A Merry Tandem Christmas

Have you ever noticed how much the Tandem Diabetes logo looks like a Christmas tree? No? Huh. I guess that’s because it really doesn’t look much like a Christmas tree at all. But the blue T under my tree this year is as wonderful to me as that blue Tiffany’s box has been to generations of the fairer sex.

Yep. I’m going back to pumping. I’m leaving the stone tools and bear skins of syringes and vials behind and rejoining the 21st Century with a shiny new Tandem t:slim insulin pump. It’s both an early Christmas present and a late Christmas present for me. Early, because before Christmas I got the call that my dirty-rotten health insurance that I always complain about approved the new pump. (I guess I need to reassess my insurance-anger issues now that they bought me a pump.) And late, because due to the timing of the approval, and the holidays, I won’t actually get the machine until today at the earliest.

Still, the mere knowledge that it was coming made for a happy holiday. I got the call last Thursday and the first thing I did—you know, after all the jumping up and down, whooping, and punching the air—was to call my wife and tell her to chill that bottle of Layer Cake Malbec we’d been saving for a special occasion. We had a reason to celebrate.

The second thing I did was, for the first time, wonder if the “fringies” were right. I just got approved for a new pump on 12-20-12. Maybe the world really will end tomorrow, I thought. Anyway, as you all know, the world is still here. So yay for that.

So I’m sure the question on all your minds was why the Tandem? And why now? I’ll take the second question first. For complicated reasons that would bore even my biggest fan, whoever you might be, now was the time. I could get a pump now, but very likely couldn’t get one later. And, bizarrely, the way my insurance works with durable medical goods vs. pharmacy benefits, it’s actually cheaper for me to be on a pump than to use 12¢ syringes. Yeah. I know. The world didn’t end, but it’s still all fucked up.

You know, at first, I didn’t even want to be on a pump again. I was extremely happy using the Lilly half-unit pen during the day, Levemir with vials and syringes in the morning and night, and tracking and controlling everything on my iPod Touch using the RapidCalc app, with the gem-like, beautiful, and stunningly accurate iBG Star meter plugged into the base. My life was simple and well-integrated. My gear burden was light. I actually had the best A1C I’d had in years. It was the first time I’d walked the ground of the sixes since I can remember.

But…

There’s always a “but” in diabetes. We should start calling it Buttabetes.

But, my health insurance—which as of last week I have mixed feelings for, rather than blind hatred towards—refused to cover the Lilly pen fills. Humalog is off-formulary. Their view was that if I needed half-unit delivery I should use on-formulary Novolog and a half-unit syringe. (The NovoPen Jr. does half unit steps, but only beyond a full unit. The only pen in the States that will deliver 0.5 units of insulin is the Luxura.) And my insurance also refused to pay even one cent towards the iBG Star test strips. The only strip they will pay for is the Accu-Chek Nano.

So I had to abandon the diabetes control system that made me happy and actually worked. I literally could not afford to keep myself alive that way. And—rubbing salt in the wound—I spend every waking hour helping people with their diabetes, which saves the insurance companies gazillions of dollars, and they won’t repay me by helping me keep myself healthy? Not that I’m bitter about it.

Sarcasm alert: I have been the King of Bitter the last few months.

I ended up, at gunpoint (well, insurance-point), back in the past with the stupid little plastic half-unit syringe. And the stupid little Nano meter. And my control went to hell. It’s not that you can’t control your diabetes with simple tools. It’s not that I was intentionally making a mess of my health just to get back at them. It was just that the extra effort of tracking everything, carrying everything, juggling everything, was just too much with my 80 hour work week. I just didn’t have the time to do all that I needed to do to keep myself in prime condition once my time-saving tools were taken away from me.

Thus, my mind returned to pumps. Ironically, it would have been cheaper, in terms of their direct cost, for my insurance to cover my simple system rather than pay for a pump and its ongoing supplies; but the pump is cheaper for me out of pocket than the syringe and vial is. My durable medical goods benefit is much better than my pharmacy benefit. Crazy, but I’ll take it.

And again, now was the time. Things are changing. As we get closer and closer to insurance reform, the pump window gets smaller and smaller for me. I was believed that I had very few months to make the move back to a pump before the pump window closed on me completely. And that meant that I dare not wait for something new and wonderful to be FDA approved, moved into production, and be available to the masses. (That said, worrying that my assessment of this could be wrong did keep me awake a few nights. But I was convinced that I needed to choose from the pumps on the market right now.)

So let’s review the Cast of Characters in the Pump Follies: The Med-T Revel, the Animas Ping, the OmniPod, the Roche Accu-Check Combo, and the Tandem t:slim.

I’m actually a fan of the Revel. When it’s working. Which for me, is not very often. I went through five of them earlier this year during my review of the mySentry system. For some reason that no one at Med-T can fathom, my body or my environment seems to reject that particular pump. Revel was out.

I can’t get excited about the Ping. While I like the look of it, and I like its reputation for toughness, I wore one for about a month or so a few years ago and hated the menu design. I liked the fact that, in theory, you could control the pump from the meter, but it turned out to be such a pain in the ass to do so that it was hardly worth the effort. It’s also insulting that the meter is twice the size of the damn pump. There were other things I must have disliked about it, too, but it’s been so long ago that I can’t recall the details. The Ping just left a bad taste in my mouth. On top of that, I have only one patient on the Ping and he hates it and can’t wait for his warranty to run out so he can get something else. Even though Animas seems most likely to be the first to integrate Dexcom G4 sensors into their pumps, the Ping was out, too.

OmniPods are cool, and as one of their certified trainers, I suppose I should feel more loyalty towards them. They also just got approved for a new, smaller pod. But while my many pod-using patients are happy as clams with their systems, for the several months that I wore the system when it was first available, I was always knocking the frickin’ pods off of my body. OmniPod was out.

I’ve played with the Accu-Chek Combo at several conferences but it seems rather primitive for something “brand new.” It’s underwhelming. It just doesn’t seem to have much to offer.

That left the new Tandem. I like the fact that it’s small—always a plus. On the other hand, I don’t like the fact that it doesn’t have a meter that “talks” to the pump. This means that anytime I’d need to correct my blood sugar, I’d have to move blood sugar numbers from one device to another device. Manually. And at first I freaked out over the fact that it’s rechargeable. A rechargeable insulin pump? What if the batteries run low out in the boonies? What if there’s a blackout? But when I thought more about it, I realized that I’ve been living for years with a rechargeable CGM, cell phone, and more recently, the iPod Touch. If there’s a blackout, I’ll go fire up my Jeep and just plug in and charge up in the driveway.

The first time I played with a t:slim in the flesh was at the Keystone Conference this last summer. That was before I had an iPod and I wasn’t too sure I liked the whole touch-screen thing. I’m kinda old-fashioned. I like buttons. My first impression was that it was an ordinary, if nice, pump with nothing more to offer than a fancy interface.

But I did love the t:slim’s IOB tracking, which is CoZmo style, which is to say it tracks both meal and corrective insulin. I also liked it’s innovative delivery system, and the fact that it used the industry standard luer-lock connection to any brand of infusion set. Boooo, Hisssss to Med-T for making their own proprietary system to corner market share.

And t:slim lacks features I wish it had. But that wish list is really moot, as no one else has what I wish for either. I wish it would let me program basal patterns by day of week and change automatically. I wish the correction factor would get more aggressive as the BGL gets higher. I wish it had a built-in meter for one less thing to carry. I wish it kept track of missed insulin while suspended when I’m in the shower in the morning. Pie in the sky? New ideas? Hardly. All of those and more were part and parcel of the circa 2006 model 1800 Smith’s Deltec CoZmo. May it rest in peace.

So perhaps more from a lack of choice than from actual excitement about the product, the Tandem was the clear winner.

My “choice” made, it turns out the local rep wasn’t sure my health plan had ever approved a Tandem yet. Lucky me. The frickin’ trail blazer. As Christmas closed in on me, rather than visions of sugar plums, it was visions of denials that danced in my head.

Initially I was blasé about the whole notion of being back on a pump. If I get it, I get it, I thought. But once my doc signed the paperwork, I started to get excited about the whole notion of being a “pumper” again. I also gotta say that Melissa Lee’s most excellent review at Sweetly Voiced helped me get excited about the machine itself. Within 24 hours I was a complete wreck and it was going to be the end of the fucking world if my insurance said “no” (again).

But the world didn’t end. The insurance didn’t say no. And today I’ve got one eye on the horizon looking for a Brown delivery truck.

A new year. A bold new adventure. And it starts with one question: do I use my last pump settings or start from scratch?

I haven’t decided yet. But either way, it’s a sweet way to start another year with Buttabetes.