Nocturnal Hypo's

[grainger]

Hey all,
Yet again I have more questions... sorry!

I have finally (yay) been referred to a hospital in London, Chelsea and Westminster which I'm happy to say seem really good.

However, I've been having a few problems recently with serious highs in the mornings.
Turns out I'm having nocturnal hypos and not waking up - this morning was a beauty of 18.2 😱. This has left me feeling really shaky today and if I'm honest pretty scared. I knew something was up and this was a possibility but I really thought I'd wake up?! (My only clue has been waking up really sweaty - sorry not a pleasant thought).

I'm reducing my background insulin evening dose tonight but I was wondering if anyone else has experienced this (without waking) and if they have any tips/advise etc?

Hope all is good with everyone!

H x

 

[DeusXM]

Best thing you can do is some middle-of-the-night testing to see how rapidly your BG is shifting. You'll then just need to adjust your basal accordingly. Once you get it sorted though, you'll feel a LOT better - it's never fun waking up with BGs that high at the best of times, and your body's procedure for fixing a hypo in your sleep will make you feel like you've got a bad hangover!

 

[Caroline]

Can't offer any advice but don't appologise for asking questions, every question is important.

 

[everydayupsanddowns]

How are you taking your levemir Grainger?

It might be worth taking in two doses (splitting) so that you can have less working overnight and more during the day of you need it.

 

[rachelha]

How are you taking your levemir Grainger?

It might be worth taking in two doses (splitting) so that you can have less working overnight and more during the day of you need it.

Grainger

I used to have a lot of problems with nocturnal hypos. I was put on to a split dose of levemir and had 12 units in the morning and just 4 in the evening. This helped a bit, but eventually I got a pump to help with this problem.

I was hypo when I woke up this morning which was a bit weird. I think I might have been low for a while as I had a dream which involved a big banquet of pastries and 3 birthday cakes!

 

[grainger]

I'm already on split dose at the moment -Levemir - 11 in the morning and 9 at night.
Reducing to either 7 or 5 tonight as suggested by the consultant today, we'll see what happens I guess.

I think the main thing that's freaking me out is the not waking up. Is that common?

 

[DeusXM]

Depends on how deep you sleep! I tend to wake up but I have slept through a few. Evidently you've enough glycogen in your liver to keep you safe. So it might not necessarily be common but it's also not rare, if you see what I mean.

However, you don't want to have a lot of 'nypos' where you don't wake up - it may mean your body gets used to having them and it's never good to lose your hypo awareness.

 

[bennyg70]

Def do some mid night testing too see whats going on. I do believe its not always the case but its certainly my nurses favourite to blame high morning readings on hypos during the night. I knew it wasnt the case for me, as when I have suffered hypos in the night I wake! I did some testing and it wasnt hypos. I then realised it was all down to what I ate the night before / My diet. Ie Id go to bed after eating a carb laden fat laden meal (Eaten at 7pm or 8) at say 11 or 12pm, then during sleepy time, the carbs would release as the fat had slowed them down so much till then and I would be high all night and wake up high.

Im not saying its not rebounds from hypos but do the testing first (At least a couple of nights worth) before changing anything!!

 

[bev]

Depends on how deep you sleep! I tend to wake up but I have slept through a few. Evidently you've enough glycogen in your liver to keep you safe. So it might not necessarily be common but it's also not rare, if you see what I mean.

However, you don't want to have a lot of 'nypos' where you don't wake up - it may mean your body gets used to having them and it's never good to lose your hypo awareness.

Hi DeusXM,

There have been many studies on this issue and it is not at all proven that the liver kicks in to 'save' you. Using CGM it has been shown that many people simply sleep through their hypo's and have very prolonged ones which if they hadnt been woken up could have been in danger of a fit or worse - and no signs of the liver kicking in for many in the studies.

Hi Grainger,

It always concerns me when a team talk about high BG's as being the results of a liver dump. How do they know? They dont. They are making an educated guess but that just isnt enough. It could be other reasons like DP (dawn phenomenon) or your LA running out. The only thing you can do I'm afraid is to do some night testing - we usually do 3am as this is when levels naturally drop and long enough after the last evening meal to be able to understand the readings. Unless you know what the reason is for chaotic levels you cant possibly rectify it. Have you ever used a CGM? If not you might find this a useful way of identifying what is happening throughout the night. Whilst it is good to test at random times - having a CGM gives you a much more detailed picture of what is going on every minute.🙂Bev

 

[Lauras87]

Are you knocking back your fast acting too?

I have the same problem but I do most times wake.

 

[Josco]

It turned out I had been having overnight hypos that I was not waking from for many months and I had not realised that it was them that was causing me to feel really ill for much of the next day. I did two hourly overnight profiles of my BGs and eventually I stopped taking Levermir at night as even just two units was dropping me too low. I recently started on a pump and have three different basal settings overnight (I have only been using a pump for two weeks) and that is helping to sort out the overnight drops although I still need more adjustments yet. I am doing two hourly profiles every night to try and get the basal rates right. But you are not alone in being unaware of overnight hypos. I can reassure you by saying that I am still here to tell the story 🙂

 

[DeusXM]

There have been many studies on this issue and it is not at all proven that the liver kicks in to 'save' you. Using CGM it has been shown that many people simply sleep through their hypo's and have very prolonged ones which if they hadnt been woken up could have been in danger of a fit or worse - and no signs of the liver kicking in for many in the studies.

I never said it was proven to happen in all people all the time. I'd like to see those studies, got a link? If this were the case, with people having very prolonged hypos, wouldn't they also have abnormally low A1Cs?

The only thing you can do I'm afraid is to do some night testing - we usually do 3am as this is when levels naturally drop and long enough after the last evening meal to be able to understand the readings. Unless you know what the reason is for chaotic levels you cant possibly rectify it.

But given you've already ruled out the possibility of hypos causing a Somogyi rebound, why then give this advice? If we accept that the liver doesn't dump glucose to recover from a hypo, then evidently by the logic you're using, the only possible solution is to take more insulin!

Unless of course we accept the possibility that actually, yes, the liver does kick in from time to time and dump a large amount of glucose. A rise from normal to 18 is a phenomenal amount of glucose and I think it would be extremely difficult to attribute this to either a failure of long-acting (very unlikely as the OP is on a split bolus) or dawn phenomenon. So where does this glucose magically appear from then, if it's not the liver either?

I completely agree that there needs to be some nighttime testing to see what's going on but I strongly suspect on the evidence presented so far, we're seeing plain ol' hypo rebounding. But yes, the final piece of the puzzle is a night time reading, although a CGMS is probably overkill. A couple of nights testing at 3-4 hourly intervals would probably be sufficient to see what's going on.

 

[megga]

I should do some testing overnight as stated and keep the data.
I had a problem with morning highs, i tried spliting my basel, then tried just having it in the morning, but nothing worked. My DSN then advised me to go on the pump.
It may be worth seeing your DSN with some B/S data, see if she thinks the pump could help you.

 

[bev]

I never said it was proven to happen in all people all the time. I'd like to see those studies, got a link?Yes - but cant get it at the moment as the person who has it is going through a family crisis - but will ask her when things are a little calmer. If this were the case, with people having very prolonged hypos, wouldn't they also have abnormally low A1Cs? Obviously the HBA1C would be impacted - but unless they were having one every single night then I doubt they would have an abnormal result.



But given you've already ruled out the possibility of hypos causing a Somogyi rebound, why then give this advice? Because you need to understand the full picture of what is going on! The OP needs to know when the rise is starting otherwise she has no idea whether it is DP or the LA running out or both. In the absence of a CGM the only way of knowing this is to test and I said 3am as a starting point and be led by the levels found. If we accept that the liver doesn't dump glucose to recover from a hypo, then evidently by the logic you're using, the only possible solution is to take more insulin! Clearly - but the OP would need to know when the rise starts and what the trigger is in order to rectify the levels.

Unless of course we accept the possibility that actually, yes, the liver does kick in from time to time and dump a large amount of glucose.A rise from normal to 18 is a phenomenal amount of glucose and I think it would be extremely difficult to attribute this to either a failure of long-acting (very unlikely as the OP is on a split bolus) or dawn phenomenon.I have seen this happen many times for both adults and children and for both reasons. So where does this glucose magically appear from then, if it's not the liver either? I have not said this never happens - the issue is that there is no real evidence to prove that it does and certainly no evidence to prove that it 'saves' people - otherwise how would so many Type 1's die in their sleep? 2 teenagers die per week sadly - clearly their livers arent 'saving' them.

I completely agree that there needs to be some nighttime testing to see what's going on but I strongly suspect on the evidence presented so far, we're seeing plain ol' hypo rebounding. Unless or until the OP tests through the night no-one can be certain what is really happening. But yes, the final piece of the puzzle is a night time reading, although a CGMS is probably overkill. The use of a CGM is not overkill at all - a CGM gives the full picture of what is really going on and unless the OP is up for testing every few minutes it makes it difficult to see the bigger picture of what is really going on. Gary Schnieder (think like a pancreas) describes lack of a CGM as trying to read a book but only reading the first line of every page (normal testing) - whereas with a CGM you get to read the whole page so understand the whole story. Many teams have a CGM available for temporary use for these sorts of issues. A couple of nights testing at 3-4 hourly intervals would probably be sufficient to see what's going on.

I will post the link once it is made available to me.🙂Bev


p.p.s Here is one of the links.

Arch Intern Med. 1984 Apr;144(4):781-7.

The Somogyi phenomenon. Sacred cow or bull?
http://www.ncbi.nlm.nih.gov/pubmed/6370162
Raskin P.

Abstract
Posthypoglycemic hyperglycemia (Somogyi phenomenon) occurs infrequently in insulin-treated diabetic patients. When it occurs it is often in children and adolescents, or patients with a short duration of diabetes. Marked hyperglycemia (greater than 220 mg/dL) after hypoglycemia results from a large meal to relieve the symptoms of hypoglycemia. Posthypoglycemic hyperglycemia correlates with falling plasma insulin levels, rather than increasing concentrations of counterregulatory hormones, whose secretion may be defective. Asymptomatic nocturnal hypoglycemia is common but subsequent fasting hyperglycemia is not necessarily the result of "rebound." More likely, fasting hyperglycemia is due to a falling predawn insulin level. Nocturnal hypoglycemia is dealt with by a readjustment in the timing and dose of insulin. The failure of the Somogyi phenomenon to occur puts insulin-dependent diabetic patients at increased risk to potential lethal consequences of nocturnal hypoglycemia.

PMID:

6370162

[PubMed - indexed for MEDLINE]

 

[DeusXM]

Because you need to understand the full picture of what is going on! The OP needs to know when the rise is starting otherwise she has no idea whether it is DP or the LA running out or both.

But either way, it makes no difference.

If it's caused by DP, then there isn't enough circulating insulin to meet her blood sugar requirements.

If it's her basal insulin running out, then there isn't circulating insulin to meet her blood sugar requirements.

Either way, the treatment regime is broadly the same.

I have not said this never happens - the issue is that there is no real evidence to prove that it does and certainly no evidence to prove that it 'saves' people - otherwise how would so many Type 1's die in their sleep? 2 teenagers die per week sadly - clearly their livers arent 'saving' them.

Where on earth is this statistic that 2 teenagers die in their sleep each week from nighttime hypoglycaemia? That is a heck of a lot of people. I am not in the slightest disputing that people can and do die in their sleep from hypos but every report I have ever read about when this happens always either seems to include alcohol or happens in an individual with a history of going in and out of hospital for both DKA and hypoglycaemic collapse. Obviously no-one should ever rely on their liver alone to save them from nighttime hypoglycaemia. Obviously everyone should work to ensure that they avoid it. But do you not agree that we should consider the possibility that liver dumps can and do happen and that this might be the cause of elevated blood sugar in the OP in the morning? I'm not saying it isn't DP or basal running out; I'm saying let's consider all the options instead of just blithely assuming one of these options isn't an option.

In any case, citing a report from 1984, before we had modern insulins or even modern blood sugar testing methods, is hardly compelling proof that the Somogyi effect cannot possibly happen. Particularly when you follow the links to the right of the page which lead to more recent reports which suggest the Somogyi effect definitely exists!

The use of a CGM is not overkill at all - a CGM gives the full picture of what is really going on and unless the OP is up for testing every few minutes it makes it difficult to see the bigger picture of what is really going on. Gary Schnieder (think like a pancreas) describes lack of a CGM as trying to read a book but only reading the first line of every page (normal testing) - whereas with a CGM you get to read the whole page so understand the whole story. Many teams have a CGM available for temporary use for these sorts of issues.

But why bother? You don't need to know what your BG is doing every minute of the night. You test before you go to bed, you test in the middle of the night, you test in the morning. That'll show you in the first instance if your BG is going up or down as a general trend. For instance, if you go to bed at 11pm at 6.5, a 3am test shows your BG is also 6.0, but then your morning at 8am is 18.0, then clearly something happens between 3 and 8am. So the next night you can then test at say 4am. Then you might find your BG is at 4.1...and you can infer a hypo must probably be taking place. Or perhaps it's at 12 - in which case it's either DP or the basal running out. Yes, a CGMS will give a more complete picture but given the option of either waiting for the clinic to sort this out, or just having a couple of nights of interrupted sleep, I'd take the interrupted sleep quicker option every time.

 

[bev]

But either way, it makes no difference.

If it's caused by DP, then there isn't enough circulating insulin to meet her blood sugar requirements.

If it's her basal insulin running out, then there isn't circulating insulin to meet her blood sugar requirements.

Either way, the treatment regime is broadly the same.

Testing throughout the night will help to understand whether it is DP or LA running out and the specific timing of this is paramount so the more tests the more information is provided. If its DP there may be a need for a pump - if LA there may be a need to alter the timings - so it is important and will make a difference to treatment.🙂



Where on earth is this statistic that 2 teenagers die in their sleep each week from nighttime hypoglycaemia? DUK. That is a heck of a lot of people. I am not in the slightest disputing that people can and do die in their sleep from hypos but every report I have ever read about when this happens always either seems to include alcohol or happens in an individual with a history of going in and out of hospital for both DKA and hypoglycaemic collapse. Obviously no-one should ever rely on their liver alone to save them from nighttime hypoglycaemia. This is the point I was trying to make - saying that the liver 'saves' people is not always an accurate reflection of what actually happens as this ability is mostly lost the longer one has diabetes. Obviously everyone should work to ensure that they avoid it. But do you not agree that we should consider the possibility that liver dumps can and do happen and that this might be the cause of elevated blood sugar in the OP in the morning? I'm not saying it isn't DP or basal running out; I'm saying let's consider all the options instead of just blithely assuming one of these options isn't an option. The best paediatric teams in the UK do not believe in somoghyi. If it existed why would Medtronic have made the VEO that cuts out if levels automatically rise?

In any case, citing a report from 1984, before we had modern insulins or even modern blood sugar testing methods, is hardly compelling proof that the Somogyi effect cannot possibly happen. Particularly when you follow the links to the right of the page which lead to more recent reports which suggest the Somogyi effect definitely exists! As the parent of a child who uses full-time CGMS it is clear to me that somogyi does not happen - at best levels will rise to 9ish - but not the 18's that is reported. There are hundreds of children on CGM's on the CWD list and their data shows no such effect either - we cant all be wrong?! The somogyi was named after its founder in 1938 and has not actually been proven with any studies to happen - the latest data does not support it.



But why bother? You don't need to know what your BG is doing every minute of the night. You test before you go to bed, you test in the middle of the night, you test in the morning. That'll show you in the first instance if your BG is going up or down as a general trend. For instance, if you go to bed at 11pm at 6.5, a 3am test shows your BG is also 6.0, but then your morning at 8am is 18.0, then clearly something happens between 3 and 8am. So the next night you can then test at say 4am. Then you might find your BG is at 4.1...and you can infer a hypo must probably be taking place. Or perhaps it's at 12 - in which case it's either DP or the basal running out. Yes, a CGMS will give a more complete picture but given the option of either waiting for the clinic to sort this out, or just having a couple of nights of interrupted sleep, I'd take the interrupted sleep quicker option every time.

My suggestion was for the OP to ask for a CGMS at clinic as a temporary measure - whilst also testing through the night. CGMS are not just for spotting one-off hypos/hypers - they are much more than that as they help with patterns and overall good control. Alex is on full-time sensors and we wouldnt do without them so unless you have used them full-time it is difficult for anyone to give an informed decision as to thier benefits.


It is your choice whether you believe it or not - but the latest thinking by the worlds experts in Type 1 (who I have met) do not believe it happens and refer to it as a 'myth'.🙂Bev

 

[Josco]

Can someone tell me what OP stands for please?! I know the other abbreviations. Thanks.

 

[Steff]

Can someone tell me what OP stands for please?! I know the other abbreviations. Thanks.

Original poster

 

[everydayupsanddowns]

Interesting discussion. Leaving night time aside... Is the suggestion that low blood glucose never results in a release of glycogen from the liver/muscles? I have read impassioned posts from parents before (following a DUK article about nocturnal hypos), but does the liver NEVER dump under CGM observation? I only ask because I believe I have seen it happen in myself (albeit without the benefit of CGM) and consequently would not basal test if I had been hypo that day. Indeed I think that was a Scheiner recommendation in the basal test sticky in the pumping section.

If it is thought to happen at some times of day, why not at night? Or is it just never thought to happen by some experts/specialists now?

Confused!

 

[HOBIE]

It isnt easy at times 😱 Sometimes i just dont want to know problems with T1. Good luck finding out 😉