system is spot on. The system monitors the inputs and doses insulin without user intervention - press go and forget about it for the next few days. Right now the only closed loop system I know of in the wild is the openaps/Loop system which is a home made device a lot of people use (JDRF is funding it's phase 3 trials). The other smart systems like the Tandem Control-IQ and Medtronics 670G are hybrid loop and do require user intervention - you have to tell it when you eat or exercise. Closed loop systems should get good results almost regardless of the person does because they are designed for zero user interactions. This makes compliance trivial, if you are wearing the pump you will be compliant. These start to go into phase 3 this year so they are probably a couple of years out at this point. Hybrid pumps will have compliance issues because people are going to do things like not tell it when they eat so the pump has to sort out the mess later. It can sort this out, but it's not going to help their TIR! I use xDrip to manage my levels and when I am well behaved I get good numbers (yesterday was 91% TIR), but getting lazy with food inputs is my usual downfall.
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Post by agedhippie on Mar 1, 2019 10:51:35 GMT -5
Aged - during non fasting hours 8am-8pm afrezza users where 100% in range. Afrezza is a prandial and not a basal. Don't look for afrezza to affect fasting BG at 2am. That is not afrezza's job. To achieve fasting "time in range" the PWD would need to do what Dr. Kendall suggested and increase the basal. ... Insulin therapy is a system. It combines basal and bolus insulin which is why the outcome is important. If the patients follow Dr Kendall's suggestion and increase their basal what will that do to their previous in-range daytime numbers because they are now taking more insulin? It's all a balancing act - basal impacts bolus, bolus impacts basal.
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Post by agedhippie on Mar 1, 2019 10:56:28 GMT -5
You are looking the CGM unit and the pump all combined into one unit. In the case of the Tandem the insulin lives in that unit and is pushed down a tube to the catheter under the skin. The pump decides what to send based on what it sees from the CGM, and on what you tell it you are doing. A pump is a miniaturized auto syringe, nothing more, nothing less. Tell it how you want the drug delivered and it does it. The newer pumps have the smarts to dynamically change the delivery based on what it sees. You have that exactly right. exact me more please. where in this unit? with a Subq Catheter, for insulin delivery, insulin stored in the unit shown, does the unit get the venous mg/dl CMG value? Specifically, can a subq Cather delivering insulin also have components to obtain a venous glucose value with out the vicinity of the insulin delivered affecting the glucose/mg/dl value? In the Tandem it uses a Dexcom sensor for the glucose levels. There is work being done on combining the subq catheter and the sensor, but that's nowhere near complete yet. Insulin bleed over is not a big problem provided the doses are not delivered in spikes.
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Post by harryx1 on Mar 1, 2019 11:19:49 GMT -5
I see the T:Slim having many benefits in the 4-12 age group. AI or predictive technology could be a good fit for that group. However, that means you have to rely on a machine (algorithms) to make those decisions & if something goes wrong with those then it could be catastrophic. I would assume the AI would still need input from the user as it wouldn't know exactly what the person is eating (banana, apple, pizza, pasta, etc). Most people want simple & easy to use solutions that don't require a lot of work. I believe Afrezza fits that scenario more than a pump.
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Post by Deleted on Mar 1, 2019 11:24:52 GMT -5
Aged - during non fasting hours 8am-8pm afrezza users where 100% in range. Afrezza is a prandial and not a basal. Don't look for afrezza to affect fasting BG at 2am. That is not afrezza's job. To achieve fasting "time in range" the PWD would need to do what Dr. Kendall suggested and increase the basal. ... Insulin therapy is a system. It combines basal and bolus insulin which is why the outcome is important. If the patients follow Dr Kendall's suggestion and increase their basal what will that do to their previous in-range daytime numbers because they are now taking more insulin? It's all a balancing act - basal impacts bolus, bolus impacts basal. Afrezza takes volatility and variability out of the system. Less combinations and permutations means less variance (volatility) and less volatility means reduced long term health complications which translates into reduced healthcare costs. On the artificial pancreas thing, at some point, there will be a software issue which is a risk of any technology. Problem is, depending how big the issue, it could mean a day or two of agony or death. Someone is going to get a false flag bolus at some point and if its in the middle of the night... Hippie, is the open source one that guy who used to run IT at Wegmans and had a kid on a pump? I think he just said F it to the industry and FDA and built his own. Pretty impressive.
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Post by mango on Mar 1, 2019 11:59:30 GMT -5
Insulin therapy is a system. It combines basal and bolus insulin which is why the outcome is important. If the patients follow Dr Kendall's suggestion and increase their basal what will that do to their previous in-range daytime numbers because they are now taking more insulin? It's all a balancing act - basal impacts bolus, bolus impacts basal. Afrezza takes volatility and variability out of the system. Less combinations and permutations means less variance (volatility) and less volatility means reduced long term health complications which translates into reduced healthcare costs. On the artificial pancreas thing, at some point, there will be a software issue which is a risk of any technology. Problem is, depending how big the issue, it could mean a day or two of agony or death. Someone is going to get a false flag bolus at some point and if its in the middle of the night... Hippie, is the open source one that guy who used to run IT at Wegmans and had a kid on a pump? I think he just said F it to the industry and FDA and built his own. Pretty impressive. The open source one is really pretty cool
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Post by InvesterSam on Mar 1, 2019 12:25:15 GMT -5
Closed loop system is what I use in materials testing as an engineer all the time. Control algorithm typically used is PID (Proportional, Integral, Derivative control of errors) to keep the deformation or load matching the intended target. The single most important requirement for the closed loop testing is the speed of action. Of two types of loading systems (screw type and hydraulic), I have not seen any screw type closed loop system due to its slow reaction (screw must turn to achieve loading and it takes time). Almost all closed loop testing systems are hydraulic system where just opening valves can deliver tens thousand pound of load instantaneously.
An example of closed loop system is driving a car. You see the road turning in front of you. Then turn your steeling wheel. You realize that you turned too much, then make a correction and you are safe (you are on the road). That is how we drive. Imagine a car that the front wheels turn after 5 seconds after you turn the steering wheel (RAA speed of action). You may be able to steer through with a good algorithm if the road turns gradually. However, it would be extremely challenging to deal with unexpected turns (or unexpected meals).
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Post by sayhey24 on Mar 2, 2019 8:52:00 GMT -5
Aged - during non fasting hours 8am-8pm afrezza users where 100% in range. Afrezza is a prandial and not a basal. Don't look for afrezza to affect fasting BG at 2am. That is not afrezza's job. To achieve fasting "time in range" the PWD would need to do what Dr. Kendall suggested and increase the basal. ... Insulin therapy is a system. It combines basal and bolus insulin which is why the outcome is important. If the patients follow Dr Kendall's suggestion and increase their basal what will that do to their previous in-range daytime numbers because they are now taking more insulin? It's all a balancing act - basal impacts bolus, bolus impacts basal. Aged - I think Sam's example of driving a car with delayed turning is an excellent example of the problem you are living with and why you were trained the way you were with old school RAAs "basal impacts bolus, bolus impacts basal". As you have said many times you have been taught to adjust your baseline with your RAA dosing. If you used a prandial which worked at the speed of natural insulin release you would not be doing this.
If you were using afrezza and did what Dr. Kendall said your overall 24hr baseline would decrease - for example 150 to 120. This will significant affect you A1c and 24hr TIR but as he said you will not see additional hypos because afrezza is in and out so fast and shuts off liver glucose release. If you view your BG as a sine wave afrezza reduces the amplitude of the BG wave and keeps you much closer to the baseline number with significantly less variability.
Your current frame of reference - "It's all a balancing act - basal impacts bolus, bolus impacts basal" changes significantly. With afrezza, afrezza affects post prandial glucose spikes to get you back to baseline and is out of the body. That allows the basal dosing to affect what you want the target baseline to be. That my friend is what we have been telling you for years and what Dr. Kendall told the world last June at ADA2018.
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Post by prcgorman2 on Mar 2, 2019 9:39:11 GMT -5
I’ve read an article (I think in DiabetesMine) for a young woman (I think T1) who was attracted to Afrezza for the reasons you are saying Seyhey, and additionally, she wanted free of an appliance attached to her body for those times she wants to be vain (her word) and wear summer clothing or a bikini. She said the appliance didn’t bother so much but the explanations to non-PWDs that went with it did. That’s not a big driver for marketing Afrezza obviously, but I thought it was honest.
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Post by agedhippie on Mar 2, 2019 20:34:26 GMT -5
Hippie, is the open source one that guy who used to run IT at Wegmans and had a kid on a pump? I think he just said F it to the industry and FDA and built his own. Pretty impressive. Evan Costik. He more or less started the whole #WeAreNotWaiting movement that has lead to the homebrew approach of Nightscout, Loop, and openAPS. I can see this splitting the endo world - if Afrezza upsets some then this is going to give them fits because never mind off-label, in this case there isn't even a label! As we have all seen the medical world changes slowly so the #WeAreNotWaiting crowd are just doing it. (Full disclosure: I use their smart CGM for managing my levels so I am not unbiased in this).
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Post by peppy on Mar 3, 2019 1:27:25 GMT -5
Hippie, is the open source one that guy who used to run IT at Wegmans and had a kid on a pump? I think he just said F it to the industry and FDA and built his own. Pretty impressive. Evan Costik. He more or less started the whole #WeAreNotWaiting movement that has lead to the homebrew approach of Nightscout, Loop, and openAPS. I can see this splitting the endo world - if Afrezza upsets some then this is going to give them fits because never mind off-label, in this case there isn't even a label! As we have all seen the medical world changes slowly so the #WeAreNotWaiting crowd are just doing it. (Full disclosure: I use their smart CGM for managing my levels so I am not unbiased in this). agedhippie , do you remember when it used to be said, "let's talk brass tacts?" So said, your treatment of choice, injecting insulin using pens. Second: How many days worth on insulin basal and fast acting plus a continuous glucose monitor you say is also in the only mechanism shown on the advertisement? Eh? Third: Additionally the charge, lithium? charge to run the syringes and the blue tooth? Fourth, these do not look like refillable mechanisms..... what is the cost? That's a start. Show me with circles and arrows how the mechanism shown labeled Dexcom G6 has in it a continuous glucose monitor, a lithium battery and two miniaturized auto syringes, pictured below. Something seems to be rotten in Denmark. I still think these auto syringes are single attachments.
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Post by sayhey24 on Mar 3, 2019 9:53:16 GMT -5
Hippie, is the open source one that guy who used to run IT at Wegmans and had a kid on a pump? I think he just said F it to the industry and FDA and built his own. Pretty impressive. Evan Costik. He more or less started the whole #WeAreNotWaiting movement that has lead to the homebrew approach of Nightscout, Loop, and openAPS. I can see this splitting the endo world - if Afrezza upsets some then this is going to give them fits because never mind off-label, in this case there isn't even a label! As we have all seen the medical world changes slowly so the #WeAreNotWaiting crowd are just doing it. (Full disclosure: I use their smart CGM for managing my levels so I am not unbiased in this). Anything which will help "splitting the endo world", count me in. A friend of mine wanted to monitor his mom who is in India. I set him up with glimp and Nightscout. In the next 3 to 5 years everyone will be monitoring blood glucose just like they count steps on their fitbits today. At that point the curtain will be lifted on the ADA and their "Step" program and the disaster it is.
Doctors will never move the ball down the field but the engineers will. The more the curtain is raised the more afrezza awareness there will be.
I heard Dr. Kendall talking about Nightscout in an interview the other week which left me with the impression he is some how involved with the group. It would be good to get these kids on the afrezza so the parents can stop worrying about night time lows and let them sleep through the night.
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Post by agedhippie on Mar 3, 2019 12:04:44 GMT -5
Evan Costik. He more or less started the whole #WeAreNotWaiting movement that has lead to the homebrew approach of Nightscout, Loop, and openAPS. I can see this splitting the endo world - if Afrezza upsets some then this is going to give them fits because never mind off-label, in this case there isn't even a label! As we have all seen the medical world changes slowly so the #WeAreNotWaiting crowd are just doing it. (Full disclosure: I use their smart CGM for managing my levels so I am not unbiased in this). agedhippie , do you remember when it used to be said, "let's talk brass tacts?" So said, your treatment of choice, injecting insulin using pens. Second: How many days worth on insulin basal and fast acting plus a continuous glucose monitor you say is also in the only mechanism shown on the advertisement? Eh? Third: Additionally the charge, lithium? charge to run the syringes and the blue tooth? Fourth, these do not look like refillable mechanisms..... what is the cost? That's a start. Show me with circles and arrows how the mechanism shown labeled Dexcom G6 has in it a continuous glucose monitor, a lithium battery and two miniaturized auto syringes, pictured below. Something seems to be rotten in Denmark. I still think these auto syringes are single attachments. The pump only holds bolus insulin (I was about to put RAA but a few people use human insulin). The pump simulates basal insulin by giving you a very small dose of bolus insulin every few minutes. This keeps the insulin level in your body correct. This has the added benefit of allowing you to modify your basal insulin throughout the day to match your basal glucose (glucose drops between 1am and 3am, and spikes after that until around 6am). How long a pump fill lasts is a trickier question. For me the pump hold about 7 days of insulin. That works quite well because I refill the pump every 6 days, and swap infusion sets every 3 days so I get two site changes to a pump refill. That's not approved practice btw as you are meant to change the insulin cartridge with the set, but that wastes insulin and is extra work. Embedded pumps can go months between refills because they use very concentrated human insulin, but those pumps are almost non-existent now. There is a rechargeable lithium battery in the pump that powers everything. The best way to answer the refill question is by pointing you at this youtube video - How To Load a New Cartridge Onto Your Insulin Pump. Tandem pumps are a pain to refill. The Dexcom G6 is just the sensor, the CGM, battery, and auto syringes. The pump you are looking at only has a single syringe, the t:dual is a dual chambered pump, but that's waiting for the Zealand pumpable glucagon trial to complete.
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Post by mannmade on Mar 3, 2019 12:21:56 GMT -5
Aged, I am not a pwd, but it seems to me that it would be a lot easier to take one shot of Tresiba per day and manage post prandial excursions with a cgm and Afrezza. I know this may sound a bit naive since I do not have diabetes but based on the success people seem to be having why would a pwd want to be tied to a pump? I know of a boy who at 21, had almost died twice because his pump was miscalibrated and he went into sever hypo. He has since swtiched to Afrezza and a cgm, dropping his pump, at his father's request (father is a doctor by the way) and now enjoys an Hba1c at about 5.9. And most importanty has not had any issues since in the two years he has been on Afrezza.
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