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Type 1 Morning Insulin Resistance

Discussion in 'Type 1 Diabetes' started by Emck, Jan 9, 2019.

  1. Emck

    Emck · Active Member

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    Hi all,

    I'm new to posting the forum, but have found it to be a very useful resource in the past.

    I'd love to know if anyone else has experienced morning insulin resistance. Over the past few months I have noticed that my sugars have been climbing quite high post breakfast.

    I do suffer from the dawn phenomenon so sometimes I can wake with higher sugars. I like to get these under control before breakfast, so I will normally take a few units of Humalog and wait until I get to work to eat. I'll then take my mealtime insulin and wait at least 30mins for this to kick in. I'm not eating anything abnormal (porridge with milk and a black coffee, maybe some fruit). I've been working on a ratio of 1:5 for this, but even if I increase the level of insulin it doesn't seem to help!

    Today my sugars shot up from 7 to 17 two hours after eating! It was as if I hadn't taken any Humalog at all!!!

    Could this be an insulin problem, an injection site problem, or an issue with the types of food that I'm eating? I know that sometimes coffee can interfere with my insulin absorption, but I have found that adequately pre-bolusing and drinking it with food can really help control this.

    Has anyone experienced this and found a solution?

    I have spoken to my doctors, who just keep telling me to correct the highs, but I'd rather get to the root cause of the problem and address this. It's getting to the stage where I'm having to take insulin, even though I'm not eating anything!! Even when I don't eat my sugars rise at this time of day! Catch-22!
     
  2. Colin of Kent

    Colin of Kent Type 1 · Well-Known Member

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    Hi @Emck and welcome. This seems like quite a common problem, and like you say, it's just a case of identifying the root cause. Are you pumping or MDI? What's your current basal setup? And when did you last check and adjust your basal setup? You need to know whether that's adjusted correctly first, before trying to work out your boluses...

    Other than that, my thoughts are that the insulin you're using could be out of date or may have been out fo the fridge for too long. Have you tried another batch/vial? Also, you could think about injection sites... do you have 'favourite' spots or do you rotate?

    Sorry if this is basic stuff to you, I'm just chucking out ideas here...
     
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  3. DCUKMod

    DCUKMod I reversed my Type 2 · Expert
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    Emck - I'm neither T1 nor an insulin user, so won't make any corrective suggestions, but will ask a couple of additional questions.

    Does this happen every day of the week, noi matter what you have for breakfast, or is it on the days you have porrridge at work?

    Has the formulation of your porridge changed, meaning it needs more insulin?

    Have you tried having something non-carby for brekkers for a few days to see if that has any impact? That might help identify if what you are eating has a part to play.
     
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  4. Jim Lahey

    Jim Lahey I reversed my Type 2 · Well-Known Member

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    Have you been gaining weight OP?
     
  5. Emck

    Emck · Active Member

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    Hi all thanks for your input!

    I'm on an MDI routine - humalog bolus/lantus basal injected at bedtime. I have recently increased my lantus dose from 38u to 42u after gaining about 0.5stone (though I am exercising and eating healthily to try to correct this). I had tried a higher dose of 44u but that had resulted in night time hypos. I think I could benefit from some new basal testing, though I use a cgm and can see my overnight activity.

    Porridge doesn't seem to be the culprit, however workdays are more likely to result in this type of reading. Weekends don't really have these kinds of spikes, though I'm generally less active on a weekend morning and as noted, morning activity can lead to these spikes.

    I've never been advised at the hospital to eat low carb, and find it difficult to think of low carb breakfasts that can be prepared at work (cereals etc. always seem to be full of sugars). The dietitian has recommended porridge as it is low GI and otherwise healthy! Any other recommendations for brekkie options would be greatly received!

    I rotate sites daily (abdomen and thighs for boluses, bum and thighs for lantus), but I guess that after 20+ years of type 1, all of my sites are probably quite well used! I had tried arms for a while but they bruised very badly and i looked like I had really been through the wars. Today's was a brand new vial of humalog and it seems to be working to bring down the post breakfast high.

    Has anyone ever changed insulin to address such a problem? When I last mentioned it to my DSN she has suggested levemir twice daily (I've probably been on lantus for over 10 years, humalog for even longer).
     
  6. Colin of Kent

    Colin of Kent Type 1 · Well-Known Member

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    Yeah, I'm sure I've read that Levemir has a much flatter action profile than Lantus. Probably worth considering. You could also think about a 12-hour 50/50 split dose of Lantus to even things out a bit.

    I seem to have a fast metabolism and I used to find that even low-GI foods like porridge (big, whole oats, no sugar/fruit/honey) caused spikes that Humalog could only just keep up with. Scrambled eggs are a good, quick alternative. And any added fat will help, slowing down the absorption of carbs by lowering the whole meal's GI.

    I think your first port of call is to retest your basal regime. Otherwise, if you make changes to your boluses, you won't really know what effect they're having.

    The workday/weekend pattern is interesting. It could be stress?
     
  7. Jim Lahey

    Jim Lahey I reversed my Type 2 · Well-Known Member

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    Incidentally, not that I’m promoting anything one way or the other, but just picking-up on one point - should you be looking for convenient, low carb breakfasts, you could do worse than gooey-centred hard boiled eggs. Cooked and peeled the night before. Salt, pepper, Tabasco if you like a little fire in your life. Served on raw baby spinach in a little Tupperware box or something - other airtight food containers are available. Keep in the fridge overnight and either take to work in the morning or eat in the shower. Shouldn’t require much insulin, super quick and easy, with the additional benefit of making you full of sunshine and immortal.

    Sorry, none of that is likely to be of much use to you, and I’m very far from informed regarding T1, so I’ll get back in my box now. Just to add though that after that many years of knowing what you’re doing, now needing increased insulin and putting on weight...could well indeed be an early indicator of resistance creeping in. I’ll leave T1’s to comment further, as I’m most definitely not qualified to offer advice on the ins-n-outs of managing it :)
     
  8. Chris Bowsher

    Chris Bowsher Type 1 · Well-Known Member

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    Fine tune your insulin ratio and try to pre bolus if you can, or change what you eat in the morning

    =my ratio in the morning is 1u:5g and in the evening it's 1u:10g
     
  9. helensaramay

    helensaramay Type 1 · Expert

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    Welcome to the forum @Emck from a fellow Type 1.
    It sounds as if this is unlikely to be anything related to the porridge if you are experiencing the highs even when you don't eat anything. So, I would not be adjusting to a low carb option if I was you (with type 1, I have not found I need to do so provided I match the timing of my insulin appropriately). But, if you do, you will have to consider injecting for protein as some find this is necessary when they have little or no carbs.
    And if this is only a morning problem, it is unlikely to have anything to do with your sites or insulin.

    It sounds to me (not a doctor), a dawn phenomenon which is exacerbated by activity and maybe stress. I don't have a theory about why this could be getting worse in the last few months.
    Maybe a changing or splitting your basal insulin could help. The Lantus profile is not flat and doesn't last a full 24 hours (some people find it only lasts 12 hours) so the spike may coincide with Lantus "running low".

    Alternatively, if you are finding your basal needs are clearly different at different times of the day (and maybe different days of the week), you could be a candidate for a pump.
     
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  10. Diakat

    Diakat Type 1 · Moderator
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    Were your overnight hypos checked against a finger prick? Just because if using libre they can read low when not.
     
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  11. DunePlodder

    DunePlodder Type 1 · Well-Known Member

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    Changing from Lantus to twice daily Levemir was a very positive change for me.
     
  12. Emck

    Emck · Active Member

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    I do try to pre-bolus and find it effective at other times of day. However, pre-bolusing is somewhat of a new thing to me. When first introduced to Humalog I was told that I could take it directly before meals (maybe even directly after) and it should work. It's only upon doing my own recent research and going onto a CGM that I have found out that this doesn't work for me. The CGM has really opened my eyes to my post-meal spikes!!

    I'll try basal testing and maybe adding some good fat to my porridge (maybe nut butter/seeds/nuts could help from a healthy perspective - don't want to just eat a block of cheese).

    How does splitting a dose work? Does this just mean that you get half a dose for 12 hours then a full dose for 12 hours the first day. then a full 24 hour dose from then on? Is the theory that there are different peaks?
     
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  13. Emck

    Emck · Active Member

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    Yes this was before I got my CGM.
     
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  14. DunePlodder

    DunePlodder Type 1 · Well-Known Member

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    I split my Levemir dose unevenly. It took me quite a while to get it "Right". I found I needed less in the morning than in the evening, but it will be different for everyone. I also found that I needed more total Levemir than Lantus, but this may have been partly because I had cut my Lantus in order to avoid overnight lows - it probably needed to be higher during the day really.
    Like you I found using a CGM a real "Eye Opener". Lantus did some strange things..
     
  15. Colin of Kent

    Colin of Kent Type 1 · Well-Known Member

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    You literally just divide your Lantus dose by two, then take each shot 12 hours apart every day. So it's the same total 24-hour dose, just split into two. This method worked for me with Levemir, as I found its action was tapering off well before the 24 hours was up.
     
  16. NicoleC1971

    NicoleC1971 Type 1 · Well-Known Member

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    As COLIN suggests, do a basal check.
    Pesonally I find that a pump has enabled me to control my DP but that delaying or avoiding breakfast combined with stress of getting to work can regularly elevate my BGs especially if I was already a little high upon waking. So you could try eating earlier and takiing the insulin earlier; if your body doesn't have enough insulin or requires energy then you will pump it out from your liver regardless! Our beta cells don't work to produce insulin nor do they work to suppress the release of glucagon (the hormone which prompts the liver to produce glucose).
     
  17. SueJB

    SueJB Type 1 · Well-Known Member

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    or the fridge may be too cold
     
  18. Emck

    Emck · Active Member

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    Thanks all for your helpful tips yesterday.

    I didn't manage to basal test last night as I hit the gym after work and that tends to decrease my insulin requirements - so it wouldn't have been a "normal" night.

    A little update in case it might be helpful for someone else.

    This morning I got up a little earlier and had breakfast before I left the house. I did notice a small rise in sugar in between waking and eating (from about 6 to 8) but my sugars have been a lot more manageable this morning. My post meal spike seems to have topped out at just over 10. So I maybe needed to increase the amount of insulin that I took (i did a 1:5 ratio and then topped this up on seeing the slight rise before eating so probably worked out at about 1.5:5 overall) or pre-bolused for longer (i took about 40 mins this time). I guess if I am eating at home then I could also try more low carb options as I would have the kitchen at my disposal and wouldn't face the wrath of my colleagues for eating boiled eggs in a small airless office!

    I'm going to try this again tomorrow and hope that it works as well! It could well be that my body needs fuel asap in the morning time or else it does a big glucose dump to compensate?
     
  19. kitedoc

    kitedoc Type 1 · Well-Known Member

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    Hi @Emck, It could be that the exercise after work on the day before has improved the sensitivity of your insulin (it does so for many people including me. Some find the effect works for 12 hours, others longer).
    So this morning's results are perhaps not going to be typical. Also the exercise might have made you feel more relaxed this morning.
    If exercise after food were possible every day, and provided it did not cause night hypos you have a possible way to improve things. But life is not always regular, fair or so propitious.
    If you are going to do something with your Lantus dose, timing, split please discuss with your DSN first.
    On an insulin pump the basal rate can be adjusted hour by hour so any upswing in BSLs due to DP can be catered for in a much more accurate way than with long-acting insulin.
    There are people on site who have set their alarm for ? 4am, or ?5am in order to wake and give themselves some short-acting insulin to offset the DP effect and improve their pre and after breakfast sugars along with enough short-acting before breakfast.
     
  20. DunePlodder

    DunePlodder Type 1 · Well-Known Member

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    @Emck You say it topped out at just over 10, what happened then? Did it come down to your target range?
    If so the only thing I can suggest is to prebolus earlier - not so easy unless you set an alarm as @kitedoc mentions!
     
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