DKA Risk?

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SimonP

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Moderator Note: This was split away from an earlier thread to allow the discussion to continue without distracting from the original thread: https://forum.diabetes.org.uk/boards/threads/glucose-monitor-with-a-high-range.108182/

On a couple of occasions I've got my pre-ride bolus very wrong and wondered how far above the off-scale high number (<22 .4for the calibration I was running last time) my blood glucose actually is, but I take a little bit of bolus insulin and keep riding and it comes down fairly rapidly.

I don't want to take the thread too far off topic, but how prevalent is DKA really for those who are using insulin? As long as you have some insulin on board (like your basal at the very least) and don't ignore it for multiple hours does it actually happen? There seem to be lots of people worried about suffering from DKA when their BG is even slightly elevated, I'm curious as to whether this is new guidance.
 
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@SimonP I have never DKA'd (and hopefully never will) and never needed to test for it in 4.5 years since diagnosis and managed to escape without it at diagnosis too, but then, apart from a very, very occasional rise to mid teens which I hit hard and keep hitting until it comes down, I don't get raised levels. The powers that be seem to be keen for us to be able to monitor ketones when necessary as the cost of an emergency admission due to DKA is very significant. Perhaps there is much less risk of it from modern insulin regimes and modern testing technology and that message is now less relevant than it used to be, but I think if my levels were hitting mid-high 20s it would be wise to be testing for them and certainly being aware of the potential dangers.
It could be that a blocked needle meant that the OP's basal dose was not delivered and therefore there isn't any active insulin. I had one this morning. Would have been so easy to miss if I wasn't very particular about doing air shots and seeing insulin express from the needle. Also, anyone with a history of struggling to manage their diabetes for whatever reason is more at risk and should therefore be more aware of the risks and the need for self monitoring as well as being given the tools to do so.

PS. I would be concerned about exertive exercising when my levels were mid teens or above. That is putting a lot of extra strain on your body. I feel the extra effort when my levels get above 10. I am sure you are used to pushing through that but it may be putting your body at increased risk, particularly your cardiovascular system.
 
I had DKA at diagnosis, like others. Since then when ill it has been useful to monitor ketones when my BG has been high, but have never gone into DKA. It is a case of reacting where levels reach dangerous levels. @Hooky93 has your team explained how to do corrections?

We should all have the facility to test BG even when we are using sensors, but I agree with others that if you are off the scale, you definitely need to be doing something to bring your levels down, and drinking lots of water. We should also be able to check for ketones. This can be sticks that are dipped in urine, which are very cheap, or in some cases Blood ketone strips. If you use a reader with your Libre this can be used as a BG and BK meter.

Like @SimonP I would use corrections to bring levels down and keep monitoring as they drop. If my levels are very high I find I am more resistant to insulin so I found I needed to alter my corrections the higher my BG was.
 
DKA is more likely if you use a pump, because if the pump fails you have no background insulin and levels will rise very quickly. But other than that I agree that whilst it’s useful to be able to check ketones, we very rarely do as a short-lived high will come down again with insulin and so will ketones. Although you may need more insulin if ketones are present, so I guess it’s useful to know that. i think you’d have to be at least in the 20s for many hours to be at risk of DKA.
 
Yes, I can now see the risk for those on a pump who would have no insulin on board at all. I was just idly curious as to how quickly it happens really.
rebrascora said:
PS. I would be concerned about exertive exercising when my levels were mid teens or above. That is putting a lot of extra strain on your body. I feel the extra effort when my levels get above 10. I am sure you are used to pushing through that but it may be putting your body at increased risk, particularly your cardiovascular system.
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High blood glucose isn't good for you, that's a given, but is there any reason to think that it's any worse while exercising? My preference to drop BG if I am running high is to do some exercise if possible, but if there's some reason that it's not a good thing then I'll have to rethink my approach.

Obviously I don't aim to run high on a planned ride, but sometimes it happens (re my initial comment about being off-scale high)
 
SimonP said:
Yes, I can now see the risk for those on a pump who would have no insulin on board at all. I was just idly curious as to how quickly it happens really.

High blood glucose isn't good for you, that's a given, but is there any reason to think that it's any worse while exercising? My preference to drop BG if I am running high is to do some exercise if possible, but if there's some reason that it's not a good thing then I'll have to rethink my approach.

Obviously I don't aim to run high on a planned ride, but sometimes it happens (re my initial comment about being off-scale high)
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I think the risk of DKA is higher when ill or, as said, if a pump fails or there’s some issue with it.

Regarding exercise with high blood sugar, I was told not to exercise if above the 13s. I once went to a Type 1 education day where we had a great, and very detailed, session on exercise. The man who ran it had slides demonstrating why exercising with high blood sugar was bad. I don’t remember the very detailed description but, in simple language, he said that exercising with high blood sugar could create toxins that ‘poison’ the body and this was potentially dangerous and inadvisable.
 
Inka said:
I think the risk of DKA is higher when ill or, as said, if a pump fails or there’s some issue with it.
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There have been warnings that COVID-19 has caused raised Ketones even with fairly normal BG. (I don't know whether that's still the case. It's possible that the earlier observations were mistaken in some way or don't apply so much to people who have some immunity or with current variants.)
 
Inka said:
I was told not to exercise if above the 13s. I once went to a Type 1 education day where we had a great, and very detailed, session on exercise.
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I’ve heard this too (though only as a general rule of thumb, and without the detail, which sounds helpful).

Increased risk of DKA with an insulin pump was stressed in my pump introduction (and pre-pump assessment / conversations).

I believe that basal gives some limited protection against DKA, but I think there are lots of DKA admissions every year of people who have taken some insulin, just not enough.

I remember a time a few years back when @Northerner had a dreadful time with a stomach upset, and high ketones which I don’t think ever quite moved into DKA, but came close at some points I think. I’m not sure if Alan was taking basal throughout?
 
If you have a Libre 2 reader, Abbott can supply both BG reading strips and ketone ones which both fit said machine. Every single glucometer I have ever had since the first one I bought (which we had to then as not yet available on the NHS) though my GP who was aware I'd used my birthday money for one was full of glee when he told me a bit later that I could now get the test strips on prescription! - has read up to c.33.3 maximum and mine still does that now. So I'm pretty stunned hearing a fellow T1 saying theirs doesn't. No idea of the max BG limit of the Abbott machine since I've never needed to use it for BG, only ketones. (and to read my Libre)
 
SimonP said:
Moderator Note: This was split away from an earlier thread to allow the discussion to continue without distracting from the original thread: https://forum.diabetes.org.uk/boards/threads/glucose-monitor-with-a-high-range.108182/

On a couple of occasions I've got my pre-ride bolus very wrong and wondered how far above the off-scale high number (<22 .4for the calibration I was running last time) my blood glucose actually is, but I take a little bit of bolus insulin and keep riding and it comes down fairly rapidly.

I don't want to take the thread too far off topic, but how prevalent is DKA really for those who are using insulin? As long as you have some insulin on board (like your basal at the very least) and don't ignore it for multiple hours does it actually happen? There seem to be lots of people worried about suffering from DKA when their BG is even slightly elevated, I'm curious as to whether this is new guidance.
Click to expand...
Hi in march 2021 I was admitted to hospital with high glucose it was in the 40s, that is when I was diagnosed. My DKA readings were between 3 and 7. It took 11 days to regulat my readings. My treatment is Lantis, Novarapid and Metformin which keep my DKA reading at 0.3. By the way I am type 3c, brought on by cancer and diabetes is a side efect from my immunotherapy treatment
 
SimonP said:
High blood glucose isn't good for you, that's a given, but is there any reason to think that it's any worse while exercising? My preference to drop BG if I am running high is to do some exercise if possible, but if there's some reason that it's not a good thing then I'll have to rethink my approach.
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I think it is down to how your body works.
High BG causes a strain on your body. If you add exercise to that strain, it can push your BG higher. I can walk with BG in my teens but anything beyond a gentle stroll would be counteractive to my BG lowering. A cycle ride or run would definitely push them higher even though they could cause a hypo below 10 if I wasn’t topping up with glucose or suspending my basal.

That said, in 20 years, 8 of which have been on a pump, I have never DKAed. I agree the risk is higher on a pump but with a CGM, you are more likely to be alerted.
 
No - neither have I - though obviously the first few years I was only boiling up pee (one jab a day of Wellcome Foundation porcine Ultralente - hadn't invented non animal insulin nor MDI) and as it was a rare event the result in the test tube was blue - most likely sailing a lot closer to the wind than ideal. So whether it's CGM or glucometer, BG in the teens, the machine tells you - and then beeps at you in another 10 or 15 minutes to test again and see what your BG is doing now. Very insistent beeping. As long as I've delivered myself the requisite correction dose (or hypo cure) I never actually rush to re-test, cos nowt much happens with such great haste with my BG ! I know I've taken the appropriate action. I also know what I did usually works cos I've done it so many times. No point whatsoever panicking now this minute - A&E are open 24hrs a day! and although it isn't healthy long term - I'm really not at all likely to drop dead or even be comatose any time soon.
 
Interesting all round, thanks for your thoughts.

I also remember boiling blue tubes very early on, and while I did have some ketone test strips many years ago, and there was a vague warning that one should be careful with extended periods of high blood glucose (which I think was pretty much a given anyway), I'd since forgotten all about it until joining this forum and reading lots of posts with concerns about testing for ketones.

I also remember reading that one should not exercise with BG above mid-teens, though with only a vague explanation that from this point exercise could increase your BG rather than reduce it, which is not what I find, which is why I've ignored that advice in the absence of any other reasoning for it.

I will do some reading and see if I can establish why that recommendation was given and report back with what I find.
 
As I understand it, when levels are higher the blood becomes more viscous (syrupy if you like) and that puts more of a strain on the heart and blood vessels, so doing strenuous exercise on top of that can cause something somewhere to be more at risk of going pop!...that is a technical term. 😉 I think it is reasonable to inject insulin and go for a steady walk when your levels are high assuming you are relatively fit, but I am not sure I would be injecting insulin and pushing on with a cycle ride, as to me that is going to cause a rapid change whilst your body/blood vessels are already under stress. I have no research or study to quote to back that up. It just feels intuitive to me to not put my body under that much stress.
 
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