Scott Hanselman

The First 12 Hours - The Medtronic Minimed Paradigm REAL-time Continuous Glucose Monitor

October 18, '06 Comments [14] Posted in Diabetes | Reviews
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It's finally here and I'm using it.  The Continuous Glucose System that I blogged about six months ago arrived today. Yes, I tend to be an Early Adopter and I've gotten nailed in the past (the Glucowatch sucked) but this one may just be a winner.

It's called the MiniMed REAL-Time System. It is an add-on (D in the picture at right) that "sips" intersitial fluid and reports an estimate of my current blood sugar to a pump that is exactly the same form factor as my existing pump. In fact, it's the same housing. I swapped my existing Paradigm 512 Pump out for this one, the controls are identical.

(Check out my Diabetes Explanation: The Airplane Analogy if you're not familiar with how diabetes works IMHO)

Out of Box Experience

Note: You should talk to your Diabetes Doctor/Endocrinologist and take a training on how to use this device before jumping in or you could hurt yourself. I am NOT a doctor - this is just one guy's experience.

The package arrived at 10am this morning. The one containing the sensor tips said "perishable" and was packed with ice packs. I put it in the refrigerator immediately. Travelling with these will be a little tricky, as it's unclear how quickly they degrade. Presumably in about 72 hours.

I transfered my settings over from my existing pump manually. The pump, glucose meter (the finger stick device) and continuous meter/transmitter (the one taped to my belly) all have unique ids. You have to tell the pump the unique id of the transmitter, as well as the unique id of the finger stick meter.

After attaching the new transmitter (with a big ass needle/canula) I told the pump there was a new transmitter/sensor. It starts calibrating and says to wait for 2 hours and then it'll want a finger stick. This two hour warm up happens every time you put on a new sensor - about every 72 hours. At noon, it beeped, then I did a finger stick test. You want to put on a new sensor when your blood sugar is stable. I woke up at 110mg/dl and it stayed that way for the morning. I pushed lunch out a bit to make sure it stayed that way. After the first calibration I started getting updates every 5 minutes.

Aside: You truly can't conceive of what it's like to have this 6th sense, this 6th dimension where you need a number to really know how you're doing. It's like getting a GPS when you're lost. Like fixing a speedometer in a broken car.
My sense of how my blood sugar ebbs and flows was heightened and I literally had one of the best blood sugar days of my life (since I was diagnosed at 21). It enabled me to make better food decisions and even sneak in a short walk after lunch that had substantive benefits.

I'm loving this device. I'm sure there will be troubles and it'll be harder to get through airport security, but I suspect that this is going to change the way I manage my diabetes. There's a value called the hA1C, expressed as a percentage, that measures blood sugar control over the last 3 month period. Non-diabetics have a value between 4% and 6% indicating that their blood sugar was roughtly 100mg/dl over that period. Mine is currently between 6.3% and 6.5%, which is high normal. I believe this device, plus my use of Symlin, will get that number to the normal range, thereby limiting my chances of compliations like blindness.

Nutshell

I still will check my blood sugar via a finger stick between 4 and 10 times a day. The meter will wirelessly tell the pump that I checked. The fingerstick is considered more authoritative than the continuous meter. In fact, the continuous meter is calibrated by the fingerstick.

The continous transmitter's sensor last 72 hours then the tip needs to be replaced. The larger transmitter lasts at least six months, then it needs to be replaced. It has a sealed internal battery. Additionally, it's interesting to note that the transmitter has a version number. Mine is 1.6, which tells me that they can improve the transmitter at least every 6 months and I won't need to do anything to see improvements in accuracy. The pump holds all the data and history information and includes both a 3-hour and 24-hour graph view.

You shouldn't make insulin dosing decisions based on the continuous meter - it's just a trendline that gives you an idea of what happens the other 23.5 hours that you're not sticking your figer.

Scott's Diabetes FAQ
or
Everything You Always Wanted to Ask a Diabetic But Were Afraid to Ask

Q: When did you become diabetic? How did it happen?

A: I had the flu (or flu-like symptoms) in November of 1994. When it was over, I was peeing all day long, had lost 35 pounds (I was skin and bones) and my dad, a firefighter/paramedic said, you need to get to a doctor, ASAP. My blood sugar was clearly high and suddenly I was a Type 1 diabetic.

Q: So that's Juvenile Diabetes, right?

A: It's not called Juvenile Diabetes anymore, as it can happen to folks in their 30's and beyond. There are (basically) two types of Diabetics:

  • Type I – used to be called Juvenile Diabetes or Youth-Onset or Insulin Dependant (IDDM). These folks nearly ALWAYS use Insulin. Typically these folks don’t produce any (or much) of their own insulin. If I don’t make it, I need to get it somewhere.
  • Type II – also called Adult-Onset or Non-Insulin Dependant (NIDDM). They are so different, it’s a shame they are both called Diabetes. These folks typically have decreased responsiveness to their own insulin. If they aren’t using their own insulin well, they need to be made more sensitive to it.

"Worldwide, there are about 171 million diabetics, but only about 10 percent of those have Type 1 diabetes. The vast majority have Type 2 diabetes, which is linked to obesity. In the United States, about 900,000 to 1.8 million people have Type 1 diabetes, the American Diabetes Association says."

Q: The pump makes all the decisions for you?

A: No, the pump is just a delivery device. It pushes insulin through a tube into small plastic needle-thing called a canula that is 9mm into my belly. I move it every 72-96 hours. The pump has a screw-drive internally that pushes a head against a syringe's piston. It's got some wizards and calculators, but it never does anything automatically, other than deliver a small background (basal) dose that I have to set myself.

Q: Why not just stick with needles? My [uncle|sister|dad|butcher] does two shots a day and he's|she's all good...

A: Taking insulin twice a day is the equivalent of going for a flight but you're only allowed to touch the flight controls twice. Better make those two turns count. Same thing with checking your blood sugar. If you check it twice a day, imagine flying from LA to New York and only checking your altitude twice.

Q: What's so great about a pump?

A: I can make little adjustments on the order of a 1/10 of a Unit of insulin, while folks with needles can usually only managed 1/2 a Unit and they'd need to stick themselves each time!

Q: Do you sleep with the pump on? Shower? What about sex?

A: You can disconnect it for ~30-60mins without ill effects, but everyone is different. While it's not connected, it's not delivering, so you'll likely need to compensate. It's not waterproof. I sleep with it on and remove it at other times.

Q: Is it hereditary?

A: Some Type 1 diabetes is, and many Type 2's are, but it all depends. I'm the only Type 1 in my family going back many years, but I know a girl who's entire family, brothers and sisters are all Type 1. Z has a 2% chance of being a Type 1 Diabetic, which is roughly the chance anyone has with one Type 1 parent.

Q: Can you eat cake?

A: I can eat whatever I like, it's how long I want to chase my blood sugar afterwards that dictates what I eat. It's all about the Glycemic Index - the speed that the food hits you. For example, an apple with the skin on it will raise blood sugar slightly slower than an apple with the skin off. Brown rice is often slower than white. White bread is satan. Going back to the airplane analogy, a food with a high GI will "pull back harder on the stick, making it more difficult to steady the plane later."

Q: Does it suck?

A: Big time. But what other choice do I have?

Q: Will it kill you?

A: Very likely. Diabetic typically die of diabetes before other things. Disability insurance is hard to get, as is life insurance, although the latter is easier than the former. However, the key is maintaining as normal blood sugars as possible. I know diabetics who've been diabetic for 50 years, and they didn't have 1/10th the tools and knowledge we have today. I figure if I can stick it out another 10 years, maybe 20, there will be a cure.

Timeline of Diabetes Care

  • Before 1922 - Certain Death. A childhood friend of my 90 year old grandmother was diabetic, was fed only lettuce and quickly died.
  • 1944 - Insulin is derived from Beef and Pork. Standard insulin syrunge is developed. Folks boil and reuse their needles. Blood sugar is tested by peeing on a stick and matching colors. Accuracy is +/-100mg/dl.
  • 1959 - Diabetes is divided into Type 1 and Type 2.
  • 1974 - First Insulin Pump/Backpack
  • 1983 - Biosynthetic Human Insulin is created. (Ya, seriously, this just happened in '83)
  • 1990 - Digital Insulin Pumps the size of a pager, finger stick tests take 45 seconds.
  • 2006 - Finger stick tests take 5 seconds, insulin pump communicates wirelessly with continuous meter.
  • 2007 - ?

Soon I shall eat cake.

(If you have other questions, post them and I'll answer them in the comments)

About Scott

Scott Hanselman is a former professor, former Chief Architect in finance, now speaker, consultant, father, diabetic, and Microsoft employee. I am a failed stand-up comic, a cornrower, and a book author.

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Wednesday, October 18, 2006 6:48:03 AM UTC
Thank you for sharing those intimate details with us.
I'm not a shy person when it comes to disabilities, as 1) I was growing up taking care of my mom who had severe M.S. (as in Multiple Sclerosis, not MicroSoft), and 2) having a nice little Chron's Disease for myself for the past few years, plus 3) being a curious guy who tends to read some general science (including medical) feeds, and finally 4) having an uncle who've passed away of Diabetes when I was a kid.
However, I've never got to learn anything about Diabetes at all. Not the differences between the "types", and not knowing about the day-to-day difficulities you people have to deal with.
It's also amusing to find out that top-notch technology that is usually taken granted when it comes to cell-phones or I-Pods can be applied to help people overcome their disailities and live a normal live.
I salute you for successing with that.
On the heavy debates around "Good Agile - Bad Agile" and those stuff, You've shown us a real lesson about agility.



(Ok, I must go now and prank someone, do a harsh criticism on a friend/teammate/family/butcher, commit a sexual harassment against my boss or set a cat on fire, or else I'll be recruited for an evengelistic group or a super-cool-and-useful-things-no-one-wants Door-to-Door company).
Wednesday, October 18, 2006 7:47:30 AM UTC
I'm happy that it's working for you so far, Scott. Question: Does you think it helps to limit sugar intake for my kids if Type I Diabetes runs in my dad's family?

By the way, I appreciate your keeping us up to date on this. One blogger I followed wrote about his son's hemophilia over a year or so ago, then stopped blogging. I still think about that boy several times a week... So it's nice of you to let us know how you're doing.
Wednesday, October 18, 2006 8:02:48 AM UTC
Jon - I think limiting sugar intake, specifically Corn Syrup and any obvious "oses" like Fructose and Sucrose is a good idea regardless. I don't know of any studies that say that limiting sugar intake prevents Type I, but I know it helps against Type 2.
Wednesday, October 18, 2006 9:32:04 AM UTC
I am Kalpesh from Mumbai, India & am a fan of your blog/podcasts. Thank you for everything

While I am not diabetic, I suggest you having a look at following links

http://en.wikipedia.org/wiki/Pranayama
http://www.knowyoga.org/tiki-index.php?page=Pranayama

Also, have a look at external links on the wikipedia page.
Hope this helps.
Kalpesh
Wednesday, October 18, 2006 1:36:56 PM UTC
I always like techy-related, not-developer things. Especially when they are well written. :)

And congrats on the new pump. I remember reading about it on your blog when you first mentioned it. I have a friend (10 yrs old) who is Diabetic. I'll be talking to his mother about this device... he uses a pump now already.
Wednesday, October 18, 2006 5:56:34 PM UTC
What really sucks about Type II (which, among other things, killed my dad) is that, while linked to obesity, is almost impossible to treat effectively without weight gain (at least for me). Talk about a catch-22.

I gained a lot of weight in college. However, once out of college, I managed to trim down quite a bit. I think this was likely a combination of change in habits and ketonic acidosis. When I was diagnosed with Type II, I was put on metformin, and I lost even more weight. However, my a1C was only down to the 7's. My doc put me on glyburide, and now I'm in the high-5's to mid-6's, but that damn glyburide has made it very easy for me to gain weight, and almost impossible to lose it. Grrrr!
Thursday, October 19, 2006 5:28:12 PM UTC
My step father-in-law (in Portland, no less) is celebrating his 50th year as a Type 1 diabetic. I have been passing along all your diabetes related information and it has been much appreciated. Thanks.
Matt
Saturday, October 21, 2006 12:50:16 AM UTC
Thanks for keeping us posted. We've just begun investigating the MiniMed pump for our six year old son with Type 1. (Continuous monitoring is not approved for children < 18 years old...yet) This disease is a bitch, but like you said, what choice do we have? I'm pleased to see the rapid pace of advancements in diabetes care. One of the benefits of having a very common disease I guess.

I read a lot of tech blogs, but yours is second to none when it comes to letting us readers get to know you as a person. Thanks for relating your personal experience with the MiniMed pump; It's more valuable than any sort of product literature from a manufacture's web site.
Monday, October 23, 2006 8:37:39 PM UTC
Can you post some specifics of the consumables cost, relative to the standard pump? Can you use the same infusion sets?

The CGM seems to be very expensive -- $999 for a starter kit whose sensor only lasts 6 mo. And that's on top of $400 "upgrade" fee for the base pump. Seems like those who purchased a Paradigm pump in the past few months got screwed...
Tuesday, October 24, 2006 3:21:15 AM UTC
Thanks for the update Scott. We are on week two of using the Dexcom for our 6 year old son (prescribed off-label). I agree that this technology is going to change everything. Even with the problems inherent in first generation products, I can not imagine going back to finger pokes alone! I have been looking for an analogy to describe the difference and Amy from Diabetesmine.com has a great one about being "addicted to the line" I quote often. I hope you don't mind me quoting you on other forums, but I also like your analogy to a fixing a broken speedometer in your car. I don't have a GPS so this one flew right over my head!
Keep us updated on the MM. I love hearing success stories with this technology!
Becky
Wednesday, October 25, 2006 10:58:31 PM UTC
Great article Scott. I too contracted the disease in a similat fashion. At the age of 30 I had what I though was a simple cold. Three weeks later I had lost 25 pounds, I was unable to keep any fluids, and had no energy. Today I'm 35 and have had type 1 under control using Lantus and Novolog. I just recently started looking into pumps as it seems that my control has been slipping over the last year. Surprisingly enough it's because my exercise has increased which hasmy blood sugars have increased as well. I hope this works out for you. I sent in a request to MiniMed myself for an informational packet.

Good luck to you on your quest for control.

Just curious what kind of pain do you find with the Sensor? and how about with the infusion set?

Thanks again for the info!


matt t.
Thursday, November 02, 2006 9:34:46 PM UTC
Very interesting info! As a hopeful for this system in the near future, It is good to see the info you have from personal experience!
Tuesday, November 28, 2006 2:37:36 AM UTC
I purchased on of the Minimed Continuous Glucose Monitoring Systems (CGMS) in July and have had nothing but problems with it. I have contacted Minimed multiple times and have tried everything they suggested. I've had sensor errors, calibration problems, sensor lasts less than 24 hours... Is anyone else having any problems? I've just quit using it in disappointment. Please comment if anyone is in a similar situation. Thanks
Randy T
Thursday, December 14, 2006 8:23:24 PM UTC
I have used the CGMS since August and I have a love/hate relationship with it.
Love
1. the trend analysis helps me better determine insulin requirements for what i am eating
2. having an alert if my blood sugar is going low or high - means i can catch an insulin reaction before it happens or avoid a high
Hate
1. inserting the sensor is painful - it is a HUGE needle and I have to insert it at a 90 degree angle instead of a 45 degree angle to get it to go in all the way.
2. calibration every 12 hours. this is easy in the morning (5AM), but more difficult in the afternoon (5PM). you lose some flexibility because of scheduling around the calibration - late lunch is out of the question because it will push calibration back and you lose the "line" if you don't calibrate every 12 hours.
3. mini-med says there is no correlation, but unless I'm fully hydrated I get lots of calibration errors.
4. expensive - $1k for start-up and $350 for 10 sensors - none of which is covered by insurance.
While it isn't perfect, it is the best option we have right now. So I'll quit whining.
another CGMS user
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Disclaimer: The opinions expressed herein are my own personal opinions and do not represent my employer's view in any way.