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Originally published July 2020, updated July 2023
"Untethered."
The word provokes images of freedom...and for many, that is exactly what they get when they go untethered. You may or may not be familiar with the term "untethered" and how it applies to a person with diabetes.
This article will aim to explain the term and give a few reasons as to why this method of management might be utilized.
When a person with diabetes decides to "go untethered," it means that they no longer wish to be attached to their insulin pump 24/7, but they also don’t want to go to injections full-time. The Untethered approach is a very controlled and deliberate combination of both insulin pumping and injections.
*It is extremely dangerous for a person with type 1 diabetes to remove their insulin pump for extended periods of time without having a secondary basal option such as injected long-acting insulin.
Generally, if one wishes to disconnect their pump for more than 10 minutes, it requires vigilant blood sugar monitoring and correction boluses to maintain safe blood glucose levels. This can be a headache and one of the downsides of pump use.
This method adds injected long-acting insulin INSTEAD of a pump basal rate.
This method can also help if you have frequent pump cannula issues or occlusions.
Many pumpers absolutely love their pump and can't think of a single reason why they would feel the need to spend hours with it disconnected. But there are many others who have found instances where disconnecting from their insulin pump has been very convenient.
Disconnecting the pump is MUCH less stressful If you utilize the untethered approach.
One example is with swimming/water activities. Many people swim or take part in frequent water activities in the summer. While pumps such as Tandem pump are water "resistant," there have been many times when kids jump in the pool with it still on. The tslim is only guaranteed to resist water up to 3 feet for up to 30 minutes. It is definitely not approved to wear while swimming.
Swimming can quickly become a dreaded activity. Each time, a person pumping will need to:
Remember to disconnect the pump before getting in the water
Remember to reconnect the pump immediately after getting out of the water
Frequently get out of the water to and clip the pump in to deliver correction boluses since you’re not receiving any basal insulin while disconnected from the pump
It’s exhausting.
One parent described her experience with her daughter’s insulin pump during an annual week-long beach vacation. Every summer, it's an entire week of:
"Wait! Your pump is still on!"
"Did you remember to clip back in?"
"Come back! I have to unclip you!"
All. Day. Long.
It can really put a damper on things when your child can't spontaneously run out to splash in the waves a little or do that giant cannonball into the pool.
Water activities are not the only concern for people that wear insulin pumps.
Certain sports/athletic activities are also not well-suited to wearing an insulin pump. One example is with competitive gymnastics, where an insulin pump can cause significant problems with certain events, namely the bar. There is not a good place to wear her pump while competing.
Unfortunately, excitement and adrenaline during gymnastics meets often causes a rise in blood sugar, which means disconnecting from the pump is extremely difficult. Using the untethered approach, a person can disconnect from her pump without worrying that the missing basal will compound the effects of the adrenaline rise.
how do you make the transition?
What does it look like to go from being 100% dependent on an insulin pump to being slightly freer?
One family who does this said, “We researched, talked to our pediatrician with all the information, and then we just jumped in.”
An important consideration is what type of basal (long-acting) insulin you will use if you decide to go untethered. Lantus (Basaglar) is the most common long-acting insulin, with 2 injections per day for 24-hour coverage, where each dose can be adjusted separately for optimal coverage. Tresiba is another common choice, but it can be more difficult during the transition periods, more about that below.
Talk to your doctor about these injected basal insulin options, starting dose, and how to transition to each.
*If you do not receive specific transition information from your doctor, particularly with Tresiba, you can learn more here. Do your research and look into several varied sources to determine the correct way to transition onto that specific insulin. This is just one resource.
In our experience, Tresiba is very log-acting, so it’s suggested that when transitioning, one starts with a dose that is 80% of the basal they are currently taking. As a rule of thumb, you can look at the total basal insulin used over 24 hours in the pump, then calculate 80% of that as your starting Tresiba dose. For added safety, round your initial dose down to start.
Example: If your 24-hour pump basal total (this is NOT total insulin used in 24 hours, you want to count ONLY basal rates) is 15 units/day, then 80% of that is 12 units, and you could round down to 10 units for safety when transitioning to injected basal.
Tresiba in particular, will continue to build up to full-strength in your system over three days, so do not increase this dose for the first 3-5 days. After five days, if you determine that you need more or less Tresiba, adjust your daily dose by a very small amount (usually 1 unit up or down) and wait another 3-5 days to see the full impact on your blood sugar levels.
Different types of basal insulin have different potencies and different durations, so it's very important to do your research before attempting a transition from pump basal.
Ashley says a person with type 1 herself, and mother of a T1 daughter says,
”I'll be honest; I was NERVOUS about this move to injected basal insulin plus bolusing through the pump. I talked about it and talked about it for weeks before I finally took the plunge. I have wanted to do it for the last two summers (at least) but always backed out.
Well, I am SO happy that I finally went for it this summer!
My daughter and I both love it. I LOVE not having to nag her constantly with "pump on," "pump off." I LOVE not having to worry that we are going to ruin her pump or void our warranty accidentally. I LOVE that when she needs freedom from her pump, I don't have to worry about fighting highs from a lack of basal insulin. And last, I LOVE that it only adds one shot once a day (with Tresiba).
Going untethered has combined the best of both multiple daily injections and pumping for us.
We now have the stability that long-acting basal insulin provides, combined with the convenience of a pump that can offer super tiny doses for food or corrections as often as needed without tons of shots! It has been a total WIN for us!”
What are the two key elements of optimal diabetes management, and how can we ensure 'luck' is on our side? The answer is simple, but not easy.