Morning Highs

[Hm121]

Hello all,

I'm looking for some advice regarding nighttime/morning highs, my levels seem to spike in the early hours of the night and continue into the morning.

I currently take 28 units of treshiba in the morning around 7 am, sometimes I may get up and my levels are fine I will take my 28 units of treshiba and it will be fine for an hour then all of a sudden it will spike high and I would correct it with novarapid. Generally I would assume that my 28 units of treshiba is too low but after midday my levels will drop slightly which says that my treshiba is too high. I did do a full 24 hour fast to work out the 28 units of treshiba, but that was several months ago.

I did use to take 60 units of lantus in the morning which was really excessive and I would generally take 40 units of novarapid in the evening with my meal before I went to bed which would stop the morning highs, which again is a lot of novarapid to take, it sort of worked I would wake with low blood sugar readings generally in the 3-4mmol/L range.
I always thought taking 40 units of novarapid before going to bed was excessive and dangerous due to the chance of hypos in the night but my diabetic consultant didn't really see a issue with it and his words were what ever works for you. It did work OK for a while untill I had some really bad hypos with in weeks of each other, luckily I wasn't alone as I wouldn't of been able to do anything to help my self. After getting a new consultant I was advices to give treshiba a go and it was OK to start with but now I'm just having the same morning highs just like I had with lantus.

I have included a graph for the last 90days of readings from my freestyle libre.

I did consider taking treshiba in the evening around 8pm and maybe taking more, but I have read other posts and majority of people say that changing from morning to night had no effect.

Sorry for the long post, any help or advice would be appreciated.

 

[Juicyj]

Hello @Hm121

You have a classic case of liver dump going on there or dawn phenomenon so taking quick acting insulin at bedtime would be an incredibly dangerous thing to do, hypos during the night should be avoided at all costs as quick acting reaches it's peak within an hour and lasts up to 4 hours in your system so wouldn't do anything to touch the sides on DP so surprised your consultant thought this was ok.

Ok so do you eat upon rising ? The action of DP is to get you going so glucose is released to perform this action, if you eat upon rising you are saving the liver doing this job as you're providing your body with an energy source, so take your quick acting for what ever you eat and see how this affects this ?

 

[Hm121]

Hello @Hm121

You have a classic case of liver dump going on there or dawn phenomenon so taking quick acting insulin at bedtime would be an incredibly dangerous thing to do, hypos during the night should be avoided at all costs as quick acting reaches it's peak within an hour and lasts up to 4 hours in your system so wouldn't do anything to touch the sides on DP so surprised your consultant thought this was ok.

Ok so do you eat upon rising ? The action of DP is to get you going so glucose is released to perform this action, if you eat upon rising you are saving the liver doing this job as you're providing your body with an energy source, so take your quick acting for what ever you eat and see how this affects this ?

Well I have tried both sides, most of the time I will skip eating first thing as I am generally high when I wake so will take novarapid to counter this and have a small snack at 10 am during my break at work.

When I do eat first thing in the morning I have to take alot more novarapid, for example I generally take 1 unit of novarapid for a 2.5 mmol/l correction and 1 unit for every 8 carbs. So let's say I wake high at 15 so I need 3 units to correct my levels and I eat 32g of carbs which is another 4 units of novarapid so 7 units in total, but when taking 7 units my blood sugar will keep rising so if I do eat first thing It's just a guess to how much insulin I need to inject.

To be honest I have assumed it was a mixture of my liver dumping excess glucose as it isn't as bad if I don't eat carbs the night before and a mixture of DP.

 

[slip]

Looking at your 90-day graph, you're also more inclined to go low midnight/early hours which could account for some (most?) of the waking highs? Although I thought 'classic DP'

As for your dosing example, if thats the case either your correction or I:C ratio is incorrect for that time of day if you continue to rise. I have different I:C and correction ratios for different times of the day (fortunately the correction ratio isn't that wildly different so I can get away with assuming 1u = -1.5mmol, and then add another u if I want to.....in the mornings only)

With regard with what Jucyj has mentioned, it might be worth eating breakfast for a good few days on the trot to see how your body reacts.

 

[Hm121]

Looking at your 90-day graph, you're also more inclined to go low midnight/early hours which could account for some (most?) of the waking highs? Although I thought 'classic DP'

As for your dosing example, if thats the case either your correction or I:C ratio is incorrect for that time of day if you continue to rise. I have different I:C and correction ratios for different times of the day (fortunately the correction ratio isn't that wildly different so I can get away with assuming 1u = -1.5mmol, and then add another u if I want to.....in the mornings only)

With regard with what Jucyj has mentioned, it might be worth eating breakfast for a good few days on the trot to see how your body reacts.

Thank you both for your replies.

Do you think that reducing my tresiba amount in the morning and eating when I wake will improve things, when I said in the first post about my levels dropping slightly after midday which may be causing most of the morning highs as my levels are dropping after midnight and my body is releasing glucose to counter this?

Last night I woke around 2:30am as I was low around 2.5 mmol I didn't feel too bad so just had 2 digestive biscuits and when I woke this morning it was roughly 20mmol at about 6:30am. So based on that would it be safe to assume that my 28 units of tresiba is too much and it needs to be reduced.

 

[slip]

So based on that would it be safe to assume that my 28 units of tresiba is too much and it needs to be reduced.

No, I'd be looking at what caused the wee hours low, and as you've said you take 40u novorapid with your last meal of the day it's most probably that.

Last night I woke around 2:30am as I was low around 2.5 mmol I didn't feel too bad so just had 2 digestive biscuits and when I woke this morning it was roughly 20mmol at about 6:30am.

This does certainly look like a rebound high from the hypo, the digestives wouldn't have hit the hypo quick enough to stop a liver dump, and then the carbs in the biscuits would have added to that a bit later, hence the 20 this morning. keep some glucotabs handy by your bed. At a 2.5 you want instant action - then you might be too late anyway. And you might want to consider not correcting that high as well as the liver will grab back the glucose at some point, usually just as the IOB is in full affect......

 

[Hm121]

No, I'd be looking at what caused the wee hours low, and as you've said you take 40u novorapid with your last meal of the day it's most probably that.


This does certainly look like a rebound high from the hypo, the digestives wouldn't have hit the hypo quick enough to stop a liver dump, and then the carbs in the biscuits would have added to that a bit later, hence the 20 this morning. keep some glucotabs handy by your bed. At a 2.5 you want instant action - then you might be too late anyway. And you might want to consider not correcting that high as well as the liver will grab back the glucose at some point, usually just as the IOB is in full affect......

Sorry I may of made things confusing, at this moment of time I don't take 40 units of novarapid at night anymore, I used to take that when I was taking lantus as it was the only thing that would stop the morning highs and my old consultant thought it was OK, but he moved back to Nigeria fortunately for me and I have a new consultant who advised I give tresiba ago and stop taking so much novarapid. In all fairness when I was taking this huge amount of insulin my control was pretty good, I was told by my new consultant that it was too good, but something changed and I had several really bad hypos where I needed assistance from other people so I stopped taking the huge amounts before going to bed.

I have now been taking tresiba for over a year now and it was OK to begin with, I did have some highs in the morning but no where near the amount I'm having at the moment, at this moment in time I'm taking 28 units of tresiba in the morning and carb count roughly 1 unit of novarapid per 8g of carb. So when I just carb count in the evening now and don't take any additional novarapid before I go to bed. The only thing whats changed recently is I have lost a bit of weight so maybe I should be reducing my insulin intake which may stop the midnight lows and reduce the morning highs?

 

[slip]

Ah OK, I did wonder if you were still taking 40u but only had to go on what you'd posted. However, I'd still say your evening meal I:C ration may be wrong - depends on what time you normally eat and what you eat may have a baring.

If your evening meal is your main meal of the day and say you eat at 17:00, a hypo at 00:00 (7hrs later) is unlikely to be because of your meals bolus, if however you eat at 20:00 (and have something that has fairly quick acting carbs) hypoing 4hrs after is possible. Obviously if you eat later it becomes even more possible, and bigger meals also allow for bigger discrepancies too.

I've just re-looked at your graph, how comfortable are you with some of the lows PM? (At least you're awake to deal with them) but it might be worth knocking the tresiba down a notch, but I can't see that having any impact either way on the morning highs & 'midnight lows'. Obviously Tresiba has a very long acting profile so you won't see any changes for the first few days if you do.

 

[Hm121]

Ah OK, I did wonder if you were still taking 40u but only had to go on what you'd posted. However, I'd still say your evening meal I:C ration may be wrong - depends on what time you normally eat and what you eat may have a baring.

If your evening meal is your main meal of the day and say you eat at 17:00, a hypo at 00:00 (7hrs later) is unlikely to be because of your meals bolus, if however you eat at 20:00 (and have something that has fairly quick acting carbs) hypoing 4hrs after is possible. Obviously if you eat later it becomes even more possible, and bigger meals also allow for bigger discrepancies too.

I've just re-looked at your graph, how comfortable are you with some of the lows PM? (At least you're awake to deal with them) but it might be worth knocking the tresiba down a notch, but I can't see that having any impact either way on the morning highs & 'midnight lows'. Obviously Tresiba has a very long acting profile so you won't see any changes for the first few days if you do.

I generally eat between 19:00-20:00 maybe a little later sometimes, I have thought before that maybe it's the evening meal causing some of this, maybe too much insulin being taken with it which would make sense.

Last night I had pork, smash veg etc...around 20:00 I injected for the smashed potato, and these are my readings from that time, I was 4.4mmol before I ate, it rose to 10.0mmol by 21:37and by 23:09 I was 5.7mmol which is when I went to sleep so maybe I still had some novarapid in my system?

As for the lows I do get signs, but last night when I woke I knew I was low but I didn't feel low if you know what I mean, some times I feel really bad, other times I have been as low as 1.3mmol and felt as if I could run a marathon.

 

[Juicyj]

Do you think that reducing my tresiba amount in the morning and eating when I wake will improve things, when I said in the first post about my levels dropping slightly after midday which may be causing most of the morning highs as my levels are dropping after midnight and my body is releasing glucose to counter this?

Hi when you take your tresiba will make no difference - tresiba is a flat profile and lasts around 36 hours so if you missed a dose and took it 12 hours later it wouldn't make any difference.

You need to eat breakfast or something at least for a good few days for your body to recognise food on board, I tend to view my control based on repeat patterns over say 3 days to see something that I would adjust my insulin dose for as there's plenty of other factors which could affect my control to rule out first like stress/exercise/illness etc, but bolus and basal needs can and do change over time anyway with growth, weight, seasonal changes which is where you would see a repeat pattern forming..

Another point to think about is eating a little earlier in the evening too, I prefer to go to bed with food digested and no active insulin on board which as I said earlier can take around 4 hours to deplete from your system.

 

[slip]

LOL Smash! Not had that for years, and when ever anyone mentions it I just think of the advert with the mechanical aliens laughing................ - and you probably have no idea what I'm talking about, 'for mash get smash'!

I've no idea what the carb 'profile' of Smash is but 1.5hrs after eating it you jumped 6 points, which to me would suggest it's carbs are absorbed quicker than the insulin is acting, but by 11pm you're pretty much back to where you started (3hrs after eating) and you've still potentially got another hours worth of insulin - judging by your correction ratio you probably had 1.5u still working. When and what dose did you do for the meal and how many carbs did you work it out to be?

Have you heard of pre-bolusing? pitty we can't go back in time (ground hog style) and try it again with a smaller dose but injected 15mins before eating.

 

[Hm121]

Hi when you take your tresiba will make no difference - tresiba is a flat profile and lasts around 36 hours so if you missed a dose and took it 12 hours later it wouldn't make any difference.

You need to eat breakfast or something at least for a good few days for your body to recognise food on board, I tend to view my control based on repeat patterns over say 3 days to see something that I would adjust my insulin dose for as there's plenty of other factors which could affect my control to rule out first like stress/exercise/illness etc, but bolus and basal needs can and do change over time anyway with growth, weight, seasonal changes which is where you would see a repeat pattern forming..

Another point to think about is eating a little earlier in the evening too, I prefer to go to bed with food digested and no active insulin on board which as I said earlier can take around 4 hours to deplete from your system.

Thanks for the info, I did read some other posts about tresiba and other people saying it didn't make any difference what time you too it, but I will just start eating when I get up and see how it goes over the weekend.

I agree with eating earlier but unfortunately that's not possible by the time I finish work and get home.

 

[Hm121]

LOL Smash! Not had that for years, and when ever anyone mentions it I just think of the advert with the mechanical aliens laughing................ - and you probably have no idea what I'm talking about, 'for mash get smash'!

I've no idea what the carb 'profile' of Smash is but 1.5hrs after eating it you jumped 6 points, which to me would suggest it's carbs are absorbed quicker than the insulin is acting, but by 11pm you're pretty much back to where you started (3hrs after eating) and you've still potentially got another hours worth of insulin - judging by your correction ratio you probably had 1.5u still working. When and what dose did you do for the meal and how many carbs did you work it out to be?

Have you heard of pre-bolusing? pitty we can't go back in time (ground hog style) and try it again with a smaller dose but injected 15mins before eating.

Haha I actually meant mashed potatoes, not sure where I got smashed from, didn't even know it was a thing, I had to Google it and just watched the advert.

I don't always weigh my portions I just guessed last night, and took 5 units for the mashed potatoes, which looking into it now seems higher then I thought, I just assumed that potatoes where higher in carbs but appears I was wrong.

I understand the principle of pre bolusing, work out and inject before you eat, but I never tend to do this and inject after I eat.

 

[slip]

LOL! well thanks for the memories even if it was by mistake!

Mash potato has a slightly high GI than say a jacket potato - boiling and mashing breaks down the carb chains into more digestible pieces basically, therefore 40g of carbs in mash (thats what you guessed at last night) will have a quicker affect on your BG than a jacket potato containing 40g carbs. Was trying to find a picture of 250g portion of mash potato........see if it compared to what you had last night.

inject after I eat.

That explains the high then in the first hour. What time did you actually do your jab last night, after you'd eaten so 8:20 ish? Unless you have a real reason to jab after I suggest you try and get in the habit of doing it just before at the least.

See how you go having breakfast - I'm not around much next week so might not respond in a timely manner.

 

[slip]

@Hm121 hows things?

 

[Hm121]

@Hm121 hows things?

Hello, sorry for the late reply been busy with work, but my levels have got a lot better in the morning now since I started eating breakfast when I woke, it took over a week to see any change but they have been good for the last several days.

I still have a few things to straighten out, as my basal is still a little too much as my levels drop throughout the day but that's a minor problem which is just solved with a small snack, but overall things are alot better, it's funny how eating breakfast first thing in the morning has stopped all the morning highs.

Thanks for all the help, much appreciated.