Does anyone have a clinical explanation for this? Last night I misjudged a bolus for a high-carb meal and was battling a raging high for six hours. I kept pushing more and more Humalog till I finally came down. I’m confident that I ended up having to bolus way more ex post facto than I would’ve had to take had I given myself the correct bolus pre-meal.
So . . . why is that? Why does it feel like the amount of insulin it takes to come down off a high is so much higher than the amount it would’ve taken to not hit that high in the first place? Why does it feel like it takes forever for a high to come down, even after you’ve pushed a corrective? It seems like once I crest over 200, there’s no getting back under 200 for hours . . . even though when I’m in normal range (~100), a similar amount of insulin will cause me to drop like a stone in under 30 minutes.
I don’t know either, but it sure is annoying. I generally don’t add a lot of insulin to bring down a high. Instead, I usually drink a lot of water. If it’s daylight hours and I’m free to do it, I’ll walk to the store and back. That will get my BG falling. But sometimes your diabetes just doesn’t care that you’ve taken more insulin.
My Type 1: “Wow, I haven’t been this high in a LOOONG time. I think I’ll look around while I’m up here.”
My insulin sensitivity factor (ISF) or the amount one unit of insulin will bring down a high is different under 200 mg/dl than over. My ISF in the under-200 range is 1:50, over 200, 1:40.
While I cannot give you the clinical reasons for “sticky” highs, I have noticed the same thing sometimes with trending lows and even trending sideways in normal range. I think of it as “blood glucose inertia.” For example, when I’m in a normal range with a sideways BG trend, I tend to “get away with an extra food treat” without suffering the climbing BG. Likewise, it seems to take more glucose to turn around some lows than it should.
I also suspect that basal insulin, both pump and pen types, if over- or under-dosed can exert a hard charging high or low.
It’s a complicated game we play and insulin and glucose are not the only factors. Other hormones and food sensitivities can also come into play. Even losing sleep can effect blood glucose.
As far as quickly bringing down a stubborn high, my best tools are an intra-muscular insulin injection and Afrezza.
If your high is the result of a bounce from a sustained very-low hypo then all bets are off. Those highs just go on for hours and there’s not too much to do about them except drink water and make a plan to avoid the next sustained low excursion. They are the result of a cascade of counter-regulatory hormones (from the sustained low) whose effect takes “forever” to subside.
I’ve heard that it has something to do with the cells not absorbing or using the insulin because your body is trying to flush everything out. I do’t know though, I may be 100% wrong!!
I know my correction factor is 1:100 or 120 if I’m under 250, if I’m above that it seems to be closer to 1:50.
I am thinking possibly the ‘pizza effect’ or the ‘Chinese restaurant effect’ are to blame. As already stated above, carb amount alone is just one factor to consider. When a large amount of carbs is combined with fats and protein it can cause your blood sugar to soar for hours and hours due to a slowed absorption rate. This can set you up for very stubborn highs. You may even be low soon after the meal just to spike for hours afterwards.
I second taking a brisk walk. That along with extra insulin will send me in the correct direction with a stubborn high. Sitting around channel surfing will take twice as much insulin and twice as long to bring me back to normal.
I’ll third the idea of a correction dose plus moderate exercise. Somehow just a bit of exercise really hyperdrives the effect of the insulin. A while back a DB educator told me there were something like 35 chemical steps to get glucose from the bloodstream into the cell at rest, but during exercise the number of steps was… ONE. A fifteen minute walk with a bit of insulin on board can knock a 200 down to a 120 for me like nobody’s business.
I also find exercise is sometimes the only thing that will break a persistent high for me. Other methods (rage bolusing, temporary basal rates) tend to take longer and eventually send me low.
Like the others physical activity seems to help me drastically with a light insulin correction. But one thing that I have learned is that if I have an unexpected high; the first thing I do is inspect the pump site. I have found that foods that I know well and understand the absorption on; this is usually the prime suspect. If the site is over 2 1/2 days old; I start by doing a site change. I will usually take a manual correction with a syringe; while working out changing out the infusion set. I had a weird high that hit me Saturday that my sugar rapidly climbing from 120 up to 213 ( say in 30 minute window) or so after lunch. It was so fast that my Dexcom failed to show me the climb fast enough. The Dexcom was reporting I was only in the 150s. In the Dexcom’s defense I was on a sensor that I had been using for 16 days; so the sensor had some age on it.
But the point I am making is there is not much sense in stacking insulin on an infusion set that is failing. Your absorption will be erratic at best.
I also notice that my insulin resistance level is more like a sliding scale the higher I go; the more it takes to get the correction to move me into the correct direction.
From a biochemical point of view insulin signalling responses are extremely complex. One very well documented effect of elevated BG is to decrease insulin sensitivity. Therefore at high BG levels more insulin is required to transport the same amount of glucose into the cells from the bloodstream.
Of course all of these comments and recommendations are rendered moot if that most insidious culprit is involved: the cortisone injection. If you’ve had one of those, you’re pretty much stuck just upping your doses and waiting it out. Can take up to a couple of weeks depending. Amazing how many orthopedists are unaware of the consequences for T1’s…
Pretty much same story with hormones. Can’t do anything except raise all pump settings by 15-25% and then watch for the crash that will inevitably come eventually.
a) after the injection the insulin has to diffuse from the upper layers of the skin to the blood. Compare that with the beta-cells that will directly release their insulin into the portal vein. So it can take 15min and more till injected insulin can start to act. It also takes hours until the insulin is fully absorbed from the injection site.
b) T1 diabetics can not produce insulin and amylin anymore. The amylin plays an important role in the digestive process because it will slow the digestion down allowing the insulin to catch up. Without amylin we will absorb all carbs at the highest rate the digestive system can provide. This is unfortunate because:
c) in case we forgot out injection or inject too late the digested carbs will be flooding our circulatory system heavily. The insulin will unfold its activity too slowly. To slow for huge carb loads that will release glucose to the blood stream for hours. Thus the insulin can not prevent a huge prolonged spike. Every added injection on top is still to late. Usually the blood glucose will normalize after hours and then very likely the excessive insulin corrections will be causing a low.
Exogenous insulin is like a truck. The digestion of carbs is like a racing car. This is why exogenous insulin can not win the race. But perhaps there are ways to be more sensitive to insulin:
physical activity will slow the digestion and muscles will burn carbs. My prefered method is to cycle for 30min.
having more muscle mass will help
massaging the injection site will increase the absorbtion rate
artificial amylin like symlin can be injected to prevent/reduce glucose spikes
I’d love to be able to just take a walk. However, these highs mostly happen in the evenings, and as I’m 6 months pregnant, I’m uncomfortable being outside during peak mosquito time any more than necessary. (I live in the South, and Zika is spreading rapidly.) I also have Symphisis Pubis Dysfunction (have had it with both pregnancies now), so exercise that’s not walking or swimming is all but impossible.
I get my regular exercise in during visits to the gym, but it’s not always practical (especially with my firstborn’s schedule) to run to the gym on zero notice.
So I’m mostly stuck pushing more Humalog through my pump and waiting it out. But since I have always had “sticky” highs, pregnant or not, I’m going to make a mental note, once my second baby is here, to just throw him in the stroller and hit the pavement when they happen postpartum.
Or, apparently, even a simple corticosteroid nasal spray. My PCP prescribed Dymista nasal spray due to a sinus infection with a clogged ear that just wasn’t responding to antibiotics alone. She was wanting to avoid decongestants as they’d raise my blood pressure… UGH.
Two doses of the Dymista had me taking 4 extra units of Tresiba and double my meal-time insulin for most of the week before I finally came down. Fasting BGs of 140-165 - higher than when I was just “sick” during the first round of antibiotics! At first I thought I’d gotten a bad batch of Tresiba as my BG would rise between meals and overnight.
If I haven’t walked outside due to rain or heat I walk around the local shopping centre where it is dry and heat controlled.
The benefit is that I can pick up my shopping when my walk is over.
I was not aware that your are pregnant. Pregnancy in general is associated with insulin resistance. The main players are increased levels of progesterone and cortisol. The transition to the insulin resistant phase can be quite sharp.
At home I pace through the house when above target. Even in the middle of night, if the cgm alarms high then I will pump .5 units and pace for about 10-15 minutes then go to bed and forget about it. Typically I have a down arrow after 15 minutes. When I’m at work I use the staircases for a similar strategy. I actually got a samsung watch to track my progress with the stair climbing and step counting, though you might do this on your phone as well. It’s nice to have a record and progress tracking when you put in a lot of effort. If I climbed 30 stories that day at work then I know it was a rough day blood sugar wise.
Sometimes it goes up to some number say 130 and then sits there forever, no matter what I do insulin, exercise, etc it won’t budge. I can pump enough humalog to kill a large whale, and it still won’t come down. Or sometimes it will crash low after the large correction and then promptly return to 130. You have to wave the white flag at that point.
Fasting BGs of 140-165 - higher than when I was just “sick” during the first round of antibiotics! At first I thought I’d gotten a bad batch of Tresiba as my BG would rise between meals and overnight.