After Diabetic Ketoacidosis

Type 1 and LADA
1

I can’t seem to find much information online regarding post DKA advice.

I was discharged from 3 days in ICU 5 days ago, and my insulin requirements have almost tripled. My basal was 11.5-14 units and my bolus was 1:10. I’m now working with 1.5U per hour basal (36 units) and my I:C is 1:5 and I’m still not getting control. I’m scared to use even more insulin, as I have never needed this much and I live alone. To avoid going super high, I’m eating nuts, cheese, meat and lettuce and not much else. I still fee very weak, and I can’t see my Endo. until the 25th.

Is it normal for my insulin requirements to go up so much? I tried switching insulins, putting on a new pod… I can’t think of what else to do. I don’t feel strong enough to exercise yet, and my resting heart rate is still hovering around 102-108 (it was 145 in the ER). I am out of the potassium supplements they sent me home with. When I left, my pH was 7.0 and my potassium was still low. My bi carb had gone back to normal. I feel like maybe I was sent home too early?

Please offer any advice.

Thanks,
Rose

2

My number one advice would be to get back on those potassium supplements ASAP (like yesterday!) if you are still supposed to be taking them. Potassium is one of the most important electrolytes involved in maintaining a healthy cardiac rhythm. Having a potassium level that is too low or too high is dangerous…

3

That’s part of the problem…IDK even know if I should still be taking them or not (like if I should be getting some more). The hospital gave me a certain amount, they are now finished, and I don’t see my Endo. until the 25th.

I have no way to know if I should take more potassium or not until I have more blood work and see my Endo.

Could my sudden increase in insulin needs mean I need more potassium? I feel completely clueless and a little scared. I don’t know how to handle this.

4

Please call your doctor’s and ask what u should do?

5

This should have been noted on your discharge instructions just before you left the hospital. If you still have this paperwork, look it over to see if the information is there. If not, I’d contact the hospital and ask them (ask for another copy of your discharge instructions and/or ask them if you should still be taking the potassium supplement. If the answer is “yes”, tell them you need a prescription if this is not something you can get over-the-counter. Be sure you get the correct dosage.)

6

Low electrolytes are part of DKA. You basically become severely dehydrated and your electrolytes like sodium, potassium and magnesium get peed out and become depleted. It is prudent to get adequate levels of all these electrolytes, preferably from food but you can also take over the counter supplements. And actually a low sodium level makes you insulin resistant. Were you low on sodium as well? Even if you left with restored sodium levels you might be prudent to use a bit of extra salt, people with normal kidney function should be fine with a bit of extra salt.

I am not aware of low potassium being involved in acute insulin resistance like sodium. Insulin resistance for a period of time after DKA is a natural consequence probably from a number of reasons beyond sodium. If you have normal kidney function then taking over the counter supplements (like potassium) at recommend dosages should be fine although not necessarily effective. But the real thing is that the high blood sugars and high levels of insulin may have left your body insulin resistant and it may take some time to really normalize. It is not unreasonable to think it may take some days, so I would urge you to be patient. Certainly check with your doctor, but patient waiting is probably the cure.

It certainly makes sense to see what your discharge orders are and check with your doctor on your potassium levels. But I would also caution you away from thinking that potassium supplements are very useful and recommend just a balanced diet. Most OTC supplements of various kinds give you 100% of RDA, but potassium supplements are really weak. You need about 5,000 mg of potassium each day. Most OTC potassium supplements give you about 100 mg in each dose so you may need to take a lot, in fact 50 pills a day, to fully replace potassium in your diet. While prescription potassium supplements like Klor-Con do contain enough potassium that you can take one or just a couple pills per day I have to ask why anyone pay extra rather than dealing with it just by making some dietary choices. There are many much more potent food sources of potassium. A cup of cooked spinach contains nearly 1000 mg of potassium. I’m just saying a balanced and prudent diet containing high potassium foods is probably all anyone needs.

ps. You should talk with your doctor to see if there are other reasons for low potassium, for instance diuretics, SGLT-2 drugs and birth control pills can cause problems. My potassium problems stem from diuretics and SGLT-2 drugs.

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7

Thank you, Brian. That makes sense. I have already seen a slight decrease overnight I went from 1.75 units all day to 1.00 unit per hour and woke up at 4.9. I have also written my Endo. for further instructions until I see him.

8

Hi @Rose_Rose,

Do you have thyroid issues? I do, I’ve experienced flare ups with hypothyroid and hyperthyroid. With hyperthyroid flare ups a high resting heart rate is common even tachycardia. Although, unless you are losing a lot of weight without doing anything really, hypothyroid issues sounds more common, severe fatigue is common with both. I would have your endo do a thyroid panel on your blood test. I have Hashimotos Hypothyroid and have had bouts when my thyroid was “exhausted” where my symptoms were similar to yours. I did switch insulins went from Novolog to Humolog and that helped a little, but it was about getting my thyroid back in line. For me, it just took time and meds.

The thing about ERs is that they are there to treat emergencies, if you are stable, they will cut you loose. Extensive blood work and diagnosis is for your primary/endo’s office.
I know you said you have an appointment scheduled, can you get in sooner? Going to the ER is usually considered an emergency visit for my endo’s office and they will see me sooner, especially for DKA. I would push to get in sooner.

Give us updates to see how you are doing.
I wish you the best,
Busybee

9

Hi Busybee,

No, I have normal thyroid (tested a couple months ago). My resting heart rate is now normal, as is my blood pressure. I wrote my Endo., but he did not answer me. I will have to wait till next Thurs. for my blood work, but I will take a look at the results online before I see him.

I am still taking double what I normally take. It’s very frustrating to not know why. I’m back to work, resuming normal activities, feel okay, eating impeccably, exercising, but my insulin requirements remain doubled.

My Mother has been staying with me and we check middle of the night, and bought a glucogen pen to be safe. I have never taken this much insulin–not even after my initial diagnosis. I really hope this isn’t my new normal and that things go back to how they were before. I’ve also gained 3 pounds (probably because I’m suddenly taking so much more insulin).

Is there anything I can do to increase my insulin sensitivity/decrease my IR?

10

Have you also tried moving your pods to areas where you don’t normally place them? Also, the literature indicates a faster take-up when the sub-Q insulin is delivered in the abdomen.

I would have extra glucose available and be a bit more aggressive on increasing your basal rate. I doubt that this is your new normal, but as the longer you go with running high, the longer it will probably take to get back to your old normal. Plus, I don’t believe we have a fixed normal. I play with my basal rates on a fairly regular basis.

11

I’ve tried 3 different areas for my pods. Right now, it’s on my abdomen, which has always been the most absorbent for me.

I’ll try increasing my basal rate even more.

I wonder if my Endo. will allow me to take Metformin while I’m adjusting or something that can help. 3lbs isn’t a big deal to me vanity wise, but if I start gaining more weight, it’s just going to make it even harder because then I’ll need even MORE insulin.

12

I’m glad to hear your thyroid numbers were normal a couple months ago. I would still have it tested. Even slightly elevated numbers could point to an imbalance somewhere.

Having experienced pregnancy 4 times, I have to ask, could you be pregnant? Might be totally out of your realm, but sometimes someone needs to ask. Please do not take this as an insult. Its that with pregnancy brings increased insulin needs. That is the only reason I ask.

Its a good idea to have another person that knows you around you during this time. So is having the glucogan kit just in case.

Having been through bouts of insulin resistance, which are so frustrating, I totally understand how you feel right now. I feel so out of control. Maybe things are never really in my control with diabetes, but for the most part, there is a large illusion of control for me most of the time. When IR comes my way, it throws me a curve ball I find difficult to handle. As for the increasing your sensitivity, I try to workout- when I say workout, I’m kind of hard core. I lift weights, weights build muscle and muscle burns more calories than fat. Cardio will only get you so far. Its good to do for a warm up or walking too. Walking after meals is good, for about 30 mins. Sometimes, I’ve noticed at certain seasons in my life, eating over a certain amount of carbs sendings my BGs sky high. Sometimes over 40grams-60grams a meal of carbs is too much. Not sure what you clock in at for carbs at each meal.
You mentioned you are on the omnipod, unfortunately, I dont know enough about that system. I’m on a medtronic pump and they have different infusion sets. I switched to a different infusion set and found relief or a break. I had to go with a longer cannula.
Not sure what your eating schedule is like, sometimes i’ve had snacks 30 mins to 1 hour before bedtime to stave off lows in the am, but I have found consistently not eating after 8pm or sometimes 9pm keeps my weight stable. Eating too late into the evening/night can also cause unwanted weight gain and IR.

Lastly, the last time had this issue, I had given birth to my 3rd child a year prior and had major issues losing weight. My doctor prescribed Invokana and it helped a lot. I lost 25lbs in 4 months and reduced my basals, sensitivity, and carb ratios significantly. It helped me a lot. Maybe bring this up with your endo at your appt?

Maybe its time to consider different pump/insulin system other than the omnipod? Just an idea.

I know I’ve thrown many ideas your way, take it one step at a time. Don’t try multiple things at once, you need to know what works and what the source was. I would document the changes you make and for how long and when.

This is all I can think of for now. I wish you the best.
Busybee

13

I’m back to normal! I took time off work and focused on getting lots or rest, keeping my stress down, drinking lots of water, exercising every day (cardio/weights) and light walking after each meal. I also ate three meals no snacks and kept everything really, really low carb (under 30g a day) to avoid taking even more insulin. I was losing my mind–scared I’d never return to my usual insulin needs. All in all, it took me about 2 weeks to get back to my normal numbers. I think I would have taken even longer, had I not worked out and kept food intake very strict. Scary to feel so out of control.

Thanks to everyone who replied and offered comfort/advice!

:slight_smile:

2 Likes
14

so glad to hear it @Rose_Rose! :wink:
Thank you for the update.
Busybee

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