Alicia: UnLeashed!
Alicia: UnLeashed!My Personal Review of Tandem Diabetes’ Control IQ (CIQ) hybrid closed loop system
2 weeks on Control IQ – too soon to call? Our newest Hybrid Closed Loop showing a lot of promise… if you know how to work it.
About 3 weeks ago we got news of the FDA approval of Tandem Diabetes’ Control IQ (CIQ) hybrid closed loop system. As the practice’s resident X2 pump user I was more than happy to take a break from looping to give the system a try. It’s been about two weeks and I’ve learned a lot and can honestly say I really like this system. I wanted to share my findings thus far.
This is my personal review, other members of our team will give it a trial and we will compare notes and experiences and come out with more “official” reviews and recommendations. However, with so many people so eagerly awaiting this system, I thought I’d share what I can now.
I will start by saying don’t buy ALL the hype!
Every time we get a new system we are always told that: it is going to make things better, you won’t have to think about your diabetes anymore, the system does all the work of adjusting insulin!
I can tell you right now this system is not an artificial pancreas (which Tandem never claimed it to be) and it is not a simple fix for all diabetes management problems. In fact, my first few days on Control IQ were a complete nightmare! (I didn’t end up in the hospital , but I had a multi -day headache from sustained high blood sugars that I couldn’t beat down using the system) This is a CHANGE in how we manage our diabetes, so it is to be expected that just tapping the system on and trying to manage your diabetes as usual is not going to work.
Automated insulin delivery is often sold as if we are going from driving a stick and grinding gears, to driving an automatic with heated seats and extra cup holders. In fact, it’s like going form driving a horse and buggy, to driving a stick. It is a lot less work, but the work is definitely still there, Once you get good at it, stop stalling and grinding gears ,you can get where you want to be with a lot less… cleanup.
How does this Hybrid Closed Loop system work anyway?
In the simplest terms, Control IQ works by targeting a blood sugar of 110, when predicted (30 minute prediction based on previous 20 minutes of movement) blood sugar is above 160 basal is increased, when predicted BG is above 180 it auto-boluses . When predicted BG is below 112.5 CIQ reduces basal delivery, when predicted BG is below 70 it stops basal.
Here is a link to Tandem’s information on the system. Tandem has webinars rolling out to educate on the system ahead of its general release later this month.
https://www.tandemdiabetes.com/products/t-slim-x2-insulin-pump/control-iq
My personal experience with Control IQ and the biggest differences I’ve experienced.
No more stopped extended bolusing
Since CIQ is easing back on basal as blood sugars drop and is much more conservative about stopping delivery entirely, we no longer get the headache of setting an extended bolus for dinner and going to bed at 110 only to wake up three hours later at 240 because the system stopped the last third of our bolus!
We can extend bolus with CIQ (Something the Medtronic 670G can not do) and as blood sugars come down basal is reduced rather than the bolus cutting off. I have seen blood sugars come down to 95 and park there for the night!
Really effective handling of mild metabolic changes
CIQ is quite good at dealing with hectic changes in activity level and metabolics as long as they are not too big. I am a mom of a toddler, so jumping up and running around for 40 minutes, or sitting bogged down in paperwork for hours, are all a part of a single afternoon in my life! From what I’ve experienced CIQ handles these quite well, with small ripples in blood sugar movement.
I typically run a temp basal or two every day for these kinds of changes in my activity, health, stress etc. But, I have not run a single temp basal for the last 6 days! In fact, there were probably some times I would have missed that CIQ caught and made much easier.
Big metabolic changes are too big for CIQ, but there are workarounds
My first 5 days on CIQ were ROUGH!! I had some hormone swings and a sinus infection that really beat up my blood sugars. Even after I got the system’s other setting needs dialed in, CIQ alone was not enough to keep my blood sugars from jumping up , particularly after high fat meals which would require an additional basal increase beyond illness. At first I turned off control IQ and handled it manually like I usually would, but then I started experimenting. I found that building a second profile with my basals set higher allowed CIQ to then increase delivery from that starting point and handle sick days really effectively. Better yet, when I started feeling a bit better and BGs came down, I did not slam low like a yard dart! CIQ eased back on basal deliver enough to let me sit nicely and safely for hours (Even on a night that got busy with patient needs and I skipped dinner) This would not have been the case if I were just running my own sick day temp basal increases!
I have not had much change in my exercise management. The exercise targets in CIQ still need to be set an hour or two in advance of exercise and have only been enough of a reduction in insulin to get me through low to moderate activity which is no different form running a temp basal for the same situations. I still have to adjust my bolus in advance of moderate or higher physical activity to avoid a drop. I can see this being helpful to reduce lows during unanticipated play time for kids when pediatric approval comes through. The reality of aerobic exercise is that we have to reduce the insulin we have active in our bodies, and those decisions have to be made hours in advance, or be considerable in size. No HCL on the market can do that on its own, since our insulin lasts for hours in our bodies.
Longer DIA & more IOB = big changes in bolus effect
The biggest hurdle I met with CIQ was the difference in Duration of Insulin action(DIA). This is one of the few hard wired settings in CIQ. It uses a DIA of 5 hours. (We could debate the validity of this for longer than the DIA of Tresiba so we’ll skip that) My typical DIA is set for 3 hours 15 minutes. This means that a correction bolus 3.5 hours after a meal would be HUGELY reduced! This was very problematic and compounded by being sick! I was actually wondering if my insulin had somehow denatured!
This was then also compounded by the fact that CIQ counts my manual bolus, and its autobolusing toward IOB calculations. And if the math of these IOB calculations predicts that blood sugar will return to target it will not increase basal. So here I was with a blood sugar of 240, a pump telling me that due to IOB I would go low, and no basal increase, FOR HOURS! I also found that over night when I should have zero IOB control IQ just was not ramping up basal enough to get my blood sugars below about a 140. This is not damaging, but I’ used to waking up at 100, so it was disappointing. That’s when I realized that in order for Control IQ to appropriately treat my elevated blood sugar I was going to have to reduce my correction factors. I ended up having to decrease those factors pretty significantly during the daytime and evening hours, and a bit less aggressively over night. After that things dialed in very nicely. The added insulin from the changed ratio was able to balance out the decreased insulin from the longer DIA and inflated IOB calculations. **HOWEVER** I still kept a profile with manual settings so that if I am running for any extended period in manual mode and basing my corrections off my shorter DIA, I wont send myself plummeting.** For anyone counting that means that I am using 3 profiles to operate CIQ effectively: my manual settings tested and proven(Alicia) , my CIQ settings with more aggressive correction ratios (Alicia IQ) and a set with control IQ correction factors but higher basal settings for sick days, hormone shifts etc (Alicia HIGH IQ… No pun intended, and actually, probably not accurate anyway)
Sleep schedule can get in the way, time it well
Another great feature is the sleep schedule. While we are sleeping targets tighten in and drop to buy us some valuable A1C lowering time over night. But the down side is that it stops auto-bolusing . Blood sugars will come down over the entire night. But a high BG would not get the “hammer” of a bolus applied. The “Sleep” feature can be turned on /off, or scheduled. The first few nights I set the time to start when my head hit the pillow .(Again, I’m a toddler mom so this is usually as early as possible!) What I found was that there was not quite enough time for CIQ to “Fix” my blood sugar before I went to bed. If I ate dinner at 7 and went to bed at 930 and was riding a little high the system struggled increasing basal all night only to get my to a 130 in 8 hours. Again adjusting correction ratios helped some. But, I found that making sure to schedule my sleep time to not start until dinner had plenty of time to get back down to target was more effective. I pushed my sleep program start time back a couple of hours and voila! I was back to target in a few hours and then watched blood sugars snuggle in nice and low for the rest of the night.
Extended bolusing past 3 hours is my biggest challenge
We are able to extend boluses in Control IQ which is a huge step up from Medtronic’s 670G HCL, but extensions are limited to a 2 hour duration. This was my biggest hurdle and I am still working on this piece. Anyone who uses a bolus extension beyond 2 hours in length (particularly those who have gastroparesis, night time digestive slowing, chronic constipation, eat a low glycemic index diet , eat large meals etc) is going to have to “relearn” how to handle these boluses. I have found that manually splitting my bolus to take about 70% of my bolus ahead of the meal, increasing the front end of the extended bolus and only extending for 1 hour, then manually bolsuing the remainder of the carbs over a 2 hour period has worked in place of my previous 50/50 over 3 hours bolus. But I am having to do a bit of work on analysis of my foods and retool my approach. This is a small step back since I’ve had years of knowing my “Go to” bolus splits and timing for lots of foods. But, the reality is that every single HCL available (including Loop) has required me to adjust my thinking and approach to how I bolus. This is a change in thinking that is going to be necessary with any of these systems and likely in how diabetes will be managed in the future, so may as well reconcile myself to that now and grow rather than get rigid and break later.
Only one new alert!
CIQ alerts if an autobolus has been administered and BG remains above 200. This is the only alert I’ve gotten from the system (I’ve not been “kicked out” or demanded of in any way!) And since I get a dexcom alert for highs over 200 it was no added burden.
Disconnecting
Tandem users often just disconnect without stopping insulin delivery since the X2 has a loud alert after 20 minutes that could scare the wits out of the entire swim team! However, on Control IQ this would really mess up IOB. If disconnecting for 20 minutes or less just stop insulin. If you are disconnecting for more than 20 minutes you’ll want to turn off Control IQ and disconnect as usual to prevent messing up your IOB. (remember if you’re disconnecting for an extended period you’ll want to reconnect hourly to replace basal)
Tight control is possible
To see what the system would do I got my blood sugar to 80 and carried about my day. Control IQ not only let me get my blood sugar to 80, it allowed me to ride between 80-95 all day! This is the first FDA approved HCL that is even capable of an A1C of a 6! That was exciting!
With these adjustments, I’m now sitting on day 5 without a single high or low alert. I’ve worked out, I’ve eaten big meals, I’ve skipped meals and I’ve dealt with some wildcards life threw my way. I have not run a single temp basal, stuck my finger, or had sleep disturbed by diabetes. This is not the simple diabetes “fix” some would make it out to be, but it is miles ahead of the past and with the right education and support can really be amazing. However, with settings that are not dialed in, unknowing providers and incomplete support users will likely be in for a bumpy ride if not a disappointing mess.
Random perks
- Bluetooth connectivity- We now the option to pair my pump to a mobile device via bluetooth to transmit data to the T-connect app, but since that app has not released yet we don’t know what it will actually do or whether we will be able to sync this data to other sites.
- One less beep- We now have the option to turn off that dreaded tube fill beep that is loud enough to wake the neighbors! However, the charge beep remains (Come on Tandem at least let us set it to vibrate!!)
The real question comes down to
“OK Alicia which is better? Loop or Control IQ?”
Honestly, that is going to depend entirely on the individual.
Looping allows for more individualized control and more aggressive targets; no tubing with omnipod Loop and more sophisticated handling of bolusing and metabolic changes.
Tandem X2 with Control IQ allows for good control with all the support of an FDA approved device; with nothing extra to carry and there is less troubleshooting when something goes wrong.
For me the question is now “Which is better?” but “Do we have a viable alternative in Hybrid Closed Loop therapy?” From what I’ve seen, my answer would be yes. I don’t want one company to win over another, I want us to have more options to meet our differing lifestyle and management needs. I am thrilled to report that it looks like we finally have another new option.
I had minimed pumps for the last 20 years and just switched to Tandem. I love it except that I go for long waks- over an hour-and end up eating to get through them because I ALWAYS end up low. Any work arounds for this?
If you have control IQ you’ll want to turn your activity feature on an hour ahead of the walk to prevent the drop. You can also use “profile hopping” and finally oyu cna turn control IQ off, or if oyu don’t have it you can run a 30% basal reduction starting 1 hour ahead of the walk.
I recommend checking out my Control IQ optimization articles and videos for more tips on life with control IQ
Hello, Alicia,
I loved your answers. I need one for my own situation.
I have terrible lows, even with my X2’s Sleep Mode turned on. All I want is some way to prevent lows (and the alarms that accompany them). There must be some way to fine-tune SLEEP to get this result. For three days now, I’ve run SLEEP from 9PM to 9AM. Some nights are perfect, some are miserable, due to lows. On miserable nights, my lows awaken me, and my anxiety keeps me up. My answer so far has been fig newtons and 6 ounces of mango nectar, which is bad for my teeth and my weight.
I’m a 77-year-old man with anxiety. Otherwise, I love this pump and CIQ.
Any thoughts?
Sincerely,
Hi Patrick,
you may be dealing with insulin pocketing due to scar tissue or reduced circulation or even under hydration. this often cause big drops in blood sugars hours later.
I would recommend reaching out to our office for a consultation as your correction factors or underlying basal rates may not be appropriate. In a clinical setting we can evaluate these settings and recommend adjustments.
finally another possibility is activity. if you have been more active that day you will be more prone to delayed onset hypoglycemia. You can work around this by actually NOT using the sleep setting, in fact you can run the exercise activity setting over night to be more conservative and avoid lows.
What is the total daily dose of insulin you can put in the Control IQ is there anyway to unlock this to take more than 99 units?
You can enter up to 100 units. however the system only uses that number for the first 6 days. after that it will base this off the actually average total daily dose delivered. entering an artificially high number will not make the system much more robust for this reason.
Thanks for taking the time for writing this I am now considering an IQ for the next step in therapy. I have greatly changed my management techniques in the past 2 years to keep control of 80-140 using a Medtronic revel with animas disposables left over after returning my vibe. Due to capacity I can only basal for 30 hrs while bolus with syringe. My secret is sticking close to 30 carbs daily but augmenting that on more physical days. Retired and on Medicare and must wait till august 1 when my warranty runs out on the vibe to get an IQ. I do have gastroparesis which does push glucose higher. Have been experimenting with a longer lasting insulin which seems to help me. I keep A1C from 6.5-7.0 for about 11/2 years now which greatly improved my complications. Pumping for about 36 years. Use a Decom 5. Lost about 22 lbs since cutting carbs down. Please send a link to any of these type discussions or podcasts, etc
Another useful way to prevent the annoying beeping once you stop all insulin deliveries is to:
1.) turn Control IQ off
2.) set a temp rate for 0% and put in a reasonable time for however long you plan on being disconnected from the pump. I tend to set it for a little longer than I would guess to be sure I don’t waste insulin
3.) disconnect and think about how smart you are. It will vibrate for the entirety of the temp rate to remind you that you’re temp rate is not delivering a basal, but I ignore it and continue my activities. Us Diabetics can usually tolerate a little vibration annoyance
4.) once you want to resume insulin, cancel the temp rate and turn Control IQ back on. I discovered this through experimentation when I first got my X2 and annoyed my family with beeps. He’s currently waiting for the update to get Control IQ, but he says basal IQ is better than the Medtronic system. Just thought I’d say the perspective of a person with limited medical knowledge about everything.
I also want to say that my dad has the same experience as you, Alicia. His first CGM and pump was a Dexcom 5g and a very old Medtronic pump that I don’t even know the model name of. When I was Diagnosed in August of 2019, I decided to go with Tandem and Dexcom. I was told the pump wasn’t as good with Tandem, but I heard horror stories about the Medtronic CGM. My dad needed an upgrade and went full Medtronic. He didn’t have a full night of sleep the entire time he had Medtronic. He finally switched to Tandem and Dexcom and has opinions about both. He hates that changing supplies for the pump is not as easy, but loves the ease of the CGM and pump bolusing.
Great tip Eric, I’ve used that on the beach and pool side to conserve insulin.
Alicia, just found this article on FUDiabetes. Thank you.
When you do a temp basal, are you going back to your Alicia profile, no CQ? I don’t see how to do temp while running CQ.
I’m pretty new to CQ.
my pleasure,
typically if I’m going to run on temp basals for a big need like sick days i turn off CIQ and use my manual profile to run the temp basal
however you can also set up multiple profiles with altered basal levels to achieve the effect of a temp rate adjustment while still having control IQ running. You can get more info on this video I made on the topic. I call it “profile hopping”
https://www.youtube.com/watch?v=a6O5G2oAvaU
I have been dealing with MAJOR highs since going on CIQ. 300+ every. single. day. I already created a 2nd profile and up’d every one of my basal rates. This only helped maintain. Once I eat, it’s a complete trainwreck. It has been truly awful. So much so, that I went and bought needles to take bolus’ from now on. I’m NOT a fan of CIQ as of yet. I appreciate your article and I just lowered my Correction factors. Fingers crossed. I currently HATE the CIQ because I cannot get the highs under control. I’m about a day or two away from turning it off completely. I’ve been T1D for 30 years and I produce zero insulin so as a heads up, I’m the one outside the bell curve (most T1Ds still produce some insulin). Thanks again for this article.
Hi Holly, i work with a lot of Tandem users to help them get CIQ use and settings dialed in. You can make an appointment if you’d like further assistance.
Holly- did you ever get the sugars sorted out? I’m with you being “outside the curve” and terrified to try this.
Can you tell us how you were able to get your blood sugar to 80 and keep it in the 80 to 95 range all day? I didn’t think the system would allow that. Thank You.
With careful prebolusing to control spikes the system did not push my blood sugar back up, I had to dial in my correction ratios to get the right balance.
the system would not push my down to an 85.
But it also did not actively push blood sugars back up to the 110 target.
Hi Alicia:
Can you elaborate on what you mean by “… dial in my correction ratios…”? I’ve been a diabetic for 50+ years and prefer to keep my sugars between 80 and 100 — I find 120 is too high and my body just doesn’t feel good. I just installed Control IQ, but could use some advice on how to get tighter control.
Thank you!
Hi pam, we would need an appointment setup for more specific guidance as I would need a great deal more data than the comments section provides. Feel free to reach out to our office to set up your appointment.
Came across this while googling…I have had CIQ (and this pump) for only about a month. I’m a tight controller, preferring to stay between 80-110 all day. My first month on the pump and my a1c shot up to 6.5 from 6.0. I was not a happy camper, and I’m trying to figure out how to stop that. Even without spiking much after meals…for example I had breakfast today, and stayed pretty steady, went from 130 to 150 hovered and then started falling. Not straight down, but sideways down. The pump SHUT OFF MY BASAL at 138. I would have landed smoothly right where I wanted to. I got so frustrated I shut off CIQ and now just have alarms to turn it on overnight because it works miracles dealing with overnight rises from dawn phenomenon. I’d love to know how to avoid that, or if my workaround is all I have.
HI Ashleigh
part of this is design, the system is not really designed for really tight control in order to achieve that we have to bob and weave
the second reason is that the system is PREDICTING a bg below 80. so rather than getting BGs to come down hard and fast (Which leads to a bounce back up and sustained high) we cant to bring them down more stealth-fully so the system doesn’t over react
short term loss for long term gains
I have a second control IQ optimization article that I wrote on this topic and keep an eye out for a video we will be sharing sometime next week on how to optimize the system for tight control.
I’m really excited after dealing with insurance to approve my pump, since late November with letters/appeals, I was finally approved to get my Control IQ pump this coming week! I’m looking forward to the education process, which I hear is tedious. I’m looking forward to getting the highs and lows- which are crazy bad- but having DM I want to be able to manage it to the best of my ability- and since having a pump its so much better controlled over the past 16 years. I’m hopeful that this will help me, even though I am well versed with the education I have received by my RD and my provider who also is a Type 1 and has had the opportunity to trial so many of the pump/CGM systems- which makes this system that much more impressive to me. I’m looking forward to getting to learn about my new side kick- attachment that will be apart of me and my Type 1 DM (35-36yrs next month!).
Great write up. Could you comment on Control IQ sleep mode suspend function and how that might compare to BASIL IQ suspend function. I like the predictive suspend on low function? I would think that the Control IQ sleep mode function would provide a better low BG suspend performance then BASIL IQ. Do you think Control IQ sleep mode operation would be better upgrade option then the older BASIL IQ system?
I find that Control IQ is more graceful and less problematic.
Basal IQ shut off all delivery, which meant that if I went to bed with a long extended bolus running, it would often cut off the end of my bolus predicting a low, leaving my blood sugar to rise quite high without the rest of the bolus. Control IQ does not do this, the bolus continues and basal is simply reduced a bit.
Likewise if preventing a low Basal IQ would stop all insulin delivery, which often lead to it stopping the drop too soon and blood sugar rebounding a bit. I find that with Control IQ i rarely get a complete suspension of delivery, and more often get a reduction in delivery of basal so when blood sugars rise it is slower and smaller and basal can resume without the spike. I consider these both upgrades.
I put Control IQ on my pump yesterday (Feb 15, 2020) and then I glanced at your article and thought your were nuts! Now I read it again
and love what you are saying. You have left some very important information that I will be able to use and I thank you for what you have put out to us. I have had diabetes longer that your grandfather checking out the girls in his high school year look for whom he would marry.
Thanks Michael, always glad to be of service.
And I just got the greatest memory of my grandfather :) thanks so much!
This is so interesting to hear about, and I appreciate the time you took to write it up! I read this with an equal mix of pleasure and dread, I have to admit. I’ve been diabetic for a long time, and this idea of a loop is a long time coming. At the same time, I have with age also decided that I am not willing to deal with the intrusiveness and lack of control that some companies seem intent on baking into their products. I won’t use a Deacon anymore because the alerts are too random and unrelated to reality (and really, if I’m hiding the thing under a pillow at the far end of the house so that I can get some sleep each night, then what’s the point of using it?) I love my Libre. Problem solved. I love my old, dinged yo Animas Vibe because it vibrates one time and that’s all. So my dread comes from the fact that all new tech seems to disregard what actual users actually want. A system that we can use to make our life better. No alarms if we don’t want them. No poorly designed interface. No unnecessarily bulky, obvious, or expensive things to carry around (I’m looking at you again, Deacon). Just a simple piece of tech that will make my life better. Why can’t that be the goal?
Good feedback on the Tandam x2 pump and CIQ. I was planning to go for it in February and now thinking more about this change. Still would like to try. Appreciate all that you’ve shared.
One great thing is that if you try it and don’t like it, you can just turn it off. no new tech to buy. you can even call tandem and restore the previous software version if you want just Basal IQ back
Well, actually according to Tandem, once you add Control IQ, you cannot currently go back to Basal IQ, Hopefully this is a temporary situation.
HI Karen,
thanks for the correction, I had spoken with Tandem engineers who had told me it would be possible, but in press releases they have said otherwise. When I followed up it appears it would be possible to be reissued a software upload on an individual basis, but that there is no “backup” or “restore point” such as one might have for a phone or computer. If a User were having adverse events with Control IQ Tandem could also replace it with a Bsaal IQ capable pump.