April 15, 2025 • 45 mins
Episode Summary
In Episode 30 of Think Like a Pancreas-The Podcast, we dive into the latest advancements in Continuous Glucose Monitors (CGMs). Host Gary Scheiner and guests Egils Bogdanovics, MD and Ginger Vieira explore the various methods of insulin delivery for diabetes management.
The trio focuses specifically on the differences between Multiple Daily Injections (MDI) and pump therapy.
Dr. Egils Bogdanovics and Ginger Vieira share why they prefer using Multiple Daily Injections over using an insulin pump.
The participants discuss the advantages and disadvantages of each method, including convenience, cost, and personal preferences. They also address the social stigma associated with insulin injections and the importance of adjusting insulin doses based on individual needs.
Key Topics Discussed- MDI offers simplicity and flexibility for many users.
- Personal experiences with insulin pumps can vary widely.
- Choosing the right basal insulin is crucial for effective management.
- Inhaled insulin can provide rapid correction for highs.
- Connected pens can help track insulin doses and improve adherence.
- Understanding insulin pharmacokinetics is key to effective therapy.
- MDI can be as effective as pump therapy with proper management.
- Carb counting may not be necessary with inhaled insulin.
- The benefits of using MDI include freedom from a mechanical insulin delivery device and the issues that come with it, lower cost, and greater peace of mind.
Pregnancy with Type 1 diabetes
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Gary (00:13):
Welcome to Think Like a Pancreas, the podcast where our goal is to keep
you informed, inspired, and a littleentertained on all things diabetes.
The information contained in thisprogram is based on the experience
and opinions of the IntegratedDiabetes Services clinical team.
Please discuss any changes to yourtreatment plan with your personal
(00:33):
healthcare provider before implementing.
I'm your host Gary Scheiner andtoday we're gonna be discussing
the how and why of MDI.
And for those of you who don'tknow, MDI stands for multiple
daily injections or inhalations.
I guess the I can standfor multiple things.
But before we jump in, make sure youthat you like, follow or subscribe
(00:56):
on your favorite podcast app sothat you never miss an episode.
And for expert diabetes supportbeyond this podcast, please
visit integrateddiabetes.com.
So now we're ready to get started.
I am thrilled to be joined today bytwo friends and colleagues, Miss Ginger
Vieira and Dr. Egils Bogdanovich.
(01:18):
Give you wanna give each of youa chance to say a little bit
about yourselves and Ginger?
Why?
Why don't you go first.
Ginger Vieira (01:24):
Hello Gary.
Thank you for having me.
I have lived with Type one for 25 years.
I've been creating videos, articEgils,and books on type one for about 20 years.
Please forgive the earlier ones.
I was 20, but um, yeah,uh, I am a huge fan.
Well fan, putting it lightly,but I'm a big fan of MDI.
(01:47):
Uh, but more, 'cause I'm not afan of insulin pumps, but I'm sure
we'll get into that a little later.
But you can find my books on Amazon, onexercise, pregnancy burnout, low blood
sugars, and find me at diabetesnerd.com.
Gary (02:02):
You co-authored one of those books with, uh, one of our team members.
Jenny.
Ginger Vieira (02:06):
Jenny, and we have a second edition coming out, hopefully next month.
New and improved.
It's 10 years.
10 years.
Uh, a lot's changed since wepublished that book 10 years ago.
Gary (02:17):
There has, and I, I remember.
When I first met you, you were afairly accomplished power lifter.
Ginger Vieira (02:24):
I was definitely having fun power lifting.
I fell into that by accident andbecause I was just trying to take
better care of my own health, Istarted lifting weights and then it
turned out I was really good at it.
I got really strong really quickly,and that really is what led me into
learning diabetes science on my own.
'cause there were so little.
He's got something back there.
Gary (02:45):
No, I, I was going through some old the archives and things in my office,
so we used to have an organizationcalled the Diabetes Exercise and Sports
Association, and I, I was proud toedit our journal called The Challenge
and find that addition there is...
(03:13):
Anyway, while I'm looking for that,Egils, tell us a little about this.
Egils Bogdanovics, MD: Yeah, sure, sure, sure. (03:15):
undefined
Egils Bogdanovich.
I'm, uh, I've had diabetes for about42 years and this, uh, this is plan
B. I, I started after school goingthrough officer candidate school,
and I wanted to fly fighter planes.
And literally a month before Pensacola,I lost 30 pounds in a couple weeks.
(03:35):
Was diagnosed with type one.
You know, plan B was to become anendocrinologist, and that's what I do now,
and been doing this for a number of yearsand loving, uh, loving seeing type ones.
I, I learned something from,from every single one that I see.
And just like Ginger, I, I am big, bigMDI as long as you're using CGM I'm a
(03:57):
big MDI proponent, although, you know,all honesty, I've tried everything.
Usually it's like a pump thatsays, not for human use, that I
get off the reps. But, you know,try, I, I do have tried everything.
Ginger Vieira (04:11):
Yeah, for sure.
I,
Gary (04:12):
I found the, the,
Ginger Vieira (04:15):
oh, geez, how funny.
Gary (04:18):
Raising the bar with Ginger Vieira,
Ginger Vieira (04:22):
Man, yeah, that is 20 years ago I was having fun, actually.
Gary (04:26):
You look younger now.
Ginger Vieira (04:29):
I'm a lot slimmer.
There's nothing, there's no better weightloss plan than not power lifting anymore.
I lost 30 pounds in like one year, noteven doing anything but walking my dog.
Gary (04:41):
Okay.
So I, I think a good first thingto ask you both about, I mean,
I, I'm a big advocate of pumptherapy for a multitude of reasons.
Why?
I mean, you're obviouslyintelligent people.
You have access to a lot of resources.
The latest, the greatest.
Why did you opt to go the MDI route?
(05:06):
Ginger tell us.
Ginger Vieira (05:07):
I really love that started with your obviously intelligent people.
I'm gonna start my next, every nexttime I see you in real life, Gary, I'm
gonna start our conversation with that.
You know, I used a pump for maybefive, seven years, something like that.
I loved it for a little while and itreally start to started to break my
(05:29):
trust and I started to really hate it.
What it does to my skin andreally hate pump site failures
and having it attached to me.
I did try again many years later, inmy late twenties for pregnancy, I put
on an Omnipod and I remember my husbandbeing like, wow, you really like this?
(05:49):
And within about three and a half weeksI was like, I am ripping this thing off.
There's no way.
And it's no offense, Omnipod,it could have been any pump.
And I would've felt the same way.
And he was like, yeah, that seemedtoo good to be true, that you
were really gonna stick with this.
And, um, yeah, I've been MDI ever since.
I just, if I think about it right now,having a pump attached to me all the
(06:10):
time, I, it's like claustrophobia for me.
Egils Bogdanovics, MD (06:15):
I've got a, I've got a little bit of that
robot, uh, feeling also when,whenever I'm, uh, pumping insulin.
I, I, as I mentioned earlier,you know, CGM for everybody.
That's, I've always been a CGM first.
Even if you're, if you're gonna bepumping, but you know, you really,
it comes down to simplicity.
You know, it's, I can go out with,with a pen in my bike, uh, you
(06:39):
know, kit and, and ride for fivehours and not worry about anything.
Um, not worrying about a sight lossor, or a kink or whatever it might be.
And, and you know, it, I mean, as farI've, as you know, that's personally,
as far as professionally, I have noopposition to having patients on pumps.
(06:59):
In fact, I, I encourage them if they,they wanna use it, but I, I've never had
a call at 2:00 AM saying my pen broke.
And, um, so once you inject,you know it's in there.
You're not worried about airbubbles, you're not worried
about a kink catheter, you're notworried about any of that stuff.
Gary (07:18):
You know you just cursed yourself.
You are gonna get a call tonight.
Ginger Vieira (07:24):
Well, can I tell you, I think this podcast actually cursed
me because I am not sure if I took myLantus last night and I, I was high
when I woke up, but it corrected soeasily that I thought, and I don't
think I've ever forgotten to takemy Lantus injection in 25 years, and
I, so I think you cursed me, Gary.
(07:44):
And then I hung steady this morning, soI thought, okay, I must have taken it.
Then I ate my apple and peanut butter.
I took my insulin.
I spiked so quickly that I'm thinking,okay, maybe I didn't take it, but I
would think I'd have ketones by now.
And be 300.
Gary (07:59):
My Ginger voodoo doll worked perfectly then.
Ginger Vieira (08:02):
Yeah, so the, the timing of this is hilarious.
And then I took a little bitof Lantus right before this.
I could have justcreated a whole disaster.
That's never happened tome in 25 years though.
Egils Bogdanovics, MD (08:14):
So you take half the dose the next morning if
you forgot it, that's your best.
Ginger Vieira (08:18):
That's what I took was half the dose.
Yeah.
But yeah, we'll see.
Egils Bogdanovics, MD (08:23):
And you're always, yeah, it's gonna
have some basal on board there.
It's not like you're pumping insulinand you just lost it three hours later.
Your, your beta hydroxybutyrateis through the roof already.
Ginger Vieira (08:33):
Yeah, it's still lingering.
I know, but it thenit's also Lantus, right?
So it already has a shorterlifespan and like Tresiba.
So yeah, I'm pretty sure I forgot.
But thank you for that encouragementand that I won't die later today.
Gary (08:47):
So everybody with type one needs a basal bolus type of a regimen.
The basal insulin can be administeredin a lot of different ways.
On a pump.
We have the ability to adjustthe basal by time of day.
It's not as easy to dothat on injection therapy.
So, Ginger, why did you choose Lantus asyour basal, or was that thrust upon you?
Ginger Vieira (09:09):
I've tried the other ones.
I, I've tried the other ones and I likedthem at first, and then like Tresiba
just became wild for me after thefirst month, it was so unpredictable.
Lantus is the most steady for meand I know exactly when it peaks.
I know that 3:00 AM isthat tricky time for me.
I actually, I I have a little, um,quirky thing I do now where I take 20%
(09:34):
of my dose at 2:30 in the afternoon andit helps me cover the evening where I
was having some really stubborn highs,which someone told me they had the same
thing happened during perimenopause.
I have no research to back that up,but it was really weird starting only
a few months ago and, and then thatallowed me to re, to only be taking 80%
of my dose before bed, which eliminatesfor me that three to 5:00 AM risk of
(09:59):
lows when Lantus is peaking po, youknow, five hours-ish post injection.
And so I know with Lantus and howI compensate for not being able to
tweak basal is, I know between 8:30and 9:30 I, if I was on a pump,
I'd need a little basal boost.
I am not getting that.
So I take a little, I, I fast, Ipractice intermittent fasting and I
(10:22):
know that triggers for me a releaseof liver glucose around 8:30.
So I take a tiny bolus around then.
Gary (10:29):
So the, the names of the insulins you, you mentioned, we have a lot of
international listeners to our podcast.
Glargine is sort of thegeneric name for the Lantus.
And the other two optionsare detemir and Degludec.
Degludec is the most long-acting of thelong-acting basal injectable insulins
(10:49):
and Devimere believe that, that, that'sLevemere, that's Novo's product was.
Are, are they discontinuingit or have they...
Egils Bogdanovics, MD (10:57):
Yeah.
They not making that anymore.
They're not making
that anymore?
Yeah.
Yeah,
Ginger Vieira (11:01):
That was like water for me.
Levimir was like saline for me.
It did almost nothing.
Egils Bogdanovics, MD (11:08):
Interesting.
Maybe you forgot to take it.
Yeah.
Ginger Vieira (11:11):
I was on it for about two weeks.
I actually fired myhealthcare team over it.
This was like 15 years ago.
They didn't believe me.
It wasn't working, and I was like,please put me back on Lantus.
And they, they fired me because I wastelling them how to do their job, I guess.
Gary (11:27):
So Egils, I see patients quite a bit, uh, who are on MDI and experience
a significant dawn effect where theirglucose rises in the early morning hours.
And then with kids, we often seethat rise in the evening when
they're making growth hormone.
So what are some of the waysyou can work around that if
Egils Bogdanovics, MD (11:45):
Yeah.
There's, there's no doubt about it.
I, you know, I was gonna say the one,one time when you really, really need
a pump and MDI is not gonna do it,is to compensate for dawn phenomenon.
And, you know, you could say,well, I'm going to take a little
bit of this, a little bit of that.
I have some patients that I, I takeTresiba as a basal, and I like it because
if I, if I miss my morning dose, Icould take it at nighttime that night.
(12:06):
And go back to morning thenext day and it's like keeping
a bicycle wheel spinning.
It's, it's pretty smooth.
But yeah, I have patients that,that aren't just even take a
little bit of Lantus at bedtime.
You know, sort of a funny combinationto compensate for that Dawn phenomenon.
But the thing about Dawn isit's not the same every day.
So you really need an automated insulindelivery device to compensate for that.
Gary (12:28):
We've actually had some success using NPH at bedtime.
I know it's kind of taboo.
Get, get away.
Egils Bogdanovics, MD (12:35):
No, no.
Gary (12:35):
But
Egils Bogdanovics, MD (12:36):
you know, in, in general, uh, you know, with, with
insulin therapy, if you understand.
You know, the pharmacokineticsand pharmacodynamics of,
of a particular insulin.
You could use anything.
You know, I used to use NPH andregular three times a day, a reverse
mix, you know, 70% regular, 30% NPH.
So even though NPH varies from day to day,like a ton, if you just got small doses
(13:01):
a few times a day, you almost overlappinghave a, have a nice basal so you know,
you can make it work as long as you.
As long as you are a smart diabetic.
Ginger Vieira (13:10):
Yeah.
You know what I take to, um, notdeal with down phenomenon anymore.
I take metformin right before bed.
It has eliminated my downphenomenon problems at 5:00 AM
Gary (13:22):
So it's, it's blunting your liver's output of glucose
in those early morning hours
Ginger Vieira (13:26):
and awesome because I exercise first thing in the morning and it
was very tedious because dawn phenomenon,dawn phenomenon isn't, you know, exactly
the same impact every morning, right?
So I would try to getahead of it and prevent it.
And so I was playing this guessing gameon top of cardio exercise and metformin
has completely eliminated that for me.
Gary (13:46):
The other half of the MDI is the, the bolus, the insulin to
cover meals and to correct highs.
And with a pump, we do it by touchingsome buttons on MDI, again, the eye
can stand for injection or inhalation.
So what are you, what are yourpreferred methods for bolusing?
Ginger Vieira (14:07):
Want me to.
Go ahead.
Go ahead.
Yeah, I mean, I'm talking too much,
Egils Bogdanovics, MD (14:10):
so, so, so I will bolus you pretty much, you know,
NovoLog, Fiasp, Humalog, Lyumjev,you know, everybody makes a big
deal about, you know, this is faster.
This is faster.
You got a few minuteshere, a few minutes there.
They're all.
To me, they're all the same.
It's just a matter oftaking it early enough.
Um, but I also like to, and you'vealluded to inhaled, I love using, you
(14:33):
know, a hit of inhaled insulin to, toreally correct those highs because I,
I mean, I see those arrows going downpretty rapidly and you know, it's.
Again, you know, it's notthe plain as the pilot.
I think that, uh, you know, if you bolusearly enough and, and pay attention
to the trend arrows on your CGM andpay attention to what you're about
(14:57):
to be doing, you know, the bolus, youknow, with MDI can be as good as it
is with, with an AID and, uh, Ginger.
You have experience with the Afrezza.
Ginger Vieira (15:08):
I'm huge fan of Afrezza, but I don't, I just got
a question about this on Instagramthis morning, saying how much?
Yeah.
'cause I posted a photo of this reallyyummy gluten-free pizza I had last night.
Oh, Gary.
All right.
And someone messaged me and said, well,how much do you take, um, how much
inhaled insulin do you take for that?
And I was like, I would never relyjust on inhaled insulin to cover pizza.
(15:28):
It's.
It's strong for a big like punch.
Right, but pizza requires like,like a flood or something?
Gary (15:35):
Yeah.
You have to triple dose over time.
Ginger Vieira (15:38):
Oh, I mean, yeah.
Egils Bogdanovics, MD (15:39):
But you could take it every, you could take it every hour.
I mean, it would work ifyou took it every hour.
Ginger Vieira (15:44):
That's really tedious though, and would be like chasing a,
trying to run with a train or something.
So I do a combination for a lotof my meals, unless it's pretty
simple of NovoLog and inhaledinsulin and I love inhaled insulin.
It's definitely a game changer, eventhough I still also use NovoLog, but
it just gives me more flexibilityand fewer injections for sure.
Gary (16:06):
Yeah.
Uh, even though though I'm on apump, I use Afrezza every Sunday
morning before I play basketball.
Because if I dose for breakfastwith normal rapid, or ultra
rapid, exactly, it's gonna makeme crash while I'm playing ball.
Yeah, the Afrezza is in and out soquickly I don't have to worry about it.
Ginger Vieira (16:23):
That's one of my favorite things about it is the, I
spend a lot less time on dog walks.
I walk my dogs several times a day,and I spend a lot less time preventing
low's from meal boluses on board.
Because of Afrezza
Egils Bogdanovics, MD (16:38):
The Great, the great thing about Afrezza is it
almost doesn't matter how much youtake because it's gonna be gone.
Yeah.
You know?
Yeah.
You, you got an hour, hour, youknow, hour and a half later you're,
you're, you're back to normal.
So, so it's, it's, uh, alot less, um, detail, uh,
requiring than, than, than subq.
(16:58):
But I agree.
I, I do the same thing.
I do both at the same time.
Gary (17:01):
How do you guys calculate your doses?
Ginger Vieira (17:03):
You don't have to.
That's what's so great about it.
I was just gonna say, you don't have tometiculously carb count with afrezza.
It's more they, I think they didit themselves a real disservice by
putting a number on these things,because everybody wants to know how
that translates to NovoLog or Humalog.
Right.
And it, it doesn't.
It doesn't translate.
And like they say that a fouris technically two and a half
(17:27):
units of injectable insulin.
Now I would take a four for arelatively very low carb salad.
I would never take two and a halfunits of NovoLog for a low carb salad.
It doesn't translate.
So instead, I think they should, I thinkof them as small, medium, and large.
Egils Bogdanovics, MD (17:43):
Yeah, blue.
Blue is snack.
Uh, green is sandwich,and yellow is pizza.
Ginger Vieira (17:50):
Yellow is bam, right?
Gary (17:52):
Pasta, potato, big potato.
Yeah.
Ginger Vieira (17:55):
Plus I mean.
Gary (17:55):
If you're doing
Egils Bogdanovics, MD (17:56):
Gary, Devil's advocate, you know, Gary, you're using
Afrezza and you're, I assume you're on,on an automated insulin delivery device.
Uh, you know, I mean, every timeyou use Afrezza you're sort of
screwing up your, your pump's brain.
You ever think about that?
Gary (18:13):
I turn off the automated part for a little while.
Egils Bogdanovics, MD (18:16):
All right.
Okay.
Ginger Vieira (18:17):
Okay.
I know a few people on a I systemsthat use it for correcting highs,
Gary (18:21):
kill the brain for a few hours so it doesn't mess things up.
Egils Bogdanovics, MD (18:24):
Mm-hmm.
Ginger Vieira (18:25):
Nice.
Good.
Gary (18:25):
Yeah.
Um, the new connected pens are anotherpopular option for people on MDI because
it offers some features of pump therapyalong with, you know, the convenience
and the ease of, of the injection.
Either of you have experienceusing a connected pen.
Egils Bogdanovics, MD (18:42):
Yeah, well, I personally use both
the InPen, uh, and the Tempo.
And you know, I, I agree.
I mean, if you think about it, you know,1% of insulin users in the planet are
in a pump, and the rest 99% aren't.
So, you know, we should, or they should,have the option of having all those
advantages of, of, of pumping and you're,you're getting about as close as you can.
(19:06):
You know, you've got, you forget, you,you know, I, I often like Ginger, you
know, forget if I took my insulin or not.
And if I look down on my Tempoand I see that I just took insulin
10 minutes ago, then I confirmsthat I did take my insulin.
Whereas if I'm not using it, I don't know.
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Yeah, so we were talking about the pensand the connected pens, but Ginger,
(20:08):
uh, have you used a, uh, connected pen?
Ginger Vieira (20:11):
I haven't, because I don't like using pen needles.
I don't tell anybody, Gary,but I stick a syringe.
Gary (20:17):
How old do you have with pen?
Ginger Vieira (20:19):
I know, I think I'm just an old, old lady.
I'm like, I resisted CDs.
I was like, no way.
I am listening to tapes forever.
So that's my problem really at the core.
Gary (20:28):
Fleetwood Mac and fog hat c uh, cassettes.
Ginger Vieira (20:31):
It was, it was a rocky.
Rocky III soundtrack Ihad, Eye of the tiger.
I wrote down all the lyricsby hand while listening.
So anyway, I um, don't like pen needles.
They leak and I don't trust them andI don't like having to prime them.
It's all about trust for me or alack thereof with all the tech.
Gary (20:47):
I hear about the leaking 'cause the drops that come out
after the needles removed, youalways wonder how much was lost.
I
Ginger Vieira (20:52):
don't that, and I don't like priming it.
That's a waste.
And so,
Gary (20:56):
Um,, yours is held together with a rubber band.
You got your syringe and your pen.
Ginger Vieira (21:03):
Pretty.
Gary (21:03):
I love the rubber band.
You know, years ago, the meter companieswere all looking for ways to make out
an all in one meter with the lancet,the strips, the meter, and it ended
up with these big, bulky devices.
I came up with my own idea using arubber band just to link it all together.
So I was thinking I'd market this.
I'll sell these all in onemeter adapters for $19.99.
(21:26):
Brilliant.
If you order today, I'll give youan extra one for no extra charge.
Just pay the additional shipping.
Shipping fee.
Egils Bogdanovics, MD (21:32):
Yeah.
Or get it off your cauliflower whenyou get it in the refrigerator.
In the, uh, at store.
Yeah.
Yeah.
Hey, Ginger, I saw that you haveyour pen without the cap on.
Without the cap on it.
Why?
Ginger Vieira (21:43):
Yeah, I tossed that as soon as I open it.
Egils Bogdanovics, MD (21:45):
Why?
Why?
I mean, I know some people they comein and they have the, the big cap
on it and you can't fit it on there.
So if you just have the little needle withthe little cap on it, this still fits.
Ginger Vieira (21:57):
And that would disrupt my rubber band system though, doctor.
Egils Bogdanovics, MD (22:00):
But you could still put the band around here and you
only have one needle for the whole pen.
I mean, I, I go through one needle for thewhole pen unless you get a tissue clot.
At that point, you just change.
Ginger Vieira (22:10):
That's interesting to hear from a doctor not changing that pen.
Egils Bogdanovics, MD (22:13):
Again.
I do, as I say, not as I do.
Ginger Vieira (22:15):
I appreciate you acknowledging that though,
and being honest about it.
I do change my syringe.
Hopefully once a day, but, orwhen it starts to hurt, I guess.
Gary (22:24):
Yeah.
I've always taught peoplechange the needle daily.
Yeah.
The pen, needle.
How long does a, how many daysdoes a pen needle last you, Egils?
Egils Bogdanovics, MD (22:31):
Well, you know, I, it, I say that I use it for the whole
pen, but it never lasts the whole pen.
You know, I'd say, you know, somewherearound a week and, and, you know,
once in a while patients will call,they say, my pen doesn't work.
I said, it works.
Change the needle.
And they called back andthey said, yes, it works.
I mean, you know, I, I, Icollect old diabetes stuff.
I have a little museum of diabetes and inthe old days they had the glass syringe.
(22:55):
Of course the metalneedle, you boiled both.
And they had this little thing calleda reamer, where after each injection
it was like a little paperclip, tiny.
You put it through the needle part of itto actually get that skin clot out of it.
'cause otherwise, even though youboil it would still clog it up.
Gary (23:13):
My Yale syringe came with a little sharpening rock.
Egils Bogdanovics, MD (23:16):
Oh yeah, yeah.
Sharpening stone.
Absolutely right.
Absolutely right.
So I've got a lot of those.
If you guys want to go old school and youreally want to go back, really old school.
Gary (23:23):
Ginger, this might be for you since you don't, like...
Ginger Vieira (23:26):
I like to start around 1999.
That's my old school.
Gary (23:29):
Yeah.
Well, you know the smart pens likethe, like the InPen, you know,
they'll do dose calculations,they'll adjust insulin on board and.
They'll document the doses thatare taken by, you know, there's a
Bluetooth communication, so it hasa lot of the benefits of, of pump
therapy without having to use the pump.
Egils Bogdanovics, MD (23:47):
Absolutely.
And the reports.
Ginger Vieira (23:48):
I think that technology, yeah, the reports.
I think that technology is sovaluable for people who need the
support and the further education.
Right?
Like, I, like both of you.
I love to study the heckoutta my insulin doses.
I'm not gonna let a device tellme how much to take, but, a large
majority of people will learn and,and get a lot of support from that.
(24:12):
Should I use one?
Yes.
Gary (24:14):
I, I may, I've been making a list of what all the potential advantages are to
being on MDI as opposed to pump therapy.
So let me run this list by you.
You can tell me what I missed.
Egils Bogdanovics, MD (24:25):
Really, it's the same list at all as all
the disadvantages of pump therapy.
Gary (24:29):
We'll, we'll get to those next, but the advantages, so convenience
and Egils, you, you emphasize this,just the convenience, just quick.
You carry it, it's portable, it's easy.
Cost is also an enormous difference.
Ginger Vieira (24:42):
Way more affordable.
Gary (24:45):
From an insurance standpoint, you know, if you get coverage for your
pump and supplies, you might still havedeductibles to meet and copays, et cetera.
Ginger Vieira (24:53):
You know, that's actually a big part of what continued
my MDI therapy in my early twenties is'cause I did not have health insurance
for about four years and there's noway I could have maintained a pump.
Egils Bogdanovics, MD (25:05):
Yeah.
Yeah.
I used to, I used to take chemstrips and cut 'em into quarters,
you know, quarters without insurance.
Gary (25:12):
Quarter, yeah.
Wow.
Egils Bogdanovics, MD (25:13):
But NPH was like 13 bucks a bottle back then.
Gary (25:16):
So you were that good with a scissor, or did you use a scalp?
Egils Bogdanovics, MD (25:20):
Well, you could, you could tell if it was like less
than 40 or over 400, and everythingin between was about the same color.
It's all kind of a, you know, Moish blue.
Yeah, yeah,
yeah,
Gary (25:29):
yeah, yeah.
Simplicity's another thing,you know, pump therapy is, you
know, it's much more complex.
You know, you gotta learn programmingand site changes and all that good stuff.
Injections are just that there,or inhalations are a lot simpler.
Uh, the portability, it's uh, it's easier.
It's probably less stuff you haveto lug with you when you travel.
(25:50):
Yeah.
The absence of adhesives and Ginger,you pointed this out as this was an
issue for you when you were on a pump.
You gotta use some kind ofadhesive to either keep the pump
or the infusion set in place.
And you don't need thatwhen you're on an MDI plan.
And then the less, fewer technicalissues there is the potential if
you, you know, take your needleout too soon, it's still dripping.
(26:13):
But otherwise you don't really havetechnical issues with pumps and
pens, whereas with syringes and pens.
But with pumps, you can have allkinds of technical issues that arise.
And we've known for years that the DKArisk is lower for people on injections.
'cause like you said, Egils, once youinject the long-acting insulin, even if
(26:34):
you forget it the next day, you still havea trace of it working for quite some time.
So it offers some protectionagainst ketosis and ketoacidosis.
So now anything I missed?
Anything else about MDI?
Ginger Vieira (26:49):
That cannula pushing fluid into your body 24/7.
The skin damage beyondthe adhesive, right.
Just the cannula sitting there.
I could not stand it.
It would get, so I havereally sensitive skin.
I have a diagnosed, like I have like thedriest skin in the land kind of diagnosis.
I don't even know the name of theskin type, but that's really what
(27:11):
it means and I just can't handle it.
It's so itchy all the time forme and just the damage it does.
Gary (27:20):
Yeah, so lipodystrophy is another potential problem we see with pump use
if the sites are not rotated properly.
But the same thing canhappen on injections.
You know, it's not really the
Ginger Vieira (27:32):
It's just sitting, there sitting there for days pushing food fluid.
Gary (27:35):
That's, that's in your head, that's in your brain.
Ginger.
Ginger Vieira (27:39):
I guess so.
It's one of my nightmare.
Gary (27:41):
It's typically not causing damage unless it kinks cause
damage.
Ginger Vieira (27:45):
Alright.
I think it's so yucky.
Egils Bogdanovics, MD (27:47):
Yeah.
I mean, lipo hypertrophy is a huge,well, it's not, as you mentioned,
it's not just pumps, it's injections.
I mean, I've got people coming in,you know, after years I finally
look at their belly and I see thatthere's a softball to the left of
the umbilicus and it's like, oh no.
Yeah, and, and it, you know, because itdoesn't hurt to inject there, so you just
keep going back to the same, same place.
Ginger Vieira (28:07):
And the absorption is terrible at that point.
Right?
Egils Bogdanovics, MD (28:09):
Oh yeah.
Gary (28:10):
Yeah, yeah, yeah.
I call it the candy machineeffect when that happens.
'cause you, you give insulin,it doesn't absorb right away.
You go high and you give more insulinand then all of it kicks in at once.
It's like that candy machine where you,the wheel turns, but your candy doesn't
quite fall so you hit the machine.
Ginger Vieira (28:29):
Is it it gets in delayed?
Egils Bogdanovics, MD (28:31):
Delayed.
Gary (28:31):
It's delayed.
And sometimes by the timethe old insulin absorbs, it's
not at full strength anymore.
Ginger Vieira (28:38):
Okay.
Yeah.
And you know any other, that's actuallya big part of getting insurance
approval for inhaled insulin is youhave to tell your doctor to put in
your notes that you have lipotrophy.
Okay.
That's like critical.
Gary (28:51):
Any other advantages of MDI that I missed?
Ginger Vieira (28:56):
Flexibility around exercise.
I think, I mean, once you figure out yourAID system for exercise, but I find it
way simpler to exercise without a pump.
Gary (29:10):
So now I'm gonna throw at you all the reasons, I prefer pump
therapy and see how you would counterthese with your MDI-- the frequency
of injections and inhalations.
Egils Bogdanovics, MD (29:23):
Hell, I mean, look at the frequency of site changes.
That's the the first thing that happenswhen I put, I mean Omnipod or t some the
use, both of 'em, you know, three dayslater it's like, didn't I just do this?
I mean, it seems like two minutesago I changed my pod and now
it's three, three days again.
(29:44):
So, I mean...
Ginger Vieira (29:45):
and the, and the tech failures, right?
It's like even if you, if you don'tmake it three days, I feel like
my pumping friends just are alwayshaving technical issues, right?
Gary (29:57):
You can't deny, even if you're having to change every 48 hours.
The number of needle sticks with MDI is...
Egils Bogdanovics, MD (30:04):
it's much, much more than that.
And, and even if you, and, and sort of,you know, to, to make the argument for
pumping insulin, if you're correctinghighs with what I recently used in
Omnipod, I might do that 11 times a day.
You know, hit use CGM.
I'm not gonna take outmy pen and take one unit.
I'm not gonna take out my pen andtake two units, you know, 11 times
(30:27):
a day to correct those highs.
So, sure.
I mean, yes, we are pink cushionsand acknowledging that I, I think
that pump will give you bettercontrol with frequent corrections.
Ginger Vieira (30:38):
I mean, also I would argue personality type though, like I did, I
did MDI through pregnancies and I stillmaintain that A1C below six without a pump
and I, I will, you know, I'm, it takesme a month to go through a pen, right?
You said it takes you a week.
So just the difference in insulin, becauseI'm five foot two woman, you're a man.
I will take out and take aninjection of a quarter unit that I
(31:01):
micromanage from this for the syringe.
Another reason why I like using syringesis I can pull back just a smidge.
It's not even, oh...
Gary (31:08):
That's and, it actually was my next item was dosing precision on a pump.
I can give a 20th of a unit.
Yeah.
I can give 0.35, 4.1.
Ginger Vieira (31:20):
I can on this too.
I just don't quite knowif it's 0.35 or if it's
Gary (31:25):
0.1.
We're gonna get a molecular scaleand see how much you're actually...
Ginger Vieira (31:29):
I have figured out that if I pull it back where
it actually looks like there'snothing in it, that for me is like
Gary (31:35):
almost nothing equals one quarter.
Ginger Vieira (31:38):
Yeah.
Gary (31:41):
One knee equals two feet.
You know you got all thesetranslations you use.
Ginger Vieira (31:45):
I do it all the time.
If I was,
Gary (31:46):
but you, you gotta admit...
Ginger Vieira (31:47):
blood sugar in the two right before exercising, I
would take what is basically a drop.
Doing exactly that.
Gary (31:54):
For young kids and anyone who's really sensitive to small
doses, you can't beat a pump.
Egils Bogdanovics, MD (31:59):
You know, years ago, years ago, they showed
that moms could drop up oneunit accurately for their kids.
Gary (32:06):
Uh, yeah, that's Ginger's a mom.
Yeah.
Uh, with a pump, we have theopportunity to sync with an
automated insulin delivery algorithm.
It'll raise and lower the, the deliveryif glucoses are trending out a range.
We don't have that capability with MDI.
(32:27):
How do you counter that?
Ginger Vieira (32:29):
I don't trust any CGM technology to be accurate
enough to be dosing my insulin.
Egils Bogdanovics, MD (32:34):
I believe CGMs good enough for, for AID
and good enough for, for using itin a non-ad adjunctive fashion.
In, in MDI, I mean itsort of, sort of, yeah.
As, as far as advantage of, of, of pump,we alluded to, you know, using CGM right.
And for years I was telling patientsthat it doesn't matter how you get
(32:56):
your insulin as long as you use a CGM.
In fact, there was a study thecommissary where injection with CGM
or pump with CGM was a lot betterthan injection with finger stick
and in pump with finger stick.
Gary (33:12):
But the AID folks did that.
Egils Bogdanovics, MD (33:14):
You're you're absolutely right.
I mean, I was, I was showing picturesof this to patients and to docs saying,
it doesn't matter how you get yourinsulin, as long as you're using a CGM.
And then six years into that study, theychanged the protocol to use AID and all
of a sudden AID went boom right down.
So that whole argument is shot.
(33:35):
Now you, you're gonna do a lot betterwith an AID and CGM than injection.
Gary (33:39):
Ginger.
Your opinion is, isshared by a lot of people.
Ginger Vieira (33:43):
Yeah, but I, I think it comes down to the same thing I
mentioned earlier is that there'sa larger majority of people who do
need AID to reach their targets.
And it's like a invaluablething for those people.
And
Gary (33:56):
yeah, what it allows though,
Ginger Vieira (33:58):
likes to micromanage everything.
Gary (33:59):
They, well, they can reach that target with less micromanagement.
Ginger Vieira (34:03):
No, no.
That's what I mean is it's necessary,
Gary (34:06):
right?
Ginger Vieira (34:06):
For a lot of people.
Gary (34:06):
People with a pump.
If, since I have such a healthy dietand I'm eating junk all the time,
Ginger Vieira (34:12):
That's what I've heard.
Gary (34:13):
I have the ability to extend my bolus delivery.
So that I don't drop after the mealand then rise a few hours later.
How do you deal with that on injections?
Ginger Vieira (34:25):
Oh, no problem.
I take, I spread out my doses.
Egils Bogdanovics, MD (34:29):
Yeah,
Gary (34:30):
That'll work.
Take multiple doses over time.
Ginger Vieira (34:33):
Yeah.
Okay.
Gary (34:35):
It'll work.
But it's, it'll, but it's work it.
Ginger Vieira (34:37):
It's more work, right.
It's, I mean, it's a trade off.
People ask me all the timewhy I'm not on a pump.
It's a trade off of what kind of workand tedious things you wanna deal with.
I don't wanna deal with thecost and the tech and the tech
failures and the site stuff.
Mm-hmm.
And you know, all of that.
Versus, sure.
I'll take two more shots.
Gary (34:58):
What about social stigma?
There's a lot of people who are hesitantto give themself insulin around other
people because of just the way it looks.
The social stigma associatedwith taking shots.
Ginger Vieira (35:08):
Those people need to go somewhere else.,
Gary (35:08):
How do you address that?
Egils Bogdanovics, MD (35:11):
I tell patients just it might be a, a
teaching moment for everybody else.
Yeah, go ahead and do it.
I tell 'em to inject through theirpants if they'd like, and it's been
shown it doesn't increase infectionrate or pull up their shirt a little
bit to go into the belly or in thesummer, go into the triceps region.
But if somebody, if somebody wantsyou to go to the bathroom and sit
in a stall and take insulin thatway, tell 'em, uh, take a hike and
(35:33):
be happy you're not taking insulin.
Gary (35:35):
Yeah.
Punch 'em in the face and then
Egils Bogdanovics, MD (35:38):
Yeah.
That'll work though.
That'll work too.
I'll bail you out, gary.
Gary (35:40):
The vast majority of MDI folks are taking injections, not inhalations,
and they do need to figure out dosesfor corrections and carbs and whatnot.
My pump does those calculations for meautomatically, and it's only a suggestion.
I mean, I can adjust it if I want,but I like the calculation and
the insulin on board adjustment.
(36:00):
So how do people on MDI deal with that?
Egils Bogdanovics, MD (36:03):
Well, you use one of those smart pens then if you really,
really want to know what your insulinon board, uh, is influencing your bolus
and you know, for patients that are, arestacking on a regular basis, you know,
taking these rage boluses because theycan't wait for a couple of hours, it's
probably a pretty good idea to use an app.
Ginger Vieira (36:21):
And to get inhaled insulin so that you don't feel the urge.
Egils Bogdanovics, MD (36:26):
Yeah.
Yeah.
Gary (36:27):
The basal, we talked a little bit about, but I, I consider the
variable basal delivery to be akey benefit of pump therapy, even
without automated adjustment.
Being able to program in lowerbasal in the middle of the day for
people who need less and higher inthe early morning or the evening
when they need more on injections.
(36:49):
You know, there, there's some creativethings we can do, but most people
are just taking that flat basal rate.
24, we talked about that already, so Idon't think we need to get into it much.
Ginger Vieira (36:58):
I mean, i, I have a little note on that is that I
really, you compensate in other ways.
So I believe, you know, I, I try toget my basal dose as low as I can.
So that I'm never droppingduring a fasted dog walk.
That's kind of my gauge for I have toomuch basal, and again, because I'm one
unit too much is a make or break for me.
(37:20):
So there's times of the month whereI go up 10% or down 10% in my dose.
Um, based on...
Gary (37:26):
In your case though, when you adjust your basal, it's 24
hours of adjustment for a dog walk.
On a pump, we can, we can make,
Ginger Vieira (37:34):
It's not for the dog walk.
It's not for the dog walk.
The dog walk is just theindicator to me that I have a
little too much basal on board.
So, but then when I say you have tocompensate in other ways, if I'm going
down to my lower dose of nine unitsa day, I know I might need a little
bit more insulin with some of my mealsor a little bit more insulin, you
know, and I mean, like, you know, thesmidge on my little syringe versus.
(37:57):
If I go up, I'm gonna needa little less, so I'm May.
I'm compensating for the lackof flexibility in my boluses.
Egils Bogdanovics, MD (38:04):
My, my, my approach to to, to adjusting that
basal is my bedtime and my morning.
You know, if I'm dropping from bedtimeto morning excessively, you know, pick
a number, 30, 50, whatever it might be,then, then I want to, you know, drop, drop
back on, on my basal and yeah, I agreed.
Ginger, you know, you know.
I, I like to use, you know, peopleused to say 70% basal, 30% bolus.
(38:28):
I like to use about, you know,60, 70% bolus and, and a, a large,
a smaller amount of, of basal
Ginger Vieira (38:35):
As little as possible.
Gary (38:37):
The pumps let us make temporary adjustments to the
basal for things like sports andexercise, lack of activity, illness.
If you adjust the basal oninjections, you're making a 24
hour plus change in your basaldelivery and not just a few hours.
So how do you deal with...
Ginger Vieira (38:58):
I have a whole book that teaches how to do it on MDI and there's
notes in there on, on pumps too, but
Gary (39:04):
Convenient that you had that ready.
Ginger Vieira (39:06):
How convenient.
Hey, there's a shelf back there.
It's just where it lives.
Okay.
But it's so doable.
You just have to first get yourbasal insulin dose fine tuned.
So again, that it's low enough.
You're not droppingduring fasted exercise.
If you're dropping during fasted exercise.
I believe you have toomuch basal on board.
And then like I said, youcompensate with boluses.
(39:27):
Now if I was going to eat a meal andthen exercise, I need to obviously
adjust the meal bolus just like Iwould if I was on a pump as well.
And you don't have to monkeywith the long acting dose once
you've got it fine tuned properly.
Gary (39:45):
Do you have any patients who use both a pump and MDI who alternate?
Egils Bogdanovics, MD: Yeah, you're looking at one. (39:52):
undefined
Um, yeah, it's, uh, every couple months,uh, and it, and, uh, you know, having
said that, there's no doubt about it.
You know, I give, uh, I do betterwhen I'm on a ID um, even though I
do really, really, really well onMDI, because, you know, I. Believe
(40:13):
it or not, I think like a pancreas,Gary, you know, it, uh, you know it.
If, if I'm going up, if Ieven, I, if I even see a trend
arrow going up, I'll hit it.
Exercise.
Yeah.
That's, that's one thing that my churchis going for a five, five hour bike ride.
Uh, you know, I think that I couldnever figure out exactly what to do
as far as insulin, Ginger, but evenpeople without diabetes need to fuel.
(40:36):
So my rule is 25 grams ofcarbs every 30 minutes.
So I go through a pile of gel.
Do the ride, but it, it wouldbe easier with, uh, with a pump.
But again, I'm gonna have abackpack full of pump gear
supplies if I'm gonna do that.
Ginger Vieira (40:52):
Yeah.
Endurance, endurance exercise.
A a pump becomes a biggame changer for sure.
It's harder with, on MDI.
Gary (41:02):
Yeah.
Um, we have quite a few patients who willalternate between pump and they'll go on
injections, let's say if they're on a, atthe beach for the weekend or doing some
kind of adventure outing where the consof pump therapy just outweigh the pros.
Being able to transition back andforth is great, and a lot of people
(41:23):
don't realize that you can do that.
As soon as you wake up, you canjust give yourself an injection
of your long-acting insulin.
Stop using the pump anddo boluses at meal times.
There's also an option called anuntethered plan where you can combine
pump and injection on the same day.
Where you get enough basal to meetyour low, you inject enough basal
(41:46):
to meet your lowest basal need, andthen you wear the pump perhaps at
night while you need more basal.
And then you, you can connect tothe pump for bolusing purposes, but
you can be disconnected from thepump all day on a plan like that.
So I guess it's safe to say MDI, whetherit's with afrezza or injected insulin.
(42:08):
Pump
therapy-- AID Automated
systems.
These are all tools at our disposal.
And everyone's gonna have their ownunique advantages and disadvantages
associated with these different tools,and it's in everyone's best interest to
learn how they can benefit from these.
If your healthcare team isn't teachingyou about them or sharing information
(42:30):
about them, seek it out on your own.
'cause clearly different systemswork best for different people.
I'm a, I'm a big fan of pump therapy
and, and the AID systems.
I think work great, but they're not at, they're not
advantageous for everybody.
Some people do better on MDI for avariety of reasons and encourage 'em to
(42:51):
do that if that's gonna meet their needs.
The best.
Uh, either of you have like aclosing summary statement you want...
Egils Bogdanovics, MD (42:57):
You just, you just used people like five
times and, and that's the key.
People with diabetes are people, andthere's an amount of technology for
everybody, and what works for oneperson may not work for the other.
But as far as you know, last words, I I,I, I tell my patients now, I don't know
if I'm jumping the gun, but I tell 'em,you know, take care of those kidneys,
(43:19):
take care of those eyes because we'regonna have a cure in your lifetime.
Ginger Vieira (43:23):
I echo the same, I do a lot of writing about cure
research for a few places, and I feelvery hopeful about the same thing.
It's definitely, I willsay, so I've, I have.
Jokingly, but I'm not joking, said thatI'll sign up for an insulin pump when it
is implantable and I'm actually gettingan the implantable ever since next month.
(43:43):
I just got insurance approval,had to fight for it for a couple
months, but I'm excited about that.
Gary (43:51):
It has interoperability designation now, so we may see
it in an AID system
before too long.
Ginger Vieira (43:57):
Yeah, I hope.
Gary (43:58):
All right.
Well, I wanna thank both ofyou for joining in today.
I, I hope I didn't insult you orlose your friendships over this now.
I respect what you're, I believeme, I respect what you're doing.
You got good reasons behind whatyou do, and, and I, I respect that.
So thanks again.
Thanks for tuning in to ThinkLike a Pancreas, the podcast.
(44:19):
If you enjoyed today's episode,don't forget to like, follow, or
subscribe on your favorite podcast app.
Think like a pancreas.
The podcast is brought to you byIntegrated Diabetes Services where
experience meets expertise, passionmeets compassion, and diabetes care
is personal because we live it too.
(44:39):
Our team of clinicians all livingwith type one diabetes understands
the challenges firsthand.
We're here to help no matterwhere you are in the world.
From glucose management to self-carestrategies, the latest tech, sports,
and exercise, weight loss, type onepregnancy and emotional well-being.
We've got you covered.
(45:00):
We offer consultations inEnglish and Spanish via phone,
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Wanna learn more?
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On behalf of Think Likea Pancreas, the podcast.
I'm Gary Scheiner, wishing
(45:20):
you a fantastic week ahead.
And don't forget to think like a pancreas.
Welcome to Think Like a Pancreas, the podcast where our goal is to keep
you informed, inspired, and a littleentertained on all things diabetes.
The information contained in thisprogram is based on the experience
and opinions of the IntegratedDiabetes Services clinical team.
Please discuss any changes to yourtreatment plan with your personal
(00:33):
healthcare provider before implementing.
I'm your host Gary Scheiner andtoday we're gonna be discussing
the how and why of MDI.
And for those of you who don'tknow, MDI stands for multiple
daily injections or inhalations.
I guess the I can standfor multiple things.
But before we jump in, make sure youthat you like, follow or subscribe
(00:56):
on your favorite podcast app sothat you never miss an episode.
And for expert diabetes supportbeyond this podcast, please
visit integrateddiabetes.com.
So now we're ready to get started.
I am thrilled to be joined today bytwo friends and colleagues, Miss Ginger
Vieira and Dr. Egils Bogdanovich.
(01:18):
Give you wanna give each of youa chance to say a little bit
about yourselves and Ginger?
Why?
Why don't you go first.
Ginger Vieira (01:24):
Hello Gary.
Thank you for having me.
I have lived with Type one for 25 years.
I've been creating videos, articEgils,and books on type one for about 20 years.
Please forgive the earlier ones.
I was 20, but um, yeah,uh, I am a huge fan.
Well fan, putting it lightly,but I'm a big fan of MDI.
(01:47):
Uh, but more, 'cause I'm not afan of insulin pumps, but I'm sure
we'll get into that a little later.
But you can find my books on Amazon, onexercise, pregnancy burnout, low blood
sugars, and find me at diabetesnerd.com.
Gary (02:02):
You co-authored one of those books with, uh, one of our team members.
Jenny.
Ginger Vieira (02:06):
Jenny, and we have a second edition coming out, hopefully next month.
New and improved.
It's 10 years.
10 years.
Uh, a lot's changed since wepublished that book 10 years ago.
Gary (02:17):
There has, and I, I remember.
When I first met you, you were afairly accomplished power lifter.
Ginger Vieira (02:24):
I was definitely having fun power lifting.
I fell into that by accident andbecause I was just trying to take
better care of my own health, Istarted lifting weights and then it
turned out I was really good at it.
I got really strong really quickly,and that really is what led me into
learning diabetes science on my own.
'cause there were so little.
He's got something back there.
Gary (02:45):
No, I, I was going through some old the archives and things in my office,
so we used to have an organizationcalled the Diabetes Exercise and Sports
Association, and I, I was proud toedit our journal called The Challenge
and find that addition there is...
(03:13):
Anyway, while I'm looking for that,Egils, tell us a little about this.
Egils Bogdanovics, MD: Yeah, sure, sure, sure. (03:15):
undefined
Egils Bogdanovich.
I'm, uh, I've had diabetes for about42 years and this, uh, this is plan
B. I, I started after school goingthrough officer candidate school,
and I wanted to fly fighter planes.
And literally a month before Pensacola,I lost 30 pounds in a couple weeks.
(03:35):
Was diagnosed with type one.
You know, plan B was to become anendocrinologist, and that's what I do now,
and been doing this for a number of yearsand loving, uh, loving seeing type ones.
I, I learned something from,from every single one that I see.
And just like Ginger, I, I am big, bigMDI as long as you're using CGM I'm a
(03:57):
big MDI proponent, although, you know,all honesty, I've tried everything.
Usually it's like a pump thatsays, not for human use, that I
get off the reps. But, you know,try, I, I do have tried everything.
Ginger Vieira (04:11):
Yeah, for sure.
I,
Gary (04:12):
I found the, the,
Ginger Vieira (04:15):
oh, geez, how funny.
Gary (04:18):
Raising the bar with Ginger Vieira,
Ginger Vieira (04:22):
Man, yeah, that is 20 years ago I was having fun, actually.
Gary (04:26):
You look younger now.
Ginger Vieira (04:29):
I'm a lot slimmer.
There's nothing, there's no better weightloss plan than not power lifting anymore.
I lost 30 pounds in like one year, noteven doing anything but walking my dog.
Gary (04:41):
Okay.
So I, I think a good first thingto ask you both about, I mean,
I, I'm a big advocate of pumptherapy for a multitude of reasons.
Why?
I mean, you're obviouslyintelligent people.
You have access to a lot of resources.
The latest, the greatest.
Why did you opt to go the MDI route?
(05:06):
Ginger tell us.
Ginger Vieira (05:07):
I really love that started with your obviously intelligent people.
I'm gonna start my next, every nexttime I see you in real life, Gary, I'm
gonna start our conversation with that.
You know, I used a pump for maybefive, seven years, something like that.
I loved it for a little while and itreally start to started to break my
(05:29):
trust and I started to really hate it.
What it does to my skin andreally hate pump site failures
and having it attached to me.
I did try again many years later, inmy late twenties for pregnancy, I put
on an Omnipod and I remember my husbandbeing like, wow, you really like this?
(05:49):
And within about three and a half weeksI was like, I am ripping this thing off.
There's no way.
And it's no offense, Omnipod,it could have been any pump.
And I would've felt the same way.
And he was like, yeah, that seemedtoo good to be true, that you
were really gonna stick with this.
And, um, yeah, I've been MDI ever since.
I just, if I think about it right now,having a pump attached to me all the
(06:10):
time, I, it's like claustrophobia for me.
Egils Bogdanovics, MD (06:15):
I've got a, I've got a little bit of that
robot, uh, feeling also when,whenever I'm, uh, pumping insulin.
I, I, as I mentioned earlier,you know, CGM for everybody.
That's, I've always been a CGM first.
Even if you're, if you're gonna bepumping, but you know, you really,
it comes down to simplicity.
You know, it's, I can go out with,with a pen in my bike, uh, you
(06:39):
know, kit and, and ride for fivehours and not worry about anything.
Um, not worrying about a sight lossor, or a kink or whatever it might be.
And, and you know, it, I mean, as farI've, as you know, that's personally,
as far as professionally, I have noopposition to having patients on pumps.
(06:59):
In fact, I, I encourage them if they,they wanna use it, but I, I've never had
a call at 2:00 AM saying my pen broke.
And, um, so once you inject,you know it's in there.
You're not worried about airbubbles, you're not worried
about a kink catheter, you're notworried about any of that stuff.
Gary (07:18):
You know you just cursed yourself.
You are gonna get a call tonight.
Ginger Vieira (07:24):
Well, can I tell you, I think this podcast actually cursed
me because I am not sure if I took myLantus last night and I, I was high
when I woke up, but it corrected soeasily that I thought, and I don't
think I've ever forgotten to takemy Lantus injection in 25 years, and
I, so I think you cursed me, Gary.
(07:44):
And then I hung steady this morning, soI thought, okay, I must have taken it.
Then I ate my apple and peanut butter.
I took my insulin.
I spiked so quickly that I'm thinking,okay, maybe I didn't take it, but I
would think I'd have ketones by now.
And be 300.
Gary (07:59):
My Ginger voodoo doll worked perfectly then.
Ginger Vieira (08:02):
Yeah, so the, the timing of this is hilarious.
And then I took a little bitof Lantus right before this.
I could have justcreated a whole disaster.
That's never happened tome in 25 years though.
Egils Bogdanovics, MD (08:14):
So you take half the dose the next morning if
you forgot it, that's your best.
Ginger Vieira (08:18):
That's what I took was half the dose.
Yeah.
But yeah, we'll see.
Egils Bogdanovics, MD (08:23):
And you're always, yeah, it's gonna
have some basal on board there.
It's not like you're pumping insulinand you just lost it three hours later.
Your, your beta hydroxybutyrateis through the roof already.
Ginger Vieira (08:33):
Yeah, it's still lingering.
I know, but it thenit's also Lantus, right?
So it already has a shorterlifespan and like Tresiba.
So yeah, I'm pretty sure I forgot.
But thank you for that encouragementand that I won't die later today.
Gary (08:47):
So everybody with type one needs a basal bolus type of a regimen.
The basal insulin can be administeredin a lot of different ways.
On a pump.
We have the ability to adjustthe basal by time of day.
It's not as easy to dothat on injection therapy.
So, Ginger, why did you choose Lantus asyour basal, or was that thrust upon you?
Ginger Vieira (09:09):
I've tried the other ones.
I, I've tried the other ones and I likedthem at first, and then like Tresiba
just became wild for me after thefirst month, it was so unpredictable.
Lantus is the most steady for meand I know exactly when it peaks.
I know that 3:00 AM isthat tricky time for me.
I actually, I I have a little, um,quirky thing I do now where I take 20%
(09:34):
of my dose at 2:30 in the afternoon andit helps me cover the evening where I
was having some really stubborn highs,which someone told me they had the same
thing happened during perimenopause.
I have no research to back that up,but it was really weird starting only
a few months ago and, and then thatallowed me to re, to only be taking 80%
of my dose before bed, which eliminatesfor me that three to 5:00 AM risk of
(09:59):
lows when Lantus is peaking po, youknow, five hours-ish post injection.
And so I know with Lantus and howI compensate for not being able to
tweak basal is, I know between 8:30and 9:30 I, if I was on a pump,
I'd need a little basal boost.
I am not getting that.
So I take a little, I, I fast, Ipractice intermittent fasting and I
(10:22):
know that triggers for me a releaseof liver glucose around 8:30.
So I take a tiny bolus around then.
Gary (10:29):
So the, the names of the insulins you, you mentioned, we have a lot of
international listeners to our podcast.
Glargine is sort of thegeneric name for the Lantus.
And the other two optionsare detemir and Degludec.
Degludec is the most long-acting of thelong-acting basal injectable insulins
(10:49):
and Devimere believe that, that, that'sLevemere, that's Novo's product was.
Are, are they discontinuingit or have they...
Egils Bogdanovics, MD (10:57):
Yeah.
They not making that anymore.
They're not making
that anymore?
Yeah.
Yeah,
Ginger Vieira (11:01):
That was like water for me.
Levimir was like saline for me.
It did almost nothing.
Egils Bogdanovics, MD (11:08):
Interesting.
Maybe you forgot to take it.
Yeah.
Ginger Vieira (11:11):
I was on it for about two weeks.
I actually fired myhealthcare team over it.
This was like 15 years ago.
They didn't believe me.
It wasn't working, and I was like,please put me back on Lantus.
And they, they fired me because I wastelling them how to do their job, I guess.
Gary (11:27):
So Egils, I see patients quite a bit, uh, who are on MDI and experience
a significant dawn effect where theirglucose rises in the early morning hours.
And then with kids, we often seethat rise in the evening when
they're making growth hormone.
So what are some of the waysyou can work around that if
Egils Bogdanovics, MD (11:45):
Yeah.
There's, there's no doubt about it.
I, you know, I was gonna say the one,one time when you really, really need
a pump and MDI is not gonna do it,is to compensate for dawn phenomenon.
And, you know, you could say,well, I'm going to take a little
bit of this, a little bit of that.
I have some patients that I, I takeTresiba as a basal, and I like it because
if I, if I miss my morning dose, Icould take it at nighttime that night.
(12:06):
And go back to morning thenext day and it's like keeping
a bicycle wheel spinning.
It's, it's pretty smooth.
But yeah, I have patients that,that aren't just even take a
little bit of Lantus at bedtime.
You know, sort of a funny combinationto compensate for that Dawn phenomenon.
But the thing about Dawn isit's not the same every day.
So you really need an automated insulindelivery device to compensate for that.
Gary (12:28):
We've actually had some success using NPH at bedtime.
I know it's kind of taboo.
Get, get away.
Egils Bogdanovics, MD (12:35):
No, no.
Gary (12:35):
But
Egils Bogdanovics, MD (12:36):
you know, in, in general, uh, you know, with, with
insulin therapy, if you understand.
You know, the pharmacokineticsand pharmacodynamics of,
of a particular insulin.
You could use anything.
You know, I used to use NPH andregular three times a day, a reverse
mix, you know, 70% regular, 30% NPH.
So even though NPH varies from day to day,like a ton, if you just got small doses
(13:01):
a few times a day, you almost overlappinghave a, have a nice basal so you know,
you can make it work as long as you.
As long as you are a smart diabetic.
Ginger Vieira (13:10):
Yeah.
You know what I take to, um, notdeal with down phenomenon anymore.
I take metformin right before bed.
It has eliminated my downphenomenon problems at 5:00 AM
Gary (13:22):
So it's, it's blunting your liver's output of glucose
in those early morning hours
Ginger Vieira (13:26):
and awesome because I exercise first thing in the morning and it
was very tedious because dawn phenomenon,dawn phenomenon isn't, you know, exactly
the same impact every morning, right?
So I would try to getahead of it and prevent it.
And so I was playing this guessing gameon top of cardio exercise and metformin
has completely eliminated that for me.
Gary (13:46):
The other half of the MDI is the, the bolus, the insulin to
cover meals and to correct highs.
And with a pump, we do it by touchingsome buttons on MDI, again, the eye
can stand for injection or inhalation.
So what are you, what are yourpreferred methods for bolusing?
Ginger Vieira (14:07):
Want me to.
Go ahead.
Go ahead.
Yeah, I mean, I'm talking too much,
Egils Bogdanovics, MD (14:10):
so, so, so I will bolus you pretty much, you know,
NovoLog, Fiasp, Humalog, Lyumjev,you know, everybody makes a big
deal about, you know, this is faster.
This is faster.
You got a few minuteshere, a few minutes there.
They're all.
To me, they're all the same.
It's just a matter oftaking it early enough.
Um, but I also like to, and you'vealluded to inhaled, I love using, you
(14:33):
know, a hit of inhaled insulin to, toreally correct those highs because I,
I mean, I see those arrows going downpretty rapidly and you know, it's.
Again, you know, it's notthe plain as the pilot.
I think that, uh, you know, if you bolusearly enough and, and pay attention
to the trend arrows on your CGM andpay attention to what you're about
(14:57):
to be doing, you know, the bolus, youknow, with MDI can be as good as it
is with, with an AID and, uh, Ginger.
You have experience with the Afrezza.
Ginger Vieira (15:08):
I'm huge fan of Afrezza, but I don't, I just got
a question about this on Instagramthis morning, saying how much?
Yeah.
'cause I posted a photo of this reallyyummy gluten-free pizza I had last night.
Oh, Gary.
All right.
And someone messaged me and said, well,how much do you take, um, how much
inhaled insulin do you take for that?
And I was like, I would never relyjust on inhaled insulin to cover pizza.
(15:28):
It's.
It's strong for a big like punch.
Right, but pizza requires like,like a flood or something?
Gary (15:35):
Yeah.
You have to triple dose over time.
Ginger Vieira (15:38):
Oh, I mean, yeah.
Egils Bogdanovics, MD (15:39):
But you could take it every, you could take it every hour.
I mean, it would work ifyou took it every hour.
Ginger Vieira (15:44):
That's really tedious though, and would be like chasing a,
trying to run with a train or something.
So I do a combination for a lotof my meals, unless it's pretty
simple of NovoLog and inhaledinsulin and I love inhaled insulin.
It's definitely a game changer, eventhough I still also use NovoLog, but
it just gives me more flexibilityand fewer injections for sure.
Gary (16:06):
Yeah.
Uh, even though though I'm on apump, I use Afrezza every Sunday
morning before I play basketball.
Because if I dose for breakfastwith normal rapid, or ultra
rapid, exactly, it's gonna makeme crash while I'm playing ball.
Yeah, the Afrezza is in and out soquickly I don't have to worry about it.
Ginger Vieira (16:23):
That's one of my favorite things about it is the, I
spend a lot less time on dog walks.
I walk my dogs several times a day,and I spend a lot less time preventing
low's from meal boluses on board.
Because of Afrezza
Egils Bogdanovics, MD (16:38):
The Great, the great thing about Afrezza is it
almost doesn't matter how much youtake because it's gonna be gone.
Yeah.
You know?
Yeah.
You, you got an hour, hour, youknow, hour and a half later you're,
you're, you're back to normal.
So, so it's, it's, uh, alot less, um, detail, uh,
requiring than, than, than subq.
(16:58):
But I agree.
I, I do the same thing.
I do both at the same time.
Gary (17:01):
How do you guys calculate your doses?
Ginger Vieira (17:03):
You don't have to.
That's what's so great about it.
I was just gonna say, you don't have tometiculously carb count with afrezza.
It's more they, I think they didit themselves a real disservice by
putting a number on these things,because everybody wants to know how
that translates to NovoLog or Humalog.
Right.
And it, it doesn't.
It doesn't translate.
And like they say that a fouris technically two and a half
(17:27):
units of injectable insulin.
Now I would take a four for arelatively very low carb salad.
I would never take two and a halfunits of NovoLog for a low carb salad.
It doesn't translate.
So instead, I think they should, I thinkof them as small, medium, and large.
Egils Bogdanovics, MD (17:43):
Yeah, blue.
Blue is snack.
Uh, green is sandwich,and yellow is pizza.
Ginger Vieira (17:50):
Yellow is bam, right?
Gary (17:52):
Pasta, potato, big potato.
Yeah.
Ginger Vieira (17:55):
Plus I mean.
Gary (17:55):
If you're doing
Egils Bogdanovics, MD (17:56):
Gary, Devil's advocate, you know, Gary, you're using
Afrezza and you're, I assume you're on,on an automated insulin delivery device.
Uh, you know, I mean, every timeyou use Afrezza you're sort of
screwing up your, your pump's brain.
You ever think about that?
Gary (18:13):
I turn off the automated part for a little while.
Egils Bogdanovics, MD (18:16):
All right.
Okay.
Ginger Vieira (18:17):
Okay.
I know a few people on a I systemsthat use it for correcting highs,
Gary (18:21):
kill the brain for a few hours so it doesn't mess things up.
Egils Bogdanovics, MD (18:24):
Mm-hmm.
Ginger Vieira (18:25):
Nice.
Good.
Gary (18:25):
Yeah.
Um, the new connected pens are anotherpopular option for people on MDI because
it offers some features of pump therapyalong with, you know, the convenience
and the ease of, of the injection.
Either of you have experienceusing a connected pen.
Egils Bogdanovics, MD (18:42):
Yeah, well, I personally use both
the InPen, uh, and the Tempo.
And you know, I, I agree.
I mean, if you think about it, you know,1% of insulin users in the planet are
in a pump, and the rest 99% aren't.
So, you know, we should, or they should,have the option of having all those
advantages of, of, of pumping and you're,you're getting about as close as you can.
(19:06):
You know, you've got, you forget, you,you know, I, I often like Ginger, you
know, forget if I took my insulin or not.
And if I look down on my Tempoand I see that I just took insulin
10 minutes ago, then I confirmsthat I did take my insulin.
Whereas if I'm not using it, I don't know.
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Yeah, so we were talking about the pensand the connected pens, but Ginger,
(20:08):
uh, have you used a, uh, connected pen?
Ginger Vieira (20:11):
I haven't, because I don't like using pen needles.
I don't tell anybody, Gary,but I stick a syringe.
Gary (20:17):
How old do you have with pen?
Ginger Vieira (20:19):
I know, I think I'm just an old, old lady.
I'm like, I resisted CDs.
I was like, no way.
I am listening to tapes forever.
So that's my problem really at the core.
Gary (20:28):
Fleetwood Mac and fog hat c uh, cassettes.
Ginger Vieira (20:31):
It was, it was a rocky.
Rocky III soundtrack Ihad, Eye of the tiger.
I wrote down all the lyricsby hand while listening.
So anyway, I um, don't like pen needles.
They leak and I don't trust them andI don't like having to prime them.
It's all about trust for me or alack thereof with all the tech.
Gary (20:47):
I hear about the leaking 'cause the drops that come out
after the needles removed, youalways wonder how much was lost.
I
Ginger Vieira (20:52):
don't that, and I don't like priming it.
That's a waste.
And so,
Gary (20:56):
Um,, yours is held together with a rubber band.
You got your syringe and your pen.
Ginger Vieira (21:03):
Pretty.
Gary (21:03):
I love the rubber band.
You know, years ago, the meter companieswere all looking for ways to make out
an all in one meter with the lancet,the strips, the meter, and it ended
up with these big, bulky devices.
I came up with my own idea using arubber band just to link it all together.
So I was thinking I'd market this.
I'll sell these all in onemeter adapters for $19.99.
(21:26):
Brilliant.
If you order today, I'll give youan extra one for no extra charge.
Just pay the additional shipping.
Shipping fee.
Egils Bogdanovics, MD (21:32):
Yeah.
Or get it off your cauliflower whenyou get it in the refrigerator.
In the, uh, at store.
Yeah.
Yeah.
Hey, Ginger, I saw that you haveyour pen without the cap on.
Without the cap on it.
Why?
Ginger Vieira (21:43):
Yeah, I tossed that as soon as I open it.
Egils Bogdanovics, MD (21:45):
Why?
Why?
I mean, I know some people they comein and they have the, the big cap
on it and you can't fit it on there.
So if you just have the little needle withthe little cap on it, this still fits.
Ginger Vieira (21:57):
And that would disrupt my rubber band system though, doctor.
Egils Bogdanovics, MD (22:00):
But you could still put the band around here and you
only have one needle for the whole pen.
I mean, I, I go through one needle for thewhole pen unless you get a tissue clot.
At that point, you just change.
Ginger Vieira (22:10):
That's interesting to hear from a doctor not changing that pen.
Egils Bogdanovics, MD (22:13):
Again.
I do, as I say, not as I do.
Ginger Vieira (22:15):
I appreciate you acknowledging that though,
and being honest about it.
I do change my syringe.
Hopefully once a day, but, orwhen it starts to hurt, I guess.
Gary (22:24):
Yeah.
I've always taught peoplechange the needle daily.
Yeah.
The pen, needle.
How long does a, how many daysdoes a pen needle last you, Egils?
Egils Bogdanovics, MD (22:31):
Well, you know, I, it, I say that I use it for the whole
pen, but it never lasts the whole pen.
You know, I'd say, you know, somewherearound a week and, and, you know,
once in a while patients will call,they say, my pen doesn't work.
I said, it works.
Change the needle.
And they called back andthey said, yes, it works.
I mean, you know, I, I, Icollect old diabetes stuff.
I have a little museum of diabetes and inthe old days they had the glass syringe.
(22:55):
Of course the metalneedle, you boiled both.
And they had this little thing calleda reamer, where after each injection
it was like a little paperclip, tiny.
You put it through the needle part of itto actually get that skin clot out of it.
'cause otherwise, even though youboil it would still clog it up.
Gary (23:13):
My Yale syringe came with a little sharpening rock.
Egils Bogdanovics, MD (23:16):
Oh yeah, yeah.
Sharpening stone.
Absolutely right.
Absolutely right.
So I've got a lot of those.
If you guys want to go old school and youreally want to go back, really old school.
Gary (23:23):
Ginger, this might be for you since you don't, like...
Ginger Vieira (23:26):
I like to start around 1999.
That's my old school.
Gary (23:29):
Yeah.
Well, you know the smart pens likethe, like the InPen, you know,
they'll do dose calculations,they'll adjust insulin on board and.
They'll document the doses thatare taken by, you know, there's a
Bluetooth communication, so it hasa lot of the benefits of, of pump
therapy without having to use the pump.
Egils Bogdanovics, MD (23:47):
Absolutely.
And the reports.
Ginger Vieira (23:48):
I think that technology, yeah, the reports.
I think that technology is sovaluable for people who need the
support and the further education.
Right?
Like, I, like both of you.
I love to study the heckoutta my insulin doses.
I'm not gonna let a device tellme how much to take, but, a large
majority of people will learn and,and get a lot of support from that.
(24:12):
Should I use one?
Yes.
Gary (24:14):
I, I may, I've been making a list of what all the potential advantages are to
being on MDI as opposed to pump therapy.
So let me run this list by you.
You can tell me what I missed.
Egils Bogdanovics, MD (24:25):
Really, it's the same list at all as all
the disadvantages of pump therapy.
Gary (24:29):
We'll, we'll get to those next, but the advantages, so convenience
and Egils, you, you emphasize this,just the convenience, just quick.
You carry it, it's portable, it's easy.
Cost is also an enormous difference.
Ginger Vieira (24:42):
Way more affordable.
Gary (24:45):
From an insurance standpoint, you know, if you get coverage for your
pump and supplies, you might still havedeductibles to meet and copays, et cetera.
Ginger Vieira (24:53):
You know, that's actually a big part of what continued
my MDI therapy in my early twenties is'cause I did not have health insurance
for about four years and there's noway I could have maintained a pump.
Egils Bogdanovics, MD (25:05):
Yeah.
Yeah.
I used to, I used to take chemstrips and cut 'em into quarters,
you know, quarters without insurance.
Gary (25:12):
Quarter, yeah.
Wow.
Egils Bogdanovics, MD (25:13):
But NPH was like 13 bucks a bottle back then.
Gary (25:16):
So you were that good with a scissor, or did you use a scalp?
Egils Bogdanovics, MD (25:20):
Well, you could, you could tell if it was like less
than 40 or over 400, and everythingin between was about the same color.
It's all kind of a, you know, Moish blue.
Yeah, yeah,
yeah,
Gary (25:29):
yeah, yeah.
Simplicity's another thing,you know, pump therapy is, you
know, it's much more complex.
You know, you gotta learn programmingand site changes and all that good stuff.
Injections are just that there,or inhalations are a lot simpler.
Uh, the portability, it's uh, it's easier.
It's probably less stuff you haveto lug with you when you travel.
(25:50):
Yeah.
The absence of adhesives and Ginger,you pointed this out as this was an
issue for you when you were on a pump.
You gotta use some kind ofadhesive to either keep the pump
or the infusion set in place.
And you don't need thatwhen you're on an MDI plan.
And then the less, fewer technicalissues there is the potential if
you, you know, take your needleout too soon, it's still dripping.
(26:13):
But otherwise you don't really havetechnical issues with pumps and
pens, whereas with syringes and pens.
But with pumps, you can have allkinds of technical issues that arise.
And we've known for years that the DKArisk is lower for people on injections.
'cause like you said, Egils, once youinject the long-acting insulin, even if
(26:34):
you forget it the next day, you still havea trace of it working for quite some time.
So it offers some protectionagainst ketosis and ketoacidosis.
So now anything I missed?
Anything else about MDI?
Ginger Vieira (26:49):
That cannula pushing fluid into your body 24/7.
The skin damage beyondthe adhesive, right.
Just the cannula sitting there.
I could not stand it.
It would get, so I havereally sensitive skin.
I have a diagnosed, like I have like thedriest skin in the land kind of diagnosis.
I don't even know the name of theskin type, but that's really what
(27:11):
it means and I just can't handle it.
It's so itchy all the time forme and just the damage it does.
Gary (27:20):
Yeah, so lipodystrophy is another potential problem we see with pump use
if the sites are not rotated properly.
But the same thing canhappen on injections.
You know, it's not really the
Ginger Vieira (27:32):
It's just sitting, there sitting there for days pushing food fluid.
Gary (27:35):
That's, that's in your head, that's in your brain.
Ginger.
Ginger Vieira (27:39):
I guess so.
It's one of my nightmare.
Gary (27:41):
It's typically not causing damage unless it kinks cause
damage.
Ginger Vieira (27:45):
Alright.
I think it's so yucky.
Egils Bogdanovics, MD (27:47):
Yeah.
I mean, lipo hypertrophy is a huge,well, it's not, as you mentioned,
it's not just pumps, it's injections.
I mean, I've got people coming in,you know, after years I finally
look at their belly and I see thatthere's a softball to the left of
the umbilicus and it's like, oh no.
Yeah, and, and it, you know, because itdoesn't hurt to inject there, so you just
keep going back to the same, same place.
Ginger Vieira (28:07):
And the absorption is terrible at that point.
Right?
Egils Bogdanovics, MD (28:09):
Oh yeah.
Gary (28:10):
Yeah, yeah, yeah.
I call it the candy machineeffect when that happens.
'cause you, you give insulin,it doesn't absorb right away.
You go high and you give more insulinand then all of it kicks in at once.
It's like that candy machine where you,the wheel turns, but your candy doesn't
quite fall so you hit the machine.
Ginger Vieira (28:29):
Is it it gets in delayed?
Egils Bogdanovics, MD (28:31):
Delayed.
Gary (28:31):
It's delayed.
And sometimes by the timethe old insulin absorbs, it's
not at full strength anymore.
Ginger Vieira (28:38):
Okay.
Yeah.
And you know any other, that's actuallya big part of getting insurance
approval for inhaled insulin is youhave to tell your doctor to put in
your notes that you have lipotrophy.
Okay.
That's like critical.
Gary (28:51):
Any other advantages of MDI that I missed?
Ginger Vieira (28:56):
Flexibility around exercise.
I think, I mean, once you figure out yourAID system for exercise, but I find it
way simpler to exercise without a pump.
Gary (29:10):
So now I'm gonna throw at you all the reasons, I prefer pump
therapy and see how you would counterthese with your MDI-- the frequency
of injections and inhalations.
Egils Bogdanovics, MD (29:23):
Hell, I mean, look at the frequency of site changes.
That's the the first thing that happenswhen I put, I mean Omnipod or t some the
use, both of 'em, you know, three dayslater it's like, didn't I just do this?
I mean, it seems like two minutesago I changed my pod and now
it's three, three days again.
(29:44):
So, I mean...
Ginger Vieira (29:45):
and the, and the tech failures, right?
It's like even if you, if you don'tmake it three days, I feel like
my pumping friends just are alwayshaving technical issues, right?
Gary (29:57):
You can't deny, even if you're having to change every 48 hours.
The number of needle sticks with MDI is...
Egils Bogdanovics, MD (30:04):
it's much, much more than that.
And, and even if you, and, and sort of,you know, to, to make the argument for
pumping insulin, if you're correctinghighs with what I recently used in
Omnipod, I might do that 11 times a day.
You know, hit use CGM.
I'm not gonna take outmy pen and take one unit.
I'm not gonna take out my pen andtake two units, you know, 11 times
(30:27):
a day to correct those highs.
So, sure.
I mean, yes, we are pink cushionsand acknowledging that I, I think
that pump will give you bettercontrol with frequent corrections.
Ginger Vieira (30:38):
I mean, also I would argue personality type though, like I did, I
did MDI through pregnancies and I stillmaintain that A1C below six without a pump
and I, I will, you know, I'm, it takesme a month to go through a pen, right?
You said it takes you a week.
So just the difference in insulin, becauseI'm five foot two woman, you're a man.
I will take out and take aninjection of a quarter unit that I
(31:01):
micromanage from this for the syringe.
Another reason why I like using syringesis I can pull back just a smidge.
It's not even, oh...
Gary (31:08):
That's and, it actually was my next item was dosing precision on a pump.
I can give a 20th of a unit.
Yeah.
I can give 0.35, 4.1.
Ginger Vieira (31:20):
I can on this too.
I just don't quite knowif it's 0.35 or if it's
Gary (31:25):
0.1.
We're gonna get a molecular scaleand see how much you're actually...
Ginger Vieira (31:29):
I have figured out that if I pull it back where
it actually looks like there'snothing in it, that for me is like
Gary (31:35):
almost nothing equals one quarter.
Ginger Vieira (31:38):
Yeah.
Gary (31:41):
One knee equals two feet.
You know you got all thesetranslations you use.
Ginger Vieira (31:45):
I do it all the time.
If I was,
Gary (31:46):
but you, you gotta admit...
Ginger Vieira (31:47):
blood sugar in the two right before exercising, I
would take what is basically a drop.
Doing exactly that.
Gary (31:54):
For young kids and anyone who's really sensitive to small
doses, you can't beat a pump.
Egils Bogdanovics, MD (31:59):
You know, years ago, years ago, they showed
that moms could drop up oneunit accurately for their kids.
Gary (32:06):
Uh, yeah, that's Ginger's a mom.
Yeah.
Uh, with a pump, we have theopportunity to sync with an
automated insulin delivery algorithm.
It'll raise and lower the, the deliveryif glucoses are trending out a range.
We don't have that capability with MDI.
(32:27):
How do you counter that?
Ginger Vieira (32:29):
I don't trust any CGM technology to be accurate
enough to be dosing my insulin.
Egils Bogdanovics, MD (32:34):
I believe CGMs good enough for, for AID
and good enough for, for using itin a non-ad adjunctive fashion.
In, in MDI, I mean itsort of, sort of, yeah.
As, as far as advantage of, of, of pump,we alluded to, you know, using CGM right.
And for years I was telling patientsthat it doesn't matter how you get
(32:56):
your insulin as long as you use a CGM.
In fact, there was a study thecommissary where injection with CGM
or pump with CGM was a lot betterthan injection with finger stick
and in pump with finger stick.
Gary (33:12):
But the AID folks did that.
Egils Bogdanovics, MD (33:14):
You're you're absolutely right.
I mean, I was, I was showing picturesof this to patients and to docs saying,
it doesn't matter how you get yourinsulin, as long as you're using a CGM.
And then six years into that study, theychanged the protocol to use AID and all
of a sudden AID went boom right down.
So that whole argument is shot.
(33:35):
Now you, you're gonna do a lot betterwith an AID and CGM than injection.
Gary (33:39):
Ginger.
Your opinion is, isshared by a lot of people.
Ginger Vieira (33:43):
Yeah, but I, I think it comes down to the same thing I
mentioned earlier is that there'sa larger majority of people who do
need AID to reach their targets.
And it's like a invaluablething for those people.
And
Gary (33:56):
yeah, what it allows though,
Ginger Vieira (33:58):
likes to micromanage everything.
Gary (33:59):
They, well, they can reach that target with less micromanagement.
Ginger Vieira (34:03):
No, no.
That's what I mean is it's necessary,
Gary (34:06):
right?
Ginger Vieira (34:06):
For a lot of people.
Gary (34:06):
People with a pump.
If, since I have such a healthy dietand I'm eating junk all the time,
Ginger Vieira (34:12):
That's what I've heard.
Gary (34:13):
I have the ability to extend my bolus delivery.
So that I don't drop after the mealand then rise a few hours later.
How do you deal with that on injections?
Ginger Vieira (34:25):
Oh, no problem.
I take, I spread out my doses.
Egils Bogdanovics, MD (34:29):
Yeah,
Gary (34:30):
That'll work.
Take multiple doses over time.
Ginger Vieira (34:33):
Yeah.
Okay.
Gary (34:35):
It'll work.
But it's, it'll, but it's work it.
Ginger Vieira (34:37):
It's more work, right.
It's, I mean, it's a trade off.
People ask me all the timewhy I'm not on a pump.
It's a trade off of what kind of workand tedious things you wanna deal with.
I don't wanna deal with thecost and the tech and the tech
failures and the site stuff.
Mm-hmm.
And you know, all of that.
Versus, sure.
I'll take two more shots.
Gary (34:58):
What about social stigma?
There's a lot of people who are hesitantto give themself insulin around other
people because of just the way it looks.
The social stigma associatedwith taking shots.
Ginger Vieira (35:08):
Those people need to go somewhere else.,
Gary (35:08):
How do you address that?
Egils Bogdanovics, MD (35:11):
I tell patients just it might be a, a
teaching moment for everybody else.
Yeah, go ahead and do it.
I tell 'em to inject through theirpants if they'd like, and it's been
shown it doesn't increase infectionrate or pull up their shirt a little
bit to go into the belly or in thesummer, go into the triceps region.
But if somebody, if somebody wantsyou to go to the bathroom and sit
in a stall and take insulin thatway, tell 'em, uh, take a hike and
(35:33):
be happy you're not taking insulin.
Gary (35:35):
Yeah.
Punch 'em in the face and then
Egils Bogdanovics, MD (35:38):
Yeah.
That'll work though.
That'll work too.
I'll bail you out, gary.
Gary (35:40):
The vast majority of MDI folks are taking injections, not inhalations,
and they do need to figure out dosesfor corrections and carbs and whatnot.
My pump does those calculations for meautomatically, and it's only a suggestion.
I mean, I can adjust it if I want,but I like the calculation and
the insulin on board adjustment.
(36:00):
So how do people on MDI deal with that?
Egils Bogdanovics, MD (36:03):
Well, you use one of those smart pens then if you really,
really want to know what your insulinon board, uh, is influencing your bolus
and you know, for patients that are, arestacking on a regular basis, you know,
taking these rage boluses because theycan't wait for a couple of hours, it's
probably a pretty good idea to use an app.
Ginger Vieira (36:21):
And to get inhaled insulin so that you don't feel the urge.
Egils Bogdanovics, MD (36:26):
Yeah.
Yeah.
Gary (36:27):
The basal, we talked a little bit about, but I, I consider the
variable basal delivery to be akey benefit of pump therapy, even
without automated adjustment.
Being able to program in lowerbasal in the middle of the day for
people who need less and higher inthe early morning or the evening
when they need more on injections.
(36:49):
You know, there, there's some creativethings we can do, but most people
are just taking that flat basal rate.
24, we talked about that already, so Idon't think we need to get into it much.
Ginger Vieira (36:58):
I mean, i, I have a little note on that is that I
really, you compensate in other ways.
So I believe, you know, I, I try toget my basal dose as low as I can.
So that I'm never droppingduring a fasted dog walk.
That's kind of my gauge for I have toomuch basal, and again, because I'm one
unit too much is a make or break for me.
(37:20):
So there's times of the month whereI go up 10% or down 10% in my dose.
Um, based on...
Gary (37:26):
In your case though, when you adjust your basal, it's 24
hours of adjustment for a dog walk.
On a pump, we can, we can make,
Ginger Vieira (37:34):
It's not for the dog walk.
It's not for the dog walk.
The dog walk is just theindicator to me that I have a
little too much basal on board.
So, but then when I say you have tocompensate in other ways, if I'm going
down to my lower dose of nine unitsa day, I know I might need a little
bit more insulin with some of my mealsor a little bit more insulin, you
know, and I mean, like, you know, thesmidge on my little syringe versus.
(37:57):
If I go up, I'm gonna needa little less, so I'm May.
I'm compensating for the lackof flexibility in my boluses.
Egils Bogdanovics, MD (38:04):
My, my, my approach to to, to adjusting that
basal is my bedtime and my morning.
You know, if I'm dropping from bedtimeto morning excessively, you know, pick
a number, 30, 50, whatever it might be,then, then I want to, you know, drop, drop
back on, on my basal and yeah, I agreed.
Ginger, you know, you know.
I, I like to use, you know, peopleused to say 70% basal, 30% bolus.
(38:28):
I like to use about, you know,60, 70% bolus and, and a, a large,
a smaller amount of, of basal
Ginger Vieira (38:35):
As little as possible.
Gary (38:37):
The pumps let us make temporary adjustments to the
basal for things like sports andexercise, lack of activity, illness.
If you adjust the basal oninjections, you're making a 24
hour plus change in your basaldelivery and not just a few hours.
So how do you deal with...
Ginger Vieira (38:58):
I have a whole book that teaches how to do it on MDI and there's
notes in there on, on pumps too, but
Gary (39:04):
Convenient that you had that ready.
Ginger Vieira (39:06):
How convenient.
Hey, there's a shelf back there.
It's just where it lives.
Okay.
But it's so doable.
You just have to first get yourbasal insulin dose fine tuned.
So again, that it's low enough.
You're not droppingduring fasted exercise.
If you're dropping during fasted exercise.
I believe you have toomuch basal on board.
And then like I said, youcompensate with boluses.
(39:27):
Now if I was going to eat a meal andthen exercise, I need to obviously
adjust the meal bolus just like Iwould if I was on a pump as well.
And you don't have to monkeywith the long acting dose once
you've got it fine tuned properly.
Gary (39:45):
Do you have any patients who use both a pump and MDI who alternate?
Egils Bogdanovics, MD: Yeah, you're looking at one. (39:52):
undefined
Um, yeah, it's, uh, every couple months,uh, and it, and, uh, you know, having
said that, there's no doubt about it.
You know, I give, uh, I do betterwhen I'm on a ID um, even though I
do really, really, really well onMDI, because, you know, I. Believe
(40:13):
it or not, I think like a pancreas,Gary, you know, it, uh, you know it.
If, if I'm going up, if Ieven, I, if I even see a trend
arrow going up, I'll hit it.
Exercise.
Yeah.
That's, that's one thing that my churchis going for a five, five hour bike ride.
Uh, you know, I think that I couldnever figure out exactly what to do
as far as insulin, Ginger, but evenpeople without diabetes need to fuel.
(40:36):
So my rule is 25 grams ofcarbs every 30 minutes.
So I go through a pile of gel.
Do the ride, but it, it wouldbe easier with, uh, with a pump.
But again, I'm gonna have abackpack full of pump gear
supplies if I'm gonna do that.
Ginger Vieira (40:52):
Yeah.
Endurance, endurance exercise.
A a pump becomes a biggame changer for sure.
It's harder with, on MDI.
Gary (41:02):
Yeah.
Um, we have quite a few patients who willalternate between pump and they'll go on
injections, let's say if they're on a, atthe beach for the weekend or doing some
kind of adventure outing where the consof pump therapy just outweigh the pros.
Being able to transition back andforth is great, and a lot of people
(41:23):
don't realize that you can do that.
As soon as you wake up, you canjust give yourself an injection
of your long-acting insulin.
Stop using the pump anddo boluses at meal times.
There's also an option called anuntethered plan where you can combine
pump and injection on the same day.
Where you get enough basal to meetyour low, you inject enough basal
(41:46):
to meet your lowest basal need, andthen you wear the pump perhaps at
night while you need more basal.
And then you, you can connect tothe pump for bolusing purposes, but
you can be disconnected from thepump all day on a plan like that.
So I guess it's safe to say MDI, whetherit's with afrezza or injected insulin.
(42:08):
Pump
therapy-- AID Automated
systems.
These are all tools at our disposal.
And everyone's gonna have their ownunique advantages and disadvantages
associated with these different tools,and it's in everyone's best interest to
learn how they can benefit from these.
If your healthcare team isn't teachingyou about them or sharing information
(42:30):
about them, seek it out on your own.
'cause clearly different systemswork best for different people.
I'm a, I'm a big fan of pump therapy
and, and the AID systems.
I think work great, but they're not at, they're not
advantageous for everybody.
Some people do better on MDI for avariety of reasons and encourage 'em to
(42:51):
do that if that's gonna meet their needs.
The best.
Uh, either of you have like aclosing summary statement you want...
Egils Bogdanovics, MD (42:57):
You just, you just used people like five
times and, and that's the key.
People with diabetes are people, andthere's an amount of technology for
everybody, and what works for oneperson may not work for the other.
But as far as you know, last words, I I,I, I tell my patients now, I don't know
if I'm jumping the gun, but I tell 'em,you know, take care of those kidneys,
(43:19):
take care of those eyes because we'regonna have a cure in your lifetime.
Ginger Vieira (43:23):
I echo the same, I do a lot of writing about cure
research for a few places, and I feelvery hopeful about the same thing.
It's definitely, I willsay, so I've, I have.
Jokingly, but I'm not joking, said thatI'll sign up for an insulin pump when it
is implantable and I'm actually gettingan the implantable ever since next month.
(43:43):
I just got insurance approval,had to fight for it for a couple
months, but I'm excited about that.
Gary (43:51):
It has interoperability designation now, so we may see
it in an AID system
before too long.
Ginger Vieira (43:57):
Yeah, I hope.
Gary (43:58):
All right.
Well, I wanna thank both ofyou for joining in today.
I, I hope I didn't insult you orlose your friendships over this now.
I respect what you're, I believeme, I respect what you're doing.
You got good reasons behind whatyou do, and, and I, I respect that.
So thanks again.
Thanks for tuning in to ThinkLike a Pancreas, the podcast.
(44:19):
If you enjoyed today's episode,don't forget to like, follow, or
subscribe on your favorite podcast app.
Think like a pancreas.
The podcast is brought to you byIntegrated Diabetes Services where
experience meets expertise, passionmeets compassion, and diabetes care
is personal because we live it too.
(44:39):
Our team of clinicians all livingwith type one diabetes understands
the challenges firsthand.
We're here to help no matterwhere you are in the world.
From glucose management to self-carestrategies, the latest tech, sports,
and exercise, weight loss, type onepregnancy and emotional well-being.
We've got you covered.
(45:00):
We offer consultations inEnglish and Spanish via phone,
video, chat, email and text.
Wanna learn more?
Visit
integrateddiabetes.com
or email info@integrateddiabetes.com to schedule a consultation.
On behalf of Think Likea Pancreas, the podcast.
I'm Gary Scheiner, wishing
(45:20):
you a fantastic week ahead.
And don't forget to think like a pancreas.
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