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Omnipod Insulin Management System

Omnipod 5 dexcom integration

Omnipod 5 Features

  • Automated Insulin Delivery (AID) pod pump uses Dexcom G6 and G7.
  • Tubeless, waterproof pods adhere to skin, contain the cannula, contain the algorithm, and communicate wirelessly to "Controller" that looks like an Android phone. The Omnipod 5 in Canada does not yet operate from a cell phone. 
  • The Controller contains an Insulet SIM card to automatically upload results to Glooko. (No cell phone plan is required for the Controller to function.)  All programming and pod changes are done via the "app" in the Controller.  
  • The user requires a separate phone to activate each Dexcom glucose sensor from a Dexcom app.  A phone is not needed again until the sensor is deactivated and a new one is inserted. After sensor set-up, the sensor communicates directly with the Pod. The pod communicates directly with the Controller.

SmartAdjust Algorithm

  • The following can be adjusted by the user:
    • Target glucose: 6.1, 6.7, 7.2, 7.8 and 8.3 mmol/L with up to 8 time segments per day. 
    • Carb Ratio: usually stronger is required at start; patients can store "custom foods" with CHO content
    • ISF (corrections) are manual via the SmartBolus Calculator
    • Correct Above
    • Duration of Insulin Action: often 3-4 hrs with initial starts. Available 2-6 hrs. 
    • Reverse Correction: turn off for most as it withholds insulin; it is 'on' by default. (three horizontal lines top left > settings > bolus)
    • "Use Sensor" in Bolus Calculator: Tapping this allows the algorithm to consider the following in its dose suggestion: 1) correction dose using manual ISF as intended by the system, 2) subtraction of IOB (“Meal IOB” and “Correction IOB” which includes insulin above adaptive basal rate and 3) insulin adjustment for CGM arrows. If “use sensor” is not tapped, or a manual blood glucose reading is not entered, no correction is given, no IOB is subtracted and no insulin adjustment is made for CGM arrows. Only insulin for grams of carbohyrate inputted or units mannually inputted would be delivered. 
    • Patient bolusing & pre-boluses practices are important as per most AID pumps.
    • (No extended bolus and no temp basal are available in automated mode)
    • (The max basal setting does not impact max adaptive basal delivery when in SmartAdjust. It only impacts max manual basal delivery.)
  • The following cannot be adjusting by the user:
    • Basal Rates (Adaptive Basal Rates)
  • Adaptive Basal Rate Notes:
    • The algorithm determines the Adaptive Basal Rate according to TDD from past pods. It can increase, decrease or pause basal every 5 minutes based on current glucose and a one-hour future glucose prediction (sensor trend, target, IOB).
    • The max basal increase is 4x current adaptive basal rate (e.g. if adaptive basal rate is 1 unit/hr it can increase to a max of 4 unit/hr). 
    • The algorithm is updated every 2-3 days with a pod change, considering TDD for the past 4-5 pods.  (Pods contain the algorithm.)
    • Optimization could take a few weeks, or less.
    • A pod will continue to modulate basal insulin even if separated from the controller. The pod communicates directly with the glucose sensor.
    • During the first 48 hours, the programmed basal rate and the TDD are referenced for basal delivery until an "adaptive" basal rate is calculated and used in the second pod.
    • Automated Mode Limited starts 20 minutes after loss of sensor reading. This mode uses the lower of either the programmed basal rates or the adaptive basal rate. An alarm will trigger after 60 minutes of no sensor data.
    • Notes:
      • Insulin on Board = Meal IOB + Correction IOB (from manual corrections + insulin above the adaptive basal rate) .
      • Duration of Insulin Action is only applied to bolus and correction insulin, not to basal insulin modulation. 
  • Initial Setup 
    • Basal Manual Programming: Since POD#1 is conservative with basal, users new to pump therapy may wish to use 50% of their current MDI Total Daily Dose of insulin/24 as the manual basal rate - with no 25% reduction in TDD as routinely seen with other new to pump starts. Those moving from another pump to OP5 may also consider 50% of the older pump's TDD/24 rather than directly transferring their existing basal settings.
    • POD #1: For this limited time, the algorithm's adaptive basal rate references the active manual basal program and the parameter that 50% of TDD is basal. Expect the first 2-3 days' time in range to be lower than desired.  It will improve with each subsequent pod. It is important to bolus with all carb intake. Give realistic expectations. 
    • POD #2 (at least 48 hrs after pod 1): The algorithm adjusts using total daily insulin from first pod and can start modulating up to 4 X the adaptive basal rate. 
    • With each new pod: The algorithm adjusts according to total daily insulin, with the past 4-5 pods having the greatest impact.
    • Important to remind patients: After each sensor change and warm-up, the PDM prompts the user to go back into Automated Mode. If they do not manually re-enter this mode, the pump will function in manual mode. 
    • Automated Mode Limited occurs after 20 minutes of no sensor value. The pod will use the lesser of these: the programmed basal rate or the Adapted Basal Rated. At 60 min, the "Missing Sesnor Values" alarm occurs.
    • Automated Delivery Restriction: Insuiln has been paused or delivering the max amount for too long. Follow instructions on screen (do blood glucose, identify cause, must switch to Manual Mode for a minimum of 5 minutes. 
    • Tunneling: Remind patients to change the pod if the pod's material is wet (insulin travelled back up the cannula). It can occur with movement of the pod depending on site, laying on pod and after bigger boluses.It may only be visible on the back of the pod vs the side material, so advise to change pod with unexpected higher readings that won't come down. 
  • Key Reminders 
    • Pod and sensor need to be in direct line of sight. 
    • Controller volume should not be on low, off or silent

 

Adjusting for Hypoglycemia

Be aware that the only glucose alarm issued by the OP5 Controller is an urgent low of 3.1 mmol/L or less. All other sensor alerts or alarms occur only through the Dexcom app on the patient's phone. 

If recurrently hypoglycemia, assess the appropriateness of using the following:

  • Increase the glucose target
  • Make Carb Ratio less aggressive
  • Make ISF less aggressive
  • If forget to bolus: 
    • > 30 min (<60 min) after eating, remind to only enter 50% of carbs; 
    •  > 60 min after a meal, advise not to enter carb. Just correct. 
  • Adjust the "Duration of Insulin Action". 
  • Adjust the "Correct Above" glucose level. 
  • Assess if bolus calcuator overrides are appropriate 
  • If a frequent boluser, suggest they tap "Use Sensor" with each bolus. This allows all IOB from past meals and corrections (which includes insulin above adaptive basal rate)  to be subtracted to prevent stacking if the carb ratio is not accurate.
  • Ask if the patient has been tapping "use sensor" in the bolus calculator for each bolus. If they have not, the system will not subtract insulin on board. This may or may not be concern depending on the cirucmstance. 
  • See "Exercise Options" (click here) for additional strategies

 

Adjusting for Hyperglycemia

Consider the following as appropriate for the patient:
  • Important to remind patients: After each sensor change and warm-up, the PDM prompts the user to go back into Automated Mode. If they do not manually re-enter this mode, the pump will function in manual mode. 
  • Check that "Reverse Correction" is off.
  • Lower the glucose target 
  • Make Carb Ratio more aggressive by up to 20%-25%
  • Set "Correct above" to equal the target glucose e.g. 6.1 mmol/L
  • Remind to bolus and pre-bolus
  • Remind to tap "Use Sensor" on the bolus calculator screen to transfer glucose reading and trend into the calculations to allow for adequate correction. (However, this will also subtract all IOB from calculations). 
  • Consider NOT tapping "Use Sensor" in the bolus calculator at times, especially if a frequent snacker with an accurate carb ratio. By NOT tapping this, the remaining bolus from the last recent snack will not be subtracted from the current bolus. The other option is to tap "use sensor" and override the bolus suggestion. 
  • Make ISF more aggressive
  • Verify that hypoglycemia is not over-treated with glucose
  • Assess, and if necessary, adjust the "Duration of Insulin Action".
  • Advise additional boluses for unexpected high readings not caused by infusion site issues or ketones.
  • If > 10% time in "Limited" mode, assess and troubleshoot sensor connections.
  • If highs secondary high fat and protein that don't respond to normal bolusing, consider a second bolus 90 minutes pc. 
  • For "topping up" insulin with transitory expected high readings e.g. after a milkshake, be aware that a sensor glucose of over 22.2 mmol/L will not be used by the bolus calculator. Options, when considering safety, could include: 
    • Input blood glucose reading (not sensor glucose) up to 33.3 mmol/L in the bolus calculator to determine extra correction. 
    • Or input "top up" grams of carb or units of insulin, but do not hit "use sensor". No IOB will be subtracted.
    • Or over-ride the bolus calculator suggestion after checking the bolus calculations. 
  • Assess for insulin tunneling (leakage). Any pump brand's cannulas can be affected as insulin can track back along the cannula and soak the adhesive material, often from site movement or larger boluses. Pods may be more prone as their weight may increase movement. To reduce tunneling or its impact, consider:
    1. Teaching patients when and how to assess for tunneling 
    2. Trying sites with less movement, and avoiding sleeping on pods. 
    3. Encouraging earlier pod changes on a regular basis, as soaking from tunneling may not be visible underneath pods.
    4. Applying Tegaderm to the skin first, then inserting the pod on top to support the cannula. Check glucose soon after to ensure the cannula has not kinked. 
    5. Using over-patches and tapes to secure the pod and reduce movement. 
    6. Consider splitting big boluses into two deliveries. Some patients independently decide to split boluses bigger than 5 units into two deliveries, if particularly impacted by insulin volume and tunneling.
    7. Discussing the use of U200 with the physician and patient to lower the volume of insulin. Numerous safety steps are required.

 

Exercise Options

Suggestions require individualizing depending on the patient, level of fitness, and the type, duration and intensity of exercise. In general, sustained, aerobic exercise tends to lower glucose levels; anaerobic or competitive activity tends to increase glucose levels.

For activities that tend to lower glucose levels, consider one or more of the following strategies, to help prevent lows.


  • Advise to start the "Activity" feature 60-120 min prior to starting activity, during and potentially after exercise. This setting further will do both of these: reduce automated insulin delivery by 50% and set target to 8.3 mmol/L. This is more conservative than just an 8.3 mmol/L target alone. It can be set from 1 hr to 24 hrs in 1 hr increments. 
  • If the activity occurs within 2 h after a meal, consider decreasing the meal-time bolus by up to 33%
  • Avoid large snacks or high glucose readings prior to exercise as can result in increased insulin delivery.

 

Pregnancy

Omnipod 5 is not indicated for use in pregnancy. This article (click here) reviews two cases of OP5 used in pregnancy. 

 

Training

  • Omnipod 5 Summary of Setup Steps
    (remember to check bottom right of screens for next steps or to activate some settings) 
    • At home, the patient:
      • ESSTENTIAL STEP: Visits  https://www.omnipod.com/setup to create Omnipod ID first (and write it down). This is required when setting up the controller at the pump start appointment. Be sure the username and password will work for logging into the controller. If not, have the patient call Omnipod support to address before they arrive to the pump start. 
      • Use the same username and password to set up a Glooko Account.Glooko - Registration 
      • Some clinics may advise the patient to completes the "onboarding" instructions inside the Controller. Some may ask the patient to just login into the controller, and wait to do onboarding with the trainer. 
      • watches all the Omnipod 5 instruction videos here.
    • Pump Trainer - have patient turn on controller and walk through the key steps per the automated setups steps. 
      • 1. Input of insulin doses 
      • 2. Setup of a pod
      • 3. Connection of Dexcom 
    • NEXT: Turn Reverse Correction off: On the DASHBOARD, tap the three horizontal lines on top left of the controller. Choose Settings > Bolus. 
    • Verify Insulin mode: on DASHboard, tap INSULIN (near top, middle) to see if Automated Mode: Active (if you see "Everyday" with blue basal rate bars,  that is manual modle.)
    • To change between manual and automated mode: Tap the three horizontal lines on top left of the controller > Switch Mode. 
    • To change carb ratios or correction factors: Tap the three horizontal lines on top left of the controller > Bolus > (tap the blue text under Insulin to carb Ratio or Correction Factor) 
    • Important to remind patients: After each sensor change and warm-up, the PDM prompts the user to go back into Automated Mode. If they do not manually re-enter this mode, the pump will function in manual mode. 

 

 

 

 

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