Why I Didn’t Buy a Dexcom

I had my monthly prenatal appointment with my Endocrinologist last week. We have seen each other once a month and traded e-mails once a week for eight months now, so we seem to sort of “get” each other now. My appointments are friendly and chatty. This month, he gave me a good ribbing for choosing not to purchase the Dexcom after my trial. He says I am the only person he’s ever met who decided that she didn’t really need it.

While he is right that I did choose not to purchase the Dexcom after my trial, his understanding of my reasons for doing so are a little off.

Let me start by saying that the device is impressive. I tested a Medtronic MiniMed CGMS several years ago when it was in trials. It was clunky, was not remote, and was not waterproof. You had to put the thing in a little waterproof shower pouch that you could hang around your neck in the shower. Really? You had to go to the doctor’s office to have the sensor inserted. To top it all off, the thing was testy. The first time I trialed it, it crapped out after just a day. The second time, the result were better, but you could only wear it for three days. Probably the worst part about the device was that it did not communicate any of its information to me, the patient. Instead, all of the information was stored in the device until the doctor downloaded it. So much for catching highs and lows.

Today’s CGMs are in another realm completely. The Dexcom sensor was really pretty simple to “install” and the user interface on the device itself, while basic, was relatively easy to figure out and was functional. The sensors are now remote, so I was not tethered to the device, and they’re also waterproof, so I could attend water aerobics and take a shower without worrying about a shower pouch. Perhaps most importantly, this new generation shares its information with me, so I have “real time” information about whether my BG is trending up or down, or is out of range. I’ve got to admit, that’s pretty helpful.

When I trialed the Dexcom, I managed to get over 14 days out of one sensor, although by the end, I was seeing a lot of ??? screens. The low and high warnings were a bit annoying in the beginning, especially when I was recovering from a low and it was STILL beeping at me. The lag-time was frustrating. But once I got the alarms set to the right levels (60 and 160 worked well for me,) this annoyance was somewhat tempered. Of course, the fact that it caught untold numbers of pending highs and lows during the trial is not lost on me. My graphs and charts from the second week, once I got used to the thing, were amazing.

So why didn’t I buy? It basically comes down to a sort of psychological burden. I really felt like the thing just put too much of my focus on this damn disease. Before the Dexcom, I was already testing 16 times a day. Now I had to do even more finger sticks either to calibrate, or because Dexcom thought I was high or low and I needed to confirm. It was like the thing was whispering in my ear all day, “Hey you … you’re diabetic. Don’t forget.”

I’m also really hung up on the idea of yet another hole in my skin. I don’t like wearing all of these devices on my body. When the pros outweigh the cons, I’m willing to do it, but otherwise, I’d like to get away from sensors and infusion sites. If they ever figure out how to put the two together into one site, then I would be really interested.

The device is big and cumbersome, too. It did not fit in most of my pants pockets, and the clip was worthless. The size and shape were a constant reminder … when the darn thing popped out of my pocket in the bathroom … when I would leave it on my desk at work during a meeting … when it took up precious real estate on my nightstand where it was jockeying for position with my tester and my juice boxes and my box of Dots.

In the end, I looked at my current diabetes regime, the fact that my A1C’s have been amazing throughout my pregnancy, that my baby is healthy, and that my non-pregnant A1C typically hovers in the 6.0 range, and I decided that the slight improvement in my control was just not worth the psychological pressure.

The day I returned the device to the sales rep, I caught a low in the 20’s only because I tested. I didn’t feel it. I wondered if I should have bought the Dexcom. I still wonder sometimes. And maybe I will change my mind one day, when my A1Cs are not as good, or the lows and highs are more frequent. But diabetes, and life in general, is all about balance. We need to find a way to manage this disease while staying mentally healthy, too. And the best way to do that is different for every one of us. For now, I think this is the best decision for me.

News Tidbits: School Lunches, Pregnancy, and Insulin Pumps

There’s not a lot new happening on the pregnancy front with me this week. My hips still hurt, my appetite is still out of control, and my belly is still growing.

Instead of posting more of the same, I thought I would share some interesting news tidbits I’ve gathered off the Web lately.

Here they are, in no particular order.

There are a lot of people getting into the School Lunch act. In particular, these two blogs seem particularly noteworthy.

Fed Up With School Lunch: The School Lunch Project, http://fedupwithschoollunch.blogspot.com/

Mrs. Q is a teacher in Illinois who is eating the school lunch everyday and reporting on her experiences. Needless to say, the experiences are rarely positive. It looks like she’s getting a fair amount of traffic over on her blog, and she has recently lined up some impressive guest bloggers including other teachers from all over the world (including an American who teaches in Japan,) fed up parents, a Food Service Director, and a student journalist who plans to fill us in on the goings-on in the world of school lunches. Pretty neat stuff!

School Lunch Found Guilty, http://schoollunchfoundguilty.wordpress.com/
This blog is manned by a 6th grade class in Queens, NY. They are documenting their daily school lunch, along with their impressions of it, in the hope of making improvements. As you might suspect, they tend to turn their noses up at the overcoked vegetables and the cold lasagna, but they are surprisingly receptive to the fresh fruit. Here’s hoping their blog garners some publicity, and even more important, some improvements in their school lunches!

In Pregnancy news, IBTHealth is reporting that pregnancy does not make you forgetful . Apparently a group of researchers in Australia recently found that the cognitive abilities of pregnant women were no different than those of non-pregnant women. I would call to tell them how wrong they are … if I could just find my phone!

This article in the San Francisco chronicle warns of the risk of Listeria in pregnancy. Apparently the risks are higher than ever thanks to our “ineffective food safety system.” There is currently no requirement that food producers test for harmful bacteria. The House of Representatives passed legistlation to close this loophole last summer, but the Senate has STILL not voted on it. The article goes on to say that while most people, including pregnant women, are immune to Listeria, fetuses are not. Miscarriage or stillbirth is the unfortunate result. I am thinking twice about my cold cut sandwiches now.

On the Diabetes front, you might have already heard that Medtronic MiniMed just got FDA approval for their new Paradigm Revel. I saw the news first over at Diabetes Mine. The Revel is a combination insulin pump and continuous glucose monitor (CGM) that includes new and improved features including mulitple alert settings for the CGM, improved screen navigation, and more precise dosing. Nevertheless, it still does not include the autmatic-suspend feature that their Veo system has. Unfortunately, the Veo is only available in Eurpoe. Seems kind of ironic given the perception in the US that countries with socialized health insurance  systems prevent such innovative technologies from entering their markets …

The Rundown: Baby Gear, Blood Sugars, and Dexcom

I have lots of different things to share today, but no good way to bring them all together. So here they are, in no particular order.

We purchased our first piece of baby gear: a travel system (AKA stroller, car seat, and carrier all in one.) Walmart was having a “Baby Days” sale over the weekend, and we found a travel system on their Website that was a pretty good price and that gets decent reviews. It’s the Evenflo Aura in “Georgia Stripe”. We like that the carrier is lighter than some of the others, and that the carrier handle is easier to grip. Also, the brown color should be good for hiding the “baby dirt” that we expect to accumulate. We were not particularly impressed with the maneuverability of the Evenflow strollers, but for the price, we were willing to compromise on that. Speak up if you know anything about this thing. Walmart has a 90 day return policy, so we can return it if we find out it’s a death trap or something.

So far our baby stash includes the travel system, two picture books, a baby monitor, and two bibs. Sounds like we better get shopping!

My belly is getting bigger. There is no denying that I’m pregnant now. And I have become an even bigger clutz, running into chairs, doorways, countertops, and doorknobs with my protruding midsection.

My appetite is at an all-time high. This is a far cry from the first four months or so when I had to force myself to eat most of the time. Yesterday we had a catered, Italian-themed lunch at work. Normally I would skip the pasta and just have a big bowl of salad. Yesterday I also had garlic bread and fettucine alfredo — two servings! I think it’s been years since I last ate garlic bread and I normally avoid fettucine alfredo for the obvious reasons. Luckily, my new, reved-up insulin-to-carb ratio took care of the carbs, so I did not suffer from the dreaded high BG spike two hours later.

Speaking of blood sugars, they seem to have leveled out a bit this week, which is a welcome relief after the roller coaster last week. I’m still treating one or two lows per day, on average, but they are mostly less severe than the previous ones. I still get the occasional high in the upper 100’s or low 200’s, usually because I miscalculated a bolus or over-treated a low, but I am aggressively treating those with insulin.

I re-started my trial Dexcom sensor on Tuesday morning and it’s still doing its thing. I think this might be part of why my blood sugar roller coaster is less extreme this week. The adhesive is starting to curl up around the edges, but the sensor is still holding on pretty firmly. Last night the device finally woke me up with a false alarm. It thought I was low, but I was actually 119. I was tempted to just eat 5 Dots and fall back asleep, but I’m really glad that I decided to actually test instead. This is the first time the device has done that.

A rep from Dexcom called yesterday to see if I wanted to move forward with a purchase. It turns out that I qualify for the device because of my pregnancy and hypoglycemia unawareness. My coverage is really good, too (90/10 for both the device and the sensors,) but I also have to pay my $200 deductible. So I am looking at about $300 for the start-up package and then $27 per month for the sensors. I realize this is much less than some of you pay, but it is still a big chunk out of my pocketbook right now. I am back on the fence. I told the rep that I would make a decision within the month.

This afternoon I am off to the Ophthalmologist to get my retinas checked out. The last time I went, everything was great and they told me that I could actually wait two years until my next exam, but that all changed when I became pregnant. Now we have to check them out again to make sure the pregnancy hasn’t caused any damage. This appointment always makes me nervous even though I’ve never had any eye problems. Still, after 27 years of this, it just feels like my eyes are a time bomb waiting to explode. according to the American Diabetes Association’s Eye Complications Web page, “Almost everyone with type 1 diabetes will eventually have nonproliferative retinopathy.” I wish I knew how much time was left on that timer!

Dexcom trial part 2: the highs and the lows

This Dexcom trial has been a roller coaster. Sometimes it is spot on, which is awesome, and sometimes it is WAY off, which drives me absolutely bonkers.

On the plus side, the other night it woke me up four times to warn me of low blood sugar and while I wasn’t always as low as it said I was, I was dropping. So it helped me  treat before I became a shaking, sweating, irrational mess. That is a huge bonus. Two nights ago, it woke me from a deep sleep when I was 27. That’s pretty scary … I was 27 and still snoozing away.

My husband commented that he liked that it was catching the lows before they became super-low, and that maybe the extra, inaccurate alerts were worth it because at least it is also catching the real lows. Although the alert is sometimes delayed, I don’t think I’ve had a low that it didn’t catch.

On the negative side, I have noticed that the trending arrows disappear with disappointing regularity. These are probably the best part of the system, and when they’re not there, I kind of wonder whether the device is worth all of the trouble. In addition, the device often gives me the ??? symbol overnight, sometimes for several hours at a time. This symbol means that the sensor can’t read my glucose at the time. The rep tells me that this happens due to some sort of weirdness with my biology … hormones or something are changing the interstitial fluid. This it a real bummer as I am finding that the alerts at night are another of the biggest assets of the device.

I put the sensor in my arm and, while the adhesive is really hanging on, the site is sometimes sore or irritated, especially if I bump it or roll over on it in bed. I was surprised to find that the adhesive is still super-sticky even after an hour in the pool on Saturday. I am actually a little apprehensive about removing this thing given the strong hold of the adhesive and the irritation at the site. I really dislike having another hole in my skin, too. I sure wish they could figure out a way to put the sensor and the infusion site all in one hole.

Did you know that you can’t take Tylenol when you use the Dexcom? If you take it, the device can’t read your glucose. Instead, it just gives you a 400 mg/dL reading until the Tylenol works its way out of your system (usually about 3 hours.) Tylenol is just about the only thing I can take for the headaches and achiness that come along with pregnancy, so this is also a pretty big disappointment.

Today is day seven of my trial and the Dexcom rep tells me that the sensor will start to fail tomorrow. After it completely peters out, I will try to restart it and see if I can’t get another couple of days out of it. She says most people get 10-14 days out of one sensor.

Also, I wanted to thank all of you who commented on my last Dexcom post. I got some good ideas from you, including changing the high and low alerts. Right now I am using 180 for high and 70 for low. I can see how playing with these from day to day or maybe changing them for overnight could be really beneficial.

Needless to say, I am still on the fence about actually purchasing a CGM. It’s a lot of money, and the hassles are real. But are the improvements to my quality of life, to my health, and to my baby’s health large enough to outweigh the cons?

Dexcom trial: A mixed bag

Today is my first day on the Dexcom trial. And it’s a mixed bag.

I inserted the sensor this morning. It took a little help from my husband, because I put it on my upper arm and we couldn’t figure out how to detach the applicator portion from the sensor pod. After a bit of fumbling, we finally figured out that we did not have the transmitter latch all the way down against my arm, so the pod would not release the applicator. Once we figured that out, it came a part easily enough.

The actual insertion was not too bad, although I did feel it. I think I would get better at it with practice, though, so the pain issue is not a big concern. The applicator really helps with this. It is kind of awkward, but once you use it once or twice, I think that you probably get pretty good at it, and it helps get the sensor at the right angle, keep it going in straight, etc. An added bonus is that it sort of hides the REALLY long inserter needle from you. Now, about eight hours after insertion, I can still feel the sensor under my skin, but it is not too bad. Occasionally I will turn my arm just right and it will pinch a bit, but mostly it just sort of feels like an infusion set.

The sensor pod and sensor are pretty low profile, but being the klutz that I am, I managed to get it caught in both my sports bra and my shirt sleeve this morning when I was getting ready for work. The tugging was a bit uncomfortable, but the adhesive held firm. I imagine you get used to having the thing attached to you, though, and automatically compensate during these sort of maneuvers.

The bad news is that it has been pretty inaccurate all day. It has been off by as little as 10 mg/dL (this was nice, but unfortunately fleeting) and by as much as 50 mg/dL. The worst part is that it is constantly buzzing to tell me that I am either low or dropping, even though my sugar has been primarily in range. I even changed the low alert to 70 (the default is 80,) but this has not really helped. I have been calibrating quite often in the hopes that this would help the sensor find the right level … this seems to be helping a smidge.

Another con is the size of the receiver. This thing is huge, and I am struggling to find a good place to stash it. You might remember from my maternity clothes post that most of these clothes do not have good pockets and certainly don’t have waistbands. So it is difficult to find a place to attach the receiver. Also, the receiver itself does not have a clip, so you have to use the case if you want to clip it to something. The case that came with the loaner that the Dexcom rep sent me for the trial absolutely wreaks of cigarette smoke, so I am not using it. Instead, I am carrying the receiver around with me, leaving it lay out on my desk, or tucking it into my sock (although it keeps trying to pop out.)

Perhaps the best part about the CGM is the trending arrows, which tell me if I am heading up or down and at what rate. I’m finding that this helps me decide when to test and treat. That is, if I am heading up or down fast (one or two arrows straight up or straight down), I will test and, most likely treat with either insulin or food. This is helping me treat before I get too low or too high.

All-in-all, I am not sure how impressed I am. It is still early, but, as I suspected, the inaccuracy is downright annoying. I’m definitely going to ride it out, though. Maybe I will get used to it, or maybe it will get better. The main goal here, of course, is to stay in range more often. After this trial, I will have to compare my BGs during the trial to my pre-trial BGs and see how they look. If I was able to stay in range more often, than maybe it is worth both the investment and the annoyance, at least during the pregnancy.

5 Month Endo Appointment

I had my regularly scheduled monthly appointment with the endo this morning and the verdict was positive. Here are a couple of takeaways:

The ketones are gone! Now that my BGs are starting to even back out (thank you, insulin resistance), I am no longer bottoming out overnight. This has cured my ketone issue and, perhaps more importantly, means that I can forgo the 2AM snack. Yay!

My A1c is even more awesome this month — 5.2. How is that even possible? I am suspicious, but the doctor is happy with it, so I’ll take it.

I have occasional slight swelling in my ankles now, but nothing to be concerned about … yet. My blood pressure is still good.
After a week of annoyingly high post-meal BG spikes, I adjusted my bolus rate yesterday. My endo is kind of weird about me making my own changes (something we disagree on), but he accepted it and we are leaving the rate alone for a week or two to see what happens.

He thinks my basals might still be a smidge too high, because I tend to spike too high an hour after a meal (160 range), but then drop to 90 or 80 at the two hour mark. This problem might sort of itself out as my insulin resistance grows, though, so we’ll keep an eye on it. Just for comparison purposes, and to show you that everyone’s diabetes is different, I just read that Kerri is now on a 1:6 insulin-to-carb ratio as she struggles with the later stages of pregnancy. In comparison, I was on a 1:6 ratio before I got pregnant (thanks again, insulin resistance!), and am now at 1:5.

My endo had lunch with the local Dexcom rep last week, and they are apparently more willing to do a trial of their CGM product now. I tried to get a trial a couple of months ago, but the rep in the corporate office would not do it. I had given up hope. I called the local Dexcom educator today and she is sending me a trial package this afternoon. She says it’s so easy that she can walk me through the set-up on the phone. So I might be sporting a Dexcom soon!

I picked the doctor’s brain a little about Metformin for Type 1s. I have been reading that more and more Type 1s with insulin resistance are using it to help with the weight gain and increased appetite that insulin can cause (See this post from Amy over at Diabetes Mine. I even read recently that they are using it more and more in the second and third trimester with pregnant Type 1s. We agreed that it is not really necessary for me right now because my insulin needs are just starting to increase past my pre-pregnancy levels and because I am not gaining too much weight (actually, I am gaining less than is expected.) But he seemed like he would consider using it during the third trimester or after the pregnancy depending on how things are going. I am happy that he was receptive.

It is snowing like crazy here again today. We are expecting another 10 inches or so before the end of the day on Thursday. Isn’t it time for spring yet?

Tomorrow morning we are off to the High Risk OB for the 20 week ultrasound and, hopefully, we will find out if this little munchkin is a boy or a girl. I can hardly wait!

In the “Safe Baby Range”

I saw my Endo yesterday. The best news of the day was my A1C: 5.6! Can you believe it?! I am so happy with that number! I only hope I can keep it up for the next eight or so months.

He spent a good deal of time with me, which was welcome  because I came to the meeting with a list of questions (big surprise, huh?)

One of his most surprising answers was about the flu shot. He said I am not in the “target demographic” for the regular flu shot, but that I should ask my OB about the H1N1 shot. That was a shock to me and I’m not 100% convinced that I believe it. Everything I’ve read says that I have two risk factors — diabetes and pregnancy. Don’t get me wrong, I really don’t want to get the flu shot. It usually leaves me with a mild case of the flu for about five days. But if it  is important for the health and safety of my baby, than I am all for it.  So I guess I need to do a little more research on this.

Another (somewhat disappointing) response was when I asked to talk to a dietician. I really need to get my food choices under control. Donuts out of the vending machine are never a good choice, but especially now. It turns out that he does not have a dietician that works with him exclusively. He would just send me over the hospital where they will likely push the ADA’s carb-laden, high calorie meal plan on me. Sigh. It is as if I am living in the dark ages. I am going to give it a try, but I am not holding out much hope.

We talked briefly about a CGM.  He is still pulling for the  Medtronic Minimed product. I have been trying to figure out why given all of the anecdotal evidence I am finding that suggests the Dexcom is better. I am guessing it is because it’s  easier for him to assess the reports if they all come from the same device. I have to admit, the Medtronic reporting is pretty  impressive.

Aside from these responses, his knowledge seems impressive, but he really  doesn’t have that compassionate, you’re-going-to-be-fine bedside manner that I am looking for. I guess I am on the fence about whether I should stick with him or jump ship. Afterall, how important is the reassurance if he is helping me reach the “safe baby range?”

This morning I have my first “pregnant” appointment with the OB. I think I will ask  him what he thinks about my Endo and see if he has any advice for me.

What have you been hearing about flu  shots for diabetics? And for those of you who have already had children, what was your medical experience like? Did you have a team, or did you work with individual doctors? If you worked with a dietician, did you find it helpful?

Chili for Halloween and a Truce with the Endo

Just a quick post today as I’m putting the final touches on my chili for the third annual chili cook off at work. Every year, we have a Halloween party complete with a costume contest and chili cook off. My company is not exactly the best place to work on a day-to-day basis, but they really do know how to throw a good party.

My Endo finally called yesterday evening. We ironed out a few things and we’ll reassess at my appointment on Monday. Basically, he does not want me to increase my basal rates, even through a temp basal. Instead, he wants me to use boluses to treat out-of-range numbers. I am also going to have to buckle down and log all of my insulin and carb intake, because my insulin pump does not do it for me (long story, but it does not communicate with the Medtronic reporting software.)

He also encouraged me to think about a CGM, which I have been thinking about, but I am leery of yet another hole in my skin. Also, he is pushing the Medtronic, and I have heard that it is not as accurate as the Dexcom. I also don’t look forward to the insurance fight to get coverage. So I guess I am still on the fence on this one.

Does anybody have any experience with any of the CGMs? How accurate do you find them? Did your insurance company make you jump through hoops to get the supplies covered? How are the insertion sites? Those sensors are so long!

Thanks for any advice you can offer! Have a wonderful weekend and a great Halloween.