Serious AM problems [Archive]

drummingfool

12-03-2008, 11:38 AM

This is about what happens every morning.

I woke up this morning, 5:45 @ 120 exactly. I had 8oz of milk and my vitamins and took my novolog for the milk. At about 10-10:30 my BS was in the 260's.

I take 52u Lantus every night, and at about lunch time my levels come back down. I HATE this spike in the morning. what should I do?

Help! This really, REALLY sucks.

rzrbks

12-03-2008, 12:13 PM

Sorry, 52 of Lantus seems just a little high---but that's twixt you and your Dr.

As for breakfast, what is your normal ratio?

For me, I use 1:15 for ANY time Except breakfast, there it's more like 1:8 or even 1:6 depending on what I have.

And by breakfast, I mean the first meal of the day. It doesn't matter if I eat at 5am or 12pm. Whatever the first meal of the day I eat when I first wake up is always gonna be somewhere around 1:6--1:8.
Now, If I intentionally skip break fast and go about a normal day and then eat lunch or supper after having been up many hours, my ratio is it's normal 1:15.

Many folks have to adjust their ratios according to the meal, the time of day, what the meal consists of and what phase the Moons of Saturn are in.

Part of The Joy of Diabetes.

I'd start with a 1:10 ratio and then adjust it either up or down based on Several days readings 2 hours after you eat.

fgummett

12-03-2008, 12:19 PM

Milk for breakfast? What percentage fat? Higher fat milk will have a lower proportion of lactose per volume, and a higher proportion of fat to moderate the postprandial BG spike :)

I agree that 52u Lantus all at one go sounds high... do you inject it all at once or break it up into multiple sites... or consider discussing with your Doctor to break it into two doses at different times of the day.

A fasting of 120mg/dl... I wonder what you would have tested 1/2 or 1 hour later even without eating... maybe your BG was already on the way up?

Do you do basal testing?

BlueSky

12-03-2008, 01:16 PM

This is about what happens every morning.

I woke up this morning, 5:45 @ 120 exactly. I had 8oz of milk and my vitamins and took my novolog for the milk. At about 10-10:30 my BS was in the 260's.....
It sounds like your DP effect overwhelms the Lantus action in the mid-morning. I have the same issue. You could try eating a low-carb breakfast (no milk), and covering it with Regular (eg. Actrapid, Humulin R) . In addition to covering your breakfast, the Regular makes up the shortfall in Lantus action. It acts over a much longer period than Novolog. It takes 45 minutes for regular to get up to speed, so you need to inject it as soon as you wake up.

You could also try using a basal insulin with stronger peak action, like Levemir or NPH. You need to time it so that the peak from the before-bed shot coincides with your increased insulin need. You may need to split the dose between morning and bedtime shots to get good 24 hour coverage. You can also mix and match. Take NPH before bed to deal with the DP, and Lantus in the morning for more consistent daytime cover.

To help work out what would work best for you, consider the action profiles of these insulin in the graph (Lantus = Glargine, Levemir = Detemir).

http://i288.photobucket.com/albums/ll181/stratplan/basalinsulincomparison.jpg

As you can see, Lantus has a weak peak action. While this is good for most people, for some of us it is a problem. Levemir has a somewhat bigger peak, and NPH has the biggest one.

Before you do anything, you really need to do basal testing. Skip breakfast and test you BG every hour until lunchtime. You will then be able to see if your morning basal action is adequate or not.

lorilei

12-03-2008, 02:25 PM

Hey D,
Hope this a.m. stuff gets under control so you can enjoy the new job! It must be frustrating!

jenb

12-03-2008, 04:13 PM

My bg tends to rise after I awaken, but before I've eaten. For instance, it may be 85 when I get up at 6:00a.m., but used to rise to 120 by the time I'd fussed around and measured again prior to breakfast at 7:15. After lots of trial and error, I've found that breaking my Levemir into 3 doses (5 units at 7:15 a.m., 5 units at 3:15 p.m. and 6.5 units at 11:15 p.m.) almost eliminates that morning rise. I also inject my bolus about 20 minutes before I eat. This seems to keep my BG from spiking more than 20 - 30 pts 45 min to 1 hour post meal.

Don't know if my experience with small basal amounts is helpful for someone using higher doses, but it might give you some food for thought.

Kat

12-03-2008, 04:40 PM

I have the same problem and it's been going on a long time. Wake up high, eat and no matter what I eat (that has carbs) my blood goes up super high. So I'm doing basal testing and all but I still need to I guess adjust my bolus for breakfast and basal for morning. =p
MAJORLY sucks!!
Hope you figure it out!

walleyedave

12-03-2008, 05:27 PM

drummingfool

12-03-2008, 05:50 PM

Gary_W

12-03-2008, 06:03 PM

I don't understand how people can say that your dose of lantus is high.
I have been told to keep upping my lantus untill my morning BG's(fasting) are normal. How do these people know your dose is high. I don't get it. I would love to hear there thoughts on this, as well as why they feel this dose should be split.
I don't know whats going on with your Bg. The more I read your other posts, the more you remind me of me. I have gone through some of the exact things you have. The weight loss and gain issues. The morning Bg issues. etc..
I can eat zero carbs for breakfast and still skyrocket in an hour..
I hope you get the answers your after bro, we'll both get some questions answered. I'll be subscribing to this 1 for sure.:)

The 'keep upping the lantus until your morning BG's are normal' is standard advice from docotors who fail to back it up with two other important questions:-

1. What is your BG before you go to bed?
2. Are you sure you aren't going hypo in the night?

The purpose of Lantus is to cover the output of your liver and to keep your BG stable in the absence of food or bolus insulin. Too often it is given in excess amounts and causes the BG to tick down slowly. If this happens in the night, you can have a nice night hypo. Your liver then has the decency to save you life by putting out everything it can. Some folks are high in the morning because of a liver dump and keep on upping the Lantus to keep the morning numbers down. It's a really good way to vanish up your own rear end. A place where I lived for quite some time and wondered where all the spikey numbers during the day came from.

The reason folks are thinking it's a lot of lantus is because it is a lot for a T1 acording to the general rules of thumb (such as they are). These rules of thumb obviously are there as a rough starting point from which to get to where you actually need to be. But looking as an average, a 50/50 split of bolus to basal is a reasonable starting point. So if Drummingfool fits this profile, his total daily dose is around 104u. Another little guideline I've seen as a starting point is that 0.5u of insulin is given per kilo of body weight. Again, only a guide but this would suggest that Drummingfool weighs 208 kilos which is almost 460lbs.

Again, everyone varies from this rule of thumb. But if there's even a tiny bit of truth in it then something else must be going on here, hence thoughts of either night hypos or absorbsion problems. If you put loads of insulin in one place at one time, you can get really bad absorbsion problems. For this reason, it's fairly common to split larger doses into smaller shots.

Splitting to dose between sites and also some overnight basal testing would be a good start on the road here IMO.

gettingby

12-03-2008, 06:05 PM

Thanks for your help, all. It is extremely frustrating to have my BG at 260 when I get to work and try to setup a complicated virtual Linux server when I cant concentrate.

I'll do basal testing, prolly on saturday. I dont want to go without breakfast on a day I have to work. I'll just have eggs or something until then. Nothing but eggs, all day. lol

Walley, I hope I get these answers too. Its really annoying, isnt it? I take 1u/5c in the AM when the rest of the day is 1u/10c. Perhaps I should lower it more. We'll se what happens in the mornings to come. Stick with me, yall! I love the support!
Dude, we will stick by you through thick and thin, good and bad. We ain't gonna desert you.
Now, with the basal dose, there is no set amount or limit on what anyone takes. We are all different and different things work for different people. I hope you find what works for you very soon.

VinceF

12-03-2008, 06:54 PM

Are there any carbs in your vitamins? Some vitamins use sugar as a binder. I was having the same type thing happening and found some extra carbs (we changed bread) then switched to vitamins without sugar added.

Dave

DanG

12-03-2008, 07:02 PM

The 'keep upping the lantus until your morning BG's are normal' is standard advice from docotors who fail to back it up with two other important questions:-

1. What is your BG before you go to bed?
2. Are you sure you aren't going hypo in the night?

I have been thinking about the DP that I have read about from BlueSky and now drummingfool. Interesting thing, DP.

I wonder if the lantus in the evening is becoming more and more of a problem for us. I quit doing evening lantus a couple years ago. I take lantus in the morning and am usually fine the next morning - I split sites for my 22 units lantus. I am thinking that perhaps the body mechanism is a bit lantus resistant and "seems" to need more and more lantus. Whereas, perhaps you can wean the body off lantus resistance by lowering the dose and switching to morning dose - a suggestion if that....

These are my suspicions - no experience to back them up, except that I quit taking lantus at night. My reasoning is that I am doing nothing from 10 PM to 7 AM and thus need no real sugar processing, therefore no need for lantus - give the body an insulin rest for a short period each day, as it is said that lantus is 20 hours duration or so.

Another lantus experience I have from time to time - always logical and generally miscalculation by me - the low that lantus produces is wicked. It is wicked loooong, sneaky, and quite resistant to sugar feeding, it seems to me. I don't like lantus low at all.

jenb

12-03-2008, 08:17 PM

I don't have experience with Lantus, but do use Levemir. I wonder if the duration of action of your basal is shorter than you think...what time do you take it at night? I don't know the Lantus protocol, but perhaps you could split the dose and take it in 2 12-hour segments. This might cover what might be a lapse in basal coverage.

xMenace

12-03-2008, 09:17 PM

Your DP sounds a lot like mine. Levemire nor Lantus will treat it well. You also need another insulin to attack that DP. If you drop hard in the night like I do, getting up at 5am or 6am and bolussing may be the only option. If you rise from midnight on, then some NPH before bed is likely the ticket.

Try to build a profile of overnight activity, but for now get up early and shoot some extra Novolog.

BlueSky

12-03-2008, 09:29 PM

... I'll do basal testing, prolly on saturday. I dont want to go without breakfast on a day I have to work. I'll just have eggs or something until then. Nothing but eggs, all day. ...
The only thing that should pass your lips during a basal test is water. Eating anything will raise blood glucose, even if it contains no carbohydrate. As soon as something gets into the stomach, the liver spits out some glucose to balance the phase-one insulin response. So if you don't have a phase-one insulin response, blood glucose goes up.

It is also not a good idea to do a basal test if you are going to be stressed at work. Blood glucose will go up, and you won't know why. For a basaltest to be maningful, you need to remove all the controllable variables - food, exercise and stress.

Lizzie G

12-04-2008, 02:05 AM

I don't understand how people can say that your dose of lantus is high.
I have been told to keep upping my lantus untill my morning BG's(fasting) are normal. How do these people know your dose is high. I don't get it. I would love to hear there thoughts on this, as well as why they feel this dose should be split.
I don't know whats going on with your Bg. The more I read your other posts, the more you remind me of me. I have gone through some of the exact things you have. The weight loss and gain issues. The morning Bg issues. etc..
I can eat zero carbs for breakfast and still skyrocket in an hour..
I hope you get the answers your after bro, we'll both get some questions answered. I'll be subscribing to this 1 for sure.:)

Hi

My basal needs vary dramatically over the day and night and its kind of obvious to me by what happens in the absence of food. I take 6 units of lantus in the evening. If this was the only basal I took my BG would rise from say 90 when i went to bed, to between 140 and 150 at about 6am. Which sounds my my lantus is too low, right? However, on this same amount of basal I know my BG will drop by approx 30 to 40 between 4 and 7pm (which i cover with a small snack if necessary) which is around the time i am driving home - not good. If i raised my lantus to 8 units, going to bed at 190 i would wake up maybe around 130 to 140, but i would be STARVING all day and at risk of hypo late afternoon, so definitely too high.

The way I deal with this is to take my 6 units lantus, then to supplement this with 4 units of isophane/NPH/insulatard (whatever you call it) at around 10 pm. this seems to cover the night adequately and allow me to get up around the same level as i go to bed. As the dawn effect carries on a little longer i also take slightly more insulin in the morning with meals and limit carbs; the later in the day the less insulin i need per carb until about 8 pm where i start rising again.

Apologies for what a boring read this is! Im hoping to get a pump and my life will be much easier!!

mazea

12-04-2008, 02:57 AM

I would like to ask do you get the vitamins/ vitamin C with no glucose added? 1 of those vitamin C tablets can have 6g carbs in glucose in them so I got some ones that have no glucose added.

Lizzie G

12-04-2008, 04:19 AM

Hi

My basal needs vary dramatically over the day and night and its kind of obvious to me by what happens in the absence of food. I take 6 units of lantus in the evening. If this was the only basal I took my BG would rise from say 90 when i went to bed, to between 140 and 150 at about 6am. Which sounds my my lantus is too low, right? However, on this same amount of basal I know my BG will drop by approx 30 to 40 between 4 and 7pm (which i cover with a small snack if necessary) which is around the time i am driving home - not good. If i raised my lantus to 8 units, going to bed at 190 i would wake up maybe around 130 to 140, but i would be STARVING all day and at risk of hypo late afternoon, so definitely too high.

i meant in the above if i go to bed around 90 i wake up 130 to 140 not 190....chance would be a fine thing!

drummingfool

12-04-2008, 05:13 AM

jenb

12-04-2008, 10:46 AM

Hi again. About splitting your Lantus: Perhaps your BG was high during the day because you need more basal; Maybe you need 35u at night and more than 15u in the morning. You've certainly been dealing with this challenge onger than I have, but I hope you'll retest your daytime basal needs and consider the split dose again. How frustrating for you!!!

Gary_W

12-04-2008, 01:06 PM

Alrighty. Let me answer some questions here.

1. I've tried splitting my Lantus dose into 2 12 hour sections, 35u at night and 15u in the morning. All that did was keep my BG in the 200s all day. So Ive tried it, and it was a no go.

2. All of the vitamins and supplements I take have a grand total of less than 1 carb. I make sure of it when I buy the stuff. Special Diabetes vitamins and fish oil, enzymes and cranberry with no sugar. Problem is, even when I skip out on the vitamins, my sugar rockets.

There ya have it. With it being 6:15 AM, Im going to proceed downstairs and scramble up some eggs, or perhaps I wont do breakfast. I'll let everyone kow how it works out today.

It's not somuch splitting it into different times of day, but splitting it into different injections; if you are whacking 50u of Lantus into one place at one time, this can potentially cause absorbsion issues. I know of one member here who swears blind that he can only inject up to 7u in a single injection without getting problems, so he (for instance) would do 7 different Lantus shots.... I know this sounds extreme and I'm not suggesting you go this far, but the more you put in with a single shot, the more your chance of getting uneven absorbsion.

The other thing to keep in mind is that any changes you do with Lantus will not reap rewards (or make you worse!) for 3-4 days. This is one of its most irritating traits. You have to experiment and suffer whilst you wait for it to make its mind up as to whether it's good or bad...

Good luck

Subby

12-04-2008, 02:34 PM

I know of one member here who swears blind that he can only inject up to 7u in a single injection without getting problems, so he (for instance) would do 7 different Lantus shots.... I know this sounds extreme and I'm not suggesting you go this far, but the more you put in with a single shot, the more your chance of getting uneven absorbsion.

Yes, I can only take a very small instant dose (whether injection or "instant bolus" on the pump) - problems consistently occur over about 3units as opposed to slow release with the pump. By "problems" I mean, deferring action by between 30 minutes and 80 minutes. I seem to have it really bad, most people either don't have the problem or maybe would only get it at much higher dosages. But yes it is the kind of thing well worth keeping in mind, especially up at the 50u mark!

I only found this out when I went to the pump (no option to "slow release" with injection - no way to definitively troubleshoot these absorption issues). Previously on MDI I had very similar kind of problems especially though the morning, as you drummingfool, and never really found the answer! I really hope you do!

drummingfool

12-04-2008, 03:35 PM

Well, Im really hoping to get said pump. My insurance kicks in on the first of the year, but its a 3000 dollar deductible. insane.

drummingfool

12-05-2008, 07:00 AM

Alright, here's an update. Let me know what you think.

1. I've eliminated my morning cranberry pill. I believe the natural sugars that occur in it aren't helping my BG in the morning.
2. I've upped Lantus to 56u at night.
3. My sugar this morning @ 6:30 was 132. Upon arriving to work at 7:30, it was at 145. I find that my spike is usually between 100 - 140pts from where I start, so I took a bolus of 5 units. I had no breakfast, only a multivitamin and a fish oil capsule.

I would have done all of this yeaterday but I woke up REALLY high. I wanted a more normal base to test all of this. I'll keep everyone updated, but please post any ideas. Thanks all!

drummingfool

12-05-2008, 12:28 PM

Looks like I found the solution in here somewhere! Let me give you all a breakdown of my morning after doing everything posted above.

6:30AM - 132
7:23AM - 146 (took 5 units)
8:35AM - 117
9:23AM - 113
9:55AM - 100
11:17AM - 113
11:53AM - 100 (lunch)

I havent seen numbers in the morning like that for a very long time :)

BlueSky

12-05-2008, 02:08 PM

The numbers are looking good. Well done! But the fact that you need an extra 5 units of Novolog in the morning seems strange to me. And I would be very uncomfortable with having all that Lantus is one go at night. You can expect a lot of insulin action variablility. In other words, some days it works fine and other days you get unexpected results.

It would be interesting to know what your blood glucose is doing at night. Could all that Lantus be causing your BG to bottom out during the night and rebound to high levels in the morning? This is the so-called Somogyi Effet, which is not as common as many people think. But it is worth testing for it. On a night when you are in the target range before going to bed, set your alarm clock to wake you up so that you can test at 2am and 4am. Let us know what your results are.