#810 Defining Diabetes: Untethered

December 15, 2022Scott Benner

Scott and Jenny Smith define diabetes terms In this Defining Diabetes episode, Scott and Jenny define Untethered.

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Scott Benner 0:00
Hello friends, and welcome to episode 810 of the Juicebox Podcast well eaten.

I'm excited to have Jenny back today for another installment of defining diabetes. And today, Jenny and I are going to define untethered. This will be the 46th installment of the defining diabetes series. It's a series that takes the time to define the terms that you use every day with diabetes, from fat and protein rise to brittle diabetes, bolusing and everything in between. Check out the finding diabetes short episodes that let you feel like you know what you're talking about. And bonus, after you listen, you will actually know what you're talking about. There are a number of different series within the podcast. So if you go to juicebox podcast.com, to see a list of them. If you do it on a browser, you'll just see it at the top and you notice the finding diabetes click on it. If you're on your phone, there's a little menu like the three lines, it's a menu click on that, then it shows you to find diabetes. There you will get a complete list of the episodes, as well as an online player and links to a number of different popular podcast apps and links to the other series. Like bold beginnings thyroid disease algorithm pumping diabetes variables, ask Scott and Jenny mental health afterdark and the diabetes pro tip episodes. This show is sponsored today by the glucagon that my daughter carries G voc hypo Penn Find out more at G voc glucagon.com. Forward slash juicebox. today's podcast is also sponsored by Ian Penn from Medtronic diabetes, get yourself an insulin pen that has much of the functionality of a pump at in pen today.com The last sponsor of the day is the Contour Next One blood glucose meter. This little blood glucose meter is the bomb. It's the best one I've ever used. I love it. Contour next one.com forward slash juicebox. Hi, Jenny, how are you?

Jennifer Smith, CDE 2:14
I'm great. How are you? Scott? Good. We

Scott Benner 2:16
are back together doing some more defining diabetes episodes. Awesome. And I am going to ask you to define something that I've never done before. What does it mean when people say they're pumping untethered?

Jennifer Smith, CDE 2:35
Oh, I guess there are probably a couple of different methods to that. One that I've seen used enough is they will take a Basal injection, right. But they will reconnect to Bolus with the precision of a pump. Remember that pumps can you know dose down to really really tiny unit markers. Whereas injections mean the tiniest marker you can get as a half a unit if you're really really good. You can do a syringe and maybe get close to a quarter unit ish. But pumps can get much lower than that so many I shouldn't say many but some people who choose basil injected insulin may reconnect to do a Bolus. I've also seen it the other way where the Basal actually is what the pump is doing. And then the Bolus is are either injections or the inhaled insulin like a Frezza. I don't necessarily. I don't think of that in the term of untethered though because technically you are connected. Yeah. So there are a couple I guess, ways to think about it. But in general, it's when you're using a basil and then reconnecting to Bolus so you're still using a pump. But not for basil purpose.

Scott Benner 4:04
Well, the lancet.com which is a reputable diabetes website. All right. Cool. Yeah. says yes, people with type one diabetes who use continuous continuous sub content, who boy continuous subcutaneous insulin infusion or pump therapy often remove their pump before extended periods of exercise, because this approach might result in reduced glycemic control and increased risk of hypo hyperglycemia. And keto Genesis. We aim to assess the efficiency and safety of a hybrid approach. This is a paper they kind of wrote about it, in which the Basal insulin delivery was divided between pump therapy and daily injection of insulin. Okay, well, this is interesting. So, so this is this follows the one thing you said so I guess what happens is, there's a whole kind of modern Heat her. How do I mean this? People who use pumps modernly would not think, Oh, I'll wear my pump and then take it off for hours and hours at a time, right? You know, it's kind of an older, like, it seems like one of those hybrid ideas, people who've been doing MDI forever, they've moved on to pumping. And then they're like, I can't pump while I'm playing soccer. So I'll take this damn thing off and blah, blah, blah. So so you're so the one thing you're talking about here is inject your Basal insulin, right? And then you have a tube pump with a sight that you disconnect the tube and connect it back. Why would someone do that beyond exercise, swimming? Or is there any real reason just not wanting to wear a pump? Or,

Jennifer Smith, CDE 5:42
Yes, not wanting to wear the pump. But like I said, earlier, it's the idea that you get the precision and the calculation of iob. And everything using the pump for the Bolus strategy is one of the reasons and I honestly, I've only had a handful of people who've really chosen to do that method. And sometimes there are good scenarios for doing that, such as a diver, for example, or you're going on a dive scuba type of, you know, vacation, and you cannot, you cannot you can't dive with a pump, relative to pressure. Yeah. So in that case, an untethered approach would be beneficial, you could take a Basal insulin, you could keep your site in. And you could return, you know, back up to the surface, and you could Bolus as you needed to. And then disconnect again, because you've got basil in the background from the injection.

Scott Benner 6:47
Okay. The other thing this reminds me of is, there are, I don't know if it's a specific person from a specific time period, if I've just seen this once in a while, from all different places, but I have periodically seen people be scared of the idea of an insulin pump. Because they think, what if it stops giving me my Basal insulin? And I don't know, like, that's one of the main fears you notice. Right? When people come from MDI, and they go to pumping, they say, but what if the thing you know, it's the thing, what if the thing stops working, I won't get insulin, and I'll be dead. At least I know, when I inject my Basal insulin, even if I forget my meals, this is there. Right? So that's what it makes me think of. And I guess it would alleviate your concern. If you had that concern. This is not something you could do with an Omnipod, though, or? Well, no, you,

Jennifer Smith, CDE 7:40
you could you could suspend the basil, you couldn't remove the pod, obviously, I mean, we all know that. But you could suspend for the length of time that the pod allows you to suspend or you could set a Temp Basal of zero for a longer duration, then you can actually suspend, which would essentially be the same idea. But you just have to remember to unsuspend or stop the Temp Basal of 0%. When you wanted to, you know what I mean? Do?

Scott Benner 8:13
Yeah, I'm just trying to think of other ways people might be doing this that I'm not aware of like, what about people who have you ever seen somebody who has, like a big insulin need? And they weren't aware? I don't know. Like, would you is there any world where you would shoot basil and let your pump give you some at the same time?

Jennifer Smith, CDE 8:33
I've Yes, with the woman that I work with in pregnancy, sometimes insulin needs go up so significantly, that the site often gets just oversaturated with the amount going in, you know, if you've got Basal rates that are two units an hour plus and your Bolus is are going to be 1520 25 units, depending on what your insulin to carb ratio is. You're talking supersaturation of this, this little tiny area underneath your skin. So not only do you end up needing to change the site a lot more frequently. You risk you risk sort of the right absorption underneath the skin as well in certain in terms of timeframe, right. So what we can do is with really large doses or need for insulin, you can downplay the basil, at least by taking the basil in a larger chunk from a Bolus of a Basal acting insulin, leave a little bit of Basal drip there. And you mainly use the site for boluses.

Scott Benner 9:39
Right? So inject the bulk of it, let the pump do a minor amount of it and then use the pump for meals and corrections.

Jennifer Smith, CDE 9:48
Correct. Yeah, I've even had some women who've done that as well as potentially once the Bolus has get so large, they can tell that they absorption is just not right for the way that Uh, things normally worked. And so we'll say, Okay, go ahead and use your rapid insulin as an injection for 50% of the Bolus and give the other 50%. You know, in terms of the pump,

Scott Benner 10:15
so, but for most people, there's no, like, I don't want people to listen to something because there's something I should be doing. I just wanted to find so you know what it is, but this is not something most people will have a need to do. Right?

Jennifer Smith, CDE 10:27
For the most part should not be okay, right?

Scott Benner 10:31
This by the way, this is interesting. The Internet tells me, essentially, going untethered means making use of an insulin pump and taking long acting insulin at the same time. This is just from a like a blog post. But it says The term was coined by endocrinologist and person with diabetes. Steven Edelman, did Steve come up with this? That's interesting. Is that a term? I

Jennifer Smith, CDE 10:51
mean, I wonder if he came up with the term kind of like John Walsh came up with the term of super Bolus? Yeah, right. I don't know. Maybe.

Scott Benner 11:00
In the future, will somebody one day Google like crush it and catch it? It'll be like this. It'll be you. Anyway, we covered this Yes. I'm thinking yes. Yeah. Cool. Thank you very much.

Jennifer Smith, CDE 11:14
Absolutely no problem.

Scott Benner 11:19
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guys, it was a short episode today but I want to thank you for listening. I also want to thank Jenny Smith and remind you that Jenny works at integrated diabetes.com If you'd like to hire her, she can help you with your diabetes integrated diabetes.com to find Jenny Smith. Hope you're enjoying the defining diabetes series. I find it to be One of the best, you know, just to hear the short conversations and leave with an understanding of a term that is going to come up over and over again in your life. It's really, I don't, I'm a big fan of it. Anyway. That's it. Thank you so much for listening. I'll be back again very soon with another episode of The Juicebox Podcast.