lyumjevsummary

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First, the disclaimer: I am not a healthcare professional. This document is created as a personal summary. No medical decisions should be made solely based on this document. Always consult your medical team before making changes to your diabetes treatment plan.

Use this link for an automatic translation by Google Translate. To discuss this document, open a GitHub project issue or reply in one of the Facebook topics in AndroidAPS Users (English), Looped (English), Looped-NL-BE (Dutch).

A warning to not make medical decisions.

Version

Version 0.13, see 8. Version history.

Table of contents

  1. Preface
  2. Expectations
  3. Lowering the mental burden
  4. Equipment
  5. Start using with AndroidAPS
  6. Suggestions
  7. I need help
  8. Overview of (partly) used sources
  9. Version history

0. Preface Navigate to top of this page

This document is part of my blog series. I do not have – and do not want – any sponsorship deals or whatsoever and pay for all equipment just like anybody else.

For quite some time, I have been reading on Lyumjev and looping. Last week we started with using Lyumjev ourselves. On this website I have summarized all suggestions I have read online. Creating it took me quite some time, with several months in preparation by reading and saving links.

What is Lyumjev? This translated quote from this article on diabetestype1.nl describes: “Lyumjev is an ultra-fast-acting insulin (a so-called URLi - Ultra-rapid lispro), which works faster than e.g. Humalog or Novorapid, and even faster than Fiasp. This insulin can better combat glucose peaks after a meal (…)”.

The shorter peak time of 45 minutes with Lyumjev, compared to 75 minutes (Humalog, Novolog, Novorapid) and 55 minutes (FIASP), seems small but is a significant difference in using all available automation in (do-it-yourself) closed loops systems. See chapter 2 for a look into the future and what can already be achieved with do-it-yourself closed loop systems!

I am convinced it is a waste of resources when everybody does the same and asks the same questions on the do-it-yourself Facebook groups. When everybody provides feedback on this summary, (new) users can improve faster with fewer basic questions, and therefore have more time to improve their personal settings.

Information in this presentation is found online, which has been shared by the online do-it-yourself community. See chapter 7 for an overview of all (partly) used sources. I want to give a BIG THANK YOU to all volunteers and medical professionals contributing to this new do-it-yourself treatment of diabetes.

I am Peter, a millennial born in 1984, living in The Netherlands, and I hope someone will find a cure for type 1 diabetes (T1D) fast. Since my girlfriend got the T1D-diagnose, both of our lives have rapidly changed. I became involved as a volunteer on the AndroidAPS project.

I commit my IT Service Delivery Management passion to a more comfortable and healthier diabetes life because of all automation possible since 2013. As a professional, I feel comfortable delivering value, overseeing all components while managing staff and costs.

All the best, Peter #wearenotwaiting #payitforward

1. Expectations Navigate to top of this page

  1. Improved Time In Range (TIR);
  2. Fewer hypers, better avoidance of hypos;
  3. Less manual interventions, therefore lowering the mental burden;
  4. Improved HbA1C;
  5. No carbohydrate entry is necessary, and consequently no boluses (see chapter 2).

2. Lowering the mental burden Navigate to top of this page

The quote below is the introduction of my blog post My first feature request to the open source community: unburdening diabetes care (or GitHub Nightscout issue 6717).

Our assumption for ‘a good quality of life’ is the combination of physical health (body) and psychological health (little as possible manual interventions). Closed loop systems really have improved my girlfriend’s physical health and ensure less worrying (especially at night). We both are very grateful for this. At the same time, I see a physical burden arise. This is because all (sensor) data, options, and alerts are always available. In one of our home discussions with my girlfriend, I asked what is most important to her. She mentioned:

  1. a healthy HbA1c
  2. a good TIR
  3. fewer life interruptions because of diabetes

Her deepest desire is to live a normal – as possible – life without being bothered by diabetes. And stay healthy in the long run!

The blog post suggests ADMI (Average Daily Manual Interactions) as a new psychical metric, which becomes opportune due to the combination of Lyumjev, a good blood glucose sensor, and all automation possible in do-it-yourself closed loop systems.

Bernd Herpichböhm has made profound contributions to the challenge of lowering the mental burden of diabetes. With his research, it seems Bernd has solved the puzzle Dana Lewis wrote in the Artificial Pancreas Book: ‘Choose one - what would you give up if you could?’. It seems, with much testing (basal rate, I/C, ISF, and DIA) and custom triggers, it is possible to get a 5 out of 5:

  • No need to bolus
  • No need to count carbs
  • Medium/high carb meals
  • 80%+ time in range
  • No hypoglycemia

See Facebook links v.5_02 E and v.5.4_12, which point to “This is a update on Looping without bolussing, and without carb inputs.”, to use with AndroidAPS or OpenAPS. Also, see https://www.diabettech.com/oref1/lyumjev-a-fully-closed-loop-case-study-with-oref1/ and https://www.diabettech.com/wp-content/uploads/2020/10/Lyumjev_w.UAM-week_Be_13Oct20.pdf.

3. Equipment Navigate to top of this page

In our setup, we use:

Contact your healthcare provider to finance all equipment.

4. Start using with AndroidAPS Navigate to top of this page

5. Suggestions Navigate to top of this page

5.1 GETTING_USED_TO_LYUMJEV Navigate to top of this page

I have read stories about different feelings when administering insulin (nothing, burning, painful, unbearable). And that it can be different for people. Users report their body adjusts on bolussing with Lyumjev, and reports suggest the habituation period will take somewhere between 1 – 2 months.

The Dutch site Diabeter, see this direct link for an automatic Google Translation, published a background article on why the body reacts differently to Lyumjev than to Humalog.

5.2 PHYSICAL_TEST Navigate to top of this page

Closed loop systems are a true blessing and definitely here to stay. A big thanks to everyone involved!

To make the most of your (do-it-yourself) closed loop systems we all need to have the best possible basic settings (basal rate, I/C, ISF, and DIA). These settings are essential to reduce the number of manual interventions. There is a high risk of poor regulation without the proper settings, and therefore difficult to avoid hypos and hypers. Because when using the wrong basic settings, it can be very annoying or even dangerous. For most of us, this means physical testing and tweaking all basic settings regularly.

Bundled four of my favorite resources to help you determine basic settings:

  1. Your medical team;
  2. Visit Waltzing the Dragon | Taming the dragon together. This website is practical and informational, with tips from the trenches. I don't see this kind of information bundled on other sites. Loads of articles, I want to highlight the following:
  3. Book. Think Like a Pancreas: A Practical Guide to Managing Diabetes (3rd edition) from author Gary Schneider. ISBN paperback: 978-0-7382-4668-0 / ISBN e-book: 978-0-7382-4669-7. This author has publications for many years (just search online), and as T1D also has loads of practical experience. In various Facebook groups, his book is recommended. I bought the e-book myself and sometimes laughed out loud while reading it. A pleasant writing style with a high information density.
  4. Currently, I am working on https://nightscoutsuggestions.com to help with basal testing based on Nightscout data. It is a prototype yet to go live with version 1.

5.3 CANNULA_SPOT Navigate to top of this page

Online, some users report good results switching cannula spots because it causes less pain and perhaps less insulin stacking. I have read spot areas as back, buttock, and belly.

5.4 CANNULA_LENGTH Navigate to top of this page

In several Facebook topics, I saw people try different cannula lengths. They mention that a longer cannula could lead to less pain on bolussing. For example, an original length of 6mm (painful) compared to 10mm (sensitive). Because of this, it may also be an improvement that infusion sets can last longer.

I saw the story on a Dutch Facebook site but do not know if ‘a medical team’ can verify this: “The nerves are located in the dermis, the thickness of the dermis is up to 3mm. If you use a 6 mm cannula, the insulin only needs to travel about 3 mm upwards to reach the nerves and generate a pain stimulus. With a cannula of 10 mm, the distance to be covered is 7 mm. The insulin has therefore spread over a larger surface, so that the concentration that eventually reaches the nerve will be smaller, resulting in less sensitivity.”.

5.5 CANNULA_CHANGE Navigate to top of this page

In some Facebook topics, I saw people suggest changing cannula spots every two days. Frequent changing could help to reduce pain, or a burning feeling, on bolussing.

5.6 BOLUS_SPEED Navigate to top of this page

In Facebook groups, many users of Lyumjev report less pain (and perhaps less insulin stacking) when insulin is administered slowly. Insulin pumps often have an option to adjust the rate of insulin delivery. See this example from the Accu-Chek Insight manual (page 117 & 118):

A printscreen of the Accu-Chek Insight manual pages 117 and 118

5.7 BOLUS_MAXIMIZE Navigate to top of this page

Online, users are reporting that a body probably will adjust in bolussing Lyumjev. Reports suggest it will take somewhere between 1 – 2 months.

When bolussing is painful, you could learn to what extend you can handle a bolus amount. With that knowledge, you can manually maximize it. When a meal exceeds your personal limit, try to administer a bolus manual several times with short intervals.

5.8 BOLUS_PARTLY_UAM Navigate to top of this page

Online, users are reporting that a body probably will adjust in bolussing Lyumjev. Reports suggest it will take somewhere between 1 – 2 months.

When bolussing is painful, you could learn to what extend you can handle a bolus amount. This suggestion is copied from https://www.diabettech.com/faster-insulin/lyumjev-part-4-persistence-is-king/: “I’ve also changed the way that I use the insulin, manually bolussing only small amounts and relying on SMB for everything else. That’s a little different to what I was doing in my first week of use where I was taking larger doses.”.

5.9 BOLUS_FULL_UAM Navigate to top of this page

Online, users are reporting that a body probably will adjust in bolussing Lyumjev. Reports suggest it will take somewhere between 1 – 2 months.

This suggestion is mentioned in chapter 2, ‘Lowering the mental burden’ of this document. Chapter 2 is for advanced users, has a steep learning curve for all do-it-yourself users, and you probably need some severe perseverance. You will need to invest time, but (hopefully) you will gain a life without bolussing because of using SMB and UAM only.

5.10 FULL_RESERVOIR Navigate to top of this page

In our setup, we use 3 ml insulin pens with 1.6 ml reservoirs (see 3. Equipment). We fill reservoirs completely (1.6 ml) to minimize refills and cannula changes. This means we use a new insulin pen, even if it’s just for 0.2 ml (which is 20 units!).

5.11 RESERVOIR_BOX Navigate to top of this page

Self-filled reservoirs are pretty hard to keep in the refrigerator because they fall over quickly. To keep reservoirs up this storage box (approx. EUR 10 + shipping costs) exists. When ordering here on diashop.de, it is possible to ship it to other countries than Germany. Diashop.de is a German website. You can use Google Chrome to automatically translate the website into your language (here’s how).

5.12BASAL_CIRCADIAN Navigate to top of this page

When you encounter the problem of finding the proper (basal rate, I/C, ISF) settings, which is crucial in using BOLUS_FULL_UAM, you could consider discussing the use of a circadian profile. Online I read several users getting good results with these settings. See https://www.facebook.com/groups/AndroidAPSUsers/permalink/2869638923257505. To search the proper I/C and ISF settings for this model, on Facebook two documents are published by Bernd Herpichböhm:

5.13 EAT_MORE_OFTEN Navigate to top of this page

Online, users are reporting that a body probably will adjust in bolussing Lyumjev. Reports suggest it will take somewhere between 1 – 2 months.

When bolussing is painful, there is always the option to reduce boluses by eating more often, and therefore bolus smaller amounts.

5.14 INSULIN_CONCENTRATION_U100_U200 Navigate to top of this page

Lyumjev is supplied as a standard concentration of U100. There is also Lyumjev U200 (link), double concentrated. U200 means a smaller bolus is needed and thus possibly a less painful feeling during the habituation period. Also, insulin accumulation seems less likely. On Facebook, I see positive reactions on U200:

  • “it is far way better for the cannula site than U100.”;
  • “I prefer it to the U100 by far.”;
  • “(…) since using U200 I never felt pain when insulin was injected.”;
  • “Also use U200 and for me it was really better”.

The option to select Lyumjev in AndroidAPS is not available. For this, there was a discussion on GitHub Nightscout – AndroidAPS, issue 527: Lyumjev U200/ML - “Request to make an adjustment in AndroidAPS to use Lyumjev U200/ml safely.”. Also, see Facebook posts like https://www.facebook.com/groups/AndroidAPSUsers/permalink/3001351296752934/ and https://www.facebook.com/groups/loopednl/posts/751246758905091/.

You need to be an advanced user to consider Lyumjev 200. The ‘do-it-yourself community’ did find a way to use Lyumjev U200 with AndroidAPS. In AndroidAPS, you need to make several adjustments for the Lyumjev insulin type:

  • Halve basal (some users mention an ‘extra margin of safety’: basal / 2 * 0.9);
  • Double ISF (some users mention an ‘extra margin of safety’: ISF * 2 * 1.1);
  • Double I/C (some users mention an ‘extra margin of safety’: I/C * 2 * 0.9);
  • Correct AndroidAPS security settings such as max IOB, max bolus, and max basal;
  • U200 is twice as strong as ‘normal Lyumjev U100 insulin’. Be careful with ‘calculating units manually’. Make sure you get used to this way of calculating!

5.15 INSULIN_MIXING Navigate to top of this page

Online, users are reporting that a body probably will adjust in bolussing Lyumjev. Reports suggest it will take somewhere between 1 – 2 months.

When bolussing is painful, some users online report that mixing Humalog with Lyumjev will help normal bolus amounts without too much pain. Steps I have read:

  • 50% Humalog / 50% Lyumjev;
  • 33% Humalog / 67% Lyumjev;
  • 0% Humalog / 100% Lyumjev.

5.16 RESERVOIR_REUSE Navigate to top of this page

In the Netherlands, health insurance pays for the equipment almost in full (see chapter 3). Despite that, on a private Facebook chat, I spoke with a do-it-yourself community member. He/she mentioned reusing YpsoPump Reservoirs once to lower equipment costs.

5.17 SWITCH_FIASP Navigate to top of this page

Sorry to hear, despite all suggestions from the online community, Lyumjev is too uncomfortable for you. You could consider discussing the use of Fiasp with your medical team, which is slower compared to Lyumjev but faster than NovoRapid.

6. I need help Navigate to top of this page

As mentioned in the prefix, I am not a healthcare professional. This document is created as a personal summary. No medical decisions should be made solely based on this document. Always consult your medical team before making changes to your diabetes treatment plan.

Online, several Facebook groups – and websites – provide do-it-yourself suggestions, background stories, and information. For this, see Facebook groups like AndroidAPS Users, TheLoopedGroup and LoopedNl.

7. Overview of (partly) used sources Navigate to top of this page

8. Version history Navigate to top of this page

  • v0.13: added suggestion RESERVOIR_BOX, suggestions increased by 1 as from 5.12 BASAL_CIRCADIAN (was 5.11), added ‘reservoir box’ in 3. Equipment.
  • v0.12: added suggestion FULL_RESERVOIR, suggestions increased by 1 as from 5.12 BASAL_CIRCADIAN (was 5.11), renamed ‘insulin pen’ to ‘Lyumjev KwikPen U100 3ml’ in 3. Equipment.
  • v0.11: update preface.
  • v0.10: minor change.
  • v0.9: minor change.
  • v0.8: changed naming of ‘Ypsomed ampuls’ to ‘mylife YpsoPump Reservoir’, added link to video on filling reservoir.
  • v0.7: minor updates; text formatting.
  • v0.6: added options to provide feedback.
  • v0.5: text review using Grammarly.
  • v0.4: updated preface with a description of Lyumjev.
  • v0.3: added links for automatic Google Translation (2x).
  • v0.2: processed feedback (6x).
  • v0.1: initial commit, copied from my Facebook topic.