Review: @TandemDiabetes t:slim X2 Insulin Pump with Dexcom G5 integration

Manny Hernandez with X2+G5

Last year, when I the Tandem X2 pump that supports software updates via USB (the only pump to do so) was approved by FDA, and they announced that their first update would support integration with the Dexcom G5 CGM sensor, I signed up for it. I left my clunky Animas Ping behind and became a Tandem pump user.

Recently, FDA granted Tandem approval for the Dexcom G5 update. And today, I am happy to report I am sporting my Dexcom G5 data on my Tandem X2 pump, as you can see above. This post summarizes my experience and feedback during the update process and over the course of the first few days of using the integrated product.

The Update
Upon receiving the instructions with my Update ID (you need one to proceed with the update), I downloaded the Tandem Device Updater:
Tandem Device Updater
After I had the software installed and running, the update literally it took under 15 minutes. This even included completing the recommended safety steps.
Update successful
In (silly) defiance to the recommendation to do the update in connection with a site change, I found myself needing to load the pump as you would have to with a site change. So, while you technically can still continue to use your current infusion site, you will need to go through the process of loading the pump. And since you need to prime by letting a minimum of 10 units flow through the tube, if you do not have at least 50 units of insulin in your cartridges, I recommend you follow their recommendation, unlike what I did… :/

At this point, my pump looked pretty much like it used to before the update… because my Dexcom receiver had not yet arrived, and it took about a week to get here…

The CGM integration
Once my Dexcom transmitters arrived, I was able to continue with the process, and get down to the really exciting stuff.

Entering the transmitter ID is a bit more “fun” than the way you enter it on the Dexcom receiver, where there’s no keyboard. The advantage of a touch screen is that the screen can be turned into a keyboard, only not a full keyboard but more like a phone pad keyboard:
Dexcom keyboard
You are prompted to verify the Transmitter ID (enter it twice), which is different from the Dexcom-only experience too. Not too sure what this does for the process, but not a big deal either.

My anxiety to be done with the rest of the process got in the way, as did my Dexcom receiver freaking out and entering into a loop where it would reboot itself over and over, as if it had sensed that it was no longer going to be with me any more (I forgot to take pictures of the Dexcom receiver acting up, and I had to do some ninja stuff to get the recurring reboot to stop, so I owe you visuals of the Dexcom screens, but I am sure you have seen them before…)

Finally, after patiently waiting for the mandatory two-hour sensor warmup period (which gave me plenty of time to finish the training and configure alarms, etc.) at 11:21, on Sep. 6, 2017, I finally saw my Dexcom G5 data on my Tandem X2 screen! 🙂

First CGM time

The Training
It will take you up to 30 min to complete the Remote Software Update – CGM Integration Tutorial. This is if you are new to the CGM or the Dexcom G5, since it covers CGM basics, how to insert the sensor, snap the transmitter, etc. I liked that it included these types of quizzes to confirm you have retained the key concepts that you’ve learned:
Not a huge deal, but the voiceover used in the tutorial was creepy at times. Also, I think the trainer speaking changes mid-module, which can be a tad disconcerting. Then again, not a huge deal.

Everyday use

After a few days of use, the pump battery has already shown signs of lasting less. This is not surprising, as it now has a Bluetooth radio to feed. But it’s still not necessarily the most fun extra thing to do. To be fair, it’s only one device vs. two (pump + receiver) I have to keep charging.

But the biggest downside I’ve found is that I am seeing the Out of Range icon in the place where you’d see the CGM reading more often than I would have expected, typically no less than a couple of times per day:
Out of Range 2
They indicate in the training that “Brief interruptions of up to 10 minutes [without CGM signal] are normal”. The truth is this doesn’t feel normal.

I have historically worn my pump in one pocket, on the same side of my body where I am wearing my infusion site. And I have my CGM sensor on the other side of the body (typically, both are on my abdomen). If I change my insulin pump to the opposite pocket (the one closest to the CGM transmitter/sensor), normally the Out of Range icon disappears shortly. I get that proximity matters to make sure the transmitter signal can get to the receiver in the pump, but we’re not talking 20 or even feet here, we’re literally talking inches… Although I am working on losing weight, I hope my belly is not the obstruction causing this! 😉

The verdict
I am delighted with being able to see my CGM data on my pump, period: full stop. Is it exactly the way I envision it? No. But it’s a MAJOR step for me, considering my choice of CGM at the present time (the world of CGM is changing rapidly so we will see what the future brings). In the meantime, here are two ideas (for my friends at Tandem and Dexcom) to make the integration better (which I assume they have already thought of):

  1. It would be amazing to offer the option to use a BG readings entered on the pump “side” of the device (while you are bolusing) to calibrate the CGM, or the opposite: offering the option to bolus for a BG being entered as part of your CGM calibration. Neither option is available, and they would make perfect sense. (Update, Sep. 10: Just realized that above target calibration BGs generate this prompt. Love it!) CGM calibration - correction
  2. Something that takes some getting used to is the fact that functions for loading the pump and for calibrating the CGM are respectively further out (in terms of button taps needed) than where they used to be pre-integration. I get that this comes with the territory, but I’d love to see the two companies explore ways to make the user experience a bit cleaner, specially re: calibrations which occur twice a day.

Unencrypted comm. protocols in diabetes tech: not a feature

Today, when I woke up I found an email in my Inbox from Animas Corporation, the J&J company that makes my insulin pump. The email was in regards to a cybersecurity vulnerability identified in the Animas insulin pump, that under certain fairly extreme circumstances could give a person “unauthorized access to the pump through its unencrypted radio frequency communication system.”

I tweeted about it, and I was a confused with the first response to my tweet (which was merely meant to inform my peers in the #DOC), indicating that the fact that there was an unencrypted communication channel was a feature of the pump. The conversation quickly started taking a different tone: “I think the opportunities of open comm are worth more than the paranoia of pump hacking for evil. #MyTwoCents” I replied with this comment:

Several hours later, I found my Twitter notifications exploding with replies, RTs and Likes opposing my comment and asking me to “show where this is a legit risk that doesn’t read like a bad Tom Clancy novel“. I quickly realized I was in way over my depth, and Twitter is a terrible place to explain complex things, so I decided to blog about it.

There are many friends in the diabetes community that I have tremendous respect for, and I feel I owe it to them to write this, because I don’t want a series of tweets in any way to be interpreted as lack of support for the way way in which they have contributed to the advancement of things in diabetes technology. Of course, I am talking about the folks behind the #WeAreNotWaiting movement, and the folks at Tidepool.

I understand what David Cintron says:

and I also understand what Howard Look @Tidepool_org says:

At the same time, and maybe because I have been in industry since May 2015, I don’t think the only two options are either completely open and unencrypted channels to communicate with insulin pumps OR proprietary and encrypted protocols. Traditional paradigms can lead us to believe that, but we live in a new world, the world I was referring to in my initial tweet, that has shown us a very ugly face in recent years. This is the world that author Joshua Cooper Ramo talks about in his amazing book “The Seventh Sense: Power, Fortune, and Survival in the Age of Networks“. The central idea in the book:

Connection changes the nature of an object…

This notion can be best understood when you consider that incredible connection-enabling tools like Twitter were central to facilitating the Arab Spring, and have recently become a recruiting tool for terrorists. We are not in Kansas any more. This is not about Tom Clancy or science fiction: all it (sadly) takes is to look around us and pay attention at the Presidential Campaign, to remind us of how different a world we live in.

So what will it take to avoid stifling innovation? How to balance it with the mandate to empower AND protect the health and lives of the patients we serve?

We should not defend vulnerabilities: we need to advocate for secure communication protocols that are exposed in a responsible manner (I am not an expert on this topic, but as an optimist it strikes me as doable) to the research and development community. To this end, I like Howard’s idea of an “innovation switch” introduced last month at the NIH-NIDDK Artificial Pancreas Workshop.

This may or may not come from the incumbent companies. It remains to be seen, but when I see what BigFoot is doing (including a crypto-chip in their upcoming pump):

and what Tandem is doing (their t:slim G4 pump exceeds the highest standards as laid out by the Diabetes Technology Society), I feel hopeful about a future where we won’t need to wait five years since a vulnerability on a Medtronic pump was first identified by a hacker with type 1 diabetes like Jay Radcliffe to identify a similar vulnerability with the Animas Ping pump, before action is taken.

In the meantime, in spite of what Jeff Dachis may claim, I will continue to say what I said on Twitter:

Pokesteps? Poke-yes!

A few weeks ago, I was lured into playing a game that has become quite popular. Of course, I am referring to Pokemon Go. Our 12-year old son had been quite a dedicated fan of Pokemon for years now, and since I missed this phenomenon growing up, half the time I didn’t understand what he was saying when he spoke about it. But I decided to give the mobile game a try.

Since I started playing, I don’t cease to be tremendously impressed about the way the game succeeds at getting you to go out and about. Not only is this amazing for kids and young adults (who grew up on Pokemon) alike, since it gets them back outdoors, the way most of us who were born in the 70s and 80s grew up. This game motivates people to get more active…

You are not told you have to put in X number of steps, you have to walk off to hatch eggs that will eventually turn into Pokemons that you can play with in the game. You are not invited to walk for 30 minutes, but without doing so you really cannot hit the Pokestops where you get the pokeballs and other items you need to catch Pokemons and make the most of your catches. The BYPRODUCT of doing all these fun things is that you put in steps that otherwise you may have not taken… As I call them, POKESTEPS!

SO this has officially become the first game since the early days of the Wii, where moving got you points and helped you advance, that I am truly excited about. Gotta catch them all!

Share your thoughts on Pokemon Go in the comments, below.