Help With Barely controlled BG Levels & Insulin Amount

[evenstill]

I just turned 30, am about 5’11”, and weigh a fairly fit 155 lbs. I’ve had Diabetes for about three years now (late onset) and am considered type 1 insulin dependant. My BG has never really been under control very well or for very long periods of time and it seems to be swinging wildly again. I’m using Novolog FlexPen for my bolus and Lantus pen for my basal. My IC ratio is around 1/5 – 1/7 and I’m currently taking 21 units basal. About 6 months ago I was taking about 23-24 units basal and my BG during the days was great and pretty stable but my BG would drop during the night if I didn’t eat a little something extra before bed (and even then it would still drop dangerously low at times). So, I reduced my basal back to 21 units and now I’m swinging around. Yesterday my BG dropped down to around 50 twice during the day then after dinner spiked up to around 450. Now, I’ve done quite a bit of reading and my diabetes educator says that I could probably be a diabetes educator myself . . . but I just don’t know what to do here.

My body just seems to do it’s own thing a lot of the time. For instance I can have a BG of 150 before bed three nights in a row with the same exact food eaten at exactly the same time and the same amount of exercise every day, and one day it will drop down to 40 or 50 during the night, another I’ll wake up with a BG of around 80-100, and another I’ll wake up with a BG of 300. What’s going on? Why can’t I seem to get my BG under control? Should I try increasing my basal again? My doctor said I may want to look into a pump but I simply don’t have the money for that. Any tips, tricks, and/or suggestions would be greatly appreciated.

Thanks,
evenstill

[BlueSky]

You need to do some basal testing. Then you can adjust the timing and/or amount of your basal dose/s until you are stable throughout the day in the absence of food. 21 units of Lantus is quite a lot. I use only 14 units of the stuff, and I weigh 72 Kg. You may get better results from splitting the Lantus dose. In spite of what the advertising says, Lantus has a definite peak. If splitting the dose doesn't work for you, switching to Levemir would be another option. Because of the more pronounced peak, there is more flexibility in customising a basal profile. It may help to look at the action profiles for Levemir (Detemir) and Lantus (Glargine) below :

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

The first thing to do do is establish where those gaps are, so get started with some initial basal testing. Here is an articleI wrote about it, whch may help. Basal Testing for MDI - Diabetes Daily (http://www.diabetesdaily.com/forum/articles/16675-basal-testing-multiple-daily-injections#post148668)

Good luck, and welcome to the forum :) .

[evenstill]

Thank you for the great info. I knew that I had to change my basal somehow but wasn't sure just what to do. I'll do some basal testing over the next few days and figure out where to go from there.

[Delphinus]

I just turned 30, am about 5’11”, and weigh a fairly fit 155 lbs. I’ve had Diabetes for about three years now (late onset) and am considered type 1 insulin dependant. My BG has never really been under control very well or for very long periods of time and it seems to be swinging wildly again. I’m using Novolog FlexPen for my bolus and Lantus pen for my basal. My IC ratio is around 1/5 – 1/7 and I’m currently taking 21 units basal. About 6 months ago I was taking about 23-24 units basal and my BG during the days was great and pretty stable but my BG would drop during the night if I didn’t eat a little something extra before bed (and even then it would still drop dangerously low at times). So, I reduced my basal back to 21 units and now I’m swinging around. Yesterday my BG dropped down to around 50 twice during the day then after dinner spiked up to around 450. Now, I’ve done quite a bit of reading and my diabetes educator says that I could probably be a diabetes educator myself . . . but I just don’t know what to do here.

My body just seems to do it’s own thing a lot of the time. For instance I can have a BG of 150 before bed three nights in a row with the same exact food eaten at exactly the same time and the same amount of exercise every day, and one day it will drop down to 40 or 50 during the night, another I’ll wake up with a BG of around 80-100, and another I’ll wake up with a BG of 300. What’s going on? Why can’t I seem to get my BG under control? Should I try increasing my basal again? My doctor said I may want to look into a pump but I simply don’t have the money for that. Any tips, tricks, and/or suggestions would be greatly appreciated.

Thanks,
evenstill

See Subby.

He opened my eyes. :D

[Subby]

Thanks for the vote of confidence Delphinus (I think)... Evenstill, basal testing as Bluesky suggests sounds the way to go to me. The link he provides is a very useful writeup, you'd do well to check it out ;)

I also posted here http://www.diabetesforums.com/forum/diabetes/36700-bolus-testing-and-corrections.html#post424847 in there I talk about how hard I found basal control with long acting, some people do have big fluctuations through the day. That's not to say you might not find success or improvement utilising long acting and basal testing techniques, look into split doses as well. Just that, well, for some, long acting is a pretty inadequate tool.

[Delphinus]

Subby, trust me.

That was a very serious reply.

The grin was a reference to our argument, but a respectful one. Maybe a humble grin.

Peace...

[Delphinus]

Sometimes I hate the net.

Lost in translation comes to mind. Blah.

If you could hear whether we had a tone or not, we'd do so much better.

In person, we'd get along great. I bet anyway.

[owlyn]

BlueSky's advice fixed me up when I was having similar problems. I now split my Lantus, and his advice helped me figure out when to take it. Made a huge difference in my fasting BG, as well as better control throughout the day, and I eat a ton of carbs.

[Subby]

About 6 months ago I was taking about 23-24 units basal and my BG during the days was great and pretty stable but my BG would drop during the night if I didn’t eat a little something extra before bed (and even then it would still drop dangerously low at times). So, I reduced my basal back to 21 units and now I’m swinging around. Yesterday my BG dropped down to around 50 twice during the day then after dinner spiked up to around 450.

The other thing I was wondering but forgot to mention and ask about, is the impact of lifestyle variables that may change day to day. Here's an example:

On Thursdays, I do something at work that's a bit harder, and takes sustained effort a bit out of the ordinary. It's stress, but not the kind of stress we associate as just bad stress. I enjoy it, but it does tire me out.

I always went high on Thursdays by about 1pm, my BGs remained high until about 6 or 7pm, the typical time for my daily resistance to drop right off. Nothing could change this. The stress is inbuilt into the nature of that work, it's not a case of taking it easy. Coming from an overall basal change it created bigger issues around the sides of this period. I found increased boluses simply cannot hope to counteract effectively. (corrections can help me a lot to bump BGs around, but not effective for such a sustained period of trouble). Until: I tried temp basals on the pump, settling on 120%, starting from 9am (hour before the shift) through to about 2pm, so effectively ending about 4 or 5. This provides targeted extra insulin when stress creates hormone release/resistance, and has solved a previously unsolvable problem, I get normal BGs during that time. Gone from hitting 16 mmol/l and up near there for hours without fail, to very rarely peaking above 10 mmol/l, and usually staying substantially lower.

To translate the temp basal in general dosage terms, think of me getting 20% more insulin for those hours. With injections you obviously can't make these exact kind of adjustments for such influences. However, being aware of lifestyle or stress influences potentially having such an impact, could be part of making sense of your variability (notwithstanding basal testing as probably the primary thrust) and you may be able to make useful adjustments. If I was on MDI, I would seriously need to consider giving the shift away: so be it, it would be a valid action to consider.

Delph, it's fine, now just forget it, kick back, and relax ;)

[evenstill]

Thanks for all the great replies!

So far I’ve been taking all my Lantus in one injection around 5:30 or 6:00pm (with dinner). Do you all think I should leave things as they are and start some basal testing or should I go ahead and try splitting my Lantus into two equal injections about 12 hours apart, one around 8:00 pm and the other around 8:00am, then do some basal testing? If I go ahead and start splitting my doses of Lantus do you think I should give my body a few days to adjust first or just go ahead and start some basal testing?

evenstill

[Subby]

My feeling is It really is your choice, I probably wouldn't change it before testing, unless you feel there is something definite to gain. I'm a big fan of split dose if it works, but you don't know yet - the profile of a single dose may be better. These are to be considered alternative profiles, rather than one necessarily being superior to the other. Especially as our basal needs are certainly not always flat through the day.

For an example of a case to go to split now, you outline an example of going high around dinner, which, if it's a trend, suggests the Lantus is not lasting the 24 hours for you. If you feel removing that trend is worth a try and might put you on better footing to proceed with basal testing, I say do it. I don't know that there is likely to be an adustment period for your body or the insulin as far as responding to the different insulin profile - but there may be for you. I'd give it a few days to be sure there's a relatively stable footing, before going to basal testing. It's more a convenience thing of not starting testing straight away, a day or two will tell you if you saw better general stability on one or two injections. You can then choose the profile that feels best to you in general, rather than getting into the basal testing and having to start over if you decide you preferred the other.

Then again, I never basal tested quite in this fashion with long acting, so there may be a good reason to stick with one injection to basal test, perhaps to truly reveal how you go with unlayered action of Lantus works with you, first. Reading Bluesky's article might mention that if it's the case.

[xMenace]

If I was to go back on MDI. and that's a definite possibility with today's economy, I'd probably be on a lower split dose of levemir and I'd take basal shots of Novarapid or maybe Regular early in the morning and at dinner. I may even do two shots of NPH instead. I don't have a good understanding of these basal insulin's action in me.

[DanG]

If I go ahead and start splitting my doses of Lantus do you think I should give my body a few days to adjust first or just go ahead and start some basal testing?

I tried splitting lantus. I had the paramedics here that night at 3am. I took lantus as you are doing, in the morning - and, about three years into my using lantus, as you are now three years into diabetes (I was using animal derived insulin for 31 years, but I have only been using chemically derived lantus/humalog about 4 or 5 years - I don't like the chemical insulin).

I handle diabetes a bit unlike many diabetics - the doctor plays very little in my insulin use and practice. I know exercise and stress and food and life affect insulin needs - I can reason through that much better than the professional with an M.D. after his name. So, after my split dose lantus trial, I began taking lantus in the morning. I like lantus in the morning, because as others here have told you, it does tend to have a peak, and it really does not last 24 hours. Taking lantus at breakfast leaves me with about 3 hours of action by the time I go to bed (as it lasts 18 to 20 hours). Lantus has a peak early after injecting - see BlueSky graph - and since I take lantus at breakfast, I am awake and can handle any spikes that its peak may throw my way because I am awake, and not asleep. I use the same amount of lantus you use - and some nights I need a couple of crackers with peanut butter prior to going to bed, as I can drop almost 100 points during my sleep - which is a decent cushion to manage, I think, and I wake at 100.

There are a few members here that do lantus in the morning, but not very many. I cannot quite fathom why the standard routine is to prescribe lantus for bed time.

[evenstill]

I'm curious, why did the paramedics come . . . was your BG too high or did it go too low for some reason even though you had only taken like half the usual amount of Lantus? If I was going to try switching from evening to morning I imagine I would need to transition by doing two half doses about 12 hours apart for a day or two then transition into taking the full amount in the morning right?

[DanG]

I'm curious, why did the paramedics come . . . was your BG too high or did it go too low for some reason even though you had only taken like half the usual amount of Lantus? If I was going to try switching from evening to morning I imagine I would need to transition by doing two half doses about 12 hours apart for a day or two then transition into taking the full amount in the morning right?

My BG was waaay low, I was completely incoherent. All I can think is that the peak of the night time half dose lantus and the running half dose of morning lantus were enough to send me waay low. Other DF members have a real problem with night time BS rises - they call it dawn phenomenon (DP), I believe. I cannot imagine why or how DP occurs. Without food, and at resting metabolism what makes BS go up? For me, BS does not go up at night with no food, no insulin.

I can't see why switching lantus from evening to morning would be much of a problem. One night, you do not take lantus, but the next morning you do take lantus. In that case, you would be without lantus for maybe 15 hours - your night lantus wears out at maybe 3PM and then the next morning at 7AM you take your next lantus. I think having no basal for those few hours could be managed by careful eating and rest. I think I just let my body rest without insulin for that short time.

For perspective - for 31 years I did lente pork derived insulin - one shot in the morning. Testape was the only management tool. I imagine there were many days where I was at BS of 300 but would come back down to 100 - I don't know. I am not meticulous about keeping things at 100 to 130. I don't like 180 when I see it, but I know a unit or two of humalog brings that down right quick.

I read about split lantus here at DF, and tried it. I may have been doing split dose lantus for several days - I don't remember, but the end was terribly dramatic and I switched to morning lantus. Many here at DF split lantus and are quite happy with results. Your original post just sounded so much like me three years ago with many night lows that were not nice, I figured I would speak about my similar experience as a point of reference to assist you in your decisions about using lantus.

[Subby]

I cannot imagine why or how DP occurs. Without food, and at resting metabolism what makes BS go up? For me, BS does not go up at night with no food, no insulin.


Resting metabolism is one thing, but there's more to the picture than that. Internal body-clock release of hormones and glucogen can play a large part in systemic blood glucose fluctuations, for some, which is basically what the DP is an example of. See this post for an explanation. http://www.diabetesforums.com/forum/pre-diabetes/36685-dawn-effect-i-m.html#post424206

Or, an internet search will turn up explanatory pages. If one doesn't have a DP or a minimal DP that doesn't create any issues at all, you can just consider yourself lucky and basically forget the issue.


I can't see why switching lantus from evening to morning would be much of a problem. One night, you do not take lantus, but the next morning you do take lantus. In that case, you would be without lantus for maybe 15 hours - your night lantus wears out at maybe 3PM and then the next morning at 7AM you take your next lantus. I think having no basal for those few hours could be managed by careful eating and rest. I think I just let my body rest without insulin for that short time.


I agree, it should not be that big an issue to just move from night to morning. Doing it with care the way Dan suggests, should be very do-able. A minimal carb dinner, extra testing, and perhaps a correction bolus or two when needed could be very handy. Alternatively you could try the split system approach you mentioned, Evenstill. Whatever you do, do it when you can give time and care to the process. Knowing how to give an appropriate correction bolus for your body and requirements, could be a valuable tool to have, in navigating transitions.

[evenstill]

Ok, since I was going to have a laid back day around the house today I decided to do some basal testing. I took my usual 21 units of Lantus yesterday evening around 6:00pm with dinner. I’ve fasted since then and am planning on eating dinner tonight. My BG at bedtime yesterday (10:30pm) was 110 and I checked it at 12:00am, 2:00am, 4:00am, 5:00am, 6:00am, 7:00am, 8:00am, 9:00am, 10:00am, 11:00am, 12:00pm, 1:00pm, 2:00pm, 3:00pm, 4:00pm, and will do so until dinner time tonight (6:00pm). My BG readings at midnight and throughout the night/day where: 73, 86, 68, 54, 63, 73, 77, 94, 110, 112, 124, 135, 133, 152, 142, and I had to eat two 5g packets of sugar at the 12:00am reading and one 5g sugar packet at the5:00am and 6:00am readings. After looking at the data I’ve got so far it looks like the amount of Lantus I’m taking is probably about right since my overall BG levels are more or less within an acceptable range with an obvious drop during the night and rise as the day progresses. So, I think that I’m going to try splitting my basal into 2 doses taking 10 units of Lantus with dinner tonight and the other 11 units with breakfast in the morning. This should help keep my BG from dropping during the night and hopefully flat-line during the day/afternoon. Any tips, tricks, or suggestions? What do you think I should do regarding my bolus? Should I keep it the same for a while (1:5) or perhaps decrease it a little (maybe 1:6 or 1:7) since I was relying on it during the afternoons to try keeping my BG levels within range?

[BlueSky]

Sounds like you are on the right track. Try splitting the dose and see what happens. Just be sure to test after meals in case the bolus ratio needs to be adjusted. Keep up the good work ;) .

[DanG]

Any tips, tricks, or suggestions?

Yes.
Based on my experience - be real careful for the next several weeks as you get used to the split during the night hours. In my experience, I crashed at night, therefore, be careful. Why did I crash? - I dunno, but I did, and it was a serious bad crash - but it was the last crash I have had.

[evenstill]

Ok, I switched to 2 doses of Lantus about 12 hours apart. I’ve been taking 11 units with dinner (around 6:00pm) and 10 units with breakfast (around 7:00am). I’ve been doing this for about two weeks now and decided to do another 24 hour fasting basal test.

The chart below shows my BG number starting at 6pm then following at 8pm, 10pm, 12am, 2am, 4am, 6am, 7am, 8am, 9am, 10am, 11am, 12pm, 1pm, 2pm, 3pm, 4pm, 5pm, & 5:30pm.

While it definitely looks better it looks like my BG starts going up around 2:00am and peeked around 9:00am then slowly started to drop off. It seems like my morning basal injection starts kicking in around 9am (3 hours after I took it) and started bringing things back down. So, looking at this I was thinking I should maybe try adding a unit or two to my evening basal injection to help control BG level during the early through late morning hours. Does this sound right to you all?

[sweetlife]

Evenstill
thats quite an efforts,I wish you will soon overcome this problem,be blessed.
just a suggestion,I would prefer to start with a lower than usual dose of Lantus and then keep raising it with tests if needed.

[Subby]

While it definitely looks better it looks like my BG starts going up around 2:00am and peeked around 9:00am then slowly started to drop off. It seems like my morning basal injection starts kicking in around 9am (3 hours after I took it) and started bringing things back down. So, looking at this I was thinking I should maybe try adding a unit or two to my evening basal injection to help control BG level during the early through late morning hours. Does this sound right to you all?

Evenstill, great work with the testing and sticking to finding a solution. I'm going to just put down my thoughts, take or leave as you will.

First, is I wouldn't be too sure that the 9 - 10 downward slope is particularly the effect of your your 7am shot kicking in. It is suggestive considering it didn't happen on just your once shot regimen, but I'd leave this issue for the moment, and focus on stopping the morning spike.

Assuming your graph does reflect what's generally going on, to make sense of this it seems you have a pretty viscous Dawn Phenomenon. DP is a release of hormones at or around the time of waking - it meed not be at dawn and the actual timing is different and may be after you get up.

Especially once you add in a breakfast and extra resistances from the DP effect, it compounds the effect.

The reason I say this is it might make it easier for you to look for differing solutions to a spike from DP: it's discussed quite a few lot now and then, in the Diabetes, type 1 and type 2 forums.

The thing I would try first, is indeed increase your night dose so that by the time 6am comes around there is a much greater amount of long acting in your system. But, with a dose high enough to help cope with the DP, what might happen is that you then experience lows in the early hours of the morning before the dawn effect kicks in.

The way around this that I used to use and others use is to eat a non-bolused, long acting, slow sustaining snack just before bed, to help keep even prevent a low from too much basal from say 10pm - 4am. The snack will need to be just right to keep BGs at a reasonable place for some hours, but you do not want it to spike you either.

I used to use a small serving of porridge (oatmeal) a few bits of dried fruit in it and with milk. Worked very well for me. The sky's the limit for what snack you could use - as long as it works. A high percentage of fat or protein like the milk, really slows the absorption and allows for a release oer a number of hours. The carbs need to "be there" and the longest acting you can find, but not enough to spike.

If you take this course of action of upping your evening basal, be sure to test a lot in the initial stages to see if you are going low through the night. One confusing thing that can happen is that going low causes a liver dump causing a high, and masquerades as the DP again. Yet they are two separate problems with different solutions. You need to be sure that doesn't happen.

Good luck - I'd be confident you get somewhere with this approach of upping the night basal (take it slow, but it might need a significant amount more to counteract the DP) but eating the right pre-bed snack.

It's worth saying you are likely to need to always eat a low carb breakfast even if you get improvement on your basal. The DP creates not only internal sugar releases, but general insulin resistance, leading to not only boluses not working so well but possible getting delayed effects which can cause havok. Best to minimise your reliance on insulin in the morning.

If you work out the technique to prevent this morning spike, chances are you may go low afterwards considering the downward force you currently exhibit through the afternoon. Watch for that. If you keep the morning Lantus dose, lowering it substantially may be required.

Remember the option of going back to just the night injection. Again, if you counteract the heightening effect, you may find with the new picture, that the single dose actually becomes more viable or suitable.

[owlyn]

Ok, I switched to 2 doses of Lantus about 12 hours apart. I’ve been taking 11 units with dinner (around 6:00pm) and 10 units with breakfast (around 7:00am). I’ve been doing this for about two weeks now and decided to do another 24 hour fasting basal test.

The chart below shows my BG number starting at 6pm then following at 8pm, 10pm, 12am, 2am, 4am, 6am, 7am, 8am, 9am, 10am, 11am, 12pm, 1pm, 2pm, 3pm, 4pm, 5pm, & 5:30pm.

While it definitely looks better it looks like my BG starts going up around 2:00am and peeked around 9:00am then slowly started to drop off. It seems like my morning basal injection starts kicking in around 9am (3 hours after I took it) and started bringing things back down. So, looking at this I was thinking I should maybe try adding a unit or two to my evening basal injection to help control BG level during the early through late morning hours. Does this sound right to you all?

Your curve looks a lot like mine did. After some experimentation, and consulting with my endo, I wound up splitting my Lantus dose to 24 in the morning, and 8 right before bed (around 11PM). My morning numbers and overall control throughout the day have been much better.

[sweetlife]

Evenstill
in addition to my last post here is a link which talk similar.I would like to have comments from others as well on this.
Can too much Lantus cause high AM BG's? - Diabetes - Juvenile - MedHelp (http://www.medhelp.org/forums/Diabetes/messages/1165.html)

[Subby]

Sweetlife, looking at that post the crux seems to be

I suspect that Lantus' action is so flat that it may cause hypoglycemia that the liver responds to but does not cause the usual hypoglycemic symptoms


I don't think this really makes much sense. Flatness in itself implies no downward movement, thus no hypo, even a mild one. Regardless, basal testing will reveal the answer as to whether the cause of morning highs are:

1. Dawn Phenomenon (or more generically stated, release of hormones leading to glocogen release and Insulin resistances, overpowering the present Lantus) leading to inadequate basal insulin and a mounting high,

-OR-

2. The Symogyi Effect/Liver dump (Lantus action too strong overnight due to either a general over-dosing OR a specific drop in basal requirements during that time - leading to a low (which, despite the thread you mentioned saying so, does NOT necessarily wake you up), leading to a liver dump, leading to a high.

Those are the two possibilities when talking about a repeating, systemic morning spike (Ok, count stress and activity in as other potential causes, if there is something substantial going on). Basal testing will reveal which it is.

In the case of evenstill, I wouldn't have thought that it is likely to be a low/rebound effect from the Lantus, considering he did not go below 150 the entire time, if the chart he provided of his basal profile is to be trusted. Still, that mantra again - more basal testing will reveal/confirm the scenario.

[DanG]

So, looking at this I was thinking I should maybe try adding a unit or two to my evening basal injection to help control BG level during the early through late morning hours. Does this sound right to you all?

Your plan of attack sounds reasonable.
However, my suspicion is much like sweetlife - that the lantus is the problem with the rise in blood sugar.
As you are trying different management schemes, might I suggest a trial with morning only lantus? - i.e. 21 units at breakfast, which may leave you without any basal insulin in your system during sleep hours. If you get to the place that you will try this for a week or so, you may find it works. I don't recall from 3 years ago whether I had high blood sugars in the morning - but I do recall that I had a problem with lantus lows early morning. Then I switched to split lantus for a week, and then lantus in the morning. Lantus in the morning makes me wake up with blood sugars at 100, consistently. My sleep time blood sugar needs to be around 150, but then I sleep like a baby as there is no insulin activity in my body - no basal, no bolus. Try it, you might like it.

[evenstill]

Dan,
That’s a good idea and I may give it a try. However from looking at my logs it looks like my BG generally spikes in the morning so not having any insulin activity at night may not be the thing for me. I definitely appreciate the input though and may give that a try in the future.

Subby,
So if I understand you correctly I can try increasing my evening basal and monitor through the night to see if my BG levels stabilize without a late night drop. If I increase my evening basal to the point that my early morning BG levels stay stable and am not seeing a late night drop then I’ve found my “sweet spot”. This would mean that my morning rise (no pun intended) is more than likely caused by Dawn Phenomenon.

If, on the other hand, the increase of evening basal causes a late night drop then the problem is more than likely a matter of the Symogyi Effect (Liver Dump) and rather than trying to correct this by reducing my evening basal injection I can correct this with a bedtime snack consisting of some complex carbohydrates in combination with some fats and proteins.

Do I understand the situation correctly? At any rate, going forward looks like I’m going to slowly increase my evening basal until the morning BG levels are right while testing during the night to watch for late night lows that would trigger a liver dump and work against my efforts to combat DP. If I start seeing late night lows then I can just eat a slow burning bedtime snack to compensate. Sound about right?

From looking at the data from my first basal test it looks like this may have been what was happening. I was taking a lot of Lantus in the evening to try combating DP which caused precipitous late night drops which in turn caused liver dump which was accentuating the DP rise and so on . . . . . I may have been dealing with both DP and a liver dump working against me. And on top of this I was taking all of my basal at one time (evening) which was wearing off by the next afternoon causing my BG levels to rise which would lead me to take extra bolus with dinner to try compensating and the whole daily cycle would start all over again. It’s basically been like this for about 3 years now with my BG levels never really under control. Thanks to everybody’s great information and advice on this forum though I think I’m finally starting to get a grip on the situation and see the way out.

Thank you all so much!

evenstill

[Subby]

Dan,
That’s a good idea and I may give it a try. However from looking at my logs it looks like my BG generally spikes in the morning so not having any insulin activity at night may not be the thing for me. I definitely appreciate the input though and may give that a try in the future.

Subby,
So if I understand you correctly I can try increasing my evening basal and monitor through the night to see if my BG levels stabilize without a late night drop. If I increase my evening basal to the point that my early morning BG levels stay stable and am not seeing a late night drop then I’ve found my “sweet spot”. This would mean that my morning rise (no pun intended) is more than likely caused by Dawn Phenomenon.

If, on the other hand, the increase of evening basal causes a late night drop then the problem is more than likely a matter of the Symogyi Effect (Liver Dump) and rather than trying to correct this by reducing my evening basal injection I can correct this with a bedtime snack consisting of some complex carbohydrates in combination with some fats and proteins.

Do I understand the situation correctly? At any rate, going forward looks like I’m going to slowly increase my evening basal until the morning BG levels are right while testing during the night to watch for late night lows that would trigger a liver dump and work against my efforts to combat DP. If I start seeing late night lows then I can just eat a slow burning bedtime snack to compensate. Sound about right?


Bang on. Good luck with it.


From looking at the data from my first basal test it looks like this may have been what was happening. I was taking a lot of Lantus in the evening to try combating DP which caused precipitous late night drops which in turn caused liver dump which was accentuating the DP rise and so on . . . . . I may have been dealing with both DP and a liver dump working against me. And on top of this I was taking all of my basal at one time (evening) which was wearing off by the next afternoon causing my BG levels to rise which would lead me to take extra bolus with dinner to try compensating and the whole daily cycle would start all over again. It’s basically been like this for about 3 years now with my BG levels never really under control. Thanks to everybody’s great information and advice on this forum though I think I’m finally starting to get a grip on the situation and see the way out.


That seems a truly excellent account for what's been going on, it feels great to be solving years old puzzles, eh :)

Of course, do expect a problem or two to crop up if you make progress with the spike. Chances are you'll start getting hypos later in the day and need to reduce your day dose. Sorry if I'm repeating myself... But getting the night/morning better is the really knotty kinks, the rest of the chain should de-kink more easily and be more straightforward.

[DanG]

At any rate, going forward looks like I’m going to slowly increase my evening basal until the morning BG levels are right while testing during the night to watch for late night lows that would trigger a liver dump and work against my efforts to combat DP.

If you read the forum link that sweetlife provided, your situation is quite similar, and one of the suggestions was... lantus in the morning only.

I would suspect that the liver dump due to lantus might be predicted as you raise your evening lantus to compensate. I suspect that at your early morning peaks, you have two overlapping lantus that might be forcing the liver dump. If raising the lantus to overcome that peak makes the peak worse, you might be forcing a liver dump. Another direction mibht be to lower your evening lantus to see if the peak drops. If that happens, you might be prime candidate for morning lantus trial? Think about it, play with it - you will figure it out, I'm sure.

[sweetlife]

I again impressed by this guy's willingness to solve his problems,congrats evenstill.
Subby you are right but somehow I think we all miss some crutial points as far as Lantus goes.
We all know that our body is different and it behave differently,same go with carb to insulin ratio,i.s.f etc..
now same must be with liver dump and D.P may be,I atleast belive in it.Why I belive it because each body has different trigger swich for B.S after 3 a.m,yes this is possible and it is always a mistery.Here I may look non scientifical as I am new in this diabetes world but somehow my logic says that start with a lower dose of Lantus.Most of doctors starts with approx 20 units of so in general but in my daughter's case I have seen a good control of a1c when I reduced her Lantus from 24-26 units to 20 units,her fasting sugar I found better when she started taking 20 units-reduced dose.
Again it will work differently in all persons so why not start with a reduce dose to do just a check?Here Evenstill body during basal test is without food and bolus but in his body there will be Lantus dose which he has taken earlier.Any reduction or adition in Lantus will be visible slowly in next week(in our case),it is not as fast visible on next day.
This is a very informative thread,tx to all who chipped in.
Edit- In most cases Lantus feds out in 18 hours,so don't you think that we should take another shot after 15 hours instead of 12 hours to avoid problem of overlaps?why I say 15 hrs is bcoz it will start working in 3 hrs which makes 18 hours(15+3)so there will not be any overlaping of 2 Lantus cycles.

[Subby]

Sweetlife, I appreciate your input. You are absolutely right, these things are very different per person.

The thing I would point out is that Evenstill is already on a reduced dose. Have a look at the graph he provided in his post above. It shows his bg through the day, without food or bolus, through basal testing. He does not go below about 150 mg/dl all day (8 mmol/l). There are no hypos at the moment, nowhere near.

So I agree with you to start on a dose that does not set off hypos. Evenstill is now at that stage. Well above setting off hypos.

If that's not what you were suggesting, I'll need to come back to this later and have another read :)

[Subby]

I just had another read of your post Sweetlife and I want to try make it clear, I post long posts and comment on lots of things, but I'm not trying to squash other people's opinions, or other possibilities out of the thread - I'm really not. My approach is that there are specific mechanics of insulin and basal matching to step through and reflect upon, given such wonderful data on the basal profile given. I'm just going along my own experience and knowledge there. I am no expert.

I didn't feel convinced by the other thread you posted here, about lowering lantus creating a better effect in itself without the mechanic of the act removing liver dumps (or other things going on). There are a number of reasons for me not being convinced there, but it's just my personal opinion. Happy to share but it seems a bit off the track for right here. But in the end, who am I to tell you you are wrong for thinking it might be some kind of random possibility for Lantus to be less effective in higher doses in and of itself? It might!

I'm just working through the basal scenario, the way I understand it. Whether that's useful or not or good advice or not I really can't judge. I hope it is of some use somehow. I try to be at least cautious and not dangerous in my advice.

I am sure Evenstill is going to try something or other, if it doesn't work, he can try something or other other. The important thing is he makes progress at some stage, however he does it. That's the beauty of getting a few ideas to work with and a few different angles explained. :)

[DanG]

Edit- In most cases Lantus feds out in 18 hours,so don't you think that we should take another shot after 15 hours instead of 12 hours to avoid problem of overlaps?

I would not do that type of overlap.
My thinking is that the body likes to be away from insulin for several hours.
In my case where I take lantus in the morning, my body is without insulins of any sort while I sleep. This provides an escape for the body to cleanse from insulins. Then, in the morning, I start the cycle all over again and take the lantus and humalog, then humalog at lunch and humalog at dinner. If you (your child) are taking lantus at night, then your body is indeed out of insulin for the last 6 hours of the day, and that is when there may be need for basal insulin because of mental and physical activities, prior to bedtime and the next lantus dose.
This is just my experience, as Subby says. For me - lantus in the morning seems to make sense in my life - better sense than my life with lantus at bedtime. Lantus at bedtime did not help my life at all!!

[fgummett]

It makes sense to me that -- if insulin levels are driven by BG levels -- during an overnight fast there would naturally be low levels of insulin in a non-diabetic. Not so sure how this reasoning figures into Dawn Phenomenon though... that is where a pump and varying basal rates really comes into its own ;) Sorry... I'm probably not being much help here... just an observation.

[sweetlife]

Thx Subby.
I just had another read of your post Sweetlife

That suggestion is for those DangG who want to split the dose.
I would not do that type of overlap.


I sincerely wish that evenstill will solve this problem,my best wishes to him.

[Lilly164]

Your story sounds quite a bit like mine. Wild swings without a readable reason, doseage changes making very little difference, etc.
Some things that have helped me are: eating a consistant number of carbs with each meal, (50breakfast, 50lunch, 60dinner), studying written records for patterns, avoiding sweets, high fat foods, and insulin timing. Taken together, these have helped. A mistake and I yo-yo back and forth again.
Maybe someone here will make suggestions that help you.
Lilly

[Lilly164]

Another thing to consider about the Lantus is timing. If it doesn't begin to act for 2 hours, then taking at 6PM with dinner covers dinner, then as dinner carbs taper off, the Lantus begins it's effect.

The book, "Pumping Insulin" says a common pattern is less need for basal between 12MN and 2AM. Taking Lantus at midnight would leave less basal on board (probably) during a time of less need. It will be kicked in during the DP time. I never was able to try this, midnight just isn't an awake time. Using natural body rhythms in timing your Lantus could help. Just something to consider.

Lilly

[sweetlife]

Dont want to open a new thread for my post so continuing here.
Today my daughter took bolus at 11 am and after taking her lunch she went to school,she took 12 units Humalog.
We wanted to go out hence I picked up her from her school at 3 p.m,came home at 3:30 and checked her BS(PPBS)it was 138,she refused to take any food as she was in a mood to come with us.
When we came back at 4:30 I told her to check her BS again as she does not have inuf courage to do a basal test(LOL)so she agreed and checked her BS,it was 83!
Does this mean that we should reduce her Lantus?She takes 20 units.
Thanks and expecting help from members.

[Subby]

Sweetlife, I just don't think I can advise. It could the the Lantus, it could be the Humalog. It could be something more specific to this event. Basal testing is not negotiable to get to the bottom of things. Without it, the best you can do is keep adjusting things and hope to hit on a better combination.

All I can suggest is looking into just how minimal basal testing can be and influence your daughter to see it is not a big deal. If you start with overnight, you don't even need to fast out of the ordinary at all to start getting the picture together. After 4 hours no food and no bolus and starting in a good BG zone, you just start taking tests on the hour/every tow hours, and record one part, of the 24 hour period. That can be just 2 or 4 hour burst at a time after the initial 4 hours setup, if you wish. And it can be done as spread out as you like - do 12am - 4am one day. Then two days later, do 4am - 8am. The rest involves skipping one meal each time, no more. So you might do 8am - 12pm, 12pm - 5pm, etc. There have been some good write ups onhow to approach basal testing. You do need to follow some rules and restrictions to make it work as far as if and when you change doses, while undergoing the tests to fill in the whole 24 hour picture (or a problematic chunk of it to work on). But, it is not hard and not something to be scared of at all.

It is vitally important you understand the process well. If you lack a good link to a good description of the process, just ask.

[sweetlife]

Noted all Subby,let me sit with her tonite and describe all this,hopefully she will agree on what you suggested Tx a tonn.

[Subby]

No problem. While considering an approach, well worth looking at is Bluesky's writeup of basal testing on injections. Basal Testing for MDI - Diabetes Daily (http://www.diabetesdaily.com/forum/articles/16675-basal-testing-multiple-daily-injection)

[sweetlife]

Evenstill please update if possible thanks.

[evenstill]

Ok, I just did another fasting basal test this week. I’m still taking 10 units of Lantus around 7am and 12 units of Lantus around 6pm. I’m also often eating a small snack before bed, usually around 12 grams of carbs. I’m attaching a graph for each test so you can see the differences. While my average daily BG seems to be lower I’m still getting quite a spike around 8-10am. Any suggestions as to how I might be able to level this off a bit?

[sarahspins]

While my average daily BG seems to be lower I’m still getting quite a spike around 8-10am. Any suggestions as to how I might be able to level this off a bit?

NPH at midnight (or bedtime) :) Just a unit or two could be all you need to deal with that early morning rise... my early morning rise is a little stronger than that, and I take 4u (as well as split doses of Lantus - 8u in the morning and 8u at night), which works pretty well for me... my fastings are generally in the 90-110 range (I go to bed at the same, usually with no snack).

There are a lot of different things that work for different people... my split Lantus dose and NPH works for me, it may or may not work for you.

[Subby]

Another idea might be a bolus of rapid acting at 7:30 or 8am, dedicated to basal maintenance. Do you have a correction factor? You could work a starting dose out from the spike you exhibit about 80 or 100 points, then make it a little smaller for more safely.

I'm trying to make some sense of the first diagram - it shows upward movement through the day - where did that one fit in with what you are saying?

[evenstill]

The top right graph is the first test I did before splitting my basal dose. The top right is a couple weeks later after splitting my basal. The bottom left is the test I did last week. I usually eat something in the evening to prevent a drop around 2:00am but then my BG is usually around 200-250 in the morning. When I’m eating (not undergoing a fasting basal test) I usually just take some corrective units with my breakfast bolus and my BG is fine by lunch. I was just wondering if there are any ideas regarding my fasting basal profile. Any thoughts about splitting my basal into 3 injections . . . . . maybe like 10 units in the morning, 10 in the evening, and 2 around midnight? Nah, I guess I don’t really want to get up in the middle of the night and take another shot. Anyway, what I’m doing now seems to be working all right I was just wondering if there are any other suggestions to improve my basal profile a bit . . . maybe prevent a rather low reading around 2:00am and spike in the morning . . . I haven’t really seen anything anywhere but thought I’d ask anyway. But I guess if it’s not really broken . . . . . why fool around with it too much more anyway. Am I right?

[Subby]

I don't mean this in a bad way, but that's just a bit dense for me to make sense of. You've mentioned the top right graph as 2 different things and a bottom left.... I just see 3 graphs in a column.

I'm really happy to give you further opinion, for whatever it is or isn't worth, but if you do want that, maybe if you point the issues out more one at a time for my poor head to take in one at a time :) These things get mighty confusing.

[evenstill]

Sorry, I’m a little low on sleep. What I meant to say was the top left is the first test I did (before splitting my basal). The top right is a few weeks later after splitting my basal. The bottom left is the test from last week. I’ll post them below in separate posts in the order they were completed. The really frustrating thing is that my BG seems so unpredictable. For instance: I can eat the exact same meals and have done the exact same amount of activities for two days in a row and go to bed with BG readings of 120. The first night I might decide to eat about 12 grams of carbs (a couple crackers & some cheese) and my BG will drop to 50 around 2:00am and be around 150 in the morning. The next night I might not eat anything and my 2:00am BG will be fine and my morning BG will be 250! It sometimes goes up when I don’t eat and drops too low when I do. I don’t get it.

[evenstill]

Fasting Basal Test 03-01-09

[evenstill]

Fasting Basal Test 03-13-09

[evenstill]

Fasting Basal Test 06-03-09

[evenstill]

Sorry again . . . . . apparently this forum won’t let you post the same pictures to the same thread more than once. I even tried changing the name of the files several times and it still wouldn’t let me upload them. I guess you’re stuck with the ones on the previous post.

[Subby]

That's ok... but just re-read your post at the top of this page, it's just that you mention "top right" for one thing "top right" again and "bottom left"... yet to me the are just 3 graphs like this:

---

---

---

maybe just explain what 1, 2, and 3 are and what you are thinking more in point form... just saying if it was simpler I might be able to comment a bit easier. Up to you.

[evenstill]

Basically, the first test (top left graph) shows an average daily BG level of 130 with a steady increase in BG level from around 70 at midnight to 230 the following evening. The second graph (top right, first split dose basal) shows an average daily BG level of 185 but the level is more consistent throughout the day with a low of 144 around 2am and a peak of 251 around 9am. The third graph (bottom left, last week) shows an average daily BG level of 109 with a low of 61 around 9pm and a spike of 190 around 10am. So my basal profile is definitely doing better than before but I’m still seeing a bit of a drop late evening/early morning and a definite spike around 8am-10am.