Dawn Phenomenon

Hi Guys

Just wondering if any of you suffer from the above. I've been diabetic for over 20 months now my ratios are as follows:

Breakfast 3:1 plus 16u BI Levemir
Lunch 2:1
Dinner 2:1 plus 1000mg metformin and 22u BI Levemir

I attended my DAFNE course mid Sept 09, in that my BI was moved from bed time to dinner time as I was high before bed and high when I woke up in the morning. For 2 days the change seemed to have worked however I have been battling against the rise of BG before bed and when I wake up.

I have recently started taking up swimming and cycling to tighten my control as I want to have a 1:1 ratio eventually!

The last couple of days my BG has been within my targets which I have been really excited about. My problem is now I'm having my dinner around 6ish my insulin taken by 630pm and I'm in bed by 10pm. QA is working as it should because for example last night I went to bed with a BG of 6.1 I woke up this morning at 4.30am thinking I was hypo but to my surprise I was 18.7??? I went back to bed and woke up at 10am with my BG at 17.2....I just don't get it.

I remembered reading a paragraph on this site about the Dawn Phenomenon and googled it, I've pasted the link below. I have my 6 week review next week and will discuss with the Consultant however in the meantime I'd be grateful for anyone's thoughts.

I don't know whether to increase my BI 2 units at dinner time but I feel I'm on plenty insulin as it is and really trying to cut back from a weight perspective.

The article makes sense but I would be interested what everyone else thinks!!

Cheers
Sam x

http://www.diabetes-support.org.uk/joomla/dawn-phenomenon

Hi Sam

I have been diabetic for 29 years and have only just completed my Dafne course In Norwich. I know how frustrating your situation is but I have a suggestion rather than you just inceasing your BI as I don't think it's the cause.

Test your BG AT 03.00 am to see if you are suffering from either 'hypo rebound' or the 'dawn phenomenon'.

It could well be that your BI need increasing but before you do that it is important to rule out all other possibilities first.

Just one other thing 'ratios' are different for everyone, 1:1 is only a starting point for Dafne it is by no means the 'norm', so please don't think it is a place that needs to be attained.

Hope this helps if it doesn't you haven't lost anything.

Tracey x

thanks Tracey. I'll certainly give it a go. If it is hypos I'm having what can be done to prevent them, do you know?

29 years is a long time you must have a lot of different experiences behind you and just goes to show all that time and still no steady cures! Maybe one day.

Thanks for the advice.

Sam x

Hi Sam

If you are having hypos you need to ask yourself why? Too much insulin, CPs not counted correctly. If you test your BG 5 hours after your supper you will know that the only insuling working is your BI. If you are confident that your BI's are working and holding you stable (both am and pm) and your ratio's are correct and your BG is still rising through the night (3am upto 11am) the next day it could well be that our friend 'Dawn' is knocking.

It is really important to establish a repeated pattern and eliminate all other possibilities, ie. exercise and alcohol before acting. I personally act to quickly then live to regret it, so believe me when I say' slowly slowly catchie monkey'!!

Tracey x

Hi,
Just to prove the people running the site, are just the same as you ;-) I am having a similiar issue to you regarding my BG being too high in the morning. Last nights 'fast' proved that its not my BI as I hypo-ed in the night, so I will now lower it slightly and investigate other options. As a point of interest when I went to the DAFNE Collaborative this year ( see User Group forum), there was a presentation by Prof Simon Heller about the dawn phenomeon. The relavent extract is
'The next two speakers gave a presentation relating to background insulin and its capability to last over 24 hours and probably more interestingly the misconceptions surrounding the Somogyi effect or rebound Hyperglycemia. It has been suggested that many high blood sugars in the morning are caused by night-time hypos. The presenters contended that this is generally NOT the case, the night time hypos only result in a relatively small rise in blood sugar. So if this is not the cause then what is ? It was suggested that the cause is a form of the Dawn Phenomenon where the body releases hormones. The factors that cause this rise are length of sleep, duration that a person has had diabetes and horizontal posture. The biggest issue with this hormone release is it occurs from 5am onwards. This means using an increase of background insulin the night before is not a good way to treat it, since a hypo would occur in the hours before the increase in hormones. The only effective way to treat it is by injecting fast acting insulin, which is a bit of an issue since most people are not awake at 5am. One method would be the use of insulin pumps, but since these are still not widely available to all Diabetics there is no easy solution.'

That doesn't provide a solution I'm afraid but it might provide an insight into what is happening to you as well as me. Unfortunately I have not seen any follow up to this, if I see any follow ups I will post on this site.

Hi Marke,
I read that paragraph re Dawn Phenomenon on this site few weeks ago and did some re search into it. Pretty much everyone on agreement that it's hormones! I took Traceys advice and did a 3am check definately not hypoing through the night. With all the excercise I've been doing I'm reducing insulin by 30% and not suffering hypos either which is good. I guess it's trial and error seeing what works and what not.

I tend to get up at 5:45am just wondering if I should follow the advice by taking correction doses at 5am or hold off till next week and speak to my consultant. They do come down fairly quickly it's not like I'm chasing them all day. Oh the joys eh!! Out if interest what have you done in terms of your highs in the morning?

Sam x

Hi Sam, Well to be honest All I have done so far is reduce my BI by 1 unit. I will leave this a while and then think about what to do next. The secret to it all is take your time and don't expect instant results. A few high readings for a while is not going to do any long term damage. Its better to take it slowly and get it right.
I would also wait and see what your consultant says, hopefully they are DAFNE aware and understand how you are managing your Diabetes. The thing about the 'dawn phenomenon' is like all other aspects of Diabetes it will vary from person to person.
I also note you are taking metformin which suggests you have a degree on insulin resistance. Unfortunately this I would guess could be causing issues. I am NOT a HCP, however having been on steriods this year and seeing the bizzare effects that they had on my BG's I know that insulin resistance is not a straight forward 'even' factor in BG's. Thats why its probably better to get the advice of experts, although it does no harm to ask for advice here. You will get support if nothing else on here.

Hi Guys,

I have quite a marked dawn phenomenon and was almost at the end of my tether until recently. I like yourselves started of checking for night-time hypos (as to be honest this is what I thought it might be) when I discovered that from 4am-8am I'd creep up from 7 to 17!! Despite many attempts to correct this I just couldn't get it sorted and when I increased my BI to a certain amount I went lo which ment I ended up being high in the morning anyway. Nightmare! It was suggested that I get an insulin pump but to be honest I hate the idea of being attached to a machine so I thought I was going to have to just out up with it and correct every morning.

However, recently I was put on Insulin I for my bedtime BI (the same as the old insulatard) which action peaks at 4 hours meaning if I time it right (ie take my bedtime jag at midnight or later) it combats the increase in BG and as a result my morning BMs have been really good. Not perfect but it is a hell of a lot better than it was (down to single figures mostly). The only draw back is you really can't take it before midnight otherwise it will peak to early and you will go lo (but if you are an owl this is perfect, or just set your alarm if you want an early bed).

This also means that you would have to split your background dose too so you'd have to take another jag in the morning of one of the new, slower release ones (eg levimir, lantus). I have to say though for me it has made a huge difference and I don't feel so disheartned with my control.

Its definately something to think about!

Nicky

PS - If you have a dawn phenomenon you are more likely to need a higher ratio at breakfast anyway to combat that no matter how fit you are as those hormones that are released to wake you up (which gives you the dawn phenomenon) are still hanging about your system. I've found that even if I wake up fine and don't eat breakfast I still have to give myself a couple of units to keep me level for lunch.

Hi Nicky

Thanks for your in put really interesting what you're saying. I've done the numerous 3am checks over the last week and I'm definately not hypoing. I spoke to my nurse the other day and discussed pumps, she actually mentioned another BI I think it maybe the one you're on can't quite remember the name. I'll speak to her in more detail next week.

When you say taking a split background are you taking a QA plus Insulin I and Levemir or have I picked you up wrong?

I had changed my ratio at breakfast from 2:1 to 3:1 few weeks ago because of the high sugars in the morning.

We'll see what options there are next week and thanks for sharing that. Always good to hear others experiences.

Sam x

Hi Sam,

Yeah you have picked me up correct! I'm on Levemir (10u) at 8am then my QA during the day (I'm on 3:1 in the morning too and 2:1 the rest of the day) and the Insulin I at midnight (14u). It sounds a bit of a pain being on three different insulins but to be honest a jag is a jag. The only think is remembering which cartridge to put in which pen! Don't want to be making a mistake like that!!

I hope all goes well with you next week and that you will get something sorted, whether it is the Insulin I or the pump. From what I've heard from people who are on the pump it is great and it does give you very tight control it's just personally I don't like the idea of it. Go with whatever suits you best.

Good luck!

Nicky