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Tandem

The Tandem t:slim X2

Tandem G6 2019Safety Reminder: When preventing DKA while using a hybrid closed loop pump

  • Place the pump in manual mode before giving insulin by pen or syringe.
  • Keep the pump in manual mode for at least 4 hours after the last injection of insulin by pen or syringe.
  • After resuming automated insulin delivery, check that the desired glucose target is set.

Pump Features 

  • Colour touch screen
  • Dexcom G6 CGM enabled 
  • Rechargable battery
  • Tubed proprietary infusion sets
  • Upgrades are done via software downloads after learning module completions.
  • Control-IQ adjusts insulin delivery to help prevent highs (automated partial corrections and increased basal insulin) and lows (automated temp basals or basal suspensions), while requiring the user to manually bolus for meals. Individualization of glucose targets is not an option except for choosing Exercise Mode or Sleep Mode.
  • The Control IQ algorithm uses a patient's programmed basal rates, and correction factors (ISF) and potentially other factors to make automated dose adjustments. Carbohydrate counting and food boluses are still required.
  • When Control IQ is active, a patient can adjust basal rates, ISF, carb ratios and do an extended bolus of max 2 hrs. They cannot control insulin duration or create manual temporary basal rates when in control IQ. 
  • Basal IQ, the feature in older models, only reduces basal insulin. It does not allow for auto-correctios. However, unlike it does allow for individualization of glucose targets e.g. in pregnancy. Tandem provides loaners for clients on Control IQ currently wishing to transfer to Basal IQ during their pregnancy. 
  • Consideration: If A1c prior to the start of using a hybrid closed loop (HCL) could drop quickly by more than 2% over 3 months (particularly for those with A1c in double digits), consider discussions with the specialist physican and patient about higher temporary glucose targets. Rapid A1c improvements have been associated with changes in retinopathy and rarely, painful treatment induced neuropathy of diabetes (TIND) or insulin edema. 
  • FYI: Tandem supplies can be purchased through DiabetesExpress.ca,  DiabetesDepot.ca and Richmond Square Pharmacy (Calgary)

How Control IQ Works

Tandem Contol IQ ActionsChart2021

 Tandem Control IQ Pump Icons 2021

 

Training & Reports

 

REPORTS

 

Infusion Sets

Tips for AutoSoft 90 & Avoiding Kinked Cannulas

If using an Autosoft 90 infusion set, sometimes the plastic cannula can lift closer to the top of the insertion needle. This can cause the cannula to kink on insertion. To prevent this from happening:

  • Twist and lift the blue needle protector
  • Lift the paper off the adhesion on the infusion set, then gently check that the cannula is well below the needle. (To avoid touching adhesive - and lifting- remove adhesive tab after the needle guard.)
  • Ensure the tubing has not been placed in the notch of the inserter before it has been pulled (cocked) back. This can easily lift the infusion set off its
    base and raise the plastic cannula higher so the needle does not have enough of a lead to insert the plastic cannula properly.
  • Once the infusion set has been pulled back, then place the tubing in the notch.
  • Check the needle and make sure the cannula is well behind the needle. Then inject by squeezing the two flat circular areas together
  • Be sure to massage the white handle of the infusion set well before removing the needle. This ensures the adhesive is well stuck to the skin. Then remove the needle by pulling the white handle (not the outside part) straight out. The needle should be straight after removal.

 

Notes for Dose Adjustments & FYI

 

Indications, TDD, Weight & other FYI

  • TDD and weight in Control IQ
    • Indications for Control IQ are TDD 10-100 units per day and weight  25-140 kg. Patients beyond these indication levels have still used Control IQ; it is then an off-label usage.  These are the maximum allowable entries into the system at initiation.
    • Control-IQ uses these initial entries to enable the algorithm to start working right immediately without awaiting past data for the algorithm. However, as time passes, the algorithm uses actual delivered TDD based on a rolling 6 day average. 
    • However, if weight and/or TDD change dramatically and regularly (e.g. off-label DIP use or continual weight loss/gain), update the information as it can impact how the algorithm works. 
  • Max Basal Rate:
    • If programmed basal rate is > 3u/hr, the system will deliver it if the CGM signal is active. However, for safety, if a CGM signal is lost for > 20 minutes the system reverts to 3u/hr as max even if their programmed rate is >3u/hr. To avoid this being an issue, suggest having the patient turn Control-IQ OFF during the two hour warm up on a new sensor every 10 days.
  • For basal modulations and automated corrections in Control IQ, the algorithm requires the following.
    • Programmed basal rates
    • Programmed correction factor (ISF)
    • The last 6 days of total daily insulin dose or the inputted total daily dose and weight at the start of using Control IQ. It’s recommended, but not required, to update these values on occasion. These should be updated to current values if resuming pump after having been off it.
    • Current and predicted glucose reading 30 minutes out
    • Glucose target (default, sleep or exercise mode)
    • Insulin on board
  • Bolus information
    • Maximum bolus size is 25u. Over that, patients would need two boluses for a meal.
    • Max extended bolus duration is 2 hours.
    • Control IQ suggests manual meal boluse and manual corrections doses using the same calculations of the pump in manual mode.
    • If the meal bolus was forgotten (e.g. patient recalls 1 hr after eating), consider a 50% meal bolus reduction, give or take, depending on the IOB and the current glucose reading. (The “Quick Status” screen will show if an automatic correction bolus was delivered.)
  • Duration of insulin action is set to 5 hours and cannot be changed in Control IQ
  • These items below can be changed in Control IQ
    • Basal rate and alternate basal profile
    • Carb Ratio
    • Insulin Sensitivity Factor e.g. Correction (may wish to make stronger if people are used to a shorter duration of insulin action e.g. from ISF of 3 to 2.5) 
    • The preset target from default (6.1 mmol/L)  to sleep to activity
  • To prevent getting Minimum Fill Notifications, fill reservoir/cartridge with about 50 units of insulin more than what is needed for tubing fill. Note: a minimum of A minimum of 10.2 units must be filled before you can stop the Fill Tubing step. 
  • Switching from another Automated Insulin Delivery Pump to Control IQ (CIQ)
    • Suggestion: Use 40-45% of Total Daily Dose (TDD) for basal in CIQ
    • For ISF use 90/TDD  (this is more aggressive than standard 100/TDD)
    • For ICR use 450/TDD (this is more aggressive than standard 500/TDD)

 

Adjusting for Hypoglycemia:

  • Address actual episodes of hypoglycemia. Frequent basal suspensions in the reports (red bars) do not necessarily indicate a need for a change unless they are regularly for excessive periods of time. Tandem indicates short suspensions are 5-30 minutes. Long suspensions are more than 30-45 minutes. 
  • Consider addressing hyperglycemia differently:  A more aggressive ISF usually results in less lows than does more aggressive basal rates and/or carb ratios. See "Hyperglycemia" below.
  • Per any AID pump, consider 5-10 g of rapid carbohydrate to treat lows and evaluate, since basal insulin delivery will also have been suspended. 

 

Adjusting for Hyperglycemia:

Assess for patterns of high readings where the automated insulin delivery cannot address the hyperglycemia. Frequent auto basal increases or hourly auto corrections do not necessarily indicate a need for change in therapy. 

Tandem CIQ: IF Time Above Range is TOO HIGH CONSIDER OPTIONS that are safe for the individual:

  1. Strengthen ISF:
    Background: Control IQ varies the automatic basal delivery from zero up to a maximum of about 4X the programmed basal rate. How much it toggles the basal is impacted by the ISF.  A more aggressive ISF (lower number) has the algorithm respond by giving:
    • more aggressive automatic basal delivery
    • and more of an automatic correction bolus, as expected
    • minimizing risk for TBR (whereas increasing CR and/or basal rate alone may result in more TBR) Note: extremely aggressive CF changes could still potentially cause TBR
    • Work with the client to adjust ISF gradually and safely. This may include moving to 90/TDD first, then 85/TDD, then 80/TDD etc. Or it may be include a more aggressive adjustment of 10-20% change to ISF with each visit, depending on the patient.
  2. Make a “no bolus” Personal Profile
    • If not bolusing during work/school hours consider a "no bolus" Personal Profile but switch back to the "usual" profile if bolusing. e.g. "no bolus Personal Profile" for workday and "usual Personal Profile" for after-work dinner and overnight and weekends.
    • Use the same basal rates, carb ratio but strengthen the ISF for this “no-bolus” Personal Profile (see notes above for Strengthen ISF)
    • Provide extensive safety education for clients/caregivers, so they are aware of how and when to use each profile (no bolus days/bolus days) appropriately.
    • Consider having patient program 3 Personal Profiles, switching as needed.
  3. Consider 3 primary Personal Profiles for patients to toggle between as needed.
    This needs to be carefully considered for safety with each individual. This may include:
    • PLUS 10-30% of usual Personal Profile (or if preferred, just one of the profile elements e.g. basal, carb ratio, ISF)
    • Usual profile
    • MINUS 10-30% of usual Personal Profile 
      (or if preferred, just one of the profile elements e.g. basal, carb ratio, ISF)
  4. Resources: 

 

Exercise Options

  • Consider Exercise Activity (mode with higher target) 60-90 minutes prior exercise. How far in advance (and when to stop that higher target) will depend on the individual, the activity, the duration and past experience.  Remember that if starting exercise with a higher glucose reading, this is not a protecting factor; Control IQ will still modulate basal rates and give partial correction doses to address this. 
  • If still experiencing lows with Exercise Activity, consider creating a new Personal Profile with decreased basal rates, less aggressive carb ratios and correction factors. Turn this “Exercise Profile” on prior to starting exercise. This may also be needed for exercise that is longer in duration (e.g.10k run) or extreme or extreme.  As an example only, as this needs to be individualized:
    • half the basal rate e.g. 1.0 u/hr to 0.5 u/hr
    • double the carb in the ratio e.g. ICR of 10 to ICR of 20
    • double the sensitivity of ISF e.g. ISF of 2 to ISF of 4
  • If a user creates an alternate profile for an "extreme" activity and sets basal at 0.1 u/hr, the pump will still modulate insulin up (to an extent) or down from that starting point and still provide partial corrections based on the ISF in the profile. 
  • "Carb loading" may result in higher glucose readings and correction boluses even when Activity Exercise is set. 
  • Longer duration exercise of over an hour may also be managed by eating a small amount of CHO every half hour without bolusing. Caution though, as higher glucose readings will still trigger partial corrections. This emphasizes the importance of setting safe alternate ISF, basal rates and glucose target for exercise.
  • Note: When setting alternate profiles for exercise (or other), new glucose targets are required to be programmed in. As long as Control IQ is on, the targets in these profiles will not be used. 
  • Turn off Exercise Activity and activate the usual personal profile 0 - 60 minutes after completing activity depending on glucose reading.
  • If worried about delayed lows overnight, consider keeping Exercise Activity on overnight.
  • If needing to disconnnect during activity:
    • Disconnect from connection closest to body - NOT from the attachment between cartrige and tubing
    • To prevent pump from beeping while disconnected, turn Controll-IQ off and run a temp basal of 0% for the duration of the activity
    • If possible, keep pump/cell phone nearby to still receive CGM alerts to address.
    • As soon as done activity, reconnect pump, turn off temp basal, resume Control IQ
  • Consider this Tandem webinar - Control-IQ Technology in Clinical Practice: Optimizing Control-IQ Management and T1D Outcomes (tandemdiabetes.com)

 

 Use in Diabetes in Pregnancy 

 

Company Contacts & "Office Hours" for HCP Questions

 

"Drop In Sessions" for Healthcare Professionals ONLY to connect with Tandem Trainers are below: 

 

Third Party Products Supporting Tandem Pumps