Sudden, Scary and Stubborn Low!

Help, I need advice from some experienced insulin users! Last night I gave myself a small 1.5u Novolog bolus 15 minutes before eating some cheese nachos and juice. Less than an hour later I felt weird (had barely finished eating) checked my BG and it was 27, checked again, 23! Did a couple gel shots and juice but had to keep taking in sugar/carbs to keep it in the 60s/70s for a couple hours before I got it stable around 100. At the time I figured I was way overcorrecting but didn’t care, but it turned out to be a struggle to get it to stay up. I have only been using Novolog for a couple weeks and this is my first low. Going so low is scary enough but it bothered me even more when it took so long and so much sugar to correct it. The highest I went was into the 140s 5 hours later even after 3 or 4 gel shots, dextrose tabs and several juice boxes…normally all that sugar would put me well over 200 and have me spilling ketones. I had a bad low with R once but that corrected very quickly with much less sugar and I went high. Anyway, I noticed I have a large purple bruise where I injected on my stomach is it possible I hit a small blood vessel? It seems my already low I:C ratio (1:20) has been climbing since starting the Novolog, not sure if my pancreas, which still makes its own 2nd phase, is now putting out a 1st phase again? Still, it was so darn fast and stubborn and since I don’t feel it until I’m really low I’m pretty unnerved about using the insulin now (still hoping to get a Dexcom). Is this just what happens sometimes?

Been there, done that. but usually very rare. I hate those stubborn lows, because at some point at least i cannot eat anymore… but i usually get them only if i overbolused way too much at a party, and then i have to pay the price… thank god i feel them early enough. dont feel hesitant to call an ambulance if stuff like that happens, they are there for a reason. and if you cannot eat anymore, IV dextrose is usually the only thing to help.
however, i do not wanna prevent you from using your insulin, after all it is still a godsent tool to manage BGL, and it takes some time to get used to and figure out the right doses.
good luck and merry late christmas :)

I'm a numbers guy. I really believe in the insulin to carb ratio, insulin sensitivity factor, correction factor, and duration of insulin numbers. They almost always work as advertised.

Until they don't! I know the type of low you wrote about. It is hard-charging and seems to come out of nowhere.

One of the most common mistakes we diabetics make is over-correcting a low. We feel the low as a fundamental threat, which it is. Our brain tells us to eat, eat, eat. When we do that, however, we often spend many hours north of 180. Over the years I've learned to be very measured in my response to hypos and that tactic has served me well. But every once in a while persistent and powerful low shows up that requires 40, 50, or 60 grams of carbs or more to keep me from passing out.

The only thing that I can conclude is that diabetes is a dynamic disease. Yesterday's formulas may not work today. I recently changed my insulin to carb ratio for dinner from 1:6 to 1:7 (a 17% reduction!) because of a low like you describe. The new 1:7 ratio seems to be working well. So, I conclude that the low that prompted that I:C change came from delivering 17% too much insulin. That made more sense to me than "the low that came out of nowhere." Still, the most important thing, is that we don't have to completely understand what happened, just that it did and you adjusted and caught it. Live to fight another day!

The important thing is that your vigilance caught this one and you responded well. You can't turn your back on this monster! I live alone and this has always made me feel vulnerable. It's one of the big reasons I've adopted every-day CGM use and live with a hypo-alert dog.

Congratulate yourself for that success, even though it doesn't feel worth celebrating. You're here to tell the tale and now a bit wiser. I wouldn't give up on the insulin. It's a great tool but also needs its due respect.

That does sound scary, and odd, that such a small bolus would require so many carbs to counter. Nachos, juice, gel shots, dextrose tabs, juice boxes, all plural, it sounds like you consumed hundreds of grams of carbs just to counter 1.5 units of Novolog. I:C ratio of 1:200? :)

I suspect you will find that, like many of us here, juice (i.e. sugar-water) just isn't worth the hassle of trying to find the right bolus, timing it right, and consuming a precise portion size of juice, unless of course you're correcting a low.

Sorry to hear your story.
You can try to check your BG before injecting. Also check your BG at 15 minute interval after eating.You need to experiment with various foods too.
Also error on side of caution and go for 1:40 ratio at first. I know you are trying to get a perfect control but being little higher at first is better than lows.

Thank you rahul, I did check b4 and I was 92. I think my ratio for dinner maybe higher than lunch although I thought having the juice with the corn chips (which doesnt raise me as much as other grains) would cover the insulin. Guess I was wrong. I thought I was doing so good too so now I’m pretty discouraged.

I thought it was odd too, such a small bolus and so fast a reaction.

I’m glad my husband was home. When I saw the 20s I told him I needed him, I was really low. He got the gels for me but I warned him I may pass out but that after I got them down plus a juice box I’d probably be ok. He was pretty shook up though, this is new to us. Thank you for the pep talk Terry, I needed it. I did respond well, stayed calm, corrected etc. But I’m feeling pretty discouraged, I had done so well for two weeks but now I’m questioning if this is going make me feel better or worse:(

I wish I felt my lows. I had too many with reactive hypos before stating insulin so I don’t feel them which is rare for someone new to insulin and an added complication. I was statring to feel like I couldn’t take in any more sugar, yuck. Merry Christmas to you too!

It seems you're struggling with wildly inconsistent responses of your body to carbs and insulin. If that persists, you may want to temporarily meaningfully scale back your carbs, and then slowly reintegrate them and see what you can handle and what you can't.

Hi LilliD,

I would say probably don't do pre-bolus anymore or do a shorter one, unless your bg is high to begin with and even then be careful. If you didn't do pre bolus then try a bolus after you have eaten instead. Another thing to try is to change your insulin/carb ratio,( I mean higher amount of carbs per unit of insulin) this can vary throughout the day and with exercise/activity. That may help to avoid this type of low but sometimes they will happen and we sometimes can't figure out why. Maybe you injected into a blood vessel or a muscle without realizing it? Your pancreas may still be producing variable levels of insulin.

Did you have insulin on board? Remember that although I think the general rule is that fast acting lasts 4 hours, it can actually still be active for much longer than that from my experience. I try to leave 6 hours or more between meals. How many carbs did you eat for the dose, did you eat a lot of fat which may have delayed the carb release. It could be a digestive issue. At night I frequently bolus after I have eaten all or most of my meal if my starting bg is low. I eat high fat lowish carb most of the time. I believe what is going on with me is either from gastroparesis or from ibs when I'm constipated, but I'm not sure. I'm on basal insulin too, still mdi, but I'm training on a pump now, so that affects things also.

Please be careful- I recommend the liquid glucose drinks if this happens again, they will raise you very quickly, they usually come in 15 to 18g bottles. I'm sure you have probably thought of some of these things but I'm listing whatever pops into my head just in case it will help you. Insulin is dangerous unfortunately, we have to do the best we can managing it. Many people prefer to eat very low carb to keep the doses lower and to hopefully have less danger of lows. Next time if you are low for that long and taking that many carbs without much response I probably would call an ambulance. You should have a glucagon pen to inject if you don't- carry it everywhere with you.

Lilli - You are so sensitive to insulin, perhaps a diluted formulation would enhance your safety and your confidence. Very few people do this, but your low insulin doses are susceptible to dose size error. The insulin manufacturers sell diluent to do this. I would think that small children would benefit from this. Perhaps there are some parents of little T1Ds that already do this. Just a thought…

how long have you experienced reactive hyos before diagnosis?

TuD member, 2hobbit1, has experience with diluting and using insulin herself.

About 5 years, didn’t realize I was going high first B4 the lows, just had the typical hypo symptoms (hunger & shakes) after eating carbs like a bowl of say, Rice Chex cereal. So I just avoided those foods. Started happening more frequently though and then I had a random BG of 198 so began testing and clearly saw the lows followed highs often over 200. The hypo unawareness started about a year and a half ago.

Yes I may need to do that. I’ve lost weight over the past 2 years, down to 110 at 5’4", less than I weighed as a high school athlete and about 15 lbs lower than I want to be. So low BMI plus when I take any med I always take children’s doses, so yes, I am sensitive. Although when I started the Novolog I was ok initially at doses of 1-2 with mod carbs (40-60g) and sometimes needed more because the 2 units was only bringing me down to 180s.

Diabetes is a marathon, not a sprint. There will be other setbacks like this, but there will also be progress, and I promise over time it does get easier.

Don't neglect the part of your care that involves attitude/mindset! I have found mindfulness meditation to be immensely helpful. Mindfulness doesn't even need to involve meditation per se--it's just about being aware, in the present, non-judgmentally--and it really has the potential to be life-changing. If that's something to which you think you might be open, I'd recommend checking out Jon Kabat-Zinn, Full Catastrophe Living.

The only thing I can add here is that I've found a good technique to bring my BG up faster when I'm low, which is to hold the juice or chewed up candy in my mouth for 2-3 minutes before swallowing. This allows some of the sugar to seep in through the thin membranes in your mouth and sublingually, giving a bit of a head start. I had a stubborn low a couple of weeks ago that wouldn't come up even after 3 glasses of juice, then I remembered to do that and it came up in 10 minutes. It's hard to remember because that panicky feeling makes you just want to gobble everything, but it really does work. Curious to know if that has worked for anyone else.

Thanks angivan I’ll try that, hopefully won’t need to in the near future. I think maybe the Level Life Glucose gel is like that, it kind of disappears in your mouth but I never thought about holding it there.

I’m not going to bolus at all and just monitor BG for a few days, see what happens. I took prandin for awhile once and when I stopped my BG was much better for six weeks or so, maybe that’s what’s happening, a super honeymoon? I didn’t bolus for lunch and ate food that would normally send me to 200 and I stayed below 120, so I’m not sure what’s going on. I will ask doc for a glucagon prescription too. I will also get some liquid glucose drinks, thanks meee. I didn’t think about insulin on board either, it had been 5 hrs since I had taken a 2u bolus for lunch (keeping a diary to track all this). My doses are already so low that’s why this surprised me and shook me up I think. I’m trying to gain weight so I was hoping to increase my carbs with the mealtime insulin as I’ve been low carb. May just have to accept this lower weight version of myself, but I haven’t been able to wear my wedding rings for 2 yrs because I’m afraid they will slip off:(