Crazy hypo in the morning

[PeteN11]

(Going off topic, anyone got a good way to remember which is which of glycogen and glucagon, I always have to check I haven't got the names the wrong way round?)

I use the letter "e" in Liver to remember Glycogen and the letter "o" in Hormone to remember Glucagon.

 

[PeteN11]

The liver holds enough glucose to deal with most hypos, so you would probably have been ok even if you had slept through it.

The liver does not hold Glucose it stores Glygogen. The liver needs to be told to break this down and release it as Glucose by the hormone Glucagon. Glucagon is produced by the Pancreas which in most T1's is fairly messed up so there is no guarantee it will do so when needed or in time. And it almost certainly wont if there is already insulin in the body.

In the OP's case he was dangerously low and nothing seems to happening on the Glucagon front. Surely it would already have started to kick in?

 

[PeteN11]

i’m not sure if i could have accidentely switched the lantus insulin for novorapid.

Glad all was OK. I too use Lantus and Novarapid.
If I had woken up to that reading of 12 I would have used my Novarapid first rather than the Lantus which I would have waited to take at my normal morning time. The dosage would have depended on what I had eaten and especially drank the night before but could have been 25 units.

Was it time for your Lantus injection and is 25 your normal dose?

What have you been advised to do for correction doses as I have been never been told to use Lantus?

As others have said get all your back up glucose ready in different parts of the house, car and work. Going out to get some whilst that low would have slowed down your recovery rate even more due to the exercise involved.

 

[oldgreymare]

No, it isn't. It's only the insulin glargine (Lantus, (a)basaglar, and Toujeo) holding a risk of bizarre hypo's, not any of the other long acting insulins.

I take 84 units of Tresiba at the moment. You say that to your thinking 25 units should be split into 2 for safety. Should I conclude you think I should split my basal insulin over 6 injections? What about people using 200 units of basal? Should they inject 16 times for basal only because you, and not their endocrinologist, think 25 units at once is too much?

Please consider the differences between different people and remember what works for you may not be the best solution for everyone else.

The only time I have ever had a serious hypo was that one time on Lantus. For the last 3 years my bg's have been managed very well without splitting my dose of long acting, and while I'm very much afraid of Lantus, I found my current long acting insulin to be very stable and predictable, I don't feel it as a risk at all to inject it only once a day.

Hi @Antje77 You are so correct to point out everyone's insulin journey is a very personal one to figure out how to calibrate and administer.

That said, I am a fan of Dr Bernstein, who's advice suggests no more than 3-4units per injection site - this is to manage the rate of absorption through subcutaneous fat a and this is Type 1 advice. So for my current Tresiba basal dose of 9-10 units, I administer this at 3-4 units over 3 sites same time once a day (my thighs) - this behaves fairly consistently, the odd "bruise", no bumps. My Novorapid bolus is anything between 1 -4 units per shot, never more than 6 units per injection time. Very rare injection site bump, but at this stage rather mottled bruised tummy (eating too many carbs).

If you have consistent levels using 84 units of basal insulin in one shot that's fantastic, but may be hard for others to achieve.

 

[Robinredbreast]

No, it isn't. It's only the insulin glargine (Lantus, (a)basaglar, and Toujeo) holding a risk of bizarre hypo's, not any of the other long acting insulins.

I take 84 units of Tresiba at the moment. You say that to your thinking 25 units should be split into 2 for safety. Should I conclude you think I should split my basal insulin over 6 injections? What about people using 200 units of basal? Should they inject 16 times for basal only because you, and not their endocrinologist, think 25 units at once is too much?

Please consider the differences between different people and remember what works for you may not be the best solution for everyone else.

The only time I have ever had a serious hypo was that one time on Lantus. For the last 3 years my bg's have been managed very well without splitting my dose of long acting, and while I'm very much afraid of Lantus, I found my current long acting insulin to be very stable and predictable, I don't feel it as a risk at all to inject it only once a day.

I take 11 units of Tresiba and around 13 ( ish ) units of NovoRapid over 3 meals. We are all so different.

 

[Robinredbreast]

Isn't it odd that we are encouraged to use a practice that increases the risk?

It's getting the darn thing right, but we all make mistakes.......that's why we have erasers on the end of pencils.

 

[Robinredbreast]

Thanks for all of your replies
Looks like it could have been a ‘lantus low’ as well, but will probably never know.
I tried Levemir before Antje, but it gave me blue spots. Maybe tresiba which you mention is different, i will check it out. Also the timer that can be added to the pen!

Btw I can def confirm that the liver can not always get you out of a hypo.

I know that only too well, scary

 

[MarkMunday]

The liver does not hold Glucose it stores Glygogen. The liver needs to be told to break this down and release it as Glucose by the hormone Glucagon. Glucagon is produced by the Pancreas which in most T1's is fairly messed up so there is no guarantee it will do so when needed or in time. And it almost certainly wont if there is already insulin in the body.

In the OP's case he was dangerously low and nothing seems to happening on the Glucagon front. Surely it would already have started to kick in?

Because insulin is injected subcutaneously and insulin switches Glucagon secretion off, T1s usually have too much of it. Not too little. Glucagon is made in the alpha cells, not the beta cells. There is no reason why a hypo induced stress response wouldn't result in the required glucagon being secreted. That T1s can't produce the glucagon required to deal with hypos is a popular myth.

 

[Hill28]

Glad all was OK. I too use Lantus and Novarapid.
If I had woken up to that reading of 12 I would have used my Novarapid first rather than the Lantus which I would have waited to take at my normal morning time. The dosage would have depended on what I had eaten and especially drank the night before but could have been 25 units.

Was it time for your Lantus injection and is 25 your normal dose?

What have you been advised to do for correction doses as I have been never been told to use Lantus?

As others have said get all your back up glucose ready in different parts of the house, car and work. Going out to get some whilst that low would have slowed down your recovery rate even more due to the exercise involved.

hi, yes it was time for my lantus/abasaglar injection. I always took it around 5/6 am to avoid high bg in the morning (dawn effect) when i get up around 7/8 am.
So on Monday my bg was 12,2 around 6am and i thought the lantus might fix this as well.

 

[Jaylee]

Because insulin is injected subcutaneously and insulin switches Glucagon secretion off, T1s usually have too much of it. Not too little. Glucagon is made in the alpha cells, not the beta cells. There is no reason why a hypo induced stress response wouldn't result in the required glucagon being secreted. That T1s can't produce the glucagon required to deal with hypos is a popular myth.

Hi,

Do you have a reliable link to a sourse/sources to back this up?

Thanx.

 

[MarkMunday]

Hi,

Do you have a reliable link to a sourse/sources to back this up?

Thanx.

By 'this' are you referring to the idea that the glucagon driven element of the counterregulatory system works for people with T1 diabetes the same as it does for non-diabetics? This is not an outlandish idea. It simply suggests that this element of the metabolism works the way it should.

More to the point, I have not been able to find a compelling argument that this process does not work for T1s. There is lots of speculation, but no suggested underlying mechanism for this supposed dysfunction. Nor is there compelling evidence of it. Only anecdotal reports. On the other hand, if T1s were not able to make glucagon when necessary, we wouldn't make it through the night. Glucagon stimulates both glycolysis and gluconeogenesis, providing much needed glucose during that extended period between meals.

After 43 ears of T1, I have no doubt that my glucagon production is as robust as it ever was. The Somogyi Effect, with blood glucose shooting up after a hypo, is further evidence of it. Yes, the stress response can be down-regulated by repeated hypos, and for me hypo unawareness is an issue. It just means that glycogen gets mobilised at lower blood glucose levels than it used to. This does not mean that the system is broken, though.

 

[EllieM]

This does not mean that the system is broken, though.

I don't disagree that the glucagon/glycogen loop can rescue T1s from hypos (I'm sure it's done it for me many times) 'but the problem is whether it can rescue you from severe hypos (I've been reduced to coma/seizure levels). An insulin overdose can certainly be used to kill non diabetics, so an accidental injection of a day's worth of bolus instead of basal can certainly be very dangerous. (Not tempted to investigate on purpose.)

Personally I am just very grateful that my pancreas still pumps out the glucagon - it must be very tough for those people with T3c whose pancreases are deficient in producing glucagon as well as insulin.

 

[PeteN11]

There is no reason why a hypo induced stress response wouldn't result in the required glucagon being secreted. That T1s can't produce the glucagon required to deal with hypos is a popular myth.

I surprised you say it is a popular myth when you have already stated......

Because insulin is injected subcutaneously and insulin switches Glucagon secretion off,

 

[In Response]

hi, yes it was time for my lantus/abasaglar injection. I always took it around 5/6 am to avoid high bg in the morning (dawn effect) when i get up around 7/8 am.
So on Monday my bg was 12,2 around 6am and i thought the lantus might fix this as well.

GIven Lantus is a slow acting insulin, I do not believe it can impact DP.
What you may have been seeing when you wait until you get up is the impact of the Lantus not lasting the full 24 hours. For this reason, I always took mine in the evening. Originally, I took it just before going to bed but sometimes Lantus has a kick at the start so I moved the timing to have with my evening meal. This allowed me to use bolus to cover when the Lantus ran out after about 22 hours.

 

[PeteN11]

hi, yes it was time for my lantus/abasaglar injection. I always took it around 5/6 am to avoid high bg in the morning (dawn effect) when i get up around 7/8 am.
So on Monday my bg was 12,2 around 6am and i thought the lantus might fix this as well.

On a normal day, if there ever is one, does your Lantus normally have the same effect of lowering your bg to those low levels? I am just surprised that the Lantus had such an affect so rapidly as it is supposed to be slow acting.

As I said before I have always been told to do any corrections with Novarapid due to it being fast acting and easier to work with as you can start off with a small dose and then add to it if your bg stays high.

Good Luck.

 

[Jaylee]

By 'this' are you referring to the idea that the glucagon driven element of the counterregulatory system works for people with T1 diabetes the same as it does for non-diabetics? This is not an outlandish idea. It simply suggests that this element of the metabolism works the way it should.

More to the point, I have not been able to find a compelling argument that this process does not work for T1s. There is lots of speculation, but no suggested underlying mechanism for this supposed dysfunction. Nor is there compelling evidence of it. Only anecdotal reports. On the other hand, if T1s were not able to make glucagon when necessary, we wouldn't make it through the night. Glucagon stimulates both glycolysis and gluconeogenesis, providing much needed glucose during that extended period between meals.

After 43 ears of T1, I have no doubt that my glucagon production is as robust as it ever was. The Somogyi Effect, with blood glucose shooting up after a hypo, is further evidence of it. Yes, the stress response can be down-regulated by repeated hypos, and for me hypo unawareness is an issue. It just means that glycogen gets mobilised at lower blood glucose levels than it used to. This does not mean that the system is broken, though.

Hi,

Yeah. Ive got just over 44 years of experience with this condition & the associated meds too.
To date, I have just about managed to stay on my feet to treat.. I also concur there can be the odd recoverable dip during the night from the fours & late 3mmols.

However, insulin works in "mysterious ways." (& so does metabolism.)
It not advisable to suggest the liver will back you up in a "bar fight" with hypoglycemia..

What I do know is when serious Lantus lows happen, (from something like too much basal.) they can recur.. Hitting it with longer acting carbs after initial fast acting treatment can reduce these recurrences..

 

[MarkMunday]

... It not advisable to suggest the liver will back you up in a "bar fight" with hypoglycemia.. ..

The only useful suggestion in this regard is to limit insulin injection amounts to a level that doesn't overwhelm liver glycogen stores. In the average person, the liver holds about 130 grams of glycogen. The similar amount of glycogen in muscles has to be used there and is no use during hypos. So if the carb:insulin ratio is say 1:10, glycogen stores will cover an extra 13 units of insulin. Many people inject way more than this, hence the additional risk. Risk that can be avoided by splitting basal and reducing boluses. Because of their effects on this system, more vigilance is required after exercise and/or alcohol too.

 

[Jaylee]

The only useful suggestion in this regard is to limit insulin injection amounts to a level that doesn't overwhelm liver glycogen stores. In the average person, the liver holds about 130 grams of glycogen. The similar amount of glycogen in muscles has to be used there and is no use during hypos. So if the carb:insulin ratio is say 1:10, glycogen stores will cover an extra 13 units of insulin. Many people inject way more than this, hence the additional risk. Risk that can be avoided by splitting basal and reducing boluses. Because of their effects on this system, more vigilance is required after exercise and/or alcohol too.

I seem to be in luck then.. I take 13u of lantus. In the evening. (Give or take sick daze & hot climates.)
I see no evidence of the "130gee" donated by the liver whilst im fumbling about half blind with a 2.5er at 3am?
I low carb too.
As I mentioned upstream, I do see evidence regarding "foot on the floor syndrome," I know I'm getting on average 10g from somewhere.. Except the morning after a few LC bevies the night before.. (They will keep the liver looking the "other way.")

Basal is as basal does, regardless of the required individual dose..
Once again, Mark. I'd love a link to the source regarding your stament on how much the average liver "puts out" in glycogen..?

 

[MarkMunday]

.... I'd love a link to the source regarding your stament on how much the average liver "puts out" in glycogen..?

Read the second paragraph. The numbers differ somewhat to what at I have seen elsewhere, but in the same ballpark. Note that glucose from muscle glycogen can not get back into the bloodstream, so is no help during a hypo.

 

[EllieM]

The only useful suggestion in this regard is to limit insulin injection amounts to a level that doesn't overwhelm liver glycogen stores. In the average person, the liver holds about 130 grams of glycogen.

That's an interesting point, and I definitely agree that lower insulin doses reduces the risk of catastrophic hypos. Not sure about the 130g though. When I had a lantus low, based on 17 units of lantus, an equivalent dose of humalog would have required 50g of carbs. I probably had about 40g of glucose, and my liver helped out and/or not all the lantus acted in one hit (I suspect at least a bit of the latter because I think there was some lantus in my system the next day) and though I went down to the low 2s I retained consciousness. But without that 40g of glucose I think I would have been lower, so am not sure whether my liver would have supplied its 130g in time....

I guess we should now go out and look up a fatal dose of insulin for a non diabetic??? (Anyone remember the story about the GP who was found guilty of murdering his wife by insulin because he googled the dosage?).

OK, my googling was pretty inconclusive (but a lot, ie 100s of units) but I don't think anyone really knows, as it's not an experiment you do on purpose....