Avoiding a night hypo

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MollyBolt

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I was diagnosed as type 1 nearly 2 weeks ago after an unpleasant DKA experience which landed me in hospital where I caught a bad chest infection too. My blood sugars have been fairly high since coming out and the diabetes team have been increasing my insulin (I started at 6u of Levemir morning and night and am now at 14u in the morning and 12u at night). My chest infection has started to get better with penicillin. Generally I wake up and have a fairly decent blood glucose number, having gone to bed with something high. So on Tuesday it was 22 at night and the first thing Wed it was10.2, Wed night it was 19.4, but Thurs morn it was 5.8, Thursday night it was 10 and then Friday morn it was 5.1. Last night though it was 7.4 (having had a day of what were low readings for me). I got paranoid I would have a hypo in the night, not wake up and then die so had two jelly babies to push my blood sugar up before sleep. I then got up in the night and was somewhat relieved to see I was at 10.

My wuestion is - was I right to worry and how good / bad a decision was the jelly babies? I know I will end up experiencing a hypo sometime but I’d rather my first wasn’t in the night and I suspect my insulin is too high because of the chest infection also pushing up my blood glucose. I am speaking to the diabetes team on Monday and have my first proper appt in hospital on Wed when I will get a freestyle. But keen to know that I should do if the same thing happens tonight /tomorrow.
 
Yes, it’s right to be concerned about hypos @MollyBolt especially nighttime ones. Do you have a Libre? Your chest infection and antibiotics will be complicating things but from what you’ve said, it looks like your nighttime Levemir dose is too high if it dropped you from 22 to 10.2.

You’ve probably already said elsewhere, but are you carb counting? What happens to your blood sugar before your evening meal and afterwards that means you’re high at bedtime? Are you high before the meal, then kind of stay the same, does it go up a lot after your meal, can you give some example figures?
 
Thanks for coming back to me. I’m not on a CGM yet - that should be given to me on Wednesday. I’ve also been told to go for fixed doses for my NovoRapid though that also will change on Wednesday I think. I have - on the advice of ppl on here - been reading about carb counting ahead of that, but have continued with the fixed doses since that’s what I was told to do.

Wednesday (chest infection at its height) numbers:
7.15am - 10.02
12 - 16.9
7.15pm - 20.4
10.15pm - 19.4

Thursday
7.15am - 5.8
12.45pm - 9.8
6.17pm - 14.8
10.40pm - 10

Friday
7.20am - 5.1
12.59pm - 7.3
6.32pm - 13
10.50pm - 7.4

Then I took 2 jelly babies and in the night I was 10.something and then at 8 this morning I was 7.9.

On Tuesday (when I was sick with the chest infection) I shifted to 14u Levemir in the morning and 12u at night at the suggestion of the diabetes team. This morning I reduced my Levemir to 12u and unless my numbers are sky high today I’ll keep it at that over the weekend. So mainly I’d like help on: what should I do if my numbers are low ish tonight (eg 7ish). Again take a jelly baby to be on the safe side? Obviously that is a very weird thing to say… I assume from what I’ve learned that basically my fixed doses aren’t sufficient and that’s why my numbers are shooting up so much during the day (and hopefully this will be resolved next week as I get shifted off fixed doses?).
 
I think you’re a bit stuck until the chest infection goes as you don’t want to increase your insulin, get better and then have too much insulin. It looks like your numbers have come down a bit overall so hopefully the chest infection is on its way out.

Fixed doses are a bit inflexible, but you can work with them by finding an amount of carbs that works and sticking to it for that same meal the next day. That is, keep the amount of carbs in your breakfast the same each day, likewise your lunch and evening meal.

Yes, if it were me, I’d have something to raise my blood sugar a little if I was 7 at night. I’d probably have some longer acting carbs as well as the jelly baby. I’d also set an alarm for 2am-ish or so to wake up and test. That provides reassurance as well as a chance to top up the carbs if needed.
 
@ MollyBolt, sorry you've got to wrestle with the chest infection as well as your new D diagnosis.

One "Golden Guidance" note that most of us appreciate is to get your basal right first. If your background insulin isn't doing what is needed well, then any bolus (=faster acting) insulin is trying to chase an imperfect basal. Since your current bolus is fixed it's a useful moment to focus on basal.
 
Thanks so much for coming back to me. The chest infection from my a&e neighbour was definitely an unwelcome addition (but I have been given penicillin so hopefully it’ll fix).

@Inka what would you suggest for a longer acting carb? 10pm feels a weird moment to crack open the beans and lentils?! (Obviously I know that’s not what you are suggesting but when I google long-acting carbs that’s what comes up.)

@proudtobeerratic - would love to get basal right, assume that won’t happen till the chest infection is gone…?
 
It’s early days for you, @MollyBolt , and most people would be only just getting to grips with their insulin regime, even without the added complication of an infection. I agree with @Inka , eat some carbs before you go to bed to be on the safe side, until you can discuss your overnight levels with your diabetes team. Longer acting carb doesn’t have to be lentils! You can slow down carb absorption by combining the carbs with fat or protein, so a couple of crackers with a slice of cheese on them would fit the bill too, or a slice of toast and butter.
 
MollyBolt said:
Thanks so much for coming back to me. The chest infection from my a&e neighbour was definitely an unwelcome addition (but I have been given penicillin so hopefully it’ll fix).

@Inka what would you suggest for a longer acting carb? 10pm feels a weird moment to crack open the beans and lentils?! (Obviously I know that’s not what you are suggesting but when I google long-acting carbs that’s what comes up.)

@proudtobeerratic - would love to get basal right, assume that won’t happen till the chest infection is gone…?
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Google can be a bit stupid :D I just mean longer-acting in comparison to glucose/jelly babies. So, maybe a plain digestive biscuit or two, or something similar. You could even have a flapjack bar, where you have a mix of longer acting and faster carbs. They’re about 18-20g carbs. Digestives are around 10g carbs. I tend to have biscuits because they’re simple, easy to snap in half in case I want 15g carbs not 10 or 20g carbs, and keep well.
 
MollyBolt said:
@Inka what would you suggest for a longer acting carb? 10pm feels a weird moment to crack open the beans and lentils?! (Obviously I know that’s not what you are suggesting but when I google long-acting carbs that’s what comes up.)
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Hi Molly. That was bad luck getting the infection on top of trying to cope with the diagnosis and infections do up sugar levels as others have said. Hopefully the penicillin will sort that out quickly. Then you can concentrate on getting the doses right for you. I'm still having to play around with mine as The Team haven't been able to get it right yet. I do what's right for me and my Nurse told me I was in charge so if I needed to increase/decrease then I can. I'm on Novamix30 and have slowly been increasing morning dose by 2 units every couple of days but decreased evening one by 1 unit and now down to 10 units.

Because my body, and I think yours, are used to running at high BGL lower readings can feel like hypos even when considered in 'normal' range I'm having to bring my averages down slowly. If I have a reading of below 10 before bed then I will have a piece of Hovis seeded brown bread toast (Other varieties are available) with butter and sometimes if around 8 put something nice extra on top. By doing that I have found I don't go too low, for me, during the night and this morning had my lowest morning reading for ages at 6.3.

Chin up. Things will only get better.
 
MollyBolt said:
@proudtobeerratic - would love to get basal right, assume that won’t happen till the chest infection is gone…?
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Yes I must admit I'm not sure how much the infection is in itsekf affecting how the basal is playing; after saying that I wondered if I had offered 'usable' help.

But at least with that idea in your mind, if your D Nurse makes suggestions that involve altering your basal do try to understand why. The logic or rationale? I spent 9 months flailing around with very direct support fortnightly from a Hospital based Diabetes Specialist Nurse (DSN) who from time to time told me to alter my basal - but never explained why and never indicated how important that was in getting to be more stable overall. Throughout that period my BG was on its own roller coaster from major lows and hypos to major highs; little in between. In hindsight it was as if I was a 70 yr old geriatric, destined to spend all day in front of the TV and with negligible future needs or plans. She was seriously adrift from my intentions!
 
Can’t really add more than what others have already said. Ride out the chest infection and once you are on the CGM that will alert you of any hypos overnight so I would say you wouldn’t need a snack before bed.
You are only a few weeks in so try not to panic and keep your head up
 
It might be helpful for you to know that as a rough guide, 2 jelly babies or 10g of carbs will raise your levels by about 3 mmols. Some people it will be more and some less, but that is a rough starting guide. So if you are on 7 at bedtime and you want to nudge it up to 10mmols, 10g of carbs should more or less get you there assuming your basal dose is correct and there is no active bolus (fast acting) in your system, so 4-5 hours after you last injected meal time insulin. I think at the moment until you get Libre and with the infection (hopefully) subsiding, you need to lean heavily on the side of caution because a drop from 20-10mmols overnight is very significant and indicates that your night time basal dose is too much. Ideally, when things are on an even keel, your basal should keep you more or less steady with a variation of up to 3mols, so dropping by 10 is a lot of extra basal. In your shoes I might be inclined to nudge levels up to 12 or or even 15 at bedtime until you get through this infection and get Libre.

It is also important to understand the limitations and quirks of Libre so I will post a link to a comprehensive list @helli made some time ago compiled from all our shared experiences of using Libre. Some of it may not make much sense to you until you start using it but important things to know are that they can be prone to false lows during the night if you lie on the arm with the sensor on it, referred to as "compression lows", so if you don't feel hypo when the alarm goes off, double check with a finger prick, always retest a true hypo, 15 mins after treatment with a finger prick because Libre will almost always show your levels have dropped lower 15 mins after treatment whereas a finger prick will usually show you recovering and Libre tends to exaggerate both highs and lows, so double check before making treatment decisions when above or below the 4-10 range. Anyway, I will link the "Limitations" post below...

forum.diabetes.org.uk

CGM limitations and precautions

Moderator Note: This helpful reply was copied from another thread as it details some of the commonly experienced limitations of continuous glucose sensors. My blood sugar has been in perfect range for days now, but although I haven't changed anything, I'm starting to get very short periods of...
forum.diabetes.org.uk forum.diabetes.org.uk
 
MollyBolt said:
@Inka what would you suggest for a longer acting carb? 10pm feels a weird moment to crack open the beans and lentils?! (Obviously I know that’s not what you are suggesting but when I google long-acting carbs that’s what comes up.)
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Breakfast cereal - I used to have a bedtime snack for ~25 years until I moved to basal-bolus, and even now I fall back to a bowl of cereal if I thought I might go low overnight (night out for example). Generally a decent mix of long and short acting carbs, plus protein and fat in the milk to make it all last longer (be absorbed slower). It does depend on which cereal you select though, Frosties are not the same as granola! (I'd go for the latter!)
 
MollyBolt said:
what would you suggest for a longer acting carb?
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On injections I used to use a digestive biscuit for my night time snack if needed. Partly because I still find them such a treat (although hard to stick to one!). An oatcake with cheese is another and probably better with the protein there to slow things down a bit.

Lots for you to manage at present with the infection as well. I hope things settle down soon for you and then you can work on dealing with D without the complication of illness alongside.
 
MollyBolt said:
You are all so great. I genuinely don’t know what I would do without this community. THANK YOU.
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How are things going so far this week @MollyBolt ?

Has your chest infection mostly cleared up now?
 
Thanks for asking! I was at the hospital today for a bunch of appointments, including getting my CGM. The CGM being a delightful addition to my life (notwithstanding recognising that it's not perfect) which makes me less afraid of night hypos. Chest infection not quite gone, but I've finished my penicillin so fingers crossed...

Because of the cyber attack on parts of the health system, I only just got my HbA1C which is now 102. Can anyone tell me the implications of this? Is it basically saying that my glucose has been high? And in time it should come down as I take insulin etc? What's normal?
 
Yes, 102 is high @MollyBolt but that’s to be expected. That will come down now you’re on insulin 🙂
 
So pleased you now have a CGM.... which system have you got? Good to hear that you understand about it's limitations. Also great to hear that your chest infection is nearly gone as that will make managing your levels easier. Fingers crossed you are entirely clear of it soon.

HbA1c is a measure of how many of your red blood cells have attracted molecules of glucose which stick to them. The more glucose in your blood, the more sticks to the red blood cells, but those cells only have a finite lifespan after which they die but new glucose free ones are being generated all the time to replace those that die. The average lifespan of a red blood cell is abut 3 months so the HbA1c result is an indication of how much glucose has been in your blood over the preceding 3 months. If you are relatively newly diagnosed or your diabetes has been poorly managed for a while or something has caused your BG levels to suddenly and dramatically increase then this result will be high but as your medicine (insulin in your case) starts to work and removes the glucose from your blood efficiently and stores it in the cells then that number will come down. When it is very high like yours, then it is better to reduce it slowly because the fragile tiny blood vessels in the eyes and extremities are vulnerable to sudden change in BG levels and BP. Usually you are given gradually lower targets for your BG level over a period of weeks until you are eventually aiming for "in range" results which are usually 4-10.
A normal HbA1c result for a non diabetic person is below 42 and 42-47 is sometimes referred to as the prediabetic range.... this is probably more relevant to Type 2 than Type 1. Above 47 is diabetic.
Obviously, no matter how low we get our HbA1c we are still diabetic and it is a delicate balancing act for those of us on insulin because we are at risk of hypos if we try to target too low a level, even in the prediabetic range of 42-47. My lowest result so far has been 43 but I was having too many hypos when I achieved that. My consultant is very happy with anything in the low 50s. That said, now that you have CGM, your "Time in Range" (TIR) is a more useful and clear indication of how well you are doing than HbA1c. For instance you could be very high some of the time and too low the rest of the time but end up with a good HbA1c result because it averages out those highs and lows, neither of which are good for you, or you could be achieving very even mid range levels the vast majority of the time and get that same good HbA1c.
There are guidelines for TIR which are a much truer reflection of your diabetes management and in my opinion are much more achievable than getting a good HbA1c.
Generally with a range set at 3.9-10 you are looking to try to achieve 70% of your time within that range and no more than 4% below 3.9. The app works all the time i range out so there are no complicated calculations to do. Once you have used your CGM for a few days it will start to generate TIR data and you will be able to access that and see how it changes over time as it will give you 7, 14, 30 and 90 days figures. If you can achieve that target of 70% in range you are doing brilliantly and you can give yourself a big pat on the back. It does however take practice and experience with insulin to learn how to balance and time things, so if you fall short of 70% don't worry, there are things you can do to improve that and we can help you work towards that goal or some of us find it relatively easy to surpass it, but working on that TIR and having it so easily accessible to be able to see how you are doing whenever you like is one of the huge benefit of CGM.
 
The CGM does also generate a "predicted HbA1c" which uses a formula to calculate it from average BG levels I believe but that is less useful as the formula isn't always accurate for everyone and most people find that it predicts lower than the actual result from a blood test by several mmols.
 
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