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RE: [IPk] Charlie Dalton
I've had some thoughts about what might up with Charlie's high daytime and
low nighttime blood sugars.
Scenario 1: Too little intermediate/long-acting during the day; so there
should be more in the morning injection
Scenario 2: Too little Regular before breakfast and lunch, so that carb is
not covered in the short term.
One way to check what's going on would be less than fun for Charlie and you,
but if he could fast from bedtime on a Friday night until noon on a
Saturday, for example, you could see what his blood sugars do overnight/in
the morning hours (testing 2 a.m., 4 a.m., 6 a.m., 8 a.m., 10 a.m., and
noon) when he's on only the longer acting insulin (so he would have his
normal insulin before dinner on Friday night and no breakfast on Saturday,
and _just_ his longer-acting insulin that morning, and then some Regular
with a good-sized lunch).
Scenario 1: Too much intermediate/long-acting insulin (as several others
Scenario 2: At what times does Charlie eat dinner, go to bed, and tend to
have super-lows that cause fits? Does he eat dinner at 6 and go to bed at 8?
If so, his dinnertime Regular is just about to hit its peak when he gets to
bed, and his intermediate/long-acting has not yet set in. If he is having
too much Regular with dinner, then his bg will drop low soon after he has
gone to sleep. Then, when the intermediate/long-acting insulin takes over,
at perhaps 10 or 11 p.m.--whoosh!!!!--down goes Charlie's bg to a dangerous
Scenario 3: Is Charlie quite physically active? Or has he been more active
than usual on the days preceding the really terrible lows at night? If so,
he may have experienced the glucose-going-back-into-the-muscules phenomenon.
When I go for a three-mile run sometime between 4 and 6 p.m., I must go to
bed on a bg of 11 or I wake up with a bg of less than 3. If my bg is between
9 and 10, I set a low temporary basal rate and let my bg rise a bit
naturally. If I'm under 9, I eat an apple or some yogurt with sugar (I aim
for 20-30 g. carbohydrate) and then set a quite low basal rate for a few
With my pump I could theoretically sidestep the higher bedtime bg altogether
set a really low (like .1 u/hr) basal profile for three hours (like 12
a.m.-3 a.m.) and see if that does it, but then if I miss a workout and
forget to change that basal to something like 1 u/hr, I will have a bad high
bg in the morning (judging from past experience!). I learned about the
necessity _for me_ of a highish bedtime bg from my diabetes educator in the
U.S. She emphasised that three post-dinner hours of a bg around 11 are way
less dangerous long-term than 10 hours at 11 and also less dangerous in the
short term than 1 hour of a bg around 1, especially if the higher bedtime bg
allows me to wake up with a great bg in the morning.
One way to check what's going on would be to reduce Charlie's dinnertime
Regular insulin and let him go to bed with a bg of about 11 and see if he
wakes up with a brilliant bg and has slept soundly through the night. If his
bg goes down significantly--from 11 to about 6--then too much
intermediate/long-acting insulin is likely the issue. The next step is to
let him go to bed with a bg of 9 or so and reduce the
intermediate/long-acting insulin one unit at a time, giving each lower dose
three or four days' try before reducing by one unit again. If you can get
the nighttime bgs sorted on a most-of-the-time basis, then sometime when
he's had a couple of hours playing actively and running around in the
afternoon, try testing his bg through the night (like at 10 p.m., 1 a.m, 3
a.m., and 5 a.m., and then as usual when he wakes up). If you see that it
drops sharply between any of the tests, you may want to make a practice of
reducing Charlie's evening intermediate/long-acting insulin by, say, 10% the
next time he's had a big afternoon on the playground or the pitch. Then
repeat the testing through the night and see what you find out.
The point is to get the Regular right so that Charlie goes to bed on a
decent bg and to get the intermediate/long-acting right so that the second
insulin _maintains_ that good bg overnight. The peaking of
intermediate/long-acting and the delayed effects of exercise on blood sugar
can really pull punches when it comes to getting a smooth line on the ol' bg
graph! (The exercise is really worth it, though!!!! We just have to figure
out how to make it work best _for_ us rather than _against_ us.)
Okay, another morning when I woke up 1.5 hours ago to do Latin and e-mailed
instead! At least I can still get in a good 1.5 hours before class....
Best of luck and all good wishes to you, your husband, and Charlie. If I
might be of any help off-list, please be in touch.
IDDM 8+ years; MiniMed pumper 6 years; nerd 20+ years
P.S. One more factor: if Charlie has a dinner that's lower in fat than
normal, he may need less Regular insulin to cover it than he would normally
take. If one regularly has, say, 20 grams of fat in one's dinner and then
one night one has pasta with meatless tomato sauce and a salad, the
onslaught of more carbs at once than usual may well lead to a higher
pre-bedtime bg, but the insulin taken to correct it will probably work well
(possibly a little too well). Keep in mind that fat slows the absorption of
carbohydrate (which is why, sadly, chocolate isn't our best bet for fixing
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