Diabetic nurse doesn't know what to do, help needed please.

[Mrs of type 1]

Hello there,

My husband who has been a type 1 for 30+ years started the Balus/Bolus system on the 25th January. All last week he spent at hospital doing the DAFNE course. He is taking Novarapid at a 1:3 ratio in the mornings and 1:1 ratio at dinner time. He has 19 units of Lantus at night, he started on 16 units but the nurse put him up to 19. The problem is the very high sugar levels of 20+ every morning when he wakes up. He takes the right amounts of corrections to get him to around 8 but it takes until evening to come down, some evenings he is quite low around 3-4 then he has a small biscuit just to bring him up to 6-7. When he takes his Lantus he is always around 7-8, but then the next morning the highs start all over again. We are carb counting correctly, the blood tester is working fine, we can't understand why this is happening. On the DAFNE course everyone was sorted out apart from my husband. As you can imagine he is feeling not only ill due to so many high sugars but very down also. We would be so grateful for any advice. thanks for reading.

 

[noblehead]

It all points to his basal dose being too low if he's going to bed at 7-8 and waking at 20, ask him to do some bg checks tonight and if his bg is slowly increasing every 2 hours throughout the night then he needs to up the dose the following day. As he increases the lantus his morning bg should stay within 1.7mmol from when he went to bed, once that's achieved he should see better levels throughout the day without the need to do many corrections.

A few restless nights sleep ahead with the testing but it's the only way to get the basal dose just right, good luck and I hope he gets it all sorted!!!

 

[novorapidboi26]

I echoed what's already been said....,

Its very unlikely he left DAFNE with the right basal dose....especially coming straight off a mix insulin.....

He needs to do carb free basal tests for the whole day.....this can be split up into several blocks.....from bed till morning....then breakfast to lunch and so on......

Ideally you want to evaluate each portion of the day one at a time and for 3 days before adjusting.....but he/you will know the process having attended DAFNE....

He might find he needs more insulin in one part of the day than the other....which is impossible to cater for with a single lantus dose..... A split might be needed....

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[kkkk]

I think a bit of testing in the night is probably needed too (I know, not pleasant and I hate it too, but something is happening, whether it be a steady rise). If it doesn't work out soon then ask the hospital whether they have a continuous glucose monitor that they could lend him to have a look at what is going on over night. I know that sometimes my sugars start rising very quickly after I wake up and I can go from being 4.5 at 5:30am (and in the 5s and with a flat graph all night) to 10 by 7am after I have got up and dressed (no eating involved at all) - so really with all that the best thing is to test and have a night of poor sleep that will hopefully get you to the bottom of what is going on - it does sound like he might need more of the lantus tho - but do the checking too it will be worth it.

 

[ancientdiabetic]

Hello Its definitely an incorrect basal dose. have you thought about splitting the night time dose its just that researach shows that basal doses wear off after so many hours (regardless of us being told they last for 24 hours) could try taking 12 units of basal in the morning and 12 units at night see what happens. also he may be prone to the dawn corus in the morning when his basal is not working so efficiently . . he can test this by not eating carbs in the morning and seeing what happens to his bllod sugars sounds very interesting !

 

[niknak15]

I had this same problem, I wore a sensor for a week, it showed I was having night time hypos and not waking therefore causing my sugars to go up caused by incorrect long acting dose, so the split it, I do some in the morning and some in the eve. Hope he gets some answers quickly


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[ConradJ]

Hello there,

The problem is the very high sugar levels of 20+ every morning when he wakes up. He takes the right amounts of corrections to get him to around 8 but it takes until evening to come down, some evenings he is quite low around 3-4 then he has a small biscuit just to bring him up to 6-7. When he takes his Lantus he is always around 7-8, but then the next morning the highs start all over again. We are carb counting correctly, the blood tester is working fine, we can't understand why this is happening. On the DAFNE course everyone was sorted out apart from my husband. As you can imagine he is feeling not only ill due to so many high sugars but very down also. We would be so grateful for any advice. thanks for reading.

This sounds like he's going hypo during the night (i.e. early hours - say around 2am) and then waking on the rebound.

There are many possibilities to this, but it's worth doing an evening 'basal' rate test to figure out what's happening with his BG prior to bed. Yes, it's a real headache, but the hunger can be mitigated with a large, carb-free salad with something like chicken to add some bulk (don't use Beetroot tho - it's got carbs!)

He could also try eating a low-GI bedtime snack (say 20grams of carbs), such as a small bowl of porridge, without bolusing for it - that can eliminate the night-time lows.

If he's still having problems after a number of trials (food, split dosage, etc) and basal tests, he should speak with his DSN / Consultant to discuss other insulin options - e.g. levemir instead of Lantus, or humalog instead of Novorapid.

Good luck - and tell him not to get too disheartened.

 

[kkkk]

I am a morning and evening person too 'cos I used to go too high at tea time when my background insulin ran out!

 

[Mrs of type 1]

I am a morning and evening person too 'cos I used to go too high at tea time when my background insulin ran out!

 

[Mrs of type 1]

Thanks for all your replies, very interesting. He has already done some night time blood testing and we found his sugar was just rising and rising every 2 hours. The next day he decided to eat nothing at all until lunch time and still the blood sugars kept rising until he was over 20! We think he needs a larger dose of Lantus but his DN is very reluctant. He spoke to her yesterday and she said to do another night of testing every 2 hours and she even mentioned he may have Dawn Phenomenon and might need to go on a pump in the future, in the meantime he can't keep on with all these highs, his Neuropathy pains are getting worse. We really can't understand why the sugar level comes down in the evening because surely by then the Lantus would be running out? Last night he done something he was told never to do, he took 2 unit's of Novarapid before bed, he was 14 due to not enough Novarapid when he ate crackers and cheese ( can't believe how much carb is in a cracker) Well it worked because this morning he was at 9 which is so much better than the usual 16+

 

[DunePlodder]

I'd agree with Conradj, he may be going low in the night then having a "liver dump" where the body puts more glucose into the system explaining the very high morning reading.
Using a CGM has confirmed that this was sometimes happening to me, I've now reduced my basal a little.
Not much fun doing basal testing but worth it.

 

[ConradJ]

Dawn Phenomenon has a lot to answer for - when I find out who she is she's going to get a piece of my mind for sure.

 

[ConradJ]

Not much fun doing basal testing but worth it.

I used to hate basal rate testing . I mean, why would I intentionally starve myself for almost 12 hours for little gain? But now, I have found that - with a little bit of planning (and help from the Mrs.) - I can cope reasonably well... and it IS for huge benefit.

Still, it leaves me begging the question: why does salad implode in the stomach in the same way a Chinese take-away does? I'm on day 2 of another basal rate test and haven't eaten carb-based foods since 07.00. I had a LARGE salad for lunch, comprising leaves, tomatoes, peppers, cucumber, cheese and chicken and yet barely two hours after eating it I feel as ravenously hungry as the Cookie Monster!!!

 

[ljwilson]

I too get very high reading in the morning. mine is due to severe dawn phenomenon, To overcome this I take an extra 10 units of Nova rapid on waking about 6am then at 8am I take my normal dose for breakfast

 

[SamJB]

Absolutely, 100% certain that his basal dose is too low. The basal insulin is to cover glucose produced by the liver throughout the day, if you don't have enough basal to cover this, the BGs will increase. The classic symptoms of this are increased BGs overnight and increased BGs during fasting. If you've tested every 2 hours throughout the night and his levels increased each time, then definitely, his basal is too low.

Every 1.6 mmol/l change in overnight BGs requires a 10% change in basal insulin. Make sure that he doesn't eat or inject fast acting insulin for around 4 hours before bed, otherwise it will interfere with the reading. Once you have his basal dose correct, you might need to tweak his insulin to carb ratio. Concentrate on getting his basal correct, this must be done before you can determine his insulin to carb ratios otherwise you won't know whether his basal has affected his post meal BG reading.

His levels might be decreasing in the evening because of his fast acting insulin. Lantus sometimes doesn't last 24 hours, but if you've got fast acting insulin in you, that will decrease his levels.

Also, you don't need a pump to deal with the Dawn Phenomenon, I experience it and I require an additional 2 units of fast acting insulin to cover it.

 

[Dougal]

Have you thought about the possibility that you have suffered a hypo during the night? A liver dump could explain the high morning readings. Try waking up once or twice during the night. If these tests are normal, it is probably dawn phenomenon.


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[SamJB]

Have you thought about the possibility that you have suffered a hypo during the night? A liver dump could explain the high morning readings. Try waking up once or twice during the night. If these tests are normal, it is probably dawn phenomenon.


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The OP has stated that they did 2 hour tests throughout the night and saw as steady rise. This indicates that this increase is down to insufficient basal insulin, rather than a liver dump from a hypo.

 

[ConradJ]

Absolutely, 100% certain that his basal dose is too low. The basal insulin is to cover glucose produced by the liver throughout the day, if you don't have enough basal to cover this, the BGs will increase. The classic symptoms of this are increased BGs overnight and increased BGs during fasting. If you've tested every 2 hours throughout the night and his levels increased each time, then definitely, his basal is too low.

I wouldn't be so 100% certain: for a long time my DS teams would insist that my basal rate was too low, then it was too high, and then I went onto a pump and still had the same high morning BGs. Then we started doing CGM tests on a 3-day basis and discovered that somewhere between 01.00 and 02.00 my BGs would just take a massive vertical dive - so low in fact that the CGM would no longer get a reading!

Currently, I compensate for that by increasing my basal rate by 500% from 02.00 to 04.00. Mostly, I wake up with BGs in the 4.5-7 region. Obviously, when people are on injections they can't possibly be expected to wake up at 02.00 (etc) every night and give themselves a pre-emptive bolus!

I was on Lantus prior to the pump and found that my control went so far out of the window that my HbA1c went through the stratosphere.

What is 100% certain is that each and every one of us is different and responds differently to insulin, carbs, stress, exercise, etc.

Also, some of these insulins are not all they're cracked up to be: there were huge issues with the introduction of 'Human' insulins and some - such as Lantus - do not last 24 hours as they were marketed to do. Maybe Mrs Type 1's husband could try a lower pre-bedtime basal does of lantus and a higher daytime dose? Or maybe there's something else, like his evening bolus is too high and not breaking down in his body as quickly as it might do due to temperment, stress, body fat, etc. etc.?

 

[Kelsie]

I would suggest the same as ancient diabetic and split the long lasting insulin dose-I inject half of my dose in the morning about 9am and then the other half at 9pm as it generally only has a life span of 12 hours not the 24 hours as some hospitals suggest. Good luck


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[SamJB]

I wouldn't be so 100% certain: for a long time my DS teams would insist that my basal rate was too low, then it was too high, and then I went onto a pump and still had the same high morning BGs. Then we started doing CGM tests on a 3-day basis and discovered that somewhere between 01.00 and 02.00 my BGs would just take a massive vertical dive - so low in fact that the CGM would no longer get a reading!

Currently, I compensate for that by increasing my basal rate by 500% from 02.00 to 04.00. Mostly, I wake up with BGs in the 4.5-7 region. Obviously, when people are on injections they can't possibly be expected to wake up at 02.00 (etc) every night and give themselves a pre-emptive bolus!

I was on Lantus prior to the pump and found that my control went so far out of the window that my HbA1c went through the stratosphere.

What is 100% certain is that each and every one of us is different and responds differently to insulin, carbs, stress, exercise, etc.

Also, some of these insulins are not all they're cracked up to be: there were huge issues with the introduction of 'Human' insulins and some - such as Lantus - do not last 24 hours as they were marketed to do. Maybe Mrs Type 1's husband could try a lower pre-bedtime basal does of lantus and a higher daytime dose? Or maybe there's something else, like his evening bolus is too high and not breaking down in his body as quickly as it might do due to temperment, stress, body fat, etc. etc.?

But they tested 2 hours throughout the night and saw a steady BG rise. They also saw a BG rise in the morning when they fasted. These are the only ways (without a CGM) that someone can tell that their basal is too low. In addition, they injected some fast acting before bed and awoke with better BGs, because that insulin compensated for the lack of basal. Classic symptoms.

I change my Lantus almost on a daily basis because it is affected dramatically by exercise. I've perfected it and it a huge contribution to my low HbA1c. These are definitely symptoms of insufficient basal insulin.