Basal insulin and night hypos

[Northerner]

I'm trying to work out what to do about my basal insulin to avoid night hypos. I have an appointment with the consultant next week so I've been gathering info for her and would also like to know in advance what possible options are available to me.

I've been diagnosed for 7 months, and for quite a time my bedtime readings were in the double figures. Since improving my control, this has dropped so that it's generally within range - between 6 and 8. However, I've suspected that I'm having night hypos at that level. If it's below 8 I have a snack, but sometimes still wake up feeling c**p. I always wake up at 4.1-4.6.

I've tested during the night for the past few nights. One night it was 7.9 before bed, no snack that night, but then 3.7 at 3 am. I had a snack and woke up at 4.5. Last night it was 6.3 before bed so I had a weetabix. At 3 am it was 3.6, so again I had a snack and woke at 4.6. I guess if I hadn't had those 3 am snacks I would have gone really low, recovered, then felt c**p.

I'm obviously going low in the night even if I have something before bed. Is it because the lantus is working too quickly? What happens if I split the dose? I've tried reducing the dose from 20 to 18 (my pen works in 2's), but my fasting levels doubled. I don't really want to be going to bed with my readings in double figures, but even a snack before bed doesn't seem to be sufficient to prevent me from going low.

Any experiences or suggestions?

 

[sugarfreerach]

hi im really sorry i cant give advice but im intrigued how you have a hypo and not know? im interested, not getting at you 🙂

 

[randomange]

I've had similar problems with Lantus. The options I tried were splitting my dose, which unfortunately didn't work for me, and changing the time of my dose. I now take my Lantus at lunchtime, which apparently makes me a bit odd, but it works for me. I still drop a little bit during the night, but I only have to snack if it's below six, and even then only something that's about five carbs.

The other thing is, is that there is a pen which goes up in one unit increments. Maybe you could ask about that, and try 19 units? 🙂

 

[sofaraway]

You have a few options.

try and get a pen that works in 1 units increments it will give you more flexibility in dosing and for alot of people 1 unit makes a difference.

You could take your lantus in the morning so the peak you seem to be experiencing happens during the day, and not overnight. the only downside to this is that your lantus will be running out in the morning, if you expereincing dawn phenomenon then it could be worse because you've got less active insulin while you are waiting for the next dose to kick in. could end you up with high fasting or post breakfast readings.

Splitting your dose will give you a flatter profile and full 24 hour coverage, which could help prevent the night time hypos. With splitting you can play with the doses and timing. Downside is that you have to do an extra injection, that may or may not be an issue for you. The times that I've considered splitting I've decided against it because the morning dose would be difficult to give at a consistent time.

I tend to go to bed in double figures and wake up 4.5-7, but I can also go to bed at 7 and wake up in the same range. I don't have night hypos.

If you can't manage to get rid of the night hypos due tot he limitations of lantus then you could be a candidate for a pump if you are interested?

 

[aymes]

Presumably your numbers are ok during the day? One thing that could be worth a go would be to test the basal during the day by having a carb free lunch, if you stay pretty steady then your basal is likely to be about right but if you're dropping it could confirm that you need to drop the lantus down but maybe increase your ratios for your bolus?

 

[diagonall]

You need to do a basal test to find out exactly where you are this site gives good advice
http://www.diatribe.us/issues/13/learning-curve.php
Your options are change the timing of the Lantus/split the dose/use a different basal/ and ask for a pen which lets you increase/decrease your insulin by 1 unit at a time.
Just my 2 pence worth.
Make sure that you have it all writen down,graph form helps with readings no end as consultants love looking at pretty pictures

 

[emma1972]

Hi

Im having the same problems as you are. I have tea about 5-6pm take novorapid which in theory should be out of my system between 10-11pm. I test after 2 hrs, always below 10 usually 8-10. Then I take lantus at 8pm but at around 1-2am I drop to about 3.7. One night I decided to not take a snack and sit and read a book as I did feel ok at 3.7. An hour later I was back up to 4.5 and then 5.1 by morning. When I phoned my DSN she said that although 3.7 is low for a diabetic some normal ranges quote 3.5-6.0 so not really a serious problem.
I have the lantus solostar which is one unit increments but I havent noticed it make a difference. If I take 16 Units I wake up at 6-8mmol and if I take 17 units I can be 3.5-5.5 with nothing in between. I like a glass of wine or whisky before bedtime and Ive found that I need to drop my lantus by around 2 units per drink or I can go low despite eating.

For the first time in a long time I never went low yesterday but again last night about midnight I was down to 3.7 no symptoms other than tingly lips. Usually during the day I get the whole shakey trembly thing but not so when watching telly and doing little.

Does anyone have the answer, a snack at night doesnt seem to make any difference to the 1am low. Incidently is this when the lantus peaks some 5 hours later?

 

[Northerner]

hi im really sorry i cant give advice but im intrigued how you have a hypo and not know? im interested, not getting at you 🙂

I don't wake up, is the simple answer. Or maybe I wake up when I have recovered from it, feeling sweaty. Or perhaps I wake up, think I'm just tired, don't bother to test and just go back to sleep. I really don't know, but I know when I've had one the following day because I feel really headachy and sometimes nauseous.

During the day I generally get the full shakin' stevens, but never at night.

 

[Northerner]

I've had similar problems with Lantus. The options I tried were splitting my dose, which unfortunately didn't work for me, and changing the time of my dose. I now take my Lantus at lunchtime, which apparently makes me a bit odd, but it works for me. I still drop a little bit during the night, but I only have to snack if it's below six, and even then only something that's about five carbs.

The other thing is, is that there is a pen which goes up in one unit increments. Maybe you could ask about that, and try 19 units? 🙂

You won't be quite so odd if I decide that lunchtime lantus is right for me too!🙂 I'll ask about the one-unit pen at my appointment, I've never really liked the Autopen 24 - delivers the lantus too quickly for my liking!

 

[Northerner]

You have a few options.

try and get a pen that works in 1 units increments it will give you more flexibility in dosing and for alot of people 1 unit makes a difference.

You could take your lantus in the morning so the peak you seem to be experiencing happens during the day, and not overnight. the only downside to this is that your lantus will be running out in the morning, if you expereincing dawn phenomenon then it could be worse because you've got less active insulin while you are waiting for the next dose to kick in. could end you up with high fasting or post breakfast readings.

Splitting your dose will give you a flatter profile and full 24 hour coverage, which could help prevent the night time hypos. With splitting you can play with the doses and timing. Downside is that you have to do an extra injection, that may or may not be an issue for you. The times that I've considered splitting I've decided against it because the morning dose would be difficult to give at a consistent time.

I tend to go to bed in double figures and wake up 4.5-7, but I can also go to bed at 7 and wake up in the same range. I don't have night hypos.

If you can't manage to get rid of the night hypos due tot he limitations of lantus then you could be a candidate for a pump if you are interested?

Thanks Nikki. I don't think I'd qualify for a pump as my readings look too good. Also, I'm one of those that, despite all the assurances, don't fancy wearing something 24/7 as I would worry about it failing or dislodging. I have thought of trying the CGMS that you spoke of elsewhere - it may be that I'm only actually dropping to around 3.5 which is acceptable. It would be interesting to see how low I do actually go and what happens to those snacks!

 

[Freddie99]

Hi Northerner,

You might want to seriously consider a split dose of the long acting stuff. Last year my Levemir was put into two doses. It seems to be working I think. Control is better than it was last year.
You might also want to consider asking about different insulins. My own is Levemir, I have been on lantus but I cannot recall what that was like. Perhaps Lantus is not the right one for you, each insulin has its own characteristics. However, I am not a medic so it can't really pass judgement on this. It would be a much safer option to ask your doctor.

Tom H

 

[Northerner]

Presumably your numbers are ok during the day? One thing that could be worth a go would be to test the basal during the day by having a carb free lunch, if you stay pretty steady then your basal is likely to be about right but if you're dropping it could confirm that you need to drop the lantus down but maybe increase your ratios for your bolus?

My numbers are fine during the day, although quite tight. I did have an unexpected succession of hypos a few days ago, but now back to normal. I think the problem has to be that the lantus starts to peak (which I know it shouldn't do) a couple of hours after injecting, then has been fully absorbed before the 24 hours is up (probably around 20-22 hours, hence my higher bedtime 'fasting' readings). Good idea about the carb-free lunch - thanks!🙂

 

[Northerner]

Hi Northerner,

You might want to seriously consider a split dose of the long acting stuff. Last year my Levemir was put into two doses. It seems to be working I think. Control is better than it was last year.
You might also want to consider asking about different insulins. My own is Levemir, I have been on lantus but I cannot recall what that was like. Perhaps Lantus is not the right one for you, each insulin has its own characteristics. However, I am not a medic so it can't really pass judgement on this. It would be a much safer option to ask your doctor.

Tom H

Thanks Tom - the more things I know about when I see the consultant, the better! Does levemir sting at all?

 

[Northerner]

You need to do a basal test to find out exactly where you are this site gives good advice
http://www.diatribe.us/issues/13/learning-curve.php
Your options are change the timing of the Lantus/split the dose/use a different basal/ and ask for a pen which lets you increase/decrease your insulin by 1 unit at a time.
Just my 2 pence worth.
Make sure that you have it all writen down,graph form helps with readings no end as consultants love looking at pretty pictures

Thanks Sue, from visiting the site I see how much better a pump is for 'fine-tuning' - as opposed to the 'one-size-fits-all' of long-acting insulin like lantus, which I can only think is bound to vary according to the individual, like most things where diabetes is concerned!

 

[Freddie99]

Hi Northerner,

I've never noticed any stinging with Levemir. Positively a joy to give myself.

Tom H

 

[diagonall]

Thanks Nikki. I don't think I'd qualify for a pump as my readings look too good. Also, I'm one of those that, despite all the assurances, don't fancy wearing something 24/7 as I would worry about it failing or dislodging. I have thought of trying the CGMS that you spoke of elsewhere - it may be that I'm only actually dropping to around 3.5 which is acceptable. It would be interesting to see how low I do actually go and what happens to those snacks!

Thanks Sue, from visiting the site I see how much better a pump is for 'fine-tuning' - as opposed to the 'one-size-fits-all' of long-acting insulin like lantus, which I can only think is bound to vary according to the individual, like most things where diabetes is concerned!

Hi Northerner, it does not matter what your A1c is to qualify for a pump. Hypos are the key to gaining a pump. Reread the guidelines 🙂
You wont notice the pump after a few days it just sits in your pocket and bleeps if it wants attention. If a pump fails it lets you know. (this is very rare) Dislodging can be a problem only if you do not tape the cannula. I use a bit of MEFIX tape and can say even on the farm I have never had the cannula pulled out on the odd occassion I have caught the tube.
As you say everyone is different and the basal insulin's can not and do not suit everyone. I have 11 basal settings in my pump to match my needs.
Sue

 

[Jenny]

Me too!

Hmmm seems like this is a lantus problem - I have never been convinced that an insulin can deliver a constant rate for 24 hours with one shot... but that is just my opinion! I had a terrible problem with dawn phenomenon for years and was advised to split my lantus - taking a larger dosage in the am and a smaller one at night - which solved the problem and has been great for years. I am now pregnant and have been having night hypo's for 31/2 months! Sometimes as low as 1.3 and they occur anywhere between 1 am and 4am. I have made an effort to go to bed with a highish reading 8 or above and it had no effect. With advice from doc I have reduced and reduced my nighttime insulin, but still to no effect. The last two nights I have stopped it completely.. am waiting to see the outcome. Though last night I did go hypo again. It is exhausting! I really think this is all tied up with the pregnancy and I am taking extra care over my control - normally I am not bad - but am being much tighter now! It is annoying isn't it - and so much trial and error. I would suggest trying the split - like I say it worked for me brilliantly until late! Doctors sometimes don't believe in doing this - but you just have to push for it. I would love a pump - but no chance of changing at the mo! Good luck - I hope you resolve it.

 

[Northerner]

Hmmm seems like this is a lantus problem - I have never been convinced that an insulin can deliver a constant rate for 24 hours with one shot... but that is just my opinion! I had a terrible problem with dawn phenomenon for years and was advised to split my lantus - taking a larger dosage in the am and a smaller one at night - which solved the problem and has been great for years. I am now pregnant and have been having night hypo's for 31/2 months! Sometimes as low as 1.3 and they occur anywhere between 1 am and 4am. I have made an effort to go to bed with a highish reading 8 or above and it had no effect. With advice from doc I have reduced and reduced my nighttime insulin, but still to no effect. The last two nights I have stopped it completely.. am waiting to see the outcome. Though last night I did go hypo again. It is exhausting! I really think this is all tied up with the pregnancy and I am taking extra care over my control - normally I am not bad - but am being much tighter now! It is annoying isn't it - and so much trial and error. I would suggest trying the split - like I say it worked for me brilliantly until late! Doctors sometimes don't believe in doing this - but you just have to push for it. I would love a pump - but no chance of changing at the mo! Good luck - I hope you resolve it.

Thanks Jenny - I don't think I can blame pregnancy for my problems! It must be very frustrating to have these problems after years of successful control - but of course, you have a very special reason to put up with it - many congratulations! I hope that things settle down for you soon.

 

[Northerner]

Well, my before bed reading was 4.6 last night so I had a slice of toast. Woke up at 3 am and reading was 6.3 so I didn't eat anything. On waking this morning reading was 5.3.

This is not what I'd expect from my experience the other night when the readings went 6.3 (weetabix), 3.6 (jelly baby and cereal bar), 4.6 on waking.

Times of going to bed and waking were the same, so I can only think that my 'liver dump' was at a different time. I guess I'd have to do the test that Sue suggests to find out what's really happening. However, that entails taking readings at hourly intervals through the night - for me that would mean a night with no sleep as it takes me ages to get off to sleep again and I'd have just fallen asleep in time for the next reading! The alternative would be the CGMS, might ask about that on Tuesday.

 

[Freddie99]

Northerner,

The results that a CGMS will give you are very useful indeed. I had one ove three days last October. Despite it being up and running over the weekend of my eighteenth birthday the results were a little unusual but it was well worth it.
However, I did find having that thing plugged into me a rather uncomfortable experience. Despite this the results that I got were worth the couple of days pain.

Tom H