DKA switching back to Humulin R from Apidra

Type 1 and LADA
1

Hi. This is my first post. Sorry it runs a bit long.

T1 for 25yrs. Diagnosed at 8. NPH + R MDI for 1st 15yrs. Things got much better after I swithced from NPH to Lente. Since then, I've been prescribed and injected almost every kind of synthetic insulin, until I started pumping with a Medtronic Paradigm about 3yrs ago. Also prescribed ACE inhibitors, glucophage and amaryl in conjunction with insulin.

A1Cs 6-7 as a kid. 7-9 since adolescence. No complications to this day, and I have remained generally athletic and healthy.

I have had many severe lows, but never experienced DKA until the events described here. I have had severe highs at various points from sickness, bent cannulas, bad batch of insulin, etc. Over the years, I have been 500 - 600 on a few occasions, but just took more insulin and was okay.

I lost my insurance and have been pretty broke, recently. I was in Mexico (best man at my friend's wedding). I bought a bottle of Humulin R at a pharmacy. It seemed legit. Not expired and the seal was intact. I pumped it for a couple weeks, and it worked fine. I just waited a little longer between bolus and eating.

When I got home, I still had some Apidra left over, but wanted to finish the bottle of R. One night after dinner I was up to 500. I took a corrective bolus. Then I threw up. I went to sleep. In the morning, my BS was down to about 170, but I threw up again. Then I was perfectly fine. I figured it must've been something I ate.

About a week later, I woke up feeling bad. My BS was 377. I threw up. bolused, drank water, threw up again. Back down to 300, threw up, bolused, threw up, back to 370. Sometimes, I slept between cycles.

I began to suspect DKA and looked on the internet. I have no insurance and no $. Also, the emergency room situation here is not good. My wife asked if I wanted an ambulance. Instead, I asked her to go to the drug store for urine test strips, potassium pills and gatorade. The urine test confirmed High Ketones. I kept trowing up every couple of hours, bolusing R, and started injecting 5 units at a time of Apidra. I had saved an old box of syriges.

In a few hours, my ketones were negative, and BS returned to normal. The ordeal had lasted the entire day. I threw out the rest of the R, and am back to pumping my Apidra reserves. I am left with some questions: My BS was high, but not that high. The R seemed to work fine, stop working, and then start working again. Have I developed an allergy or resistence to Humulin R, while on Apidra? Anyone had similar experiences?

2

What an ordeal! Good you were able to handle it well yourself.

Since you had no problem with long term R in the past, it doesn't seem likely you'd develop resistance or an allergy now. Typically, an allergic reaction shows at the site of injection. I use both Apidra & R without problems. Sounds more likely that the R lost potency, or was in the process of losing potency even though it wasn't near expiration. Odd that it worked on & off. Perhaps it wasn't stored properly before you bought it. I've had off vials of Apidra.

3

Humilin R is actually human insulin. It is extremely rare to develop an allergy or resistance to human insulin. There are some people who react to the preservatives in insulin, but overall, reactions to the newer modern (non-human) insulins is more common. More likely, your insulin went bad.

Even R can go bad. And you did get it in Mexico. I've actually bought R in Mexico and there were lots of corner stores which had R in little fridges, but I didn't trust them. It is entirely possible that the insulin was not stored properly or was exposed to light.

And sometimes insulin failures can cause high variability rather than just all going bad. Insulin can polymerize and you may not even see it. The insulin molecules start to form little strings and it slowly spreads throughout the vial. And if you don't mix it (we don't usually mix R), then sometimes the insulin will work, and othertimes it will be useless.

I'm sorry you had to go through this, it sounds terrible and frightening. It can be very hard trying to figure out what has gone wrong, particularly when you feel so terrible.

4

Wow, glad you were able to handle that yourself! BSC's description sounds like the most probable. Most importantly, I have learned from this post that you really can handle DKA on your own (in the past, I have always just gone to the ER. Now I know there is a way to treat myself faster).

5

Thanks, bsc. Makes a lot of sense. I did buy it from a fridge in one of those corner stores, and I never checked or mixed the R.

It may have also have had something to do with the infusion site.

It was a pretty bad day, but a good learning experience.

6

I haven't had an off vial since N & R about 20 years ago. Never had any problems with Apidra, either. I didn't notice anthing at the infusion site.

I feel a little different sice I started the pump, though. More sensitive to highs and lows. A couple of times, I had an itchy feeling at the infusion site. When I pulled out the cannula, a ton of blood came out. Almost like I'd been shot. Hasn't happened to me for a while, though.

7

Thanks. I should probably add a disclaimer that this isn't necessarily the safest way to handle DKA. I felt pretty confident, but would have gone to the ER if my BG went much higher. It would have been nice to have had an IV handy. Hopefully, this was the first and last time.

8

Bernstein actually recommends using intramuscular (IM) injections to perform corrections. They can act much faster than a regular subcutaneous injection. If I had a very high blood sugar and the onset of DKA I would not hesitate to use an IM injection. Bernstein uses his delts on his shoulder, I just use my thighs and just go right into my quads. Then I can walk around to get the blood flowing even more.

9

10

Is that for all corrections including the common half to one unit to get back to where you want to be when your'e somewhere between 140 and 180?

11

I recommend reading the book. There is no reason to wait for a correction.

12

Absolutely.

13

I pump and have no interest in using my back-up pen to give myself an inaccurate 1/2 unit correction so that I spend an hour less at 140. If I'm anxious to get down quickly I'll take a correction and do some exercise which gets me down to under 100 in no time.

If your correction ratio is lower then the IM approach might make more sense.

14

In Bernsteins first book he recommended intravenous injections. His first book was published before he was an M.D. and IV has not been mentioned in his later editions as I'm sure the medical profession would black list him.

I rarely get above 250 because we now have CGM but in 50+ years I've been out in the ozone before. In the 1970's I did use IV corrections, by following Bernstien's recommendations, when I approached DKA. Nowadays I find that that the deltoid shoulder muscle injections work very well. If need large corrections I never use the pump, I add syringe injections. Bernstein also points out to split the SubQ injections into multiple locations which will speed up absorpbtion volumes.

15

These were the first shot I'd taken in 3 years (since pumping). I took it in the shoulder, and it seemed to help a lot. I see why he no longer mentions IV. Great piece of diabetic trivia.

Since I've been pumping, I try to rotate as much as possible. The stomach is the only site that works well for me, though. I used Medtronic CGM for a while. It was pretty bad. I noticed other people here post similar complaints. Also, doesn't leave much real estate for pumping. I still disagree with Bernstein about MDI vs. pump, though. I remember some other strange practices, too, like testing the backs of your fingers, and taking the temperature of your bath water.

16

The problem with DKA is that it makes you resistant to insulin. It also takes a long time to get rid of the ketones that build up in your blood. If you are chronically in ketosis a little, then it does not take much to push you over the edge,

It is impossible to manage your sugars properly while in DKA. I'm only glad you got it together rather quickly. This has happened to me only when I have had my cannula come out without me knowing it,

There is a failsafe way to prevent it. If you take small doses of Lantus even while on a pump, you will not enter into DKA. Even if your cannula comes out etc,
You just need to deduct it from your basal insulin on your pump.
( my total basal insulin is about 22 units per day) I will inject 10 Lantus and use my basal on my pump to deliver the rest. I just reduce by 50%.

I did this the times I had DKA because it was too difficult to recover without it.

17

I've been monitoring Ketones every day, since. All negative. My BS did spike very high the first times I was able to hold down food, though.

Interesting Lantus technique. I'm kind of surprised someone will give you a Lantus prescription, while on the pump. I took Lantus 2x/day for a while. Sounds like a pain, but I can understand why. I haven't been trusting my pump as much since the incident.

I was having problems at infusion sites, about a year earlier. It turned out that I'd mistakenly gotten a box with 9mm cannulas, instead of the 6's that I normally get. I called Medtronic, and was able to exchange them.

I checked now, and realized that they sent me a few boxes of 9's again! This likely explains why I went into DKA. I called and explained the situation to Medtronic. I had a full order of 9's + another box that had been mixed in with a previous order of 6's. They insisted that I was supposed to be getting 9's. They also insisted that I couldn't return the box from the older order. Eventually, they gave in, but it was unpleasant.

18

I keep lantus on hand in case i have pump troubles.Some times I just switch off if I need a pump break for a few days. My doctor was the one who suggested using it along side my pump for DKA. As long as you account for it, It should be ok.
I don't understand why the different cannula sizes matter that much.
There is not much insulin in 3 mm of tube.
Although you should have the right ones, they should send you free ones.

Also little known factoid. If you go to a pharmacy in California and you tell them you are insulin dependent, they will sell you insulin with no prescription. I did this while I was without insurance for 3 months.

19

The cannula size makes a lot of difference, because I do not have much fat on my body. The first time they sent 9's, I was getting highs. I pulled out the cannula, and it had bent in half under my skin. Same thing the next time. Sometimes I get No Delivery errors, sometimes not. I think that even if the cannula doesn't bend, it may get clogged if it's stuck in muscle tissue. Haven't had this problem with 6's. I've been cutting 3mm off of the tips of the ones that they won't replace.

20

Maybe consider the sillouette they are 8 mm and they go in on an angle almost parallel to your skin. I have not had one clog or bend with humalog or novolog. The only trouble is when they come out without me knowing, That happens with all of them though.
I think Animas calls them Comfort.