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Type 1 How to counter the dawn phenomenon on Lantus/Novorapid? And why does it only happen on some days?

Discussion in 'Ask A Question' started by Catsymoo, Sep 23, 2019.

  1. Catsymoo

    Catsymoo Type 1 · Well-Known Member

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    Good morning all. Woken up on a lovely number of 15.9 this morning - not the first time in the last few weeks and not happy with this considering my post meal BG last night about 10:30pm was 14, and I injected an extra unit to ''correct to 10'' as my DSN has instructed me.

    I've gone back to Lantus once a day at 7pm, injecting 30-31 units, and I am on a low to moderate carb diet. Yet I rarely see my levels below 10 if I'm being real. I've practically started living off of eggs, meat and halloumi because I'm fed up with my constant high sugar levels. I probably inject under 10 units of Novorapid a day. The issue is if I am starting high, my level just builds on that whenever I eat, and hovers around 15 all day. Yet last weekend my level dropped from 10, to 8 to 6.9 within an hour and the 8 to 6.9 was after I ate a snickers! This was with 1 unit of bolus 5 hours prior just to cover a few spoonfuls of ice cream. Although the drop was probably because I was in bed all day with a new partner, having about 5 ''workouts'' and then a shower. ;)

    What do you guys do to counter the dawn phenomenon without a pump? I set my alarm for 3am the other day and tested, and I am defo not going hypo over night. It's like it slowly rises overnight. I've even pushed my Lantus back from 5pm to 7pm. I did inject a couple units at 3am that day but still woke up at 11.7 .
     
  2. Muneeb

    Muneeb Type 1 · Well-Known Member

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    The rise could be for a number of reasons.

    Firstly I'm not sure why you were recommended to keep your glucose levels at 10 mmol/L before bed, that's too high as it is, and then if it is going to rise its only up from there.
    You really need to carry out a fasting basal test to see if the lantus dosage is correct, that is the basis, then you can carb count for food etc., you don't really need to restrict what you eat to eggs, meat etc. if you are type 1 on insulin.
    I generally inject lantus between 9-10pm as it tends to peak around 8 hours after, so catches the 3am dawn phenomena if it occurs.
    But the types of food you eat make a significant difference to how your levels react hours after eating, high fat/protein meals will lead to rises 3-6 hours after eating, so using novorapid to cover it from eating doesn't generally work.

    Other reasons it may occur is:
    Insulin may be off
    You may be getting ill
    More stress/lack of sleep
    Insulin dosage is not correct/timing not right

    Why doesn't it happen all the time?
    The food you eat changes, the timings change, the activity levels change, there's so much that affects levels day-to-day.
     
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  3. Kim Possible

    Kim Possible Type 1 · Expert

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    @Catsymoo - are you 100% certain that your morning high is due to dawn phenomenon.
    There are a number of options and only middle of the night readings will help you work out the cause
    - the purpose of Lantus is to keep your bg stable when you are doing nothing (e.g. eating or exercise) to change it. If your BG continues to rise through the night, this suggests you do not have enough Lantus. Unfortunately, to complicate things, stress, sickness, bad night's sleep can impact the amount of glucose that is dripped from your liver ... and the amount of Lantus you need.
    - dawn phenomenon will see a level BG throughout the night until your liver releases glucose to give you the energy you need to get up. Typically, this happens around 4am but depends on what time you usually get up.
    - some foods, especially those high in fat such as a curry or a pizza, will take longer to release carbs. For example, I have found my BG can rise 5 hours after eating a pizza if I do not time my insulin dose correctly. The usual way of handling this is to have a split bolus (NovoRapid) - take half with the meal and half a few hours later. You can see if your evening meal is causing your BG rise if it rises in the first few hours of your night and then stays stable.

    As Muneeb says, going to bed with a BG of 10mmol/l is usually considered high. However, there may be a few reasons why your DN suggested this.
    - if our bodies have become used to a high BG, it needs to be retrained slowly. Fast reduction in BG can cause problems with, for example, your eyes.
    - if you have been susceptible to hypos which you have not noticed until very low, it is often suggested to raise the target BG ... again to retrain your body to become used to a higher BG.
    - if you are susceptible to night time hypos, it can be recommended to run your BG higher over night.
     
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  4. Catsymoo

    Catsymoo Type 1 · Well-Known Member

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    I didn't even think of the protein/fat thing. I had an Indian last night and I actually came onto these forums to see what the good options are. I had saag paneer (wasn't sweet in the slightest), egg bhuna and chicken tikka main. (Just chicken, no sauce), and my own cauliflower rice. My level was 17 a few hours before eating, and 14 2 hours after and I bolused 2 units I believe. I figured it was OK and heading in the right direction. That makes sense if it can take 5-6 hours to hit.

    Although I am experiencing these morning highs a lot, even when I eat my normal food. I've set my alarm at 3am a couple of times and noticed my BG is climbing - or NOT dropping from a bolus correction at bedtime. I went to bed at 14 one day, I bolused 1 or 2 units, woke up at 3am - still 14. Bolused 2 more, down to 11mmol at 6am. Needing 3-4 units to get from 14 to 11 to me suggests something is rising overnight. But if I increase my Lantus I tend to drop without food which is obviously the wrong dose. I might see what happens if I start taking my Lantus later and later each day. There have also been other days where I go to bed with high BG, don't correct, yet am in range when I get up. Seeing a drop over night of 16 down to 5 tells me my Lantus is too high, surely? I feel that my diabetes is so flipping temperamental. I don't trust my insulin at all.

    This morning I had a 5g carb bar, with a 4g carb latte. I injected 2 units and 2 hours later my level had risen to almost 17, so I went home sick from work. I felt nauseous and couldn't do anything. It's dropping a bit now, down to 12.
     
  5. MeiChanski

    MeiChanski Type 1 · Well-Known Member

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    Hello @Catsymoo
    It might be worth seeing a dietitian to help you with information on food - usually high fat foods combined with carbs slows down the absorption, so you'll end up high after your novorapid ends. By the looks of your food items, it seems quite high in fat. Also have you spoken to your consultant or dsn about considering another basal insulin? Some have experienced that Lantus doesn't quite last 24 hours - some need a split dose or some have changed to another basal insulin. I would suggest some research on different basal insulins to combat DP.
     
  6. Catsymoo

    Catsymoo Type 1 · Well-Known Member

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    Starting to wonder now if there's something wrong with me and my insulin resistance is really high. I don't understand how I'm back up to 17 again when I've had 3 units since my 12 reading and less than 20g carbs. That should easily cover what I ate and lower my BG under 10.
     
  7. MeiChanski

    MeiChanski Type 1 · Well-Known Member

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    Hm, when you have time, you could do a basal test to see whenever it is too little, too much or just right. I usually find I’m quite insulin resistant in the morning, so I’ll do a different insulin to carb ratio otherwise I’ll be high until lunch. I don’t know if you prebolus for your food, depending on my level, if I’m high, I’ll correct it, wait until it comes down then take another dose for breakfast, wait for a bit then proceed onto eating.
     
  8. MeiChanski

    MeiChanski Type 1 · Well-Known Member

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    Again, could it be the monthly hormones?
     
  9. Catsymoo

    Catsymoo Type 1 · Well-Known Member

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    I'm on the minipill, so I doubt it. :(
     
  10. EllieM

    EllieM Type 1 · Well-Known Member

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    Look, I'm on MDI (humalog/lantus) and like you I have issues with morning high blood sugars. My clinic lends me a cgm on occasion, and I keep a food/insulin diary for a week. After that they adjust my basal and insulin ratios. Honestly, I could probably do this for myself now (the adjustment). I've resisted the libre (or rather an allergy means it doesn't work for me, though I live in hope that a new sensor will help) so work by doing numerous (50 or so) blood tests a week.

    So, my correction ratios change (I need more insulin) both in the morning and if my blood sugar goes high. Though I do have a certain amount of DP. my high morning readings usually follow one of the following
    1) cheese plus too much food at night. If I have cheese with my evening meal then my pre bed blood sugar can be absolutely fine, and I still wake up at 15.
    2) Misjudging the carbs of my evening meal. I generally am fairly low carb during the day, but go up to 40 to 50g at night. It's easy to misjudge the amount. Recently I went back to basics and tried weighing my food plus looking up the amounts in a current carb counter - it was very easy to miscount.

    Basal. As others have said, you need to get this right before doing anything else. I run mine slightly low, because I don't want to worry about night hypos and when I increased by 1 unit I got too many day hypos. But that's a deliberate choice by me and means I have to correct with humalog at bed time quite carefully. When I have a morning high I generally don't eat till I get my level down, but that's just me.
    Carb ratios. These do change with time and activity. How confident are you that yours are correct? Might be time to recalculate, but you really need to get the basal right first. (And yes, multiple workouts of any kind can definitely increase your insulin sensitivity. I've recently reduced my bolus significantly just because I'm going to the gym more often.)

    But honestly, given that you're low carb and running high, I'd suggest that you need to revisit your basal amounts.

    Oh, and supposedly if you're going low carb and have a lot of protein, you have to count it as 50% carbs????

    Can you get your clinic to give you a libre so as to make the testing a little easier?
     
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