The Inspiration for the Untethered Regimen
Several years ago, I had a type 1 patient named Lloyd B. whose diabetes was very well controlled. He was on an insulin pump, and he loved the ability to give himself boluses throughout the day and night without having to stick himself a zillion times. He also wore a CGM, but it was well before CGMs communicated with pumps like they do today. His A1c and time in range were excellent.
Lloyd’s main challenge was that he loved to scuba dive, so he had to take his pump off for hours on end. Anytime he was underwater for more than an hour (which was usually the case on his dives) his glucose control deteriorated. His glucose values eventually went super high, and when he tried to correct, he would crash and the roller coaster would begin. Super frustrating!
I came up with the idea of the “untethered regimen” so Lloyd would be able to go for long periods of time without being tethered to his pump. The name for it came to me when I was watching my daughter Carina play tetherball. In fact, I took a picture of her playing and used it in my presentations to patients and providers to illustrate the concept, and to show off how cute my daughter Carina was!
How the Untethered Regimen Works
I instructed Lloyd to take an injection of basal insulin every night which was 75% of his basal requirements, and the remaining 25% was to be given by his insulin pump. When he took off his pump to scuba dive, he had 75% of his basal on board, which was enough to keep his glucose values from rising because the exercise from diving helped make up for the 25% of basal he wasn’t getting. These percentages can vary though, depending on individual need and how much basal is needed (based on the exercise). The ratio could be 50:50 for example. You can see in the image below how the basal requirements were split between the daily injected long-term insulin and the basal rate of the pump.
How to Try the Untethered Regimen
For this regimen to work, you have to take your basal dose every day even if you do not plan to exercise or take off your pump. Many of my patients use this regimen to untether themselves from their pump for a weekend, or if they are going to Hawaii and might be in and out of the water often.
If you would like to try untethering for a weekend, when Friday comes around take 100% of your basal requirements (such as Lantus, Toujeo, or Tresiba) at dinnertime, and then take your pump off at bedtime (you want the basal to start working before you take off your pump). For your boluses, use an insulin pen and/or Afrezza. Give yourself the same dose of basal on Saturday night. On Sunday night, don’t take your basal dose of injected basal, but go on the normal basal rate of your pump when you put it back on. You don’t have to do any delay because it works right away since you’re giving the basal as fast-acting insulin.* This type of “pump vacation” will be smooth. without a disruption in glucose control.
The Untethered Regimen on Wikipedia
There you have it folks…the famous Untethered Regimen, which somehow got on Wikipedia. Feel free to ask me questions in the comments below!
*This sentence was corrected.