The Story of the Insulin Onion

I turn 29 years old in 9 days. But yesterday afternoon I was 30.

30 mg/dl, that is.

The day started out as any other. I woke up early so that I could get in a long run — 7 miles — before I was going to meet some other Minnesota bloggers for brunch. Never met them before, so I was excited. The run started off normally enough, but I started to notice my quads hurting more and more, and more and more. Finally, after about four and a half miles I stopped to stretch. It was only then that I could hear a faint buzzing sound penetrating the music in my headphones. I took off one earbud and immediately was crestfallen. The buzzing was actually the screeching of a dead pod.

I was at least two miles from home and my husband was out at our apartment, so I knew I was on my own. Although my Dexcom still had me firmly at 200 mg/dl, I knew it was a lie. I knew that with the 30 grams of carbs I’d consumed and a no basal for God knows how long, the combination of that and exercise was going to spell disaster for me. My body does not like it when I deprive it of insulin. I attempted to run a bit more, hoping that I might either get home faster or perhaps keep my blood sugars down with whatever basal was still in me. But I pretty much failed and practically hobbled home, my legs burning with ketones. (I don’t know if my legs are really burning from the acid of ketones, but that’s what I assume.)

My husband could hear the screaming pod as I walked into our kitchen and immediately gave me a sad face. He knew what that sound meant.

“It’s been dead since halfway through my run,” I said. I asked him to bring me a bottle of insulin, a new pod, and a glass of water. I tested my blood sugar and I was 385 mg/dl. Like I said, the Dexcom lies when it comes to exercise (which is such an unhelpful time to be inaccurate, btw).

I changed the pod and corrected. Then I gave a little bit more for the missing basal. And then I decided to increase my basal 50% because I, you know, assumed I had ketones and that’s what I always was taught. Take more insulin for ketones.

Although I could barely move, I didn’t want diabetes to ruin a perfectly good social event. At brunch, I pretty much ate what I wanted. Sometimes when my blood sugar is high I sort of shrug my shoulders and indulge because, hey, I’m already high, right? Not like I’m ruining any blood sugars here. They already suck! So I indulged in a cinnamon roll, some biscuits and gravy, and pineapple. There was also copious amounts of bacon involved. I kept bolusing for my food.

But I also made a tragic error.

My Dexcom wasn’t showing a decrease in my blood sugars — I was firmly planted at HIGH for a couple hours at this point — so I tested my blood sugar. 455 mg/dl. And I corrected. Not that reduced correction from the IOB I had from previous boluses, but the whole thing. And that was on top of some pretty liberal doses for my brunch.

About an hour later, I had a down arrow at Target. Finally. Whew. And when I got home I decided to take a nap. I hadn’t had much sleep in our first night in our new house, and between that, the 7 mile run, and the crazy blood sugars, I was wiped out. So I took a nap for about an hour or two. When I woke up, my BG was in the low 100s and looked stable.

Or so I thought.

A little while later, my Dexcom finally alarmed that I was low. But a juice box wasn’t enough. I was tanking. And fast. The low blood sugar symptoms were really started to kick in hard and I felt awful. Low blood sugars, for me, are painful. My legs and hands felt like they were being crushed. I don’t know how explain it, but low blood sugars are agonizing.

Dexcom now said I was in the 40s and dropping, not rising. I told Erik to get me another juice box. I tested my blood sugar while he was gone. When he returned, I flashed him the meter.

30 mg/dl.

Not my lowest blood sugar ever (that was a 29 mg/dl at diabetes camp, of all place), but pretty close.

I drank the juice box. I suspended my insulin pump. Erik brought me some chocolate and a graham cracker with peanut butter. Of course, all this food was not reacting well with my Victoza-induced suppressed appetite and I was getting a horrible stomach ache. On top of that, I started sweating profusely. Apparently it was bad enough that Erik started blotting my arms and legs with a bath towel!

My Dexcom swore my blood sugar was rising, but I knew it was lying again so I tested. I was 51 mg/dl. A little bit of movement over the past hour, but not nearly enough.

This is the part of the story where I tell you that I’m an idiot. Because you’re probably thinking to yourself, “Allison, just take some freaking glucagon!” Well, I don’t have any glucagon. Nope, none. I haven’t owned a glucagon since…. Yeah, exactly. I don’t know if I’ve ever filled the prescription in all the years I’ve been on my own. Anything I tell you will just sound like an excuse, which they are. But it just never felt important. Like it wouldn’t matter if I did or didn’t have it.

Well, yesterday, I wished I’d had a glucagon. I thought about calling one of my many Minneapolis PWD friends, but decided to wait just a little longer to see if a third juice box would do anything.

On top of that, I wasn’t entirely sure what I would do with a glucagon once I had one. I was fully conscious and able to eat. I only knew about giving glucagon when you’re unconscious. I figured I wouldn’t need the entire dose if I was awake. How do you dose glucagon for severe lows? At the ADA Scientific Sessions, Jeff Hitchcock had mentioned his daughter Marissa using mini-doses of glucagon when she had low blood sugars and morning sickness, but he didn’t say anything about how much she actually used.

Earlier this afternoon, I had a call with Jennifer Smith, my CDE at Integrated Diabetes Services and I recapped for her the adventures of the day. I asked her how someone should dose glucagon when they’re awake. When do you decide to use it and how much should you take?

Jenny said that using glucagon when you’re awake can be beneficial when you’re either at a very low blood sugar (such as 30 mg/dl) or when you’re not physically able to eat enough to bring your blood sugar up without getting sick (such as morning sickness or if you had a big meal earlier). Very low blood sugar can take a long time to come up and glucagon just works faster. Jenny said that the recommended dose would be half of the glucagon kit. A whole dose is 1 mg, but taking half that is enough to bring blood sugar up quickly.

The low blood sugar seemed to drag on forever, and I couldn’t understand why my blood sugar was tanking even though it had been so many hours since I’d given insulin. My blood sugar didn’t start to really come up until almost eight hours after my last correction, almost three hours after I started treating my low blood sugar! Shouldn’t the insulin be done working by now? Not so, according to Jenny.

She explained that when you give a huge dose, or a lot of doses close together, the insulin forms a bubble under the skin. Rather than just popping, the bubble slowly breaks down. Jenny described this as being a bubble because insulin is a liquid, but I think of it more like an onion. Layer by layer of insulin starts to work, but the inner layers can work until the outer layers have dissipated. The larger the dose, the bigger the insulin onion.

When you take a huge dose, your duration of insulin action is much longer, and your insulin on board might be a lot more than you think. This is what happened to me and why my blood sugar started dropping so far from my last bolus, and also why it took so long to come up. I had a lot more insulin on board than I thought. Jenny suggests splitting a large correction, taking some by pump and some by injection, or splitting your injection into two separate locations. This prevents a big insulin onions from forming.

Eventually, my blood sugar recovered. It actually recovered a little too well, and I almost hit 400 mg/dl again! But I was more careful with correcting and only needed a couple of small corrections.

My blood sugar when I woke up? 90 mg/dl.

layeredonion

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7 Responses to The Story of the Insulin Onion

  1. StephenS says:

    Wow. I was right where you were around midnight last night. Glad everything came out okay in the end. Great information… I never knew this about large doses.

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  3. I have had the same issue happen when my cannulas kink…my endo tells me to never do a correction through the pump when over 250 mg/dL and that advice has helped keep the insulin onion effect from taking place. I’ll let the pump tell me how much to take, but I won’t hit that final ACT button to get it to go through. I don’t like to gamble with the possibility of insulin onion around the infusion site having more layers than I thought, and the pump telling me to take more and more insulin and then crashing (that has happened too). I have to be careful though to not stack doses using this method (another way I’ve crashed after an extreme high). I never thought about taking really large doses in multiple places before though, that’s a good idea as well.

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  5. Robert Slack says:

    This was a fascinating entry. Over the years I’ve often been frustrated by how best to treat very high readings. I had one on Christmas day evening (what fun!) Christmas Lunch had been fine, insulin coped well, then about 6pm I was tempted by a very small portion of Christmas pud. I bolused then we had a half hour walk, coming back to watch TV. I have a Dexcom & saw I was still climbing, perhaps the pudding wasn’t such a good idea..

    Half an hour later I’d jumped to 14, time for more insulin. A further 45 minutes & still rocketing upwards, confirmed by blood tests. I changed my insulin cartridge & took some more. By 11:30pm it was finally starting to fall. I peaked at 19.3 Of course the next phase was worrying about it dropping too far – I sat up later just waiting for it to level off which it eventually did.

    Now after reading your article I realise that each bolus was in my stomach – I was in company and it’s the easiest to get at. I was rotating through an arc but still closeish I guess.

    Hopefully it won’t happen again for a long time but I’ll try a couple of small additional doses at different sites. It makes logical sense. Thank you for this.

    Beware the Insulin Onion & the Christmas Pud!
    Robert

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