Please someone explain how to deal with the Dawn Phenomenon. My endocrinologists say to increase my nighttime dose of basal so that my morning fasting BG is at the target rate. But I think (from my few attempts to wake up before dawn and measure the BG) that this morning rate is (significantly) higher than it has been during the night, due to the DP. Of course I wouldn't want to increase basal and go low overnight. So I guess my 2 questions are:
a)when calculating basal for the night, how far into the morning do I go b)What to do with the DP - just add to my breakfast bolus to bring it down?
Thanks to all of you out there and a Good, Healthy (Jewish) New Year!
It is best to not go high to start with. Even though bringing it down in the morning will help. All the info that is out tells us that if we keep our sugars in normal range as much as possible, then we can avoid complications better.
I use a CGM so it was easy to see when my sugar spiked at night, It was always one hour before I woke up. I adjusted my basal and now I flat line all night,
If I go to bed very late or very early, it throws things off, but never enough to cause me trouble with lows. I get about a 50 mg/dl bump and I try to go to bed at 100 or so. If i wake with 150 , It isn't the end of world, still many people get a bigger bump than that.
If you dont want to invest in a CGM then you can just test every hour on the hour a few nights to get an idea. For most people the PDP happens just before dawn :)
so you can start checking about 2 hours before you wake until, well when you wake, It is very likely to be in that time frame.
You wrote "...my sugar spiked at night.. I adjusted my basal and now I flat line all night". Is this with a pump? How would one adjust the basal to flatten the spike without causing hypo, without pump?
Yeah, with a pump/ CGM it's a lot easier, as you can select the rate at which the fast acting insulin trickles into you so you can have more when you need it. With adjustments, I usually try +/- 5-10% until it gets the number where I want. I think that usually the night basal is a smaller amount than the day so it may help keep your BG from crashing out too much? There may be some overlap too, if you get spikes in action from basal insulin? Lantus/ Levemir are supposed to be flat but I think some people report some variability of the action. This seems reasonable as some people with pumps report having different basal rates over the course of a day too.
I struggle as you do with DP. With shots, you have limited control. I use a split basal and adjust my nightime dose to "try" to control my DP. A good insulin dosing approach is to increase your nighttime basal until your morning numbers reach target (usually defined as awaking with the same blood sugar you went to bed with). You need to be aware and protect yourself against hypos, this may involve setting an alarm and testing. In the end, you may find that there is no solution that meets the goals of no hypos and good morning numbers. In which case, you just do your best which is the highest dose you can tolerate without any lows.
That is basically where I am at and I still often awake high. There are some things you can do beyond that. Some people employ NPH as a nighttime "booster," since it has an intermediate profile, it can provide a bump in insulin overnight without causing as many hypos at other times. Bernstein recommends that you wake at like 3am, test and inject insulin (he suggests Regular) to provide that badly needed bump. I just can't stomach this, I have enough trouble with sleep. And finally, you could just do what I do, do the best you can and test and correct upon waking. I am insulin resistant in the morning, so you may find you need a different correction factor for these corrections as well.
May the new year bring you a string of good morning numbers.
Thanks Brian, that just about describes what I am dealing with -- and that maybe there is no great solution :( Would you recommend to go to sleep at target BG and work from there - or to go to sleep with a higher BG so you can take more basal and be a little lower in the morning? (does this make sense at all?)
I like to go to bed with a good fasting blood sugar with no food in my belly and no bolus in my blood stream. Everything else just adds variables. Of course, I don't always do what I like.
I'm on a pump now, and my highest basal rates are in the early morning to control my blood sugar when waking up. Even with that, I still wake up high sometimes if I do anything differently, like not eating breakfast as soon as I get up.
Without any basal rate increase (such as when I was on Lantus) I could go to bed at 6.0 (118 mg/dl), be the same at 3:00 AM, and wake up at 17.0 (over 300 mg/dl) at 7:00 AM, easy. It was impossible for me to increase my Lantus enough to cover that without going low during the first part of the night. In the end, the only solution I found—which worked great—was to wake up at 3:00 AM and give myself 2-3 units of Humalog. I wasn't willing to do this forever, and this was the primary reason I went on the pump. (My pump trainer was all surprised; she said I was the first person she'd met in 10 years who cited control as the primary reason for going on the pump, rather than primarily convenience.)
In addition to more basal, I also need to give myself more insulin to cover breakfast as well as to correct high blood sugar in the morning. If I'm usually using an I:C of 1:10 during the day, I use one of 1:8 during the morning; and if I'm usually using an ISF of 2 during the day, I'll use one of 1.6 in the morning. At the moment I'm using an I:C of 1:8 during the day (and 1:6 at breakfast) and an ISF of 1.6 (and 1.2 at breakfast). My pump settings change throughout the month and seasons, but if I don't use more insulin than usual at breakfast for boluses, I end up spending the entire morning high. The morning for me counts until about 10:00 AM, then I go back to my usual settings for the rest of the day.
My CDE suggested some time ago to set a temp basal as soon as I wake up. I usually only need this on work days but I increase by 20% for about 2.5 - 3 hours. It works very well. Until I eat breakfast that is ;) But that would only work if you're on the pump naturally. Are you?
no Stacey and jen - i'm not a pump. I'm trying to figure out how to deal with this without pump (and preferably of course without waking up at 3AM)
Back in the day when I was on MDI, I used to take 3 units of NPH at bed time to manage my DP. That would mean 3 different insulins of course for you, but maybe your Dr has other ideas.
They used to make lots of different ones. I used to take Ultralente and Lente. Which all have different lengths and inset of action and duration.
I think you could find one that could work if you took it at bed time and could time it right
here again, as long as liver is still paying attention to insulin, yes this should all work.
on otherhand metformin can be far more effective. for me it was.
best wishes and thanks for comments.
Negg, I'm on shots, too. I take my larger Lantus dose at 7 am in the morning. I figure it probably wears out by 2 am. So 9 pm I take a wee percentage of the total as a booster. I know percents on split dose are much more even than mine in most people, but mine works with me. I take 5/6 of the total at 7 am and 1/6 of the total at 9 pm. I am at 100 when I go to bed and 100 when I wake up in the morning. I worked at getting the percentage at night over quite a long period because it takes 3 days to settle out. Be patient.