Tuesday, May 14, 2019

Do you use an insulin pump? Then check your prescriptions...

Not that long ago you would have probably had an MP3 player of some sort, a phone, a GPS for the car (one of those that you fixed to the windscreen), a camera, books of paper maps and maybe something like a palm pilot that worked when you were in WiFi.

Now you, probably, just have a phone that does it all. All your eggs (insert plant based alternative for this metaphor to work) are in one basket.

I found myself in this position on Friday evening.

My OmniPod needed changing something I did very efficiently (it takes me so little time to do this now). Within a minute of completing the POD change the PDM displayed an error screen advising me that the POD was not working and should be removed. I removed it as instructed but then found the PDM screen to be frozen. None of the buttons worked and it wasn’t going into auto-shut off as it normally would. I called the technical support line and spoke to a chap that helped me through the reset function. After a few attempts where the reset was not working the decision was taken to supply me a new PDM. In view of the weekend this would be provided to me by Tuesday.

The tech support guy asked me if I had backup kit that I could use to which I confidently answered yes.

I was only partially right! I have insulin pens that I carry all the time just in case. However what I had not realised was that the Levemir I use was out of date by 6 months, something I only realised after I had injected it, it didn’t do anything bad to me, in fact I don’t think it did anything at all as when I woke in the morning my sugars were at 17mmol – unheard of for me even when I was struggling with overnight sugars. The NovoRapid by comparison was in date but by a matter of days. This was now Friday night close to 10pm – how would I get prescriptions updated in time?

I called NHS 111 and felt like a total fraud as this was not an emergency or something medical this was a lack of preparedness on my part.

I explained the situation and was advised that a Levemir prescription would be available for me at a specific pharmacy for the morning and that I should contact them first thing. The Pharmacy opened at 8:30 and I was at the door when they did. They had no record of my prescription at all and suggested that it might have gone to my normal pharmacy that I use for this. They opened at 9am. I waited int ha car and called them as soon as they opened. They had nothing either. I went back to the 111 service and they promised to chase it up within an hour and get back to me.

An hour passed and I called them, they had no record of my call so we went through the process again. This did yield a result with the out of hours doctor calling me and saying that a prescription would be at the original pharmacy within the hour. I went back to them on the hour and there was nothing that had come through. They were now close to their closing time so issued me an emergency prescription using a paper based facility that they had. I had my Levemir that was in date!

The other issue was that I use my PDM to test my blood sugars too. With this not working I needed to find a spare meter. I had one with a nearly full barrel of test strips. Over the weekend I was fine on insulin pens and using my Accu-Chek Aviva Expert. However I then realised that I did not have any spare test strips.

All of which takes me back to the first point. Technology is great when it’s working but with increasing reliance and seeming reliability comes complacency. I have used an OmniPod for a couple of years and bar the occasional pod failure have not had any issues. The PDM failing is more serious than that. Not only is it my insulin delivery method it’s my blood testing method too. Without doubt the two most important technological dependencies that I have. 

My health and well being depends on it.

The lesson has been well and truly learned. I have now got (or have on order) prescriptions for insulin pens for Levemir and NovoRapid, I will check the expiry dates of these and add them to my diary so I know when they expire and do not get caught out again. Similarly I will have a couple boxes of test strips for my backup monitor and if they have an expiry I will do the same. It took a lot of chasing around and calling on resources that are over stretched to try and sort this on a Saturday morning, something that was wholly avoidable had I been prepared.

The issue isn’t that the PDM malfunctioned or that NHS 111 couldn’t get a prescription through its that I never thought about it. I thought I was prepared with spares for what I needed but as I have not really needed them I wasn’t.

If you are an insulin pump user you need to do this (assuming like me you haven’t already);
  1. Check your backup kit – do you have pens/needles/test strips and insulin
  2. Check the expiry date on the insulin and either order replacements (making sure to throw away the old stuff) or add the dates to your calendar/diary so you don’t miss it
  3. Make sure you have back up test strips and that your meter works (and that you have batteries for it) 
Technology is remarkable these days, things do not often just fail. This leads to complacency which is exactly where I found myself. In a jam because of that. Hopefully, if you’ve made it this far into the post, you can avoid this!

Massive shout out and thanks to the people at MyOmniPod support, Spa Pharmacy and NHS 111.

Thursday, May 9, 2019

Winchcombe Cross Marathon - 5th May 2019

 Advertised as a marathon with +2,500ft of elevation.

Well, the distance is right (although I got lost and did an extra couple of miles) but the elevation is way off. Closer to +3,400ft! The Winchcombe Cross is a set of race distances all run in the same day on similar courses. A half marathon, marathon, 37 mile ultra and 50miler. 

I was doing the marathon having made the decision earlier this year to not do ultras for this year at least. 

Registration opened at 7:30 with a start time of 8:30. I was up early and stressing about the day so headed over earlier to catch the Ultra start and see Rob who was doing the 37miler. 

Training for this event has been good from an overall mileage perspective (around 600 so far in 2019, but distinctly lacking long runs. I’d done a 15 and a 20 miler prior to the event and have been averaging maybe 38 miles a week. 

There was a race briefing at 8:20 before we started at 8:30. 

The route starts with an easy section down to Winchcombe high street, across the road down a hill then onto the trails. Leg 1 was an out and back to Temple Guiting, I was surprised at the amount of tarmac but the views were stunning. 

The weather was perfect really, slightly cool with some cloud but dry and little/no wind. 

The field strung out as runners settled into their own pace. I had a plan to run 9min miles for as long as I could figuring I could get to 20 miles at that pace and then just finish the last 10km by any means. 

I had a thought that I could do something between 4hrs and 4.5hrs. Come the end I was slower than that but happy enough with my day. 

Heading into Temple Guiting I somehow missed the arrows marking the course and ran past the turn for the checkpoint. By some distance too, maybe by 3/4 of a mile. Realising my mistake i turned around ran back but knew that any chance of hitting my targets just got harder. 

I was doubly disappointed though as at the point I went wrong I was in 2nd place. I only knew this as I had crossed on the route with Rob who told me. By the time I righted myself on course I was way back, it was only 7 miles in and so there were plenty of runners piling in behind me. I don’t know if there was a bit of distraction in hearing I was in 2nd and believing my own unfounded hype. I was trying to just keep my pace steady and stick to targets because it was early in the race and genuinely as much as I would love to do well in a race I don’t ever have expectations of doing so.

To compound the issue, I then went wrong leaving Temple Guiting! Just not paying attention and thinking too much about how to make up lost ground rather than focusing on the moment I was in. Another turn round when I realised and more emotional drain. The physical impact would happen a little later in the race.

Making my way back to the race HQ for the next leg I made up ground on some runners and was pretty comfortable. I went through the checkpoint as quickly as I could, keen to continue to make up some ground. It was at mile 15 that I had a physical problem of sorts. There were runners ahead of me and as I crossed a field that was pretty rutted I took my eye of what was in front of me for a second and twanged my ankle. I say ankle but on reflection and examining where I have some soreness it is actually on the outside of the shin a couple of inches above the ankle bone. My foot gave way and I felt my leg twang, like elastic as I corrected the instability on the ground. The pain shot up through my leg and for a second I thought that was it.

It calmed down and I set about walking to see if I could just walk it off. I have had situations like this before and have the mindset that provided it’s not hanging off I will finish. This is primarily borne of not racing a lot and so when I do, I want to finish. I think that if I maybe raced more often I would be less concerned. I walked a bit and it eased. The rest of my race would fall into a pattern of run walk, running on tarmac and downhill was quite sore but uphill and flat was fine (although I walked the uphills too!).

Leg 2 was, for the marathon, a loop. Running through leg 2 and then rather than coming back, if I was doing the ultra, continuing around into leg 4. This made for a better running experience as while the terrain was stunning it’s nice not to retrace your steps. Plus the 4th leg took in the famous Belas Knapp.

As I approached this there were more people around as this is a spot for tourists and walkers. Up to this point there had not really been anyone around other than those in the event itself. As I got to Belas Knapp I did think about the ultra-runners coming up that way. The climb out of Winchcombe is pretty brutal gaining close to 750ft in the space of maybe a mile or two. Running down this was hard enough.  

As you pass Belas Knapp there’s a steep field that takes you down to a small wooded section, you clear that then it’s downhill past the cricket club and back onto the high street. Running down through the field I could hear thunderous footsteps behind me. My first thought was that cannot be one of the event runners? It wasn’t. It was a small bout maybe 10 years old running full tilt through the long grass and having the time of his life. His sister, slightly older, was behind him and much more tentative. He stopped just in front of me and as I got close I asked him if he was racing me. He replied that he was and took off again. So fast! I think that even if I had not run at all I could not have let the handbrake off enough to run like he was.

He was just running down hill without a thought for his knees and ankles or anything. It really made me smile and was quite uplifting. When you try to explain to someone why you run it’s because sometimes it feels like that. That being an intangible thing really, something you have to experience to understand. A combination of being immersed in the moment without a thought in your head, a flow state where the action of running is for that moment all consuming. You’re doing it but it doesn’t register as conscious thought or physical feeling.

Reaching the woods I knew the route back having run this previously. It’s a short hop to the high street then up to the aid station and the finish.

I crossed the line with 4:57:20 on my watch. The total distance I covered being 28.75 miles and with +3,471ft of elevation gain.

It’s not often I finish something and think I want to do that again but for this one I really did. I think it’s because I know if I didn’t get lost I would save around 15 minutes and if I do more longer runs I can probably take another 20 minutes or so off that time and maybe get closer to the 4:30 I thought achievable.

My blood sugar control through the event was excellent. I was up at 6am and tested with a blood sugar of 5.5mmol. I had something to eat undercutting the carbs count by around 50%. This meant I would be higher by the time I got to the start line but not an issue as once I start running it drops pretty-quickly. I also put in place a -50% temporary basal for a 7hr duration. Because the doses of insulin that I use are quite small this is the maximum reduction the pump can accommodate. At the start of the race my blood sugars were 14mmol, high but for a short period and not concerning.

Nutrition strategy was pretty simple and a combination of 33Shake gels and Tailwind with a couple of bars with me just in case. The plan was to sip tailwind and have a gel every hour. At the half marathon point I tested my blood sugars and they were 7.2mmol. Perfect!

I set off again and did not test until the leg 2/4 checkpoint where they were 5.5mmol. This was probably the most stressful blood test I have done. There was an ambulance crew there and one of them spotted what I was doing and came across to check. He was stood on my shoulder watching. I have never felt under so much pressure to deliver a good reading. When it popped up with 5.5mmol I was so relieved. He just said “that’s perfect” and seemed happy enough.

Because I was out for longer than expected the pump notified me when the temp basal had ended. I set another -50% for 3hours and continued. My blood sugars at the end were 11mmol. A combination of my slowing pace and probably taking on too much food. There was a creeping upward trend for a couple of hours but it soon righted itself as I had something to eat and administered correct bolus amounts.

Later in the evening I set a -25% basal for the overnight period as knew from experience that I would go low otherwise. This was borne out with a waking blood sugar on Monday of 3.1mmol.
I was using the OmniPod through the event and had no issues. In fact, for this race an alert that a temp basal had finished and then being able to set up another while still moving was pretty awesome. There is no fire and forget that you get with pens. I had the pod on my arm but the conditions were such that it was not over exposed at all so performed as it should. The facility of being able to administer reductions on the fly proved invaluable not only during the event but in the period post event and then through the night.

I really enjoyed the event, the course was beautiful, the conditions couldn’t have been better really and the organisation was perfect. I want to do it again next year and that’s a first for me really. No higher praise?

Thursday, May 2, 2019

Bit of an update; diabetes, carbs and running

I have been in a good run with my diabetes of late. There have been some unexpected spikes but the biggest change has been my overnight sugars and the changes I have made to achieve this. This post will be validated or blown out of the water on Wednesday when I get my blood test results and the all import HbA1c number. 

At the time of my last check up I was struggling with blood sugars overnight. Too high as evidenced by waking levels of regularly >10mmol and in reality an average of around 12mmol. These days it has been much more between 5-8mmol. A significant change borne of two main changes that are wholly related. I now trust my going to be blood sugar levels and can do this as I am eating a lower carb meal in the evening.

Previously I would test my blood sugars before going to bed and if it were less than 7mmol I would worry then eat something without insulin and then wake up with a high reading in the 10-12mmol range. What I do now is trust the levels as I understand them better. The understanding and trusting the insulin on board calculation. If my blood sugars are 6mmol but with no IOB at bedtime then I trust that and go to bed. When  wake my blood sugar levels are similar.

I have been able to achieve this through eating a lower carb evening meal and doing this much earlier in the evening. The last point being particularly important as I tend to be an early to bed early to rise kind of guy. My evening meal now comprises around 20-30g of carbs and does not include anything remotely related to bread, pasta or rice. While I am not low carb (I am  a long way from sub 50g of carbs a day) this small change has made such a difference that it is something I will be extending to my lunchtime meal. I just need to figure out how to transport salad in a rucksack when I run to work so that it is still edible at lunchtime!

The bread, pasta, rice thing is very interesting and has been a source of problems for me. This is as it relates to the evening meal specifically. If I were to eat pizza or rice my blood sugars would spike significantly later on the same night. I have counted the carbs and tried various combinations of extending the insulin delivery (a feature of the OmniPod) by an hour or two except that this resulted in high sugars followed by  a significant drop. It’s just been easier (and I feel better for it) to not eat those foods at night.

The other aspect of my blood sugar control I have gotten a grip on has been the use of the temp basal feature. As someone that run-commutes I have struggled with afternoon blood sugar drops. I could be at 8mmol leaving the office at around 5pm and after an easy 30minutes of running my blood sugars would be sub-4mmol. I have started the temp basal reduction earlier in the day and also worked to not have any insulin on board from lunchtime or afternoon snacks. Oe of the issues here is that I can only do a temp basal reduction of 50%. The pump cannot accommodate a greater reduction as my insulin levels are so low. I have experimented with suspending insulin but this makes me nervous and I am unsure of how long to reasonably do this. Should I start this an hour before I am due to be exerting myself or just for the period of exertion?

This is where a feature of scheduling on the OmniPod would be awesome. The features to reduce insulin delivery for time periods is great and what would be even better would be a facility to schedule the reduction. I have given this some thought and think something like the following would work incredibly well for me. On an assumption that I will be running at 5pm I would look to do the following.

3pm :: Temp basal reduction of -50% (this being the current pump limit. If this could be smaller I would do a -50% for 3-4pm then -80% from 4-6pm)
5pm :: run home (I would want my blood sugars to be around 7/8mmol and have no insulin on board. I may also need to eat something (around 15g of carbs) before leaving.
6pm :: the temp basal of -80% would finish
6pm-9pm :: I would look to have a -25% temp basal reduction and depending on the intensity of the 5pm run may even extend this to a 4-5hr period

I did this, sort of, just last night. On Wednesdays I run with Bath Road Beers Run Club.  We set off for the club run at 7pm. Earlier in the day, at 4:30pm, I applied a temp basal reduction of -50% for 4 hours. At 1800hrs my blood sugars were 8.2mmol. I ate around 25g of carbs without insulin. I ran a pretty hard 6miles and when I tested my sugars at just after 8pm, when I got home, they were 4.2mmol. I had an evening meal quite a bit later than normal that was around 45g of carbs (a little higher than normal as I had a vegan protein shake with it). When I went to bed at 10’ish my blood sugars were 12mmol. I had insulin on board and new that I had the effects of the run still in me. I set up a temp basal of -25% at 9pm for 5hrs to cope with this as I have had situations where I have gone low over night.

When I got up this morning my blood sugars were 8.8mmol. A little high but, I think, managed quite well with lots of variables to contend with.

As I mention above the impact of low carb in evening meals has been incredibly significant and something I want to explore further. My reticence only being that I train a lot and while I never feel under powered (my April numbers have been really good; 151 miles run at an average of 7:52 per mile and an average run length of 7.22miles) I am a way off being a fat adapted runner and this takes time to achieve. Something I am not sure I have the patience for. It’s also worth noting that my weight has been pretty stable for the last couple of years at around 150lbs. A weight I am comfortable with. It had though, recently started to creep up and only a couple of weeks ago I was at 156lbs. Still not massive but the wrong trajectory.  Three weeks on lower carb evening meals and I am back to 151lbs. I need to make sure it doesn’t go too far the other way now but as an experiment of 1 it shows that this works.

It's funny as I have always thought of myself as a good diabetic. Recently I have felt much less like that and struggled a bit with the emotions that throws up. I want to keep the OmniPod and that was at risk following my last appointment as my blood sugars were not showing an improvement that warranted the investment that having this device comes with. I am hoping for an improvement on my HbA1c numbers as having to give it up will be a very bad situation to find myself in. Fingers crossed!