Constant lows and highs

Type 1 and LADA
1

Hello everyone. I’m new to the forum and have been having some lows and highs that I cant seem to control. I was diagnosed as Type 1 about 14 years ago and I’m currently 60 years old. Last year I had a brain blead (AVM and Aneurism) so please excuse my writing skills as I still suffer from short and long term memory issues. I take MDI and for some reason I cant seem to control my night time lows/highs. I can wake up with a low reading of 3.5 one week and then the next week I can wake up with 12 or higher. I usually have the same things to eat weekly so I’m not sure what’s causing these swings. For example I was in the 3.8 range for about a week and then went up to 8-12 for the following week. I didn’t change any eating habits so this is what’s causing me lots of grief. I’m. not sure if moving to a pomp will help as I’ve always been on MDI. I’m sorry if I’m not asking the wright questions but I thought I could start here.

Thanks so match for any help :slight_smile:

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Paul – Welcome to the TuD forum! Congrats on a willing curiosity about your glucose control. I have a few questions that might permit me and others to give you more appropriate answers.

I see that you’ve had a stroke. Arteriovenous malformation (cause of brain bleed stroke) is new to me so I’m don’t know what blood-sugar effects, if any, it may cause. Are you (or your doctors) aware of any metabolic effects of AVM? I experienced an ischemic stroke three years ago, so I suspect some overlap with your cognitive symptoms. Is one side of your body more affected than the other?

Can you describe a typical day of eating? Food has an incredible effect of blood glucose. If you can, describe the amounts and timing.

Do you exercise? How often and what duration?

Can you afford to use a continuous glucose monitor (CGM)? Awareness of glucose fluctuations and trends is key to unravelling your unique metabolism. Even wearing a glucose sensor for 30 days every 90 days will teach you a lot about what you eat, the effects of sleep, and how your exercise affects your BGs.

If I was faced with your circumstance, I would narrow my variety of meals to just a few so that I could learn how these foods affect my BGs. You don’t have to live this way forever but limiting the variable for a few weeks or a month can teach you a lot.

If you don’t already, I would try to keep a consistent bedtime each day. Setting an alarm for bedtime can create a good sleep habit!

Try to make regular any stress-relieving practices you use. Meditation, singing, playing an instrument, breathing exercises, or praying are some skills to hone good BGs.

I’ve used a pump for almost 50 years, so my preference is clear. I use an algorithm that lives on my phone to tweak an ever-evolving insulin profile. Some people prefer not to live with that level of control. I understand. My personality fits well with pump therapy. I find that, ironically, once the finite list of levers is mastered, it makes life simpler as it mellows metabolic mayhem. (Controlling glucose variability is just as important, maybe more, as A1c and average glucose.

By the way, I believe that writing is big therapy for the brain and I encourage you to continue!

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Thanks so much for your reply, Terry. I’m not sure if there are any effects regarding my AVM but I was in surgery for about 12 hours, and they performed a craniotomy to fix the AVM and Aneurism. My memory is what I have the most trouble with as I’m currently reading at a grade 6 level.

A typical day of eating would be:

  • Breakfast: Greek Yogurt (plain) with a few apple pieces, a couple of banana pieces, some peanut pieces and a few blueberries.
  • Lunch: Decaf coffee and an apple.
  • Dinner: Some types of meat like chicken/ground beef etc. and some grilled vegetables.

My dinners are typically low carb. I rarely eat out for dinner as that can usually be very high carb and I don’t like taking a lot of insulin with dinner. On the weekends I usually have scrambled eggs and again with some choice meat.

I’ve been a runner for the last 30 years and still run 4 times a week. I also walk a very lot and usually get about 20-30k in steps each day. I weigh about 170lbs at 6 feet tall, never smoked and have always looked after my weight etc.

I wear the FreeStyle Libre 2 so I’m not sure if that’s a CGM?

I sleep regularly and usually it’s bed at 10pm and then wake at about 6am.

I’ve never used a pump and always taken daily injections for my diabetes. I don’t mind taking my Apidra daily but now I’m worried about the swings I get. It seems like on any given day I can be at 3.8 in the middle of the night and then next week I can be 12.9 the following week with no real change to my eating habits so it’s very frustrating.

Hopefully this helps :blush:

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Your diet and habits seem exemplary. The swings are indeed puzzling. What is keeping you from trying a pump? It seems to me that any hybrid closed loop system would provide some help — cutting off insulin when you’re low and increasing it when you’re high. There’s a learning curve with these things, but they should provide some cushion against the high/low swings.

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I use Apidra as well. What long-acting insulin do you use? Most long-acting insulins do not give solid 24-hour coverage. Taking the long-acting twice per day is way to compensate for lack of 24-hour coverage. I’ve had good luck (for short-term pump vacations) with Tresiba (Degludec) using once per day.

Yes, the Libre 2 is a CGM. Good habit.

Your exercise and sleep routine sounds great to me!

I would recommend experimenting with adding slightly more protein, at least temporarily to see the effect on BGs. I would try eggs and meat for breakfast.

Many people, including me, at first, wouldn’t give sardines a fair try. They’re great for protein and Omega-3 fatty acids. I highly recommend them.

Do you pre-bolus for your meals? If so, how much in advance of eating?

Some people suffer no blood glucose ill effects from eating an apple by itself. Many T1Ds have an excursion north of 7.7 (140) when they do. Instead, try eating only half and adding some peanut butter or cheese. Eat the peanut butter or cheese first. Your Libre is your friend to help make these choices.

Keeping your blood glucose variability calm is a big deal in my book. More variability (as measured by standard deviation on your Libre) creates more variability. Time in range is another way to look at minimizing variability. Squeezing at least 2/3 of your daily Libre readings between 4.0 and 7.0 is a good target.

I only mention these ambitious targets because I think they are likely attainable by you and they will produce consistent results with a good quality of life. In any case, you need something worthwhile to steer towards. We all differ, of course, so your experience may vary.

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Thanks :slight_smile:

I use Lantus and take 20 units at 9pm every night. Maybe I should try taking it twice, one at 9pm and then another at 9am?

I usually take my meal time insulin about 30 mins before eating and that seems to work for taking it with food. I generally don’t have many issues with my numbers after eating its the night time numbers that are causing me stress. Like I said changing from 3.0 to 14.0 on any given night when eating the same meals is frustrating.

I have attached my reading from last night but Saturday night I was 3.8 most of the night.

Libra
Libra1200×1558 301 KB

Thanks again for your help.

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Hi Paul. I’m also a T1D on MDI. I was going to ask about what the graph looked like, thanks for sending that. What does your dose calculation look like?

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Sorry, I’m not sure what you mean?

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Sorry, I’m just adding another message for you. I take Lantus (20 units) for my 24hr insulin. If I take this twice daily would that help? I thought it was supposed to last 24 hours so wouldn’t I be getting 10 units at 9pm for 24 hours and then another 10 units at 9am for 24 hours?

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I’ve never taken Lantus myself but I’ve read many accounts of people reporting that one dose per day gave them unsteady coverage, BGs like you write about. If it were me, I’d split the total daily dose in approximately half and deliver it twice per day.

Your vigilance with your Libre and finger-stick meter should help you make adjustments. I would be tempted to deliver the Lantus at bedtime and then at wake-up time in the interest of not forgetting this added task. You might consider an uneven split (40%/60%) if you adopt say a 10 pm/6 am routine.

This requires you to do the extra work and perhaps get some help from a knowledgable doctor. I personally prefer to change insulin dosing plans on my own. I’m not comfortable telling you that you should do this, only that this is what I would do if I were in your shoes.

I believe in personal experimentation, good vigilance and record-keeping in making insulin adjustments.

I have personal experience with Tresiba and know it is very forgiving with the time of day that it is delivered once it reaches its “steady state” after several days on a new routine.

As @Tnyc said, a pump used with a hybrid closed-loop system would probably make your life easier. On the other hand, a pump brings more complexity and failure points.

Here’s what my AI search gave me when I entered “Lantus doesn’t last me a full 24 hours”:

AI Overview

Learn more

It is important to discuss any concerns you have about your Lantus not lasting the full 24 hours with your doctor or diabetes care team

.

Here’s why and what you can do:

  • Individual Variation: While Lantus is designed to provide a steady level of insulin over approximately 24 hours, the absorption rate and how long it lasts can vary from person to person.
  • Potential for Blood Sugar Rise: If Lantus wears off before your next dose, your blood sugar may rise.
  • Possible Solutions:
    • Splitting the dose: Some doctors recommend splitting the daily Lantus dose into two injections administered 12 hours apart to address this.
    • Adjusting dosage: Your doctor may need to adjust your Lantus dosage based on your blood sugar levels and other factors like physical activity, diet, and overall health.
    • Changing insulin type: Some individuals have found that other long-acting insulins like Toujeo or Tresiba work better for them in providing a longer duration of action.
    • Reviewing eating habits: Late or high-fat/high-protein evening meals can affect blood sugar levels overnight.
    • Checking your Lantus pen/vial: Ensure your insulin is stored correctly and hasn’t been exposed to extreme temperatures, which can affect its effectiveness.
    • Addressing insulin resistance: If insulin resistance is a factor, your doctor may suggest lifestyle changes like weight loss (if applicable) or adding oral medications.
  • Consulting your doctor is crucial: They can properly assess your individual situation, determine the cause of the shortened duration of action, and suggest the best course of action for you.

Remember: Do not make any changes to your insulin regimen without consulting your doctor first.

Here’s a 2009 TuD thread addressing your issue:

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Thanks everyone… The problem I see is that last night (from my picture I added) wasn’t even working all night. I take it at 9pm and therefore it should of at least worked over night? Its almost like I had no Lantus at all :frowning: This was a clean fresh container…

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I should have said how do you calculate your Apidra dose? For example are you using a Carb ratio when calculating how much Apidra to take for a meal? What else, if anything do you include in your bolus dose calculations?

Needing to split a lantus dose to even out its effect would show up an either consistent elevated BG in the 4 hours before you dose or consistently needing to increase your dinner dose to stay within range. You’ll need to look at your past CGM data, are you familiar with Libreview ?

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Once in two doses. 10 units at 9AM and 10 units at 9PM in your case.

Everyone who responded is dancing around the issue because no one, quite rightly, wants to give medical advice. Talk to your doctor.

Most docs do not encounter people like you or, indeed, many of us who have a relatively restricted diet; your diet is certainly low carb and approaches keto, zero carb. I’ve done that but I enjoy my wife’s food way to much and would not abandon it while she is around.

What I have found is that I did need to do Lantus in two doses; not “twice per day” split the dose into two per day. I also needed much less Lantus when doing a lot of exercise. Splitting the dose helped because I didn’t go low and I also didn’t go high.

These days I do use a pump and I use a system that automatically adjusts my insulin; it responds automatically to my high and low BG. That’s not the answer it’s more like the sugar coating on the cake.

I read a couple of your earlier experiences from back a few years and they’re worse than mine because you were misdiagnosed. Given what you are doing you can work out what your body really needs. There are standard ways for T1s to determine basal requirements (the Lantus) and bolus requirements and you are in a good position to do this.

There are also the standard medical determinations of basal requirements for a T1. A rule of thumb that works for me is 50% of insulin as basal (Lantus) and 50% as meal; you might want to check that out because I think you will find that you are way off that.

YDMMV I tend to go back to the basics when things don’t work; clean the carb, check the spark plugs etc. For T1D the basics are the basal, easy to find by experiment, the bolus, easy to find by experiment and then deal with the variables; how many times a month do I play golf? 0. That’s an easy one for me :slight_smile:

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I started on a pump over 15 years ago because I had trouble with Lantus. I think you are taking way too much Lantus for your weight, activity and diet. As suggested above, some basal testing is in order. I believe that your Lantus does not last the 24 hours. So from dinner to bedtime you are riding on your Apidra dose. Your 9pm dose of Lantus (too high a dose) pushes BGs down so that in the middle of the night your liver releases glucose and then you go high. Basal testing is definitely in order. Of course, a smart pump would be best.

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A few thoughts on maintaining even blood sugars, and apologies if this seems basic:

  • Consistency of food yes, but types matter, so low glycemic carbs and high protein help even out numbers
  • Workouts affect responses, so you need to be aware of the intensity of your workouts, and for me, high intensity workouts tend to increase lows, either by revving my metabolism, decreasing food intake, or increasing insulin sensitivity

As for changes:

  • Have you considered weight training? At 60 and just doing aerobic work, you might be losing muscle. Doing both aerobic and strength work might help with metabolism
  • The pump is often recommended for people that have problems maintaining blood sugar level
  • Follow up on the calculation/equation you are using. There seems to be some confusion, but you need to be able to calculate your insulin needs based on current BG level, activity, and food intake. You might already do this, but you seemed not to understand @spdif question
  • Consider Tresiba for better long-term insulin dosing
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Hi Willow4,

Thanks but I only take my 20 units of Lantus at 9pm. The first picture I sent was from Sunday night and I will add a new one from last night. My numbers were better last night but I’m still confused at how I can be up to 15 one day and then match lower the next day. Both days were the same 20 units of Lantus at 9pm and very similar dinners.

Please see Monday nights reading…

Lantus_Monday_Night
Lantus_Monday_Night1569×2110 480 KB

Thanks so match :slight_smile:

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Thanks Jamaslgoe,

Please don’t apologize for the basic questions. After my brain bleed my memory has been match harder for me. I haven’t worked since the bleed (website developer/programmer) and basic tasks like reading can be slow for me. I’ve gotten better from how it was but I don’t think much of the loss will come back fully at this point.

Yes, maybe I should add some weight training but I’ve always been a runner so its just something I do.

I will be talking to my Doctor on the 12th so I have lots of questions to ask :slight_smile:

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I explained in my previous post how you can take the same 20 units one day and go low and then go much higher the next day. Twenty units of Lantus per day, even divided into two shots, are too much for a person your weight, diet, and activity level. Do some basal testing. OR reduce the amount of daily Lantus by 1/2 unit every 3 days while also dividing the Lantus into 2 unequal parts and watch the results. You probably should not be taking anywhere near 20 units per day of the stuff.

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I’ve heard it’s tougher for white collar workers to get back after serious brain issues, as their employment is based on the one thing that is sometimes diminished. It is easy to feel despondent but keep trying. Hope and hard work can keep you going, and even if nothing improves - unlikely - or never gets back to what it was before, it will help keep you upbeat. It is like exercise in some ways in that you’ll never get better unless you push yourself.

BTW, I work in software engineering as well, and have been primarily an aerobic fitness practitioner, although I’ve lifted on and off over the years. Currently, I’m getting more heavily into it, but still, my favorite workouts are on the rowing and cross-country ski ergometer, along with spinning. Rowing was my favorite competitive sport - not high-level, but regional on-the-water events - and cross country skiing is one of my favorite recreational activities. Both have heavy strength components. As for yourself, maybe mix it up a bit, if you can and would enjoy it.

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OK, just looked at your last graph. It shows that you had a slight rise in BG when you awakened. Completely correct. Then you took a bolus for your breakfast which started bringing your BG down. Don’t know how much bolus you took. Then at 9am you took Lantus and the graph shows you going low by 10am. Maybe too much bolus for food and definitely too much Lantus. Do basal testing OR begin reducing the amount of Lantus and watch the effect as I described above. OR change the basal insulin to something else as someone suggested above. OR get a pump. The problem is your basal. It is dangerous to go low at night.

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