Obscure levels - advice welcome!

[Ivostas66]

Good morning all,

My levels have been really stable for some time and I even managed 99% in range for almost all of last week (averaging around 6.2). That has all changed, drastically, over the past three days.

After eating a few days ago, I checked my BG prior to bed (around 7mmo/l) and happily nodded off. Checked my levels when I woke and it had rocketed to high 20s in the night, levels I have not seen since diagnosis almost 4 years ago. I have spent the next couple of days unsuccessfully trying to get back in range. Corrective doses were having no impact and so I changed my pen (just in case the insulin was compromised). The first injection caused me a huge hypo yesterday, although Librelink was not scanning - which apparently happens when BG is plummeting. Mrs J found me covered in sweat and incoherent in the kitchen. 4 Jelly Babies caused me to head up to 19 though, which makes no sense. Checked my BG last night as I was sweaty and shaky, Libre said I was 4.8 so I had a couple of Jelly Babies, but rocketed to the mid teens again. Chemist has offered to change my batch of insulin, but that will take a couple of days as they do not stock FIASP and have to order it. DSN was not able to offer any advice other than to keep checking BG regularly and that I might be ill (I feel perfectly fine other than symptoms of hypo and hyper).

Help!?!

 

[Inka]

How long did you wait for the corrective doses to work before you changed your pen and corrected again? Could the insulin have stacked? When you’re high, it can take 3 or more hours before you see your blood sugar start dropping.

Going up overnight suggests a possible basal issue. What basal are you on? Are you sure you injected the basal that day? Have you changed your basal cartridge/pen too?

All you can do is monitor (I’d finger-prick personally) and see how things go.

 

[helli]

Sorry your diabetes is misbehaving at he moment @Ivostas66

I too use Fiasp and do have some issues when my levels are high. I find that it takes longer to react when my levels are high and then suddenly drops. I have to be careful not to rage bolus and stack because it appears not to be working.

Have you checked your Libre readings with finger pricks before correcting?
Libre is inaccurate when high (and low).

 

[rebrascora]

Sorry to hear you are having a rough time. You haven't had your Covid vaccine recently have you, as that caused BG upheaval for some of us?

I'm with @helli. My Fiasp often doesn't appear to work when levels go high and eventually I will get desperate and jab in a bit too much (rage bolus) and then it's like all that insulin that was sitting doing nothing for hours suddenly gets it's act together and hits my blood stream on mass. I also need a bigger correction factor when levels are above 10 and probably bigger still above mid teens, but thankfully I haven't been there since I started Fiasp. I find a bit of exercise after corrections with Fiasp can make it more effective (or get it going if it is sitting there doing nothing) Best to be conservative and give it time but we all know how easy it is to get frustrated and jab a bit more, especially when the first couple of corrections look like you injected water. I wonder if Fiasp is affected more by insulin resistance than other QA insulins.

It may be that your basal needs are changing. The days are getting shorter so that can trigger an increase in basal needs or it may be that you have an infection brewing, if the vaccine in not the cause, but I would look at your basal dose.

 

[Ivostas66]

Sorry your diabetes is misbehaving at he moment @Ivostas66

I too use Fiasp and do have some issues when my levels are high. I find that it takes longer to react when my levels are high and then suddenly drops. I have to be careful not to rage bolus and stack because it appears not to be working.

Have you checked your Libre readings with finger pricks before correcting?
Libre is inaccurate when high (and low).

I think because my control has been good, I have nor noticed the issue with FIASP and high levels. I moved to FIASP earlier this year as my consultant and DSN were finding that Novorapid was anything but rapid with me.

I actually found that all of my testing strips and cassettes for finger pricking were out of date and so borrowed one from another type 1 who conveniently lives next door. The levels were surprisingly similar.

I have switched to my new sensor today (three days early) to see if that has any impact. It's actually the first Libre 2 that I have used and I had an alarm just whilst out, which was extremely helpful in avoiding a hypo. I have been 'in range' from 10am this morning. I am hoping things stabilise, but will just keep monitoring as best I can.

 

[Ivostas66]

How long did you wait for the corrective doses to work before you changed your pen and corrected again? Could the insulin have stacked? When you’re high, it can take 3 or more hours before you see your blood sugar start dropping.

Going up overnight suggests a possible basal issue. What basal are you on? Are you sure you injected the basal that day? Have you changed your basal cartridge/pen too?

All you can do is monitor (I’d finger-prick personally) and see how things go.

I was waiting about an hour between corrective doses - that was the advice of my DSN too as I had asked her if it might be worthwhile injecting sooner. The rise last night has baffled me as 1 jelly baby to correct a low level should not have led to a reading in the teens throughout the night.

This is all very strange as I have had issues with post prandial spikes in the past (helped considerably with a move to FIASP) but never periods where I am high and cannot bring levels down.

 

[Ivostas66]

Sorry to hear you are having a rough time. You haven't had your Covid vaccine recently have you, as that caused BG upheaval for some of us?

I'm with @helli. My Fiasp often doesn't appear to work when levels go high and eventually I will get desperate and jab in a bit too much (rage bolus) and then it's like all that insulin that was sitting doing nothing for hours suddenly gets it's act together and hits my blood stream on mass. I also need a bigger correction factor when levels are above 10 and probably bigger still above mid teens, but thankfully I haven't been there since I started Fiasp. I find a bit of exercise after corrections with Fiasp can make it more effective (or get it going if it is sitting there doing nothing) Best to be conservative and give it time but we all know how easy it is to get frustrated and jab a bit more, especially when the first couple of corrections look like you injected water. I wonder if Fiasp is affected more by insulin resistance than other QA insulins.

It may be that your basal needs are changing. The days are getting shorter so that can trigger an increase in basal needs or it may be that you have an infection brewing, if the vaccine in not the cause, but I would look at your basal dose.

Thank you for that. I have been fine on FIASP since I switched earlier this year and found it much quicker acting than Novorapid that I was on previously. However, my BG is rarely higher than around 10 and as such I have no experience until now of it not impacting upon my BG levels. I inject 8 units of Toujeo each morning in the spring and summer, but tend to increase to around 10 units in the late autumn and winter. I shall keep an eye on things over the next few days - hoping this is sorted before I am back at work next week.

I had my vaccines quite some time ago and as such I doubt very much that it is linked. I also test regularly as my father in law who is unwell has only been allowed 1 vaccine as his illness is one where second vaccines have had a negative effect upon sufferers.

 

[Inka]

I was waiting about an hour between corrective doses - that was the advice of my DSN too as I had asked her if it might be worthwhile injecting sooner. The rise last night has baffled me as 1 jelly baby to correct a low level should not have led to a reading in the teens throughout the night.

This is all very strange as I have had issues with post prandial spikes in the past (helped considerably with a move to FIASP) but never periods where I am high and cannot bring levels down.

Are you sure your DSN said that? I think it’s very unlikely so perhaps they weren’t clear or you misunderstood? Some DSNs actually advise leaving it 4 hours. If you correct, then correct again one hour later you run the risk of a massive hypo as the first correction won’t have started working or, indeed, finished its peak. So each correction mounts up - known as insulin stacking - then each correction starts working in turn and you potentially have a cascade of insulin leading to prolonged hypos over a number of hours. This is potentially very dangerous.

An example - your blood sugar is 18, you take a sizeable correction dose. One hour later your blood sugar is 18.1 - you then take another sizeable correction dose. Another hour later, your blood sugar is now 17.5 - still high, so you put in a third large correction dose. You test at 3hrs after your initial blood test, and your blood sugar is now 13 - better but still too high, you think, so in goes another correction. 20 minutes later you start feeling weird and sweaty - the cascade of corrections has started and all those doses you put in are now starting to work. You’ve actually had far more insulin than you need (because you didn’t leave your correction long enough to work) and you spend the next few hours stuffing down glucose and snacks.

That’s the optimistic version.

 

[Inka]

FiAsp doesn’t suit some people and for some suddenly seems to stop working. Google “FiAsp like water”. So perhaps that’s contributing to your highs too. Humalog is generally faster than Novorapid and doesn’t have the problems associated with FiAsp, so you could always change to that if your problems continue.

 

[helli]

I actually found that all of my testing strips and cassettes for finger pricking were out of date and so borrowed one from another type 1 who conveniently lives next door. The levels were surprisingly similar.

Did you check at a random time or do you always check when you were high (or low) before correcting?
Many people find Libre is most accurate when our bloods are behaving. When I go high (double figures) Libre over estimates my levels so I need to check with a finger prick before correcting. Likewise, lows, especially at night, could be compression lows so should be checked with a finger prick before treating a hypo.

 

[helli]

FiAsp doesn’t suit some people and for some suddenly seems to stop working. Google “FiAsp like water”. So perhaps that’s contributing to your highs too. Humalog is generally faster than Novorapid and doesn’t have the problems associated with FiAsp, so you could always change to that if your problems continue.

I think it is one of those cases where we are all different.
Humalog made NovoSluggish look like a thoroughbred race horse for me.

 

[Ivostas66]

Did you check at a random time or do you always check when you were high (or low) before correcting?
Many people find Libre is most accurate when our bloods are behaving. When I go high (double figures) Libre over estimates my levels so I need to check with a finger prick before correcting. Likewise, lows, especially at night, could be compression lows so should be checked with a finger prick before treating a hypo.

I checked when I was low and also when high. The thing that stands out is that a scan of lower than four followed by a correction does not always show on the Libre graph as being that low. I have had discussions with DSNs when I told them I hypo'd and they then say - we class a hypo as a reading below 4, and you were above 4. When I tell them to look at the log they see the 'red' levels, and then hopefully realise I am not making it up.

 

[Ivostas66]

I think it is one of those cases where we are all different.
Humalog made NovoSluggish look like a thoroughbred race horse for me.

One of the dieticians I have worked with referred to Novorapid as Notveryrapid and received a telling off from the DSN! I was warned that FIASP can have a sting in the tail. Maybe that is what has happened a couple of times in the last few days.

 

[helli]

The thing that stands out is that a scan of lower than four followed by a correction does not always show on the Libre graph as being that low.

Libre uses interstitial fluid rather than bloods and this is 15 minutes behind.
The algorithm Libre 2 uses attempts to predict the current value. This is great most of the time but can be an issue when the direct of the trend changes such as correcting hypos.

 

[rebrascora]

Whilst I find that sometimes it seems like I have injected water, it usually does kick in eventually (could be considered a sting in the tail) but it seems to almost "get stuck" somewhere and need a second or third dose to kick it into action or as I said before, some exercise will usually help to set it away, particularly when levels have got into double figures.

I am quite pleased that I persevered with Fiasp beyond the 3 month period when I really wanted to kick it into touch and go back to NR. It has taken time to get a feel for how it works and to be brave enough to use more than I would like when it needs it. I do feel that I have to be more "generous" with it than NR but I gain some pre-bolus time when my levels are in range. If I take my eye off the ball and levels get too high, then it is always a battle to get them back. These days I often do corrections between meals at 8 if the arrow is heading upwards but my low carb diet influences that tactic. Obviously if you were eating carbs which would spike you above 8 then that might be dangerous.

The thing that stands out is that a scan of lower than four followed by a correction does not always show on the Libre graph as being that low.

I don't understand what you mean above.... Surely you wouldn't inject insulin when you are low...... Or do you mean a hypo treatment. If so, then the Libre has an algorithm which tries to predict ahead what your level will be to compensate for the delay between BG and interstitial fluid. If the next readings are above 4 then it is almost like it edits the hypo out..... usually because you were never actually below 4 in the first place. My Libre usually reads 1 mmol lower than BG at the lower end of the scale anyway.

As regards your levels bouncing back up into the teens after just 1 or 2 Jelly Babies it may well be as a result of the liver dumping glucose as a response to rapidly falling BG levels, particularly if you had a bad hypo.

 

[trophywench]

Well sadly judging by a lot of the pre/post meal readings on Libre sensors it looks like Novo isn't working within 10 minutes any more (though the current one bled like stink when it was inserted and has been far from accurate ever since although it certainly does read, just not anywhere near BG even for obviously allowing for the 10 min or so time lag. I haven't rung Abbot, as one couldn't possibly allege it's a faulty sensor - plus of course I hadn't got any more and not time to order new ones. I now have 2 more so when I have a shower later both it and a new pump cannula/ refilled reservoir/pump battery will all get sorted)

To pre bolus, it means you need to know how much of what you are likely to eat at mealtimes that far in advance, which kind-of looks like a couple of hours and I usually don't even think about it until 2 minutes before I go to start preparing it!

Lunch would be easier because that's normally a sandwich plus whatever happens to take my fancy be it a few out of Pete's bag of crisps or a slice of his cheese/bacon roll (ie a sausage type roll c. 3ins long) or half an individual pork pie with cheese pastry or ditto a pork & pickle one. Medium sliced 50/50 so roughly 38/40g carb. But then - still got to remember to test BG at 11 am and tell lies to my pump (via the handset/meter) to have the bolus - which is potentially perilous as it would tell a paramedic I had my lunch and insulin at 11 am when I pass out in the high street alone & hypo at 12 noon!

 

[Inka]

I think it is one of those cases where we are all different.
Humalog made NovoSluggish look like a thoroughbred race horse for me.

Yes, we are 🙂 My “generally” was carefully chosen

Different insulins suit different people and it’s important that everyone has the option to get the best insulins for them as an individual.

 

[Ivostas66]

Update...I have been in range from around midday yesterday, which I am really pleased with. Small steps and all that! Went to bed around 7mmol/l and woke to an 8. Going blackberry picking with my daughter later and then thought we'd bake a few pies for the neighbours this evening.