Hard-charging low persists, repeats and baffles

Treatment Insulin
1

The problem

I’ve been working on adjusting basal rates on my pump to counteract lows occurring in the midnight to 2 a.m. timeframe. These lows are not like any I’ve had before. These are lows that resist added glucose. Let me say that again, these lows don’t respond when I eat glucose tabs!

When this started happening, I couldn’t accept this reality. It’s been a basic law of my diabetes metabolic life for over thirty years. When I go low, drink some juice or eat something fast and carbby and 15-20 minutes later, my metabolic ship rights itself.

It typically happens a few hours after I go to sleep. My practice is to eat my last meal in the early evening so that could climb into bed with very little to no insulin on board (IOB). At the most, I might have less than 1.0 units IOB. Then, after midnight, my CGM would vibrate with a 70 alarm and shriek with an audible alarm soon after. I bleery-eye rollover and check the CGM number. It says 68 and a slight downward trend, a sideways arrow but the dots are marching downhill.

Mystery deepens

No problem, I told myself, just pop a Dex4 glucose tab and roll over. Fifteen minutes later I get another sub-70 alarm and now I’m down to 62. WTF??! OK, mysteries happen. Pop another Dex4 and try to get some sleep. Fifteen minutes go by and now I’m hitting the obnoxious 55 alarm. So I get up and fingerstick, thinking maybe the sensor has drifted off. Nope. Fingerstick comes in at 54. So I eat two Dex4s; that makes 4 total for the episode and I’m baffled.

My last meal was more than 6 hours ago and even with a duration of insulin set at a conservative 5 hours, I’m showing no IOB. I didn’t do anything unusual exercise-wise and I didn’t drink any alcohol. Fifteen to thirty minutes later my CGM complains again; now I’m down into the 40s! The episode duration now stretches to over an hour, I’ve thrown over four glucose tabs at the low and it stubbornly resists. So I eat two more tabs but also get up and chase them with a glass of water.

Finally, after about two hours, my BG turns around. But it turns around with a vengeance and skyrockets to 300. It’s as if all my glucose tabs were held behind a dam and let go all at once, too late and too much. Here’s a graph of the action:

I decide to get up and deal with this

The first lesson I draw is that I need to physically get up when this happens. I need to drink water with my glucose tabs and don’t go back to sleep until the low is neutralized. A few nights nights later it happens again:

This time I do get up, treat with repeated glucose tabs and drink water. I also start adding insulin to counteract the glucose corrections. It took me over an hour but things turned out better. I eliminated the big BG bounce.

Maybe the basal rates are too high

So I start adjusting the 10 p.m. to midnight and midnight to 2 a.m. basal rates. The next night I’m rewarded with this trace:

I took a glucose tab or two and my BG responded. I didn’t need to physically get up. Progress. Here’s the next night:

So things are moderating but I still have that post midnight downtrend. The green strip ranges from 65-140 mg/dl. So that quick jump from the bottom to the top of the range is a mid-sleep glucose tab and its response. Things are getting better but my goal is to sleep through the night with no interventions and a good steady in-range BG line.

In the eye of the storm, a no-hitter

Finally, I’m rewarded with this 24-hour beauty yesterday:

It’s back

So, I conclude that I just had some out-of-whack basal rates and that’s the reason I had those hard-charging lows. But last night, a wrench is thrown into that hypothesis:

My basal rate was unchanged from the good day before. I went to bed with little to no IOB. I actually omitted my usual evening walk. Same symptoms that started this mystery. Woke up to the 70 alarm, took one glucose tab, no response, took another followed by the 55 alarm. CGM went down to “Low” or under 39 mg/dl but fingerstick showed 48. I got up and took a few more glucose tabs and also took two units to counteract the expected rebound.

I’m going to pick up a glucagon emergency kit so that I can mix up a mini-glucoagon shot if this happens again. I’ll take 15 units measured with an insulin syringe instead of the big dose in the kit. I’ve done this before with good results.

Two hypotheses

So, what the heck is going on? I have two theories. The first is that the lower valve in my stomach is not opening and holding back my glucose tabs. I have gastroparesis, so that is a possibility. The second is that my liver stops putting out its usual drip of glucose. Kind of like when I drink a few glasses of wine and the liver gets preoccupied processing the alcohol and the usual liver glucose drip is interrupted and I go low in the wee hours of the morning. I’ve witnessed that event many times.

I’m baffled. I’ll go to my endo next week but I don’t expect much enlightenment on this issue. I’m on my own. Any comments?

2

Maybe you answered your own question when you said you pop a tablet and “roll over”

I’ve learned the hard way that laying down / sleeping entirely changes the way your digestive process works. Try popping a glucose tablet then sitting up and reading a book for 15 minutes instead… (I know easier said than done). This goes along with your first theory of your stomach not digesting the glucose-- just realize your body positioning and sleep/ wakefulness can affect that situation a lot.

I wouldn’t recommend messing with glucagon unless you’re in an emergency situation.

3

Thanks for the reply, Sam. I do find when I get up and treat with glucose tabs, it does seem to resolve more quickly. With my impaired digestion, that idea makes sense.

I’m still puzzled why my BG is diving just after midnight with no IOB and after turning down my basal rate for the 10 pm to midnight period. I am cognizant that everything with diabetes cannot be explained or at least understood. There does seem to be an X-factor that we must learn to roll with.

Having said that, sometimes I think we give up too early in our quest for expalnations, writing it off to diabetes mystery, when sometimes it is explicable.

Well, my early conclusion to just get up every time this happens seems to be a good one. At least when I’ve done that I’m able to rationally add some insulin to pre-empt the expected BG bounce.

4

Can’t comment on the pump issues but try treating stubborn lows with glucose gel instead of tablets, hold/swish in your mouth (under tongue too) swallow and drink water. Seems to work better for me anyway:)

5

My quick take is that your basal is too high for maybe 20:00 - 0:00 (if there’s no IOB), AND that you are treating with too little glucose, AND that you might want to consider adding some protein, especially if you are going to treat with only 1-2 glucose tabs. At least, that’s what I would do based on MY protocol - aka, not LCHF.

I do like your idea of delayed digestion of the glucose tabs. I sometimes will crunch a tablet up and slowly let it dissolve in my mouth - I think that helps get the glucose into the bloodstream faster because of all the blood vessels in the mouth/tongue.

6

You know, Lilli, I’ve not tried glucose gel before but I have let glucose tabs slowly dissolve in my mouth while drinking water. It seems very close to the concept of glucose gel. In other words it moves the glucose from a solid to a liquid. I wonder if there’s anything else to the gels that I’m aware of. Thank you for the comment. Perhaps I should try out a gel.

7

I dropped the 9:00 p.m. to 12:00 a.m. basal from 0.6 down to 0.3 two days ago and today I dropped it to 0.2. That’s an aggressive drop and I’ll be curious if that doesn’t do the trick tonight. In the past when this kind of thing has happened, I usually had to back off the extreme change and reverse direction and brig it back a bit. But this is what my body seems to be demanding so I’ll just follow it.

I used to adhere to the 15/15 rule for treating lows, 15 grams of glucose and wait 15 minutes and measure again. I’ve found when I have little to no IOB, I can often take just one tab or even a part of one tab. But in this situation I was ultimately throwing 5, 6, or 7 tabs over an hour’s time and not seeing a BG bend back up towards normal. This experience acts different than what I’ve done for many years.

You could be right. Perhaps I need to at least take two tabs to start with. In any case, I will not roll over and try to go back to sleep. When this happens, I will get up with the 70 alarm, eat two glucose tabs and drink water and stay up until the trace bends up.

Thanks for your response.

8

Forgive me for preaching to the choir, especially since you are way better at the CGM than I am, but remember that the interstitial fluid will lag behind your BG.

The other point that I was maybe not clear on was this. If your BG is going lower because of too much basal and/or your body being way more efficient with insulin all of a sudden, then a small amount of glucose is going to get into and out of the bloodstream pretty quickly, whereas adding some protein (1-2 teaspoons of peanut butter?) might take a bit longer to process.

I know you’ll figure it out. You have amazing tenacity.

9

Boluses last a long time. when I’m physically mildly active,working I can bolus and eat, then two and a half hours later eat again. Without a bolus. Before I found this I was using a 0.2 basal. I discovered this by using address for a while until breathing hurt.

10

I don’t mind re-examining basic concepts since sometimes revisiting the basics can uncover the cause of problems. I’m pretty comfortable, however, with the CGM lag time and I don’t think that it’s involved in this scenario. My overnight lows in the past were well-treated with glucose only but I have had instances where a teaspoon of peanut butter gave me a nice flat line. I usually consider doing something like that but don’t feel like that’s at the bottom of this as I think I’ve identified the source of this problem.

So last night I reduced my 9 pm to midnight basal rate from 0.3 units per hour to 0.2 units per hour. A few days ago I was 0.6 units per hour. Last night I enjoyed a restful 10 hours of sleep with this great line:

For some reason, this has been a tougher problem to troubleshoot for me than others. My thoughts about digestion delay inhibiting glucose tab action and liver abnormalities confused my thinking. Before I conclude for certain that basal rates were the root cause, I’ll need to witness a few more good nights like last night.

If a too-high basal rate from 9 pm-midnight is the culprit here then I will be reminded once again about troubleshooting-101. It’s best to start with the most likely reason and then work your way toward testing the less likely reasons.