Infusing Damage?

photo (20)One great thing about my job is that I occasionally get to hear some of the best in the biz (and by “biz” I mean diabetes…) talk about some very high level science, advancements, and treatment regimens. I’m always curious to hear what doctors who have been doing this for decades have to say about living well with diabetes. A few weeks ago, a tenured physician in the northwest said that he’s recently had to take several patients OFF their insulin pumps due to a build-up of scar tissue. We are now finally at a time in the world of diabetes where some people have spent double decades in a row on pumps – and others also on a CGM at the same time.

As anyone who wears an infusion set knows, cannulas don’t feel like cute little kittens gently licking your skin when they go in. No, it’s a bit more intrusive than that, as the hole it makes has to be large enough to get insulin’s big-ass molecule into your bloodstream. And most of us have a favorite spot for our pump sites – you know the one that’s a little hard to reach, because it’s out of the way and not somewhere you’ll yank it out? That spot that’s started to look like the skin of an orange left out in the sun, all pock-marked and leathery? Yeah that spot. It’s tired. And the tissue under it is tired too. And if you’ve been rotating through limited sites with your pump and your CGM for a few years, you probably know what I’m talking about.

The doctor giving the talk has now encountered folks whose tissue was beat-up enough from repeated infusion sets that he had to force them to take a break from their pumps and go back to injections for a time – how long of a break he prescribed I am unsure. Perhaps indefinitely. And he said this is a very real problem in his practice, and one that he’s seeing much more often as folks with diabetes are now progressing from diagnosis to tenure on devices without a break.

This was news to me. The concept totally makes sense, but I had not considered this in my long-term thoughts about diabetes. I’m usually concerned with what the best/coolest/most accurate/up-to-date technology is, and of course also thinking about how I can best minimize my glycemic excursions. For me, that answer involves technology, and I’d be heartbroken to give it up right now, and also a lot worse off in the control department. That said, I want to be able to preserve the tissue underneath my devices so that I’m not forced to take a break at a tougher time or worse – damage my tissue in a way that would prevent my use of closed-loop system one day or another solution.

So, questions for the crowd are: 1.) What’s been your experience with this and 2.) do you know of any ways to prevent this – is rotating pump sites enough? Would love to know how others are dealing with this!

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I remember when I was first diagnosed and on one injection of Regular/NPH mix per day, I was told to rotate sites — I had eight choices: the two arms, two sides of the stomach, two butt-cheeks, and two legs. Nowadays, with the number of needles penetrating the skin (whether MDI or pump/CGM) I realize how laughable that was, and how I’ve discarded that rotation-theory a thousand times over in later years.

Wow, that is also news to me! I’ve been pumping for 12 years or so, and I do try to rotate my sites, but within a fairly small number of areas. As with so many other things diabetes-related, whether you develop problems with this probably varies from one person to the next. But I may try to expand my horizons and start placing my pump in other areas. Thanks for the tip!

With bad enough care you can manage to mimic the same problems with injections.

Let me give a random example. Pretend that you are looking at a male of the 30 to 40 age group with 37.8 years of diabetes (oddly specific? doesn’t matter!). Back in the day, the injections were administered to arms, legs, bottom. Only for the last 25.8 years or so was the stomach area even considered injection-real-estate (partly because 2 year olds have no stomach fat to speak of, I suppose).

Now if one were to inject always at work into the left side of the stomach, just above the trousers, so as to avoid pulling the shirt out very far – that area will be pierced a lot. And it will scar. And produce more fat than neccessary. And lumps. And stretch marks (although the last might be a result of beer and food rather then injections).

And that is without the pump.

So yes. Now, in retrospect: Rotation is the way to go. Sufficiently large spacing between positions to give them weeks to heal before they are attacked again. Weeks, not days, certainly not hours.

However: Needles are getting smaller still, and the ginormous pipelines-of-doom currently attached to teflon-pump-kits are not neccessarily the end of the technology curve. There is certainly reason to hope for less damaging technology, which would also be aided by even faster acting insulin. That won’t stop the scarring, but mean less insulin stored in the tissue for later.

Which makes me wonder wether the return to pens is not going to do the frying-pan to fire maneuver. As those basal deposits are going to create new problems…

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