I saw my endo today and I was given a sample SymlinPen 60. I've blogged previously about my experiences with Symlin. So in this post I'll just talk about the pen itself.
When I got home I snapped some pictures before using it.
As you can see the pen itself is a little longer and thicker than a large ballpoint. It's an awkward fit in my shirt pocket, only about a half-inch of the clip is actually holding it in place. I'll definitely keep it in my diabetes kit.
I had planned to use the pen at lunchtime. When I opened the box and took the cap off I found...no pen needle in place. That's right, the sample cannot be used immediately. It's like a Christmas toy that has no batteries and all the stores are closed.
Luckily I had some 10-year old pen needles left from when I used an insulin pen, and once I got home I grabbed one of these. It fit perfectly.
The pen has a dial at one end that lets you choose to dispense Symlin in doses of 15, 30, 45, or 60 micrograms (mcg). For comparison, 10 units of insulin is equal to 60 mcg of Symlin. Many people with type 1 diabetes will use 45mcg or less per meal. If you have type 2 diabetes and are taking insulin then the Symlin 120 pen is probably more useful, it will deliver either 60 or 120 mcg.
To start with I attached the pen needle, dialed up a 15 mcg dose, pulled back the end to prime the pen and dispensed the dose into the air. This was to fill the needle. I repeated this several times until I saw a stream of Symlin.
Then I dialed up my regular dose of 60 mcg and was able to inject it using the wonderfully small pen needle. If you put the needle cover back on, you can replace the pen cap with the needle still in place.
There's an interesting design feature, where you can stand the pen on end. I'm not sure what the benefit of this is, or whether it's just a side-effect of having a built-in plunger. There are markings on the barrel of the plunger that help you determine whether it's pulled back far enough. This is especially useful when the cartridge is almost empty and there may not be enough Symlin left for the dose you want.
Note that once you've pulled back the plunger the only way to undo this is to dispense the dose. If you dial up too small a dose you can choose a larger number and pull the plunger further back. If you've dialed up too much, you need to just dispense the Symlin into the air.
As you push the plunger there are soft clicking noises. I didn't count these, but there seems to be one click for a 15 mcg dose and three or four (I didn't count carefully enough) for a 60 mcg dose.
Once you've started to use the pen, you can store it at room temperature up to 86 degrees F (30 degrees C). Unopened pens must be stored in a fridge.
Overall I think this is going to be a lot easier than carrying around a vial and syringe. I wish the pens themselves weren't disposable, but that seems to be the way these things are made nowadays. I think I'd give the pen design a score of 7 out of 10.
To improve the score Amylin would need to include a pen needle with their samples and reduce the size enough for this to fit in a normal shirt pocket. I think this will be a useful addition to my diabetes kit.
Update: As I've used the pen I've paid more attention to how it works.
When you press the 'plunger' to deliver there is one click for every 15 mcg. One each click 15 mcg is actually delivered, so it's a chunky delivery. Because of the pH of Symlin (4.0 which makes it acidic), that first click stings a little. After it stops clicking the plunger still has a way to go, but the last part doesn't deliver anything.
Also, when you dial up a quantity and start to pull back the plunger it clicks, again one click for every 15 mcg. If you pull slowly you can count the clicks. This is probably helpful for anyone who has vision problems. Nice design feature Amylin!
I was reading Forbes magazine this evening and noticed a full right-page advertisement that started with this statement.
3rd Law of Healthonomics Soaring healthcare costs are only the symptoms. You've got to start treating the disease.
The remainder of the advertisement reads.
Most employers are rethinking their responses to escalating healthcare costs. Why? They recognize chronic diseases are the root problem. Example: An employee managing his diabetes might cost $5,000 per year. An employee not managing his diabetes could cost up to $45,000. The win-win here is that by providing employees incentives to lead healthier lives an helping them to manage their chronic diseases, you reduce your healthcare costs. And you'll have healthier employees. Sure beaths the alternative.
The DTCC FAQ page includes the following summary of how the DTCC works:
The Diabetes Ten City Challenge establishes a voluntary health benefit for employees, dependents and retirees with diabetes, provides incentives through waived co-pays for diabetes medications and supplies, and helps people manage their diabetes with help from a pharmacist coach in collaboration with their physicians and diabetes educators.
I like the idea of waiving co-pays for meds and supplies to help with better diabetes management. I just wonder whether this program is aimed at people with all forms of diabetes, or just those with type 2? Given that one of the sponsors is GlaxoSmithKline, I'll bet I'm right. Will is lead to better benefits for insulin pumps and continuous glucose monitors, or will the focus on cost reduction mean these important technologies are less covered?
This program is being tried by a number of employers in the following cities: Charleston/Spartanburg; Cumberland; Chicago; Colorado Springs; Dalton; Honolulu; Los Angeles; Milwaukee; Pittsburgh; and Tampa Bay.
Have you been enrolled in this program and can you give any feedback on how it works for you? I'm interested in seeing if this is the start of a new approach to diabetes care across the country. And I'd love to know whether or not it includes all types of diabetes.
If you've got diabetes you already know that one of the big challenges is loss of feeling in your feet. This is caused by peripheral neuropathy and it often leads to foot damage because you can't feel the pain of an injury to your feet.
So those of us with diabetes are taught early and often to protect our feet. "Don't walk barefoot" is a standard mantra.
Today I was doing my random walk through the internet and I came across a product called Vibram FiveFingers. I've not bought a pair and I have no connection to the company.
These things look very interesting to me. And the thought of having a barefoot experience of sorts is intriguing. I really like the look of these, someone has clearly put some thought into the design (diabetes product makers take note).
I'm blessed with wide feet, but according to the FiveFinger FAQ (I had to use this alliteration it was too tempting) the material accommodates wide feet. So that removes one obstacle for me.
Have you ever heard of, or bought a pair of these? I'm tempted, but at $70 and more for a pair I'd love to know before I invest in them.
An article in today's Washington Post reports on research that has found stem cells in the pancreas of mice. I'm not sure whether it matters, but it appears these were regular mice or NOD (non-obese diabetes) mice.
"This demonstrates a stem cell repair mechanism in the pancreas that, if we understand it more, then we can help develop more cures with either transplantation or with drugs that can increase the body's own stem cells and beta cells," said Paul Sanberg, director of the University of South Florida Center for Aging and Brain Repair in Tampa.
I think this is another example of research that can contribute to thinking differently about how our pancreases truly work. It may be a long time before this research leads to human treatment, but it's another step in the right direction.
Today, January 23rd 2008, the American Diabetes Association (ADA) and the members of the congressional diabetes caucus will hold a briefing to announce the annual diabetes cost estimates for 2007. Maybe if you're in Washington you can drop by and listen to the briefing.
During this briefing, speakers will release staggering new figures about the direct and indirect costs of the disease, and reveal the devastating expense incurred by Americans.
I'll be interested to see how much the incidence and cost of diabetes has increased. And also whether any new legislation is proposed during the briefing.
Update: The final estimated cost(PDF) for diabetes in 2007 was $174 billion. The US Population last year was about 300,000,000 people. That means the toll of diabetes was about $580 for every person in the US.
If a cure is ever found that would mean that huge amount of money could eventually be put to better uses. Hey, I'd happily take mine as a tax break!
PARADE Magazine (which comes in some Sunday newspapers) is holding this contest where the 8 charities that attract the most individual donations will receive $50,000 and be featured in PARADE magazine article. This is a great opportunity to raise visibility for diabetes research.
To help you donate to JDRF through the Network for Good organization. Your donation can be of any size. You'll have to register with Network for Good to do this (I just did) and then you can donate via Paypal or with a credit card.
To me, this seems like a relatively inexpensive way to raise awareness of the importance of diabetes research and the search for a cure. I hope you'll agree because right now JDRF is not even on the top 10 list for this contest.
I've had type 1 diabetes for a long time and I've spent much of that time hoping for, and thinking about, a possible cure for diabetes. But I'm also very interested in the research that JDRF is doing on an artificial pancreas.
I can understand how a closed loop between a continuous glucose monitoring system and an insulin pump could work to control my basal (background insulin) rate. But I really didn't see how it might also be possible to effectively give boluses (larger doses for meals or BG correction) with such a system.
Yesterday I stumbled across a short paper in Diabetes Care, Detection of a Meal using CGM. The authors describe a Meal Detection Algorithm that allows them to detect a meal about 30 minutes after the person has started eating!
It's not perfect - but we already know that's true for most of diabetes care. Uf this brings the Artificial Pancreas a little closer and make diabetes treatment a little easier, I'll take it.
Insulin is not a cure. But automatic insulin delivery is a step in the right direction.
Update: There will be a workshop with updates from the artificial pancreas project in late July 2008.
Don't be put off by it's length, the real information is within the first 40 pages. It's a readable and informative document. And the Significant Barriers to Adoption that are covered starting on page 35 are still here today. It's worth reading.
If you're a regular reader, you know that I created the Diabetes Search Engine that uses Google technology to let you search over 800 sites that are all related to diabetes.
I add new sites to the engine list many times a week. And I decided that I'll occasionally post a list of the ten sites that I've most recently added. If you haven't already tried the engine out, I think you'll find it very useful. All advertising raised goes to support Dr. Faustman's research for a Type 1 diabetes cure.
I hope you'll check out some of these sites. I had a hard time stopping at the first ten!
InsulIndependence.org is "a worldwide project aimed at changing diabetic lives through adventure travel, educational outreach, and web-based community support."
so much sweeter is a fairly new blog from Carly. She's a graphic designer from PA, and she's the proud wearer of an OmniPod.
The Biggs Picture is a blog from Angela. Like many oph us she struggles with diabetes and technology. She seems to like kitties.
D.A.D. Innovations is a startup company that makes and sells diabetic driver car window decals and other handy products. The company was founded by Lisa, who's dad has diabetes.
Trying To Be Human is a blog from Araby62. "Various and sundry thoughts on living with type 1 diabetes from a thirtysomething wife, daughter, sister, aunt, friend, and lady-in-waiting to a certain feline."
Dodging Diabetes Charity Dodgeball Tournament. I think the name is obvious. This is the 3rd annual one and it happens in Bethesda, Maryland. They're looking for participants and sponsors.
The Diabetic Runner Challenge is a site that challenges you to run and raise awareness of diabetes and the upcoming 2nd World Diabetes Day in November.
Camp Possibilities is a camp for "children with diabetes between the ages of 7 and 15 who, due to the complexity of their disease, often do not get the chance to go to a summer camp". It's in Darlington, MD.
If I don't talk with you before then, have a great weekend!
Some time ago I mentioned the upcoming release new version of the Dexcom. It will let you calibrate the system without needing that darn cable. You can also use any blood glucose meter. Dexcom calls this 'open coding' and it is meant to be available around March 2008.
There two big advantages to this small change:
You don't need to carry the darn cable anymore
You can calibrate the Dexcom using any blood glucose meter
So why do I think this is such a big deal? Bear with me while I give a long explanation.
Last year I saw my A1C levels improve from April (just after I'd started the Dexcom) to July. But in October my A1C was back over 8.0%. That means my average blood sugar was around 200 mg/dL. However the Dexcom software said my average blood glucose was around 152 mg/dL, equivalent to an A1C of about 6.5%. That's a huge difference. One of the numbers must be wrong...or could they both be right?
Here's how I think the problem arises.
I calibrate my Dexcom with a OneTouch Ultra blood glucose meter. Like most meters, it's accuracy is about plus or minus 20%. (This is what is 'acceptable' according to standards for blood glucose meters.) So if it reports my blood glucose(BG) was 150, it's actually somewhere in the range of 120 to 180 mg/dL.
When I calibrate the Dexcom with it, the Dexcom uses that information when it calculates as my BG values. From experience I know that the Dexcom has a tendency to slightly low ball the numbers. So when it reports my BG at 80 mg/dL, my meter is likely to say it's around 95 (effective range 76 to 114). Result - I'm using a meter with a lowish accuracy to calibrate a continuous glucose monitor that's also got a lowish accuracy.
Perhaps my A1C is high, because I'm carefully using inaccurate systems to keep it within a tight range. It's just the wrong range!
I was given a WaveSense meter last year to review. I liked it a lot, it has a really good design and is easy to use. I even put a YouTube video up that showed the WaveSense in action. The folks had clearly put a lot of thought into the meter. The big thing about WaveSense meters is their accuracy. They certainly conform to ISO standards, all readings are within 20% of the true value. But with these meters, most readings are also within 10% of the real number. So if it reports my BG level as 150, then it's almost definitely between the range 135 to 165 mg/dL. That's way better, to my mind, than the 120 to 180 range for other meters
One thing I noticed whenever I used the WaveSense is that it would frequently give me a higher reading than the other meter I was using at the time. At the time I thought this was strange. Now looking back on it I realize that this is probably because of the WaveSense's better accuracy. The other meter was giving me a slightly lower, but less accurate, reading. Which made me correct with less insulin because I thought my BG was closer to the target that it really was.
When Dexcom allows me to use any meter I want to, I'm not going hesitate. I'll switch right over to the WaveSense meter that I've been using as a backup ever since I got it. That'll give me a third advantage: better A1C results, I hope!
I can't wait.
Update: I got to try out the new Dexcom model for about a week and I've posted about the Dexcom Open Choice with a video and my thoughts on the changes. Good stuff Dexcom.
Note: I currently own shares in Dexcom, I try not to let this ownership influence what I say about the company or its products.
The FDA has a new approach for reporting problems with blood glucose meters and continuous glucose monitoring systems (CGMS).
Once a glucose meter or a CGMS goes into widespread use, unforeseen problems may arise because FDA's approval process cannot always detect adverse events that are rare or related to the clinical use of the device or the users’ techniques and skills. FDA also cannot always detect manufacturing problems or problems with the product labeling (including instructions for use) after the device is on the market.
If you use any of these systems they'd like to hear from you when you encounter any of the following type of problems.
Device problems including
reagent or instrument failure
defects in product design
product instability
any other device problems that compromise patient health or safety
failure to perform according to performance characterized in package insert
incorrect test results that cause or contributed to an incorrect patient diagnosis and/or treatment
Use-related problems including
inadequate and/or misleading labeling or confusing user instructions Use-related problems
inadequate packaging or poor package design
any other user problems that compromise patient health or safety
The FDA will hold your identity in strict confidence. This means they won't release it to the public. But they may share it with the maker of the device, unless you request them not to do so.
Finally a way to get attention to system issues that annoy you! Full details on the FDA website.
Today the two companies announced that they will work together to integrate Dexcom continuous glucose monitoring into Animas insulin pumps.
"The new technology will enable the Animas® pump to receive glucose readings and display this information on the pump’s color screen. Users will have access to real-time glucose readings and trending in addition to receiving alerts for low and high glucose readings. Having real-time readings displayed on the pump screen will not only allow users to make more timely adjustments to their insulin delivery – it will eliminate a separate receiver, reducing the amount of equipment required to use CGM and the pump system."
According to the news report this should be available in 2009 or early 2010. And again it's a non-exclusive agreement, leaving Dexcom free to work with other pump makers.
Researchers have been able to get liver and pancreatic cells in diabetic mice to produce insulin by using a naturally occurring protein. According to the article I read, by injecting a protein called Pdx1 into the abdomens of mice, insulin production is restarted in the mice. Pdx1 has a structure that allows it to pass into the pancreatic cells, enter their nucleus and cause insulin production to start.
According to Dr. Li-Jun Yang, founder of Transgeneron Therapeutics, "What is remarkable is that the protein also promotes regeneration of insulin-producing cells in the pancreas, allowing the diabetic mice to become normal."
It all sounds like it has possibility. I'd just caution readers not to get too excited.
This is research and I'd guess it's many years away from any kind of application for people with type 1 diabetes.
I recently realized that I'm paying sales tax to the Commonwealth of Massachusetts for each box of Dexcom supplies that I purchase. The sales tax is not reimbursable, so if I order 10 boxes a year for a total of $2,400 I will support our glorious Commonwealth to the tune of $120.
I'm starting to raise some issues about this with my local reps and the tax office here in Massachusetts, or Taxachusetts as some of us fortunate enough to live here will call it.
So I thought I should gather some information from my readers. If you live in the US and you've purchased either Dexcom sensors or blood glucose strips please let me know the following.
Note: This is for non-prescription items. Massachusetts has different rules for test strips if I get them on prescription, versus if I buy them over the counter. So please let me know if you're purchased these items without a prescription.
Those of us with diabetes that take insulin know a lot about needles. We inject many times a day. We may also use needles to take Symlin, or simple to puncture our skin for blood glucose testing.
Well now there's a possibility that we'll see truly pain free needles in the future.
A team of researchers has created hollow needles, made of ceramics, that are so fine that you don't feel them.
There are no pictures of these yet, and it's not clear when or if they'll be on the market. But I'm intrigued by the quote in the press release:
“Microneedles may be integrated with micropumps and biosensors to provide autonomous sampling of blood, analysis, and drug-delivery capabilities for treatment of chronic disease,” he said. “For example, one needle, pump and sensor unit would assay the glucose level in interstitial fluid of patients with diabetes mellitus. Another needle, pump and drug-delivery unit would deliver insulin in a continuous or programmed manner.”
I like the idea of having a micropump instead of the pager-sized unit I carry around with me all the time.
Today Dexcom, who make a continuous glucose monitoring system, and Insulet, who make the OmniPod insulin pump, announced that they will work together to integrate Dexcom's CGM capability into the OmniPod's handheld system controller, the Personal Diabetes Manager. This will take time. According to the press release "Development, clinical and regulatory efforts are expected to continue throughout 2008, with an anticipated product launch in mid-2009."
The agreement is not exclusive, so Dexcom may also work with other insulin delivery device makers to combine with their technology.
Today Amylin announced that the pen form of Symlin is available. The SymlinPen 60 can deliver 15, 30, 45, or 60 micrograms per dose, so it's clearly targeted at people with Type 1 diabetes. These doses correspond to 2.5, 5, 7.5, and 10 units on a standard insulin syringe. The SymlinPen 120 can deliver 60 or 120 micrograms per dose. The pens can be stored at room temperature up to 86 degrees F (30 degrees C) after first use.
I have a long blog post about what I've learned from using Symlin. For those of us already on Symlin this is a welcome step forward.
What I'd like to see next (anyone?) is C-peptide in pen form. I'm not holding my breath!
I did it again. I booked a summer weekend in a Yurt for the middle of the year.
You can call me crazy (I think my wife believes I am) but these places are popular and sell out quickly. If you decide to go, I think you'll be pleasantly surprised. It's like 4-star camping, and an easy introduction to the outdoor life.
Mel of Orsa Aetas introduced me to Doane's Falls and I know we'll also pay another visit there while we're in the neighborhood.
Diabetes: technology, devices, software, and other stuff.
About Me
Name: Bernard Farrell
Location: Massachusetts, United States
I was born in Ireland and now live in the US.
I have had Type 1 diabetes for over 35 years. I struggle with my blood sugar, the same as most people with diabetes.
I wear a Cozmo 1800 insulin pump and a Dexcom SEVEN CGM to track my blood glucose levels. I also take Symlin to help control my post-meal blood sugars.
I'm blessed by God, and every day brings the possibility of a cure.
Then I dialed up my regular dose of 60 mcg and was able to inject it using the wonderfully small pen needle. If you put the needle cover back on, you can replace the pen cap with the needle still in place.
The SymlinPen 60 can deliver 15, 30, 45, or 60 micrograms per dose, so it's clearly targeted at people with Type 1 diabetes. These doses correspond to 2.5, 5, 7.5, and 10 units on a standard insulin syringe. The SymlinPen 120 can deliver 60 or 120 micrograms per dose. The pens can be stored at room temperature up to 86 degrees F (30 degrees C) after first use.
