New T1 needs help with highs and lows please

[RN25]

Hi, I am newly diagnosed type 1 and started insulin last Thursday. The specialist nurse decided to start me on a low dose of mixed fast and slow Humulin, 10 units, before breakfast and before dinner. She suggested I would need to increase by 2 afyer 2-3 days until I reached the right level. I speak to her again in a week or so.
My libre is alerting me to low blood sugar overnight at 4.4 (the nurse set it a bit higher to give me chance to address the low before I'm having a hypo, without having to resort to a load of glucose). So I have had a seeded oat cake in the night and that seems to work ok but getting woken up is not ideal. However I am then getting high levels on a morning. Today it was 8ish about half an hour after getting up which isn't so bad.I took the insulin then but by the time I started breakfast 30 mins later it was 11ish, then peaked at 15 ish an hour or so after breakfast. Its currently coming back down and I will probably have to snack to head off a low in an hour or so. The nurse told me I must have carbs with my meals, so today I had 2 boiled eggs, half an avocado, some feta and a smallish slice of buttered sourdough toast.
I don't feel I should be increasing my insulin as I am getting lows, but how do I stop the highs? I had potato with my dinner last night and that was ok, I didn't spike. Should I just avoid bread? Or perhaps have the bread an hour after breakfast (1.5 hrs since the insulin) to give that a chance to kick in? I'm worried without carbs I'll go low.
And what can I eat on an evening to stop the overnight lows?
Am I better off grazing throughout the day rather than having 3 meals? The humulin brochure suggested 4 meals so yesterday I had yoghurt, nuts, seeds, banana and strawberry before bed to see if that would stop the low but it didn't.
Has anyone got any tips to stop the morning and post meal highs , and to stop the lows? Yesterday lunchtime I started to go v low so grabbed some sushi. That was a bad idea - I went sky high so I guess sushi is off the menu!
Any help greatly appreciated. Thanks

 

[JoKalsbeek]

Hi, I am newly diagnosed type 1 and started insulin last Thursday. The specialist nurse decided to start me on a low dose of mixed fast and slow Humulin, 10 units, before breakfast and before dinner. She suggested I would need to increase by 2 afyer 2-3 days until I reached the right level. I speak to her again in a week or so.
My libre is alerting me to low blood sugar overnight at 4.4 (the nurse set it a bit higher to give me chance to address the low before I'm having a hypo, without having to resort to a load of glucose). So I have had a seeded oat cake in the night and that seems to work ok but getting woken up is not ideal. However I am then getting high levels on a morning. Today it was 8ish about half an hour after getting up which isn't so bad.I took the insulin then but by the time I started breakfast 30 mins later it was 11ish, then peaked at 15 ish an hour or so after breakfast. Its currently coming back down and I will probably have to snack to head off a low in an hour or so. The nurse told me I must have carbs with my meals, so today I had 2 boiled eggs, half an avocado, some feta and a smallish slice of buttered sourdough toast.
I don't feel I should be increasing my insulin as I am getting lows, but how do I stop the highs? I had potato with my dinner last night and that was ok, I didn't spike. Should I just avoid bread? Or perhaps have the bread an hour after breakfast (1.5 hrs since the insulin) to give that a chance to kick in? I'm worried without carbs I'll go low.
And what can I eat on an evening to stop the overnight lows?
Am I better off grazing throughout the day rather than having 3 meals? The humulin brochure suggested 4 meals so yesterday I had yoghurt, nuts, seeds, banana and strawberry before bed to see if that would stop the low but it didn't.
Has anyone got any tips to stop the morning and post meal highs , and to stop the lows? Yesterday lunchtime I started to go v low so grabbed some sushi. That was a bad idea - I went sky high so I guess sushi is off the menu!
Any help greatly appreciated. Thanks

I'm a T2 and I'm not on insulin, but I'm going to meddle for a second anyway: Did you check the hypo against a finger prick? A CGM can give you a compression low at night, meaning if you lay on it, it doesn't read right and it'll give off a hypo-alarm, while you're not actually hypo. So if it happens again, test with a finger prick and see whether you're really, actually headed toward hypo-territory, or if it's just a matter of turning over and not laying on that arm/side. You don't want to give yourself a hypo-treatment if you don't need it. And if it's compression/fake lows keeping you from slowly going to the dosage that is ideal for you, that wouldn't be right either. So before you decide on anything, check the low with a finger prick, and go from there.

Hope that helps.
Jo

 

[Juicyj]

Hello @RN25

Welcome to the forum, lots of support here, however sadly no one here can give you insulin/medication advice in regards to doses, when first diagnosed you enter a 'honeymoon' phase, so the pancreas when less stressed with the new insulin coming in will start to revive it a little, this can last for a few months but it means insulin doses need to be adjusted in line with readings given. You may well of had a compression low during the night so always use a glucose meter to check in real time what the sensor is reporting during low/high events. Also you will have good hypo awareness so will know from the feeling of going low which can leave you feeling jittery and quite rough, always carry glucose on you at all times and within arms reach so next to your bed, in your pocket etc etc, hypo gel, glucotabs or even a small carton of apple/orange juice does the trick.

Report your readings back to your nurse for guidance and do not worry about the highs so much at this stage, takes a while for insulin and your body to settle in, first few weeks are going to be a bit of a roller coaster.

You will in time be able to take quick acting insulin to match carbs eaten so can juggle your carb intake with insulin taken but at the moment follow your nurses guidelines to eat some carbs each meal and keep a food diary with your BG readings to show your nurse where your highs/lows are happening, they will keep you on track at this stage so dialogue with them is vital.

You are just finding your feet at this stage, it takes a while to bed in with your t1d so take it easy on yourself and don't be too harsh or critical if things are going right, you will get there, always shout on here for any support though, loads of us about

 

[SimonP78]

Could we see your libre graph please?

Do you check the overnight low with a fingerprick test? It may be a false "compression" low.

Subsequently going high may be dawn phenomenon (DP), or might be overtreatment of the low (I know you're not eating much, but it may be that you're just grazing the alarm value in a gentle U-shaped curve and therefore don't need to bother to treat it really (perhaps going to bed with a marginally higher BG would fix that). Much easier to work these out seeing a graph.

What exactly is/are the insulin(s). Is it a Mixtard of some description? Most MDIs use a pair of pens with rapid insulin for bolus and very slow insulin for basal, but perhaps what you have is one approach for those who are newly diagnosed, I don't know.

 

[RN25]

Hello @RN25

Welcome to the forum, lots of support here, however sadly no one here can give you insulin/medication advice in regards to doses, when first diagnosed you enter a 'honeymoon' phase, so the pancreas when less stressed with the new insulin coming in will start to revive it a little, this can last for a few months but it means insulin doses need to be adjusted in line with readings given. You may well of had a compression low during the night so always use a glucose meter to check in real time what the sensor is reporting during low/high events. Also you will have good hypo awareness so will know from the feeling of going low which can leave you feeling jittery and quite rough, always carry glucose on you at all times and within arms reach so next to your bed, in your pocket etc etc, hypo gel, glucotabs or even a small carton of apple/orange juice does the trick.

Report your readings back to your nurse for guidance and do not worry about the highs so much at this stage, takes a while for insulin and your body to settle in, first few weeks are going to be a bit of a roller coaster.

You will in time be able to take quick acting insulin to match carbs eaten so can juggle your carb intake with insulin taken but at the moment follow your nurses guidelines to eat some carbs each meal and keep a food diary with your BG readings to show your nurse where your highs/lows are happening, they will keep you on track at this stage so dialogue with them is vital.

You are just finding your feet at this stage, it takes a while to bed in with your t1d so take it easy on yourself and don't be too harsh or critical if things are going right, you will get there, always shout on here for any support though, loads of us about

 

[RN25]

Thanks very much for taking the time to reply and for the reassuring message. Will take your and Jo's advice re checking the overnight lows. Its currently over 15 after a small piece of bread with lunch (and a packet of monster munch oops), so it may be time to increase the morning dose at least tomorrow. Thanks

 

[RN25]

Having some issues replying :-D sorry for any confusion

 

[RN25]

Could we see your libre graph please?

Do you check the overnight low with a fingerprick test? It may be a false "compression" low.

Subsequently going high may be dawn phenomenon (DP), or might be overtreatment of the low (I know you're not eating much, but it may be that you're just grazing the alarm value in a gentle U-shaped curve and therefore don't need to bother to treat it really (perhaps going to bed with a marginally higher BG would fix that). Much easier to work these out seeing a graph.

What exactly is/are the insulin(s). Is it a Mixtard of some description? Most MDIs use a pair of pens with rapid insulin for bolus and very slow insulin for basal, but perhaps what you have is one approach for those who are newly diagnosed, I don't know.

I'll try to attach the graph.
It's Humulin M3 which is apparently premixed 30% fast acting and 70% slow in one pen. I'll double check with a fingerprick test tonight. I'm half asleep so tempting not to bother and go back to sleep!

 

[grantg]

something to bear in mind taken from abbots freestyle website.
Accuracy:
Low MARD: The FreeStyle Libre 2 Plus sensor demonstrates a low overall MARD of 8.2%, indicating high accuracy.
High Percentage Within ±20%: 91% of glucose readings fall within ±20% of the actual blood glucose value, exceeding the strictest regulated standards for accuracy.
Outstanding Low Glucose Range Accuracy: The sensor also shows outstanding accuracy in the low glucose range (<3.9 mmol/L), with 98.9% of readings within ±1.1 mmol/L.

tbh I'd be tempted to ask your DSN if ok to lower alarm a little bit, as it is set higher than normal that is IF fingerpricks are off (give 10-15 mins difference lag time for CGM). eg if CGM at 7:05 says 5 and if finger prick at around 7:15-7:20 said 6.5+ ( or ±20% of 5 = expected range of ur finger prick between 4 and 6) thats my understanding anyhow.)

if its any consulation my early graphs were always high big spikes though were simular they have sorta more or less setteld still with a few lows and indeed a couple of highs from time to time. highs i deal with via exercise/drinking water. lows just some quick acting carbs (getting sick of jelly babies)

i was told to try ensure for long acting (in ur case the longacting/mix) should always be around the same time each day, if your not doing that already try see if that helps to make a difference. I'd ask for dietician appt, after speaking to them and getting some pointers etc I've found its been a lot easier to try regulate them

 

[becca59]

I’m interested why the nurse put you on to that particular mixed insulin. In the NICE guidelines for type one it states that you should no longer be put on that type of insulin. But straight onto the basal bolus regime which is far more flexible. Perhaps be worth questioning.

 

[RN25]

I’m interested why the nurse put you on to that particular mixed insulin. In the NICE guidelines for type one it states that you should no longer be put on that type of insulin. But straight onto the basal bolus regime which is far more flexible. Perhaps be worth questioning.

Ah ok, I will ask about that when I next speak to her. Could it be because I hadn't been eating carbs so she didn't have much clue as to how much I should start on?

 

[SimonP78]

I'll try to attach the graph.
It's Humulin M3 which is apparently premixed 30% fast acting and 70% slow in one pen. I'll double check with a fingerprick test tonight. I'm half asleep so tempting not to bother and go back to sleep!

Looks like you may have too much IoB from your evening meal as average BG is fairly stable up until 02:30, then starts falling.

If you only had a seeded oatcake to treat the hypo at ~4am, I'd not expect to see such a large rise, if I had to guess I'd say this is a combo of the oatcake carbs and dawn phenomenon (unless it was a massive oatcake!)

 

[RN25]

Looks like you may have too much IoB from your evening meal as average BG is fairly stable up until 02:30, then starts falling.

If you only had a seeded oatcake to treat the hypo at ~4am, I'd not expect to see such a large rise, if I had to guess I'd say this is a combo of the oatcake carbs and dawn phenomenon (unless it was a massive oatcake!)

Just a small nairns one, 5g carbs.
I had been getting dawn phenomenon before the insulin too when I was barely eating any carbs. What can I do about that?
So if too much IoB in the middle of the night should I reduce my teatime insulin? (It's mixed slow and fast in one).
I increased breakfast insulin this morning but still had super high peak 1.5 after breakfast, 2 hrs after insulin and again after lunch (2 x weetabix for breakfast, beans and small sourdough toast for lunch), with lows in-between. It was already going high before breakfast though.
Libre says 8.6 now before teatime insulin, haven't done pinprick yet. Will probs wait till after kids bedtime for insulin/food so 7.30-8pm. Is that too late?
Thanks all for the advice!

 

[RN25]

Just a small nairns one, 5g carbs.
I had been getting dawn phenomenon before the insulin too when I was barely eating any carbs. What can I do about that?
So if too much IoB in the middle of the night should I reduce my teatime insulin? (It's mixed slow and fast in one).
I increased breakfast insulin this morning but still had super high peak 1.5 after breakfast, 2 hrs after insulin and again after lunch (2 x weetabix for breakfast, beans and small sourdough toast for lunch), with lows in-between. It was already going high before breakfast though.
Libre says 8.6 now before teatime insulin, haven't done pinprick yet. Will probs wait till after kids bedtime for insulin/food so 7.30-8pm. Is that too late?
Thanks all for the advice!

Wowser- 25.5g carbs in the weetabix!

 

[Melgar]

Just a small nairns one, 5g carbs.
I had been getting dawn phenomenon before the insulin too when I was barely eating any carbs. What can I do about that?
So if too much IoB in the middle of the night should I reduce my teatime insulin? (It's mixed slow and fast in one).
I increased breakfast insulin this morning but still had super high peak 1.5 after breakfast, 2 hrs after insulin and again after lunch (2 x weetabix for breakfast, beans and small sourdough toast for lunch), with lows in-between. It was already going high before breakfast though.
Libre says 8.6 now before teatime insulin, haven't done pinprick yet. Will probs wait till after kids bedtime for insulin/food so 7.30-8pm. Is that too late?
Thanks all for the advice!

The dawn phenomenon (DP) is a natural process that your own body initiates. It's triggered by your circadian rhythm system, which triggers the release of cortisol along with hormones, its preparing your body for activity. For those people with insulin resistance, the DP can rise quite high. Non diabetics also have this same phenomenon but it is quickly dealt with and the rise, if any, is far less.

Ed spelling

 

[ViktoriaM]

Sorry for the long post in advance as choising the right tratment is complex and very individual. I hope my post is useful in explaining the difference between basal bolus regime and mixed insulins.
But as a first stepI would definitely talk to your DSN about the mixed Insulin and why she chose it for you.
As it was already mentioned above it is not used that often anymore for Type 1. It can have its advantages if the right dose is found. Its 25 years since I had a sort of mixed Insulin it was not the right thing for me.

With a mixed insulin you have to eat a certain amount of carbs at certain times for it to work, so there is little flexibility to eat less or more. Another disadvantage in my opinion is that as it is mixed it is not possible to change the long acting without changing the short acting as well. So it is hard to dose correctly if the bodys insulin needs change throughout the day. In my opinion this aproach is more of match your food to your insulin.
With a basal bolus regime it is the other way around you match the insulin to your food or other activities. It offers more flexibility in when and how much to eat. For this to work the amount of carbs needs to be calculated and then how much fast acting to use. Just an example and not to be taken as medical or dosing advice. A meal has 50g of carbs and your personal carb/insulin ratio is 10g of carb needs 1 unit. Of insulin you hypothetically need 5 units of insulin to cover that meal. With this regime it is also possible to correct high blood sugars earlier as a correction dose of fast acting can be used. The bolus insulin is supposed to keep your blood sugars stable throughout the day when no food is eaten. For some people this approach has the disadvantage of needing to inject more often.

I hope this helps to understand the advantages and disadvantages of each approach and is not making things more confusing.

For the more immediate problem of the highs and lows I would ask what the effect curve of the mixed isulin is(sorry not sure if this is the right term in English)basically at what time after injecting it is the most effective. With that knowlegde it might be possible to time the meals to avoid the highs and lows.

 

[SimonP78]

I think dealing with dawn phenomenon would probably be easier with basal-bolus rather than pre-mix, as you could bolus fast acting to bring the rise down without also taking on a massive amount of intermediate/long acting insulin.

Interestingly an intermediate duration insulin (like the "long acting" in M3, but without the short acting part) is one possible option to deal with DP - if you were to take it before bed and it peaked in the early hours as your DP takes effect. This would likely be in addition to taking a normal basal dose though. At least that's something I might try if I had persistent DP (rather than FotF - Foot on the Floor, which is a much more acute rise in BG when you actually get up rather than from the early hours while asleep.)

The difficultly of reducing your supper-time pre-mix is that you require enough short acting units to cover the carbs in supper. I used to have a Mixtard 50 pen (50-50% short-ish and long-ish - I say "ish" as the older insulins are neither as short nor as long acting as the modern insulins used in typical basal-bolus treatments) which I would use when out for food in the evening, but what I really wanted was a mixtard 70 (or whatever one might call it, with 70% short acting and 30% long acting) which would have better matched the insulin I took when not out, i.e. when drawing my own up from vials with a syringe. It wasn't too much of a problem for me as when out I tended to run low anyway, but it would have caused problems using it when not out as I'd either have run high after supper, or gone low in the early hours as you do.

One approach for DP is to accept that you're not trying to get a flat overnight BG, but you want a U-shaped profile, where your BG is effectively dropping all night until the DP kicks in, and then hopefully it doesn't rise as much as it might otherwise and when you wake up you can hit it with a dose of short acting (see my first paragraph.) This would likely be easier to achieve with a basal insulin (or a non-mixed intermediate acting insulin), though some care must be taken with this approach as anything that reduces DP will mean you end up running low - so things like alcohol or exercise to which you're unaccustomed.

I'm sorry there are not really any answers above, we're not allowed to give medical advice and I think it would be worth discussing your your team to see what the options are and what their reasoning was for putting you on M3 and what their thoughts are about what to do next. It is your diabetes though, so I'd not be afraid to suggest things and experiment (carefully) on yourself.

Please do let us know

 

[Nick25]

I can well understand your concerns but take it from someone who has had T1 for 55 years and counting you are doing fine for such a recent diagnosis . Things have moved on since I was first diagnosed and continuous monitoring is both a blessing and a curse. Libre boast great accuracy but if you read all the information people warn that a newly fitted monitor takes time to settle , it doesn’t cope well with fast changing levels and can produce different figures between Libre and blood finger pricking measurements when rising or falling. Add in the “foot on the floor” effect ( I find a jump from 6 to 8 not unusual getting out o bed) and it is quite usual to have varying results . Add in that exercise can lower blood sugar ( half an hour gardening and I need a digestive - more accurately 10 minutes after starting I need the biscuit) ) and other health issues can alter figures ( my BG goes up 24 hours before I become aware of physical cold symptoms) and it is a miracle that we manage to maintain a reasonable set of figures at all. On the topic of “ reasonable figures” of course medics are going to set you targets but understand that some short term variations are a) inevitable and b) not that harmful . The long term damage that everyone is trying to prevent stems from extended periods at high BG levels so a quick spell up to 12 and back down is fairly harmless ( personally I can actually feel slightly unwell around 12) so try to avoid that, but have had occasions when dealing with low BG that I have created higher than 15 and had to give myself a small dose of quick acting insulin . I still have a Libre profile like the Dolomites even though my GP and diabetic clinic describe my figures as excellent! It takes experience to get rectification carbs quite right. .
Be careful with the low blood sugars ( jelly babies in a pocket , the car glove box, the partners bag, by the bed ) and rest will follow in time.

 

[RN25]

Thank you to everyone for taking the time to reply. I am taking note of all of your advice, it's all a bit overwhelming to reply individually at the moment. I have left a message for my diabetes nurse to contact me. I am still going high on a morning and after most meals so I have increased my morning insulin. The lows come quickly though once I'm back in the 5-6 zone. I guess I just need to learn to time snacks right and then it's just the overnight low that's the main problem. I am tired from the libre waking me up. I had planned to have a decent before bed snack last night but my glucose was still high from dinner and I wanted an early night so I didn't. Alarm went off around midnight at around the 4 mark. I ignored it and it went off again so I had an oat cake. Then I couldn't get back to sleep for ages. It rose again this morning, probs steeper rise from when I get up.
Its currently 14.2 post lunch... carbswise just one piece of bread. I had had an emergency oat cake and 1 jelly baby just before lunch as had gone down to 3.1 libre (3.9 pinprick). I started feeling funny only once my glucose was rising again - is that normal. I'm very thankful for the libre warning me!

 

[grantg]

Careful if +14 for a few hours may want to check ketones alongside if extended period of time exercise. Hope you get a call back from your team ok best wishes