new Type 1 diabetic with morning peaks of glucose

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Chris88

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Hi all,
Recently diagnosed with Type 1 and lucky to be using Freestyle Libre 2 sensors but now I have discovered I cannot control my morning surge of glucose post breakfast. I have reduced carbs, increased insulin but still get a large surge of glucose post breakfast (18 to 20). Any advice would be grateful. I am using glargine 6 units daily then lantus as needed before (and after if needed) meals.
 
Hi,Welcome to the forum!

How long are you injecting before you have breakfast? And what are your numbers before breakfast?
It may be worth looking at increasing the time in between injecting and eating. Are the numbers of 18 to 20 from the Libre 2 or a BG meter?
Sometimes Libre will say your numbers are that high when the spike isn’t that high in reality.
 
Usually inject 30 to 40 mins before food.
Glucose is usually 6 to 9 on wakening.
Numbers are from Libre 2 which I have recently started using and has been a revelation as finger pricking for past 4 months had not identified post prandial peaks
 
Welcome to the forum, @Chris88
Sorry to read of your morning rises.
As you say, Libre is an eye opener but you need to be aware of its limitations.
For example, it is calibrated for accuracy between 4 and around 9 mmol/l. Therefore, any readings in double figures need to be checked with a finger prick.
I am not suggetting you are not experiencing a rise after getting up (often called Foot on The Floor) where our livers helpfully dump glucose into our blood stream to give us the boost we need to get going. However, the rise may not be as great as Libre is suggesting.

Do your levels return to more normal levels without a further bolus?
if so, your insulin dose is likely to be ok but may need to be even earlier … r you could try a faster acting insulin such as Fiasp.
If your levels need another insulin boost, your dose is not high enough.

I find i experienc Foot on The Floor if I have done no exercise the day before and if I have no carbs. A small breakfast with a small amount of carbs is enough to convince my liver I am not starving so it can hold back the glucose dump.
 
Thanks Helli, very interesting.
My levels return to normal after a bolus dose so perhaps I need a higher dose in the morning.
Your ' foot on the floor' scenario sounds about right,
Thanks for your help , I still have lots to learn.
 
Chris88 said:
Hi all,
Recently diagnosed with Type 1 and lucky to be using Freestyle Libre 2 sensors but now I have discovered I cannot control my morning surge of glucose post breakfast. I have reduced carbs, increased insulin but still get a large surge of glucose post breakfast (18 to 20). Any advice would be grateful. I am using glargine 6 units daily then lantus as needed before (and after if needed) meals.
Click to expand...

Glargine & lantus is same insulin, lantus is brand name for glargine

2 years ago switched to Fiasp which helli mentions above, it's lot faster acting than novorapid so does deal with spikes better at reducing them & bringing them down, use my fiasp in pump but you can get them in pen cartridges
 
I was going to say exactly the same as @nonethewiser - Lantus = glargine. What faster acting insulin are you using to cover your meals?
 
Hi @Chris88

It is great that you have got the Libre and as you have found it can throw up some surprises.

Just another idea apart from the change in timing of your bolus, what do you eat for breakfast. Is it the same each day? I was amazed to find that porridge gives me a massive spike, however much I tweaked doses and timing. Eliminating that has left me with a gentle breakfast blip. You could try changing your breakfast and see if that makes a difference.

I also found conning my liver in the morning useful. I had some carb free snack by the bed and a couple of nuts before I got up told my liver to leave me alone as I was not starving.
 
Yes, I too wondered about which quick acting insulin you are using as Glargine and Lantus are the same thing and will be your basal insulin.
I find that it is best if I inject my breakfast bolus before I get out of bed to counteract Foot on the Floor. I then potter about with my morning routine, getting washed and dressed, preparing breakfast and having a coffee whilst the insulin is battling my liver dump. For me the timing at breakfast is 45 mins with Fiasp but I needed 75mins with Novo(not so)Rapid otherwise I would spike up to 15 even a low carb breakfast of yogurt/berries and seeds and then come plummeting back down later which really wasn't pleasant. Now I rarely go above 7. Finding the right timing for you is absolutely key, so you might want to extend your prebolus time by 5 mins every few days until you find the tming which reduces that spike without you hypoing first. The timing is also dependent upon your waking reading, so I will need less prebolus time when I wake up in the 4s than I will if I wake up on 8. Injecting before my feet touch the floor really helps though.
 
Thanks for replies and apologies for my error: quick acting insulin is lispro not lantus.
Are 'dawn phenomenon' and 'foot on the floor' the same thing?
I have noticed my glucose levels rising before I get out of bed in the morning, normally 7 to 9 mmol/l, then regardless of quantity of carbs or insulin dose I use they surge to about 15 to 18 within 40 mins.
I think I need advice from my DSN but I am struggling to get a response from phone calls or messaging: I will try again tomorrow!
 
DP and Foot on the Floor are pretty much the same thing but DP occurs before you wake up r get out of bed whereas FOTF is more sociable and waits until you get out of bed. They are both caused by the liver pumping out glucose to give you energy for the day ahead. Unfortunately as a diabetic you don't have insulin output from your pancreas to deal with it, so injecting insulin is the best that you can do.

When do you inject your Lispro for breakfast ie before you get out of bed or after you have got up and been to the bathroom etc?

How long do you wait between injecting the Lispro and eating breakfast?

When do you inject your Glargine? Could it be running out or at least past it's peak, right when you need it most?
 
My routine is to get up about 7am, go to the loo, go downstairs inject glargine 6 units and lispro 6 to 8 units then eat breakfast about 15 minutes later. Breakfast is normally 2 x Weetabix + milk+ 10 blueberries.
I accept glargine might be running out but I have only been using it for a couple of months and that was the dose the DSN suggested I use; it seemed to be ok at first.
If I go to work (3 days per week) glucose peaks at about 16 mmol/l then gradually comes down over the morning.
If i play golf in the morning (3 days per week) glucose peaks at about 16 mmol/l then plummets to under 4 after about 8 to 9 holes (1hr 45 minutes later) and my Libre alarm goes off. I then munch on glucose tablets until the end of the round.
Any suggestions?
 
My thoughts are that taking your Glargine at bedtime.... the later the better, might be better than taking it in the morning so that it is hitting it's peak activity as your levels start to rise in the early hours and injecting your breakfast bolus before you get out of bed and perhaps giving it longer between injecting and eating your breakfast (increasing the length of time you wait by 5 mins every day until you find the point at which you don't spike above say 10 or 12.

On the days that you are going to play golf, the answer would probably be to reduce your breakfast bolus by maybe 1-2 units but you would need to experiment with that to figure out how much reduction you needed. You are looking for your levels to be roughly back to where they were before breakfast by lunchtime without having to eat extra carbs. That would tell you the amount of insulin was correct for that activity. It is a common strategy to reduce bolus insulin if you are going to exercise whilst it is active. The timing of the bolus insulin ahead of eating breakfast is what governs the height of the spike, so if you want to reduce that, you need to inject your insulin earlier and give it more time to get working before you eat breakfast. If your levels are returning into range or to pre breakfast levels before lunch then your bolus insulin dose (Lispro) was correct, you just didn't give it enough of a head start on the food. This is why I keep my insulin by the bed and inject before I get up so that I give it maximum time to work before I eat breakfast. I also inject my basal insulin at the same time and for the same reason. In fact I set my alarm for an hour before I am going to get up and inject my basal insulin then and go back to sleep for an hour and then inject my bolus insulin just before I get out of bed. The I potter about in the bathroom and get myself a coffee and make breakfast and once Libre shows my insulin is kicking in and my numbers start to drop I eat breakfast. I used to spike up to 15 almost every day and then plummet back down to 5. Now I rarely go above 8 with the same breakfast and the same amount of insulin, but just getting the timing right.

The problem you are seeing is almost certainly a combination of the Glargine running out right when you need it most and the bolus insulin having to battle those rising glucose levels even before it starts working on your food. It is basically fighting a losing battle until that Glargine kicks which takes about an hour, by which time the glucose from your Weetabix is hitting the rafters.

You should discuss any changes with your DSN before implementing them and if you do decide to change when you take your Glargine, make sure the alarms on your Libre are set to wake you through the night if you drop low or set an alarm to check your levels between 2-3am for the first couple of nights if you don't have alarms for whatever reason.
 
Another experiment you could try, if you haven’t already, is to switch breakfast away from Weetabix, to see if the spike is the same. Perhaps try a different cereal eg muesli, porridge, or granola, or try a slice of seedy bread toasted.

Although Weetabix is a wholegrain cereal, and high in fibre, that doesn’t necessarily mean it will be ‘slow release’ for you as an individual.

Many members on the forum find breakfast cereals very challenging to dose insulin to match.
 
Thanks to both of you, particularly 'rebrascora' for your comprehensive replies: great insight.
I will try what you recommend: dosing , varying meals, varying times e.t.c. and see what happens, it is is nice to know I am not alone in dealing with morning peaks and troughs. I will, of course, attempt to include my DSN in my experiments.
Thanks again
Chris
 
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