Quick Drop Followed by Sudden Rise and Ketones

[Binary]

I don't know if this is age related (hormones) but my since last Summer on and off after my son (7 years old) has spells where his evening insulin requirements go shooting up within about half an hour off sleeping but only once he is asleep. Last Summer a background 0.10 units per hr (Omnipod) would keep him steady then he went through a spell were shortly after falling asleep he would go from 0.10 to 0.50 units per hour for about 4 hours. This happens on and off then evening demand drops back off.

Currently the patern seems to be to fall asleep start dropping followed by a sudden and very rapid rise for several hours after. This evening for example based on the libre reading he was 7.9 at 20:03 evening meal food still in system for half an hour and told to go to sleep. 20:34 eveing meal insulin out of system bg 4.7 and droping slowly. 20:58 6.2 and rising slowly. 21:28 9.3 and rising fast, ketones 0.5. Suggested correction 0.25, gave 1 unit due to ketones plus recent experience. 22:30 12.2 steady with 0.9 ketones, 1.5 units by given by pen. Current holding at 12.3.

We have spells where insulin requirement is pretty steady and then have times like now when it can just change at a whim. No real advise from clinic, seen two consultants and various nurses they all express surprise and because his HBA1C has in the last been in the 6's they have been very happy and just told us to keep on doing what we are doing.

I just feel these episodes are getting bigger/stronger and therefore harder to keep under control. Is this normal or maybe an indication that there maybe other issues that we are not aware off

 

[phdiabetic]

Are you checking blood sugar on a meter as well as the libre? It may be inaccurate - for example, while he was in bed he may have slept on top of the sensor, causing a false low reading, whereas in reality his blood sugar was on its way up (pump problem? Hence the ketones).

It is definitely not normal to regularly get ketones - anything higher than a trace amount of ketones indicates a serious issue, and if this is happening regularly then there is something wrong with his control. I would recommend bringing this up with your endo.

 

[Deleted Account]

It seems a shame that healthcare teams rely so much on HbA1C. I understand it is a relatively easy measurement for them and a single number that provides an indication of the average BG over the last 3 months. However, it is one number and it is an average so it hides the roller coaster of readings we get in reality.
Do you have the option to upload your readings to something like Diasend for your healthcare team to reveiw? This should illustrate the problem with facts rather than what they may (unfairly) think is an obsessive parent who is looking for perfection at all times.

 

[Binary]

Are you checking blood sugar on a meter as well as the libre? It may be inaccurate - for example, while he was in bed he may have slept on top of the sensor, causing a false low reading, whereas in reality his blood sugar was on its way up (pump problem? Hence the ketones).

It is definitely not normal to regularly get ketones - anything higher than a trace amount of ketones indicates a serious issue, and if this is happening regularly then there is something wrong with his control. I would recommend bringing this up with your endo.

I didn't check his bloods on a meter last night, will do tonight if I get a repeat experience. Could he have developed a sleeping pattern that produces a false reading initially after falling asleep? It is happens for a few day/weeks etc and then stops again. I wouldn't normally test for ketones unless we are getting readings over 15. I did last night to try to get a better understanding of it.

A year ago he was pretty stable on 0.10 units per hour between six and midnight but then went through a spell were it increased to 0.5 units just to stop it getting higher then 12.0 and then it settled back down again. He was teething at the time so wondered if it was related to that but his diabetic team hadn't heard of anybody else experience so were dismissive off that that and I don't think they would have believed us if wasn't for the data we uploaded for them to view.

 

[Binary]

It seems a shame that healthcare teams rely so much on HbA1C. I understand it is a relatively easy measurement for them and a single number that provides an indication of the average BG over the last 3 months. However, it is one number and it is an average so it hides the roller coaster of readings we get in reality.
Do you have the option to upload your readings to something like Diasend for your healthcare team to reveiw? This should illustrate the problem with facts rather than what they may (unfairly) think is an obsessive parent who is looking for perfection at all times.

Earlier in the year we had a couple of months were his was really stable, bloods rarely above 10 and certainly a blip if it hit 14. Ketone testing just didn't happen. Then it all goes all over the shop and his background requirements seem to change every few days.

His diabetic team only seem to be interested in reviewing the previous two weeks and once they know his hba1c, they are like next please. At best we might get told it's hormones, his growing etc although apparently growth shouldn't kick in till the early hours of the morning.

At our most recently appointment the new dietitian ask for a quick chat, discussed what he eats when we bolus and suggested that we should try blousing 80/20 2hrs for cereal. He gets all his insulin 20 minutes upfront for cereal since the libre highlighted the rise and sudden drop that he was experiencing.

 

[noblehead]

This happens on and off then evening demand drops back off.

If it's on and off then look at what your lad is eating earlier in the evening when these high's occur, many of us type 1's find that a meal high in fat can cause insulin resistance many hours later (and has a prolonged effect well into the early hours of the morning), just something to think about @Binary and I'm sure your lads dietitian will be aware of this already.

 

[Binary]

If it's on and off then look at what your lad is eating earlier in the evening when these high's occur, many of us type 1's find that a meal high in fat can cause insulin resistance many hours later (and has a prolonged effect well into the early hours of the morning), just something to think about @Binary and I'm sure your lads dietitian will be aware of this already.

When I say it's on and off, it can go on for a couple of weeks. For that reason I don't think it's what he is eating. Requirements changing from time to time so maybe we haven't got his insulin quite right.

Unfortuntely I don't have much confidence in the dietitians at the moment. We needed one when my boy was first diagnosed and by the time we saw one 8 months later we were already carb counting. She was new to the job and diabetes. She has recently been replaced by a more experienced dietitian but again new to diabetes.

I am not saying they aren't useful or necessary. They are for some especially if this is all new to you it's just that with 3.5 years experience of which type 1 diabetes, combined with 3.5 years daily food recording and plently of reading up so far the conversations I had feel have been more to their benefit then mine.

 

[Binary]

Thanks and apoliges for not replying earlier the figures for the following night were as follows:

21:08 5.4 dropping slowly
21:30 4.5 dropping slowly
21:34 4.3 dropping slowly
21:35 5.6 BG
21:36 0.2 ketones
21:38 4.4 steady
21:52 4.3 steady
22:07 5.5 steady
22:29 6.3 rising slowly
22:42 8.1 rising slowly
22:43 8.6 BG

The last few days it seems to have calmed down again possible because I have made some changes to both bolus and basal. I have put him on a higher background and reduced his insulin per carbs from 1 unit per 8 carbs to 1 unit per 9 carbs.

I did wonder if the drop and sudden rise could be the result of any other possible issues but it may well just have been to much insulin for meals and not enough background insulin which appeared to work well initially but the tailend of the insulin being stonger then the remaining food causing a drop followed by the sudden rise due to the background not being up to the job.