Struggling With Mornings

[Levy]

Hi, I recently swapped back from Tresiba (used it 5 months) to Levemir and I've really been struggling with my mornings since.

No matter how much insulin I take or how long I wait before eating, I spike like crazy after breakfast. This morning I took 2u on my way to work for dawn phenomenon. Then injected another 6u for a bacon sandwich (I'd normal take 4u for that). I waited almost an hour and ate after I saw it starting to drop, yet now I'm still spiking up like crazy?!

Apart from correcting the dawn phenomenon, increasing my IC ratio for breakfast AND waiting between injecting and eating, I have no idea what else I can do to stop this? I normally have yoghurt and blueberries with a little bit of granola sprinkled in and the same happens.

To clarify, this never used to happen on Tresiba or even when I was on Levemir before. I don't understand why it's happening now! Has anyone else struggled with this?

 

[novorapidboi26]

With the current insulin/carb ratio do you always get back on target by lunchtime?

The dawn phenomenon is a tricky beast which can only be solved with a pump ultimately, but the process does continue in to the morning if you don't put something in your stomach to digest....its this digestion that will tell the liver its services are no longer required.....

so without eliminating that DP variable making sense of the behaviour of your corrections and carb doses is quite difficult.....

 

[Juicyj]

Hi @Levy This is the most frustrating part of t1 that gets me every time, you do the same thing each day and get different results

How long has this been happening ?

I would bite the bullet and try eating at the same time as taking your DP correction dose and taking your bolus at the same time to start. It may be that your morning ratio needs to be increased, but try eating first thing if you can and if it's still sky rocketing then try increasing your morning bolus ratio.

 

[Levy]

With the current insulin/carb ratio do you always get back on target by lunchtime?

I haven't been getting back in range until about 3pm

Hi @Levy This is the most frustrating part of t1 that gets me every time, you do the same thing each day and get different results

How long has this been happening ?

About since I changed back from Tresiba to Levemir - a couple of weeks.

When I was on Levemir before, I had no issue whatsoever. I would take 1.5/2u at 7am on waking which would keep me flat until breakfast. I would then bolus 1:8 just before eating, and again no huge spikes at all.

When I changed to Tresiba, there was no more dawn phenomenon so I stopped taking a correction on waking. My 1:8 ratio for breakfast remained the same so nothing else changed to my mornings.

Currently, I'm taking a 2u correction at 7am (although I forgot this morning and didn't take it until 8am) and a 1:6 ratio 45 minutes before breakfast (while on the same doses of Levemir as I was before, taken at the same times) and it just doesn't seem to be working! It's like any bolus I take in the morning is just mostly ignored and I usually remain in the low teens until 3pm when it suddenly drops back down.

 

[novorapidboi26]

I assume you have done some basal testing due to the insulin change......? is it a single dose...?

Its best to rule out dosing inaccuracies first you see.....

is your waking correction always the same and do you wake at the same level every morning? what is that level?

 

[Levy]

I assume you have done some basal testing due to the insulin change......? is it a single dose...?

Its best to rule out dosing inaccuracies first you see.....

is your waking correction always the same and do you wake at the same level every morning? what is that level?

I take a split dose of Levemir - 17u at 9am and 10u at 10pm. I did do basal testing when I first swapped back and apart from the DP the basal doses keep me pretty stable throughout the day and night.

My correction isn't always the same, if I wake up a bit lower (4/5) I might only take 1u, if I wake up in the 6/7/8 it'll be 1.5/2u. That's what always worked perfectly before.

 

[novorapidboi26]

You seem to be clues up which is good.....

The only things left to try if it was me would be to;

assess your correction factor
eat as close to waking as you can, preferably a small carb so you can give some insulin too.....
assess your insulin/carb ratio, due to you saying you don't get back down to target till 3pm...

you said you tested your basal when you changed back.....how long ago was that....? it may be worth fine tuning the morning dose to see if you can squeeze a little bit more out of it....

 

[Levy]

It was around two weeks ago that I last checked the morning. To be fair, I don't think upping my morning dose would help seeing as I take it at the same time as breakfast so that won't impact on my spike (it's already happening by then). Increasing my nighttime dose won't help either because I hypo during the night on higher doses (I started off at 12u and worked my way back to this nice flat line).

I think you're right in that I need to assess my correction/bolus doses. My ratios have almost always been the same throughout the day (I've taken 1:8 for every meal and 1:3mmol for correction all day for as long as I can remember). Having to suddenly almost double this in the morning is a scary concept for me to get my head around which is why I've been reluctant to play with my doses too much.

 

[novorapidboi26]

It sounds to be more of a 'foot on the floor' effect [if that's the expression] as opposed to DP as you aren't waking up on particularly high levels....single figures basically...

a tactic I used to tackle my DP, which was waking on double figures so may not apply to you, was to get my evening basal dose in just before going to bed......resulting in a stronger dose by the time the DP started....helped a tad....

my correction factor in the morning when injecting was 1 unit to drop 1.5mmol, as opposed to my daily 1:2...so definitely worth exploring that....

 

[Levy]

It sounds to be more of a 'foot on the floor' effect [if that's the expression] as opposed to DP as you aren't waking up on particularly high levels....single figures basically...

a tactic I used to tackle my DP, which was waking on double figures so may not apply to you, was to get my evening basal dose in just before going to bed......resulting in a stronger dose by the time the DP started....helped a tad....

my correction factor in the morning when injecting was 1 unit to drop 1.5mmol, as opposed to my daily 1:2...so definitely worth exploring that....

Yes, you're right it is foot on the floor - sorry for the confusion!

 

[kitedoc]

Hi @Levy,
I have been on Levemir/Novorapid mdi in the past for about 12 years before moving to an insulin pump. But have been on insulin for 51 years altogether.
What you are going through is the real bugbear for most TIDs at some stage I think!?
1) can you go back on Tresiba? (and why did you change to levemir anyway (an easy question to ask in hindsight of course)?
2) could you have gained weight or developed a resistance to levemir ? As your graph might indicate the 10 pm Levemir is not really effective after 8 to 10 hours. And the Dawn phenomenon comes along to boost your BSLs at just the 'wrong time'.
3) when you were injecting 12 units of levemir at 10 pm when were the hypos occurring?
4) injection sites - are they rotated? abdomen only? or leg sometimes? any fat pads (lipohypertrophy?
5) with the flare up of your BSLs in the morning the am levemir is too flat in profile I would think to have much to do with the BSLs settling til near 3 pm . If your am levemir lasts say 10 hours that could cover you until 6 pm when maybe Novorapid bolus covers dinner and basal requirements til say midnight.
What if you tried usual pm dose of levemir at 12 mn on several occasions and just see what happens ? as well as carrying out bolus adjustments as others have suggested? I would ask you to discuss this with your doctor say by phone first and also see if you could go back on Tresiba.

 

[Levy]

1) can you go back on Tresiba? (and why did you change to levemir anyway (an easy question to ask in hindsight of course)?

I could, even if only to see if the problem persists. The problem I was having with Tresiba is that because my Levemir doses are quite different (17u vs 10u), I was really struggling to find one single dose of Tresiba that suited me. I would either drop during the night, or rise during the day if I dropped my dose.

2) could you have gained weight or developed a resistance to levemir ? As your graph might indicate the 10 pm Levemir is not really effective after 8 to 10 hours. And the Dawn phenomenon comes along to boost your BSLs at just the 'wrong time'.

I have not gained weight

3) when you were injecting 12 units of levemir at 10 pm when were the hypos occurring?

It was a steady drop all through the night, with the hypo eventually occuring early morning (4-6am)

4) injection sites - are they rotated? abdomen only? or leg sometimes? any fat pads (lipohypertrophy?

Injection sites are rotated every single time. I rotate my Novorapid around my abdomen/arms, and rotate my Levemir around my legs and bum. I never inject in the same leg twice in one day, and always inject them at least 10cm away from the last injection spot.

5) with the flare up of your BSLs in the morning the am levemir is too flat in profile I would think to have much to do with the BSLs settling til near 3 pm . If your am levemir lasts say 10 hours that could cover you until 6 pm when maybe Novorapid bolus covers dinner and basal requirements til say midnight.
What if you tried usual pm dose of levemir at 12 mn on several occasions and just see what happens ? as well as carrying out bolus adjustments as others have suggested? I would ask you to discuss this with your doctor say by phone first and also see if you could go back on Tresiba.

I could play around with the timings. The thing is that I often go to bed before 12am so 10pm is really the latest I could take my evening Levemir without risking me going to sleep without having taken it (I'm quite forgetful so work from alarms!). I could try bringing my morning dose forward to 7am rather than 9am with breakfast - it might have a chance to start working that way by the time I eat?

 

[novorapidboi26]

I could try bringing my morning dose forward to 7am rather than 9am with breakfast - it might have a chance to start working that way by the time I eat?

I would agree with this tactic....

 

[Levy]

Another thing I was potentially thinking - and this is going to sound very controversial - is going back to Tresiba to keep the nice flat lines and stop the 'foot on the floor'. Stick with the lower dose that kept me flat during the night/morning, but then top it up with a small dose of Levemir in the morning to deal with my increased need during the day.

I doubt that would get any support from a professional though

 

[Levy]

Argh!!! See this is what I mean! I took 3u to correct a 13.8 and it only dropped me 5mmol when it really should have been 9mmol!

Next I'll go have lunch and even if I correct more now, it'll spike back up and then finally come down around 3pm like other days. I just don't get it!

 

[Fairygodmother]

Are you eating the same thing for breakfast as you previously were when you were using Levemir? I find that some foods will spike and take ages to come down and others won’t. The amount of energy used makes a difference too.

 

[novorapidboi26]

Argh!!! See this is what I mean! I took 3u to correct a 13.8 and it only dropped me 5mmol when it really should have been 9mmol!

Next I'll go have lunch and even if I correct more now, it'll spike back up and then finally come down around 3pm like other days. I just don't get it! View attachment 26944

Correction factor seems to be different [less effective] than you think it is....

 

[novorapidboi26]

Another thing I was potentially thinking - and this is going to sound very controversial - is going back to Tresiba to keep the nice flat lines and stop the 'foot on the floor'. Stick with the lower dose that kept me flat during the night/morning, but then top it up with a small dose of Levemir in the morning to deal with my increased need during the day.

I doubt that would get any support from a professional though

As foot on the floor is a hormonal response I don't see how Tresiba would stop it.....although it sounds like it may have previously done a good job of hiding it.....

using two basals isn't too crazy I suppose, I wouldn't personally do it......I am quite strongly for a split basal, always...

 

[Levy]

Are you eating the same thing for breakfast as you previously were when you were using Levemir? I find that some foods will spike and take ages to come down and others won’t. The amount of energy used makes a difference too.

Yes! There's only one of two things I'll have for breakfast which are both foods I know don't spike me (yoghurt and blueberries most days or a bacon sandwich as a Friday treat).

 

[Levy]

Correction factor seems to be different [less effective] than you think it is....

But it never used to be! I don't understand how my correction factor can suddenly have doubled from one day to the next