Groggy upon waking

[Thrill]

Hi all,

Having been T1 for a few months now, the past two weeks I have been having a bit of trouble upon waking. I generally wake around 6:30am weekdays and until around 11am I feel groggy and almost hungover. Feel dizzy, clumsy, and generally c****y but BS seem ok. I usually wake between 6.2 - 7.2.

I'm worried my Levemir at night is the cause. I was started on 2 units of Levemir at night, but if I found my BS was upwards of 9 mmol before bed I would double the units to 4 to ease the readings overnight.

First things first, is this bad practise? Maybe I am confused as to what my Levemir should actually do for me, I appreciate it's long acting, background insulin. I seem to think if sugars are high before bed then to inject more Levemir.

Throughout the day my Blood Sugar control is generally pretty good and I feel my best at around 5.5 - 6.5.

I have never done a basal test as I'm not sure how to actually do one advice would be appreciated on this part.

Any advice is welcome. I'm on fairly small doses of NovoRapid. My ratio is 0.5 per 10G of carbs.

Thanks all! I would attach my overnight Libre readings but they're generally significantly higher than they actually are!!

Edited by moderator for language.

 

[EllieM]

Hmm.

You use bolus (short acting) to correct temporary highs and compensate for food, the basal is there to keep you going in the absence of food or insulin (eg over night). If you go to bed at least 4 or 5 hours after your evening bolus then the difference between your night time and morning readings should tell you roughly whether your basal is right. (Of course, it's more complicated than that eg the dawn phenomena means that some people's livers pump out sugar when they wake which raises blood sugar even if they don't eat.)

My understanding is that you don't increase the levemir to cope with high evening bs, but with a change between evening blood sugar and morning blood sugar. However, I'm not a doctor, and my body no longer produces insulin, so I'd strongly recommend ringing your diabetes clinic and getting some advice from the experts who understand your treatment and history.

Increasing your levemir from 2 to 4 is a doubling of the dose, which is a BIG change.

It's possible that you're going low overnight and then your liver releases sugar to correct the low, and you have a hypo hangover in the morning. Is this consistent with the libre readings?

Have you been given a figure for novorapid required for a correction doses (eg .5 units for 2mml/L)?

Bear in mind that you're still in the "honeymoon" period, so your body is still producing some insulin and you will need more in the long term when your body stops producing insulin altogether.

 

[Draco16]

Hi all,

I'm worried my Levemir at night is the cause. I was started on 2 units of Levemir at night, but if I found my BS was upwards of 9 mmol before bed I would double the units to 4 to ease the readings overnight.

First things first, is this bad practise? Maybe I am confused as to what my Levemir should actually do for me, I appreciate it's long acting, background insulin. I seem to think if sugars are high before bed then to inject more Levemir.

Hi Thrill, yes this is insanely bad practice! You're doubling the dose and asking it to do something (correct a high) that it is not intended for.

Recently diagnosed your insulin needs will change, so 2 units may not be right for you any longer, but if you're good (ie flat ish) later during the day and feeling good as you say they might well be.

What I think is going on here is that Levimir hits a peak about 6 hours after injecting, so it may be sending you low, then you might be getting a glucose dump to correct that, or DP. It's hard to say but doubling your Levimir dose is definitely not helping.

Do you know your short acting correction dose? eg 1/2 unit drops your sugar x mmol/L

Use that correction factor if you are over 9 going to bed. That will correct the high, then Levimir's role is just to flatline you.

Many people could tell you about basal testing... but I think you need to get your head around the role of different insulins, correction doses, etc first and then basal test. A couple of hours of your own research will save you tens of hours of feeling rubbish, plus you have a more complete picture of your situation.

The Libre graphs are still useful as it is the trend that is important, not the absolute values if you believe them to be too high. Can you post them please?

 

[Thrill]

Thank you Ellie and Draco. Very hard for me to reply back to fairly lengthy messages on my phone (Need my laptop) but I have taken on board your comments so thank you very much. It's all very knew to me and I'm a bit of a tweaker (probably not a good idea with Diabetes!).

I don't have my correction dosage yet but I am supposedly 0.5 u per 10G of Carbs for NovoRapid (which seems to fluctuate depending on the day)

Attached are a few days of graphs. I've been out the country for a few days but today, 31st March I have felt fantastic almost all day. Thurs & Fri were bad days, felt groggy all day so they are good examples. I only popped in 2 Units of Levemir Friday evening (maybe 3, I didn't record it on my Neo either)

Attached are my graphs, thank you both and I look forward to your replies.

I have missed out the 25th as it didn T have much data on it, probably due to travelling.

 

[Draco16]

Hi @Thrill - thanks for posting these. No apology need for tweaking, it's an essential T1 skill as nothing ever stays constant! But as long as they're small tweaks - rather than eg suddenly doubling something - then vital to experiment and adapt as time goes on: continuous improvement is the goal.

On these graphs:

1. You mentioned you're on an overseas trip, but is the timezone the same? eg 0300 on the graph you're asleep i'm assuming?
2. How many units of Novarapid do you take per day?
3. Do you bolus for all meals / snacks? If not when do you / don't you.
4. Do you pre-bolus (ie inject Novarapid a few minutes before eating)?
5. You said the Libre over reads, if you say compared meter v libre 5 hours after eating and injecting Novarapid what is the difference then? (This time allows for a better comparison)
6. Anything else around how much exercise you do, how many carbs you eat, is this consistent day to day, etc would be useful
7. Oh why do some of the graphs not have the full 24 hours of data?
8. Do you do airshots before you inject?
9. You're on such small Levimir doses is the pen still good? i.e. less then 4 weeks old from being taken out the fridge?

Certainly one thing you might want to consider is splitting Levimir into two injections per day, many of us do as it is generally acknowledged that it runs out after 18-20 hours or so, that might be at work here.

 

[Fairygodmother]

Hi @Thrill, and welcome to the exclusive T1club.
I agree with the responses of @EllieM and @Draco16 - and especially that you contact Your DSN and ask about correction doses and splitting Levemir. You say your grogginess decreased on 31st March and your graph shows you woke with better bs that day so enabling decent waking bs might be the clue. I find that if I don’t catch the Dawn Phenomenon in time then often the whole day’s affected and I have less energy.

I’m also reading Matthew Walker’s ‘Why We Sleep’ which is very scientifically informative concerning the factors that disrupt us. Many of these are already well known through experience. Did you cross many time zones while you were abroad? Have you been having sufficient sleep? According to Walker both can seriously affect our ability to concentrate, to operate well. Insufficient sleep can also detrimentally affect our immune systems.

It’s good news that you had a less groggy day, may all your days be groggy-free!

 

[Thrill]

Hi @Thrill - thanks for posting these. No apology need for tweaking, it's an essential T1 skill as nothing ever stays constant! But as long as they're small tweaks - rather than eg suddenly doubling something - then vital to experiment and adapt as time goes on: continuous improvement is the goal.

On these graphs:

1. You mentioned you're on an overseas trip, but is the timezone the same? eg 0300 on the graph you're asleep i'm assuming?
2. How many units of Novarapid do you take per day?
3. Do you bolus for all meals / snacks? If not when do you / don't you.
4. Do you pre-bolus (ie inject Novarapid a few minutes before eating)?
5. You said the Libre over reads, if you say compared meter v libre 5 hours after eating and injecting Novarapid what is the difference then? (This time allows for a better comparison)
6. Anything else around how much exercise you do, how many carbs you eat, is this consistent day to day, etc would be useful
7. Oh why do some of the graphs not have the full 24 hours of data?
8. Do you do airshots before you inject?
9. You're on such small Levimir doses is the pen still good? i.e. less then 4 weeks old from being taken out the fridge?

Certainly one thing you might want to consider is splitting Levimir into two injections per day, many of us do as it is generally acknowledged that it runs out after 18-20 hours or so, that might be at work here.

Hi @Draco16,

1. I only visited abroad for a few days, so been back now since Saturday and left on Wednesday around 4:30. The time zone was +1. I'm always asleep by 3am!
2. It depends on what I am eating, I am doing this 'carb counting' routine recently which is what my Diabetic Nurse has advised. Not having much luck with it to be honest so I'm going back to my educated guessing which seems to be working a treat.
3. Yes, unless I am low ish and take a light snack I don't bother.
4. Yes pre bolus
5. The Libre always reads higher than it actually is. Yesterday evening it was reading 12.3 yet was actually 10.5 so I injected 3 units which brought me down nicely for overnight.
6. I have an active lifestyle but at the moment doesn't include dedicated exercise until I can sort all this out.
7. No idea!
8. Yes
9. I should think so but cannot guarantee.

Splitting my Levmir so maybe 2 units in morn and 2 units before bed?

Thanks for all your help.

 

[Draco16]

Hey, ok i'd definitely start a new Levimir pen, previously when you were doing 2 units per day even with the airshots that pen would have lasted up to 75 days (300/4)... way too long.

I doubt you have a half unit Levimir pen, as perhaps 3 units (1.5 x 2) would be best place to start. Though generally I think you may not be taking enough Levimir so 2x2 is where i'd start with splitting. I asked re how much Novarapid you take to try to understand the balance between the two. Crudely something loosely around 50:50 is common for long v short acting. But at just two Levimir per day I expect you are taking much more Novarapid?

I think you do need to take more Levimir looking at your graphs as you're generally running a little high, and it looks like the Novarapid does it's job to an extent but then loses and you start trending up again as you don't have enough background.

Stick with the carb counting, while you say you're guessing you probably are carb counting. It's tricky as carb ratios change over time and often time of day.

Usual disclaimer chat to your DSN before making the changes, and any increases in insulin keep a close eye for hypos and have treatments close to hand.

Oh and nice correction last night.

 

[Thrill]

Hello, woke up feeling good today!

Levemir pen changed to a new one from the fridge. This may help too so thank you!

The diabetic team popped me on a half unit Echo pen for NovoRapid but the pen is broken so waiting on a replacement from Novo Nordisk.

I take anywhere between 2 and 7 units depending on meals a few times a day. When the DSN got me carb counting I was hypoing almost every day, now the half unit pen is broken I'm not correctly working everything out as I can't inject half units. Things are good at the moment.

At what times should I split the dosage? Morning and before bed? Or maybe lunch time and before bed? I currently use Levemir before bed which may differ +/- 1 hour.

Thanks for your help really appreciated. Still not sure what my blood glucose ranges are but I think anything from 5-7 before meals is good?

Many thanks

 

[Draco16]

You're looking for 2 times of day 12 hours apart when it fits with your life. If occasionally you're a couple of hours early / late that's fine.

For me I do 6.30am / 6.30pm as they just work with my schedule. Personally I wouldn't set just before bedtime as a time to inject long acting, as if you forget you won't have a chance to remember until you wake up high the next morning.

Target ranges are here:

https://www.diabetes.co.uk/diabetes_care/blood-sugar-level-ranges.html

You're still early days so be be relaxed if you're not in these ranges all the time, but slowly slowly keep making small tweaks as needed to get there.

And remember your long acting will probably start to be more effective now with the new pen, better 24 hour coverage, and more units (4)... this may well reduce your novarapid requirements, try and get hold of that half unit pen again asap.

Good luck with it!