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 late September 2021.

Commercial choices

If you want a commercial closed-loop system, at the moment you could use the Medtronic 770G or 670G. Note that the loop design of these is quite a few years old at this point, and is dependent on Medtronic’s own CGM. But it is commercially supported. The 770G will be upgradeable to their future 780G’s algorithm.

The Tandem t:slim X2 is likely to be getting a “Control-IQ” firmware update with something similar. Probably in 2022. Until then the t:slim is not an option for looping.

Currently the t:slim is available in Australia only with the Basal-IQ (low-glucose-suspend) firmware.

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 can 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).

OpenAPS and AndroidAPS use the “oref” algorithms, as does a new beta for iPhones called FreeAPS X (which otherwise uses the same pump-comms framework as Loop).

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 as well as Libre (when combined with MiaoMiao/Nightrider/Bubble/Droplet/etc devices) CGMs. The pump itself doesn’t have to talk to the CGM: the loop controller does that.

Libre2 support is a bit harder at the moment.

It is possible (but not convenient) to use Medtronic’s Guardian2/Guardian3 CGM (as used on the 640G/670G pumps) to drive a loop, but that involves carrying a lot of extra hardware (including the Medtronic pump as receiver).

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

As at the 27th of September 2021 (with the end of Accu-Chek Combo sales) there are currently no longer any loopable pumps available in Australia. There are however some lights on the horizon.

People with Combo pumps can of course start looping if they want. I started using a Combo (specifically for looping) in 2018, and it’s a solid pump. These pumps have warranty for 4 years from their new purchase date.

There are some new loopable options on the horizon, but they’re not accessible for everyone yet. I’m expecting this to change over the coming months. No timeline guarantees are available for these updates, but it seems likely that several new pumps will be loopable “out of the box” within the next 6 months. Hopefully a lot sooner, but I have to reinforce that there are no guaranteed timelines at this point.

The DANA RS can also be used with AndroidAPS. However Australian sales of this pump have ceased, 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, just as above with in-warranty pumps. It works with AndroidAPS.
  • DANA R, and DANA RS both 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. Note that Veo pumps with firmware 2.7B or later can not be used for looping.
    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.

Single-use pumps

The Omnipod DASH system was recently introduced into Australia, although it is expensive. About AU$40 every 3 days, with no subsidy from health insurance or NDSS at this point. To get pods you do need to go through the usual “pump start” process with your DE to get signed up as an Omnipod customer.

These pods are now working with a beta of AndroidAPS. The pods talk directly to AndroidAPS via Bluetooth: no “link” device or PDM needed. However while this will hopefully appear in the main AndroidAPS code soon, we don’t know a timeframe for that.

A few people have been able to arrange themselves a prescription from an overseas doctor for the older “Eros” OmniPods and then have friends or family in that country ship boxes of new pods to Australia. That falls under the allowed importation-for-personal-use rules. They then use these with either AndroidAPS or Loop using a Riley/Ema/OrangeLink radio bridge. The pods still get expensive though.

Not loopable

If you have a Medtronic 640G, 670G, or 770G, these can not be used with any DIY looping system. You can use them with AndroidAPS in “open loop” mode, where the software continually gives you instructions on what to set on the pump, but the software cannot control the pump directly.

The same applies to the Tandem t:slim X2 and to the Accu-Chek Solo.

What’s coming?

As mentioned, an AndroidAPS update to support the DASH is expected. Support for the DANA-i is expected at the same time.

Tandem have their closed-loop “Control-IQ” system in the USA for the t:slim X2. It will be here eventually.

Medtronic‘s next closed-loop system looks to be the 780G pump. The 770G is a precursor to that which uses the 670G algorithms but will be upgradeable to the 780G.

Insulet are working on getting their Horizon (“OmniPod 5”) loop system to market. OmniPod 5 has not reached the market anywhere in the world yet.

Diabeloop is a French company with European approval for its system, using a growing set of pumps. It has a locked-down controller device talking to a Dexcom CGM, and works with at least: Kaleido “patch” pumps, the Accu-Chek Insight, and the DANA-i. We will continue to watch its development in Europe, but it’s hard to imagine any Australian deployment at the moment. It will also be used in Japan with the MEDISAFE WITH pump.

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

Tidepool is a US company who has forked off a version of the opensource Loop system (which runs on iPhones) and is applying 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.

Lots of development is continuing in the open source projects, although there are rarely 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 September 2021 are listed above.