Closed-loop pumps in Australia

We’re talking about a closed-loop system which ties your CGM and insulin pump together so that it decreases or increases insulin flow as required to help maintain your target glucose levels. Not all pumps can do this.

All this discussion is written with the Australian environment in mind.
This document was current as of July 2020.

Commercial choices

If you want a commercial closed-loop system, at the moment you could use the Medtronic 670G. Note that the loop design of this is quite a few years old at this point, and is dependent on Medtronic’s own CGM. But it is commercially supported.

The Tandem t:slim X2 is likely to be getting a “Control-IQ” firmware update with something similar, but probably not before 2021 (and maybe not before 2022?). Until then the t:slim is not an option for looping.
Yes Control-IQ is available in the US. But in Australia we don’t yet have the earlier Basal-IQ low-glucose-suspend, although we do now have the Dexcom G6 CGM required for both of those.

DIY choices

Or you might decide to build your own “DIY” loop system using a compatible pump, and start looping now. These are currently “class-leading” in terms of features compared to the commercial offerings we know about. But you need to take on responsibility for building and running the system yourself.

DIY Support

Because they are not regulated systems approved by the TGA as medical devices, you can’t purchase these loop systems or have them provided as systems by others. Legally you must build it for your own use. But there are large and active communities of other people who have done it for themselves and will help you to do the same. Such as the “Aussie, Aussie, Aussie, Loop, Loop, LOOP!” group on Facebook.

For medical practitioners to suggest the use of such systems (they couldn’t provide it for you) they would be going “off-label” somewhat. But the tools of the insulin, the pump, the CGM, and how your body responds to them are things that your medical team should still support you using. As per the 2018 Diabetes Australia position statement on DIY technologies:

[…] there will always be some people who accept a level of risk and choose to take the DIY approach. These people should continue to receive support and care from their diabetes healthcare professional and the health system.

Just don’t go to your doctor and ask them how to set it up.

There are three major DIY systems, each with different features and pump choices:

  • OpenAPS runs on a pocket Linux “rig” computer.
  • Loop runs on iPhones.
  • AndroidAPS runs on an Android phone (even if it doesn’t have a SIM or network connection).

But for now this is mainly an overview of the pump choices without going into all the ins and outs of each system.

CGM choice

All of the following systems can be used with Dexcom G5 (and G6 when it arrives) and Libre (when combined with MiaoMiao/Nightrider/etc devices) CGMs. The pump itself doesn’t have to talk to the CGM: the loop controller does that.

It is possible (but not convenient) to use Medtronic’s Guardian2/Guardian3 CGM (as used on the 640G pump) to drive a loop, but that involves carrying a lot of extra hardware.

If you use a Medtronic 522/722/554/754/523/723 pump and OpenAPS or Loop (see below), you have the option of using Medtronic’s old CGM that links to those pumps (using a “MiniLink” transmitter). But most people prefer the Dexcom CGMs.

Pump choices

You currently have a few pumps to choose from, compatible with various of the above loop systems.

You can purchase a new Accu-Chek Combo and use it with AndroidAPS. This is the pump & loop I’m currently using.

The DANA RS can also be used with AndroidAPS. However Australian sales of this pump seem to currently be on hold, with the manufacturer concentrating on their future DANA-i pump (for which no dates or software support details are known).

Or you can decide to use an older out-of-warranty pump.

  • The Accu-Chek Combo, DANA R, and DANA RS all work with AndroidAPS.
  • The Medtronic Paradigm (515/715/522/722) or Veo (554/754, with firmware version 2.7A or earlier) can be used with OpenAPS, AndroidAPS, or Loop.
    The older Medtronic Paradigm 512/712 pumps can also be used with AndroidAPS and OpenAPS. Unfortunately with OpenAPS the 512/712 (but only those models) are missing a few useful features such as SMBs.
  • If you manage to find an American Medtronic Paradigm Revel (523/723) with firmware 2.4A or earlier you can use that with OpenAPS, AndroidAPS, or Loop too.

Note that Medtronic Veo pumps with firmware 2.7B or later can not be used for looping.

What’s coming?

Tandem have their closed-loop “Control-IQ” system in the USA for the t:slim X2, using the Dexcom G6 CGM. But when it would be available in Australia is anyone’s guess at the moment.

Medtronic‘s next closed-loop system looks to be the 780G pump. Apparently the 770G is a precursor to that which uses the 670G algorithms but may be upgradeable to the 780G. The 770G has approval for sale in Australia, but Medtronic have not yet made any announcements.

Insulet are working on getting their Horizon (“Omnipod 5”) loop system to market, using their Bluetooth-enabled Omnipod DASH pumps (note that we’re unlikely to see Omnipod pumps reach Australia).

The next DANA pump from SOOIL, the DANA-i is likely to be paired with several commercial loop systems.

Diabeloop is a French company who has received European approval for its system, which currently uses Kaleido “patch” pumps and a locked-down controller device talking to a Dexcom CGM. This system has been in development for years, but it’s still early days. It might support some other pumps in the future. We will continue to watch its development in Europe, but it’s hard to imagine any Australian deployment at the moment.

CamAPS FX is a UK-based system that currently supports the DANA RS pump, and runs on Android phones.

Meanwhile, the DIY systems will continue to evolve.

Tidepool is a US company who is branching off a version of the open source Loop system (which runs on iPhones) and plans to apply for FDA approval to use it with Bluetooth LE enabled pumps. Their first target seems to be the Omnipod DASH pumps. Presumably they are also intending to work with other BLE pumps over time. Tidepool Loop will share a lot of code with the opensource Loop system, “cross-pollinating” development in both directions.

I know lots of development is continuing in the open source projects, although there are no timeframes on expected results. It might take months, years, or some of these might not eventuate. But I’m aware of work being done to add support for more Bluetooth-enabled pumps to all of OpenAPS, AndroidAPS, and Loop. The YpsoPump is on this list.

But for now the options in Australia as of July 2020 are listed above.