HIGH BG at night & rise in morning.

[LionChild]

I am a Type 1 Diabetic.

Does anyone have any insights into the following? If so, thank you in advance!!

Despite posting several weeks ago, my Blood glucose remains frequently (though not always) very high in the mornings. (for me anyway). By that I mean 10 mmoles plus. Sometimes it starts climbing high at night - to around 9.5.by about midnight, and then stays really high all night long. I have been taking Levemir at night at 4 units, and in the morning I take 3 units. I usually take the 4 units before I go to bed at around 10 pm, and therefore surely this cannot mean the Levemir needs increasing as it would not run out so quickly? So, the BG stays high all night long and then in the morning has been over 11 mmoles. I wondered whether it might be a case of the Somogyi effect -that I might be taking too much insulin for my evening meals? --- as quite often it goes low, even to a hypo later in the evening, ( I treat, not overmuch I think), and then still rises so high in the mornings. The rise is gradual, but very obvious. and again, it is from about 3 am.....which would seem to indicate a possible Dawn Phenomenon effect? The thing is, although the BG tends to stay quite high in the morning up until around 12 midday, or sometimes later, ---it does tend to go down usually quite quickly after about an hour when it would go to around 8 mmoles, normally. I also notice if I get up late - say around 09.30 - the BG has more time to climb higher to 9 mmols+. If I get up around 7 am for example, and inject Levemir, (3 units), and even perhaps 1 unit Novorapid at that time, it will stop the rise from getting, in my view, too high at around 10 mmoles. It would then be more like 6 mmoles.

So, I am trying to ascertain whether the high rise at night, and through the night in particular is due to the Somogyi effect, and injecting too much for the evening meal, resulting in the rebound effect later, or whether it is simply the Dawn Phenomenon (but how can it be that, if frequently my BG is high Before I go to sleep? I am puzzled as this pattern is very new to me. I was diagnosed as Type 1 in 2019 - so surely it can hardly be said I am coming out of the Honeymoon period..?

Maybe it is just timing of the Novorapid injection for the evening meal? Usually I give it around 30 minutes before I eat?

Very puzzled at these sudden changes!

Insulins are within date.

 

[SimonP78]

Can you show us a graph of BG? Sounds like splitting your evening meal bolus would make sense to avoid the low you get in the middle of the evening. The thing about those lows, is that the food you ate (and dosed for) is still being absorbed and you'll have taken on board more carbs to deal with the low. The result is you end up going high into the evening as supper is digested.

You may well also have a dawn effect rise going on, though the extra rise at say 3am might simply be that your evening bolus has finally been exhausted so there's a BG uptick.

 

[LionChild]

Can you show us a graph of BG? Sounds like splitting your evening meal bolus would make sense to avoid the low you get in the middle of the evening. The thing about those lows, is that the food you ate (and dosed for) is still being absorbed and you'll have taken on board more carbs to deal with the low. The result is you end up going high into the evening as supper is digested.

You may well also have a dawn effect rise going on, though the extra rise at say 3am might simply be that your evening bolus has finally been exhausted so there's a BG uptick.

Thanks Simon! My thoughts about your final sentence however is that how can I be running out of Levemir at 3 am, when I only took it around 10 pm?

I will try to attach some photos of two examples of these rises...

 

[LionChild]

 

[LionChild]

Can you show us a graph of BG? Sounds like splitting your evening meal bolus would make sense to avoid the low you get in the middle of the evening. The thing about those lows, is that the food you ate (and dosed for) is still being absorbed and you'll have taken on board more carbs to deal with the low. The result is you end up going high into the evening as supper is digested.

You may well also have a dawn effect rise going on, though the extra rise at say 3am might simply be that your evening bolus has finally been exhausted so there's a BG uptick.

This one, also recent from 6 July, is a bit different however....

but then again, This....?

 

[LionChild]

Can you show us a graph of BG? Sounds like splitting your evening meal bolus would make sense to avoid the low you get in the middle of the evening. The thing about those lows, is that the food you ate (and dosed for) is still being absorbed and you'll have taken on board more carbs to deal with the low. The result is you end up going high into the evening as supper is digested.

You may well also have a dawn effect rise going on, though the extra rise at say 3am might simply be that your evening bolus has finally been exhausted so there's a BG uptick.

Oh I see you said bolus may be running out, not basal. My mistake.? Did you mean Basal though??

 

[SimonP78]

Thanks Simon! My thoughts about your final sentence however is that how can I be running out of Levemir at 3 am, when I only took it around 10 pm?

No I meant the bolus, if your food is still producing glucose while being digested when the bolus runs out (is broken down) you may well then see an uptick in BG

 

[LionChild]

No I meant the bolus, if your food is still producing glucose while being digested when the bolus runs out (is broken down) you may well then see an uptick in BG

So rather than being too much bolus, it could be that I am not having enough Novorapid? And the mid- evening hypos (and sometimes beyond) are simply because conversion to glucose is incomplete at that point in time? So then I treat it, and maybe over-do it...? Or maybe it is the timing of injection and eating time.....that is awry? Gosh, it is SO complicated!!

So would you rule out my needing to have MORE Levemir at night?

 

[SimonP78]

It's quite hard to work out whether something is dawn phenomenon or insufficient evening meal bolus/food being converted to glucose after the bolus is finished, one way is to skip your evening meal, or eat something early/low carb and see what effect it has overnight. Also note that evening snacks (nuts, cheese, all these things I do!) that don't contain carbs (i.e. they are protein, fat) will be converted to glucose very slowly over the course of the night, which also confuses matters and means a small pre-bed correction dose may be required.

 

[SimonP78]

So rather than being too much bolus, it could be that I am not having enough Novorapid? And the mid- evening hypos (and sometimes beyond) are simply because conversion to glucose is incomplete at that point in time? So then I treat it, and maybe over-do it...? Or maybe it is the timing of injection and eating time.....that is awry? Gosh, it is SO complicated!!

If it were me I would split the bolus dose, take part (half?) of it when you usually do, then take the rest perhaps an hour after you've eaten.

Hopefully this will stop the low from occurring and also remove the high overnight.

 

[LionChild]

If it were me I would split the bolus dose, take part (half?) of it when you usually do, then take the rest perhaps an hour after you've eaten.

Hopefully this will stop the low from occurring and also remove the high overnight.

Thank you very much Simon. I will try what you say, and split the bolus!!

 

[SimonP78]

Let us know how you get on tomorrow

 

[eventhorizon]

Before using a pump I was on Levemir for years and never worked out a decent basal regime. My DN convinced me to try Tresiba and my overnight levels became a lot smoother and flatter, and only needed one basal shot a day.

 

[LionChild]

Before using a pump I was on Levemir for years and never worked out a decent basal regime. My DN convinced me to try Tresiba and my overnight levels became a lot smoother and flatter, and only needed one basal shot a day.

Thank you , eventhorizon, I will bear that in mind!

 

[LionChild]

Let us know how you get on tomorrow

Hi Simon,
Thank you for your interest and your help. This is the pattern of things yesterday-- and a screen shot of this morning etc:
and the documentation last night and this morning:


Sunday evening:

19.16 5.6
19.41 Novorapid (3.5)
20.01 Dinner: Seabass Salad medley
20.56 7.7
20.58 Novorapid (2.0)

21.45 Levemir (4.0)

23.45 5.8
00.47 4.7

Two small squares dark chocolate

Early hours of Monday

02.47 4.7
05.10 6.6

07.13 .......... 8.1, then 8.5 climbing again!


Furthermore, experience has shown me that if I do not get up in the morning, and I inject at 7 am- ish or before that, before about 09.30, (3 units levemir & 1 unit Novorapid), it is likely to climb up to 9+ mmoles...

 

[SimonP78]

Looks like that has avoided the post-supper low and kept you reasonably flat overnight - I realise it's only a single sample point mind you so your interpretation of what's happened may be different (and mine is likely wrong so do tell me!)

If you're happy with treating the dawn phenomenon/foot on the floor rise then all is fine, otherwise I suppose you could perhaps look to increase basal though you'd probably need to go to bed with a higher blood sugar to avoid going low overnight. Other ways of reducing the morning rise are alcohol and exercise (not necessarily together!) the day before.

 

[LionChild]

Looks like that has avoided the post-supper low and kept you reasonably flat overnight - I realise it's only a single sample point mind you so your interpretation of what's happened may be different (and mine is likely wrong so do tell me!)

If you're happy with treating the dawn phenomenon/foot on the floor rise then all is fine, otherwise I suppose you could perhaps look to increase basal though you'd probably need to go to bed with a higher blood sugar to avoid going low overnight. Other ways of reducing the morning rise are alcohol and exercise (not necessarily together!) the day before.

Well, Simon, (and anyone else who wants to chip in?!) , tonight I had no dinner and apart from a coffee at around 17.00 hrs without insulin--- when BG was 4.7 -- I have had nothing to eat since early afternoon. (about 14.25 - lunch rather late today), and later my BG went up to 8.9 at 21.35 despite that. That is extremely weird for me. At that point I was so troubled I took 1.5 units of Novorapid to bring it down, and BG is now at 22.23 STILL 8.0... but clearly has gone down a little?

Again, creeping up quite steeply, but actually from a much earlier point than before! (Now, the coffee at 17.00 hrs may have to take SOME of the responsibility but I do not think it would lead to such an incline right up to tonight like this?)

Today's graph (Monday night 8th July), at this time now looks like this:

Really this is all very weird! Now, At 23.13, BG down to 7.5 atm...
I will be staying up tonight at least until 12.30 to follow this. Because of taking the Novorapid, I am delaying the Levemir tonight for a bit (4 units) for fear of triggering a hypo during the night (and sleep!) What a roller-coaster this is, and how anxiety-provoking!!?

 

[SimonP78]

Some people report (and I think I get the same to some extent) and effect whereby if they don't eat, their livers produce glucose. This is most often reported by T2 diabetics in relation to breakfast and FotF, however, I think it also holds true for those taking insulin, which means that one doesn't necessarily get the expected reduction in BG. Perhaps there's something similar going on here, I don't know.

I've never intentionally skipped meals to do basal tests, if I do skip one it's because I'm doing something else so it's hard to compare my BG response with what is expected for a "standard day". People do these tests though so I wonder if anyone else can chip in to say whether they see "unexpected" rises?

OTOH it's hard to pick apart what might be extra because of no food vs what is usually produced and the effect of different insulin sensitivity. If you can manage it, it would be interesting to see what happens overnight and then make a decision about adjusting basal and timing of any required correction bolus.

FWIW your numbers look good and are in range, I think if you can avoid mid-evening low (e.g. split dose) and deal with the morning rise with a bolus and just try this out for a while you may find it works, and you may also find that external factors change what happens. Best to get a week or more's worth of vaguely repeatable behaviour under your belt before starting to fiddle with basal rates or thinking about doing other exciting things like splitting basal.

But please everyone else out there with some thoughts please chip in!

 

[LionChild]

Some people report (and I think I get the same to some extent) and effect whereby if they don't eat, their livers produce glucose. This is most often reported by T2 diabetics in relation to breakfast and FotF, however, I think it also holds true for those taking insulin, which means that one doesn't necessarily get the expected reduction in BG. Perhaps there's something similar going on here, I don't know.

I've never intentionally skipped meals to do basal tests, if I do skip one it's because I'm doing something else so it's hard to compare my BG response with what is expected for a "standard day". People do these tests though so I wonder if anyone else can chip in to say whether they see "unexpected" rises?

OTOH it's hard to pick apart what might be extra because of no food vs what is usually produced and the effect of different insulin sensitivity. If you can manage it, it would be interesting to see what happens overnight and then make a decision about adjusting basal and timing of any required correction bolus.

FWIW your numbers look good and are in range, I think if you can avoid mid-evening low (e.g. split dose) and deal with the morning rise with a bolus and just try this out for a while you may find it works, and you may also find that external factors change what happens. Best to get a week or more's worth of vaguely repeatable behaviour under your belt before starting to fiddle with basal rates or thinking about doing other exciting things like splitting basal.

But please everyone else out there with some thoughts please chip in!

 

[LionChild]

So, if you have not fallen asleep by now, Simon from boredom, here is the latest for Monday/Tuesday:

Monday July 8, 2024

(No Dinner.)

17.16 4.9
Coffee (no insulin)
20.57 8.6

+21.07 Novorapid (1.5)

21.35 8.9
00.33 7.8

0.54 Levemir (4.0)

0.38 7.7

Morning Tuesday July 9.2024

(No breakfast or drinks.)

05.24 7.1
07.53 5.7
08.00 6.8
09.02 6.8
09.21 6.2

Quite different....?

BG was 4/5 mmoles repeatedly for most of the afternoon!

I have not yet changed the Levemir source.
Nor the amount.
I changed only last night, the timing of the Levemir injection, and of course earlier in the evening had 1.5 units of Novorapid at 21.07 because bg was high at 8.6, and had been running high all day (Monday)----except for the blip of 4.9 at 17.16.

And then, today (Tuesday evening), this is how it went this afternoon and tonight:

At 16.48 glucose went down to 4.4, and remained low-ish like this all afternoon, having to drink some Lift juice to bring bg up several times.

Again, later, I had NO evening meal, and still the rise up to 8 mmoles at 09.30.

It has occurred to me that maybe the insulin is faulty, so I changed the vial, rather than the number of units of Levemir tonight. I injected 4 units as usual about 09.49.
If that doesn't work, then I think the next thing to try will have to be to change the number of units of Levemir? ...but I cannot see how the lack of Levemir could result in running out at 3 am (when normally there begins a sharp rise), when I only inject at around 10 pm every night?

So blood glucose at 22.09 tonight is 7.9.
And surprisingly tonight at 23.08, it has actually gone down, and is 7.3

Any further thoughts, Simon?

And thank you!