Over night highs

[Richard F]

I just started using a libre before lockdown, so 3 weeks now. Really impressed.

One thing that's highlighted is overnight highs, I had no idea.
My routine was check sugar before bed, then in the morning it was generally, a little lower. I though I had that one cracked.
It's soaring from about bedtime, peaking somewhere between 15 and 20 in the small hours, before dropping down to normal 4-6 on waking.

I'm on Nova rapid (typical day 8-12units)and a split lantus basal (breakfast 9units, bed 9 units) weighing in at 11.5stone, generally healthy A1c of around 64%.

I'm not sure when I'll be able to attend the clinic, any advice?

 

[Richard F]

Reading up splitting Lantus maybe the wrong thing to do.

I might try going onto one evening dose per day. Waddya think?

 

[DunePlodder]

Reading up splitting Lantus maybe the wrong thing to do.

I might try going onto one evening dose per day. Waddya think?

Hi Richard,
That rise and fall really is enormous. Is it happening every night?
Does this make any sense to you:
To get so high it looks as though you've perhaps eaten something late evening with an insufficient bolus.
Then to get blood sugars down again by morning your basal must be too high.
So high basal is compensating for insufficient bolus?

I'd say you need to do some proper basal testing.
A couple of good sites:
https://integrateddiabetes.com/basal-testing/
https://mysugr.com/basal-rate-testing/
(Unfortunately blood sugar values are in mg/dl - just divide by 18.)
Basal testing is a pain but is well worth it. The Libre will make it easier though.

Personally I had some problems with Lantus and did better on Levemir - just a thought worth bearing in mind for the future.
Good luck!

 

[Richard F]

Thanks, yes it's doing it more often than not.

Dinner at around 6.30-7pm, I do enjoy a glass of wine or two afterwards, no snack, nothing from 9pm. Sugars seem okay around 11pm, then rise in a ludicrous curve, before dropping to normal again..

I started splitting the lantus after regular night time hypos. Definitely need some adjustment to smooth it out.

 

[DunePlodder]

Thanks, yes it's doing it more often than not.

Dinner at around 6.30-7pm, I do enjoy a glass of wine or two afterwards, no snack, nothing from 9pm. Sugars seem okay around 11pm, then rise in a ludicrous curve, before dropping to normal again..

I started splitting the lantus after regular night time hypos. Definitely need some adjustment to smooth it out.

It does look odd. I also had problems with overnight hypos on Lantus. Not sure I have any real answers for you. Perhaps try another basal insulin or try for a pump?

 

[Richard F]

I've discussed a pump @ the clinic, keen to try one once things are opening up again.

 

[DunePlodder]

I've had my pump (Tandem t:slim X2) for about a year & I'm really happy with it.

 

[searley]

If you were having night time hypos then you were having too much in the evening.. 1 option is to have 1 lantus at night but take less units this way it will control the night time heights. But if you are then getting really high mid afternoon as the lantus runs out then you may wish to split the dose

You don’t have to split 50/50 You could have slightly more in the evening less in the morning

My DSN does not like split doses but for most people langurs will only last 16 to 18 hours

You could ask your don about tresiba rather than lantus as this last up to 72 hours still taken once a day but has a more steady release rather than langurs that peaks after 3 to 4 hours

But until you can see your dsn I would change the split so you have a unit or 2 more before bed..

I must stress this is just my opinion and I’m in no way qualified to tell you what to do

 

[Richard F]

Thanks chaps.

 

[Richard F]

Too early for anything definitive but I've started taking all my lantus in the evening.

Last night, this is fairly typical looking at my graphs.

6.30 pm dinner, homemade chicken curry, chickpeas, veg, potatoes, small piece nan bread. No evening snacks.
8-9 pm BS around 9
11 pm BS 11.1 correction of nova rapid 1u+ lantus 18u
Midnight BS 15
Breakfast 7.30am BS 4.7

What gives? Any more insulin and I'd be going hypo.

 

[searley]

Could just be more Lantau than you need at the moment if it’s a pattern (3 days plus) then reduce dose by a couple of units or if you are worried about night time hypo drop some units now and start increasing slowly every 3/4 nights if needed

 

[Richard F]

Could just be more Lantau than you need at the moment if it’s a pattern (3 days plus) then reduce dose by a couple of units or if you are worried about night time hypo drop some units now and start increasing slowly every 3/4 nights if needed

What I can't get my head around is why my BS is peaking around 3am before dropping back at breakfast time.

Not sure how a reduction of basal will help?

 

[searley]

Lantus peaks 3 to 4 hours after taking it so if you take it at 11 it peaks between 2 and 3 am and continues through the night

 

[Richard F]

So to reduce overnight highs, a couple of units of nova rapid, before bed but a lower basal?

 

[searley]

The idea of background insulin is to keep you stable not reduce you levels so if you goto bed on 10 you would pretty much stay on 10

If you are 15 before bed it indicates that your rapid you had with the evening meal probably wasn’t enough..

Corrections are only done with rapid so yes if you feel your levels are too high rapid is what you use to correct that.. but with care you need to make sure you don’t drop too low or you’ll be asleep through the hypo

The ideal is to have the level better before bedtime that way less risk

 

[Richard F]

This is the problem.

I can go to bed BS 8 when I wake BS 4-5, all good..

Except with no intervention it typically peaks at 15 sometimes 20 in the wee small hours before dropping back down.

I had no idea before the libre it was doing this.

 

[searley]

Some people do suffer from liver dumps in the light or early hours of the morning ( dawn phenomenon) if most of the rest of the time you are ok don’t worry too much for now

 

[Bishop]

This is the problem.

I can go to bed BS 8 when I wake BS 4-5, all good..

Except with no intervention it typically peaks at 15 sometimes 20 in the wee small hours before dropping back down.

I had no idea before the libre it was doing this.

Hello Richard
Looking at your posts I think your high BS are due to your rapid insulin not matching correctly your diner. And to be fair, waking back into normal BS is indicating that you probably overdue your Lantus.
The easiest way to test this is to not eat anything at all in one evening. Get a good lunch, stabilize your BS and then just take your normal Lantus dosage and see how it goes. I am pretty sure the food you eat for dinner is not bolused correctly.
Be careful with that Lantus, as I said, is highly likely you are taking too much.
If you want more help I am more than happy to help. I am type 1 as well.
Goodluck!

 

[Richard F]

Thanks for your response.

I'll try tweaking, perhaps I've been over reliant on the basal for control. Sometimes I'm having very little bolus with meals, only 1 unit per 20g of carbs.

 

[Richard F]

Okay, starting to make sense. The 1st couple of days were strange with some lows and corrections whilst I got used to the new regime.

I have one overnight basal of 15u instead of a split dose of 9u am/pm
Over night highs not as bad, typically peaking at 12 instead of 15-18
Morning BG still OK @ 4-6
Averages dropped from 10.1-8.8
Time in target up to 60% from 48%
Estimated A1c down from 64 to 61 (its been 64 for the last couple of yrs)
Carb insulin sensitivity 20/1

I was expecting to be using more bolus, but that's reduced too, typically 7-10u as opposed to 10-12u. Total daily insulin down to 22-25 as opposed to 30u.

Basal is supposed to be around 50% of total requirement. Mines closer to 70%, but I don't feel like tweaking it much more.

All in all very satisfactory. The libre is a revelation, looking forward to going onto a pump.