Dawn Phenomenon

[JJF1290]

Hi all, first post I know. Being Type 1 Diabetic for four or so years, currently take Levemir as my "long-lasting" insulin and novorapid as my fast-acting one. I split my dose of Levemir, morning and night and take Novorapid when required. Don't have my full numbers to hand as last time I saw my consultant he recommended I go to once a year appointments for the time being as I was doing so well, really good hba1c numbers. Recently though, I realised I've hit a bit of a snag.

As the title suggests - I think I'm suffering from the Dawn Phenomenon. The reasons for this are the following. I've noticed this trend over at least the past couple of weeks but thinking back I've been suffering for this for a fair bit longer.

1) Go to bed with a generally good blood sugar level, between 5.5 - 7 mmol.
2) Wake up around 4am - generally speaking it is the same or slightly higher (but still within that range). Definitely not "low".
3) Wake up again at 7am and my blood sugar is something absolutely ridiculous, I've had highs of 14 when I've woke up three hours after a level of 6 in the past week.

Now, I know about the effect going low during the night can have and how that raises your blood sugar level in the morning - but I know recently I've not been doing that because I know the symptoms I get when I have done that - sweats, confusion, crazy dreams, feeling literally like death in the morning. So I'm guessing it's not that.

I have also recently been taking my levemir at the time where the "peak" time should be when I'm getting the big peak in sugar levels, its effect has been negligible as I've slowly upped my dose of levemir at night and I'm obviously reluctant to do too much at once in case of going the wrong way in terms of hypos.

I also tried having a small snack at 4am with a dose of novorapid, which actually worked and my blood sugar was normal when I woke up, but I'm not 100% if this is a worthwhile long-term solution. Perhaps it is.

Does anyone have advice on this and what I can do to combat the Dawn Phenomenon? The obvious answer would be to get an appointment with a Doctor again if I need to change medications but generally speaking, I've been managing everything perfectly well, apart from early mornings. So I'm reluctant to change medications unless I have to as I'll have to learn everything again. I must also note I haven't been doing too much exercise recently.

Any advice appreciated!

 

[noblehead]

Oddly enough my bg would increase if I slept later than 7.00 but would be fine before then, I had to pre-empt this by getting up before 6.30 and have some breakfast which worked every-time.

I'm using a pump now so can set a TBR if I decide to sleep late and this deals with the bg rise, you might want to discuss about the possibilities of a pump yourself if you don't have any luck in getting your waking levels down.

 

[Neemo]

Hey @JJF1290,

I can 100% relate to ur post.

Its been soo incredibly frustrating to get my liver to behave..

I'm assuming that you've performed tests in early morning (1 am, 2 am etc) to exclude
Somogyi effect as the cause?
http://www.m.webmd.com/diabetes/morning-high-blood-sugar-levels

Personally, I always have an excellent pre bed BS. But, when I have carbohydrates within at least 4 hrs prior to bed - my BS ALWAYS shoots up to the 14 range.

So the 2 ways I 'manage' morning highs is to;
1. Either workout post last meal (pre betime)
2. Avoid carbs after 6pm on non workout days.

Hope you conquer it; I've had way too many days in the past start off with a morning high. Even a small high (9,10) can make you feel/look ****, but 14 is a horrible start to the day.

 

[JJF1290]

Thanks for the replies so far, I've only ever had the option of a pump brought up once (when talking about injection sites as I wasn't using my arms very often and my stomach was taking a battering!) but it's something that would obviously help things stayed as they are, and at least long-term they are an option. I've noticed a jump from at least 5:30am onwards, which is probably just down to my body clock starting up earlier.

Regarding Somogyi - I don't think this is the cause as I generally go to bed late anyway and have tested numerous times just after going to sleep (woke up for some unbeknown reason) and they've always been fine. When I get somogyi generally I'll be covered in sweat and my fiance would wake up and see me sweating, so it could be that I guess, but I'll rule it out for the time being. The other thing is that I eat dinner generally quite early, like 6pm, go to bed at 11:30-12 and still get these massive jumps early morning, which puts me back for the entire first half of the day. At least I know I'm not the only one.

I read somewhere about eating a snack in the middle of the night, a very low carb or protein snack in order to "trick" your liver to not bother to throw our a ton of glucose, I'm not sure though about the scientific merits of that!

 

[tim2000s]

What you also don't talk about is the timing of your two levemir injections and the size of them.

For example, I take 14u of Levemir in the morning and 6u at night. My morning one is now taken around 7.30am and my evening around 9.30pm. This is to take account for the fact that the duration of Levemir is affected by the dose. Smaller doses last much less time than larger doses.

What you could be finding is that, if you don't take a particularly large dose of Levemir, your dawn phenomenon is coinciding with the Levemir effectively "running out" (which is why I have a 10hr and 14hr duration on my two - to avoid the overnight one running out, but also stopping overnight hypos).

 

[tim2000s]

I'm puzzled by that, though it might be the "semantics" that you are using.
The duration isn't affected by the dose, only the "peak amplitude" if you like (of the absorption curve). But if that "peak amplitude" is low, then as the absorption tails off, there is less "under the curve" to have any effect. But the time duration from end-to-end of the absorption curve is the same.
So there is a danger that, in order to have more "under the curve" towards the end of the absorption, the "peak amplitude" wil lbe too high and cause a hypo.

Whilst I agree with the majority of that statement, experimentation has shown a couple of other characteristics. Unfortunately, the duration of absorption is affected by the dose:

At small doses/kg of bodyweight, the absorption rate starts to drop at about 10-12 hours (looking at the 0.2 U/Kg graph) and is effectively doing nothing for the next four hours. At higher doses, the insulin is shown to continue to be absorbed for longer.

With a larger dose, we also see that the absorption rate takes longer to peak and the peak lasts longer. To be honest, the larger doses shown on here equate to an injection of 90+U which I think are mostly unrealistic, but at the bottom end, around the 0.2-0.4U/kg level, there is a noticeably different effect.

 

[JJF1290]

Brilliant, thanks for your help all. I'll use some of the things mentioned and come back to you. It's probably the most annoying thing about internet forums when someone asks a question, it gets answered and then you don't know if it was the correct answer.

Thanks again

 

[tim2000s]

I've seen graphs like that before, which was what I was describing, and tbh if someone is making small adjustments of their dose, a graph like that is irrelevant. Basically, if they are injecting an amount down towards the lower end of the Y axis, they may as well not bother injecting anything, because there are far bigger variables going on in the body.

An interesting observation. What is your basis for it? Are you a type 1 (I'm afraid I can't tell as your profile is hidden from me)? I inject at below the 0.2U/kg in both my split doses and it gives me a suitably flat fasted bg level without a massive peak in absorption. What you are suggesting is that it isn't worth me doing this as my body would compensate any way...

 

[fozzie84]

I have been experiencing the dawn phenomenon through the last year and it is the main reason I am going on a pump, however in my experience the following things helped me wake up with a better blood sugar. Either not eating a snack after dinner, or, injecting for any snack no matter how small, some form of exercise before bed, or whilst I wouldn't suggest this as a long term solution, I find if I've had a rum and coke or similar that improves my morning readings! But I've found its not an exact science.

 

[tim2000s]

You don't need to go to the Vatican to find out if the Pope is a Catholic. It is possible to click on someone's message count to see their messages (even when not logged in)

Well then, I'll assume, as I don't particularly want to read through 293 messages to find a statement that you are T1, that you are...

In which case I still ask how you arrive at the determination that at a dose of 0.2U/Kg or lower:

they may as well not bother injecting anything, because there are far bigger variables going on in the body.

?

 

[tim2000s]

Brilliant, thanks for your help all. I'll use some of the things mentioned and come back to you. It's probably the most annoying thing about internet forums when someone asks a question, it gets answered and then you don't know if it was the correct answer.

Thanks again

Quite. The only way you can really determine the answer is to test what's going on and determine yourself. There are usually multiple answers to a question and a number of ways to address the issue, and we can offer up the options that might help.

 

[Wurst]

I find If i eat late in the evening i.e. > 20:00 then I suffer from the dawn phenomenon and can do little to stop it. It is particularly pronounced if I've consumed something fatty or carby and even an extra shot of bolus or increasing my basal does not help. So it might be worth reviewing your eating schedule.

 

[tim2000s]

The funny thing is that I only seem to get large DP when I'm eating a reasonable amount of carbs between about 6 and 9pm (>40g) and at other times, it's generally around a 0.5mmol/l rise in BG level. Given my daily routine is to get up at around 5am, I'd expect to see something occur around that time at weeknds, but I don't.I think DP can be a lot more complex than people realise.

 

[tim2000s]

You better tell the website person who wrote this then
http://www.diabetes.co.uk/blood-glucose/dawn-phenomenon.html

I've said before on this forum (whenever I decide to contribute) that there are multiple control systems in the human body, each with hormonal signal loops and/or nerve signals in the control loop, and they can impact one another in subtle ways.

In a non-diabetic, the control-loop for BG is fairly robust under "disturbance" inputs, but the treatment of T1 is an "open-loop" control. The whole ethos of treatment of T1 assumes that the "disturbance" inputs are known and un-changing from one 24-hour period to the next, and that once the diabetic has established his/her open-loop control method, any disturbances will be temporary. But this is completely untrue because, as well as continually changing short-term disturbance inputs, some longer-duration disturbances can creep in. It is this that can be frustrating, because when there is a change, it can take a long time to find out why, if ever. And sometimes, things just switch back to the way they were, because the disturbance input has changed again.

So if there is a rise in BG at dawn, if it becomes persistent, one has to think what has changed. It could even be as simple as something at work, that adds stress, which changes the amounts and timings of hormonal release, which in turn impact the timing and release of other hormones. In the non-diabetic, this might go un-noticed, or it might cause one to start waking up feeling less refreshed. But the T1 will notice changes, and a change in the dawn rise could be a result of something obvious that is being over-looked, or something less obvious that takes a while to suss out (if ever)

As the writer of the site says:

"High morning blood sugar can be down to a variety of things, including insufficient insulin, incorrect medication dosage, carbohydrate snacks before bed and more."

In other words, test, document, and review to try and find a pattern. It may be dawn phenomenon that the OP is seeing, or something else. Without consistently taking steps to review, it remains difficult to diagnose and deal with.