Hyperglycaemia in early hours of the morning

Age: 22
Type 1 diabetes for ~4 years
Insulin: Lantus & Novorapid
Activity level: high - regular exerciser, sports participation and active job (Personal Trainer by profession for last two months)

I am struggling with elevated blood sugar in the mornings. I generally have good control over my blood sugars (all my HbA1C tests have been between 6.5 and 7.5) but my readings before breakfast are always high. In the last two months I have increased my training intensity as I have begun a resistance training programme; and things seem to be getting a bit worse.

I am finding myself waking up a lot more frequently between 02:00am and 04:00am needing to go to the toilet due to high blood sugar. Sometimes when I wake up in these early hours of the morning needing to pee, I will do an injection to try and bring me back down by the time breakfast comes around - but my blood sugar doesn't seem to change, and sometimes i end up even higher by breakfast time! I've been gradually increasing my lantus does to try and counter high blood sugar during the night but this hasn't seemed to have done anything yet. I have done a little bit of research about elevated blood sugar in the morning and I think I am struggling with either the Dawn Effect or the Somogyi Effect.

I know that the biggest HGH secretion comes during deep sleep and that HGH has a countering effect on the action of insulin. So would higher levels of HGH (induced by all this resistance exercise I'm now doing) be the cause of my elevation in blood sugar in the mornings?

Shall I just keep increasing my lantus (and reducing my novorapid doses during the day) to try and lower the nighttime blood sugar levels?
Or would splitting my lantus doses help?

Any thoughts/advice would be greatly appreciated!

Thanks
Tom

Hi,

You should basically review you overnight BI requirements.....

When you increase your dose, remember to do 3 am tests, more if you like, so you can paint a picture of whats happening over night.....

It could be you need more BI, or it could be the Dawn Phenomenon, or could be you bouncing back from a hypo.........

you can quickly rule out the hypo by taking some overnight results........the dawn phenomenon doesn't really ever go away, everyone gets it, its just some see a much more noticeable effect.......there are means to tackle it though.....

For some one as active as yourself the only way to go is on a split BI dose, preferably Levemir..........have you considered Levemir.....?

Do you not suffer from regular hypos due to the activity and the inflexibility of the Lantus......?

The HGH, which I have limited knowledge on probably isn't having this effect. From reading about it, it builds muscle, increases energy, so in fact the insulin requirements and effectiveness will likely increase, which may make you hypo rather than high......but as I say, don't know much about it.....

Although I don't train/exercise like you, I've struggled with the same high morning BG and extra QA (humalog) at bed time or during the night to correct high BG then often has no effect. Even doses as high as 6 or 8 units do nothing, and I've ruled out hypos being involved.

I'm on a split dose BI (levemir) and although this helped a bit, it wasn't great. I think for me the morning levemir wasn't lasting until bed so I was starting to creep up then and found it hard or impossible to correct, so ended up with high morning BG.

I've brought my bedtime dose of levemir forward to tea time now, so I have more of a 12ish hour gap, but not an even dose split: 7units at breakfast, 12 units at dinner. This seems to work better for me most of the time, although if i eat and therefore have any QA after about 7 or 8 in the evening my bedtime and then morning BG can get very unpredictable again so I try to avoid any evening snacking!

So I'd recommend levemir and possibly a split dose, if your DSN thinks that would be suitable for you.

I've recently boosted my lantus up to around 14-15 units (from around 11 units) and I take this just before bed (typically around 2230).

My question with regards to splitting my lantus is this:
Surely if 15 units during the night isn't enough.....then 7-8 units twice a day wont be enough either. I'd just be going to bed on 7-8 units of lantus rather than 15.....I don't see how that would help?

If you think about it as your body needing xunits per hour....each hour between bed and the next morning potentially needs a different rate of background. ...

BAsically its not a fixed amount you need even though your giving yourself a fixed amount.....

WHen I was injecting I had 38 overnight and 22 during the day....so the am and pm could be completely different....

THAT'S why the pump is so effective as you can program a rate in for every hour if you wanted....

Hi Tom,

I split my Lantus in January, but my reasons for doing that is that the Lantus wasn't lasting the full 24 hours, so BGs were going up between dinner and bedtime. Since splitting, no further trouble there This is not for the reason that you are thinking of splitting yours though.

Has upping your Lantus increased hypos during the daytime? If not, then you should be able to increase your Lantus dose. I don't think there is a need to split unless you see it running out early, as I did.

Has your diet changed at all? You mention increasing your training intensity. Have you increased your portion sizes at the same time? There are some foods that I can go to bed with readings of around 6, and wake at 3 am with readings of 17. Foods like lentils, beans, chick peas etc all do this to me. My only way to get around it is to take extra QA at bed time after one of these meals, even if my BGs are perfect at bedtime. It is all a bit of trial and error.

Dawn phenomenon doesn't affect me at all, in fact quite the reverse - my breakfast ratio is only 1/3 whereas all other meals are 1/2, so I can't help you with any of my experience there, but here are some practical tips to help when the BGs are high.

1) Check for ketones if your BGs are over 17.

2) Injecting directly into muscle will halve the time it takes to absorb the insulin. If I have a really high reading and I want to get my BGs down fast, then I inject straight into my bicep, and within 90 minutes, all of the QA is absorbed (Humalog) rather than waiting for 3-4 hours. For best results, rub the injection site after injecting and flex the muscle a couple of times. I only need a 4mm needle for this, but some people need an 8 mm one. The amount of QA needed when doing this is exactly the same as when injecting into fatty tissue, e.g if you need 3 units of QA to drop a BG that is 9 mmol/L high, then you still inject 3 units into the muscle. The only thing that changes is the rate of absorption.

3) If you can test BGs for a few nights at different times, you can see when your BGs start to elevate. If it is within a few hours of heading to bed, then taking some QA at bedtime (injected normally into fatty tissue rather than into muscle) could help delay the rise.

4) If you can afford a weeks monitoring with a CGM (Continuous Glucose Monitor) (Not cheap unfortunately), then you can see your trends over a week, see when the BGs start to rise or drop and then work your injection regime into that.

Hope that helps,
Warwick.

A few things. Firstly, it is generally believed by the experts that run DAFNE that rebound from night time hypo's is a myth. They believe that if you wake with high BG's its either Dawn P or something you did the evening before. Secondly if it is Dawn P you would not normally expect it at 2am, it is a hormonal process to ready your body for starting the day thus you would expect it from 4am-ish onwards. This is obviously not set in stone since we are ALL different but its not generally the case. One option to consider is switching to Levemir and having a split dose, obviously you should do this in consultation with your Diabetes Team not off you own back.
You might also try reading 'Your Diabetes Science Experiment' as mentioned in other forum posts. This is a book written by Diabetic who is also a power-lifter so she understands and explains the effects of different types of exercise on your body.
Good luck if you want to try injecting into muscle, ouch, I would guess its painful and not a recommended method for injecting insulin...

I was told that injecting into muscle would be painful, but haven't found it any more painful than injecting into the abdomen, in fact often it doesn't hurt at all, whereas some injections into the abdomen reach an 8 out of 10 on the pain scale. I do only use 4mm needles though so I think it only just reaches the muscle :-)