Can anyone explain this

[Spannerx]

Hi all,

I've been diagnosed since 2009 and for as long as I. Can remember I have always dropped blood sugar during the night before it completely spikes. I am on a high dosage of insulin my carb to unit ratio is about 1.5 units per gram of carbs. I am currently on novarapid for food each day and 60 units of tresiba at night. Here is an example of what happened this morning as you can see it's pretty controlled in the day and then when I sleep it starts to drop usually goes to 3.8 before spiking in the early hours in the morning.

I have no control over this as I am asleep. A pump is not an option due to the large quantities of insulin I have to take it would mean a pump change each day essentially I think I am on the right dosage of tresiba anymore and I will drop more than my usual 3.8/4 and it could be dangerous. This morning is quite extreme result where I caught it with over 20 usually I wake up before it gets that high to take a corrective dose of 14 units which see me throughout the rest of my sleep until I am able to get into my morning routine and then I am able to control again.

First picture is an extreme example from this morning which made me feel awful due to how high it went and then the second is my 90 day average to show I am fairly good at controlling when I can. It's just frustrating that I can't control while I am asleep.

 

[Inka]

Hi @Spannerx The dropping overnight might be normal. I find my blood sugar drops. I’m careful about not correcting at night or eating late. My blood sugar can also drop if I have a nap during the day, so I put all this down to my body relaxing when asleep and less stress hormones.

A rise in the morning is quite common and is called Dawn Phenomenon, where your body releases glucose ready to start the day, but you seem to have a massive rise!

Rude question, but how’s your weight? As you say, you’re on a lot of insulin so must have insulin resistance surely. Have you been given Metformin for this? Your ratio is 1:0.66g (I think - bit early for Maths!) That is, one unit only covers 0.66g of carbs.

Another thought - with such large doses, are your injection sites ok? Perhaps poor absorption is contributing? Do you split your Tresiba dose?

 

[rebrascora]

Hi and welcome to the forum. Just read your other post and love your positivity about how diabetes changed your outlook on life.

Can I ask if you double check that low at night with a finger prick because it looks like it might be a "compression low". This can happen when you lie on the sensor for length of time and it compresses the tissue under the sensor that the filament is sampling. That compression can lead to a false low reading. Frfom that graph it looks like you were about 10mmols and then suddenly dropped which is often a telltale sign of a compression low as your basal insulin (Tresiba) shouldn't drop you that suddenly. You can see the graph comes back up to about 10 and then there is a slight kink in the line as it rises further but at a slightly slower pace. I am guessing that you ate/drank some hypo treatment and that is then taking you up to 20+ but there may also be some Dawn Phenomenon incorporated into that rise.

What do you use as a hypo treatment?

The important thing is to always double check a low alarm during the night with a finger prick BG test before having any hypo treatment unless you feel obviously hypo. Once you know about compression lows you learn to think about which side you are lying on when the low alarm goes off and look at the graph to see if there is a sharp dip and ask yourself if you feel hypo and those 3 things can help you identify a false "compression low" without having to finger prick, but if in any doubt, do that finger prick test.

 

[Inka]

Another thought - could you try a concentrated insulin for your basal, thus reducing the volume you have to inject?

 

[Spannerx]

All good theories and thank you for your help.

On the 1st one I am classed as overweight and you could be right the injection sites don't feel hard or anything but the fact I am injecting such high doses In one area could cause a bit of insulin resistance for the high doses.

Point 2 is also very valid I had heard of the compression low for false readings happening at night. However often if I wake up I do have low symptoms for me the best way I describe my lows is like being drunk without the dopamine rush of being drunk and yes on this occasion I did correct it. I treated it on this occasion with about 8 fizzy sweets and then a chocolate bar on this occasion a golden whisper. Which could be the reason. I think it went higher than I usually catch it.

I will look to invest in another finger prick. To double check the low and how severe it is. As the one I did have got taken off my prescription and to be honest I work in IT so looking to drive it and technology forward and when the Libra was available on the NHS I jumped at the chance and it's changed how often I check my blood sugar so much that I now check my BG more than ever I just wish it existed 10 years ago more technology however brings this kind of data to my attention and wants me to know why.


Also point three my last consultancy meeting which was about this time last year their was a discussion on a more concentrated dose which. Will decrease the amount however they wanted more data. I suppose I have to wait for my next meeting to decide on this.

I think all three answers are valid and it could be a combination of the three working against me however as I said with access to the libre we now have more data. Than ever to focus on what is causing our BG to make drastic changes I am just looking for a reason why mine does this. I have heard of the dawn phononenom and it was discussed that it's possible I could have type 2 which is why more data was needed before prescribing a higher dosage.

 

[Inka]

Yes, possibly you overtreated that hypo @Spannerx Easily done at night! I stick to Dextro glucose tablets at night to stop overindulging. I find I need less hypo treatments at night.

 

[SimonP]

Another possibility is that you've got the wrong dose for your supper - dropping low then going high is a classic indicator of mismatched food absorption to bolus absorption. What are you eating for supper (what type of food, how many carbs, how much insulin in terms of your expected ratios i.e. are you dosing for the full carbs at the start, etc., and at what time?)

You may very well also have dawn phenomenon which causes your blood sugar to start to rise from the early hours due to various hormones kicking in and if you don't actually have enough bolus on board for a late/large supper it will push your BG even higher.

 

[Leadinglights]

There is no way you should have had the finger prick stuff taken off your prescription as even with the Libre you still need the ability to test manually.

 

[Robin]

Do you drive? It’s a DVLA requirement to carry a glucose monitor and strips at all times while driving, so you can check any sensor results , or have a back up in case of sensor failure. If you don’t drive, I hope at least you were asked before your strips were removed.
The instructions that come with the Libre also tell you to double check with a strip if you have any readings that seem 'off' so you shouldn’t have had them removed from your prescription.

 

[Tdm]

Yes, possibly you overtreated that hypo @Spannerx Easily done at night! I stick to Dextro glucose tablets at night to stop overindulging. I find I need less hypo treatments at night.

I'd say its an overtreated hypo...you just need 15g of fast acting carbs...and chocolate isn't recommended as a hypo tratment.

 

[helli]

@Spannerx like others that rise sounds like an overt treated hypo but you did say you chose that day as it was an exaggerated rise.
It is common to become insulin resistant when our BG is higher so I need more bolus to correct. What I often forget is that I am resistant to all insulin at that stage - both the bolus AND the basal - this means when my BG gets too high, my basal is no longer able to keep it steady so will continue to rise even if I took the correct correction bolus dose.

Looking at your other graph, it seems to me that your average overnight is not too bad. As said above, it is common to drop slightly during the night which you are seeing.

I would second (third?) the advice to get a finger prick meter to check lows and highs. Libre (and all other CGMs) have limitations, especially on lows and highs so you do need to be able to check. Even Abbott now recommend checking with a finger prick if your symptoms do not match the reading on the graphs.
I am very surprised the strips were removed from your prescription. That suggests your GP does not understand CGM technology which is very scary.

Another thought regarding pumping is whether you could use one for basal to manage your changing basal needs throughout the day and night but continue to bolus with an insulin pen. I have read of others doing this.

 

[everydayupsanddowns]

Sorry to hear your BGs are messing you about overnight @Spannerx

Hope you can find a few tweaks to your system, and adjustments and workarounds to reduce that drop-and-rise most of the time.

Let us know how you get on and whether you find something that works.

 

[rebrascora]

I think having a hypo treatment protocol is useful so that you are not tempted to overtreat them.

The standard advice is to double check a Libre low with a finger prick unless obviously hypo, eat 15g of fast acting carbs which is 3 jelly babies or 4 glucose tablets or most of a small carton of orange juice, wait 15 mins and retest with a finger prick. Do not rely on Libre for that follow up test as it will invariably show your levels have dropped even lower in that 15 mins period and you will be tempted to over treat. If the finger prick shows your levels have come up above 4 then you might consider 10g of slower acting carbs like a digestive biscuit. If the finger prick still shows you below 4 then you have another 15g of fast acting carbs.
Like @Inka generally I find I don't need much hypo treatment at night and usually I will just need 1 or possibly 2 jelly babies to bring me up. I almost never need 3 jelly babies anymore and almost never need follow up slower carbs either, so it is a question of adjusting your treatment protocol to what your body needs. It can also be helpful to set your low alarm somewhere above 4 (mine is set at 4.5) and if it goes off generally I will just have 1 jelly baby to nudge my levels up a bit. If I have missed the alarm and gone below 3.5 then usually I will have 2 jelly babies and that will do it. This works for me and prevents me from over treating and ending up on the glucose rollercoaster and as mentioned those high levels in the mid teens or 20s can lead to quite significant insulin resistance, so if you can prevent over treating hypos you can hopefully improve your insulin resistance.

It might also be worth setting a high alarm so that you can take action with a correction before you get that high.

 

[Spannerx]

Again thanks guys.

Here is the data from this morning I get woken up all the time with high BG symptoms banging headache busting for the loo. Good news is it shows no low the only tweak I made was to change my injection site location slightly up on my stomach from the bottom of my stomach.

I think the frustrating thing is my control throughout the day is fairly good rarely ever going above 10 and then night time hits I'm asleep so can't correct in time until I've woken up. My high glucose alarm is set to 14 however my phone is often set to vibrate only due to my job at which case the symptoms are often more effective at waking me up than my phone.

I think my next steps are to get a new BG finger prick metre to get an idea of a more accurate result when I wake up. The thing is however I know my symptoms very well and the symptoms do match up a lot with what the libre tells me. I tend to get high blood sugar symptoms kicking in after about 12.5 and then low BG symptoms at about 3.8 to what the libra says.and I need to do some research into basal Vs bolus so that I can come equipped for the right questions for my next appointment

The other thing is I know the libra is not for anyone however for me personally it's helped my control I have managed to bring my hba1c levels down to a pre diabetic level using the libra which is. A significant improvement from before that. Probably mainly because I would only do the finger prick anywhere between 2/4 times a day and the libra gives a constant data stream all be it with a slight time delay between 10/15 minutes.

I know if I can get this morning spike sorted then I can probably gain a full control and lower my average further which would mean that I can go about the rest of my life with almost no symptoms of high/low BG with exceptions of a cheat day when I fancy a Dominos/having a drink or when I'm about to come down with an illness.


Again thank you for your advice.

 

[rebrascora]

With that new information of no carbs to treat a low, that is looking like a huge Dawn Phenomenon.

Do you do any exercise? I find that exercise the previous day can reduce my DP significantly. It doesn't have to be anything overly exertive. A good brisk walk can do it.

It looks like your liver is releasing a whole lot more of it's stores on a morning than it needs to and along with the high insulin doses, they are both elements of Type 2 diabetes and I wonder if your initial diagnosis of Type 1 was correct or you have perhaps developed Type 2 as well as having Type 1. Have you considered trying some Type 2 strategies to see if you can reduce your insulin resistance and lose weight, as that should reduce your liver output and also reduce your large insulin doses, which are likely only going to make matters worse over time.

 

[helli]

Do you do any exercise? I find that exercise the previous day can reduce my DP significantly. It doesn't have to be anything overly exertive. A good brisk walk can do it.

I too find exercise the previous day can make a big difference to DP.
However, for me, it needs to be "intensive" exercise (enough to raise my heart rate) for at least 20 minutes to make any difference.
We all have different levels of fitness, so a walk maybe sufficient to raise one person's heart rate whereas someone else may need to go for a run.

@Spannerx If this rise is repeatable, I wonder if it is worthwhile setting an alarm at "silly o'clock" (about 3am looking at that graph) to give yourself a "pre-emptive correctional bolus". Obviously, be conservative and bear in mind that Libre (and all CGMs) have a tendency to over-egg high readings until you get a finger prick meter.

Thinking about finger pricking, I am concerned you have no meter.
<I know, I know. It is none of my business.>
In your position, I would get a cheap meter to tide me over until I can get one and strips from the GP.
This will give you a better insight into the height of those morning spikes.

I know if I can get this morning spike sorted then I can probably gain a full control and lower my average further which would mean that I can go about the rest of my life with almost no symptoms of high/low BG with exceptions of a cheat day when I fancy a Dominos/having a drink or when I'm about to come down with an illness.

Please remember there are many things that affect your BG. Some like food and insulin maybe under your control. But others such as illness and stress are harder to manage.
Therefore, I avoid the term "control" with regards to my diabetes. I prefer to think of it as "managing" my diabetes.
I applaud your desire to lower your average further but please remember to look after your mental health and avoid obsessing about bumps and troughs along the way.
I am not suggesting you give up on lowering your morning spike, especially when the symptoms of a high are so horrible, but the idea of "gaining full control" is unlikely to be possible.

The other thing to remember is that the recommended diet for someone with Type 1 diabetes is the same as the diet for someone without diabetes.
<As an aside, if you are eating a low carb diet, this may be contributing to your insulin resistance.>
Eating something "normal" like a pizza or having a drink is not "cheating". It is "living" with Type 1 diabetes.

Sorry, I will stand down from my soap box.
Feel free to respond with something like "Yes Mum!" 😉