Overnight Hypos with No Insulin

[Rosie Longstreeth]

I’m at 21 year old type 1 diabetic having been diagnosed at 14. In the last 4 months I have had a hypo every morning sometimes as low as 1.6 mmol//L and have tried everything I used to take 20 units of levemir in the evening and 30 in the morning but now I only do a morning levemir injection and no evening and yet I am still having hypos in the morning. My freestyle libre shows that my bloodsugar rises to around 22 and drops very very quickly down to 3 having taken no novorapid or levemir at dinner time or in the evening and sometimes even after a midnight carb snack. My nurse and doctor have no idea what is going on and don’t know what to suggest as it feels like I have tried everything! I am not sure if it is to do with hormones having come out of teenage years but I was just wondering if anyone else has had the same issues and then what to do about it?

 

[Boo1979]

Have you been able to do any comparison BG readings? I find the libre is sometimes spot on with registering nocturnal hypos but at other times is up to 5mmol out compared to a finger prick test, the libre reading was always lower than BG reading from a fingerprick test.
Is theres a pattern to when the libre is showing hypos, Id be tempted to set an alarm for a few nights and do some fingerprick tests to compare

 

[Rosie Longstreeth]

Have you been able to do any comparison BG readings? I find the libre is sometimes spot on with registering nocturnal hypos but at other times is up to 5mmol out compared to a finger prick test, the libre reading was always lower than BG reading from a fingerprick test.
Is theres a pattern to when the libre is showing hypos, Id be tempted to set an alarm for a few nights and do some fingerprick tests to compare

Yes I have found the same sometimes but at the moment it has been pretty accurate as I have usually done a finger prick test as well when having the hypos. And yes it seems to be in some sort of pattern and I have also tried waking up to do the finger pricks which have also been very accurate! I have attached a photo oh what my usual pattern is from my libre.

 

[danielrob91]

Those levels are all over the place bro! When are you having your last meal with insulin? Why are you so high in the evenings? What time do you go to bed?

 

[Rosie Longstreeth]

Those levels are all over the place bro! When are you having your last meal with insulin? Why are you so high in the evenings? What time do you go to bed?

I know ahaha I normally have dinner at about 7 and I take a reduced dose of novorapid so that might explain the high but if I take more I tend to have a hypo in the morning because of the unexplained drop. I usually go to bed around 11/12.

 

[EllieM]

Are you treating the hypo with glucose or did your liver pull you out of it?
Any chance your insulin uptake is being delayed by overuse/poor rotation of injection sites?

Increasingly wild suggestions coming up...
Any chance you're T2 not T1
Could your liver be pumping out less glycogen for some reason?

Not so wild suggestion (in fact my best guess)
I'd be looking really really hard at your basal requirements - I assume your clinic have tested and retested your needed amounts. My gut feeling is that you need less basal and more bolus....

 

[alphabeta]

Are you treating the hypo with glucose or did your liver pull you out of it?
Any chance your insulin uptake is being delayed by overuse/poor rotation of injection sites?

Increasingly wild suggestions coming up...
Any chance you're T2 not T1
Could your liver be pumping out less glycogen for some reason?

Not so wild suggestion (in fact my best guess)
I'd be looking really really hard at your basal requirements - I assume your clinic have tested and retested your needed amounts. My gut feeling is that you need less basal and more bolus....

Exactly.. maybe the basal is messed up

 

[Rosie Longstreeth]

Are you treating the hypo with glucose or did your liver pull you out of it?
Any chance your insulin uptake is being delayed by overuse/poor rotation of injection sites?

Increasingly wild suggestions coming up...
Any chance you're T2 not T1
Could your liver be pumping out less glycogen for some reason?

Not so wild suggestion (in fact my best guess)
I'd be looking really really hard at your basal requirements - I assume your clinic have tested and retested your needed amounts. My gut feeling is that you need less basal and more bolus....

It was my liver that caused the high in the morning. My nurse did check all that and I think my rotation is fine at the moment.
I’m not sure about that! I’ll suggest it to my nurse in my next meeting.
Yes we’ve changed it a lot and still trying a few things but yes thats probably the reason!

Thank you!

 

[alphabeta]

It was my liver that caused the high in the morning. My nurse did check all that and I think my rotation is fine at the moment.
I’m not sure about that! I’ll suggest it to my nurse in my next meeting.
Yes we’ve changed it a lot and still trying a few things but yes thats probably the reason!

Thank you!

Classic dawn phenomenon?

 

[Rosie Longstreeth]

Classic dawn phenomenon?

Would the insulin resistance last until the evening?

 

[alphabeta]

Would the insulin resistance last until the evening?

There is something to consider:
-You are taking Levemir which can act 12H or 24H based on units/kg.
-You are taking Levemir in the morning
-The pattern is high at night, low at 6AM, high again.
This suggests a theory to be confirmed by blood sugar tests only: maybe you basal is wearing off too early and dawn phenomenon also known as liver dump is causing the hyperglycemia in the morning but this doesn't not explain the drop in the first place. I would take the room temperature into consideration in that case I couldn't think of anything else. Maybe you are sleeping in a hot room? Anyway I'd recommend discussing the basal insulin to change it to pre bedtime with your medical team ONLY.

 

[slip]

Is everyday pretty much like this? What time do you do your basal? (20u?), what time did you have breakfast lunch and dinner that day and what did the meals consist of and number of carbs, and number of bolus units taken?

Just wondering if the drop early morning is the liver grabbing back and replenishing it's store from the previous hypo (the morning before).

To state the obvious You're all over the place! Do a basal test first, then generally treat the hypos quickly (yeah difficult when you're asleep) in the hope of stopping the liver dumping, hopefully that'll stop the roller coaster and then you can concentrate on bringing your levels down.

 

[Rosie Longstreeth]

Is everyday pretty much like this? What time do you do your basal? (20u?), what time did you have breakfast lunch and dinner that day and what did the meals consist of and number of carbs, and number of bolus units taken?

Just wondering if the drop early morning is the liver grabbing back and replenishing it's store from the previous hypo (the morning before).

To state the obvious You're all over the place! Do a basal test first, then generally treat the hypos quickly (yeah difficult when you're asleep) in the hope of stopping the liver dumping, hopefully that'll stop the roller coaster and then you can concentrate on bringing your levels down.

Yes pretty much the same everyday! Usually around 9 or 10 am I take 30 units and then having breakfast straight after and taking between 6-10 units of novo rapid. My meals usually have some carbs in but not lots and I try and stay away from too much fast acting sugar (chocolate, sweets etc).

That makes sense but yes as you said it I don’t always wake up for them! I don’t know how I can stop my levels from dropping so fast at night so I don’t end up having the hypo!

 

[slip]

I don’t know how I can stop my levels from dropping so fast at night so I don’t end up having the hypo!

by not having a hypo.........

So you're low carbing and therefore not taking much fast acting bolus insulin, you also take a fair amount of basal insulin (I think you need to do a proper basal test TBH) only in the morning, correct? The only way I can see your BG dropping as it does early morning is because of the liver grabbing back, at that time you would not have any meaningful insulin on board. The only reason the liver grabs back is because of a previous hypo. You are in a catch 22 situation.

Do you always hypo at around 5am every day?

 

[EllieM]

The only way I can see your BG dropping as it does early morning is because of the liver grabbing back, at that time you would not have any meaningful insulin on board.

Levemir's 24 hours though???? Hypo's happening 20 hours in?
I'd be doing everything possible (eg set an alarm) to avoid that early morning hypo....
Having said that, I still think you need to address the basal.

 

[Rosie Longstreeth]

by not having a hypo.........

So you're low carbing and therefore not taking much fast acting bolus insulin, you also take a fair amount of basal insulin (I think you need to do a proper basal test TBH) only in the morning, correct? The only way I can see your BG dropping as it does early morning is because of the liver grabbing back, at that time you would not have any meaningful insulin on board. The only reason the liver grabs back is because of a previous hypo. You are in a catch 22 situation.

Do you always hypo at around 5am every day?

Yes only in the morning. Yeah that does make sense. 5 or 6am hypos yeah!

 

[Rosie Longstreeth]

by not having a hypo.........

So you're low carbing and therefore not taking much fast acting bolus insulin, you also take a fair amount of basal insulin (I think you need to do a proper basal test TBH) only in the morning, correct? The only way I can see your BG dropping as it does early morning is because of the liver grabbing back, at that time you would not have any meaningful insulin on board. The only reason the liver grabs back is because of a previous hypo. You are in a catch 22 situation.

Do you always hypo at around 5am every day?

Also..I have to eat a lot of carbs before I go to sleep (12 or 1am) and my nurse suggested to try not having the carbs do I don’t get the spike so it won’t go down as fast but I’ve tried doing this for a few days and I end up having a worse hypo than I did before..I don’t know if that’s relevant!

 

[slip]

So how many carbs do you have before bed? and how many roughly during the day? Thats an odd response, I'm tagging @Lamont D as he might have something to say.

 

[Rosie Longstreeth]

So how many carbs do you have before bed? and how many roughly during the day? Thats an odd response, I'm tagging @Lamont D as he might have something to say.

Two or three pieces of toast or something similar and then during the day it varies.

Also I just feel like it was such a sudden change like almost overnight..it’s just so strange!

Brilliant, thank you.

 

[Scott-C]

@Rosie Longstreeth , it's all a bit of a puzzle, will maybe get back with a few thoughts on it later on, but, meantime, if you're using libre regularly, there's a small transmitter called "blucon nightrider" which you can buy for £96 from www.ambrosiasys.com as a one-off cost, put it on top of your sensor with a plaster, link it to an android app called xDrip+ and it'll automatically read the sensor every 5 mins, so it'll give you hypo alerts.

Obviously, that doesn't address the underlying issue, but it'll at least mean that while you figure out ways of sorting it out, you'll at least have the security blanket of getting woken up by the phone ringing if you drop too low instead of getting repeated hypos night after night, which must be sooo tiring.

You can set the hypo alarm to any level you want, so, say you set it to 6 or 7, it'll catch you on the sharp drop down from the teens, and give you time to figure out how much carb you need to tail it off so it stops about 5.5 instead of going into hypo-land and not rebounding too much.

It'll maybe give you a bit of respite while you get the larger issues sorted out.