Accidental levemir overdose, what now?

[trophywench]

Hypostop was disgusting. Not RIP at all. It deserves to suffer like we had to!

 

[Scrumpyjack65]

Hypo seizures are terrifying @Scrumpyjack65 I wouldn’t have any more Levemir until your next dose is due. I’d also run slightly higher than I normally would, just to be safe.

With your pens, you could also stick a ‘9’ and a ‘2’ on them very prominently. When I have a pump break, I talk to myself when I do my basal. Sounds mad, but I say to myself something like variations of this “Ok - morning basal. I’m having 9 units, ok? Dial up 9. Stop! This is the morning and my dose is 9. Yes - inject” The point is to get my brain off auto-pilot and double-check by repeating the salient points to myself, allowing myself extra time to spot a mistake. It works for me and I feel safer doing it.

Take it easy and I hope you feel ok.

Hi Inka, this is the first time Ive had a pump break, clearly I should have done before. Out of interest how often do you have a pump break? Being on a pump can be very exhausting at times. I like the idea of the repeating thing, that would work as my husband thinks Im as mad as a hatter anyway!

 

[Scrumpyjack65]

Hypostop was disgusting. Not RIP at all. It deserves to suffer like we had to!

Hi, Ive never used it, based on your recommendations now is not the time to start trying it Id say.

 

[rebrascora]

Well, I talked myself through my Levemir dose this morning, so that is the start of a new habit for me. It started with, "Now Powelly, are you paying attention? Have you got the BLUE Levemir pen? How much are you going to inject today? Right dial half of it up....inject....Now the other half...etc"
Still managed to get straight back to sleep with no trouble at all despite giving myself a good talking too! 🙄 😎

 

[Inka]

Hi Inka, this is the first time Ive had a pump break, clearly I should have done before. Out of interest how often do you have a pump break? Being on a pump can be very exhausting at times. I like the idea of the repeating thing, that would work as my husband thinks Im as mad as a hatter anyway!

I have no fixed schedule really. I take a break when my sites seem to need one and/or are stressing me out. I’ve also taken brief breaks in order to compare MDI with pump. I looked at control then and compared the two systems. I tend to take longer breaks rather than the two days a week I described someone else doing. This is because I like to build up my basal on MDI and get everything settled, including basal injection times. So, I don’t want to go to that effort and then take a break for only a few days!

I’ve been back on my pump months, but I might take a break in the Summer hols so that I can go to the beach and so on without thinking about my pump.

Also, the fact I was able to do it successfully, made me feel good. Sometimes a change is as good as a rest, and Type 1 is extremely tedious. I did go back to my pump refreshed after my break.

 

[Scrumpyjack65]

Hi, thanks for your helpful response. Gosh, two days on a break as suggested by someone else, doesn't seem long enough to even get started. I like your approach of having some time off to re-think for a bit, summer hols being a case in point. It's so good to be able to do things more spur of the moment I have found rather than have to plan things hours ahead of time as I did on a pump, it drove me mad.

I'm going to keep persevering on pens until I get it pretty good, despite the disgust of my DSN. Hey, she sees the pump as a great thing, but she is only advising from a medical perspective, not the actual day-to-day living with it. I am sure I will return to the pump "one day" but not yet. Pens are the way for me at the moment, obviously using the right doses !!

Enjoy your summer without a pump 🙂

 

[Elenka_HM]

Your experience sounds quite scary @Scrumpyjack65, hope you are okay now!

I read @rebrascora ' s battle with the big dose of Fiasp, in the waking thread I believe, and was wondering then what to do if the insulin you inject too much of is basal. It seemed logic to eat a ton of carbs to compensate an excess of rapid insulin, but with a basal, would that lead to a massive high? Should we eat carbs but in smaller amounts during the day? That's considering one realizes the mistake on time for any of this, which I know is not always the case, unfortunately.

 

[Bruce Stephens]

Should we eat carbs but in smaller amounts during the day?

Pretty much, yes. I think in all cases the idea is to keep monitoring and be ready to adjust as necessary (with bolus or carbs).

 

[Proud to be erratic]

Should we eat carbs but in smaller amounts during the day?

That would be my instinct also, but I'm not medically qualified. To your body, insulin is just insulin, ie it doesn't know about different release speeds or profiles etc. So a gradual intake of carbs to feed the gradual release of insulin seems appropriate.
As said above, monitoring and adjustments will be imperative .

 

[rebrascora]

The thing I find with basal insulin is it seems more potent than basal. For instance, say I take a couple of units less basal to account for some planned activity during the day and then I don't do it, I need several corrections of Fiasp maybe totaling 5 or 6 units, whereas if I had taken those 2 additional basal units they would have held me steady. I also happens when I need a basal increase.... I will have a couple of days where I am repeatedly correcting with 2 units of Fiasp every few hours, so I up my basal by a couple of units the next day and it is all resolved.

I would be interested to know if others experience the same or if this is perhaps some anomaly of my low carb diet or maybe of Fiasp. I am not sure If I can remember it being like that with NovoRapid but I didn't have Libre then to compare things so well.. I do find that generally I need a bit more Fiasp than I did NR to do the same job. I still use a rough 1-10 ratio but corrections are more 1 drops me 2 unless I also do exercise, rather than 1 unit drops me 3mmols with NR whether I exercise or not.

It is a really good question @Elenka_HM . I have only ever made the mistake of injecting quick acting insulin instead of basal. The first time was a relatively minor (looking back on it although I did panic at the time) 7 units of bolus at bedtime instead of basal. It was quite nice to have a few high carb treats at bedtime to soak it up as I don't often eat that sort of stuff. I was at my partners at the time and he buys all sorts of cakes and biscuits so I had plenty of naughty things to choose from. That second time when it was 24 units was very much a race against time to get carbs into my system before the Fiasp rendered me unconscious and was just pure panic and nausea.
If I injected my morning dose of basal in the evening, I imagine I would be spending the whole night awake and trickle feeding carbs and monitoring my levels or eating a very big bag of roasted peanuts, which seems to be ideal for slow released carbs to match basal activity from my experience and then setting alarms for throughout the night to wake and check how I was doing. I would like to hope that I won't make any such silly mistakes ever again, but I am human so it cannot be guaranteed. It is really good to pose and discuss it though and perhaps develop an idea of what you might do if it happened to you, so that in that moment of panic you have some knowledge or thought of what would be a good way to tackle it.
The mistake I made was that I didn't realise that such a huge dose (24units) would kick in so much faster than my normal dose of 3.5 units which takes 45 mins so I initially thought I had plenty of time and started with eating prunes which are medium release, but then my levels started to plummet like a stone, so I hit the Dextrose and JBs and then the coffee with sugar in desperation. because more than 1 cup of coffee stimulates my liver to release glucose as well as the warm sugar solution with it being a good option to hit my blood stream quick. I really do not ever want to go through that ordeal again but hope that by discussing it, there is an element of preparedness for myself and others.
Obviously you can never be prepared if you don't realise your mistake like Sally, but discussing strategies to prevent it is helpful, so really appreciate Sally bringing it to the forum for discussion.

 

[Proud to be erratic]

The thing I find with basal insulin is it seems more potent than basal.

Just to clarify: is it bolus that seems more potent to you than basal? If so, that doesn't surprise me; I think its not actually so, but because the basal is slower releasing there is more bolus around to give the perception of increased strength. But my understanding from Gary Scheiner's book was that insulin is insulin: the body doesn't discriminate about its origins or profiles.

For instance, say I take a couple of units less basal to account for some planned activity during the day and then I don't do it, I need several corrections of Fiasp maybe totaling 5 or 6 units, whereas if I had taken those 2 additional basal units they would have held me steady.

But you are now comparing apples with pears. Because you initially chose to underdose and circumstances change (happens to me a LOT, because of other ailments as well as daily events) by the time you choose to make a correction with Fiasp, your BG is higher than you would wish and your natural resistance to insulin is increased; so more bolus required than if you'd taken the original planned dose. Also, perhaps, if you'd taken a bigger (harder) first correction then the 2nd correction might not have been needed.
Because of MDI without Libre, along with early bad experiences of hypos , hypers and roller coasters, there is an inbuilt (trained) tendency to be cautious - possibly forgetting that with Libre frequent scans give great visibility of where one's BG is. Libre (1 or 2) provides the opportunity to take bolder decisions, with the penalty of more frequent monitoring, but the potential gain of tauter BGs. With MDI and finger pricking it was more a case of dosing and see what happens in 2, 4 or even 6 hrs time.
When I had Diabox working on my android phone with real-time CGM reading from Libre 2, it was simply amazing to see the minute by minute changes along with numerically quantified trends from 0.5 to 7 mmol/L/min. You really could see if there was a true crash happening or just a momentary flicker. Freestyle Libre 2 is good, but a long, LONG way from excellent and once you've tasted excellent the good seems a lot less than good. My control was far superior with Diabox than now, frustratingly without it for tech reasons beyond my tech capability.

I also happens when I need a basal increase.... I will have a couple of days where I am repeatedly correcting with 2 units of Fiasp every few hours, so I up my basal by a couple of units the next day and it is all resolved.

For me, with Tresiba, I can't sensibly change basal and expect an instant response. So I simply use bolus to correct after the event. But, in a normal day, I also adjust my bolus to reflect my planned activity, by as much as a 75% reduction. I surmise you are adjusting your basal instead; if you are adjusting both then your maths needs to be better than mine!

I would be interested to know if others experience the same or if this is perhaps some anomaly of my low carb diet or maybe of Fiasp. I am not sure If I can remember it being like that with NovoRapid but I didn't have Libre then to compare things so well.. I do find that generally I need a bit more Fiasp than I did NR to do the same job. I still use a rough 1-10 ratio but corrections are more 1 drops me 2 unless I also do exercise, rather than 1 unit drops me 3mmols with NR whether I exercise or not.

I correct at 1:2 with NR. My Endo asked me to try 1:3, but it was insufficient. His DSN assumed I was weaker than 1:3 when I recently reached out and advised me to harden to 1:3 - then was surprised when I told her I was already at 1:2. Now, I keep 1:2 as my ratio, and apply an adjustment % increase to my combined food and correction bolus, when circumstances require significant BG lowering.

It is a really good question @Elenka_HM .

Completely agree.

I have only ever made the mistake of injecting quick acting insulin instead of basal. The first time was a relatively minor (looking back on it although I did panic at the time) 7 units of bolus at bedtime instead of basal. It was quite nice to have a few high carb treats at bedtime to soak it up as I don't often eat that sort of stuff. I was at my partners at the time and he buys all sorts of cakes and biscuits so I had plenty of naughty things to choose from. That second time when it was 24 units was very much a race against time to get carbs into my system before the Fiasp rendered me unconscious and was just pure panic and nausea.
If I injected my morning dose of basal in the evening, I imagine I would be spending the whole night awake and trickle feeding carbs and monitoring my levels or eating a very big bag of roasted peanuts, which seems to be ideal for slow released carbs to match basal activity from my experience

Yes, its a good idea to know in advance what should be your immediate "go-to" food for that particular slow-release requirement and something like peanuts is handy because they are widely findable if away from home.

and then setting alarms for throughout the night to wake and check how I was doing. I would like to hope that I won't make any such silly mistakes ever again, but I am human so it cannot be guaranteed. It is really good to pose and discuss it though and perhaps develop an idea of what you might do if it happened to you, so that in that moment of panic you have some knowledge or thought of what would be a good way to tackle it.

As part of my early training in my career I was advised to always make a plan; plans can and should be changed; with a plan you have something to lean on, without a plan you only have chaos and panic.

The mistake I made was that I didn't realise that such a huge dose (24units) would kick in so much faster than my normal dose of 3.5 units which takes 45 mins so I initially thought I had plenty of time and started with eating prunes which are medium release, but then my levels started to plummet like a stone, so I hit the Dextrose and JBs and then the coffee with sugar in desperation. because more than 1 cup of coffee stimulates my liver to release glucose as well as the warm sugar solution with it being a good option to hit my blood stream quick. I really do not ever want to go through that ordeal again but hope that by discussing it, there is an element of preparedness for myself and others.
Obviously you can never be prepared if you don't realise your mistake like Sally, but discussing strategies to prevent it is helpful,

And from that strategy make YOUR plan ...

so really appreciate Sally bringing it to the forum for discussion.

Agreed.

 

[Inka]

I think @rebrascora meant that basal was more potent? Anyway, in my opinion, basal is more ‘stealth’ than bolus in that you can think you’re fine then it will suddenly kick in. However, in what you describe above - needing multiple Fiasp corrections because you took too little basal for your situation - I’d say that that’s not so much potency, more par for the course with insulin (both types) It needs to be there ahead of time and working. If that window is missed, it takes more insulin to get back where you should be.

As an example, if I take 3 units of bolus for my evening meal when I really should have taken 4 my blood sugar will be above target at 2 hours. I will then usually need more correction than the ‘missing’ one unit. Conversely, if I were to inject 3 units on a 1:10 ratio but not eat enough carbs for those 3 units, I’ll need more than the missing 10g carbs to put my blood sugar up.

To me, it’s all just a reminder of how clever our pancreas is and how difficult it is to mimic it with external insulin.

 

[helli]

I would be interested to know if others experience the same or if this is perhaps some anomaly of my low carb diet or maybe of Fiasp.

I have been using Fiasp for a few years and it certainly took some getting used to.
For me, the speed at which it starts to work is very dependent upon my blood sugar levels.
If my levels are in the 4s and 5s, it will work instantly so I have to bolus AFTER eating. If my levels are over 10, it can take an hour to start working so I take care to correct before it gets to this level. (This is not "insulin resistance" until I get over 15 because I don't need a different correction factor.) If my levels are in the 6s and 7s, I can bolus just before eating and if they are in the 8s and 9s, I bolus 15 minutes prior. This may sound like a pain but most of the time, I am in the 5s or 6s.

On a slightly different note, unfortunately pumping does not stop me from making mistakes with my dose. My pump and CGM are both controlled by the same app on my phone. This is great because I don't have to switch apps or readers to work out my bolus dose. Each night I check my CGM with a finger prick and calibrate it if necessary.
A few weeks back. I was staying in London for a couple of nights for work. As I got ready to turn in for the night, I did my usual finger prick check and calibration before cleaning my teeth. I was 7.2 - a little higher than usual but restaurant eating is harder for carb guessing.
I read for a while and then, just before turning out the light, I checked my levels and noticed I had 7.0 units of insulin on board - I had given myself a manual bolus rather than a calibration. So, at 11:45pm in the middle of Shoreditch on a Tuesday, I had to get dressed and go and find 100g carbs. Thankfully, I found a corner shop but I don't recommend stuffing yourself with chocolate and flapjacks that late at night.
It was a lesson learned and, after I had berated myself for the mistake, I gave myself a pat on the back for remaining calm and vigilant afterwards and was grateful to know I can look after myself (or correct my own mistakes).

 

[Inka]

Scary @helli ! It’s a good job you realised. What app is it? Does it show you bolusing, if you get what I mean? On my Dana app, once I press to start the bolus, a big syringe comes up on the screen showing a visual representation of a bolus being injected and the syringe emptying (apologies for rubbishy description). I like this because it’s a very in your face image of what’s happening.

 

[helli]

Scary @helli ! It’s a good job you realised. What app is it? Does it show you bolusing, if you get what I mean? On my Dana app, once I press to start the bolus, a big syringe comes up on the screen showing a visual representation of a bolus being injected and the syringe emptying (apologies for rubbishy description). I like this because it’s a very in your face image of what’s happening.

It is the Medtrum app. It has a circle which changes colour when you bolus so I should have noticed.

 

[Proud to be erratic]

I think @rebrascora meant that basal was more potent?

Interesting, my auto interpretation was that bolus is more potent, because of my assumption there is more bolus around than basal because of the longer endurance of basal and a certain number of basal units have to be more dispersed (or released gradually) to achieve that endurance.

Anyway, in my opinion, basal is more ‘stealth’ than bolus in that you can think you’re fine then it will suddenly kick in.

I have no experience to support that 'feeling' of stealth. I find my Tresiba fits the analogy of the ocean going container ship; strongly powering itself along, needs days to react to a course change and a great challenge to bring into port! Whereas the NR is reasonably reactive and I have, twice in the last 25 days, had to increase my basal. I had surgery on 28 May which of course bumped my BG up; now after 24 hrs in A&E I'm on a surgical ward waiting for an emergency op. But the bolus adjustment to cover the basal increase has been managed reasonably well, now I understand the mechanics (or should that be fluid dynamics?!).

However, in what you describe above - needing multiple Fiasp corrections because you took too little basal for your situation - I’d say that that’s not so much potency, more par for the course with insulin (both types) It needs to be there ahead of time and working. If that window is missed, it takes more insulin to get back where you should be.

Totally agree. Had that conversation with a Consultant Surgeon this morning, who tried to reassure me that they "knew how to manage T1s"; the red flag was lifted. I politely, but robustly explained that we are all unique, one size doesn't fit all; timing was essential (but still needed prior information about the intravenous nutrients in terms of their glucose content and rapidity into my body; he went silent - clearly hadn't thought it through! I'm now waiting to see a dietician.

As an example, if I take 3 units of bolus for my evening meal when I really should have taken 4 my blood sugar will be above target at 2 hours. I will then usually need more correction than the ‘missing’ one unit. Conversely, if I were to inject 3 units on a 1:10 ratio but not eat enough carbs for those 3 units, I’ll need more than the missing 10g carbs to put my blood sugar up.

To me, it’s all just a reminder of how clever our pancreas is and how difficult it is to mimic it with external insulin.

Yes, not just external insulin for me. No exocrine functions or digestive enzymes; no glucagon hormone to tell the liver to open the glucose store; no somatostatin hormone to balance glucose and insulin. Amazing organ which (when you've got it) works most of the time without instructions from our brains.

 

[rebrascora]

I have been using Fiasp for a few years and it certainly took some getting used to.
For me, the speed at which it starts to work is very dependent upon my blood sugar levels.
If my levels are in the 4s and 5s, it will work instantly so I have to bolus AFTER eating. If my levels are over 10, it can take an hour to start working so I take care to correct before it gets to this level. (This is not "insulin resistance" until I get over 15 because I don't need a different correction factor.) If my levels are in the 6s and 7s, I can bolus just before eating and if they are in the 8s and 9s, I bolus 15 minutes prior. This may sound like a pain but most of the time, I am in the 5s or 6s.

I certainly find it very similar with Fiasp, but on a morning even if my levels are in the 4s I need to give it at least 30 mins and 10-15 mins at other times. This morning Libre said 3.6 on waking (Finger prick 5.2 so no hypo treatment) injected 3.5 units and still waited 37 mins before eating for Fiasp to win the battle with FOTF and start dropping my levels before I ate (Libre was in the red the whole time. That probably sounds really dodgy to most people but it is a consistent result every morning that I have come to have confidence in although I do track my levels very closely to watch for the tide turning and breakfast is always sitting ready for me to eat it when it is time. I work off my Libre trends, not by timing it, which is how I know it is consistent.

If levels get higher it definitely takes longer and I have to be very proactive in keeping levels below 10 otherwise I will be high for hours and for me I usually find stacked corrections work better to bring it down, which is why I do my utmost to keep it below 10. Larger single corrections with Fiasp seem to sit there for ages and then drop me too fast when I take my eye off the ball, so smaller stacked corrections seem to be safer for me when I hit double figures, usually an hour apart but again, I watch my Libre closely and if levels continue to rise an hour after the first correction even if it is only a few decimal places, it is time for another. If I see it has dropped a few decimal places I give it another half hour and then decide if it needs a bit more.

Just to clarify: is it bolus that seems more potent to you than basal? If so, that doesn't surprise me; I think its not actually so, but because the basal is slower releasing there is more bolus around to give the perception of increased strength. But my understanding from Gary Scheiner's book was that insulin is insulin: the body doesn't discriminate about its origins or profiles

Apologies for my error. @Inka was correct I meant that basal units seem to be more potent than bolus.... certainly in the case of Fiasp anyway for me but I do feel that the potency of Fiasp alters much more in different circumstances anyway than I ever found with NR. I proactively keep my levels below 10 as much as possible and often correct on 8 so I don't feel it is insulin resistance that requires more Fiasp in those circumstances. It just seems that if I up my basal a little bit, I need a lot less Fiasp.
I do wonder sometimes if I could actually manage just on Levemir with my low carb diet and if overall I would need less total insulin units a day. I would need to be quite disciplined and focused though and I don't think it is a sustainable long term strategy but I might experiment with it one day when I have some time on my hands and no distractions.