Hypoglycemia onsets - why ?

SHORAN said:

Hello fellow diabetics...

Have any of you got some ideas what could be happening with me ?

I'm starting to get hypos when I shouldn't as far as I can tell. It's a bit strange .

These are happening either in the middle of the night like 4 am, or first thing when I am about to wake up between 7-8 am. ( readings between 3.8 to 2.8 ! )

I have been struggling over the last 6 months to try maintain steady blood sugar levels.
Much tweaking with ratios with the fast acting and basal insulin etc.
I have up till right now ( over this this last month ) starting to get it quite good, controlled and not too hyperglycemic. Ratios seem better etc.

Right now I'm not adjusting my insulin for my slight illness ( cough, bit of a sore throat ).
I'm eating as I usually do and injecting accordingly etc .... but I'm getting these hypos !

Annoying!

Advice anyone ?

Thank you,
Shoran

NB:
Since around April of this year....

I have been fully on fast the fast acting and basal insulin since I was properly diagonsed as a T1 ( to be exact probably a T1.5 ) rather than a T2 which I was my diagnosis 5 years ago.

Click to expand...

Just a T2 here, but are they true hypo's? Do you check them against a finger prick? Because there's such a thing as compression lows: if you sleep on your patch, it can read lower than you really are and sound the alarm needlessly. Something to check before you start adjusting anything, maybe?

SHORAN said:

Hi Jo,

Thanks for your input - much appreciated.

Yes, I did check with a finger prick and I was still deemed low .

I suspect that maybe I should perhaps increase my carb intake slightly, reduce the correction ratio for my fast acting insulin : post meal corrections necessary before I go to bed when I am "ill" - would avert these hypos ?
Maybe take slightly less basal - the background insulin too at night. ( only when I am "ill" )

Usually though as far as I know, normally one is meant to INCREASE your insulin slightly when "ill" ...!

Odd....

Click to expand...

Not my area of expertise, I don't use insulin. I did find though that rather than going up, whenever I had Covid, my numbers would drop like a stone. So if you have tests still laying around, maybe check what you've got before you put a blanket decision on all insulin adjustments when ill. Who knows, some ills may spike, others could drop. I hope someone'll be along soon with more useful input!

Illness normally increases blood sugar levels as you say @SHORAN but as my previous diabetes nurse used to say 'never say never'. Insulin requirements can change over time, so I'd start by doing a fasting basal test overnight, then move on to checking carb ratio's etc, but only changing one thing at a time, so you know which one needs tweaking.

SHORAN said:

Usually though as far as I know, normally one is meant to INCREASE your insulin slightly when "ill" ...!

Click to expand...

Unlike @JoKalsbeek , I am on insulin, and I'm another one who has to watch out for hypos with covid!

SHORAN said:

These are happening either in the middle of the night like 4 am, or first thing when I am about to wake up between 7-8 am.

Click to expand...

SHORAN said:

I suspect that maybe I should perhaps increase my carb intake slightly, reduce the correction ratio for my fast acting insulin : post meal corrections necessary before I go to bed when I am "ill" - would avert these hypos ?

Click to expand...

I don't think that increasing the carbs with your evening meal would do much for hypos occurring between 4 and 7 am, the meal is likely long gone by then.
At what time do you usually take those post meal corrections? If there is more than about 4-5 hours between correction and hypo I wouldn't expect them to be the cause. But if it's shorter, you may well be onto something here.
At what time do you usually take your Levemir? According to this graph it works strongest between some 5-8 hours after injecting. Any correlation to be found there?

SHORAN said:

for quite some time ( about a month) I seem to have got the night time basal unit amount about correct - by morning my fasting level is usually anything between 7-10 mmol/L

Click to expand...

If your fasting is between 7-10 but you've had a hypo in between, something is off.
When hypo, our livers kick in to add glucose to the bloodstream, so even if a mild hypo is left untreated it may cause you to rise. And if treated you expect it to rise of course.

SHORAN said:

Presently I'm carb counting at 1 unit for 7g of carbs , but for the evenings ( dinner ) it changes to 1 unit to 6g carbs .
Corrections ( post meal ) I do 1 unit for each 3mmol/L that I need to come down by.

Click to expand...

Do you need corrections often?
If so, you might want to adjust your ratios again. Personally, I find it much easier to eat a little something if I see my graph trending down after a smidge too much insulin than to wait for a correction to do its work, but this is personal preference and also depending on circumstances. And it needs a CGM of course or I wouldn't be able to catch a drop before I go hypo.
If you use a CGM, you might want to set the low alarm a bit higher at night so you wake up before you're actually too low, preventing a hypo is better than treating one.

Any alcohol involved?
As long as the liver is busy dealing with the alcohol, it won't chuck out as much glucose as usual. So nighttime lows are very common after drinking, unless you take measures to prevent them.

Lastly, insulin needs are far from static, they change over time and even from day to day so the tweaking is an ongoing thing.
In my case, I was diagnosed 8 years ago and for the first 4 years the amount of insulin more or less steadily increased until settling on 100 to 120 units of basal and a varying amount of bolus.
Until a year ago, when my insulin needs started dropping again, no change in diet, just a very little bit of extra exercise, a very small amount of weightloss. It's only in the last 3 months or so that it has settled again at 58-70 units of basal (and less bolus as well). Just to say that things can and do change.
(More info on that here: https://www.diabetes.co.uk/forum/th...in-the-proverbial-and-nighttime-hypos.202925/ , and on how ridiculously our insulin needs can fluctuate here, in case you want to read more: https://www.diabetes.co.uk/forum/threads/adding-metformin-to-insulin.184734/ .)

I have no experience with using insulin, but is it possible that *because* blood sugar tends to go high when ill, that this is part of the equal and opposite reaction to a high. Is it true that after blood sugar goes high, it can go equally low later on? I would think that you eatin gmore carbs is the opposite of how to adjust it. What would happen if you had a small protein snack before bed, like a slice of meat or cream cheese on celery? Something that will not raise blood sugar and be slow to digest over time. Would that keep things from going too low later? Another idea is that you said your blood sugar was going too high after dinner? Are you eating too many carbs at dinner to begin with?

It could of course simply be that your basal needs are dropping for whatever mysterious reason, like what happened to me this year.

Hopeful34 said:

Illness normally increases blood sugar levels as you say @SHORAN but as my previous diabetes nurse used to say 'never say never'. Insulin requirements can change over time, so I'd start by doing a fasting basal test overnight, then move on to checking carb ratio's etc, but only changing one thing at a time, so you know which one needs tweaking.

Click to expand...

After my covid jab I had iirc a 2 week spell of low blood sugars, and I ended up reducing basal to avoid going low/snacking continuously. I can't be certain it was the jab and not something else, but the timing seems very coincidental and there's nothing else (such as more exercise during that period) that I noticed.

While mentioning exercise, have you been doing more (it doesn't have to be running marathons, even just walking more regularly can have an effect)? This can result in lower overnight BG levels due to heightened muscle insulin sensitivity (and liver glycogen replenishment.)

SHORAN said:

The diabetic consultant never did explain how they arrive at a certain number of units recommened for basal.
I thought there would be a tried and tested special formula ... Weight x3.2 divided by number of times one goes to the toilet per week multiplied by how many slices of toast one has weekly to the power of 3. Bingo !

Click to expand...

Don't forget to include the colour of your socks in your formula, very important part of the equation!

SHORAN said:

My brother and father both only do one shot of basal at night just a puny 20 units !

Click to expand...

A lot depends on which basal you use.
You're on Levemir, the shortest acting of all basal insulins, which for most works best if taken twice a day because it doesn't really cover 24 hours. (And there are exceptions, some do well on Levemir once a day.)
Lantus works a little longer, so it's usually recommended to take once a day, although many people found that twice a day suits them better.
And then there is Tresiba, very stable and long acting, once a day works fine. With the downside that adjusting the dose takes a long time as well, unlike with Levemir where a dosage change will have effect on the same day.

SHORAN said:

So suddenly your basal needs dropped - was it a one off ? ( were you ill ? )
Has you basal need remained less ever since this mysterious change or has it gone up and back to what you used to take ?

Click to expand...

Story in the first link.
I'm still on 58-70 units of basal, as opposed to the 100-120 I'd been using for years. Speculation as to why is in that linked thread, but it can just as well be because I have new socks, who knows.
Wasn't all that suddenly, more something that took at least 6 months where I kept having to reduce.

SHORAN said:

You are on a lot of basal how come how did they figure that amount out ? - hope you don't mind me asking ?

Click to expand...

The only time a HCP told me how much insulin to take was when I started basal 8 years ago, when I was still thought to be a T2.
If I remember correctly, the instructions were to start with 8 units and titrate up every 3 days until I liked what I saw on my meter.
I may have titrated up a bit quicker, and soon found the sweet spot, unless I ate something. Ever since, I've kept adjusting my basal depending on what Libre and fingerpricks tell me.

So after two months of pretty good numbers unless I ate something, I begged for bolus insulin and asked the practice nurse to give me 3 weeks to work it out and reassess after her holiday. I had to promise to be really careful, and she didn't like it much that I wanted to start while she was away, but it worked so well that she didn't dare advise me on dosing when she came back.
I switched to hospital care after rediagnosis two years later, but my endo is happy with my numbers and never tried to tell me to do things differently.

I guess in a way I wiggled myself through the cracks of official guidelines to work things out on my own, which suits me well. Although throughout, I've been very happy knowing my HCP's would be there, should I have had any questions.

SHORAN said:

Infact i printed ogf an amarical insulin calclation sheet guidance.I need to study it.

I should probably perhaps try ( with consultant guidance ) quite a specific method of calulating and outlining ones basal and bolus needs according to this info I gleamed .

Click to expand...

Insulin calculation guidelines are meant to start with when starting from scratch, a rough idea, and you/your HCP are supposed to go from there to tweak to individual needs as guided by blood glucose.

The basal/bolus advice will likely say something like basal and bolus insulin amounts should be roughly 50/50. Perhaps this works in someone perfectly following the eatwell plate and eating the exact same amount of carbs every day.
For someone like me, eating fairly low carb, my ratio between basal and bolus is roughly 80/20 on average. But not every day. While my basal stays more or less the same, I may need as little as 10 units of bolus or as much as 55 units of bolus, depending not only on food but also on time of month, activity, colour of my socks.

To my thinking, this 50/50 rule of thumb is only useful as a flag to look into if there is a reason why someone uses way more basal than bolus or the other way around, it's not a goal by itself.

The same goes for calculation sheets for insulin amounts.
Two people of the same height and weight can need vastly different amounts of insulin. That's why we usually get started on a low dose and slowly titrate up, it's the only way to find the right dose.
The only way to find out is to look for patterns and to keep notes of food, activity, insulin doses and bg.
Once you're close to what you want to see, it doesn't make sense to start from scratch again, you'll want to tweak things based on your patters and search for causes where things aren't as you want them.

Exactly like you are doing on this thread!

I was initially prescribed insulin, I'm type 2, because I was having extreme BG spikes into the mid-high 30's when I was having chemotherapy. One of the drugs was/is Dexamethasone, which is a steroid and well known for increasing BG levels. I was having to use double and sometimes double and a bit more of Humalog 200 (fast acting insulin) to keep my BG around 20 on chemo days and gradually reduce it over the next couple of days as the Dex left my body.

This is when I started recording my BG before and 1 and 2 hours after each meal. I made myself a table in Libre Office Writer (I never got the hang of spread sheets and to tight to pay for Microsoft office) I also recorded my carb intake for each meal, which started to give me an idea of just how much Humalog 200 was required with each meal. Not an exact science, but very good guide for me.

At the moment I am trying to get my BG down under 10, and with my diabetes teams help we are gradually fine tuning everything. My latest task has been to increase my basal dose by 2 units every 3 or 4 days. I have asked for my diabetes nurse to contact me, as I started out with 20 units of Lantus and I'm now at 44 units. Whilst it keeps my BG around 7-8 during the night, the second I get out of bed my BG rockets to 10 or above, even if I only get up to go to the toilet.

The good news is, where my BG was normally 13-15 during the day, it is now down to 10-11, so we are going in the right direction. For me the biggest change was when I started injecting the "correct" amount of insulin for the amount of carbs in my meal and my BG before each meal.

According to my Libre 2 my BG has been on average 10.6 over the last 60 days, so at least I'm having a positive effect, albeit slowly. My concern is the amount of Lantus I am injecting.

Anyway, thank you for reading this long post and if my experience only helps one person in the group, then it has certainly been worth it.