Type 1 Morning Insulin Resistance

Emck said:

However, pre-bolusing is somewhat of a new thing to me.

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If you've got a kindle, I'd recommend getting a copy of Sugar Surfing, by Stephen Ponder. He's an American endo who is also T1, and was one of the first users of cgm.

I found it a really useful book when I first started using libre a couple of years back, and later with a transmitter for full on cgm.

The book's got lots of advanced tips on figuring out pre-bolusing, split bolus, "waiting for the bend", corrections etc.

He's not some crank either - some hospitals are referring to it as "further reading" in their cgm guidance.

Another book I found useful was Beyond Fingersticks, by William Lee Dubois, again on kindle. Again, he's an early cgm user. It's a bit dated now, about 10 yrs old, which is like pre-history in cgm terms, but still a lot of useful basic principles of what to expect and, just as importantly, what not to expect from cgm.

There's an amusing bit where he looks into the future from 10 yrs back and imagines us being able to see our bg on our phones!

Good luck!

Hi @Emck, I've been using Lantus for years and found that I started to have a higher insulin:carb ratio in the evening. At the suggestion of my DSN I split my Lantus dose, and I take uneven amounts - 9u at 8am, 12u at 8pm and that seemed to fix it for me. However, if your ratio is higher in the morning and you take one shot of Lantus at night, it doesn't seem to me as though your problem arises from Lantus running out - it should be later in the day for you to see that effect. I think a lot of the other suggestions here are much more likely, just thought this might help to rule out one possibility. Like Scott said, good luck!

I take 6 units of Abaseaglar in the morning and 12 units at 6pm ( approx.) I used to get high readings in the morning but couldn't up my basal as I would go hypo in the night. Split does works well for me.

My BS also goes up in the morning even without food so I have to take insulin to keep it down.

Emck said:

guess it's all trial and error. I need to fine tune to work out my prime pre-bolus time.

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It's well worthwhile spending time on it.

When I first went on novorapid, the doc said inject before meal, did so, ended up thinking regular bounces up to 10 to 15 was just "normal".

Found out about pre-bolusing a couple of yrs ago when I got libre.

I started looking at the daily graphs on the libre pc software each week, looking for the lowest post-meal rises and that gave me some good clues on ratios and pre-bolus timings.

Decided that about 20 mins worked for me, which ties in with the novorapid maker's advice that it takes 20 mins to start working (may differ for other insulins and people).

The upshot is that meals, which a few yrs ago, would have left me knocking 15, can be "tamed", so that I'll get a modest bounce to around 7 or 8, or add a few tweaks, and it's possible to have a gentle downward curve and then rise and no spike at all (as you found with the porridge, although that was probably taking it too far - I'd be getting messy too with 40 mins!).

After you find your sort of general guideline pre-bolus time, it's possible to add a few bells and whistles.

I'll start with my basic 20 mins, works most of the time, but I'll also pay attention to the general trend of what's been happening on the cgm graph for the last few hours.

If it's trending up, I might lengthen it as the insulin needs a bit more time to start dropping me before I hit it with food.

Or, if it's already trending down, I'll shorten it.

I'll also think about how "fast" the carbs are: a low GI meal would shorten it, and high GI would lengthen it.

One of the things which cgm and Sugar Surfing brings to the game is the idea of not being shy about doing corrections between meals.

I'll obviously try to figure out the correct bolus and timing for a meal, but if after an hour or two I'm getting clear signals from the cgm that I got that one wrong and it is starting to race too high, I'm not slow to fire in another couple of units to drag it back down.

If you decide to insulin-stack like that, setting up the Active Insulin symbol on libre is really useful for this sort of stuff. The code in the professional options section is CAA1C. Set it up, then enter each bolus shot and as time goes by, it'll tell you IOB. If I think I'm starting to go too high, and am trying to make my mind up about whether I should correct or not, knowing whether I've got roughly 1u or 5u iob is going to help with that decision.

This sort of stuff doesn't work all the time, T1 is too darned unpredictable for that, I still have fliers, but, all in all, it improves the odds.

Give it a go!

Hi @Emck. Some good advice on here.

Thought I would chuck my peenies worth in as I had exactly the same symptoms as you until recently. I also suffer from DP in the mornings and need to give myself 2 units of insulin when I first get up before travelling to work. I used to then give 12 units of NR before having porridge and no matter how much I prebolused I still ended up either spiking soon afterwards or later on in the morning. This is because of the low GI nature causing a later spike. I found a really good way round this and it's called Chia Pudding. It's essentially a low carb breakfast that needs to be prepared the night before. I mix with choc protein powder to give it a nice taste but there are lots of different options to flavour it. This has only 5 grams of carbs and flatlines my blood sugar until lunchtime. I've found it is the best way of managing it. Still need a couple of units to deal with the protein but works well.

Emck said:

I have ordered some chia seeds, so will give this a try!

I think that pre-bolusing and eating before leaving the house has had a really good effect on my levels overall. Though I'm struggling a bit with night time hypos, so really need to find some time to basal test this week (it's a bit of a tough time personally so this has proven difficult).

I'm managing well with porridge and think that I'm going to be able to reduce my morning ratio, as I'm often going hypo a little after breakfast.

I hope that this post is helpful for anyone else struggling with the same issues. I had searched for months for a solution for this and it proved quite simple. I guess my liver just got panicky if I didn't eat first thing in the morning and dumped glucose!

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Well it sounds like you are starting to get it sorted which is really good to hear.

I just find that the Chia seeds give me a flat line BG during the morning which sets you up for success for the rest of the day. Definitely worth flavourinhg up the Chia seeds though as they are not great just by themselves. Lots of recipes on the internet. I find 3 tables spoons of seeds mixed with 300ml of water gives the right consistency and keeps me going easily until lunchtime.

Emck said:

I have ordered some chia seeds, so will give this a try!

I think that pre-bolusing and eating before leaving the house has had a really good effect on my levels overall. Though I'm struggling a bit with night time hypos, so really need to find some time to basal test this week (it's a bit of a tough time personally so this has proven difficult).

I'm managing well with porridge and think that I'm going to be able to reduce my morning ratio, as I'm often going hypo a little after breakfast.

I hope that this post is helpful for anyone else struggling with the same issues. I had searched for months for a solution for this and it proved quite simple. I guess my liver just got panicky if I didn't eat first thing in the morning and dumped glucose!

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We seem to have about the same problem and the amounts of basal insulin. I also have porridge in morning around 7 am about 15 mins after i take my Novorapid. We also seem to take about the same insulin carb ratio, I am 1:4

My BG could be around 5.8 when i get up but by 10 this can rise to around BG of 11. However by lunchtime this will usually drop back to 5.8. It is only by using the Libre that i was able to see this big spike. It happens with me most mornings

I have tried Chia seeds added to the porridge but they made no difference

As others have suggested this may just be late dawn phenomenon. maybe worthwhile discussing with doctor with a view to getting put on a pump. This is what got me moved onto the pump waiting list

As long as your other BG are not too bad, try not to get to obsessed with Libre figures and spikes, i know i did

smc4761 said:

We seem to have about the same problem and the amounts of basal insulin. I also have porridge in morning around 7 am about 15 mins after i take my Novorapid. We also seem to take about the same insulin carb ratio, I am 1:4

My BG could be around 5.8 when i get up but by 10 this can rise to around BG of 11. However by lunchtime this will usually drop back to 5.8. It is only by using the Libre that i was able to see this big spike. It happens with me most mornings

I have tried Chia seeds added to the porridge but they made no difference

As others have suggested this may just be late dawn phenomenon. maybe worthwhile discussing with doctor with a view to getting put on a pump. This is what got me moved onto the pump waiting list

As long as your other BG are not too bad, try not to get to obsessed with Libre figures and spikes, i know i did

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@smc4761 Sorry to confuse -just to be clear - you dont add the chia seeds to your porridge. You soak the chia seeds overnight (3tbl spoons to 300ml water), add flavouring and then consume them. There is onlky 5 grams of carbs in this so you should hardly have to give yourself any NR if at all.

Emck said:

Yes after it topped out at 10.4 it dropped back steadily into target. I didn't really experience any DP last night (I normally don't after exercise as it does increase my insulin sensitivity (I need to bolus a lot less). I aim to be in the gym/run around 3 times per week, but as you say this isn't always feasible and every day certainly isn't a possibility for me!

I have experienced the same highs on mornings after the gym, so this is hopefully an improvement. I'll try the same approach tomorrow and hope to see the same results. I think it's important that I pre-bolus as soon as I wake, any minimal activity (showering, brushing teeth etc.) seems to trigger an upswing in my BSL. I guess I could pre-bolus, snooze for 30mins and then get up?

My consultant has told me that I don't yet qualify for a pump, but I might plead the case the next time I'm in. My DSN had suggested that Levemir was the next step to try to counter these issues. However if I could demonstrate that my basal rate needed tweaking hour by hour, then that might help my case for a pump. I just want to try and get a solution to this sooner rather than waiting for my next hospital appointment!

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For me i require double the amount of insulin everyday with the first meal of the day. Then after that it goes back to normal insulin to carbs ratio. perhaps something similar with you?

Emck said:

A new element to add to this thread...

This morning I had to run my husband to the airport before 5am.

To try to counteract the above issues, I had a little bit of insulin (2u humalog). Cut to 3 hours later and my sugars have risen from 6.4 to 15.4!

Has anyone got any tips for this type of scenario? It's not a frequent occurrence, but I really can't stomach a full breakfast at 4am and I would be scared to drive with too much insulin on board. When I do take my insulin on waking now it is proving to be much more effective and can lead to hypos if I don't eat on time.

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I would say if you ate nothing at all, then that wouldn’t help that morning rise. Your body needs something, so that it isn’t worrying that you are not going to feed it. If nothing in stomach as you are forging ahead it will shoot out glucose from the liver. To prevent my morning rises I inject, eat a very small amount -10 carbs- and inject a couple of hours afterwards if the Libre shows I am still rising too much. In effect I pretend I am on a pump. I wouldn’t have dared do this before seeing the rises on the Libre.

Similar to Emck, I need double the insulin in the morning to cope with my liver dumping glucose when I first get up. Also if you have a stressful car journey that will also require more insulin. If you have a routine then just do some regular testing to understand how much insulin is required each morning. I tended to find my needs stayed fairly static.

Has anybody else tried a small protein snack eg a handful of nuts, pecans, cashews, macadamias if you can afford them. This stops my predawn phenomena delightfully.

I have exactly this problem but it runs in 1 or 2 week phases. So this morning I woke up on a 13 which is where it had been all night. Aware of the fact that morning humalog doses had not been doing much I injected 8 and waited an hour for breakfast. 20 minutes later I am at 17. Just like I had never injected anything!

Clayton1977 said:

I have exactly this problem but it runs in 1 or 2 week phases. So this morning I woke up on a 13 which is where it had been all night. Aware of the fact that morning humalog doses had not been doing much I injected 8 and waited an hour for breakfast. 20 minutes later I am at 17. Just like I had never injected anything!

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Hi and welcome to the thread! This is a bit of an old thread so I'm not sure if those who have posted will still be around. To help others, could you give a bit more information? Have you read the rest of this thread? Possible illness? Possible injection site if this is happening in 1 or 2 week phases, is it when you reach that same injection site again perhaps? Insulin maybe been left somewhere too hot/too cold? Have you tried ringing/emailing your diabetes team for advice? They might be able to help better as they will have a fuller picture. Is there any pattern you can see from the previous day if it is happening on a 1-2week basis? Eg the night before is the night you video call friends during lockdown so you're less active than usual so maybe need more basal (just for example!) Sorry for the many questions!

I've eventually come to the conclusion that the Dawn Phenomenom is going to remain the bane of my life. I have tried every conceivable way of trying to combat it and have finally realised that I just need to pump whatever it takes in order to keep my sugars from rising to sharply to sometimes silly levels for what I've actually eaten. It helps enormously having an automatic pump with close to real time blood sugars to help control my sugar levels.