DKA caused by Apidra "allergy"...?

T1 for 23 years, Apidra with Revel Pump & intermittant CGM. Intermittant insulin resistance thought to be caused by hormonal changes (female cycles)

This is my 4th bout with DKA over the 23 years of being T1. The first time was from the flu, the other two times were directly related to being overstressed (19 hour days, not paying attention to food intake, and high stress work environment). THis time is different though - I don't know what the cause is nor do the docs, but we have a few guesses.

I'm wondering if anyone else has experienced anything similar. Still in the ICU as I type this, but on my way out once I can appropriately demostrate that I can sustain my own bloodsugar levels with just me and the pump. Here's what lead up to this mess.

Been eating the same diet for 5 weeks for weight loss and BS control:

Mon-Sat:
Brkfast:
Organic, veg fed, no antibiotic eggs
preservative/additive free,uncured bacon

Lunch & Dinner:
1/4c - 3/4c organic pinto beans, red kidney beans, or lentils
20-30g protein - usually organic, clean chicken or grassfed beef
Salad - veggies only, no dressing OR broccoli/green beans

Sunday ("Free Day"):
Brkfast: Same as above

Lunch & Dinner: Food at will, but not exorbitant, meaning I may
have a chocolate chip cookie or two, and a slice of pizza, but not
the whole bag of cookies, or the whole pizza etc.

Last Tuesday, eating regular weekday menu, I woke up at 280. All day I fought to keep it from continuing upward. Increased basal to 125%. Tuesday evening, the insulin resistance subsided, figured whatever it was had passed.

Wednesday evening insulin resistance started again and proceeded to get more resisant throughout the day. Started with an increased temp basal of 110% and throughout the day ended up at 140% which would only keep me around 250, couldn't get it any lower than that. Happened to have 3 month check-in with Endo who put me on Metformin which I had never had before. Took 1 - 500mg tab before bed and set my basal to 130%. Throughout the night my BS remainded around 350. I turned up the basal rate back to 140% and told the BF to make sure he woke me if any pump alerts went off. By 3:00am I can't sleep and BS won't come down below 350. Throughout the night I'm also doing finger sticks besides watching the CGM and taking boluses accordingly. By 6:30am it is clear I'm headed for DKA with the physical discomfort I'm now feeling (nauseau, dizzyness, all over body-aches).

Go to Hospital and DKA is coming on FAST. After the first day of my pump and IV treatment they say no more pump, IV with Novolog only. Primarily b/c BS isn't moving much. The DKA is reversing, slowly, but my numbers aren't coming down. Once they take me to 100% Novolog, BS responds as it should. We are getting consistent 100/110 BS readings for several hours, serum keytone levels are back to normal and electrolytes are pretty again. Now this is were it gets funky. At this point I am stable. My body has demonstrated that it is no longer in DKA and my BS is responding favorably and as expected, so they put me back on the pump exclusively - no more IV treatment, just Medtronic and me. Early morning today, I start out with 102 BS from the IV therapy, then switch to pump/Apidra only set-up and self-evaluate my BS. BS is going up. I haven't had anything to eat or drink except water. BS is going up, and not just kind of up, but up, up up - to just under 400. I Take my basal rate to 3 units/hour which showed great results with the novolog IV therapy, no results with my Apidra/Pump set-up. Get bf to run home for new, sealed Apidra, to rule out the posibility of a bad bottle - same thing, no BS changes.

At this point we, the nurse, doc, bf and I, are all grasping at randoom unknown factors. We end up switching back to 100% novolog, no more Apidra via my pump. Dramatic, favorable results ensue. Discharge is geting closer. BS was 87 at last check.

So - what the heck? Once I'm home I will check the batch numbers on all of my Apidra bottles to see if they are from the same batch. But if they are from different batches... is it possible that a certain type of insulin will not "play well" with my body when it has for 2+ years before? And what about this coming on so suddenly? Has anyone else experienced anything like this? This all seems so strange.

Notes: Metformin was stopped by ICU doc siting Metformin sometimes causes acid/base problems. This doesn't appear to be the issue here, but might have contributed

BS prior to this unexplained episode have been below 200 and predictable.

I'm female and hormones were thought to possibly be the catalyst for insulin resistance, but that doesn't explain the favorable results with the novolog vs. Apidra.

Anytime your BG will not respond to a correction you should correct using a syringe change infusion set and reservoir. It's not uncommon for someone using a pump to have unexplained high BG, insulin absorption issues, infusion site rejection, and infusion sites that just refuse to work and not a clue why. I would not recommend turning up basal to correct Hyperglycemia. High BG can cause insulin requirements to skyrocket...double or even higher.

Your IV insulin requirements would be much lower than with sub-Q insulin to maintain the same blood sugar.

Note: If my first correction does not work with my pump then the next one is with a syringe. My ISF (correction factor) doubles at 300 and triples at 400, I will always use a syringe when my BG is 300+.

Sorry you're in ICU. Know firsthand how utterly horrible DKA is. Glad you're doing so much better.

Second John's suggestion. With stubborn highs, use a syringe & inject in a new spot. Not uncommon for scar tissue from pumps to cause absorption problems. Also agree with John that IV insulin produces quick & more predictable results. No absorption issues with IV.

Thanks for the insight. I'll have to get some syringes - haven't used one of those in a while.

After some thinking and weighing of all the data points, the ICU doc, my endo, and I have come to realize that my body must have generated anti-bodies to Apidra. Evidently this is not unheard of with medications, although this run-in for me seems a bit abrupt and rather violent. But my body has made its point and so for me, I will be changing types of insulin every year and a half to 2 years from here on out.

Aprida is known for crystallizing in pump tubing, Esp in the hot weather.
I tried it for several months and I like how fast it is, but I would have to switch off it for the summer because it would clog and not deliver.
Medtronic told me that it is not recommended in their pumps. This was more than a year ago, so I don't know if that is different now.

I do know that many people have this same trouble.

I get DKA very fast, just having my cannula come out for an hour can start it,

If I were you I would switch to Novolog or humalog. I use novolog now all the time. It has good track record even on hot days.

I have no personal experience with Apidra, I use Humalog, but I've wanted to try Apidra for sometime but my Endo does not seem very keen about it at all. No specific reason given. A friend of mine with insulin resistence could take Apidra at some really scary amounts, and it was like injecting saline. Nothing would happen.

I think your experience with both insulins does proof that you are right. This leaves many questions but most importantly you have found a solution. Something to keep in mind for using apidra in pumps.

I know the feeling of DKA and I know it hits me fast, I have had it even below 200.
Usually it happens when my pump cannula comes out without me knowing.
It starts with me feeling a little sick and my sugars being high, Then my sugars do not respond well to correction, and the sickness gets worse,
I usually need double the insulin for a while to get clear of it. I think it is the PH that causes me to get sick, but I don't really know. It does not occur unless there is NO insulin for a time, That is why it very rarely happens to people on MDI.( on basal insulin like lantus)
I never had it occur until I went on a pump.

I have never needed to be hospitalized for it ( knock on wood) I am grateful that I can feel it coming.

On the whole metformin thing. Metformin is "contraindicated" for patients with DKA or who are at risk of DKA. The combination (metformin and DKA) significantly increases the chances of Lactic Acidosis occuring, on top of DKA, a double whammy that can put your life at risk.

It would be prudent to talk with your doctor about these risks. It might be good to hold off on the metformin until you are comfortable that your DKA is behind you.

Timothy, Do you have severe dehydration, vomiting, excessive urination, nausea & high ketones being under 200? I also feel ill with high BG, but different than when I was DKA. Only way I can describe was feeling that every cell was poisoned, which it was—acidosis.

I get excessive urination and dehydration when Im over 170. I know it is DKA because i get dizzy and nauseous. There is another feeling that I can't explain beyond the feeling of DKA. It do not alwyas get it, My post was suggesting that you can have near normal sugar and still be in DKA.
You body needs some insulin all the time and if you are getting none you body switches to burning fat.Then the ketones build up. DKA is not dependant on your glucose level but instead by the presence if insulin or lack of it,

Actually, the feeling at 170 is unlikely to be DKA. DKA is a combination of high blood sugar, ketones and acidosis. DKA is really triggered by an insufficiency of insulin which leaves the body "starved" and starts a process where glucagon rises to tell the liver to provide fuel (glucose and ketones). There is no insulin to "moderate" the liver and it goes into overdrive, producing large amounts of glucose and ketones which cannot be taken up (still no insulin). If your liver is producing high levels of ketones and causing acidosis, then it is also producing large amounts of glucose.

Most people start to excrete glucose in their urine at a blood sugar of 160-180 mg/dl (the renal threshold). But I suspect that what you feel at 170 is simply being hyperglycemic, not actual DKA. I could be wrong, a ketone test would show it.