MDI, Why?

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Kameran Ulferts, University Of Nebraska-Kearney '18
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No, this is not some other type of condition. When I first heard the term “MDI”, I immediately thought of mesothelioma commercials. If you google MDI, various company and organizational names pop up. After a silly amount of research, I came to understand that MDI actually stands for Manual Daily Injections. Oh, duh, SHOTS!

Being a person with type one diabetes for almost ten years, I have always heard interesting verbiage regarding diabetes and treatment methods. “Are you on the pump or shots?” is a common question to receive when asked about diabetes (no, not a breast pump, or shots of alcohol). From my observations, when this question arises, a good majority (this is a blog, not a research article) of people with type 1 diabetes will respond and explain the insulin pump therapy they are using. I, myself, was on an insulin pump for seven of my nine years with diabetes.

Now? I’m not “on the pump”. I am using MDI. Why, you might be wondering? (If you’re not wondering, you can stop reading this and go back to looking at your Facebook feed. However, I can assure you that this might be more interesting than reading about your great aunt’s new pyramid scheme).

Why MDI:

When you google “the pros and cons of manual daily injections vs. insulin pumps” you will see results like this: (If you’ve already read these before, or if you’re just a general T1D knowitall like me, feel free to skip this part).

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Pros of injections:

  1. Insulin injected will almost always goes into the body the way the person intended for it to

  2. Less extreme high blood sugars- long acting insulin is in the system for 24 hours

  3. Cost- insulin and syringes, or pens (composed of an insulin cartridge and a dial to measure the dose) are cheaper with or without insurance

  4. Unattached freedom- no adhesive or clunky pump is attached to the body

Cons of injections:

  1. Accuracy- Only able to use single-unit doses

    1. Disclaimer/plot twist- The InPen from Companion Medical is a “smart insulin pen” and it operates in ½ units

  2. Pens- sometimes leak little drops of insulin after injecting

  3. Studies show that people using insulin pumps tend to have better A1c control

  4. More adjustments- may need to compensate by adjusting carb-intake or insulin ratios at certain times of day

Pros of an insulin pump:

  1. Control and accuracy- the pump does all the math and calculations (carb ratios for a bolus and basal rates)

  2. Simplicity- the pump is easy to use when a person receives the proper pump training

  3. One injection every three days as opposed to 10+ per day

    1. No need for long acting insulin

  4. Extended bolus- spreads out a dose of insulin over any amount of time

  5. Temporary basal rates- Has the ability to split basals in half or double them with the click of a button

Cons of an insulin pump:

  1. Site failures- bent cannula, site torn out by accident, unknown reason, etc.

  2. Tubing- gets caught on things, is sometimes obvious when worn outside of clothing

  3. Possibility of mechanical failures- sometimes not weather/water resistant (a lot of articles mention this in regards to older versions but hello it is ~2019~, these pumps are made to withstand some wild stuff)

  4. Skin sensitivity- skin is sometimes sensitive to the adhesive tape and scar tissue can form from infusion sets

  5. More extremes- the possibilities of extreme high blood sugars and low blood sugars, due to the cons stated above

  6. Cost- the parts to an insulin pump (the pump itself, infusion sets, reservoirs, batteries, pump clip etc.) can amount to a lot of out of pocket, with or without insurance

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Okay, so now you have the bread and butter of how most people with diabetes look at these treatment methods from both sides. What treatment comes down to is this: it is YOUR CHOICE. When you make this decision, you should take into account your lifestyle, habits and your future goals with T1D. I could go on and on about examples but it still comes down to personal preference.

Now, my personal preference?

I didn’t write this blog to tell you that you should or should not choose one treatment option over the other. I didn’t write this blog to tell you that choosing a pump or MDI will change your life and all your diabetes physical and mental complications will disappear. I didn’t write this blog to give you an easy way out.

Quite frankly, after being on an insulin pump for seven years, going back to injections was not easy. For me, no one ever recommended I take a break from the pump. No one ever talked to me about being burnt out while on the pump. It seemed like everyone thought the pump was always the right answer.

For me, burnout happened when I was on the pump. After reflecting on my worst diabetes days (you know, the “wow, I don’t feel good and now the physical and mental effects are ruining my prior engagements” kind of day) happened because of complications with my pump. Some of these reasons line up with the reasons listed above, some don’t.

 

  1. Not to be dramatic but bent cannulas were ruining my life.

Okay, that’s dramatic, but seriously! I would have a bent cannula in my infusion set once every THREE-FOUR times I changed it. It came to the point where I would carry around two extra sites with me AND an insulin pen to correct the obnoxious highs that followed. I attempted to switch to other types sites with really not much luck (Okay I get that it doesn’t bend but excuse me… a STEEL cannula??? No thanks, fam).

 

  1. OvErCoRrEcTiOn

I used the insulin pump in a way that actually started dangering my health (again, this is in retrospect). I didn’t realize I was doing this until I got the Dexcom Continuous Glucose Monitor. Any time I would see my numbers trending upward, I would pull out my insulin pump, sometimes without thinking, and just send another unit or half unit to try to correct a potential high. I did this because I developed high blood glucose anxiety. The thought of going over 200 terrified me. I became obsessed with the data and the control. After using the Dexcom Clarity app and running my reports, I noticed that I was at a high risk for hypoglycemic events. At my first adult endo appointment, my A1c was 6.1% and I didn’t feel as excited as I thought I would. I thought back on the past year and all the hypoglycemic events I endured (one in particular dropped me to 23)... All those lows at the price of getting a good number so family, friends and doctors would pat me on the back. I did this to prove to others that I am in control of my diabetes. When, in reality, the need for control took control over me.

 

  1. Skin sensitivity

Because of the bent cannulas, I would be so nervous to insert a new site. Due to this new found fear, I’ve “accidentally” left sites in for too long and consequently, I’ve developed scars and scar tissue. In the winter months, I’ve noticed my dryer than usual skin is also very sensitive to adhesives and I have developed scars from that as well.

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How has MDI helped? Well I’ve been using MDI for almost a month now and it has humbled me in ways I never anticipated.

  1. Cannualas?

Yep, those issues don’t exist for me anymore and I’m pretty pumped about it (no pun intended, hehe). Every injection I give myself with my Novolog pen, I know that insulin is going into my body. Through this experience, I have also learned which places of my body are more insulin resistant than others (for ex. Insulin gets into my system quicker when injected into my upper hips than when injected into my thighs). Also a side note, I haven’t gone above 250 since I’ve been on MDI. Not because I’m still crazy overcorrecting, but because my long acting insulin is always there as a safety net.

  1. Overcorrection?

This has been a process but I am finally getting used to WAITING and being PATIENT. That’s right folks, after seven years of pumping and having immediate access to insulin through pump controls, being on MDI gives me time to THINK longer about what I’m doing, how I’m correcting and the possible future result. Having to physically go into my purse/pocket and grab the pen and put the pen needle tip on the pen gives me so much more time to consider how a bolus will affect me. MDI also makes me think more mindfully about how many carbohydrates I’m consuming.. For example, when there’s cookies in the office, I realize that the cookie is probably not worth the 1-2 units I would need to get my pen out and inject for.

  1. Skin sensitivity?

When I first started MDI, I had a few bruises from my long acting insulin but I have since switched from Lantus to Tresiba. After that, I have not had an issue. My skin actually got a double break from adhesives for three weeks when I had a shipping issue with my Dexcom. I’ve been addressing the dryness of my skin (not by going to the diabetes section of Walgreens) by adding double the moisturizer to my skin at night (facial moisturizer and extra healing lotion products).

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Why do I think this is important to share?

As people with type 1 diabetes, we are strong, we are quick thinkers, we are diligent, we are dedicated and, as of right now, we are going to have this disease for the entirety of our lives. Who says we have to stay on the same care management path the whole time? Well, okay, if your diabetes care team strongly suggests one path, then maybe trust them on that ;)

What I’m getting at is that switching to MDI is challenging but disconnecting from the pump was the challenge I needed to reconnect with myself. I decided to write this because I feel as though the general T1D community is so pro-pump that they forget (or don’t consider) why others switch to being pro-MDI. Through this experience, I have reevaluated my T1D care patterns, habits and routines by journaling and recording how I’m feeling. Using MDI has helped me to understand and appreciate myself and my body in ways that I’m still discovering today.

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Kameran Ulferts is a recent graduate of the University of Nebraska - Kearney. She is a co-founder and former co-president of the CDN Chapter there. She just completed her student teaching experience in Houston, TX, and graduated in December with a K-12 Art Education degree. She currently works as an Extension Assistant for the youth development program 4-H where she facilitates College & Career Readiness and STEAM programming to children of all ages.