Experts Please Guide : Dawn Phenomenon


#1

Whew hope I spelled it right!
I am waking up to higher blood sugar numbers.
My honeymoon period is going thru some changes. I have had to increase my basal and my meal bolus.
All is good with that.
I check my nighttime levels 3 times a week and those numbers are good as well.
So I wake up 30-40 points higher than my comfort level.
My comfort level is 90-100 upon waking.
So I am wanting to give myself a bolus early morning to prevent that rise.
A pump is not an option for me.
The correct protocol?
Wake up every half hour to determine the rise time?
Bolus at rise for safety or bolus earlier?
Thanks.
Ann

Type One, MDI, Tresiba, Novolog and Novolin R.
63 Female. Low Carb AC1 5.7, Diagnosed Aug 2017.


#2

DP (Dawn Phenomenon) is always a struggle, more so if you’re using a basal/bolus MDI regimen rather than a pump. I could never get satisfactory control of mine when I was on Lantus-Novolog; taking Metformin helped ameliorate it a bit, but it was only when I switched to a pump and was able to program a higher basal rate for the wee hours of the morning that I finally wrestled it down.

It’s just one of the disadvantages of “flat” basal insulins like Lantus or Tresiba that once you take 'em, that’s it, they’re going to do what they’re going to do and you can’t adjust it. But if pumping doesn’t appeal, you might consider taking a low dose of NPH at night. NPH is not flat, like modern basal insulins, but has a peak about 4-5 hours out from injection. so if you can work the timing out it should achieve max effect around the time DP is kicking in. I have a deep and abiding aversion to it because of 20 years on it before Lantus was available, but if you’re careful and incremental with it, it can be a good thing. Here’s a pretty good article on the whole question:


#3

This is why a pump would be better for you, long term. You may need,like myself, and countless others, an increased basal beginning sometime after midnight. My increased basal starts at midnight and ramps up to a peak around 2-3AM and tapers back down to my daytime rate around the time I rise. That generally works well for ME. YMMV. I only gave an example–not a suggestion for you to emulate.

EDIT: After years of doing what I mentioned above, I just checked my pump settings; I’m surprised that I simplified the basals so that I get the same rate at midnite, until 5AM. .725 at midnite and .6 at 5AM. Looks like I’m going to have to redo that, as it was set up that way following surgery. I’m glad I just looked at the settings!


#4

Thank you…and the pump is not an option for me.
Maybe when I get Medicare.
Dreading that process.


#5

Thank you and alas pump is not an option for me maybe when I get Medicare.


#6

OK. Well, you can still manage on MDI if you read up on how to best control night time bg’s. I never did manage to do that using Lantus and Humalog. I’m sure others have used more complicated MDI than that and may be able to suggest something for you.


#7

Thanks Dave44! Hoping so!


#8

https://www.sciencedirect.com/topics/medicine-and-dentistry/dawn-phenomenon


#9

A pump is also not an option for me and I basal on Lantus and have been able to cure dawn phenomenon with careful analysis of CGM curves. My dawn phenomenon always started at 4 AM so for a while I got up at 4 AM every day and took bolus humalog to counteract but that was not the answer. I then realized that the phenomenon always happened and extent was due to the long acting carbohydrates I had eaten at my 6PM meal. I gave up my supper carbs and now only do carbs at lunch or very minimal at dinner. That gave me a straight line all through the night, however, I found that taking 8 units of lantus, my glucose level dropped ever so slightly every 15 minutes or so throughout the night. Then cut back to 7 units of Lantus and my glucose would rise ever so slightly every 15 minutes throughout the night. I am fortunate to have a digital pen that delivers insulin in 0.1 units and found that at 7.4 units, and little to no dinner carbs flatline my readings throughout the night. PS - my morning comfort level is also 80-100. Hope this helps.


#10

Whew deep reading here will delve more deeply as I just scanned a bit. Loads of info and considerations.


#11

Oh goodness, lots to figure out and you did it.
I will work with fewer carbs at dinner time fingers crossed that helps.
I am also going to check in at 4 and 5am just to see what those numbers are.
Thank you.


#12

@NatureOrbs - Carbs (or glycogen released by your liver at around 4am) are not the predominant cause of early morning rise in blood glucose.

Your body has an adrenal release (it secretes higher levels of growth hormone, cortisol, glucagon and adrenalin). These effectively increase your short-term insulin resistance, after which even normal low levels of glucose in bloodstream cannot be neutralized.

My dawn phenomenon (aka DP) is now at the point where at 3:30am, my basal pump dose increases from 0.3U per hour to 1,5U / hr. Even though I pump, I now need to awaken at 4am to check BG and decide if I’ll give myself an additional 1.5Unit or 2.5Unit bolus of Humalog.


#13

Thank you so much to learn truely missing the honeymoon days.
I so appreciate all this insight here! Very helpful!


#14

Maybe I can’t justify the science but works for me.


#15

Me too. But here’s a thing I just learned. If you’re on Medicare and doing MDI, your insulin is treated like any other pharmaceutical and is subject to the Part B donut hole, so you end up having to pay for it out of pocket for a month every year. That just happened to a T1 friend of mine who recently started Medicare, and she was shocked. Fortunately I was able to help her out by giving her three vials of Novolog from my Diabetic Zombie Apocalypse Emergency Stash. It was an eye-opener for me too—I’m not far off from Medicare. But it turns out that it’s not a problem if you have a pump: the insulin is treated as a component of the prosthetic device and covered under the durable medical equipment benefit.


#16

Have you ever split your basal? (I didn’t read everything posted here).

I would call 90 to 100 a pretty small (kinda unrealistic) target. Your target makes me nervous. I feel like your trying to throw a machete at a grain of sand. There is simply not much room for natural system variability. I would throw a word of warning about monkey-ing around with something that’s not broken.

Your blood sugar machine cannot even likely read within the precision of the target that you are trying to hit. Does that make any sense?

Like, your expectations might be setting you up to feel very uncomfortable. Does that make sense? More than you ought to.


#17

Can you tell us where you get this pen and does it come in Tresiba?


#18

30 to 40 over your comfort level honestly isn’t that bad for dawn phenomenon. I would go up much higher without my pump. It would be nicer to wake up in a more perfect range, but as a type 1 you’ll find all sorts of things will play with your blood sugar. A pump , sorry I’ve know it’s been said, but a pump is one of the best helps with it.

My basal rate is .50 from 11-5:30 am and 2.20 from 5:30-9:00 am to cope with it.
And that doesn’t always work completely!

I feel you Jim in Calgary, i don’t wake up early to catch it, but a lot of the times I am giving myself .50 to 1.50 extra units upon awakening. You can’t automatically set it for extra because you don’t always need it! But if I wake up in the early morning hours the first thing I do is reach for my CGM to check what I’m at and to see if I need an extra dose!


#19

The pen is only a delivery system and does not contain any insulin. The pen is Compatible with the current 3 ml insulin cartridges from the manufacturers:
Lilly® Sanofi-Aventis®
Berlin-Chemie® Novo Nordisk®
I have one of these pens for Humalog and 1 for Lantus and have been using Pendiq pens for about a decade. Please note that they are not FDA approved and therefore not available in the US but I do import mine from Germany and Germany will send them to the US. My opinion is that we are a 3rd world country when it comes to diabetes and better treatment options are available outside US. The pens are wonderful but would not consider them highly robust as they tend to wear out in about 18 months (at average 5-6 shots per day) and a real pain to get warranty service from Europe. They are manufactured in Korea.

Humalog cartridges for these pens are available in the US, however, Lantus cartridges are not. I therefore buy my Lantus cartridges in Canada or anywhere else in the world. I don’t use Tresiba so not sure if and where Tresiba may be available in cartridges.

Pendiq 2.0 Insulin Pen delivers 0.1u Increments


#20

Love the Zombie reference and yikes I should have a stash.
Your story confirms my fears about Medicare.
Big Sigh.