Basal Insulin low or dawn effect?

[Mbabazi]

Hi all.

I have a question. I suspect that my basal may be low for my needs but I wanted to ask what you all thought. I've observed a trend where my bgs will go down at some point in the night but then start to rise as i wake and continue to rise. I know I have the dawn effect and always have but I'm wondering how one knows whether it's that or the basal being low. Take a look at my graphs from when I woke a little before 6am. The dip in the morning is from a short walk but I'm still within the range of 8. I haven't had breakfast yet and so no bolus and are only due for my basal in another hour plus. Any thoughts would be highly appreciated.

 

[helli]

The way I look at my overnight graphs to determine the cause of highs is
- if it shows a BG rise from before I went to bed and then plateaus, It is likely, I did not have enough bolus with my evening meal. The rise may be some time after my meal if it was something fatty. I find pasta has this affect.
- if it shows a continuous rise all through the night, it is likely to be too little basal.
- if it shows a flattish line which then starts rising in the early morning, it is likely to be dawn phenomenon.

So, I think (but I am not medically qualified), you are seeing DP.
I find my BG will continue to rise until I eat in the morning as my liver thinks I am starving myself so continues the glucose dump. Therefore, you may find eating as soon as you get up may halt the rise.

There is another possibility which depends upon the basal insulin you take. You mentioned that you are due your basal in the next hour. I forget which basal you take but if it is one that you take once a day, it is possible that it is not lasting a full 24 hours. Before I started pumping, I took Lantus which lasted about 21 hours for me. I took it in the evening so I could "fill in" the gap with a bolus which is not possible in the morning.
If you are taking twice daily Levemir or a longer acting basal like Tresiba, this is unlikely.

 

[Inka]

Similarly to @helli i find delaying breakfast can cause a stubborn rise @Mbabazi Your blood sugar looks quite stable overnight but I too wonder what basal you’re taking as that can make a difference.

 

[nonethewiser]

Another who finds bg will continue to rise if don't eat breakfast.

 

[rebrascora]

Looking at those graphs your overnight levels look really stable and you only have a slight rise in the morning. If you take your basal in the morning I would bring it forward and inject it as soon as you wake up whilst still in bed and that will allow it to start acting as your levels are rising. I also find I need to supplement my basal on a morning with 1.5-2 units of fast acting insulin, but I have a much more pronounced rise than you as mine can shoot up 6mmols in the first hour after I get out of bed. I don't consider that part of my breakfast ratio because I need it whether I am having breakfast or not, it is just a bit of a helping hand with that surge of glucose from my liver on a morning until my basal insulin get going. I am not suggesting you need that at the moment but it may be a tactic that you need later if you start to see a bigger rise and if you are going out for a walk, then it would not be a good idea because exercise can make bolus insulin much more effective, but I think from those graphs, your basal dose looks to be holding you nice and steady, but injecting your basal as soon as you wake up may help prevent that slight rise or at least keep a lid on it.... but to some extent it is dependent on the basal insulin you use.

 

[Mbabazi]

Hey everyone. Thank you for the advice. I only just caught up on all of it now but was meaning to share some follow up graphs.

I will implement moving my basal earlier in the day, it may be that as it nears the 24 hour mark, it starts to work less and that doesn't help with the dawn phenomenon. I can also try to have blast earlier and therefore take mealtime insulin then which might help.

I wanted to share some daytime graphs where I've observed that I will bolus for a meal and will have some rise from it and then lower numbers and then a rise again 3 or so hours after that meal.

Take forecastle this graph now. I ate dinner around 7pm and too meal time insulin for it and indeed my numbers started to come down and then back up after 3 ish hours. This also hapenned after breakfast which I had around 9.30. Do you see the trend I'm seeing? I feel that because I try to calculate my mealtime insulin, if I manage to go back down after a meal, I should stay down. I'm considering increasing my bolus even by 2 units to see of thia trend improves. Thought?

 

[Mbabazi]

The way I look at my overnight graphs to determine the cause of highs is
- if it shows a BG rise from before I went to bed and then plateaus, It is likely, I did not have enough bolus with my evening meal. The rise may be some time after my meal if it was something fatty. I find pasta has this affect.
- if it shows a continuous rise all through the night, it is likely to be too little basal.
- if it shows a flattish line which then starts rising in the early morning, it is likely to be dawn phenomenon.

So, I think (but I am not medically qualified), you are seeing DP.
I find my BG will continue to rise until I eat in the morning as my liver thinks I am starving myself so continues the glucose dump. Therefore, you may find eating as soon as you get up may halt the rise.

There is another possibility which depends upon the basal insulin you take. You mentioned that you are due your basal in the next hour. I forget which basal you take but if it is one that you take once a day, it is possible that it is not lasting a full 24 hours. Before I started pumping, I took Lantus which lasted about 21 hours for me. I took it in the evening so I could "fill in" the gap with a bolus which is not possible in the morning.
If you are taking twice daily Levemir or a longer acting basal like Tresiba, this is unlikely.

I'm taking Lantus and only once a day. They've just changed me to trojeo but I have a lnatus pen to finish this week. I think your criteria for making that judgement is spot on. I feel I have both the dawn effect and the basal dose issue.

 

[rebrascora]

What was your evening meal and what ratio are you using or are you on fixed meal time doses? That sharp rise about 9-10pm looks like you didn't have enough insulin. I would be wary of increasing a bolus by 2units. Try just one and see how that works out. Always best to err on the side of caution.

Your morning graph looks remarkably stable for breakfast time. That is normally when people get big spikes. I used to go up to 15 every morning in the early days/weeks/months and then come crashing back down 2-3 hours later. Do you exercise after breakfast? Just wondering if that may be helping?

 

[Mbabazi]

What was your evening meal and what ratio are you using or are you on fixed meal time doses? That sharp rise about 9-10pm looks like you didn't have enough insulin. I would be wary of increasing a bolus by 2units. Try just one and see how that works out. Always best to err on the side of caution.

Your morning graph looks remarkably stable for breakfast time. That is normally when people get big spikes. I used to go up to 15 every morning in the early days/weeks/months and then come crashing back down 2-3 hours later. Do you exercise after breakfast? Just wondering if that may be helping?

Sorry I meant to increase my basal by 2 units. Not bolus. I exercise in the morning before breakfast and then when I'm working from the library like yesterday will walk 20 minutes there so that's what I did after breakfast. That's why I was suprosed that it later started to rise before lunch. The exercise in the morning also helps with the dawn rises but only slightly for me. I'm working on a 1 to 15 ratio but the nurse said we can adjust in time. How long did it typically take to get a good sense of your ratio and does that change and why? Sometimes even when I eat the exact same thing at the same time, I'll have remarkably different results

 

[rebrascora]

You are doing absolutely brilliantly, particularly at this early stage and there is nothing to worry about on those graphs at all. You are aiming to achieve 70% time in range not 100%. I think a lot of us like to do better than 70% here on the forum, where we are perhaps a bit more motivated and focused than the majority of Type 1s and perhaps there is an element of competitiveness, not necessarily with others but just with ourselves to keep improving our TIR (I can be guilty of this), but as long as you are achieving 70% you are doing amazingly well, so do be aware that you can get too obsessive about ironing out every spike at a cost to your everyday life and mental health. Don't push yourself too hard, because you are in this for the long haul and it is very easy to get burnt out.
Personally I don't see anything on that graph which suggests an increase in basal is needed so I would be cautious about increasing it by 2 units.
If the rise in the evening towards bedtime is a common feature then you might want to adjust your evening ratio a bit.... maybe 1:12 or something, but if that was a one off then don't worry about it. You should only ever adjust things when you see a trend. Sometimes the "daily patterns" feature on the Libre can help you identify trends.

 

[Mbabazi]

You are doing absolutely brilliantly, particularly at this early stage and there is nothing to worry about on those graphs at all. You are aiming to achieve 70% time in range not 100%. I think a lot of us like to do better than 70% here on the forum, where we are perhaps a bit more motivated and focused than the majority of Type 1s and perhaps there is an element of competitiveness, not necessarily with others but just with ourselves to keep improving our TIR (I can be guilty of this), but as long as you are achieving 70% you are doing amazingly well, so do be aware that you can get too obsessive about ironing out every spike at a cost to your everyday life and mental health. Don't push yourself too hard, because you are in this for the long haul and it is very easy to get burnt out.
Personally I don't see anything on that graph which suggests an increase in basal is needed so I would be cautious about increasing it by 2 units.
If the rise in the evening towards bedtime is a common feature then you might want to adjust your evening ratio a bit.... maybe 1:12 or something, but if that was a one off then don't worry about it. You should only ever adjust things when you see a trend. Sometimes the "daily patterns" feature on the Libre can help you identify trends.

Thank you for this sound advice

 

[everydayupsanddowns]

I think @Robin describes her overnight levels as a ‘washing line’, dipping down in the middle and rising at both ends.

I have to add extra insulin to my breakfast carb count (about a unit) to counter the rise of ‘foot on the floor’ when I get out of bed. A stronger breakfast ratio doesn’t work, as my FOTF is fairly constant and doesn’t scale if I have a bigger or smaller breakfast.

Hope you find a strategy that works for you. 🙂

 

[Robin]

I think @Robin describes her overnight levels as a ‘washing line’, dipping down in the middle and rising at both ends.

I do indeed, and when I get a graph this shape, I usually reckon I’ve got my basal tweaked as best as I can. Any increase in basal and I get a flatter line in the morning, but whoosh down the minute my head hits the pillow, a decrease in basal and I get a nice flat line when I go to bed, but a steep climb up into double figures in the morning. So the 'washing line' is the best compromise.
I also need a couple of units extra with my breakfast, which like @everydayupsanddowns , I take as a constant, whatever I’m having for breakfast, rather than tweaking my ratio, which wouldn’t work.