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.
Kevin Clark
Just a thought on pumps. I use a Dexcom G6. It attaches to the body with no tubes and Stays on when you shower, swim, etc. this reduces the chance of not receiving insulin. You can also stop the basal dosing completely when you dcercise
Emily
I appreciate this post! I’ve had T1D for 4 months and have been dying to get on a pump and away from MDIs. This post gave me some perspective on the pros and cons of each of them. It’s a great conversation starter for my next endocrinologist visit!
Christel Oerum
Good, I’m glad. And a pump might be exactly what you need. I hope you have a good endo appointment and if a pump is right for you, that you get one soon.
Gina Brink
I’ve been a T1D for 26 years now. I have always felt I’ve been getting the shaft from all the endos I’ve seen. (Upstate NY). It has just been confirmed to me that I have! I am sooo under educated in diabetes! I started reading Dr. Bernstein’s no ok a couple months ago, and diabetes is a complicated disease. I recently moved to Florida and have an appointment coming up with a new Endo. I am better informed, thanks to reading your articles, and Dr Bernstein’s book. I’m going in with this new Dr with trails a blazing! I’ve literally been uncontrolled since the beginning of my diagnosis. And I’m starting to experience the classic complications like peripheral neuropathy in my eyes, neuropathy in my feet, orthostatic hypotension, neuropathy in my hands, etc. and I’m only 43 years old. I keep being told I’m too young to have these issues. And I TOTALLY agree. So where’s my help? I just want to say thank you for your education in your articles!
Christel Oerum
Self-advocating, especially when it comes to your diabetes management is so important. Glad that we can be a part of that and that you feel more empowered going into your next appointment.
Andrea
Thank you for this post! I have been T1D for over 30 years, I have been complaining about the potency of humulog to my endo for 20 years. My sensitivity is 7 mml/unit and is getting higher with age (?). sounds great but is a nightmare. Any little change in any part of my day can send me soaring from one end to the other. Because of this I rarely exercise, it causes 2-3 days of sporadic very low lows. So then I can’t really do anything. I have been wondering if changing to a really long acting insulin would help, and then use fiasp or humulog for meals and corrections. I used to have lots of nighttime lows but that was with the older long acting insulins. I have an appt with my endo this month and will definitely discuss it with her. Thank you for all of the information that you post!
Christel Oerum
I think having that conversation is a really good idea. And I’m glad to hear that you’ve noticed that sporadic activities will impact your blood sugar greatly. That’s the first step to making meaningful informed changes
Jim Cheairs
Thanks for the informative article. T1D since 1995. Though currently looping, was MDI for 19 years and was very comfortable with it – fairly good outcomes. You provided me with a new way to look at long acting insulins for basal control. Makes sense. May go back to MDIs someday. One benefit that I really liked though Endo’s frown upon this is being able to inject IM for times when I needed a faster on board response to stop a spike.
Lucy
Hi Christel—I am a 42-year veteran of T1 diabetes. My insulin jouney began with taking a combo of long-acting insulin with regular insulin twice a day—long before MDI.
I’ve been on a pump for 20 years now, and have had pretty good control, but what really made a difference in my A1c levels were when CGMs came around. As a result, I’m in much tighter control, but there are drawbacks. Like a loss of spontaneous activity.
The thing I’ve always disliked about the rapid insulins has been issues with spontaneous activity and plummeting glucose levels. I’ve learned how to plan my workouts with insulin timing, etc., but I feel so constrained at having to plan EVERY BIT of activity so my glucose doesn’t drop too much. It seems to me that if I decide I need to clean the house I shouldn’t have to plan for it an hour in advance by cutting my basal rate and having some carbs.
Your post about MDI really made me stop and wonder if a combo of taking a long-acting insulin for my basals while using my pump (I use an Omnipod) for precise meal and correction boluses might be worth a try. Some might argue that a pump’s better for basals because you can vary the insulin amount per hour, and that is true, but for me, my basal rate is pretty flat anyway.
I do wonder if the rapid insulin supplying my basals (Humalog) is a little less steady than what a basal injection of a slow insulin could provide. Hmmm…time for a talk with my endo.
Any further advice you can give is most welcome!
Thank you for all you do.
Christel Oerum
That is a really interesting idea. I don’t see why a combination couldn’t work. You could even do one of the 12-24 hour basals in the morning (Levemir/Lantus) and still keep a small basal from the pump at night if you need to.
I hear you loud and clear on the frustration of having to plan out everything from going for a walk to cleaning. So if this solution could make your life better without making messing with your blood sugars, why not?
Camille
Do not use Omnipod and lantus together it will give you crazy low bg
Christel Oerum
If you work with your doctor and ensure that you don’t have too much IOB going I think it can be done. But should be done in a safe manner and in collaboration with a medical professional
Larry O’Baker
You wouldn’t need to worry about DKA with a pump and CGM. You set your CGM Alarms to whatever you want so you would know if there is a problem and you are going to high. Am I missing something?
Christel Oerum
You can go into DKA even with “normal” blood sugars (called euglycemic diabetic ketoacidosis) which is why it’s usually not recommended to suspend your pump for more than 60 minutes. As for CGM, I love mine, but they can fail as well
Shaun
How the heck am I just learning of InPen NOW!? Wow… I am going to contact my doc asap. Ive been waiting forever for something like that. For me, just having 1/2 dose increments + the data tracking that comes along with it will be a game changer… I am curious how the cost of the cartridges differs from standard insulin pens though. Obviously this will be dependent on your insurance coverage, but I hope they are considered one in the same…
Tony Sangster
Interesting read. For me after 45 years on insulin the multiple injections needed (novorapid and levemir) had reached up to 8 plus per day with night hypos still a feature. The insulin pump helps=ed to stop the night hypos and stabilise BSLs over all. With me exercise initially causes an increase in BSL and about 4 to 6 hours later a BSL drop. There are biochemical explanations for this (adrenaline surge causing release of liver glycogen in the first, and replenishment of muscle glycogen stores in the second). So management of BSLs on mdi was problematic. With the insulin pump I can manipulate settings much much easier to achieve a good bsl result from exercise plus if there is a change in the routine (e.g. rain stops being able to exercise) the situation gat be readily changed with a pump.
Also there was no easy way I was able to overcome the effect of the Dawn phenomenon on my bsls without a pump, without risking hypos or sleep deprivation from getting up at 3 to 4 am and injecting some short-acting insulin. However since starting on the low carb regime as advocated in Dr Bernstein’s Diabetes Solution and including a keto component I can now achieve the next BSLs and HBA1Cs ever in my 52 years on insulin plus I tend not to have raised BSLs with exercise and fall in BSL is less prominent and more easily dealt with. I only use cgm occasionally to check levels and because of the lower insulin doses required I have few hypos and only mild ones if that. I am tempted to try mdi again but it is not easy with what happened in the past which led me to go to the pump. But I do wonder whether I would have needed the pump back then if I had known about Dr Bernstein and about keto diets. I am not saying that Dr B’s regime and keto diet are for everyone. There are adjustments in salt and magnesium intakes and need to ensure vitamin and mineral intake is satisfactory. The higher protein and fat intake gives some health professionals the willies but there is not proof that saturated fat or cholesterol causes heart disease. There is flawed science and statistics which suggest so but no causation has ever been found.
Christel Oerum
It is hard to say. Some (I’ve tried this as well) only use the pump for nighttime basal and do MDI during the day. You won’t know if you don’t experiment, however, I know that can be somewhat nerve-racking.
IMT1D
What a great perspective on the pros and cons of each delivery mechanism and the different types of insulins used. Everyone is different in their reactions to each. And, I’m glad we have advanced technology so that you can choose what works best for your diabetes.
I’ve been T1D for over 30 years, without any heart, eye, or nerve complications yet.
When diagnosed, I started on NPH for long-acting and it was always a complete disaster overnight after exercising. I’d go super low and then, high after treating. I hated the rollercoaster. I tried Lantus and same thing would happen, but I’d really convulse when it started working, albeit unpredictably.
I was completely ready to give up on taking insulin and just call myself terminal when my endo learned of something called a MiniMed 506 pump in 1994. It was my life saver and changer.
The machine still works, but I have upgraded to a newer model : – )
I have multiple basal rates overnight and it is keeps my blood sugar steady all night long between 90 and 100. I have no worries at all! For my diabetes, a tenth of a unit really matters.
Thanks for sharing.
Christel Oerum
Thank you for sharing your story. The multiple basal rates is definitely an upside for pumps
Kevin Clark
Hi. Thanks for this informative article. I have been type 1 for 58 years. I have used multiple injections, various pumps and cgms. I now use an Omnipod pump that has no tubes and you leave it on 24 hours per day and never take it off. Makes the delivery of insulin very constant. Changing my basal rates seems to let me keep my blood sugars in control during exercise. I use 3 different basal rates during sleep and have very few hypoglycemic reactions at night.