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Dealing with Dawn Syndrome

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RichardFromHampshire

Active Member
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I have been an insulin injecting diabetic for nearly 22 years and I currently use 4 injections per day, 3 of humalog and 1 of Lantus (before bed).

Generally I am well controlled (HBA1s are below 6) and I do quite a few blood glucose tests to keep it this way (anywhere up to 10 in a day).

Happy so far.

However, in the last 2 years or so (pretty much since I started using Lantus) I have been suffering from what i now realise is termed the "Dawn Syndrome" whereby my blood sugar levels rise extremely rapidly from about 2am to 3am in the morning until when I wake up at around 5am so that my levels are usually 16 mmol/l when i test in the morning. This necessitates a large dose of Humalog to correct and usually means I have no more than a glass of mil until lunch (as my body doesn't seem very receptive to the insulin in the morning and having anything more results in even higher blood glucose).

Having done a little research via the web i understand why this occurs (it isn't because of night time hypos - I have eliminated this possibility) and also I understand that a pump could well help to control this. Hence I have requested a pump from my diabetes consultant and will be getting one sometiume in the future.

However, I presume many Type 1s must suffer from this "Dawn Syndrome" and must also control it via their normal regimen and not via a pump. Given i don't know when I will be receiving the pump, can anyone suggest how I can go about controlling it? I did find that if i took a large dose of Humalog during the night then this could counteract the effects of the Dawn Syndrome but this isn't ideal given it disturbs my sleep and also risks a serious nightime hypo when I don't actually eat anything!

Any help/advice is appreciated :)

Thanks

Richard
 
What a lot of people do is spilt there background insulin, this can lessen the effect of the DP's...

You say that this started when you changed to Lantus, you haven't said what regime you were using before this change... If you've changed to lantus as part of changing your regime from 2 injections a day to the basal/bolus then it might be worth discussing with you diabetic team changing to Levimer instead... For splitting purposes, levimer tends to split better than lantus

If you've got a very steep raise of blood glucose with DP spliting will help to lessen the raise but tends not to bring it back into line so I would also nag your diabetic team to see if you can get an insulin pump as soon as poss.
 
Richard, another thing that may allow you to have a little more for breakfast (!): one of the features of Dawn Phenomenon is increased insulin resistance as you've discovered, this affects everybody not just diabetics, but sadly we're not able to deal with it without external help.

Increased insulin resistance means you have to inject more insulin, possibly quite a lot more, to deal with the same amount of carb. My insulin/carb ratio in the morning is almost double the evening figure, but some people find they may have to inject 3x or even 4x what they normally would for the same amount of carb later in the day. It's a bit scary at first, injecting such a large dose of insulin, but I can now eat breakfast safe in the knowledge that my bg won't spike unnecessarily.

The only way you'll be able to determine this is when you have your basal set correctly so do that one first. Of course on a pump you can program it to vary the ratio on an hourly basis if required, along with the basal rate, to deal with DP or any other fluctuation. Good luck with your quest for a pump!
 
Many thanks for both helpful replies - thinking on when i changed over to Lantus, I may have the dates wrong (I may have been using it for considerably longer than 2 years - the memory isn't what it once was!).

I am definitely going to be pushing for the pump (hoping, given all the experiences/advice I have picked up from users on the web, that it also helps me deal with my ballooning weight).

I feel somewhat stupid that I have been getting myself in a tiz over the last couple of years with this DS and nobody in the diabetes care team that I see every 6 months had ever mentioned "Dawn Syndrome". I always got blank faces when I described the problem I was suffering and the only thing that was ever suggested was to raise my dose of Lantus (which caused its own problems). I was fitted with a CGM for 2 3-day periods but even with these results (which clearly showed the BG rising in the morning) no-one made any connection with Dawn Syndrome.

I feel embarrassed that i never searched the problem on the web - as the first time I did that i came up with many references to high morning blood glucose caused by something called "Dawn Syndrome"! If only I'd been more pro-active 2 years ago!
 
Way to go Diabetes team. Sadly they seem to work on a need to know basis at times which of course helps no one. Suggestions for DP before you go for a pump include

Splitting Lantus - am and pm
If still rising, then you can raise your pm Lantus and also change the times to give you a good fasting bg. Also means that morning Lantus can be a bit of a help if you are getting higher bg (though of course your rapid acting will be doing all the work there

Some people have a small low carb snack at night but TBH I think this works best for people who are rebound hypo, or type 2's whose liver dumps it they dont eat.

Also, I find my ratios much higher too. I would also say that milk is quite carby and full fat is better than skimmed (though is suppose in both cases it depends on how much you drink) Milks is quite fast acting too. If I have a latte then YIKES.

Maybe some charcuterie/cheese/eggs would be better for you in the mornings ?
 
Hi Richard
you say you've only had this problem since being on Lantus, have you considered changing your basal insulin again? Not everyone is suited to any particular type, and there are many different long-acting insulins available. What insulin were you on previously, and how was your BG control prior to changing to Lantus?
I would have probably considered the Dawn phenomonon(had I heard of it), or insulin resistance while I was on Lantus, as the cause of my erratic inconsistent control for 4 years. I was swinging between 2 and 15 every single day, and could never predict what I'd wake up with in the morning-BGs that is :D
In my situation, for whatever reason, Lantus just didn't do it's job. Lantus claims to be a 24 hour basal insulin, as does Levemir, the profile charts look impressive; but if they were true why would anyone need to split their doses?
Before you go blaming yourself (as I did) or your body for malfunctioning, consider the possibility that your synthetic analogue insulin might not be the one for you. Especially if you've ruled out other posiblities.
Best to see your Doc, and hopefully he'll help you get some stability in your control.
Best of luck
Jus
 
Hi Jus

Thank you for your comments - I think it is probably the thing I will do next (changing insulin) if I find I have to wait until the new year for the pump (assuming my PCT allows me to have one of course, which hasn't been confirmed) and assuming splitting the lantus dose doesn't achieve anything.

Before the Lantus I was using Humulin (think that's what it was called) and while I rarely had 15+ BGs in the morning I also suffered quite a few nighttime hypos.

Richard
 
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