Inexplicable (to me!) Hypo's

[Clem]

Hi Guys,

My first post and I apologise as I am asking for help/shared experience.

I have been Type 1 diabetic a long time (36 years diagnosed at 18 months) and have just moved from my old 2 shots mixed per day regime to a basal/bolus one with Levemir/Novorapid.

I have been on it for about a month now and have changed things an awful lot fron the "default values", a lot of ideas gleaned from users on this forum. I have moved to split Levemir and have Carb Ratios worked out for different times of the day (4 am, 5.5 lunch and 6 evening). Some days it goes great, others not so great but I felt I was making progress...

...until now. I have a problem I cannot rationalise. I split my Levemir 8AM/8PM (as I found it was only lasting 21 hours) and I eat my lunch around 1 or 2PM. However, I am getting Hypo's between 6-8PM.

I do not understand this as;
1) Should my Levemir spike be around 3PM (+7 hours or so)?
2) My lunch-time NovoRapid should be completely gone by 6PM?
3) My previous evening Levemir should be virtually gone by the time I am having Hypo's (based on the 21 hour experience I had).

So I am struggling. It does not happen every day but has happened 3 times in the past week. Discouraging as I felt I was making progress.

Any help/ideas gratefully received!

[Gary_W]

Hello Clem, and welcome to these forums. I hope you find the help you need.

I cannot answer your question exactly, but would like to suggest that perhaps your basal needs are not matching your injections. My basals vary wildly throughout the day (hence the pump these days).

Have you tried actually testing your basal by doing a fasting test? It would be interesting to see if you are falling at that time of day in the absence of rapid insulin. It's all very well trying to adjust things, but if your basal is off then nothing else consistantly makes sense.

The other thing I would say is that Novorapid typically lasts 5 hours in most people. It will ALMOST be gone by hour 4, but there is still about 10% left which could be dipping you into hypo teritory. If you thing your basal is OK and your 2 hour PP number is OK then perhaps try taking your lunchtime ratio a little more in the gentle direction.

Do you always test at the 2 hour point after eating? If not, get an alarm / set your mobile phone to test and see how you are going. In me, I need to be around a 6.8 - 7.5 at this stage. Any lower and I MAY drift hypo at hour 3-4 after eating. Any higher and I'll stay a little high.

Good luck :)

Gary

[Clem]

Thanks Gary. I do test after eating but not religiously 2 hours after - is that a "magic" time after number? If so I can move to it.

As for the basal/fasting test I have done my own "self" experiments but this has just confirmed that my basal rate varies or is wrong as I can wake up at the right level in the morning but climb significantly after that. I have read about the basal tests in this forum but have not found a definitive guide. My next step I thought was to buy the "Think like a Pancreas" book.

[DanG]

I am getting Hypo's between 6-8PM.

I take my lantus in the morning.

I started lantus about 5 years ago and was taking it in the evening but had lows early in the morning. I read here how some split the lantus - like you are doing now. That is when the paramedics came over one morning at 3AM and that was the last time I did lantus in the evening. I have been taking 25 units lantus in the morning at breakfast and have been fine without hypos in the evening. I offer that as a suggestion for you to consider. I have been diabetic for 34 years when I was 22 years old.

[REDLAN]

...until now. I have a problem I cannot rationalise. I split my Levemir 8AM/8PM (as I found it was only lasting 21 hours) and I eat my lunch around 1 or 2PM. However, I am getting Hypo's between 6-8PM.

Yep I've split my Levemir too, as it doesn't last the full 24 hours. The thing to note is that the action of levemir is not flat, despite novonordisk claiming it is. It has a definite peak around the 2-3 hour mark. In type 2 patients (the only action curve I can find), there is a second smaller peak around the 10 to 12 hour mark - this could go some way to explaining hypos around this time.

link to site with graph below....

Levemir Official FDA information, side effects and uses. (http://www.drugs.com/pro/levemir.html)

The second thing to note is that action of Levemir can vary by a large degree between individuals. For instance some people report actions lasting less than 12 hours.

The other thing to take into account is the natural variations in body rhythms that occur throughout the day. Blood pressure, cholesterol, fats, insulin resistance all vary throughout the day. Some of this may be associated with work and the extra adrenalin required to cope with said work - BP usually drops as soon as the person get's home from. It is likely that activities such as work will have a similar effect on insulin resistance. A sudden drop in insulin resistance, and hey presto, although the Levemir is tailing off, its still too much insulin for your needs.

I also get times of the day where I am particularly at risk from hypos, which have nothing to do with insulin timings. Usually they come for a while and then go again. In the past 2 weeks I have had the reverse problem, where my insulin timings should help to keep my blood sugar down, but instead it has been rocketing off into the teens with little provocation.

The key to this is to use the tests to note patterns, and then use them to make adjustments to your regime, and there are 2 ways to respond...

1) scale back your morning Levemir

2) knowing that you will go hypo in the evening - eat earlier, or have a small snack.

test them and see what happens. For preference I would try scaling back the Levemir first, only adding in the snack option if my blood sugars were not satisfactory during the day. Also worth bearing in mind is that your problems with hypos might be temporary.

(I personally experience a great deal of variation in insulin needs which is dependent on the weather - hot and sunny weather can see my insulin needs decline by around 30%)

[Clem]

Redlan,

Much appreciated.I will take all of the above into account. Itis reassuring to know a) I am not the only one with the problem but b) there are people out there (like you) who have mostly cracked it.

Thank you.

[UpNorth]

Welcome to the forums :)


One word: Basal testing! It's the easiest way to find out what's going on with your basal needs.

If you simply can't get it to work with levemir, try to use an old school basal insulin like NPH (I can't believe I just said that:eek: ), or try Lantus instead of Levemir (some people can't get along with Lantus, some can't with Levemir, they're similar but not the same) or start the fight with the british system to get a pump so you can set different basal doses for different times of the day.

I've been T1 for 4 years now (in a few days) and been on either MDI or a pump all the time.

[CarolinaJoe]

Clem:

I definitely feel the frustration in your words. I too have had Type 1 for many years, over 42. I am right there with you. I took a single shot daily in the early days, then multiple shots, and for the last 12 years I have been on the pump. My situation is different but I have some thoughts.

When I go through times of changing insulin needs, like being sick or getting older and being less active, I really try to minimize the basal/bolus interaction so I can observe them separately. I will eat only things that are 100% predictable so I can eliminate as much accidental BG variance as possible. Nutrition labels help conciderably with this, but you really need to use foods that you have experienced sevel times. I would guess that after 36 years you might have some well known problem-free foods you could use. I set my basal constant all day usually 0.5 u/hour, then eat only these predictable foods, and by watching my BG throughout the day I can usually get a good idea of which way to adjust and basal bolus rates. This process works like a combination of fasting and post prandial. I find it helpful to get as close as possible to seeing whan is going on in me.

I also believe that I can restore good control, even without perfect insulin dosages, if I am very careful eating. Once I regain control, the dietary freedom can be brought back cautiously.

I hope you figure it out.

[mortis505]

Hello and welcome to DF! Here are some links for Basal Testing (http://www.diabetesforums.com/forum/330495-post7.html). And the book you mentioned might not be a bad idea. After all, "Cuz knowledge is power." - Schoolhouse Rocky