LifeAfterDx--Diabetes Uncensored

A internet journal from one of the first T1 Diabetics to use continuous glucose monitoring. Copyright 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, 2013, 2014, 2015, 2016

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Location: New Mexico, United States

Hi! I’m William “Lee” Dubois (called either Wil or Lee, depending what part of the internet you’re on). I’m a diabetes columnist and the author of four books about diabetes that have collectively won 16 national and international book awards. (Hey, if you can’t brag about yourself on your own blog, where can you??) I have the great good fortune to pen the edgy Dear Abby-style advice column every Saturday at Diabetes Mine; write the Diabetes Simplified column for dLife; and am one of the ShareCare diabetes experts. My work also appears in Diabetic Living and Diabetes Self-Management magazines. In addition to writing, I’ve spent the last half-dozen years running the diabetes education program for a rural non-profit clinic in the mountains of New Mexico. Don’t worry, I’ll get some rest after the cure. LifeAfterDx is my personal home base, where I get to say what and how I feel about diabetes and… you know… life, free from the red pens of editors (all of whom I adore, of course!).

Tuesday, April 21, 2009

Vulture update #3: Will the real 850 pound gorilla please stand up?

If we didn’t tar-and-feather George W. Bush for the mess we are in now, I don’t think we should do it to Med-T for trying to drum up a little insulin pump biz. OK, I never thought I’d come to Med-T’s defense, but I think they are being unfairly flamed for their recent “jump ship” offer to Cozmo users.

Now, there are several important things to remember here. For those of you who use other pumps the best way to understand us Cozmo pumpers is to just think about Apple Mac users. Yep. Loyal, a little bit fanatical, and possibly even irrational about our gear.

Part of this is mystique. Part of it is what you are used to, if you started pumping with a Med-T you are used to it, and it beats the hell out of shots, and you really don’t know what you’ve been missing, and…Ooops, a little bias slipped in there. But part of this is vastly superior pump, from a purely medical perspective. Here is what makes the Cozmo rock: a real insulin on board computer.

Last night, my buddy Rick and his wife Alice came over for dinner. He’s a tech guru (see? I was careful not to say “geek”!) and brought everything we needed to get started on the Audio version of The Born Again Diabetic; you know, for you ‘books on tape’ lovers. Anyway, he also Type-1, and also wears a Guardian CGM and an OmniPod.

As we were installing software and testing headsets, our mutual BGL followed an amazingly identical excursion path from Deb’s low-fat-diabetes-friendly-gluten-free dinner (Julia Child’s Hell). At about 250 or so, Rick was contemplating a correction. He plugged the numbers in and OmniPod suggested something in the neighborhood of 3.8 units to bring him back down to target. “What do you think?” he asked me.

I think you’ll kill yourself, I said. I checked my IOB screen and saw that I had 7.3 units in my body with a duration of action at right on three hours. My pump pays attention to all insulin. OmniPod, Ping, and Paradigm all assume that if you took insulin for food you counted right. In their minds, scissors cut paper, rock breaks scissors, and carbs cancel insulin. In my mind, even the best of us never count our carbs right. I like seeing the whole picture.

Interstinly, although not necessarily actually true, I was told by an Insulet insider that when they were developing the OmniPod they surveyed Endos about which method of counting insulin on board that they preferred. 51% preferred the Med-T way (carbs cancel meal boli) and 49% preferred big picture. Why this wasn’t made a user-selectable option is beyond me. Maybe that would have made FDA approval a nightmare.

So, as you can see, the Cozmo method of looking at insulin and corrections is quite a bit different from the rest of the pack; and for me anyway, is a major key to good control. Cozmo also features the ability to have a pre-programmed basal rate for weekends that kicks in automatically, a disconnect feature that tracks lost basal while you are in a hot tub with groupies, a hypo manager that looks at your BGL, your insulin on board, and your carb/insulin sensitivities and recommends a precise number of carbs to save your ass in each individual hypo situation, rather than having to trust your luck to the rule of 15 (eat 15 carbs, wait fifteen minutes and see if you are dead or having an excursion). It also lets you pre-program a curve to increase the insulin needed for correcting highs by percentages. In most folks, the higher you go the more insulin you need to knock it down. Anyone who has taken multiple corrections on an Animas, Med-T, or OmniPod knows this. Cozmo lets us say “well, if the BGL is over 300, please increase by 15%. If I’m over 350 please increase by 18%. Of course, you can use whatever numbers work for you.

I’ve got a kid at the mid-school on a Med-T pump under my care that frequently forgets to bolus. If he were on a Cozmo I could instruct it to alarm if no meal bolus happened between 11:55am and 12:10pm, right when he should be in the cafeteria pushing buttons on his pump and eating a less-than-healthy-for-anyone public school meal.

(Rio’s mother is cooking brunch. Rio just came into the library to tell me “this restaurant is really busy today. The President and Michelle Obama just walked in.” God, I hope not, I’m wearing and lint, dust, and grease covered shirt from crawling behind our clothes dryer to try and fix the damn hose. Anyway, no question which side of the family he gets his active imagination from).

Other features of the rudely retired Cozmo pump include fancy combo and extended boli, simple temporary rates; and a few things I never use like a basal testing system, a custom meal function, and food data base. Cozmo was revolutionary in its time for a simple, plain English menu system, but frankly, OmniPod has beat the pants off Cozmo on this front.

But the party is over. Unless all of us Cozmo users can band together to buy the pump from Smiths, we are all screwed sooner or later. I’m absolutely tickled to have what may be the last Cozmo sold. With my black sense of humor, I’ve decided to name it “Custer.”

So I know that in four years I’ll need to choose something else. I also know that in four years we won’t even be able to recognize the insulin pump market as things are changing so quickly. I love my Cozmo. So do all the other Cozmo users. But in a decade from now it would like owning a Radio Shack TRS-80 personal computer when everyone else has super computers. It would be like sticking with 8-track instead of CD, or BetaMax instead of Tivo.

Back to the vultures. We all must change. Some of us in four years. Some of us tomorrow. We all need to get in a life boat before the ship sinks and set out for an island. At this point there are three islands to row towards: Med-T Shoals, Animas Atoll, and OmniPod Isle. The Hilton at all three islands has the red carpet out. And there is really nothing wrong with that.

Med-T simply moved the fastest. Kudos for nimbleness, given the size of the company. But at this point, even though very, very, very few Cozmo pumpers need to do anything, all three other players in the insulin pump market have something in the order of a 90-day come join us deal. They vary from firm to firm, but they all want you. So let us be clear here: Med-T showed up on your door step with flowers first, but now all three major pump players are wanting to marry you and have “upgrade” offers on the table. They are all putting some pressure on you by making you choose soon. Making you choose before you need too.

So should you change? If your warranty is almost up and your insurance will buy you a new pump: yes, you should change. If you really don’t like your Cozmo, you should change. Some folks like the idea of the tubeless Pod approach. Some folks like the sound of using the Ping to control a traditional pump without taking it out from under clothing. Some folks need integrated CGM. (I would, however, say that it would be better to wait if that is your motivation.) It won’t be long before all the other pump folks have CGM working with, talking too, part of their pumps. Before the ball drops in New York this year I expect to see more than one new CGM enabled pump. This more than anything else, is probably why Smiths lost their nerve. They saw the future. And it was expensive to get there.

So why do so many people harbor the kind of hostility for Med-t that is usually reserved for Microsoft? Because they are viewed as the 850 gorilla in the diabetes biz.

But I am here to reveal a secret. They are not. Animas is. By a long shot.

In 2008 Med-T rang up 2.81 billion dollars in sales. Yep, billion with a “B.” Remember they make artificial hearts and all kinds of non-D stuff too. They’ve got about 17.4 billion in capitalization; the equivalent of money in the bank.

J&J, who owns the Animas pump, rang up 17.75 billion in sales with capitalization of 41.37 billion. J&J made more in one year than Med-T is worth. J&J’s pockets are deeper than most medium-sized countries. Lucky for us they don’t have an army.

No wonder Smiths, an English company with ’08 sales of only a hair over a billion dollars was feeling ill-equipped to get into a row with these two.

That said, tiny Insulet Corp, makers of OmniPod has to use the ‘M’ word instead of the ‘B’ word. They rang up only 20.81 million in 2008 with capitalization of 108 million. If they can kick Med-T’s ass without an established, loyal, and fanatical customer base; you’d think that Smiths could have made a better go at it. They weren’t even losing money; they just didn’t want to spend anything to go to the next level.

Anyway, the point is, in all of the David-and-Goliath drama, don’t hate Med-T for being big. Med-T isn’t the big player.

It is Animas that casts the long shadow.


Blogger CALpumper said...

Ouch on many fronts.

I think I understand why you are pointing out Animas. But I am still a bit unsure.

And once again, I am falling in love with the Cozmo.

I do like my Animas 1250 But it's all I know. And with No health insurance I don't have the ability to even Consider other options.

Either way, great imagery, great post. Thanks!

10:12 AM  
Anonymous Anonymous said...

I jumped ship to Animas in Jan,the two other options really weren't options in my book. And I like it fine-except for that stupid IOB inaccuracy.Gets me low more often then not.(so I have to do complex basal add-ons in my head,which is a major pain) I miss that Cozmo feature.
(and respectfully disagree about Medtronic wanting to take over the entire world,they are evil imo.)

1:45 PM  
Anonymous Anonymous said...

I don't like that animas was taken over by J and J...but at least they don't have the bad past practices of the Med T people. They were actually one of the major reasons for the laws about what is good to give and what is not. Med T is crying because 7 of 10 new pumpers are going to animas or omnipod. I realize I will need to be careful with animas because of the cozmo. I personally am miffed can't get a new cozmo, but will go with animas over the SATAN company which drove cozmo out of business.

2:29 PM  
Blogger Jana said...

Although J & J is a bigger company, MedT does have the bigger market-share for insulin pumps, which makes it the 850 lb. gorilla, imo. But I don't really mind that--there's *always* an 850 lb. gorilla, right? My problem with MedT (and hence my regret in choosing a MedT pump) is that with a large market share they can afford to be somewhat complacent about introducing new features such as the Ping-style system (which I would *kill* for, being a young woman who likes to hide her pump) or a properly functioning integrated CGM. Maybe this will change since they're rapidly losing market share, but somehow I doubt they'll take action quickly enough (especially if they are successful in luring many a Cozmo-pumper to their side...)

4:49 PM  
Anonymous Anonymous said...

They are both huge and need watching. J&J has the leading share in BG strips. LifeScan creates about $1B in profits each year. So why is it that the innovation in the continuous monitor has to come from smaller companies?

The answer to that questions bugs me.

1:45 PM  

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