Rule of thumb for high highs?

Type 1 and LADA
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Last night I had a high high that peaked at 350mg/dl. I had changed my infusion set before bed and apparently landed on an unusually bad site. It took about 3 hours to get back in range (<180)
I realized the problem around 3:30am. (I should have known earlier but had stupidly turned off alerts.) At that time, I changed sites and injected myself with 4u of Novolog. Normally, at night, 1u = 65mg/dl drop so 4 units = a drop of 260.
I realize there were other factors at play here: my BG rose gradually to that very high level indicating that I must have been essentially without basal insulin for three or four hours since the site change. Also, I realize that insulin sensitivity lessens the higher one’s BG.
I was pretty upset/disappointed that it took so long to get back in range.
My questions are:

  1. Should I have taken more insulin and does anyone have a rule of thumb for high highs — like 1.25 times the amount of insulin you’d normally take to make the same change that you’d get from that amount of insulin if you were in range?
  2. Using Novolog or a similar insulin and without adding exercise, how long is a reasonable expectation to right the ship from such a high high? That is, it took about three hours to rise that high. It was going to take a long time to come back down unless you really took a lot of insulin and ended up having to eat in a couple hours.
  3. This is kind of a different topic, but does someone know the shelf life of Afreeza? I think it would have been great in this situation but it was an unusual situation and I don’t see myself using Afreeza more that 2-3 times a year assuming I’m able to obtain it at all.
    Finally, I get that there are no hard and fast formulas, but I’m looking for educated opinions/guesses.
    Thank you!
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Bringing down a BG high of 350 can be tricky business. Doing it at night, expecting any kind of normal rest, is not reasonable. You’re already aware that insulin resistance is much higher when you’re that high.

The variability of a correction is not knowable and if you want to be safe you need dependable alarms, like a bedside alarm clock or two cell phones. I think your mindset needs to start with the acceptance that a good night’s sleep is a write-off at this point.

I use Afrezza but the dose estimate is just as much a guess as the liquid insulin. If it were me, I would take a 4-unit Afrezza dose combined with liquid insulin delivered via a syringe directly into a muscle. I then would set alarms to wake me up two hours, then three hours after the corrective doses.

It will take longer than you wish to get back into range. It’s the unfortunate reality of going that high. Drink lots of water; it will help with the correction and ensure that you don’t sleep through your alarms.

Your estimate to increase your correction insulin 1.25 times seems reasonable provided you are confident in the alarm mechanism. By the way, I only think of the Afrezza dose as 50% of the liquid insulin dose. In other words I estimate that a 4-unit Afrezza dose acts like a two unit liquid insulin dose. This knowledge comes from direct experiment and should be personally confirmed.

Your actual insulin deficit comes from not only bolus doses that were not absorbed but, just as important, basal insulin. It is very important that you deliver all corrective doses with a syringe. The stakes are much too high to bet that the newest site/set will act normally.

This is the motivation that some people adopt the un-tethered protocol. I’ve tried it and it works really well. Adding a basal insulin, like Tresiba, to your pump therapy could be preferable.

I have used Afrezza well beyond its shelf life date, many times. I think delivering an IM shot is a reasonable alternative.

I resist ever changing my infusion set in the evening. Your experience is the exact reason why.

By the way, congrats on successfully bringing this situation to a good conclusion!

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Thanks so much for your advice, Terry. I really appreciate it.
I had a 5:30am alarm set as well as putting my dexcom “low” alert at the highest possible setting (100mg/dl) which I thought would give me plenty of time to act if I was dropping.
I’ve never given myself an IM injection. It sounds painful. My syringes (and I did use one for the 4u injection) have what seem to me kind of stubby (8mm) needles. Would I need a longer one to hit muscle or is that plenty long enough if you aim for the right spot? Is the quadricep a go-to muscle for that kind of injection?
I think I was sort of OK with my BG dropping slowly once it started dropping. What got to me was that it didn’t really drop at all for maybe 45 minutes which I both understood as normal and feared meant that my injection had had no effect. I’m assuming both Afreeza or an IM injection would start showing results in less time – 15 minutes?

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I don’t have enough experience with bringing down high-highs to give advice on your situation but it sounds like you kept calm and did really well. I usually don’t expect a correction to make much progress until about an hour in even when I’m just correcting a 180 or 200.

I will bump up my basal - sometimes to 150% - when I’m correcting a high number and count on Control IQ to put some brakes on if I start to fall too far.

Glad it all worked out and congratulations to getting back to a safe number by morning.

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I strictly use fast-acting Humalog insulin but have used Novolog with virtually identical results. What I do may not work for you because I only get a 15 mg/dl drop for 1 unit of insulin and have a digital pen that delivers insulin in .1u rather than standard pens in .5u or 1.0u. Therefore I have a much more comprehensive range to play with on the amount of insulin and pen delivery capabilities.

My goal is to come in for a soft landing, as nothing is worse than coming down from a high and then roller coaster like a ping pong ball to stabilize. My fast-acting insulin has finished its useful life after 1 hour 45 minutes.

In your case, with your parameters (using 1 hr 45 min insulin life), I would take 75% or three units of insulin to expect a drop of 65x3=195mg/dl to 155mg/dl. I would set an alarm to wake me exactly 2 hours from when I inject the insulin and look at my CGM. I should have flat-lined then and looked for 15 minutes of flatline. Then take another dose from there, if I am at 155, this final dose will take me to 90 after another two hours. If I flatlined other than 155, I would subtract 90 from my flatline number, divide by 65/u drop, and inject that result. So, the total time back to normal is about 4 hours. Small pesky gremlins, such as the dawn phenomenon, may also have to be accounted for. I expect a lousy night’s sleep but find that I sleep well as long as I do this and forget it until the 2-hour alarm wakes me up. If I worry about it, I get a lousy night’s sleep. YMMV.

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Here’s a Dr. Bernstein video about giving IM shots.

I’ve followed his advice to use a 12.7 mm long syringe. That is about 1/2". Some people may need a longer needle. I usually use the deltoid muscle that’s in the upper arm.

Afrezza and an IM insulin injection usually start a BG drop at about 20 minutes.

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It can take a while. If you have very little fast-acting insulin on board, like at night, it can take significantly longer (in my experience) than if I do have fast-acting on board. 45 seems normal, to me.

One thing I’ve tried a couple of times but not enough to say with any certainty how effective it is, is to give two shots of fast-acting correction rather than one (but of the same dose of insulin overall). So if I thought 2 units would fix a 350, and I wasn’t going to exercise or do any activity in the near future (like at night when I’m trying to sleep) so there wasn’t a risk of dropping quickly, I might try splitting those units into two different syringes and injecting in different parts of the body at the same time. To increase the insulin’s power over a given period of time.

Again, you want to play it safe, first and foremost, and steady drops may be the safer option. Just throwing it out there.

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It takes 4 hours for correction insulin to take effect, so the trick is to never get high. But, of course, failures occur. In that case, you want to be careful (especially overnight) to not over dose in an effort to make it come down normally because that’s how people rollercoaster into a severe low after a high.

It’s good to establish a procedure for treating highs when you suspect that the hardware your using or the insulin has gone bad. You want to follow a strict procedure because in order to see if any single intervention has been successful will take hours. So, if you don’t find the source of the problem quickly, then your really sick for a long time. It’s a tricky situation, but it sounds like your on top of it.

I’ve never had the guts to do an IM shot. :sweat_smile: I remember a guy on this site many years ago who tried IV insulin to fix highs. We all tried to talk him outta that. He was insteresting. I wonder what ever happened to him.