Spike after Humalog

Recently became insulin treated diabetic (MODY 1 diagnosed in 2013 but can no longer take oral meds because of pregnancy) and am stumped by how I’m reacting to humalog in the evenings post-dinner.

Take this evening as an example. 130 before dinner, took 3 units humalog (which has been plenty for me the past few weeks) with 3.5 servings carbs. An hour post-meal I’m at 106 but at 90 minutes I start climbing, often up towards 200 ~4 hours post-meal. Only happens with dinner. I take the humalog 15 minutes before eating.

I’m still educating myself on this new treatment landscape. But this has me baffled. Has been happening for over a week.

Any thoughts would be greatly appreciated. I’ve even started googling whether the insulin could be spoiled somehow.

I’m not real familiar with MODY, but I believe it can get worse over time?

First, hormones can really mess up your blood sugars, some women really have a difficult time for a week every month, I’m sure pregnancy hormones might do the same thing.

If it seems to happen only at dinner, then it is something about dinner. I don’t know enough about pregnancy and hormones but I suppose if certain levels vary during the day that could cause a nightly issue.

But you might look at what you are eating? The most likely cause of later rising of BG levels would be how much fat is in your meal? Fat delays metabolism of your food or carbs, even though your carbs are low it’s possible the insulin is already gone by the time the carbs hit your system.

Plus in people that eat low carb, they usually need some insulin for the fats and protein they eat. I don’t low carb but I’m sure someone will be along that can help you more with that.

That of course only works if maybe you are eating higher fat meals at dinner, unless hormones also play a part in time of day.

I agree with Marie that it might be what you’re eating. I need to bolus for fat, but also for high amounts of protein. If I have a steak for dinner I can expect my BG go go up several hours later, and my next fasting number might even be higher than usual.

Also, if I eat a lot of carbs of any kind my BG might look great for a couple of hours and I think I’m in the clear, but then my BG will spike. In those cases I try to pre-bolus part of the dose, and then add the rest when I start eating. If I have dinner and a dessert I bolus completely separately for them rather than adding the carbs together and bolusing once.

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When I was pregnant, some 40+ years ago my doctor told me to be careful. Whatever your BS is the babies is -10 of your reading. I don’t know if this has changed but talk to your endo. When your BS gets to the 200 point does it start to decline?

Looks like you need to dose for that 3.5 carbs serving as if it were actually 4.5 servings.

You should be evaluating the effectiveness of your meal dose with a BG 2 hours after eating. That’s the data point that tells you if your dose was effective…not 1 hr, not 90 min, check at 120 min.

For example, If you ignore that I ate that banana, then this 9:30 meal dosage was effective. It wasn’t, because I had to eat a banana to keep from going low, but lets pretend that banana doesn’t exist. BG = 87 at 9:30 and BG = 74 at 11:30, so pretty similar numbers. Thats good.

I don’t know how many units you take for 3.5 carbs, but lets call the new, better dosage Y units per 67.5 grams.

3.5 carbs might be 15 grams per carb count, so 15g x 3.5 carbs = 52.5 grams of carb.
4.5 carb counts is 15g x 4.5 carb counts = 67.5 grams of carb.

Y units per 67.5 grams of carb = Y units / 67.5g = Y/67.5 units per grams of carb, or
Y units per 4.5 carb counts = Y/4.5 units per carb count = Z

If you eat 15 grams of carb, or 1 carb count, then (Z u/15g ) x 15g = how many units you take for 15g, or one cab count. If you eat 50g, then (Z u/15g) x 50g = Z x (50/15) = number of units that you take for 50 g.

Can someone check my maths?

How many grams is one carb count for you? 12 or 15g?
How much insulin do you take for 1 carb count?

This would be easier with actual numbers, lol. One of us can just run the numbers for you.

What basal insulin are you using? I agree with what everyone has said about delayed fat/protein, but another possibility is that your basal insulin is running thin in the evening.

Thanks for the replies everyone. I really appreciate it. I’m new enough to insulin dosing that I don’t have it dialed yet how much exactly I need for each unit carbs (which is 15g for me). And my reactivity seems to change throughout the day. In past weeks, I’ve been able to do 1 unit humalog for each 20 g of carbs and maintain tight control 2 hours later. That seems to be ineffective in the evening.

I’ll try to take a closer look at the fat/protein issue.

Right now, my endo only has be dosing basal in the evenings. I’m doing humalin n NPH, 2 units, at bedtime.

I’ve got much more to learn about managing all this, so appreciate all the feedback.

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I am not familiar with MODY though but generally type 1’s have a honeymoon period where they still make some insulin until they don’t. So the requirement for insulin goes up with time as they make less and less insulin. Plus you have that hormone thing with pregnancy.

So commonly all of us have insulin carb ratios that are different person to person. But we also have different ratios for different times of day. It is common to need more insulin either at night or mornings.

I did misunderstand the servings of carbs versus carbs you ate. But it still holds that if there is higher fat in your meal it delays absorption.

So when I eat my vegan pizza which is not as high fat as “regular” pizza I have to take my insulin dose in 3 stages because there is 30 grams of fat and about 100 carbs. But a “regular” pizza has a lot more fat and people sometimes dose for it hours after they eat it.

But be careful of dosing too high at night and trying to make adjustments because you do not want to hypo. Maybe switch your bigger meal earlier so it is easier to dose at night.

You may possibly need a different insulin/carb ratio for dinner. Or you may need a better basal insulin. If you can qualify for an insulin pump, you’d be able to get much tighter control with a pump, because a) it uses all rapid-acting insulin (much better than NPH) and b) you can have different basal rates for different times of day, as well as different insulin/carb ratios.

For now, you may want to up your insulin/carb ratio for your dinner dose of humalog. But if you do, change it very gradually until you figure out what works. Like, if you’re at 1 unit to 20 g carbs now, change it to 1/19 for a day or two, then 1/18 etc.

Good luck with it and keep us posted.

Ahh, yes, that’s a must simpler way to do it. If you know darn well that your off in the eave, you could try 1u per 15g carbs for a couple days in a row. But, like Ruth4 suggests, only small changes at a time.

From your description I might suggest two or three things, based on my non-MODY and non-pregnant experience.

Perhaps increase the pre-bolus time. If you’re @ 130 and bolusing 15 minutes prior to eating, try 20-30 minutes.

Second, if you’re having a larger amount of protein/fat (which is pretty common for dinner), you might try a second bolus 90-120 minutes after eating. Some folks count protein/fat grams @ 40% of a carb gram.

Third, maybe try reducing the portion size and/or reducing the amount of protein/fat.

NPH is an intermediate acting insulin that generally lasts 12-18 hours max with a significant peak and drop off after that. I would suspect you have little to no basal coverage by dinner which is partially responsible for what you are experiencing. Are you able to switch to a modern basal insulin (Lantus, Levemir or Tresiba)?

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Ooh, good point Scott_Eric. I didn’t even think of that…just went right into my “NPH is horrible” mode of thinking.

Given you are MODY and pregnant, your insulin requirements may fluctuate greatly.
Based on your current low injected insulin doses, your body is still producing significant insulin, but there is no easy way to know how much, and how it may change.

My suggestion is to get CGMS (dexcom or libre), so you can have real time visibility to your trends, which will likely change greatly throughout your pregnancy. Maybe consider pump (omnipod) to allow tweaking basal (non meal time) insulin.