Artificial Pancreas Systems (APS, also termed “automated insulin delivery” AID systems) are here and we are not waiting! On 2020-Aug-1 BCDiabetes began supporting in-house installations of open source (DIY) APS with the tubeless Omnipod Dash-Dexcom G6-iPhone master branch "Loop" system. Although not Health Canada-approved, BCDiabetes considers the current version of Loop (Master branch) to be the best entry level open source APS available for most adults & children with good family supports. It uses a conservative algorithm that has been installed by our estimates on more than 32,000 individuals worldwide & is more affordable ($20/day) given coverage by BC Pharmacare of both the Omnipod system & Dexcom G6.
BCDiabetes now uses the acronym SOSAPS (supported open source APS) to describe its clinic-run, clinic-provided APS installation service. People using any version of OSAPS are still generically described as using “Loop”, being “Loopers” or to be “Looping”.
For the fascinating history of Looping see this 55 minute youtube by Ben Mammon. And for what things were like only a few years ago see this 55 minute BCDiabetes APS “The Weekly” webinar from 2020-May focused on closed-loop pump systems in general.
For those who are looking for an APS system who are not willing to use a non-health Canada approved solution, and for whom cost is not a consideration, today we equally recommend the Tandem T-slim with Control IQ and the Medtronic 780G. Two more retail APSs are expected to be covered by BC Pharmacare in late 2023/2024: the tubed Ypsomed CamAPS & the tubeless Omnipod 5. If you wish to start with Medtronic, Tandem, Omnipod or Ypso, email us & we will support you by filling in the necessary forms and continue to work with you afterwards. For a CAD$ cost comparison of the various APS options in Canada see rows 7-9 of this spreadsheet. It assumes no BC Pharmacare subsidy & that the up-front cost of the pump is amortized over 5 years. For a comparison of the features of all APSs worldwide see this spreadsheet.
Want to know which is the best APS algorithm, including open source and retail? So do we, which is why we are in the planning stages of a randomized control trial comparing them all. Watch this space for details.
BCDiabetes has to-date installed SOSAPS in its various flavors (Loop, freeAPSX_NexGen =iAPS, AndroidAPS =AAPS) on 380+ clients (including the youngest at 3 years, on 40 children under 10 years of age, and in 35 adults older than 70). Loop’s elegant interface and simple algorithm makes it our preferred choice for most clients and the only choice for age < 14. Some prefer iAPS because of its greater flexibility which comes at the cost of greater complexity. For reasons some prefer Loop over iAPS click here. To hear the argument “Why should iPhone users choose the Loop app at all?” made by our in-house iAPS code contributor & iAPS user Marc Fournier click here. AAPS is currently the only choice for Android users - it has the same logic and controls as iAPS.
BCDiabetes does not currently support CGM using any versions of the Freestyle Libre. This will change soon after the upgrade to the Freestyle Libre 2 app expected in July that will effectively turn Libre 2s into oversized Libre 3 & with the expected arrival of the Freestyle Libre 3 in 2024.
In case you want to build, install & configure one of these offerings yourself, here are the links: Loop master branch, iAPS & AndroidAPS. If you have built it but would like help with installation and configuration, for iAPS click here, and for Loop go to bcdiabetes.ca/handouts and type Loop into the search bar. For visuals on SOSAPS installation check out our youtube “how-tos” for Loop, iAPS and AAPS (a better version with normal aspect ratio will follow shortly).
Because Loop, iAPS & AAPS are not Health Canada approved, we require an online signed consent & waiver including an undertaking that users will not copy or distribute the installation to others without our consent. Adult BCDiabetes clients should complete this adult consent & waiver; guardians of minor BCDiabetes clients should complete this consent & waiver for minors. For parents or guardians who wish to be able to remotely give commands for carbs, boluses and overrides to their kids, on a case-by-case basis BCDiabetes also offers Loop Caregiver which runs on the parent/guardian’s iPhone.
At the time of your third Loop installation appointment (see below) you need to be wearing a Dexcom G6/G7 with an active connection and
EITHER an
iPhone 13 or newer with an
Omnipod Dash pod up and running with PDM (and spare pod, no Orangelink required)
OR
Omnipod Eros pod up & running with PDM (with spare pod) plus Orangelink Pro
OR
Android phone (OS 9+) running Dexcom G6/G7 with
EITHER an open-source modified version of the Dexcom G6 app known as BYODA (uninstall the regular Dexcom app first)
OR
instead of BYODA install an open-source app known as xDrip
AND
Omnipod Dash pod up & running with PDM (no Orangelink required) OR
Omnipod Eros pod up running with PDM plus Orangelink Pro
If you have an iPhone, enable Apple Health & install TestFlight from the App store and disable automatic iOS updates. Disabling iOS updates is to prevent Dexcom failures which sometimes occur after iOS updates (Dexcom is typically 3 months behind).
Regardless of whether you have an iPhone or Android, or an Eros or Dash pump, you need a Looping Safety/Emergency kit in case of component failure.
If you would like to have an OSAPS installed at BCDiabetes you first need to become a BCDiabetes client. To do so you will need a referral from a licensed physician, preferably your endocrinologist/diabetes specialist - click here for our quick referral form. Not all endocrinologists/diabetes specialists support Loop - if this describes your endocrinologist/diabetes specialist BCDiabetes will reach out to them to understand why this is the case and to try to keep the peace. Once you have been established on Loop BCDiabetes typically likes to see its Loop clients every 6 months for a year and annually thereafter. You should continue to see your regular endocrinologist/diabetes specialist for your regular non-Looping diabetes follow-up.
In advance of the referral you may email us requesting an appointment or register online. Once we have the referral you will be seen within 2 weeks for a regular appointment either in-person or virtually. The cost of the appointment and follow up will be covered in full by your Canadian provincial medical plan with the exception of Quebec. For Quebec residents the fee is $1500 (initial appointment plus up to two weeks of daily follow-up plus 2 month follow-up). BCDiabetes does not routinely offer care to non-Canadian residents. If a non-Canadian resident has a letter from his/her referring physician asserting that BCDiabetes' level of care is not readily in their country of residence, BCDiabetes may offer its services on a case-by-case basis.
Loop installation is typically a three appointment process: the first appointment (usually virtual) is an introductory session; the second appointment (usually virtual) is to set up a Nightscout account, provided at no cost to you as long as you are an active client, and to review Nightscout and to learn how to interpret & analyze your CGM and Looping data. The third appointment is preferred in-person but may be offered virtually at the discretion of BCDiabetes staff - it lasts 60-90 minutes. For iPhone users we will share a link to the latest builds of either the Loop app or iAPS on BCDiabetes’ TestFlight account at no charge. For Android users we will share the latest build of androidAPS from our own cloud source both at no charge. After app installation and configuration we will follow-up with you on a daily basis until you are independently able to make adjustments (for most users 2 weeks is sufficient) and then see you every 6-12 months.
If you are not trained on the Omnipod & are a BC resident we will fill out & email a certificate of medical necessity form to Insulet (the manufacturer). Once your payment details are sorted a starter kit with 2 pods will be delivered to your home within 2-3 business days: once you have been trained online (2 sessions 3 days apart) & been certified, you are ready to Loop.
To learn more about Loop & iAPS from a treatment/care-giver/physician point of view see this 40 minute youtube recording of our Loop 101 Journal Club episode 2023-May-2 presented by Nabeel Khan, our diabetes technologist. Nabeel’s powerpoint is here.
Looping Hardware:
Looping Safety kit:
BCDiabetes requires that a Looping Safety kit be carried by all its clients who use insulin pumps, including all Loopers, at all times. The bare minimum is a pen of rapid insulin with needle and finger-poke glucometer. And every client on intensive insulin therapy needs to understand & follow sick day management when they are unwell and sugar is consistently > 10.
Omnipod pump system setup
request that a BCDiabetes staff member complete paperwork (Letter of Medical Necessity) or email Andrew Muirhead phone +1--604-754-6195.
Omnipod pod purchase
both Eros & Dash, can also be purchased directly in Canada from Diabetes Express phone 1 866-418-3392 fax 1-855-233-3146 providing the client was trained in Canada.
Omnipod pods may be purchased online without a prescription & with no questions asked from these 4 US sources (verified 2023-Mar-23).
Dexcom G6
request that a BCDiabetes staff member complete Special Authority & prescription or order online or email Anthony Petrovich phone +1-604-363-8776
OrangeLink Pro
These are now only required for the Omnipod Eros (not for Dash pods): order online & pick up at BCDiabetes.
Medtronic 780G email Jennifer Rogers phone +1-778-839-2750.
Tandem Control IQ email Teri Currie phone +1-778-995-1268
Ypsopump email Sarah Peterson phone +1-604-805-6384
Online Loop Support
After Loop installation and initial daily intensive support in-house, we encourage BCDiabetes Loopers to join the BCDiabetes Loop support Slack channel (130 members) moderated by a non-physician BCDiabetes staff member. Other options include
https://www.facebook.com/groups/TheLoopedGroup/
Credits due:
The open-source community APS in general
Ben West (openAPS and Nightscout)
BCDiabetes clients who use SOSAPS
Praveen Samuel: lead SOSAPS physician trainer
Nabeel Khan: diabetes technologist, programmer, app builder, iAPS documentation
Ben Mammon: medical inspiration, OSAPS advisor, app builder, OSAPS superuser
Marc Fournier: online support group admin, iAPS code contributor, app builder, OSAPS superuser
Sergey Skobkarev: systems engineer
Gerri Klein: BCDiabetes in-house Omnipod pump trainer