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stubborn night lows

Discussion in 'Parents of Children with Type 1' started by kail, Mar 6, 2015.

  1. kail

    kail Approved members

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    I'm trying (sleepily) to ponder why we have had some lousy nights with lows lately. Why we are having them is one issue but for now I am trying to figure out why they are not responding as I would expect.
    When we were first diagnosed and for many months after that we treated lows with about 15 grams which was usually a juice box. A few months ago as she started dropping out of honeymoon we found that even 5 grams would sometimes bump her up 100-200 points. So most of the time now we are treating lows with 5-7 grams and 10 at the most. There has been no problem or change with this during the daytime.

    Then three weeks ago we had a really bad night (happened to be our first night with dex). She had eaten dinner well but had already dropped lower than I liked before bed and we gave her a snack. Right now I can't recall how low it went or what we gave. I think we actually treated a mild low and then bolstered it with a snack. She was over a hundred before she went to sleep and 29 when dex alarmed low (reading 67) 45 minutes later. Yikes! I will try not to bore with details but basically I treated her with 15 grams and rechecked in 15 min and she was coming up nicely. Dex started trending up then down again 45 min later. Finger sticked showed 45. Repeat (treat, recheck improving, then low again 45 min later). Treated again and finally numbers climbed and then stayed around 250 for the next 12 hours. I don't know if it all finally absorbed or her liver kicked in. This all took place from about 10 to 2 and her humalog was given around 6:30 or maybe 7. Three days ago we had almost identical night except numbers not quite as low (45 to 70). Gave 17 grams bedtime snack because she was 94 about 2-2.5 hours past humalog. Was hoping to head off a low but ended up battling lows from around 10-2 again with nearly 3 boxes of juice given periodically as she dropped again and again. Last night was a little different. Fine at bedtime and good numbers most of the night then dropped at 4:30 to 61. treated with 1/2 juice box because I reasoned there was no humalog on board AND I am a slow learner. Waited too long I suppose and checked her 30 min later and she was 55. Gave the rest of the juice box and went looking for more since I had exhausted my bedtime stash and had stupidly not fixed this while I was waiting the first time. By the time I found more I decided to wait the full 15 min rather than giving more immediately. So checked her again a few minutes later and still 54. Gave another 3 ounces and finally she started climbing up.

    I am not understanding why she is requiring 40-60 grams to treat lows at night time even when she has only the tail end or no humalog on board at all. Previously when we treated lows at night (which was rare) she responded quickly to 7-15 grams.

    I am wondering how aggressively I should be treating the low the first time. Should I immediately give 30 grams for example rather than worrying that it will send her over 400. Then I suppose I need to figure out why it is happening at all. I have been fiddling with our lantus dose. 3 units seems too little but 3.2 sometimes seems to be too much. I'm wondering whether we need to split the dose. Anyway thats another question though and mostly I am wondering about the lack of response to the carbs at night.
     
  2. quiltinmom

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    I don't have experience with splitting lantus doses, but it does seem like your problem is with too much basal. That would cause recurring lows at night.

    You mention her TDD doubled recently. Maybe you should pull back on both basal and dinner ratio and see what happens. I would do that before getting more aggressive with lows, especially if they are happening frequently.

    Also, look at her activity level during the day before the lows. A high activity or excitement day can manifest during the night.

    What are you using for lows? Always juice? I wonder if experimenting with different things would be useful. Will she eat tabs?

    This began right as you began cgm...that is suspicious. I wonder if maybe she has been rebounding before, but you didn't catch it. Which would support the 'too much basal' theory.

    Ask your endo. They know her better than we do.
     
  3. kail

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    Thanks for those thoughts. I should probably change my sig. We thrashed around coming out of honeymoon and dealing with 3 illnesses between mid march and mid Jan but have been relatively steady since then. Now that you mention it I did have another really bad night about a week before we got the dexcom which is what finally convinced my DH to go along with it. I have been trying to back off a little during the day. I was thinking our lunch and dinner doses were too high and we have been inching off. Then I thought maybe I should decrease the lantus but we started getting more steep spikes and drops so I edged back up on the lantus and down further on the humalog. I'm talking about a basically impossible to meausre amount between 3.0, 3.1 and 3.2 units for the lantus. We have some lows during the day usually mid afternoon but mild lows and respond well to small amount of carbs. During the day we do juice but also smarties or dextabs or banana etc but at night I only give juice because she is mostly asleep.

    Oh, perhaps I should also add that we are mid way through evaluation for celiac disease with multiple positive antibody tests and just waiting to see GI to discuss biopsy etc. No obvious symptoms though unless this is one of them.
     
    Last edited: Mar 6, 2015
  4. quiltinmom

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    Celiac can cause some weird things I think...hopefully someone who has experience with it can help out on what gluten does for bg's in a celiac.

    If it was my kid, I think I would adjust the lantus so it would be 'perfect' at night, then use meal boluses to make up for missing basal, if needed, during the day. Does that make sense? The way I see it, a post meal spike is preferable (depending on how high the spike is) to feeding lows at night. In a perfect world, you won't have either. Maybe we will see a perfect world someday. ;)

    One more thought. What time of day is she getting lantus? I looked but you either didn't mention it or I couldn't find anything about when she gets it. Some people have better results giving it in the morning or mid day instead of night. That way she is awake when the shot is 'new' and any resulting lows are easier to deal with.

    I think with such tiny doses, splitting it could be hard. I wonder what would happen if you gave different amounts with each shot (I.e. slightly More during day, less at night). That might help. Talk to your endo first though.

    Do you plan on pumping? That would also help with those tiny dose adjustments, not to mention better meal boluses. I assume you have a reason for not pumping.
     
  5. Snowflake

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    Yes, stubborn night lows were our spur to request follow-up celiac testing. Apparently, the gut damage can cause malabsorption of food, leading to lows. We were seeing lows that resisted multiple treatments almost every night for several weeks, no matter how we adjusted insulin dosing - that convinced us the culprit was something more than insulin.

    After celiac diagnosis, the gf diet pretty quickly got us back to bgs that we were more accustomed to. That said, I agree with quiltinmom that you should also continue talking to your endo about whether changes such as splitting are warranted, and also whether the endo thinks that celiac could be at play here.
     
  6. kail

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    thanks everyone. Perhaps if it is a sign of celiac disease it might make it easier for us to accept and get on with a gluten free life. We have our GI appointment tomorrow.

    On the lantus we are giving it at about 9pm and sometimes (but not always) she will drop around 3 or 4am. Currently we are trying to adjust between 3 and 3.2. For most of the past year we were on 1 or 1.5 units so it wouldn't be difficult to split but one more shot and I don't know if it is necessary. I certainly wouldn't do it without discussing with the endo. I was more just frustrated with the delayed response at night in responding to juice for lows. We had another night like this since I posted this. She dropped low around 3am. I gave 15 grams of juice for 58 on the meter. Rechecked in 15 and she was 48. Gave another 15 grams. Waited around 15-20 min and she was 52. Grrrr. Woke her up more and managed to get about 1/2 a roll of smarties in which is only 3 grams but I thought maybe it would absorb better. Within 10 minutes she was climbing and after 20 min she was 80 something. Of course then she went over 200 for the rest of the night. She shouldn't need 36 grams of carbs to recover from a low of 58 but unless I should be waiting longer to give more I am not sure what else to do when she is not going up. I don't know if she really responded better to the smarties or it was just time that started her heading up. I can try to get her to eat smarties or tabs with her next low at night but its hard because she is only half awake at best and I don't want her to choke.
     
  7. Nancy in VA

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    Emma takes longer to absorb so I would recommend that if you see an uptick at 15 mins to wait it out a little, especially now that you have Dex. Obviously if the second reading is lower I would give a bit more.

    On Lantus, once you get to the point that you aren't over treating the low and you are treating about right, I would follow the juice with some protein about 30 min later to help keep BG up. Since Lantus isn't variable many people often need the protein later to help keep BG up.
     
  8. wilf

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    Try moving the Lantus to mornings.

    Lantus can often have a "peak" in the timeframe of 4 to 6 hours after injection where it is working a bit harder, and can cause lows in that time. That effect will only get stronger as Lantus doses come up.
     
  9. mwstock

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    If there is a pattern of lows, I would reduce the Lantus. I would recommend working closely with your medical team.
     

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