unmanageable nighttime highs

Carolin

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Am posting on our teenager's behalf, who has had diabetes for 1 year now and maintained very good control until about six weeks ago. Since then, the glucose readings are consistently high at night, no matter what he eats or when he eats; and no matter how much insulin he injects to correct those highs, or which ratio he uses, the readings do not reduce. Daytimes are fine.

He has (in consultation with his diabetes team): changed insulin cartridges; increased his nighttime Levemir, and the timing of his nighttime Levemir; changed his nighttime insulin ratio. Nothing makes any difference.

We are at a complete loss as to what is going on. Is there anything else he can try?

Perhaps also important: he tends to eat at around 7 or 8 pm, mainly (but not exclusively) slow(ish)-acting carbs, rarely more than 60 carbs. Levels stay between 5 and 6 and then rise rapidly at around midnight to >10 mmol, where they will stay (level) until breakfast. Insulin, if injected, works only after at least three hours, if at all. He wears no pump, but has a CGM...
 

Juicyj

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Hello @Carolin

Out of interest what does he eat in the evening ? A fatty meal can delay the carb absorption so will cause a high during the night. Also has his exercise levels increased at all ? When is he injecting levemir ? Has his sites been checked for lumps and is he rotating sites ? Also does he split his levemir injection ?

There's always a reason and if not changing basal to say tresiba which is long acting (36 hours approx) could also prove beneficial.
 

urbanracer

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I am experiencing similar problems at the moment. I eat at around 20:30 because that's when the missus gets home.

Last night I went to bed with glucose levels of 4.6. When I woke up they were 13.0. I am thinking that my bolus insulin is running out before the carbs kick in.

I have found that a virtually zero carb meal like an omelette seems to stop massive overnight rises.

The only other things I can suggest is a) talk to the doctors about a change of insulin to an intermediate, and b) eating earlier if possible.
 

Engineer88

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Sounds like a pump might help he might need varied basal rates - what rapid insulin is he using and what is its response time in the day?
 

Carolin

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Hi Juicyj,

no fatty meals, just wholemeal carbs (rice, pasta, other grains) and vegetables. Sometimes pulses. It doesn't really seem to matter what he eats - for example, a dinner of scrambled eggs and peppers has the same effect as, say, a plate of pasta. Exercise has stayed the same, he rotates injection sites (but injects in his arms, mainly) and he has moved the evening Levemir injection to 6 pm (from 10 pm; mornings at 6 am).

Re Tresiba - once risen (the rise takes about an hour), his levels remain flat throughout the night if he doesn't correct, I thought that suggested that the basal insulin was fine? Very happy to stand corrected.

And would a different basal insulin somehow make the short-acting insulin more effective (as mentioned above, corrections don't seem to work, or work extremely slowly, at night. All good during the day though)?
 

Carolin

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Hi Engineer 88 and urbanracer,

thanks for your suggestions. Re pumps - he isn't keen on sticking more than one device on his body, and on balance, the CGM seemed the more important option... but he uses Humalog and during the day, it takes about 15-20 minutes to take effect.

Re intermediate insulin - can this be combined with fast-acting insulin (i.e. Humalog during the day, and intermediate in the evening)? Am concerned about the potential loss of flexibility, but I guess something has to give...
 

Engineer88

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Hi Engineer 88 and urbanracer,

thanks for your suggestions. Re pumps - he isn't keen on sticking more than one device on his body, and on balance, the CGM seemed the more important option... but he uses Humalog and during the day, it takes about 15-20 minutes to take effect.

Re intermediate insulin - can this be combined with fast-acting insulin (i.e. Humalog during the day, and intermediate in the evening)? Am concerned about the potential loss of flexibility, but I guess something has to give...

How old is he? is it likely he is growing/hormonal?
 

Carolin

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16!

I had thought about it, but his team did not suggest that this could the reason.
 

urbanracer

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How old is he? is it likely he is growing/hormonal?

When I discussed my overnight rises with the hospital's diabetes nurse she also told me it was likely to be hormonal and I'm 57 now.

@Carolin - I notice that you'd written somewhere above that your son had changed has basal timings. When did he do this? Basal often takes a few days to effect any change.

I don't know how intermediates work with bolusing and I don't want to misdirect you so I'll not comment further. Maybe your doc' can help you out with this, there's no harm in asking.
 

Carolin

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Hello urbanracer,

thanks a a lot; he changed his basal timings two weeks ago.

Will ask about intermediates.
 

Circuspony

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I did a day of very low carb for all my meals so I didn't have to take novorapid. It showed that with just tresiba on board my BG levels stayed very consistent and I didn't get a big rise overnight.

So that proved to me it was food related. Next steps are to work out what food isn't matching my insulin profile at night. Might be worth a try.
 
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