I’ve lived with type 1 diabetes since 1997, and I have been managing my diabetes with insulin injections (multiple daily injections – MDI) since day one. I briefly tried an insulin pump, and it was not for me, so I’m back to being happy and thriving doing MDI.
In this post, I’ll walk you through my journey and why I choose to use insulin pens over an insulin pump.
My goal with this article is not to sway you either way, but to tell you my experience and to give you the rundown of the pros and the cons of insulin pumps and insulin pens respectively.
With the right knowledge, we can make informed choices, and it will be up to you to choose what seems right for you. There’s no one-size-fits-all with anything when it comes to diabetes.
Table of Contents
My device journey
When I was diagnosed with type 1 diabetes in 1997, I was handed a blood glucose meter and a prescription for prefilled insulin pens. Prefilled means that the insulin was already in the pens, all I had to do was screw on the needle and draw up the number of units I wanted to dose. When empty, I just tossed the pens in the trash.
As with anyone on MDI, I was prescribed short-acting insulin to cover food (bolus) and long-acting insulin to act as background insulin (basal).
I don’t remember exactly what type of insulin I was prescribed but it required me to eat certain times — it was probably NPH insulin. This basal insulin had a little ball in the mixture (like some bottles of nail polish do), and I had to gently move the ball through the liquid to mix it before use. Not exactly optimal, but it worked.
As newer insulins came to the market, I switched to using Levemir as my basal insulin and Humalog as my rapid-acting insulin, covering food and corrections for highs.
The only thing that has changed for me since is switching from a prefilled Humalog pen to a durable pen, and then from a normal durable pen to a durable Smartpen. A durable pen simply means that the pen is reused and only the insulin cartridge is tossed when empty.
The upside of a durable pen is that it can give ½ units of insulin (the prefilled used to only be able to do 1-unit increments). The upside of a Smartpen (I use an InPen) is that it helps keep track of my active insulin on board (IOB), supports me in calculating my doses, reminds me when I need to take my basal insulin, and automatically records (through Bluetooth to my phone) all the injections I take.
I’ve also added a continuous glucose monitor (CGM) to my diabetes toolbox, and that has been a real game changer.
When I tried rocking a pump and why it didn’t work for me
In December 2017, 20 years into my life with diabetes, I decided to try an insulin pump. I wanted the best care, so I decided to try Looping. Looping is a DIY (Do It Yourself) version of the artificial pancreas technology.
A normal insulin pump will automatically (based on what it’s programmed to do) deliver small amounts of rapid-acting insulin, such as Novolog, Humalog, or Apidra, 24/7. Some use the newer insulin, Fiasp (another fast-acting insulin) in their pump, however, Fiasp is not FDA-approved for use in insulin pumps in the United States.
You still have to prompt the pump to give you a bolus for food or correction, but the background insulin is programmed and automatic.
With Looping (the DIY system) and the newest Medtronic 670G system, the pump takes it one step further by adjusting your basal insulin doses based on your CGM readings.
If the system thinks your blood sugars will go too low, it will suspend administering insulin until it determines that your blood sugar is at a safe and stable level. If it thinks your blood sugar is rising, it will give you more insulin.
This is brilliant, and I’m such a huge fan of the technology, but there is a problem. And that problem, and ultimately why an insulin pump didn’t work for me, is that the pumps are pumping rapid-acting insulin 24/7.
The drawbacks of rapid-acting insulin
Rapid-acting insulins such as Novolog, Humalog or Apidra take 15 to 20 minutes to reach the bloodstream once injected. It doesn’t peak until 1 to 3 hours after it is injected, and it will stay in the body for 3 to 5 hours total.
The new kid on the block, Fiasp, hits the bloodstream and peaks a few minutes faster, but similar to the other rapid-acting insulins, it stays active in the body for 4 to 5 hours.
The risk of DKA
So, if you’re on a pump, you’ll need rapid-acting insulin to be circulating at all times to prevent Diabetic ketoacidosis (DKA) from happening (assuming you have no insulin production whatsoever). Should the pump malfunction and stop delivering insulin, you’re at a heightened risk of going into DKA and ending up in the hospital.
If you take your insulin via MDI, which means you always have background insulin on board, the risk of DKA is much lower (this, of course, assumes you don’t forget to take your daily background insulin dose.)
Low blood sugars & exercise
Since rapid-acting insulin lasts 3 to 5 hours, those using an insulin pump need to be very proactive in planning exercise or any movement at all. When exercising, going for a walk, or doing everyday tasks like vacuuming, you’re at risk of experiencing low blood sugar if you have too much rapid-acting insulin onboard. Since an insulin pump delivers rapid-acting insulin all the time, you most likely will have too much insulin in your system for any type of spontaneous movement the majority of the time.
Whether or not we use an insulin pump or MDI, we all need to adjust our rapid-acting insulin if we want to exercise or move around without going low. However, on MDI I only have to worry about any bolus injections I’ve taken in the last 4 hours since my basal insulin hardly gets impacted by activity.
When using an insulin pump, I also had to worry about the insulin I’d received as basal for the last 4 hours. Of course, that can be done. But for me, all that basal adjusting was just much more of a hassle compared to using MDI to manage my insulin.
Pumps have benefits but not enough for me
As mentioned, I was Looping so the pump would adjust my insulin when it estimated that I was about to have a low or high blood sugar. And it did, just not effectively enough.
Since rapid-acting insulin lasts for 4 to 5 hours in the body, there was no way the Loop system could keep up with my activity level. Yes, it got smarter, but my days are rarely the same and I’m a very active individual. I was dropping low way too frequently unless I disconnected and micromanaged the entire program.
For many, the system is life-changing. If we had access to insulin that worked faster and had a shorter duration, I’d probably be using an insulin pump.
The upside of basal (long-acting) insulin
Basal insulin doesn’t get impacted by activity in the same way as rapid-acting insulin. That means that I only have to think about adjusting my mealtime and correction boluses if I intend to exercise or just be active. That means that if I decide to exercise right out of bed, there is no adjusting insulin. I just go. Same deal with afternoon exercise, as long as it’s more than 4 hours after the last bolus.
Some guidelines say to reduce long-acting basal insulin on days when exercise is planned, and I sometimes do that. But all I adjust is my nighttime basal. My endo suggested splitting my basal into a morning and an evening dose, and it has worked wonders for me.
I keep my daytime dose the same (except for days where I’ll be sitting all day, like during a long flight, then I’ll increase it) and adjust my nighttime basal depending on my activity level. That means that I don’t have to plan ahead when it comes to my dose. I adjust it after the day is over.
Pros and cons
When it comes to choosing whether to manage your insulin with injections or an insulin pump, the choice is very personal — and the choice is yours! Both methods have their pros and cons.
Pros of using an insulin pump
- Ability to set a variety of basal rates to match your personal needs, with the option to set small dosing increments
- Some integrated systems can adjust insulin based on CGM readings
- Pumps keep track of IOB, help calculate doses, and have detailed reporting available
Cons of using an insulin pump
- Being disconnected for more than 4 hours or pump failures can quickly lead to DKA
- The modern insulins last too long in the body for the modern pump systems to really make sense
- Having to be attached to a device 24/7
Pros of multiple daily injections
- Long-acting basal insulin hardly needs adjustment for activity
- Not having another device attached to you
- Less risk of DKA due to basal insulin and no device failure
Cons of multiple daily injections
- ½ unit is the smallest unit increment you can dose
- Basal can only be adjusted 1 to 2 times daily (depending on whether you split your dose) and the impact of that adjustment isn’t immediate
- Regular pens (not Smartpens) do not have a bolus calculator or track IOB
What’s right for you: injections or a pump?
So maybe you love your insulin pump or your insulin pens, or maybe you’re ready for a switch. Maybe you’re wondering if the grass is greener on the other side and switching to a different insulin delivery method would improve your diabetes management and make life easier.
In my opinion, you can achieve healthy blood sugar levels with both methods. What determines your success is how that method of insulin delivery fits with your lifestyle, your personality, and your willingness to deal with the cons of either method.
For some, the risk of DKA with a pump doesn’t outweigh the stress of having to take at least 4 to 6 insulin injections every day.
When I asked the Diabetes Strong community on Instagram if they used an insulin pump or MDI, the responses came back 50/50, which seems to indicate that my theory of there not being a “one-size-fits-all” is true.
I hope this post helped give you a more nuanced picture of the “Pump versus MDI” discussion. And if nothing else, you got to know me a little better.
Kimball Wiggins
Can I just ask please, how do you get as an adult, type 1 diabetes. Thanks!
Christel Oerum
Type 1 diabetes is an autoimmune disease that can hit anyone at any age. About 50% of those diagnosed are above the age of 21 years. Basically, no one knows why some people develop the disease but it’s most likely genetic
Alison Millington Carmichael
Great read and very timely for me as I’m currently trying to decide whether or not to try a pump. My Endo team are strongly suggesting it, however for the reasons you mentioned I’ve been postponing it. I too prefer having the long lasting on board. I am very active with various activities and struggle with not being able to participate at the spur of the moment. I’ve been living with Type 1 Diabetes for only 2 1/2 years. I’ve been assisting in the management of my sons T1D for 8 years, he’s 19 (diagnosed at 11) He had a pump for two years (participating in a study.) He is now back on the pens. Progress with research and technology is happening so fast for managing Type 1 Diabetes, which is truly fantastic. I feel it is only a matter of time before there’s a true breakthrough. In the meantime it is great to have so many options available and the freedom to chose as we wish.
Christel Oerum
Thank you for that thoughtful note. I completely agree that technology development is fantastic, but it’s also ok to not want to utilize it
Fredric P Goldberg
I enjoyed reading reading your article! I also was diagnosed with type 1 in 1969, I was 13 y/o at the time. I started off with NPH insulin. I feel much better off now that I am on Lantus in a Tandem Pump, because it is also my Dexcom G6 receiver. I only need to take one small device with me (all the time except when I am in the shower), and it manages my insulin, and warns me of problems if my blood sugar is too low, and it AUTOMATICALLY takes action (suspendending insulin). If you are using a DEXCOM sensor, that I seriously can not see why you don’t use this. Yes you have to be attached to a pump 24×7 (except when in the water, eg bath or shower). But I have a nice pouch which I bought for my pump with a belt that goes around my waist. It’s not really a problem being nude with my pump (I also have a CGM transmitter on me all the time which is about 1″ x 2″ x 1/4 inch thick), I swing the pump around my waist to someplace where it doesn’t get in the way. So to put it in other words your list of:
“Cons of using an insulin pump”
1. Being disconnected for more than 4 hours or pump failures can quickly lead to DKA
Don’t go on a swim for such a long period!
2. The modern insulins last too long in the body for the modern pump systems to really make sense.
Not really. Ask any Tandem pump user.
3. Having to be attached to a device 24/7
THIS IS THE MAIN DRAWBACK! It is 2.25″x3.33″x .75″ and will be attached to you all the time. This is what you need to get used to. But if you use a DEXCOM Sensor, that is already attached to you, this is what you need!
Holly Peterson
Great article, I learn something new every time I read of other’s experiences. Thank you!
I am a long time pumper. I coordinate my exercise (downhill skiing) with temporary basal rates. I recently took a vacation from the pump because I planned extensive time in the water. I was not a satisfied with my control mostly because small corrections were difficult to make with injections. I look forward to the upcoming technology advances with both pumps and MDI.
Christel Oerum
Me too! Imagine when the insulins available act more like insulin should. A shorter duration would make a world of difference
Christina Ponce
I enjoyed reading reading your article as well! I also was diagnosed with type 1 in 1997, I was 13 y/o at the time. I started off with NPH and R insulin. I also tried the pump when I was expecting with one of my pregnancies but I didn’t stay on it long term because I preferred pens after my pregnancy. I’m back on NPH and R insulin because I’m in nursing school and do not have insurance. To be quite honest, I’m doing great (just have to wait a little to eat). By the way I also love lifting, I believe it helps tremendously with my blood sugars. The most units I use at meal times is 2 units. Thank you for sharing your experiences!
Christel Oerum
Thank you.
Great that you make those options work for you (although the no insurance always make me sad). I just met another woman yesterday who’s also very happy on NPH. I guess it’s all about knowing your body and the insulin you inject and everything is possible
Lois
Thank you very much for your story , I am Lois , I have type 1 for 32 years now , tried the pump ,hated it . I didn’t like having it attached to me all the time , so stopped it.My endow said I was his only failure and I said sorry but I have to feel right.
I am on Levimir twice daily plus short acting , at least three times with corrections. I am doing fine , still have hypos but Endo says it,s the best I can do.
I don,t have much damage ,just starting a bit of neuophathy in my foot but other wise okay , I feel I have been lucky.
Christel Oerum
I’m glad you’re doing well. I’m “only” 21 years into my diagnosis and lucky to have no complications at this point. As I mention, if we’re willing to inject when needed and with the available tools I believe we can achieve excellent diabetes management with MDI
Shauna
Hey christen, god I love you young things!
I have been a terrible diabetic for 30 years now, and with the advent of social media and pumps, insulin pens etc have slowly taken more notice of my diabetes.
But it wasn’t till I found you on insta that I reallllllly started to take notice!
I just don’t think I will ever catch on to the basal and short acting blah blah, but this article on the “Inpen” has really made me sit up and take notice.
It sounds soooo perfect for me, and the app ? whoa!
Can’t wait to find it all and give it a go.
I started way back when on disposable needles but was probably only injecting maybe once or twice a day cause I simply hated doing it, in complete denial I was!
Then along came the “Insujet” a fantastically painful delivery system but alas, it simply couldn’t deliver below 10 units of insulin and my whole problem with my diabetes and insulin delivery is that I just don’t eat enough to keep up that looping system you talk about.
I, more recently trialled a small pump called the V-Go (for type 2 diabetics), I LOOOVED it but it delivered way too much short acting insulin over 24 hours for me and I wound up having a couple of ugly hypo’s!
And i can’t afford a proper real pump as I’m not on any form of heath benefit (and here in Aus you can’t afford one without medical cover), so the Inpen that you mentioned will be my go to if I can get it.
Not even sure it’s available here in Australia but will find out, so once again thank you for the eye opener, it’s been an amazing journey with you and your writings xx
Christel Oerum
Hi – so glad you found Diabetes Strong. Thank you for that kind note.
Unfortunately, the InPen is only available in the US at this time. Bummer. However, the app I mention (RapidCalc) although not FDA approved, is available globally. You might benefit from using that in combination with a durable insulin pen
Karen
I was on an insulin pump for 5 years, and over time I realized it wasn’t for me. Your post resonates as all the reasons I switched back to MDI. My endocrinologist has never understood it! Thank you for the validation, I’m not the only one. I love all your posts!
Christel Oerum
Thank you.
I’m sorry to hear your endo isn’t understanding / supportive. You’re welcome to share the article with him/her 🙂
Richard Vaughn
Christel, this presentation on MDI vs pumping is excellent! You are a very talented writer, and you explain everything so well! With your ebook and your articles, you show your talent as a teacher. I was a college teacher for many years, but I taught math. My talent with math has helped me a lot with my diabetes management. lol
I used MDI for 62 years, starting in 1945 when I was 6. I have pumped for 12 years, starting in 2007. I prefer pumping because I started at age 62, and I had a rather stable and consistent day-to-day schedule. I also like the variable basal rates, the option to use temporary basal rates, and the option to suspend all deliveries.
I really like the Diabetes Strong support group. In my opinion, it is one of the best on Facebook.
Do you ever attend the Friends For Life Type 1 conference in Orlando? My wife and I will attend this year, in July. It would be nice to meet you.
Christel Oerum
Thank you so much for the kind words and support! You’re a great example of how different technologies can work for us in different stages of our life.
Unfortunately, I don’t think I’ll be in Orlando for Friends For Life this year. I’d love to go, but live in California, so it’s quite a trip. Would love to meet you too, and hopefully, we’ll find a time and place.
Thank you for all you do
John Haitch
Excellent Article. I am a Looping pumper but what you say is very fair and balanced. Exercise is very hard to manage on a pump and I have tried many different approaches.
Christel Oerum
Thank you. Yeah, I know a lot of people who love Looping, which is why I really wanted it to work for me as well. And who knows, I might give it another go someday