I read everything on this web site and when I read about The Un-tethered Regimen for pumpers, I thought it was a great idea. I believe that trying the un-tethered approach to pumping would benefit my 12 year old daughter. She has to disconnect for volleyball and for swimming and this is very difficult to manage. In addition, I think it would help smooth out the high blood sugars caused by bad infusion sites and other temporary pump problems. My daughter also wants to try it. Our endocrinologist, who practices at a renowned hospital for children in Indianapolis, has never heard of it. The pump specialist on the team also had not heard of it until I mentioned it. Both do not understand the concept and will not go along with us trying it. My daughter’s last A1c was 6.8 so they do not see the need to mess that up. Maybe they are right about that, but I think we could have fewer times where the blood sugar goes over 300 mg/dl [16.7 mmol/L] by trying this approach. We also had a scary near-DKA episode last summer following a day of swimming that I do not want a repeat. Are there any published articles about this regimen that I could refer to them in order to raise their awareness?

In addition, in case of a pump failure where it is necessary to temporarily go to shots, the endocrinologist has us using Humulin N. I think Lantus would be a better choice. What is the most common recommendation for this situation?

The “un-tethered approach” is one endocrinologist’s suggestion for long periods of time when pumps cannot be worn, i.e., at the beach. It is not intended for compensation, to my knowledge, for problems when catheters come out, clog or pumps fail and would not be expected to work under such circumstances because there may be too long periods of time without basal insulin delivery even with alterative Lantus “basal” coverage. So, I would suggest that you go back and discuss this with your diabetes team so that you can talk about the pros and cons of this approach since they know your child’s needs.

When pumps fail and one must revert to insulin injections, there are no hard and fast rules. We usually suggest using fast-acting analogs (Humalog or NovoLog) every three to four hours based upon blood glucose results and adding about 15 to 20% more than usual doses to compensate for the “missing” basal insulin. This allows resumption of the pump rather quickly when replacements arrive within 24 to 48 hours, usually. We usually do not recommend either NPH or Lantus under such circumstances since it would take 3 to 5 days to figure out the proper injected basal insulin doses needed and then another 3 to 5 days to go back on the pump doses and “wash out” the injected doses. However, there are probably many different approaches and, most consistently, one should recommend using the approach of the team who knows your child the best. So, again, go back and ask them for their advice and have a discussing of alternatives with them.

SB