Lemonade Life

Wednesday, May 02, 2007

The TOTO Technique

Christine and I devised this nickname for my own little "untethered" regime after deciding that I wasn't technically on Steve Edelman's Untethered Regime. On his regime, you take 75% of your basal as Lantus and wear the pump all the time. But I take 100% of my basal as Lantus and I don't wear the pump except for when I eat. So we decided it deserved it's own name: Tether On, Tether Off.

I haven't written much about it since I switched three weeks ago. At first, I had really good results. Then I had really lousy results. Now, I'm havning mixed results. My blood sugar average is actually better than it was before, but that's just because I'm swinging a lot more. I'm like the diabetic Tarzan.

The pattern was pretty clear and it was exactly what I expected. Lows first thing in the morning (on the pump, my lowest basal was between 3am-6am), a fairly stable afternoon once my bolus ratio was turned up a couple notches to make up for the lack of an increased basal rate, then a normal afternoon and dinner and then high at bedtime. It was pretty much like that everyday for awhile.

I kept lowering my Lantus hoping to kill the morning low, but so far, I've either woken up low or overkilled somewhere else and woken up high.

I decided a couple days ago to try splitting the dose to see if I could fake a basal rate change. 11 units of Lantus at 10 pm (I almost wrote bedtime, but what 21-year-old goes to bed at 10pm?) and 14 units of Lantus at 10 am. Today went surprisingly well in the afternoon, but I'm still high because I underbolused for dinner. Oh well. Can't prevent everything.

I actually think I might scrape the two shots a day theory in favor of doing Lantus in the morning. I think the reason why I am high at right at 10 pm (I do my post-dinner test when I take Lantus) is because the Lantus isn't lasting a complete 24-hours and I'm starting to creep up. Does that sound right, O Wise Lantus Users? Maybe if I switched to the morning, when I need less insulin, it would match things better.

At any rate, the TOTO Technique is definitely still in the adjustment period. Lantus amounts have changed, followed by bolus ratios changes. Hopefully something will finally kick in and work. However, I would like to say that I absolutely adore not having to sleep with my pump on. I had no idea how much I hated it until I stopped doing it. Not that it was the end of the world or anything.

Oh, and I bought my first pocketless skirt in New York. I still haven't found a dress that isn't completely unflattering with my pudgy stomach, but I'm quite happy being able to dress without thinking about the pump.

But boy am I happy I don't have to do bolus calculations. There are somethings that you just can't get from anywhere but an insulin pump


At May 03, 2007 2:55 AM , Blogger Heidi said...

Hi Allison

I can imagine the struggle of going from pump to injections :-) I've spend the past year struggling the other way around, switching from injections to pumping, but before that I was on Lantus for 3.5 years.

Initially, I too would take the shot at 10 pm, but due to fasting BG-issues, I tried out a few other combinations in collaboration with my D-nurse. First, we changed the timing of the shot to first thing in the morning. However, this resulted in fasting sugars just as bad as they had been with NPH (i.e. 14-20 mmol/l (252-360)), so that didn't last long.

Splitting the dose was up, but didn't really seem to do the trick either, so my D-nurse suggested trying to stay with a single shot and move it back to the evening, just a few hours earlier. After a while we settled with taking the Lantus shot at 6 PM, which is just around when I usually eat my dinner, so it was very convenient, and it worked great for me.

From my experience, I too am quite sure that the effect of Lantus does not last a full 24 h - at least not with the same effect, it may have a small tail, but for me it didn't seem to have the same effect after passing the 20 h mark or so. This also would explain why having the shot in the morning was no good for me (dawn phenomenon combined with a receding effect of Lantus = morning highs for sure!). Comparing my current basal rates with this theory about Lantus also fits very well with the fact that what worked best for me with Lantus was to take the shot at 6 pm. With the pump my basal is very low in the late afternoon (0.15 u/h, compared to 0.4-0.85 the rest of the day and night), and this match the assumed receding effect of Lantus around the 20 h mark very well.

Anyway, I guess that what I wanted to say here was just that I recognise the struggle, and that maybe changing the time of the single Lantus shot will be just as good and maybe more convenient than having to split the dose. According to my D-nurse, there is really no good or scientific reason, just plain tradition, to stick with giving basal insulin injections only at bedtime and/or in the morning. Lantus, and Levemir for that matter, can be given at any time of the day, as long as one then stick with that time (+/- an hour or so) from day to day.

Good luck in getting a hold of the TOTO technique, and all the best for your exciting future plans!

At May 03, 2007 4:15 AM , Blogger jill. said...


First, this 21ish year old goes to bed at 10pm (but that's also why I'm commenting so early) ;)

About the Lantus woes. I've fiddled a lot with my timing of Lantus (mostly due to either massive morning lows or trying to schedule my workout)

For me, my Lantus activity sort of declines slowly in the last 5 hours of the supposed 24 hour flat line. If you're going to split the dose to prevent a morning low, for example, I would take a small amount at night (say 5 or 6 U) and the majority of your dose in the morning (that way you'll have a slightly higher "basal" during the day and afternoon and your lowest Lantus activity will be in the early morning.)

That being said, I stopped splitting my dose and I now take all 21U before my bedtime at 9pm. I time my workout during the lowest part of Lantus activity after dinner (a temp-basal, if you will). I've had to tweak some insulin:carb ratios throughout the day, but over all it seems to work well.

Also, you could always take the lowest dose of Lantus you need at night in order to sleep sans-pump and then reconnect if you need a little basal during the day.. but you would have to get the thigh-thing for your skirts and dresses :)

Good luck! (Sorry for writing a novel) It this a permanent change or temporary pump vacation?

At May 03, 2007 4:18 AM , Blogger kath said...

Why are you going off the pump? I really don't understand, but then again, the only insulin I've been on other than the pump was 25/75 -- which I like to call dog insulin, since I'm convinced it would only work if you ate two meals a day.

Very curious.

At May 03, 2007 6:37 AM , Blogger Scott said...

The issue is that Lantus and Levemir are both very long-acting (around 24 hours, maybe slightly less) when many people do not require flatlined basals for 24 hours. The only mid-range (6-10 hours) insulin remaining is NPH, which has a peak, although it works great for some of us. The issue seems to be that long-acting analogs are positioned and really designed for type 2 patients, not type 1 patients.

One solution might be to consider changing the time you dose ... try doing it in the morning, as its likely to stop working while you are sleeping and thus reduce your basal insulin delivery at that time. The notion that it has do be given at night before bed is just dumb, it can be given whenever you are able to take it!

At May 03, 2007 10:36 AM , Blogger Allison said...

I know I've only received 4 comments, but I feel like my concerns have been addressed really well! Thanks!!!

Kath, I know it seems strange to go "backwards" in terms of insulin therapy, but I have been on the insulin pump for almost seven years, and I wanted a little bit of a break from having to incorporate it into every wardrobe item, getting tangled in it, and having to worry about reconnecting it for swimming and such during the summer. I definitely LOVE being on the pump and I full intend to return to it, though I haven't picked a definite end point for my TOTO Technique Trial.

I think I'm going to switch to a morning shot today, which means I will have to wear the pump for the rest of the day in order to get rid of the Lantus I took last night... Okay, I can hear my insulin pump beeping... now where did I put it?

At May 04, 2007 7:59 AM , Blogger Scott K. Johnson said...

Just dropping by to say that I really don't have anything useful to add. Typical of me.


At May 04, 2007 11:24 AM , Blogger Bernard said...

I'm curious. I assume that you wear an inserted set all the time and then just connect the pump to bolus for meals - is that it?

Or do you simply use the pump as an insulin on board calculator and use shots for meals also?

At May 04, 2007 11:27 AM , Blogger Allison said...


Yes, I wear a set all the time and simply connect when I eat, hence the "tether on, tether off" title. I keep my basal at .2u/hr so that the tubing doesn't get air in it, so sometimes I will wear it for longer periods just because .2u doesn't really do significant damage to blood sugars. I am tethered for meals and if I need to do any special insulin changes like a square wave bolus or temp basal, but for the most part, I don't wear it.

Like right now.


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