Assisted hypo?

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UnexpectedDiagnosis

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Type 1.5 LADA
So I'm on holiday in Tenerife and I've been here for 7 days.. diabetes has gone great until this morning.

I tested at 10am and I was 6.5 then suddenly at 10.30 I felt very dizzy and confused. Normally I get lots of warning of a hypo but this one was not normal as none of my normal warning signs appeared only confusion and dizziness.

So my Mrs and 2 kids were in the apartment with me and they said that I said I felt dizzy which I can remember saying but then I have no recollection for about 5 mins where they say;

I said I was dizzy but kept walking around in circles, they said I was not responding to instructions and they made me sit down initially thinking I was joking about but I stared straight through them like they weren't there and then my left arm started shaking / shivering and my mouth was open. They then gave me a bag of haribo and told me to eat some and I just kept rolling them up. They then forced me to eat sweets and I just stared into space for a minute. Then I can remember from this point being confused why I'm on the sofa and when did I eat the last of my haribo? I have no recollection of the above and fear it was an assisted hypo and possibly a seizure.

The extra heat walking and all inclusive food has generally been ok to manage but I just dive bombed rapidly this morning and it was different from anything I've experienced.... any advice ??

I've been trying to keep my BG elevated to compensate for a 10 miles extra a day I've been walking so lowered from 20 to 18 units of Toujeo and that helped me stay above 4.
 
Hi. Sorry to hear you had a nasty hypo although my first thought is to query that it was actually a hypo. Did they scan your Libre/other CGM to check your levels? Did your sensor low alarm not go off? What do you have it set at? I am assuming you have sensors for monitoring your levels and if not, why not? All Type 1s(LADA) should have Libre or other CGM if they want it.


When did you reduce your Toujeo? 2 units is not a big reduction if you are walking 10 miles a day every day or even most days, I know they generally advise a change of 10% and see how it goes but in your situation I would need to reduce it by 2 units each night if I was consistently doing 10 miles a day, especially if you don't normally walk much. Added to that the heat and that can also impact your basal needs. If you are all inclusive, I am guessing alcohol may also have been involved and that could certainly impact you the next day, so that is something else that would factor into my basal reduction calculations. .

Are you still on fixed doses of bolus insulin as your signature mentions?
Had you bolused for and eaten breakfast before this happened or were you skipping breakfast that day or having a late one? Just trying to work out if this was a basal insulin issue or a bolus problem.

Personally I am not a fan of Glargine (Toujeo is a Glargine insulin) as a basal insulin because it can occasionally get trapped in tissue and then release later sometimes weeks or months I believe, when you least expect it. It happens rarely but it is a known issue.

If you are newly diagnosed then it may be that your own beta cells are reviving a bit with the support of injected insulin and possibly the heat and have fired up again and possibly caused this, so lots or possibilities, but if you hadn't had breakfast or bolus insulin, then I would be looking at reducing your Toujeo dose further.
 
What time did you have your Toujeo and/or Novorapid @UnexpectedDiagnosis ? The issue with glargine is that you can get unexpected and sudden hypos because it sometimes doesn’t crystallise and form a slow-releasing depot of insulin, but, instead, releases all at once thus causing hypoglycaemia.

I see from your earlier thread that you don’t get hypo symptoms until you’re pretty low. I strongly suggest you try to reverse that by endeavouring to stay above 5 at all times. Hypo awareness can be lost quite quickly if you’re running low a lot.

What did you have for breakfast and at what time?

Hypo symptoms aren’t static. They change. Sometimes you’ll get a particular symptom but another time you won’t, so don’t rely on any specific symptom. There are loads - some obvious, some more subtle. Confusion is most definitely a hypo symptom, but so are things like ‘brain slowness’, feeling weepy or snappy, a tingling lip, a funny feeling on your face, changes to vision, etc etc.

The Libre won’t keep up with a sudden drop and could, for example, show somebody is 5.2 when they’re actually 2.8 and falling fast, so always be aware of that and fingerprick if you feel funny.
 
rebrascora said:
Hi. Sorry to hear you had a nasty hypo although my first thought is to query that it was actually a hypo. Did they scan your Libre/other CGM to check your levels? Did your sensor low alarm not go off? What do you have it set at? I am assuming you have sensors for monitoring your levels and if not, why not? All Type 1s(LADA) should have Libre or other CGM if they want it.


When did you reduce your Toujeo? 2 units is not a big reduction if you are walking 10 miles a day every day or even most days, I know they generally advise a change of 10% and see how it goes but in your situation I would need to reduce it by 2 units each night if I was consistently doing 10 miles a day, especially if you don't normally walk much. Added to that the heat and that can also impact your basal needs. If you are all inclusive, I am guessing alcohol may also have been involved and that could certainly impact you the next day, so that is something else that would factor into my basal reduction calculations. .

Are you still on fixed doses of bolus insulin as your signature mentions?
Had you bolused for and eaten breakfast before this happened or were you skipping breakfast that day or having a late one? Just trying to work out if this was a basal insulin issue or a bolus problem.

Personally I am not a fan of Glargine (Toujeo is a Glargine insulin) as a basal insulin because it can occasionally get trapped in tissue and then release later sometimes weeks or months I believe, when you least expect it. It happens rarely but it is a known issue.

If you are newly diagnosed then it may be that your own beta cells are reviving a bit with the support of injected insulin and possibly the heat and have fired up again and possibly caused this, so lots or possibilities, but if you hadn't had breakfast or bolus insulin, then I would be looking at reducing your Toujeo dose further.
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As always thanks for the long response, I'm not sure why I didn't get the alarm I just seemed to dive bomb which doesn't normally happen.

My partner tested me when I was out of it and force fed me sweets when she saw a reading of 2.7. We had our first lie in, I had taken toujeo at 9.56 and we were heading out for breakfast but I didn't take my rapid. I was 6.7 when I took that dose and typically I can go an hour or 2 before needing food or anything but this came on so quick it's nuts for saying I wasn't doing anything just showering and dressing etc.

I only lowered by 2 units as I was generally not going that low but just needed a small adjustment, I did have cocktails later into the night than normal and maybe I'm a little dehydrated but I do drink alot of water.

It's the fact I have no recollection and I was shaking etc... freaked me out a little it sounds like a seizure almost.
 

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Inka said:
What time did you have your Toujeo and/or Novorapid @UnexpectedDiagnosis ? The issue with glargine is that you can get unexpected and sudden hypos because it sometimes doesn’t crystallise and form a slow-releasing depot of insulin, but, instead, releases all at once thus causing hypoglycaemia.

I see from your earlier thread that you don’t get hypo symptoms until you’re pretty low. I strongly suggest you try to reverse that by endeavouring to stay above 5 at all times. Hypo awareness can be lost quite quickly if you’re running low a lot.

What did you have for breakfast and at what time?

Hypo symptoms aren’t static. They change. Sometimes you’ll get a particular symptom but another time you won’t, so don’t rely on any specific symptom. There are loads - some obvious, some more subtle. Confusion is most definitely a hypo symptom, but so are things like ‘brain slowness’, feeling weepy or snappy, a tingling lip, a funny feeling on your face, changes to vision, etc etc.

The Libre won’t keep up with a sudden drop and could, for example, show somebody is 5.2 when they’re actually 2.8 and falling fast, so always be aware of that and fingerprick if you feel funny.
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I have been trying to stay higher especially while on holiday due to heat, exercise and hydration.

Today I went from being 6 - 8 range for 16 hours to a sudden and very quick dip. It just went from 0 - 100 real quick and for the first time since diagnosis I was really caught out

The confusion went from me feeling a little dizzy and saying "oh I feel dizzy" to then continuing to walk in a circle about 15 times and the family just thinking I'm nuts which is why she made me sit and tested me. It just makes very little sense
 

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@UnexpectedDiagnosis If you took the Toujeo at 9.56am and had the bad hypo at 10.30am, it seems likeLy that’s the answer. Google “Lantus hypos” or “Lantus lows” (Lantus is the more common form of glargine). I’d never take it.
 
I agree with @Inka that it is almost certainly your Toujeo (Glargine) unless you accidentally injected NovoRapid instead.... I did that once but thankfully realized as I was putting the pen back in the case. 24 units of bolus insulin makes for a fun breakfast!!
How much of the bag of Haribo did you need and what size bag was it? Just to give us an idea of how much insulin was involved in causing that hypo. Ie was it a normal 15g fast acting carbs or did you need most of a large bag? ie 100g or more?

Just a further comment from looking at your graph, your levels dropped from 10 to 6 mmols between 3am and 9am, so that would suggest that your basal insulin dose may be too high still. Ideally look for trends over a few nights but particularly after this scary incident, I would be looking to lower your Toujeo dose a bit more, especially as you have 2 hypos showing on your graph from the night before.... which might be bolus related but if you lower your basal dose it should give you more room for error at the bottom end of your range.
Too many hypos will erode your hypo awareness and whilst the technology is good, it isn't fool proof as you found out, so need to run your levels higher for a bit. Don't worry about long term complications of running a bit higher because this is less of a risk than those lows right now and once you get things more stable then you can work on bringing levels down a bit again,

In your position I would be asking to try a different (non Glargine) basal insulin when I got back to the UK. Tresiba or Levemir would be the two main alternatives. I love Levemir because it is really flexible and I can adjust it from morning to night and day to day because my basal needs change a lot, but others find Tresiba gives them nice steady predictable results, particularly if you have quite a regular lifestyle routine.
 
Inka said:
There’s a thread on here:

https://forum.diabetes.org.uk/boards/threads/severe-hypo-after-lantus.92983/

But also a number of similar incidents online, eg

https://forum.tudiabetes.org/t/lantus-lows/14248/27

.
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You may have hit the nail on the head with one of these links; " My warning sign for a upcoming lantus low is when blood comes out of the hole after I pull the needle out right after injecting lantus, most every time I’m due for a low within 20 min to 1 hour, dropping from 150-180 to 40-60 or so. It depends upon how much lantus is absorbed into the capillary."

This morning I bled once I pulled the needle out which is rare so I may have injected into a capillary.. I can cope with that but I really don't like the symptoms I got. After talking more to my partner she said my whole body was shaking, I was shaking my head side to side with my mouth open and my daughter said I was like a zombie I wouldn't stop or listen to simple commands and not remembering it is fairly disturbing tbh. Is that normal for a hypo?
 
Whilst I can appreciate how scary it can be when you experience a "Lantus Low", I would like to emphasise that these are rare.
I took Lantus for 12 years before migrating to a pump and never experienced any issues. It is still my backup basal in case my pump fails and I have full confidence in it.

There are newer (and probably more expensive) long acting insulins available now with other reasons for changing. If I was still on MDI, I would follow @rebrascora onto Levemir as I like the flexibility. However, for someone with a more stable life, Tresiba may be better.

The reason for adding my comment is to alleviate any worries you may have following this morning's experience and the comments from users of other basal insulins for the remains of your holiday.

I hope you are able to enjoy the rest of your break. And second the comments about contacting your DSN or diabetes team when you return.
 
UnexpectedDiagnosis said:
You may have hit the nail on the head with one of these links; " My warning sign for a upcoming lantus low is when blood comes out of the hole after I pull the needle out right after injecting lantus, most every time I’m due for a low within 20 min to 1 hour, dropping from 150-180 to 40-60 or so. It depends upon how much lantus is absorbed into the capillary."

This morning I bled once I pulled the needle out which is rare so I may have injected into a capillary.. I can cope with that but I really don't like the symptoms I got. After talking more to my partner she said my whole body was shaking, I was shaking my head side to side with my mouth open and my daughter said I was like a zombie I wouldn't stop or listen to simple commands and not remembering it is fairly disturbing tbh. Is that normal for a hypo?
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Severe confusion, being unable to speak or process what’s going on are all hypo signs. Seizures due to hypoglycaemia look a bit like tonic-clinic seizures - ie jerking involuntarily.

If you think it was due to the Toujeo, what I’d consider doing is taking it a little earlier in the morning and then monitoring closely afterwards for an hour maybe for peace of mind just to make sure all’s well. As @helli says, some people can take Lantus for years and never have an incident with it.

Definitely do let your DSN know when you’re home, but don’t let it spoil your holiday. You now have a possible explanation and that alone should reassure you and allow you to keep it at the back of your mind while enjoying your time abroad.

Hypos like that are always unsettling whatever the cause, so take it easy and be kind to yourself.
 
Sorry to hear about your severe hypo @UnexpectedDiagnosis

That blank stare, zombie state, and repeat action / inability to follow instructions reminds me of the severe hypos I used to have. Thankfully I’ve not had that experience for a decade or more, but they used to really shake me up. And my family too.

Good to know you are aiming to keep your levels a little higher - as the DVLA will need to be told about that hypo if you are a driver, so you need to avoid having another at all costs.
 
Just update that the DVLA do NOT need to be told about this hypo as a hypo is only considered as being assisted if you have medical intervention such as an injection to pull you out of it. A partner helping is not an assisted hypo
 
UnexpectedDiagnosis said:
My partner tested me when I was out of it and force fed me sweets when she saw a reading of 2.7.
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Sounds like you got someone who wasn’t applying their own rules properly. This bit sounds like you were not able to treat the hypo yourself because by your own admission you were out of it and your partner had to force feed you the sweets. The DVLAs own guidance says needing that kind of help (eg you were too out of it to treat it yourself) they do need to know. But if your partner just fetched the treatment for you, and you were aware enough to know you needed them and to eat them, then they wouldn’t need to know.
 
Source here, “partner had to force feed you sweets because you were too out of it to treat the hypo yourself” fits “partner administering glucose because you could not treat the hypo yourself” to me.

So for anyone else in the same situation I’d suggest they do need to notify DVLA, even if the DVLA then decide to take no actio

 

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Literally an hour ago a senior diabetic nurse classed my hypo as a moderate hypo... and said its not assisted as it wasn't medically assisted.

She told me that i had no reason to inform them... but do as you wish
 
UnexpectedDiagnosis said:
Literally an hour ago a senior diabetic nurse classed my hypo as a moderate hypo... and said its not assisted as it wasn't medically assisted.

She told me that i had no reason to inform them... but do as you wish
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Pretty clear that you do need to inform them from your own admission that your partner had to force feed you glucose because you were too out of it to treat it yourself. But it’s your responsibility to inform them not your diabetes nurses decision, so your choice.
 
I'm following the guidance I've received from the medical professional looking after me... I told them and let them advise me whether they considered my incident as a severe hypo, which they didn't.

She said she'd inform my GP if she thought it was needed and didn't. If I was just trying to not get the DVLA involved I wouldn't even have mentioned it knowing that they have a duty to notify.

In my opinion I've been open and honest with medical professionals who then guide me, since they are experts and I'm not it's probably wise to follow their advice is it not
 
UnexpectedDiagnosis said:
In my opinion I've been open and honest with medical professionals who then guide me, since they are experts and I'm not it's probably wise to follow their advice is it not
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I’d personally vote not, since you’re the one that’s read and signed the agreement to follow the DVLA guidelines, but as I said it’s your responsibility and your decision
 
@UnexpectedDiagnosis - this episode sounds very much to me like a 'one off occasion' and IMHO you have actually done what also appears to me as absolutely the right thing to do about it.

Why comments have been made by others about alcohol being involved is because

1. Oh yes it can exacerbate dehydration - and like it or not, being optimally hydrated means that your Libre sensor is much more likely to reflect a more accurate reading of your blood glucose about 10 minutes ago BUT in any event when BG is changing very quickly it is never going to be all that reliable, hence exactly why we are all warned to check any such scan result with a proper fingerprick blood test before assuming it IS correct and treating a reading under 3.9 or over 10 and - more importantly in this case

2. It normally has the effect of reducing anyone's BG !!

So - when you know you're going to have more than 'just the one or two' - please please make certain you have enough to eat - if not during, before is definitely OK or even after might be - as long as you're still capable! 😉
 
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