Understanding a bedtime high

[dqmomof3]

We're two weeks into diagnosis, and I am learning daily, I think. But I'm confused by one thing (only one thing in this hour, anyway!) What in the world do I do about a bedtime high? Our treatment regimen is Humalog before breakfast, before lunch, and before dinner, and then Lantus before bed. On the second night we were home, Jayden was over 500 at bedtime. I called the endo, she said up the Lantus to 15u instead of 10u and that should take care of it. So I did, but now that I know more about how Lantus works, that doesn't make any sense at all!

So, last night we get a reading over 400 at bedtime. I dosed the 15u of Lantus (now our standard dose) and put her to bed. I did not check her during the night. She woke up this morning at bg of 101. Dosed for breakfast (she had oatmeal), bg an hour and a half after eating was 211. Before lunch, 2 hours after last check, bg was 125.

I'm having a hard time understanding what is happening here. How can bg go from over 400 to 101 in the course of the night? Is it safe for her to go to bed at night with bg over 400?

Help, again!

[Gwyn]

Hi,

I don't have all the info your endo has, but it seems to me that your Lantus dose may now be a bit too high.

During the honeymoon lots of crazy things happen, but generally speaking, you need to find a lantus does that keeps you mostly stable overnight along with a pre-breakfast numer that is in range.

I doubt that your endo was "treating" the bedtime high with Lantus, but was trying to get your overall numbers down to a lower level.

It sounds like your breakfast humalog bolus is pretty good as about 3 hours after breakfast she was back to her morning number, but it may be that you need more insulin at dinner time to keep her from being so high at bedtime.

[Flutterby]

how are is bedtime for dinner? it could be that she needs her dinner dose adjusted, and back off the lantus a hair.. she shouldn't have to go to bed at over 400.. if lantus is dose correctly she won't move more than 30 points (I think that was the number) in either direction all night.. your daughter is CLEARLY doing that.. so something, somewhere is wrong.. and I'd start with that dinner ratio..

also, you are correct in that the lantus shouldn't be used to correct highs like that.. you should be using humalog to correct the highs..

[dqmomof3]

OK, I don't think we have ever had a move of less than 30 points overnight! Let's see:
Dec 29-30 drop of 153
Dec 30-31 drop of 310
Dec 31-Jan 1 drop of 74
Jan 1-2 drop of 290
Jan 2-3 rise of 20
Jan 3-4 drop of 162
Jan 4-5 drop of 19
Jan 5-6 drop of 200
Jan 6-7 drop of 145
Jan 7-8 drop of 78
Jan 8-9 drop of 93
Jan 9-10 drop of 66
Jan 10-11 drop of 136
Jan 11-12 drop of 44
Jan 12-13 drop of 315

So...obviously I need to take this to my endo tomorrow, but where do I start the fix? When I have the Lantus at 10u instead of 15, her daytime numbers skyrocket. The 15u keeps her daytime readings at 250 or under. Should I be more concerned about the nighttime numbers staying within 30 points of where they started, or should I be more concerned about the daytime numbers being high and having to do extra correction?

I'm determined to do my best for my daughter, but I hate this disease!

[saxmaniac]

I would point out to the endo that 300 is a bit large of a drop to have overnight, and ask why they wanted to increase it. It's pretty odd since you're overnight numbers show a bit of drop.

If you have a high at night like that, you want to consider increasing the dinner dose of fast-acting (long term) and maybe do a correction dose (short-term) with Novolog. The latter takes some delicacy to avoid lows, if you do it, be conservative and check hourly. I wasn't comfortable doing until about 6 months into it, and it's still nerve-wracking to do at times.

[Gwyn]

It will likely take a while to get things where they should be. (And then of course it will all change and you'll start over again.) But it will get easier, I promise!

Your endo will likely change your lunch and dinner ratios first so you'll be giving a bit more insulin per gram of carb that you have been at those times. This hopefully will have your DD in a lower range before bed.

If your daytime numbers aren't creeping up too high and the crazy nighttime drops don't happen too often, your Lantus might be just fine where it is. IMO If she is not going low at night, not waking up low, and is usually in range at breakfast, this is not the place to start your tweaking.

Best of luck with your appointment!

[mph]

We are dealing with this now, we just changed from NPH to Lantus last week. I'm certainly no expert, but I think we have the right dose of Lantus with a night time drop of less than 40......it was actually almost EXACT last night (after drops of 300 down to 140 a night .... with the WRONG doses of Lantus)!!!!!!!! Here's what I have learned (mainly fom the parents here ).

Fix the Lantus first!!!!! Then the mealtime ratios one at a time, ideally, starting with breakfast (with CDE's advice as needed). You want to ELIMINATE those huge drops at night while you are ALL SLEEPING so she can go to bed at a decent number and wake up within a few points of that good nightime number!!! You don't want to "have to" have her bg high in order to reduce the risk hypoglycemia from having too much Lantus which will pull her down ALL night!

If you try to fix ratios first, your nighttime numbers will STILL drop or rise too much if your Lantus dose is incorrect. Then you will be chasing lows or highs all day trying to "fix" the problem that started at night!!!!!

Morning number is best in the "range" of 15 more or 40 less than bedtime number. A drop of (too much) more than 40 means too much Lantus (ask your endo their "range"). It's a good thing she WAS so high at bed or she could have gone hypo with those large drops.

Check EVERY night, at least every 3-4 hrs, when making changes to Lantus doses especially if you are starting at a high dose and working down......though the other way, low to higher is MUCH safer.....and you'll get more sleep!!!!!!

Re-checking dd's bg at your bedtime and at 3am are a MINIMUM when making adjustments!!! (IMO, and our endo's). What dose did you use the 11th? Because that drop of 44 is perfect. I'd start there and see. But think about what else could have affected her bg that night (exercise, food amounts, food types, mood, illness, etc). Consider those before selecting a starting point. Ask you endo which dose to try out. Check EVERY sports night!!!!

Aventis (makers of Lantus) recommend starting the Lantus LOW and working UP to an "acceptable" range. The high mornings and/or daytime hours from a too low dose of Lantus can be fixed with a little extra humalog until you get the Lantus set correctly. I wouldn't correct AT bedtime just yet. She may NEED the extra if the Lantus drop is too big. Are you feeding her a bit extra uncovered carbs on sports nights to avoid late night drops!!! Ask endo how much to try.

By not correcting at bedtime, you can "see" sooner if the Lantus dose is "holding" or "dropping" her. Check after all fast acting insulin is done (most likely 4-5hrs after last humalog injection and 2hrs after any "free" snack, if she can have one.....I check AFTER 5 or 6 just to be sure....when I go to bed). But I must say, a bedtime reading over 400 would be tough NOT to correct. Yet, bedtime corrections are very tricky, as many children need only HALF the daily correction dose for night time. Get the Lantus correct and mealtime ratios and you won't NEED bedtime corrections...... often.

Lantus is a 24 hr shot and too much will pull her down "some" during the day and WAY too much during the night. After you get the right Lantus dose (w/in about 40pts), the higher daytime numbers can be fixed by changing mealtime ratios one at a time until you find a pattern for her. Do the breakfast ratio first (after Lantus is set).

Don't forget, if you lower the Lantus from where you are at now, you will have to naturally give more humalog at meals to cover what the higher dose of Lantus was doing during the day. But her nights will get smoother with less of a drop.

In the end, with all doses set, you will probably want to send her to bed around 150 (ask endo for their target # for YOUR dd) and expect a drop of about 40 which would bring her into morning at around 110. A nice way to start the day! But it takes time and diligence. You can do it!

Of course, YDMV, so keep in contact with endo for guidance. PLUS her insulin NEEDS will change!!!!!!! That's diabetes, especiallly in the beginning!

Happy homeschooling, too!!!!!!!!

[wilf]

Possible problems:

1) Giving the Lantus in the evening, not the morning. In some children, Lantus has a "peak" at about 6 hours, which can lead to significant BG drops.

2) Going back and forth between 10 and 15 units Lantus from gym days to non-gym days. I don't think you can do this with Lantus. If you want as basal insulin that you can "turn on and off" then you need to be using NPH. Many on here don't like it, but we do and we use for just that reason..

3) Too much Lantus. Notable in the list of numbers you posted is that BG drops EVERY night. Once you have your basal dose set BG should be pretty steady.

[dqmomof3]

I think you are absolutely right about the Lantus. I'm going to ask the endo tomorrow about switching the Lantus to mornings instead. The only thing I can see about moving the Lantus back to 10 is that on the days I only give 10 her bg numbers are really high. Is it better to have less Lantus and dose a smaller I:C ratio?
I don't know anything at all about NPH. Could you tell me a little more about that? A PM is fine.

[wilf]

Instead of having 2 different Lantus doses for gym and non-gym days, I would discuss with the endo the idea about having 2 different target ranges and I:C ratios.

So you go with a consistent Lantus amount - though you'll have to see if 10 is the right dose..

Then you need two templates or game plans:
1) for gym days
2) for non-gym days

1) On gym days (the equivalent of our synchro swimming days), you could:
- make sure BG is in the 150 to 200 range going in;
- make sure there's no bolus or correction insulin working;
- make sure she has her PB+J snack just before gym starts;
- measure every hour, and have something (a sports drink like Gatorade?) there to keep her BG up around 150;
- have a hearty supper after, with a lower I:C ratio (less insulin per unit of carbs);
- aim for 180 BG at bedtime (give a hearty bedtime snack if she's lower than that);
- test at midnight and 3 am.

2) On non-gym days:
- go for a 100 to 150 target range;
- bolus using your normal I:C ratios;
- aim for 120-140 at bedtime;
- test at midnight to make sure you're on track.

The above presupposes that the Lantus has been set properly, and she's waking at about the same BG as she went to bed at..

*******

As for NPH - it is an older, interesting insulin. It has characteristics of both basal and bolus insulins, in that it has a "peak" which can be used to cover meals but it also lasts for a long time in the body with reasonable basal coverage for the period outside the "peak".

Some endos use it as a basal insulin, and we learned how to "play" with it from the doctors in Germany where DD was diagnosed. DD gets it with each of her boluses through the day. On synchro days we can just skip the prior NPH, so there's nothing pulling BG down while she's in the water..

So here is a typical day:
Breakfast - 2 Novolog, 6 NPH
Lunch - nothing (covered by the NPH!)
After school on normal days - 1 Novolog (for grazing), 5 NPH
After school on synchro days - no insulin
Supper on normal days - 3 Novolog, 1 NPH
Supper on synchro days - 2 Novolog
Bedtime - 3 NPH (though we're just in the process of switching to Levemir for bedtime)

You can chat with the endo about what they think will work best for you (Lantus or NPH).

Bottom line - you have the right idea, in that you need to treat gym days differently from normal days. Discuss with the endo how best to do that. Good luck!