Fully Closed Looping - finally at my destination? Yes and No

There are fantastic group of people in the open source community who have developed AndroidAPS (a hybrid closed loop 'artificial' pancreas for Android).

This system can be set up to talk to your CGM (continuous Glucose monitor such as Libre or Dexcom) and use the BG data to control your BG semi-automatically.

The inputs required once you've configured the extensive settings and parameters are things like Carb declarations (how much you eat or plan to eat), planned exercise, and any of the more difficult patterns like pizza or pasta that need extended carbs.

To make this work really well, ultra-fast insulins (Fiasp or Lyumjev) make it much easier, as the time needed to pre-bolus is much reduced - a few or no minutes in advance of a meal and the insulin will be doing it stuff in 15 to 20 minutes or so.

Lyumjev (Humlaog with a vasal dilator ( Treprostinil ) added to speed up absorption) which is slightly faster than Fiasp (Novorapid with added nicotinamide/B3) - both of these make 'looping' easier to perform and less guess work for the end-user

This works really well, however still needs human-intervention to make it work.

There is a variant of AAPS written by Tim Street, called 'Boost' which uses the AAPS code, and adds a boost function to intercept UAMs (Un Announced Meals) and hit them harder with more insulin - so the end-user doesn't need to tell the HCL anything about whats being eaten (unless its pizza and pasta etc that need extended carbs, in my experience anyway)

Boost and be seen as a fully closed loop - I've been running this for 4 months now, and have only told it when I eat pizza (for 4-6 hours of extended carbs), otherwise its sorts itself out without me touching it.

There is a large amount of configuration required to ensure it gives enough insulin up front to avoid high BGs (in excess of 10mmol) for very long, and avoid a crashing low after a high BG, but once tweaked it really does replace the pancreas.

I'll update with more information in my next post - I have very nearly achieved a proper diet without me over bolusing or waking up in either high or low

Not quite perfect, but a step int he right direction and much better than we could ever achieve without the open-source community working to innovate and drive the pharmaceutical companies to develop faster and harder to improve our lives now, not in 15 years.

Libre 2 Changeover Time Trick

 The Libre 2 should last 2 weeks, at changeover time there is always the 'will it start, won't it start' question which could mean you're not getting readings for at least an hour, possibly longer if the sensors fail.

I had once bad day when 2 Libre's failed one after the other, which meant 3 hours without readings, and really impacted my DIY looping - here is how to get wound that problem.

Use a miaomiao 2 reader with xDrip - I have a couple of these from before xDrip fully supported the Libre 2, and there was a good period of time when I couldn't get anything working properly.

1. Put the miaomiao on the old sensor and change the 'Hardware Data Source' in xDrip to 'Libre Bluetooth' and connect to the the miaomiao in Bluetooth devices, without stopping the sensor
2. Once that's done the miaomiao will continue to use this sensor after its expiry time (it only expires in the LibreLink app rather than actually stopping working) and you're ok to carry on using the Libre 2 for a good few more hours (though accuracy starts to decline, its still ball-park ok)
3. Then start the new Libre 2 using the Librelink App (or patched Librelink app in my case) and wait for it to start. Once its starts ok, you can stop the sensor in xDrip and start the new sensor as normal, if it fails to start, carry on using the old Libre 2 and miaomiao until you have one started

Its a work-around but keeps your loop running until you get a good sensor signal with the new Libre 2

I'm currently looking at switching to Dexcom One - not sure if there is a similar way to avoid dead time with a Dexcom yet.

Insulin Pump Renewal Time (again)

 Since being put on pump therapy I've had 3 changes.

The first pump I chose was an Animas 2020, followed by and Animas Vibe - then when Animas withdrew from the pump market the only option at the time was to go for a Medtronic 640g

The Medtronic works more or less exactly the same way as the Animas pumps did - i.e. it was a long way behind the other pump companies developments and was 'old tech' before I got it - 4 years on its a bit like watching Star Wars on VHS - ok at the time but looks like you need an eye test now

Advances in pump therapy mean we can now use pumps integrated with CGM to create a 'Hybrid Closed Loop' system - the pump works as an artificial pancreas as long as we tell it a few basic things (like how much we've just eaten) and it does the rest based on our current BG readings, IOB, etc.

I'm under Derby CCG for my Diabetes Care, and in Nottingham for everything else (prescriptions etc)

At pump renewal time I've been offered the following pumps:

• Medtronic 780g
• Omnipod Dash
• Tandem t:slim (possibly later in 2022)
• DanaRS or maybe Dana i (possibly later in 2022)

The big hit here is looping - Imagine how life changing it would be to be able to have my pump altering insulin in the background if I go high or low? Now that's attractive - so how to achieve that given there are only 2 pumps available?

Self fund sensors on the Medtronic - that's a minimum of £1820 per year - taking into account Derby are usually 12 months ahead of Nottingham in approving things - that could be £3640 before I get the kit to use Medtronic looping and wouldn't give me the tech for BG on a watch etc. - as it's not available directly (though there may be some fudge loading data into xDrip+ I guess)

I'll admit I'm not a fan of Medtronic - the pumps are 'ok' but suffer from cases cracking, there customer service has been terrible (improved over the last 18 months, but things like Christmas come as a complete surprise every year and you cant get consumables for your pump) etc. They also tie you entirely to their equipment and sensors - no open API or freedom to integrate kit that they don't make so I prefer not to use them

So the options are the Artificial pancreas open source apps on the internet - More on those shortly as they drive pump choice for me, to integrate with my existing Libre2 sensors

NHS approval for CGM

 It looks like this week NICE will approve CGM (continuous glucose monitors) for addition to Health Authorities formularies so can be put on individuals repeat prescription in a more general manner.

Currently they have only been available for qualifying children who need the support of these specific devices.

That means that closed loop systems are within reach ok UK diabetics - for some time Medtronic have been trialing closed loop in some LHAs (local health authorities), recently some other pump manufacturers have announced the same capabilities tied to their own CGM censors.

Taking into account the time it takes for LHAs to gain funding and approve products for prescription, and the current funding crisis caused by Covid, it may be some time before we see those products available in Nottingham (for example) and it may be triaged on a case by case basis until the LHAs can see benefit from cost savings and life quality to those taking up the opportunity for CGM and the Closed looping.

I have a pump renewal coming up in May 2022 - I'll take advice from the Derby Diabetes specialists to see what its likely to happen, however I'm currently planning on using my Libre2s linked to xDrip and Nightscout, a new DANA RS pump (open API) and AndroidAPS to perform the looping. That should buy me 4 years for it all to settle down, and I can review what's happened next time when its all sorted out.

Interestingly there is a new 'Libre 3' device that seems to be CGM rather than flash - more on that when I work out what that might mean

Its not easy being a Diabetic - you need one foot in the medical camp (I have spent most of my life being 'an organ' - in this case a pancreas) and one foot in the technology camp - I have no idea how this will work out when I hit 70 and still need to be switched on to compiling Android apps and whatever the new version of Bluetooth protocol stack is doing.....

Diabetes Tech and how it hangs together for me

 As some background, I have the following bits of kit helping me manage my T1D:

• Medtronic 640g Insulin Pump
• Contour Next Link USB Blood Glucose reader
• Tidepool
• 600 Series Uploader
• Nightscout
• Freestyle Libre 1 and Freestyle Reader
• 2 x MaioMaio 2
• Google Pixel 2 XL (Android 10) Phone
• xDrip+ Nightly build
• Pebble Smartwatch

Medtronic 640g Pump

This replaced my Animas pump, when Roche pulled out of supplying Insulin pumps in the uk.

Not a great gadget - it does everything fine, and has all required settings / programs, however the level of support is not as good as Animas, and the essential products that were supplied as standard with Animas are not available.

The Canula design was changed a few years back, so they shatter when removing them from the reservoirs (to prevent re-use) which can be annoying when parts of the cannula fail and you're stick int he middle of no-where and just need to do a quick fix.

Battery life is approx 10-15 days

Belt clips wear out quickly, and although replacements are available (as long as its within 1 year of supply) they don't last well. In addition to this, after 3 years of wearing a pump, the pump itself is work on the belt clip, so new clips do not stay on well. Roll on the 4 year renewal!

Contour Next Link Blood Glucose Meter

Works well, although the lance isn't to my personal comfort. Accuracy of the blood strips was questioned in the UK - although never noticed a problem myself. I tend to use this only to upload data to Tidepool and into xDrip+ / Nightscout

Tidepool

On-line application that gathers data from Nightscout and xDrip+ along with readings from your pump and Libre scanner, and displays it in graphs and detail to help you plan your changes and review 'what went wrong' and then give you the info to go fix it.

Data can be loaded directly from your devices (pump and blood test machines), or by sending it all directly from xDrip+

600 Series uploader

Pulls the info directly from your Medtronic pump (basal/bolus settings, CP amounts, insulin delivered etc) and sends it to xDrip+

Once installed on your phone, you plug a OTG USB cable (On-The-Go is a special USB cable type, but widely available) between your phone and the reader, and it sucks the data off the pump and into xDrip+

Nightscout

This allows you to create your own website that shows your current Blood Glucose and the events (boluses, food intake etc) that constantly updates in a graph form. Great if family need to keep an eye on you and check you're safe

Freestyle Libre 1 and Freestyle Reader

One of the great steps forward -  A flash glucose monitoring system (from Abbott) which measures interstitial fluid glucose levels. The system comprises a sensor and a reader. ... At each scan, the reader displays current glucose levels, levels over the previous 8 hours, and whether glucose levels are trending upwards or downwards (and how fast).

Works really well with the following things to be aware of:

• BGs displayed are approx 20 minutes behind real time. You may need to check using a Blood test if you need a 'whats happening now' test
• When inserted it takes 1 hour to activate after you first swipe it with your reader. This is supposed to git it time to settle down with your interstitial fluid and calibrate itself. If you can do it, insert it a day or maybe 2 days before activating - the readings are more accurate
• They tent to come off in hot weather - I use 3M Tagaderm film to stop that happening (also means when you walk into a door frame they stay put (that happens more than you realise, till you start wearing one of these things
• From time to time they don't start up - usually due to blood getting in the sensor when you insert them. If this happens they are replaced by Abbot, usually take 1 week to get the replacement, so worth keeping a couple in stock if you can

MaioMaio 2

 Another great leap forward - AS bluetooth transmitter for the Libre - sends the data to xDrip+ on your phone, is rechargeable (mine lasts about a week between charges) and can be held on by simply sticking it to your arm on-top of the libre using a larger 3M Tagaderm. You don't need the self adhesive strips they send with the MaioMaio that way - and you can remove it for charging

Google Pixel 2 XL

Seems to work ok with the above kit - Google don't put additional software enhancements in the way of the basic Android O/S (like Samsung can do) and this one seems to work ok for me. Battery life is impacted by xDrip+ (lots of bluetooth activity) so you'll end up charging it up more than usual.

I can't get xDrip Vehicle mode working any more (google updates stopped that) so maybe another phone would be needed to get that working

xDrip+ Nightly build

Awesome - pulls all your tech together and give a detailed way of gathering the data in one place. Graphs whats going on with your Blood Sugar, and allows you to set alarms for highs and lows, and predict when they might hit you. If you've not seen it - go have a look, it can be challenging to set up first time, but its incredible.

I use the Nightly build to keep up to date with new features - usually wait a couple of days after its published in case there are issues

Pebble Smartwatch

Best I've found as an all rounder, but getting older now - means you always know your blood sugar levels and are warned when they drop.

Doesn't work as an xDRip collector (where the watch talks directly to your MaioMaio when out of reach of your phone, but I'm not sure what watches do work - the info out of the xDrip community is a bit 'scattered' and I'm not sure what works or doesn't at the moment

XDrip+ and Watches

If any of you work in IT, you know that developers very seldom write documentation for the rest of us.

The xDrip team write some incredible software, that gives my diabetic life a massive leap forward in manageability, sometimes its hard to find up to date info on how parts of the system work (thats up to date at least).

The official info is here and has some great reference info: Nightscout cgm-watchfaces

Its possible using xDrip to get the display and high/low warnings etc on a bluetooth enabled watch, there are several types supported:

• Android Wear OS
• Pebble (all types)
• Amazfit
• Bip
• GTR
• BlueJay
• Lefun band
• MiBand

I initially bought an old Pebble Time (ebay £10) as these are now legacy, but after wearing it while fixing the car (it got covered in brake fluid) it fell to bits and I had to superglue it back together as a temporary fix.

I then started looking at the Android alternatives, as this is mainstream tech and seemed to be the easiest to get running, plus should have support going forward.

The watch I picked was a 2018 Ticwatch Pro - again from eBay (about £110 I think) which has been fine for the last 18 months or so. Then Google started changing the way Apps can be loaded onto a WearOS watch - they look to be forcing developers through the Playstore, which is difficult for an open source app and development team.

So for the moment there is a question on whether we will be able to load xDrip onto Android for updates etc without jumping through (IT) hoops, which lots of us find difficult to do.

I started to look back at the old Pebble watches and see if there was something I could pick up cheaply that would do the job, as Pebble was bought out by Fitbit in 2017 (and then shut down) the watches are getting old, and batteries in them starting to fail.

To get a Pebble to work, you need to load the Pebble app from the Playstore, then patch it using http://rebble.io (google 'pebble rebble' to find them)

Once thats done, you have the Pebble app with the associated store of watch apps/watch faces etc.

Here is what I've learned from looking at the watches themselves:

• Original Pebble Model 301BL (BL is black)
• Old and batteries usually failed by now, unless replaced.
• Essentially 2 types
• original kickstarter one, thats glued together
• the newer one, that has 4 screws on the back (screws are T3 torx)
• Batteries can be replaced (£15 quid on ebay) but its a reasonable bit of work to strip them down and solder the very small connections - not for the faint hearted.
• Monochrome screen
• Pebble Steel Model 401B
• Some working ones about on ebay if you keep looking (£15-£20)
• Lots suffer from Screen Tearing - the connector in the watch goes loose, so you have to take it to bits and jam something (toilet paper works fine) in the back over the connector and screw the back on again (T4 torx screws), lots of Youtubes on how to do this
• Monochome screen
• Strap is a stepped connector on the watch - special for the Pebble steel, so if you need one expect to pay £12 on Amazon or £20 on ebay
• The strap pins are screw in - not sure what the sizes are, but if you buy a working watch without them (I did) its probably easiest to buy a broken one an use the pins for spares
• Battery life 3-4 days using xDip
• Pebble Time Model 501
• Colour Screen (yay!)
• Battery life is usually 'ok' but mine lasts about 1.5-2 days before needing charging as its getting older
• Case is glued together so if you need to get into it - its a 'warm up with a hair dryer' job
• Pebble 2 Model 1002
• Newest (the last of the line) of watches before being shut down
• Heartrate monitor
• Colour screen
• Buttons on the side wear out (you can buy these 3D printed if a replacement is needed)

Pebble sold best in America - so lots more on ebay.com if you can stomach the postage costs to the UK

Philips Diamondclean toothbrush hard reset

The Philips Diamondclean sonic toothbrushes stimulate blood vessels - so are recommended for T1s

Mrs Cheeseseeker has a pink one of these and every now and again it locks up and wont do anything - it charges ok but the button does nothing.

If you google for sonicare reset - you get instructions for other types of Philips tooth brushes that have more than one button to press, which say:

1. Place your handle on the charger.
2. Press and hold the power button together with the intensity button (intensity up) and the mode button for at least 2 seconds
3. You will hear 3 beeps and see the battery light flashing green

That doesn't work as there is only the one button.

To fix this problem you need to do the following:

1. Make sure its charged (at least partially)
2. Take it off the charger
3. Hold the button down for about 30 seconds - keep holding it and it should then light up and start cleaning

Brush fixed and a happy Mrs Cheeseseeker