Lantus and high morning blood sugar levels.

[mark1975]

Hi,

I am taking 14 units of Lantus every evening at the same time (8pm).

If my bedtime levels are in the 5 to 7 range then my morning levels are in the 9 to 14 range (last night they were 6.8 before bed then 13.9 when I woke up).

If I increase the Lantus all that seems to happen is I have night time hypos around 1am. If I decrease Lantus then my morning levels go even higher.

I tried taking Lantus in the mornings for a few weeks, I had no night time hypos and my daytime background levels were OK but my levels in the morning were around 12 to 18.

So I have moved Lantus back to the evening.

The only thing that seems to help is eating a big snack before I go to bed so before bed levels are around 10 but obviously this is not ideal and it doesn't work all the time.

On the odd occasion when my morning levels are OK then they tend to be fine for the rest of the day.

I have been thinking that splitting my Lantus may help but I'm not sure.

My last few hba1c's have been in the 7.4 to 7.8 range.

I hope all this makes sense!!

 

[DeusXM]

It sounds like you might be suffering from rather pronounced Dawn Phenomenon.

Assuming this is the case, are you eating breakfast in the mornings? I find getting something carby in your stomach first thing in the morning trains my liver to calm down and not panic first thing - takes about a couple of weeks to get going but it might work.

Other options are going for a protein snack before going to bed. This won't spike your BGs but ensure you've a constant slow supply of glucose to keep you going. This is sorta feeding the insulin though, which isn't good.

A more left-field option is booze. Alcohol distracts your liver from putting out glucose and a nice glass of whiskey or red wine might just do the trick - you'll need to keep an eye on your levels though the first few times you do this. If you're having 'nypos' from increasing your Lantus, you don't want to exacerbate the situation by keeping your liver preoccupied.

 

[Northerner]

How soon after rising are you eating and injecting? I found out a while ago that if I tested as soon as I rose I would be fine, but if I then didn't have breakfast for an hour my levels had risen considerably. As DeusXM suggests, this is when your liver gives you a boost in the morning due to the release of cortisol as you wake. People also tend to be more insulin resistant in the mornings and become more sensitive as the day progresses and more activity is undertaken.

My solution was to inject as soon as I wake and then eat maybe 15-45 minutes after, seems to work well. Overnight and the rest of the day were fine, although my mealtime ratios did reduce i.e. I needed less insulin per 10g carbs as the day progressed as I was obviously covering to some extent for the inadequate lantus. Couldn't split it due to only being on 1 unit, and then no units recently!

 

[mark1975]

Northerner & DeusXM - I take my Humalog and eat my breakfast as soon as I get up.

DeusXM - A small glass of red wine does keep my morning levels ok but any more than one glass or any other types of alcohol other than spirits don't make any difference.

If I take a correction dose of Humalog at breakfast to get my 2 hour post breakfast levels down then 3-4 hours later my levels will be too low.

It always seems like I'm chasing my levels when they start off high and whatever I do my body does the opposite!

 

[Northerner]

Mark, have you ever considered/been considered for a pump? Sounds like the different basal rates you can set up would be helpful in your situation.

 

[mark1975]

Hi Northerner,

I have thought about a pump and would consider this option.

However my diabetes is managed by my GP which is far from ideal, I am seen by the clinic at my hospital occasionally but sometimes not for 8 to 12 months at a time and this is only because I mentioned the problems I have been having with my control to the eye clinic who referred me to the diabetes clinic.

I have spoken to my local NHS trust about my care and they told me that it is their policy that my care is managed by my GP.....

 

[Medusa]

grrr.... although i do believe if you can get on the dafne course it will help your case for a pump....

 

[Northerner]

Hi Northerner,

I have thought about a pump and would consider this option.

However my diabetes is managed by my GP which is far from ideal, I am seen by the clinic at my hospital occasionally but sometimes not for 8 to 12 months at a time and this is only because I mentioned the problems I have been having with my control to the eye clinic who referred me to the diabetes clinic.

I have spoken to my local NHS trust about my care and they told me that it is their policy that my care is managed by my GP.....

For a Type 1 I believe this is wrong, your GP is unlikely to have the specialist knowledge of a consultant and your practise nurse will certainly not be a trained DSN. I would tell your GP you wish to be referred to a diabetes clinic for all your diabetes care and have regular access to a DSN. If this doesn't work then contact PALS at http://www.pals.nhs.uk/

 

[trophywench]

What happens if you move the timing of your jab nearer bedtime? - assuming you don't go to bed at 8pm LOL. Thing is, 5 hours is just about Lantus 'peak activity time - no way is the action 'flat' LOL

So If you could move the peak of it nearer to 'rising' time, you might not need to do anything any more complicated.

Do you ever stick the alarm clock on for in the middle of the night to see what your BG is doing whilst you are asleep? I think doing that at a few different times on different days, might give you a clue.

 

[Emmal31]

I had the exact same problem a while ago so I split my lantus and since then I don't really have night hypo's anymore.

 

[everydayupsanddowns]

Just another thing to check... do you have a 1u Lantus pen? I was always quite sensitive to dose tweaks, and 1u up of down made a disproportionate difference in terms of the amount of rapid that was then required/not required to correct a basal overflow/shortfall (after it had settled in for a few days).

Agree with others though that dose timing and/or splits can make a big difference to Lantus. Alternatively Levemir might be worth a try (more suited to splitting as its activity tends to be shorter). And pump would sort out DP if it is that.

 

[mark1975]

Thanks for all the help - I really appreciate it.

Here's an update:

My Lantus pen does increase by 1 unit.

I have moved my Lantus to 10pm from 8pm to see if that makes any difference.

Levels around 2am to 3am vary widely with no apparent pattern.

Levels from the last few days:

Monday before bed - 6.5 (14u Lantus, no supper).
Tuesday morning - 14.6.

Tuesday before bed - 5.4 (14u Lantus, 3 digestives).
Wednesday morning - 11.1.

Wednesday before bed - 4.6 (14u Lantus, 4 digestives).
Thursday morning - 18.0.

 

[DeusXM]

Try looking at 5am-6am levels - if it's dawn phenomenon, your levels should be 'normal' at this time and only elevate later.

 

[Northerner]

Those readings are a little confusing, but might there be other factors at play such as daytime activity levels? I know that when I was taking my lantus (long story!) if I'd eaten 4 digestives before bed my levels would have been pretty high by morning! But that doesn't really correspond to the night you had no biscuits, so I think you need more data in order to point at a possible conclusion. The dawn testing would also help, as would more 2/3 am tests so you can get a better picture of what's happening - a right royal pain, but the best way short of a CGM! 🙂

 

[everydayupsanddowns]

My thought looking at those few results was, "I wonder what you had for eve meal" It is quite possible, even if I've eaten at say 6pm, for me to still need some active insulin at bedtime to cope with what's left of the evening meal - depending on what we have eaten.

 

[rachelha]

Have you discussed changing to twice daily levemir injections? I did this for due to exactly the problems you are having. It did help, although a pump is better (for me anyway). The levemir acts for a shorter amount of time (I think about 12 hours) I would have just 2 units at about 7pm and then 10 at 7am. This helped with the night time hypos but meant I was not going high all day long.

Hope you manage to find a solution

 

[mark1975]

I had a bad day chasing levels yesterday as they started out so high.

Last night before bed: 12.6 (14u Lantus, no supper)
This morning: 9.9

I'll do some during night and early morning tests to see what they show.

Thanks again for all your help and advice.

 

[trophywench]

Do you realise that Lantus takes 3 days to settle down before you can actually see if any change is working? - so if you changed it Monday night, Thursday night/Friday morning ie last night/today, are the first tests you can rely on to start to see the picture with.

This isn't an old wives tale by the way - when you start on a pump they work out your doses for you that you start off with and err on the cautious side and yes, you can adjust and correct boluses, but you are told not to do any fasting testing to check if your basal rates are right, for the first 3 days. This is to ensure all your long acting insulin is out of your system.

So what's it looking like now?

 

[martindt1606]

I'm taking 24 units of Lantus at 07:30.

Up until last week I had a spell of 2 - 3 weeks where my morning BS was the same or just under my bed time BS or where I would expect it to be when I had injected a small novorapid correction dose before bed.

For the last 5 mornings the morning BS has been consistently 5 - 6 mmol higher than I would expect.

I haven't changed my routine but did change my Lantus pen Wednesday morning - so 3 days old pen 2 days new pen. Perhaps tomorrow will be fine as I've heard it can take a couple of days for a change of lantus to take effect.

Alternatively perhaps its the warm weather.

I dont want to increase my lantus as I have a recurring problem late afternoon where I am dropping below 4 from just over 6 between 18:00 and 18:45. Even when I have a small (10-15 carb snack...)

Having just reread the above if the high morning readings are as a result of a bounce back from late afternoon - perhaps I should try reducing the lantus.

ITS ALL TOO ********** COMPLICATED.

 

[mark1975]

OK so I've been doing some different blood sugar level checks as suggested in this post and here http://www.diabetes-support.org.uk/info/?page_id=120

During the daytime, fasting levels seem quite stable, they usually drop by 1 or 2 mmol apart from 1 occasion when they rose by 6 for no reason. So this suggests that my Lantus is working OK and the dose is not far off being correct and could maybe even drop by 2 units.

During the night is where the problems begin! They are dropping most nights up to 6 mmol but never to hypo levels (so far).

My morning levels are always higher than when I went to bed by anything from 2 to 10 mmol.

The higher my levels are when I go to bed, the closer my morning levels will be to them and the biggest drop during the night occurs.

The lower my levels are when I go to bed, the higher my morning levels will be and the smallest drop during the night occurs.

I hope this makes sense!