From Odense, Denmark:
I am 24 years old, have had diabetes type 1 diabetes for 12 years, am fairly active (playing soccer and bike riding 10-40 km a day), and I am on four injections a day (Actrapid before meals and Insulatard at bedtime). My last A1c was 6%, but I frequently experience high fasting glucose readings (typically 10.0-17.0 mmol/L [180-306 mg/dl]).
I have discussed it with my medical team several times since I cannot seem to find a pattern in the readings that might explain them being so high. With approximately the same amount of exercise, food and similar glucose readings at bed time (around 8.0mmol/L [144 mg/dl]), the same amount of Insulatard (currently 16 U) seems to give a fasting glucose reading of 3.1 mmol/L [56 mg/dl] one day and 14.5 mmol/L [261 mg/dl] the next. I realise that it could be because of nocturnal hypoglycemia and/or the action of other hormones such as growth hormone and glucocorticoids during sleep and in the early hours of the morning, and I have therefore occasionally tried to do a test at 3:00 am, but this have not provided me with any answers (a reading of 5.2 mmol/L [93 mg/dl] at 3:00 am typically gives a reading of 10.0 mmol/L [180 mg/dl] before breakfast).
Do you have any suggestions? I have been advised to go down to 12 U of Insulatard at bedtime, but when I tried that, my fasting readings were even higher (above 20 mmol/L [360 mg/dl] ). Are there any guidelines for how high the reading at 3:00 am is supposed to be? My doctors have not been able to answer this question; they only say (as I already know and have heard many times) that the reading at bedtime is not supposed to be under 7.0-8.0 mmol/L [126-144 mg/dl].
It's not easy to properly answer your questions through this medium. I'm prone to use such a regimen in every patient, and the results are generally fine. Blood sugar at bedtime should not be higher than 7.0-8.0 mmol/L [126-144 mg/dl]. nor lower than 6 mmol/L [108 mg/dl]. One more suggestion is to always use the buttocks for the bedtime NPH injections. Finally, a switch to an intensified insulin regimen utilizing Humalog or Novolog for meals with Lantus (insulin glargine) as basal insulin might help. Ask your diabetes team for further assistance.
[Editor's comment: Several additional thoughts:
- Since your hemoglobin A1c is 6%, I'm not sure how worried I'd be, since these high values appear to be transient.
- Your situation might well be clarified by monitoring sugar levels continuously for several days to try to sort out what's happening in more detail. See The Continuous Glucose Monitoring System and ask your diabetes team if it's available.
- If you are unable to use the CGMS, you could play detective on your own by monitoring blood glucose levels every hour or two over the course of a typical (usual food intake and exercise) a few 24-hour periods. This would give you a clearer picture of where the problems lie.
- If you are currently eating a bedtime snack, you might consider decreasing its size, changing the type of food, or eliminating it altogether.
- Your 3:00 am blood sugar seems to be within the normal range, so I suspect you have a true dawn phenomenon. A change in the timing of your bedtime NPH to an hour or two later might solve your fasting blood sugar problem.
- Since it appears that decreasing your bedtime NPH increases your fasting blood sugars you might trying increasing the NPH by a unit or two to see what happens. If you do this, be sure that someone is aware you've done so, and is prepared to help, in the unlikely event that a severe insulin reaction were to occur.
- You don't say what your blood glucose levels are throughout the day (before and two-hours after meals). If you are not currently basing your pre-meal Actrapid on carbohydrate counting and are having to "chase highs" all day long, this is a problem.
- Dr. Songini's suggestion of a switch to Lantus with a rapid-acting analog at meals is a good one. However, it is my understanding that Lantus is not yet available in Denmark with the exception perhaps of clinical trials. You could inquire as to where these trials are being conducted and participate in the studies. As an alternative, a switch to Ultralente in spilt doses 12 hours apart as basal with the rapid-acting analog before or after meals (based on carb counting) is another option you might explore.
- Finally, insulin pump therapy affords the most flexibility and ability to "fine tune" blood glucose levels of any currently available treatments for type 1 diabetes. This is another choice you should consider.
Your problem will only be solved by doing a lot of detective work and problem-solving with your diabetes team. I suggest that set up a consultation time and bring a printed copy of this response with you. Do not make any changes in your regimen without first discussing them with your own healthcare providers. SS]
Original posting 11 Jun 2002
Posted to Daily Care
Last Updated: Tuesday April 06, 2010 15:09:33
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