[Gary_W]

Hi,

Thanks to you all on here, I'm doing very well these days. Last HBA1c was 6.5 and I know that it's improved since then as I've been running lower still. It's amazing how addictive decent control can be, and with that in mind, I'm just wondering about the morning spike.

Breakfast typically is around 50-60g of carbs and this morning consisted of 2 rounds of wholemeal toast with butter and a grapefruit. Whilst I need a 1:10g bolus for the evening meal, my morning shot needs almost double that. For this meal which is 55g of carbs, I need 10 units to cover.

This morning was typical of my morning readings

Waking BG - 4.9 (88)
1 hour post breakfast 14.2 (256)
2 hour post breakfast 11.5 (207)
3 hour post breakfast 7.0 (126)
4 hour post breakfast 5.3 (95)

I'm very happy with the fact that at the 4 hour point I am back to my pre meal result, and due to my basal being bang on I know that it will stay here even if I delay lunch for another couple of hours.

What I would really like is to be back down to 7 or less at the 2 hour point just to minimise the time that I am high for. Is Apridra the way to go for me or can anyone suggest anything else?

I'm not going to beat myself up too much about this as my control is very good overall, but if a minor change can do it then great. That minor change will not be me eating 10g of carbs for breakfast before anyone suggests that

Thanks

Gary

[DeusXM]

It sounds to me like your basal isn't bang on - it's fine for the afternoon but it isn't for the morning. It might be worth splitting your basal so that you take more in the morning to cover your DP and less in the evening - it'll take a bit of working out exactly how your percentage split should be but it should work out in the long run. It might even work out that you need less basal in the morning and more bolus/

There isn't really much difference between Apidra and the other bolus insulins so I don't think it'll make a massive difference if you change thetype of bolus insulin.

[JediSkipdogg]

Deus, what he has is almost dead on what I have in the morning. I have my basals running perfect for using the same basal and waking up at 5:00 am (work day) or at 10:00 am (non-work day.)

My first meal requires 3 times the amount of insulin as every other meal. I then also spike up extremely high during it and then return to normal about 3-4 hours later.

Apidra does work alot faster. It actually helped my morning meal however messed up my other meals. The problem you have to worry is during your other meals you may have to somehow draw the bolus out or else risk going low. On my pump, that's easy, but I didn't have enough time to study the profile it had with me.

Good luck.

[RLK]

Gary, do you bolus ahead of time for meals? If not, you might try taking your breakfast shot 10-15 minutes before you eat. This gives your insulin a head start of sorts. It works well for me and getting my post-meal spikes more under control.

[Gary_W]

Thanks for these replies

Deus - I did do a fasting test a while back and my morning BG didn't go far. I hear what you're saying and will try it again just to see if the amounts are OK.

What I don't get is how splitting the dose would help here; I currently do the Lantus in one go right before bed, so surely this has the maximum amount of it working at its peak during the morning / early afternoon. If I did some in the morning instead then it wouldn't cut in quickly enough to help with this problem would it? I'm more than happy to be put right on this one.

Jedi - We do sound like we share this one. In the UK, it seems to me like you cannot get a pump unless you cannot control your BG any other way. As my clinic recons that 6.5 HBA1c is the best they've ever seen then I don't fancy my chances. Is Apidra available in a vial? If so, I guess I could use it for breakfast and use the novorapid for other meals... That would get around the fact that I haven't seen an Aventis pen that I like.

RLK - Usually, yes I do. Still seem to skyrocket in the morning. Always have. You should see me on cornflakes...

Gary

[June91]

I too have heard that Apidra works faster, no personal experience though.

[Lloyd]

I use Apidra in my pump, my postmeal numbers are back to premeal levels 2 hours after eating.

-Lloyd

[jen_slc]

The short answer... it depends.

The long answer... your situation is very much like mine while I was on Humalog and then Novolog. My 2-hr readings were always on the high side, no matter what I ate, but came down to normal levels within 3-4 hours; and if I corrected at 2 hours, I would be low at 3-4 hours. Now that I'm on Apidra, I don't get those prolonged spikes from meals, and I love it! Plus, I don't drop low at 3-4 hours. I eat, get up to 130-150 at the 2-hour mark, come back down to 100-120 at the 3-4 hour mark and hold steady there until my next meal.

I also have the same situation with breakfast ratios vs other meals - a 1:6 or 1:7 for breakfast and 1:10 or 1:12 for other meals. And actually, my post-breakfast readings are some of my lowest post-meal readings of the day (100-120).

So yes, it's possible that Apidra could help, but it depends. It might work well for you, it might not.

[Gary_W]

Thanks again for the replies.

Jen - it certainly sounds attractive and I'd like to give it a try. I now just have to convince the healthcare professionals at this end.... The clinic I visit told me I should only blood test immediately before meals and then before bed, so they just are not going to get what I'm trying to achieve here; there take is that if I am under 7.0 before a meal then that'll do....

I think I'll just try my GP who is generally receptive to new ideas.

Gary

[Gary_W]

Well I just did a fasting test this morning to just check that it's not my basal giving problems. My last meal was yesterday at 5.45, all I've had since then was a cup of tea with sugar at about 7.45 last night due to a mild low. I overshot more than I'd expect (low gi dinner...), and I was 7.2 (130) shortly before bed. I whacked in 2 units and woke up with a nice BG of 5.3 (95). Well, that was my first test at 8.30 but I'd been up a while. Honest

Since then, I've tested every 30 mins.

9.00 6.4 (115)
9.30 5.7 (102)
10.00 6.1 (110)
10.30 6.0 (108)
11.00 5.7 (102)
11.30 5.8 (104)
12.00 5.4 (97)

So the worst I had was a 1 point rise first thing.

As the basal seems spot on (IMO anyway) and I need 10u of insulin to cover 55g of carbs in this time period, what's the cause? At the back end of the day I'm on a 1:10 ratio and surely by that time the lantus would be running out too?

It just seems to me that my digestive system is far quicker than the insulin in me at this time of day.

Gary

[NoraWI]

I use Novolog and shoot 2 to 3 units for DP when I get up in the morning and before I drink my single cup of coffee with whipping cream and liquid sucralose. I get up at daybreak and my breakfast follows at least 2 hours later. I never, never, NEVER eat cereal or bread or anything carby at that time and generally don't have to shoot any more until lunch. My breakfast generally is egg (or eggs) and sometimes meat or cheese. Works for me. I try to eat low (actually moderate) carb, especially for breakfast, otherwise my control goes to pot the rest of the day!

[xMenace]

Gary, same boat here. Some things I've tried are
- super-bolusing. I borrow my late morning basals and include it in my bolus. I found my Humalog bolus extends the 6.5 hrs John Walsh claims it does, and this does have some impact.
- I bolus 1/2 hr early in the mornings now. I thought it would make a big difference, but it's only marginal.
- Low GI foods help some, but not that much in the mornings. I like my breakfast too.
- If at all possible, I spread my breakfast out. If I have fruit or juice, I'll have it an hour or so late if I can.
- Get an early read on your DP. If I'm high in the mornings, I don't just correct for it, I also up my bolus to prevent my next high. That first test is very often an indicator of how my whole morning will go. I make sure to follow up with tests, especially the hour before lunch.

I may also try Apidra soon.

[Gary_W]

Thanks for the replies again

Nora - I guess I could go with eating very low carb in the morning, but personally I'd rather not. I really enjoy a couple of rounds of toast and some fruit and whilst I occasionally go with the eggs it is not something I'd choose daily.

xMenace - Super Bolus in the UK? You do realise that we still prescribe a small poltice and a course of leaches for most things Pumpers.....

I've tried the 1/2 hour early bolus, and whilst it helps a little it doesn't really do the trick. And having two kids, I tend to sleep for as long as I can and then it's breakfast so it's not that often that I get to give it a head start! It's certainly something I do when I can.

I try to eat as much low GI stuff as possible. Grapefruit contains around 15-20g of carbs and has a GI of 25, so it's low in terms of GI and GL. The bread I eat is always grainy, and typically has around 35-40g of carbs for the amount I eat. As I said earlier, most breakfast cereals finish me off as this little lot gets into me slowly by comparison

Due to the aforementioned kids, I'm quite often woken up at weird times of the night / early morning. It's not uncommon for me to test my BG just to see how it's going. And, since getting my basal right, it's tends to be bang on the same figure as when I have when I get into bed.

Good news is that I just had a telephone appointment with my GP who is leaving a prescription for Apidra at reception. I cannot get it until tomorrow afternoon as none of the pharmacies around here have heard of it. Special order only. At least I know it'll be fresh

[xMenace]

**** life always gets in the way.

[kidvid]

I've always had a morning spike problem. And a noon-time spike problem. I use Symlin for both meals and I can usually keep it below 200. This would be for a 35-45 g. meal. I use Apidra in my pump, and split my bolus 60-40, 2 hours. Carb to insulin ratio is 10:1 both meals.

I'm a big believer in Symlin. I've only had T1 for 18 months, and I've been on Symlin for 14. I'm convinced the sooner you begin using it after diagnosis the easier it is to build it into your routine.

Joe