Help with highs and lows

[FinnbarB]

I am a career for my mother who has been insulin dependant for over forty years and is now a young 80. I am looking for any help and/ or advice because over the last 6 weeks or so her blood sugar levels just don’t seem to make sense anymore!

She takes a daily dose of Insulatard (was 26units) just before breakfast. The problem she is having is that during the first part of the day from mid morning up to lunch, we are struggling to keep her from going low and having to eat lots of snacks to avoid this. Then after about an hour and a half after lunch it starts again and she has to keep topping up with snacks to prevent lows. However, at dinner time, she seems almost over sensitive to food and the smallest thing will send her blood glucose climbing steadily and it doesn’t stop till it reaches the low 20’s. This is clearly way out or proportion to the food she will have eaten. So we see this series of lows and then highs every day. If she is high at night it stays that way and then seems to have another boost around 4am so is even higher when she wakes around 6.45am. She has Actrapid which she can use for sick days but whenever she has taken this recently her blood sugar drops slightly but by the next morning is even higher.
This is causing a great deal of stress which is making it worse. Her GP has referred her to specialist nurses for advice and their initial thoughts are that she is taking too much Insulatard and want her to reduce it.
Does anyone have any ideas at all?. I should add that prior to this her control has always been quite good.

 

[Inka]

Hi @FinnbarB 🙂

Sorry your mother is having difficulties. That must be stressful and upsetting. Insulatard has a peak so maybe that’s what’s causing the lows a few hours after her injection? I wonder if she’d be better off reducing the Insulatard and possibly having a fast-acting meal-time insulin in addition to cover her food (even if not for every meal) You might also want to discuss whether the Insulatard injection could be moved to later in the day to help cover the night better.

There’s also the option of a change of insulin eg to Levemir, which allows you to split the dose (morning injection plus evening injection)Your mother could then have less Levemir in the morning and more in the evening if required. The 4am rise could be the Dawn Phenomenon (a surge of glucose to get ready for the day) or it could be the Insulatard running out.

It looks like her insulin regime would benefit from a bit of an overhaul.

But as you say this change is recent, I’d also want to find out why. Stress of lockdown? An illness or infection?

How often does she test her blood sugar? I don’t know why having Actrapid would make her higher the next day as that sounds strange. One possibility is she’s going low then having a rebound high, but that’s just a guess. It seems like she could definitely do with an expert eye looking over her regime.

 

[FinnbarB]

Hi @FinnbarB 🙂

Sorry your mother is having difficulties. That must be stressful and upsetting. Insulatard has a peak so maybe that’s what’s causing the lows a few hours after her injection? I wonder if she’d be better off reducing the Insulatard and possibly having a fast-acting meal-time insulin in addition to cover her food (even if not for every meal) You might also want to discuss whether the Insulatard injection could be moved to later in the day to help cover the night better.

There’s also the option of a change of insulin eg to Levemir, which allows you to split the dose (morning injection plus evening injection)Your mother could then have less Levemir in the morning and more in the evening if required. The 4am rise could be the Dawn Phenomenon (a surge of glucose to get ready for the day) or it could be the Insulatard running out.

It looks like her insulin regime would benefit from a bit of an overhaul.

But as you say this change is recent, I’d also want to find out why. Stress of lockdown? An illness or infection?

How often does she test her blood sugar? I don’t know why having Actrapid would make her higher the next day as that sounds strange. One possibility is she’s going low then having a rebound high, but that’s just a guess. It seems like she could definitely do with an expert eye looking over her regime.

Thank you Inka, you are right, my sisters and my mom are all getting stressed about it because we can’t see any logic and in the past on the whole we always have.
Mom has a Libre as of a couple of days ago and that has been very helpful in spotting the lows and preventing them. In the morning time however the levels just seem to plummet quickly and can catch us out. There does seem to be a trend that her levels rise more after she has had lows.
The thing we find baffling is that we can be tootling along steadily and one small thing like half a biscuit will set off this steady rise which seems unstoppable. The reaction and the subsequent rise from say 6.5 to 22 in about 5-6 hrs just can’t be related to the food item itself. Something else must be triggering.
We are hoping that this specialist nurse will be able to work through it and find a new regime as you say. She has prescribed a Novorapid pen to cover dinner but I’m not sure it will stop this big surge effect.
Thank you for your support and suggestions.

 

[SB2015]

Thank you Inka, you are right, my sisters and my mom are all getting stressed about it because we can’t see any logic and in the past on the whole we always have.
Mom has a Libre as of a couple of days ago and that has been very helpful in spotting the lows and preventing them. In the morning time however the levels just seem to plummet quickly and can catch us out. There does seem to be a trend that her levels rise more after she has had lows.
The thing we find baffling is that we can be tootling along steadily and one small thing like half a biscuit will set off this steady rise which seems unstoppable. The reaction and the subsequent rise from say 6.5 to 22 in about 5-6 hrs just can’t be related to the food item itself. Something else must be triggering.
We are hoping that this specialist nurse will be able to work through it and find a new regime as you say. She has prescribed a Novorapid pen to cover dinner but I’m not sure it will stop this big surge effect.
Thank you for your support and suggestions.

Hi @FinnbarB and welcome to the forum.

Having the Novorapid pen can certainly make things a lot easier, as this will deal with the rises after dinner. The amount of insulin is likely to depend on the amount of carbohydrates that your mum eats each evening. Is she used to counting these? If possible to get things settles it may be useful to try to stick to a similar number of carbs each evening for a while.

It may still be necessary to adjust the background insulin, and it would certainly be worth discussing a switch to Levemir which can then be split to a mornin and evening injection. This would enable her adjust one without effecting the other.

Keep in touch with the Specialist Nurse and keep asking questions on here.

 

[Inka]

The thing we find baffling is that we can be tootling along steadily and one small thing like half a biscuit will set off this steady rise which seems unstoppable. The reaction and the subsequent rise from say 6.5 to 22 in about 5-6 hrs just can’t be related to the food item itsel

Yes, that does sound strange. Either her basal isn’t working as it should, there’s some underlying cause eg infection, or she possibly has some insulin resistance. I definitely think her basal needs looking at. You could also get her injection sites looked at or, at least, described over the phone to the nurse in case they’re causing a strange pattern of insulin absorption.

She has my sympathy. It’s incredibly frustrating when your diabetes plays up. It throws you right off kilter. Hopefully, with a few tweaks and adjustments, she’ll be heading back on track soon.

 

[trophywench]

Insulatard is neither long acting nor short acting and 100% OK sometimes, if it happens to suit your body and your routine BUT - it's a very old fashioned type of insulin and does not adapt itself whatsoever when something changes - either in the way you happen to lead your life or, with your own body.

As we age - both of those things get more likely. Years ago even with no outside employment most housewives would be doing their housework, probably one day would be washing day, shopping on certain days, visit to library and paying the bills at that end of town on another, bed-changing and clean bedrooms another etc. She'll certainly be less active now generally even if she was like Eileen Fowler and still leading ladies keep fit sessions into ripe old age.

Bodily organs normally wear out as we age whether we acknowledge that or not - it isn't only a matter of finally accepting that ALL your body hair is grey, not only what's on your head! (and the former bothered me more than the latter, my dad told me with glee in my late teens when I first had head hair highlights professionally done that if I'd just waited another 40 years or so, I wouldn't have needed to pay for the privilege - cheeky bugger!)

It's going to be quite a shock to everyone's system to learn how to adjust to a more modern and flexible routine involving more jabs every day, but like others, I think you'll all need to adapt if you want to keep your mum for as long as you can. Thank heaven her doctor is enlisting specialist help! Use it.

Hope you get it sorted out soon and good luck!

 

[Pumper_Sue]

Here's a link to insulatard for you to read https://www.medicines.org.uk/emc/product/3848/smpc

You don't say if your mum is type 1 or two but either way the insulin being used does not last 24 hours and is for background use only.
So you need to talk to someone about splitting her insulin dose into two injections and also having some insulin to cover her meals.
The reason your mum is so low in the morning is because the dose is way to high and then the high blood sugars later in the day are because the insulin has run out.

 

[FinnbarB]

Here's a link to insulatard for you to read https://www.medicines.org.uk/emc/product/3848/smpc

You don't say if your mum is type 1 or two but either way the insulin being used does not last 24 hours and is for background use only.
So you need to talk to someone about splitting her insulin dose into two injections and also having some insulin to cover her meals.
The reason your mum is so low in the morning is because the dose is way to high and then the high blood sugars later in the day are because the insulin has run out.

Thank you! Moms sugar was so high this morning that she was quite unwell with ketones. We have got the novorapid and have been in constant touch with the diabetic specialist nurses. Fingers crossed they will now be able to adjust everything and get her back in balance.

 

[everydayupsanddowns]

Thank you! Moms sugar was so high this morning that she was quite unwell with ketones. We have got the novorapid and have been in constant touch with the diabetic specialist nurses. Fingers crossed they will now be able to adjust everything and get her back in balance.

Good to hear @FinnbarB

Like @Pumper_Sue, I suspected the single dose of insulatard might be acting too strongly early on, then running out later. The suggestion to split the insulatard into 2 doses to spread its action at a lower intensity is certainly a good one to put to the nurses.

Hopefully a more stable basal coverage will allow you and your Mum a little more flexibility, and to adjust the Novorapid doses to match her meals.

 

[FinnbarB]

Good to hear @FinnbarB

Like @Pumper_Sue, I suspected the single dose of insulatard might be acting too strongly early on, then running out later. The suggestion to split the insulatard into 2 doses to spread its action at a lower intensity is certainly a good one to put to the nurses.

Hopefully a more stable basal coverage will allow you and your Mum a little more flexibility, and to adjust the Novorapid doses to match her meals.

Hi,
The nurses have split the Insulatard as you say, one at 8am and the other at 8pm. Using the novorapid to deal with unexpected highs and meals. Fingers crossed we see things settle.

 

[Inka]

Good news @FinnbarB That should help a lot. It might take a few days to get the amounts right, but it sounds like your mother is now on the right path.

 

[trophywench]

Have you also been asked to encourage her to drink more, should she display ketones on the meter? Plain water is best for this TBH, but anything completely carb-free can help even if not ideal.

 

[FinnbarB]

Good news @FinnbarB That should help a lot. It might take a few days to get the amounts right, but it sounds like your mother is now on the right path.

Yes, thank you. It’s been a difficult time but we are feeling more positive now.

 

[FinnbarB]

Have you also been asked to encourage her to drink more, should she display ketones on the meter? Plain water is best for this TBH, but anything completely carb-free can help even if not ideal.

Yes, Mom was told to drink water to flush ketones and they are now negative again thankfully.