Delayed rise after hypo treatment

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Evergreen

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Type 1.5 LADA
It’s been a while since I’ve posted, but I’m back with a question I hope someone has some knowledge on! 🙂

For whatever reason (weather/hormones etc) I’m more sensitive to insulin which has resulted in some (mild) hypos as my carb ratio seems to be wrong now. I tend to treat them with lift tablets or dextrose tablets.

Ive noticed that the tablets help stop the drop after about 15-20 mins, which is great. However my blood glucose then continues to go up for 1.5-2 hours, sometimes longer. That surely isn’t the fast acting still? How long do you usually keep rising after hypo treatment?

I should say I am on HCL, so obviously my basal had been suspended for a while before hypo. I imagine that’s not helping with this rise. Could basal suspension be the reason for the rise or might it be my liver possibly dumping in some glucose?
 
I find hot weather can mean my bolus works faster and over a shorter time @Evergreen This means I can go low after a meal, which I treat, but then have a later rise. Perhaps a similar thing is happening to you?
 
Which loop are you using @Evergreen ?

My money would be on the basal suspend having a delayed glucose rising effect. Though it could also be your liver getting twitchy as you suggest.

Hybrid closed loops are aiming to prevent hypoglycaemia by reducing or suspending basal. But the algorithms all have their own different settings about when that suspend/reduction starts, and how long it lasts after levels are back up again.

My experience of Medtronic’s predictive low glucose suspend on the 640G (not a true HCL, but close) acted much earlier, and for longer than Tandem’s Control IQ on the tSlim. I had more rebounds to higher levels on the Medtronic system, but it was mych better at preventing hypos on its own.

The tSlim tries a gentler basal reduction first, and only fully suspends if it predicts a hypo within 15 minutes. tSlim also restarts insulin much earlier, and will even give a corrective mini-bolus if it sees levels rising rapidly (i’ve even had it mini-bolus because of the rise due to my hypo treatment a few times!).

How low are your BGs going? And how high do they get afterwards. Having a hypo tends to make more hypos statistically more likely on the same day - so a rise to higher numbers can be a useful precaution.

It’s really a question of how well the loop’s algorithm matches your body’s needs. my suspicion is that you may be better off just leaving it? Or perhaps reducing the amount of hypo treatment you are giving? But hypos are worse for you than highs. TIR recommendations allow 25% of time above range, but only 4% below.
 
Thank you both, very helpful!

It’s interesting about the warm weather. I’m not sure this was it as it wasn’t actually that warm here yesterday. I am going to keep an eye on this though and see if I can see a pattern.

I also wonder if it is the basal suspension. It had been suspended for 2 hours before the rise (I am on the Omnipod 5).

I only dipped to 3.8 before my dextrose stopped the drop (7 grams). Then it slowly went up to about 7 mmol, but after 1.5-2 hours I had a straight arrow up to 11 mmol, looking back I was getting basal but it definitely hadn’t been in my system for long enough to actually start working. I did some squats which got me back down to 9 mmol, so unsure how much it would have kept rising.

The Omnipod 5 generally works well for me, but I have noticed it doesn’t adapt fast enough to my changing needs. My consultant is talking about possibly moving to the Ypsopump. Anyone have any experience with this algorithm and does it adapt better to changing needs?
 
Evergreen said:
I also wonder if it is the basal suspension. It had been suspended for 2 hours before the rise (I am on the Omnipod 5).

I only dipped to 3.8 before my dextrose stopped the drop (7 grams). Then it slowly went up to about 7 mmol, but after 1.5-2 hours I had a straight arrow up to 11 mmol, looking back I was getting basal but it definitely hadn’t been in my system for long enough to actually start working. I did some squats which got me back down to 9 mmol, so unsure how much it would have kept rising.
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Ah this is interesting. So the stray into low BG was ‘only’ modest (did you cross-check with a fingerstick?)

Are you using Dex or Libre2 with the Omnipod?

You could work out what 2hrs of basal suspend is at your theoretical basal rate for that time of day I suppose (Does the Omnipod 5 algorithm base decisions off a profile you define like tSlim?).

Might be interesting to leave one alone and see how long you stay in double figures before drifting back down.

On a case-by-case basis, you may want to consider a micro-bolus once BGs are up above 5 and stable - but you risk the sort of double-dip that tSlim has frustratingly given me a few times doing that.

I wish there was a slider system on these algorithms so you could tune them, “Act earlier ————— Act later” and “Stronger ————— Gentler”.

It’s about finding the workarounds to get the algorithm to work for you, and keep you safe. 🙂
 
A slider system would be amazing!

I don’t actually think I could see anywhere what my average basal rate is on the Omnipod (I could be wrong though!). They do seem to be quite cagey about the algorithm and how the pod works out the basal rate beyond taking 50% of your TTD as a flat rate.

I had a similar situation after breakfast this morning. I have clearly entered a insulin sensitivity phase again…

I decided to treat earlier this time as an experiment. I took two lift tablets when I noticed a downwards trend about 1hr 15 after breakfast with a BG of 6 mmol. It worked! Slowly brought me up to 6.5 mmol with no later spike. I assume because my basal didn’t suspend very long at all. I’m now slowly drifting back to my target of 6.1 mmol
 
Not one I’ve tried I’m afraid.

The most ‘tweakable’ and personally tailorable algorithm seems to be CamAPS, but you need an Android phone to run that on.

CamAPS is the one they recommend for pregnancy, because it can be adjusted more
 
The YpsoPump uses CamAPS, I think @Evergreen I turned a loop down but my clinic uses CamAPS and is pleased with it. They use the Dana i pump with CamAPS but I think they were planning to add the YpsoPump to the choices too.

Oops, forgot to say that if your basal was suspended for that long that could well be the issue.
 
Having read through the other ideas and your responses @Evergreen , there is the likelihood of it being a late reaction to the suspend. I also wonder whether you adapt your use of quick acting carbs according to the level and to rate of decent. I use one JB if just below 4, and then increase according to decrease and rate. I am using the Medtronic HCL with the 780. I get an early warning of lows,(5 ish) and if I treat these with no bolus I will get a high later on, but if I give a small amount of quick carbs along with half the bolus, it seems to head off the Hypo as well as avoiding spikes later. If I ignore the warning and get below 4 (yes I know that I should heed the warnings) then I need the quick acting without insulin, and will be bouncing for a while. So my lesson has been to react to early warnings.
 
SB2015 said:
Having read through the other ideas and your responses @Evergreen , there is the likelihood of it being a late reaction to the suspend. I also wonder whether you adapt your use of quick acting carbs according to the level and to rate of decent. I use one JB if just below 4, and then increase according to decrease and rate. I am using the Medtronic HCL with the 780. I get an early warning of lows,(5 ish) and if I treat these with no bolus I will get a high later on, but if I give a small amount of quick carbs along with half the bolus, it seems to head off the Hypo as well as avoiding spikes later. If I ignore the warning and get below 4 (yes I know that I should heed the warnings) then I need the quick acting without insulin, and will be bouncing for a while. So my lesson has been to react to early warnings.
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Thank you, that’s interesting. I took a lift tablet yesterday around 5mmol when I could see I was lost likely going hypo if I didn’t treat and it worked perfectly without a bolus, but I get what you are saying. I suppose it will be experimenting.

My insulin needs seem to differ wildly as well which is a problem I’ve had since diagnosis several years ago. It’s actually the main reason I was recommended for HCL. It’s definitely easier to manage on a pump, but I’m still struggling massively with the unpredictability of how much insulin I’m going to need for a meal on a random day!
 
Inka said:
The YpsoPump uses CamAPS, I think @Evergreen I turned a loop down but my clinic uses CamAPS and is pleased with it. They use the Dana i pump with CamAPS but I think they were planning to add the YpsoPump to the choices too.

Oops, forgot to say that if your basal was suspended for that long that could well be the issue.
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@everydayupsanddowns and @Inka, that’s both interesting.

I know someone on the ypsopump who’s very happy with it. My hospital does not seem to be very experienced in using it however.

I would love to be able to manage my changing insulin needs a little better and wondering if the ypsopump might be the answer, but the amount of options to change might also be a little overwhelming…

I get on pretty well with the Omnipod so it’s a difficult choice!
 
If the Omnipod is your first pump, it’s worth considering trying another. It’s all a bit of a leap of faith when you try a new pump - I remember being quite stressed the first time - but usually you’ll find it was a good move.
 
Thank you, I think I needed to hear that! I might see if I can speak to my consultant to find out what the options are.

Would you have any advice on how to deal with the stress of rapidly changing insulin needs? I’m not even sure what’s going on and whether it’s normal what I’m experiencing, but it’s really stressing me out!

I can’t work out what is causing these changes in sensitivity but I’m bouncing between carb ratios of 1:8 one day and 1:15 the next. So far the hospital haven’t given much advice, so unsure if everyone experiences changes like this?
 
Depending on your sex and age, it could be hormonal @Evergreen I’m finding perimenopause is bringing erratic sugars. Could it be that? Your own pancreas might be spluttering a bit and confusing things too.

It is very stressful. My only advice is to use your CGM alarms wisely and be kind to yourself.
 
I am female and hormones have crossed my mind…so far not quite seeing a pattern with it though.

I think it might be a little early for perimenopause although not completely impossible either!

It is definitely stressful and on certain days it feels like I don’t really get a break from having to act one way or another which is frustrating. I’m hoping it is ‘just’ still a prolonged honeymoon period and it’ll settle one way or another
 
It’s more likely to be your own pancreas @Evergreen but it was worth mentioning. Yes, it’s a nuisance but HRT helps a lot.
 
Evergreen said:
I am female and hormones have crossed my mind…so far not quite seeing a pattern with it though.
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I have quite significant insulin need fluctuations based on my monthly cycle and hormones. It became so obvious that just a few months after diagnosis, if I had numerous lows, I knew I would probably ovulate in the coming days. And if I had otherwise unexplainable highs, I would know my period was about the start.

Compared to my average insulin usage over my cycle, I can need plus or minus 30% insulin. I need more just before my period starts and less mid-cycle when I ovulate. This affects my bolus factors more than my basal rate.

Since my insulin needs change so regularly, Omnipod didn't sound like a good option for me. I went with Tandem T:Slim X2 and can create 6 different profiles, one for each of the four chapters of my cycle (period, post-period, ovulation, pre-period), plus one for illness and one temp profile for holidays or other one-off events that would affect my blood sugar.
 
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