Untethered Regimen
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The untethered regimen is a technique combining the use of an insulin pump with a slow-acting insulin such as Lantus or Levemir. This allows an insulin dependant person to disconnect the pump when desired while maintaining the flexable benefits that the insulin pump can provide.
This technique is becoming more popular with insulin pumpers who are taking control of their diabetes. This is a philosophy promoted by Dr. Steve Edelman, a type 1 diabetic and insulin pump user as well as an endocrinologist, who wants to see a diabetes regimen be tailored to the needs of each person so that good compliance to diabetes care as well as a happy lifestyle can be achieved simultaneously.
Dr. Edelman himself developed a desire to remove his insulin pump for long periods for swimming and sports, up to a full weekend. He developed his technique known asThe Un-tethered Regimen for the benefit of being free from the tether of being connected to the pump all the time.
Since then, several techniques have evolved by different insulin pump users which combine Lantus with an insulin pump.
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[edit] Removing the pump
For various reasons, the pump may need to be removed. Some of these reasons include sports, water activities and for a personalised control of the treatment.
[edit] Sports and Exercise
Depending on the intensity and duration of the sport, insulin pump users typically use a temporary basal rate to reduce the amount of insulin delivered to match their reduced need of insulin as a result of exercise. The reduction, perhaps 25% or 33%, is determined by each person in conjunction with sound diabetes principles learned from a certified diabetes educator and by trial and error (with blood glucose monitoring).
In some cases, the insulin pumper may desire to continue to wear the pump during sports to retain the untimate flexability to increase and decrease insulin delivery as needed. This is when the basal rate of the pump is adjusted to a reduced level.
In other cases, the pump user may prefer to take the pump off all together: this is when a combination of a slow-acting insulin and the pump basal rate work well together. The pump can be removed during a preplanned activity (anything from football practice to water skiing to dancing in a prom dress), and then the pump users continues without the pump with the reduced basal insulin coming completely from the Lantus or Levemir. After the activity is complete, the pump goes back on.
[edit] Water Sports
While some of the new insulin pumps are waterproof (at least when they are new), the high cost of the pump often leads to the removal of the pump when planning to get wet.
The pumps can always be disconnected for short periods for bathing with little issue. However for parties in the hot tub or for a day at the beach, removing the pump and going "untethered" can be a welcome vacation.
Different water sports place different demands on the situation. Sailing might be thought of as long dry periods of sitting down -- interrupted by unpredictable wet periods of embarassment. Swimming laps in a pool for an hour every morning is a great aerobic activity. Yet a toddler in an outdoor pool partially filled with water may get the most intense workout of any. Each situation demands that the pump user learns how to use the basal rate from the pump for a portion of the basal insulin needs combined with Lantus for the remaining portion so that the pump can be removed and that blood glucose control is maintained.
In order to enjoy their favorite water sports on a regular basis, each pump user will work with their diabetes care team to develop a plan that works best for them.
[edit] Several Days
Dr. Edelman first developed his Un-tethered Regimen because he wanted to remove his pump for the weekend. He prefers to use his insulin pump on workdays to benefit from its flexability, in which case he doses Lantus for 3/4 of his total basal insulin needs and uses the pump to deliver the remaining 1/4. This way, the pump basal rate can still be temporarily adjusted up and down as needed. Then on Friday night when he usually gives his daily Lantus injection, he will dose for 100% of his basal needs with Lantus and then take the pump off for the rest of the weekend. He then uses an insulin pen as needed for his food and correction boluses. Alternatively, the insulin pump could be connected back to the quick disconnect site on the infusion set when needed. Then on Sunday night at Lantus time, Dr. Edelman doses for 3/4 of his basal needs with Lantus and then reconnects the pump.
Sometimes, an insulin pump will require repair. Pump manufactures offer the best possible service on 24 hour call on a "as soon as possible" basis. Yet there are times when an insulin dependant person has no choice to remove the pump for a few days. It is good to be familiar with this technique.
[edit] Ketoacedosis
All insulin dependant persons will become very ill with diabetic ketoacidosis when denied insulin for a sustained period. The period of time varies with each person and their situation. An insulin pump problem at night (such as running out of insulin, or an unexpected dead battery, or leaky infusion set tubing) which goes undetected can lead to ketoacedosis before morning. Slow-acting insulin such as Lantus or Levemir can be used for a large portion of the basal insulin needs, and the pump basal rate program can be used to fill in the remaining basal need. Lantus injected once daily is a nice insurance policy for all pump users, but this can be a real benefit for some insulin pumpers who tend to develop ketoacedosis quickly.
