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.
This is fantastic! I thought that the conversion of basal pump insulin was not 1:1 with a long acting insulin. Specifically, I thought the pump insulin was 75% of the basal as a conversion because it is slowly absorbed. Thoughts?
It really depends on so many factors. In general, folks who are converted from MDI to a pump are told to take 75 to 80% of total daily MDI basal dose and use that amount for the basal rate over 24 hours in their pump. Some folks are 1 to 1. Depends on how well adjusted the basal insulin dose was with the MDI regimen.
So, if I understand this correctly, for a 1week trip to Hawaii I would have to take 75% of my basal as a long acting insulin every day of the year? Is there a way to do this without adding the burden of ALWAYS having to add a daily basal dose plus pump therapy??
You would only need to take your injection of basal insulin the week you are in Hawaii and at the end go back to your pump. You do not need to ALWAYS inject the basal insulin. Only while on vacation.
Thanks! So to try untethering for a weekend, the pump stays off completely from Friday night to Sunday night- but I am confused by, “on Sunday night go back to the reduced basal dose” before putting the pump back on. Is this meaning that the untethered REGIMEN (not just the weekend trial) – which let’s say, could go the entire summer, simply requires a daily “boost” (a %) of long acting insulin via injection? and for that same period of time, the basal via the pump is at the reduced % rate..? And then boluses, depending on the “mood” (if I’m wearing pump or not at the time), would be delivered either via the pump or the pen? It’s the % basal that is the tricky part (I might need to run by my endo), right?
to clarify- my confusion is why- on Sunday night- I would go back to a “reduced” dose of basal via my pump, after the trial weekend. Wouldn’t I go back to 100%, until the next time I want to “try” untethering?
Sorry for the confusion. I think you are correct in that I made an error. On Sunday night you would put your pump back on with the normal basal rate you were using before you tethered, and obviously not take the injected basal at all that you were doing over the weekend. I hope that is clear but I get why you were confused. You can untether over the long term. No time limit. You need to experiment what percentage of basal injected insulin versus your pump via trial and error.
Love your untethered option and explanation. Just to confirm, this is the proper way to use flex pens for basal and bolus while wanting to take your pump off for any amount of time? My endo has prescribed me long-acting and bolus insulin pens to use on vacation, but I can never seem to truly mimic what my pump does for me and always end up having extreme fluctuating BGs. I have issues with keeping my site on securely after being in the water for long periods of time (and wasting tons of supplies), so I am interested in doing this for a week while on vacation.
I think you will like this regimen as it allows for better control while on vacation. You might consider getting infusion lines with a bent needle so you can take it in and out without wasting infusing lines.
I am going to untether for the weekend and I am confused about how many daily basal units I will need to inject. I was on MDI until 6 months ago and taking 10 units of Tresiba when I went on Omnipod 5. My pump indicates that my current basal program is .35U/hr over a 24 hour period.
The Omnipod has done wonders for my time in range but limits the length of time I can actually surf (2 hours instead of the 3-4 hours I normally was in the water).
The percent of basal that you would take really depends on how active you’re going to be. The more active you’re going to be, the less basal you’ll need. So perhaps you could try 5 units of Tresiba at dinnertime, and then take off your pump at bedtime. If you were to take off your pump right away, it takes a while for the Tresiba to start working and you might go high. Theoretically, the shorter-acting basals like Lantus work a little better in this regimen because it does take more time for Tresiba to equilibrate in people, but you could try it and see what happens. Make sure you have your insulin pen with you in case you need to give yourself a correction dose. But I would say 5 units of Tresiba at dinnertime and then leave the pump on for 3-4 more hours before you take it off.
When this regimen was designed, pumps did not communicate with CGMs and people were using Lantus (or glargine). Lantus is not as good as Tresiba, but it does get into the system faster than Tresiba and that may affect how you respond, so it’ll be trial and error. Let us know how it goes.
As a T2D who uses the Omnipod 5 I decided to try going untethered to help keep me stable. I have been using this method for 3 weeks and it is wonderful! Before my pump would shut down my basal when it thought i was ‘going low’,but now since my basal is on board it can’t shut off and it prevents the high peaks! I LOVE IT. Thank you for the suggestion. My A1C was just 6.1 with a TIR of 91%.
Wow, that’s awesome! Thanks for letting us know!
This worked great for me while on vacation in Hawaii!
Awesome! It’s really a nice option.
Thank you for the explanation. Can I keep my infusion site in and give my meal bolus via the pump with a quick reconnect?
You can do that, however you need to make sure that you prime the tubing completely before you give a bolus because there might be some dead space, which would give you less than you think you gave yourself.
I have done similar to this for a couple of years. My site would occlude, and before I knew it my bg would be high enough to start giving me ketones. I use about 50% of my basal as Tresiba, & reduced my pump basal, for 24 hours.
I am using Omnipod 5 and tried an experiment with Tresiba that seems to be working. However I take 25% of the Tresiba (sub for basal) in the morning (6 units) and then let Omnipod do the rest of the work). I never go untethered as I keep the Omnipod 5 going all the time. Occasionally I overcorrect around 9-10pm if I am at 180 (taking 0.5 units) and I get awarkened around 1-2 am at 85. Usually I can take some glucose tabs and correct, but I worry I’ll go even lower so I stay awake watching my bg. A big plus is that I no longer get lumps and infusion problems at the canula site at the end of the 3 day wear cycle. i was having to change my pods every 2 days before — expensive! Do you have any recommendations with this “hybrid” approach.
The untethered regimen is really not meant to be used while you’re wearing an insulin pump. In the old days before Insulet, you could take off and put on a tube pump any time you wanted to. I would think that either you’re not getting enough basal through your pump at certain times, but you can always adjust that. I don’t see the benefits of what you’re doing – if you need more basal, instead of adding a shot of Tresiba, which you can’t take back, I would just ask your HCP to adjust your basal rate. If you’re doing well taking the Tresiba than you can simply adjust your basal so you don’t have to take that shot anymore. What’s nice about adjusting your basal rate is that you can adjust it at any time. Once you inject Tresiba, it stays in your system for a good 24 hours+. You’re kind of defeating the purpose of having an insulin pump with a basal rate that you can adjust.