OK, so I didn't get to reply to any of the discussion as my post was closed. If anyone would care to respond, hopefully, without closing this thread (ha!) I'd truly appreciate it because I really am hoping for some help here. And YES, I have asked my Endo, I see her next week. she just keeps saying pump..ugh. Somogyi (sp) effect is a liver dump, no? Isn't the reason we take basal is to stop the liver from dumping, that's what it does, no? Also, DP it's the natural process of us waking up and hormones (adrenalin, cortisol) being released, which, in turn causes the liver to dump glycogen but we don't make insulin to counter-attack it, no?
Anyway, I digress. I'm only coming down as shown on my CGM because I'm taking novolog during the middle of the night and a lot to bring that huge spike down. I can't figure out what's causing that? It's a high after a low that I'm catching, I think, before I go too low.
Anyway, I did 5.5 u am and 4u pm (didn't drop overnight, didn't feel need to eat in middle of the night either) and actually stayed flat around 108 with no food or bolus after 6pm, unit 4am but then started rising and by 5am I was 150 and by 6am I was 165 and continue to rise with a ton of novolog trying to bring it down. This is what continues to happen. Is this DP and can levemir help this or is it simply not enough levemir, how does one know? I'm going to go to 5.5am and 5u pm levemir and see what happens. I cannot seem to get this right.
I've read ALL the books, I've tried everything. I also thought once we DO find our correct MDI basal dose, we're not supposed to be changing it all the time, correct?
I have to change my own basal often, depending on whatever, and sometimes for no reason I can fathom. But yes, you do need to FIND the base and go from there. So if your bg is rising at 5am then you need to adjust your basal either the timing or the dose. I pump so I would up my own basal around 2am... T1 and liver dump (a made up shenanigan in fact)is NOT likely but maybe you are not a T1 at all. Sarah, I know that thread got closed but did you read it?? As I suggested before, you really need to get some advice from your health care folks, we can only tell you our experience and it seems to not help one bit. I think I am more frustrated with your "trying everything" more than you are.
This is a stupid question but are you eating pizza for dinner, or a 12 oz rib eye??
Seriously, read the article above. You do realize we take basal to stop the liver from dumping glycogen (sp?) that's what our basal insulin does. The liver has a huge component in Type 1 diabetes, more then Type 2 actually. But, that's why type 2's take metformin, it's the same thing. Me, 'not a T1 at all', are you new on this website? I was DKA diagnosed weighed about 80 lbs. If you're frustrated then don't respond. Also, if you've read any of my past posts I eat low carb about 50 grams per day and am encouraged to eat more and gain weight. Please!
And, yes...if my BG's go up at the 'DP' time, around 4am...my question was for those who have experience on MDI and asking if MORE levemir helps with this DP or only bolus?
Here's another article for you to explain what basal/bolus insulin does for a type 1 diabetic and explains the liver's process. http://type1diabetes.about.com/od/insulinandmedications/p/Basal-And...
New?? Nope, not to TuD, the DOC or Diabetes. But then, being old school and having some long years of living with this and suggestions of healthy experience with any of this seems to get more scorn than appreciation. LOL about.com is not a source I would go to for medical advice...I prefer science and medical field proven research. I do wish you all the best in your pursuit of control, Sarah.
seriously....why do you think you take BASAL insulin, what do you think it's doing and it's role if one's not eating? google anything you want. JDRF and ADA have huge discussions regarding the entire endocrine process.
Sarah, my own basal keeps me flat....no matter what I'm doing or not doing/eating or not eating. And I know how to adjust it when necessary. I am pretty in tune with my endocrine system - until it tosses a dodge ball now and then. When that happens I fix it and go on with my bad self - LOL. I am hoping you can get a handle on yours - google is not medical advice just cuz it's got folks like moi trying to help ;)
Insulin converts food into energy. I think basal, more than preventing liver dumps, is to facilitate the energy conversion process on a cellular level. If your basal insulin is off, it can perhaps produce the spikes although I've found, as I've moved from R/NPH to a pump and then a pump/ CGM, that I'm really dismissive of "liver dumps" and am more suspicious of metabolic slowdowns after bedtime. I think the 4-6 AM rise is programmed into us, to facilitate hunter-gathering. I only fixed it by cheating with a pump, that allows me to precisely attack those particular numbers.
you're odd! that's all i have to say...LOL! Next time Gary comes on TUD you can tell him his article is wrong, too. LOL!
Getting Down to Basals
by Gary Scheiner, MS, CDE
Unlike its more famous little brother bolus, which is the rapid-acting insulin given to cover those delicious carbohydrates in our diet, basal’s job is much more mundane: to match the liver’s secretion of glucose into the bloodstream (and to prevent the liver from oversecreting glucose). Everyone’s liver does it, and a healthy pancreas responds by secreting a small amount of insulin into the bloodstream every few minutes.
How would we manage without basal insulin? Not so well. Because the liver is secreting glucose into the bloodstream continuously, a complete lack of insulin, even for just an hour or two, would result in a sharp rise in blood glucose level. Basal insulin also makes sure that the body’s cells are nourished with a steady supply of glucose to burn for energy. Without basal insulin, many of the body’s cells would starve for fuel. Some cells would resort to burning only fat for energy, and that leads to production of acidic waste products called ketones. The combination of dehydration (caused by high blood glucose) and heavy ketone production (from excessive fat metabolism) leads to a life-threatening condition known as diabetic ketoacidosis (DKA). http://www.diabetesselfmanagement.com/articles/insulin/getting_down_to_basals/all/
and again, i was referring to lantus/levemir when adjusting basal not a pump, which yes basal rates are changed all the time. hence, the main reason one goes on a pump...so they can indeed 'change' basal rates. it's different on MDI as we're shooting long acting insulin not short acting so changes can't take effect w/in a few hours and often takes days to see any changes with MDI basal.
Sarah, the gist of what I had to say on the other post was that your CGM did not look like Dawn Phenomenon. Your BG went up by 100 points starting in the early morning - but then it went back down by 100 points and was back to normal at about the time you were getting up. There are a lot of things that can make your BG go up by 100 points, but Dawn Phenomenon is not one of them - DP typically increases BG by only 20-30 points. And as a T1 producing none of your own insulin, your BG must have gone back down in response to injected insulin. My guess is that it was a correction dose, but maybe that guess is wrong?
So what I suggested was to give more information about the day that your CGM recorded. When did you take insulin injections and how much (all of them - bolus, basal, and corrections)? What did you eat during the course of the day and night and at what times? If you don't have all that information saved, then try to run your CGM for another day and record all that insulin and food information and upload it all here.
In my experience and that of others here it IS possible to get good basal coverage using Levemir or Lantus. But it takes time, and it requires you to keep tuning your injections based on your results. This is also true for a pump - you don't just plug it in and your basals are covered correctly - that takes time and a lot of tuning also. So this will require a lot of work on your part - lots of record keeping and testing and trial and error. But maybe we out here in internet-land can help based on our own experience doing the same thing.
Once you get the amounts and timing adjusted it should be pretty much the same from day to day with some exceptions - the exceptions being days where you eat very differently, exercise very differently, experience different hormone levels, go through a seasonal change, you put on or lose weight, etc. Believe it or not, this isn't as bad as it sounds - I tend to inject the same basal Levemir injections every day for at least a few months at a time. And again, this is just the same as being on a pump, where basal requirements will change for the same reasons.
The answers to your very basic questions are 1. yes you are not supposed to be changing your basal all the time, 2. basal should cover your BG and keep it reasonably constant when you are not eating food and injecting bolus insulin.
Sarah, you're quite right that the liver is constantly secreting a background amount of glucose that is covered in a T1 diabetic by basal insulin. But Karen is also right that background glucose is not the same as a "liver dump" - by definition a "liver dump" is when your liver unpredictably and unexpectedly releases a huge amount of glucose all at once - and that is what Karen is saying doesn't happen to her as a T1.
Anyway it was a sidetrack into "liver dump" that got the last discussion off the rails and closed, so I think it is best to leave the idea of "liver dump" alone - I really don't think it will add anything to your attempt to adjust your basal rates using Levemir or Lantus.
I just read what you wrote above and saw that you are taking a correction in the middle of the night that brought your BG down. Good - that makes sense.
Then my conclusion is that either you are either taking your PM levemir too early, or are you are not taking enough of it. What times are your levemir doses? Have you tried taking the PM dose right before you go to bed? Have you tried increasing the amount of your PM levemir dose?
As Jag wrote I would like to suggest that your dosage of levemir is too low. The liver is the tricky part here. For the liver the insulin is the only indicator for the glucose level. But the liver does not measure the glucose level itself. In a healthy body there is a higher level of insulin present when carbohydrates have been digested and are about to pass into the blood stream. In this case the insulin will indicate to the liver to turn its release rate down and to prepare for the intake of the coming glucose (the liver acts as a deposit for glucose). In case of a low the production of insulin will stop immediatly. This allows the liver to release more glucose. Here I assume that the Alpha cells are not functional anymore - as it is typical for T1 diabetics. Without the Alpha cells only the liver will moderate the lows which is much slower. Now imagine you have a low from a high level of insulin. The Alpha cells will not react and the liver gets the signal from the insulin that carbohydrates will fix the problem. As a result there is no counter regulatory response at all.
Now imagine you have less insulin present than you need. For basal insulin the length of duration is often proportional to the dosage. Most diagrams for insulin activity are for 10 units. If 10 units can cover 14 hours (Levemir) then 4 units might only cover 40% of this duration => only 6 hours are truely covered. So after 6 hours the coverage is insufficient. Without coverage the liver get the signal that less insulin is present = low blood glucose. It will then raise its release rate above the standard level to work against this "virtual" hypo. This can result in a very rapid spike in the BG like you are experiencing.
Levemir is not as even as Lantus. This little spike is has might lead to early lows and to the assumption that the dosage is too high. But with higher dosages the spike will happen later than it has before. The two spikes of two shots will sort of combine to one more evenly distributed activity if the correct dosage for both shots has been reached. The goal is to get to an even coverage that prevents the spike from the liver. In your shoes I would take bold steps. I would increase the basal rate for every shot by 1 unit every day (+2 for the day). I would also try to get them as even as possible. For this experiment to be successful it would be important to reach at least 7 units per shot - even with additional eating. These 7 units might be capable to cover 11+ hours which might be sufficient. But please test your BG often or use a CGM.
For me the injection pattern 7/7 every 12h is more smoothly than 7/5 for example. I eat one joghurt at night and this seems to be the key here. The basal dosage is sufficient to prevent the DP. The joghurt is sufficient to prevent going low at night. On top of that I get additional proteins. Seen realistically I face the same challenges but have developed strategies that work for me - most of the time. Did I write that I woke up this morning with 188 mg/dl ;-)
I agree with J1...timing is important when using Lantus/Levemir,I have used both,I would need to hold off injecting until 10:pm or later in order to time the spike so it would fall between 3am and 6am when my DP was active. If I injected early I would go low because my basal requirement is very low until around 3am. Too early would = a low BG around 1 am with a massive rebound starting around 3am. Basal insulin is not reliable and can have a 30 to 40 percent variation in utilization from one injection to the next...it's action it's very unreliable.
It's just not a reliable enough insulin for intensive insulin therapy...This is not a mystery...that's why your doctor is trying to get you on a pump...if you where not obsessive and proactive he probably would have not recommended a pump for you.;-)
I do not agree with your statement that basal insulins are not reliable. A generalization to "can have a 30 to 40 percent variation in utilization from one injection to the next" is not helpful here.
Sarah...I think most suggestions here have been covered pretty well. One thing Id like to add is it may help to introduce NPH into your regimine. I also deal with DP, and if I were on MDI I would add a small amount of NPH at night. The nice thing about NPH is it DOES have a peak at about the 6-8 hour mark, then settles back down. That would be an effective way to combat thos early morning liver dumps. Sure, it would add a third insulin to your tool belt, but it could be very effective.
As always, YMMV, and talk to your doc before changing anything in your care.
OK, thanks SO MUCH guys! Holger, yikes...sorry you woke up to 188, not fun. So, I will take everything advised here and start today at 5/5 at 10am - 10pm and stay at that for 3 days at least. I totally agree, it's the wrong amount and wrong times and I think too that an equal divided levemir dose is the best way to go, my endo did say that, 'to split dose evenly' as it's easier on the body. It seems, if I take any more then 5u either way then my AM dose runs into my PM dose and I have a HUGE drop at 12 - 1AM and then a huge spike, like 100 points (so, something liver wise or whatever is happening there). Thank you again SO much! You guys are simply AWESOME! :)
I haven't read any of the replies, but if you are rising in the early morning (like 3am - 5am) without first going low, then that's the dawn phenomenon. What you are describing with having to get up in the middle of the night to take rapid insulin and still being high is the exact (and really only) reason I went on the pump. Long acting insulin can't help with a strong dawn phenomenon because their profiles are essentially flat. You might try waking up a bit sooner, like 3am, to take insulin and see if that heads off a rise. The only way I could control my dawn phenomenon on Lantus (split injections) was to get up at 3am every night and take a 3-4 units of Humalog. I wasn't willing to do that forever, so that's why I asked my endo about a pump.
Hi Jen....THANKS! that's the thing, I do believe you're actually correct and that was my question(s) in the beginning...does this look like DP or just not enough Levemir? I was also told levemir can't help with DP..but, I'm going to try 5/5 and see if it helps at all (maybe that too will be too much and I'll just drop and rise anyway). It just seems no matter what amount of Levemir I give, I can't get that rise to stop (but it's a huge nearly 100 point rise and very quickly, it seems) and taking more levemir has never worked. I too have to take novolog middle of night to combat it. This too is the reason for a 'pump' for me. THANKS!
Note that it isn't necessary to move your AM levemir dose just because you are moving your PM levemir dose. If your day-time coverage is good (and based on that one CGM graph you showed it looks like it is), then I would inject your AM levemir the same as you are doing now - which I assume is when you first wake up.
For future reference, here's a link to that earlier (closed) discussion where you present your CGM graph: LINK
