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trouble shooting nights on MDI

Discussion in 'Parents of Children with Type 1' started by kail, Apr 30, 2015.

  1. kail

    kail Approved members

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    Well I think I managed to delete my long rambling post which is rather annoying. Let me see if I can redo it with a more succint and understandable post.

    My DD4 is managed with humalog and lantus. She is about 1.5 years past diagnosis and bouncing slowly out of her honeymoon and we are a couple months into a celiac diagnosis as well. I am trying to fine tune the nighttime management. We were having scattered severe night time lows for awhile but seem to have resolved on gluten free diet (at least we are getting something out of it).

    We were seeing a strong pattern where she spikes about 3-3.5 hours after her dinner humalog which is usually about 1-2 hours after she goes to sleep. She would rise steeply and plateau usually over 250 and stay there for several hours then drop around 3am through 6:30 when she would start to rise. I ended up trying to deal with this by giving her a correction dose around 11-12 when she was over 200 and climbing but then sometimes she would go low at 3-4 am. I tried to deal with this by switching the lantus from 9pm to about 6-7 pm thinking maybe we were getting an accentuated drop around 3 due to a lantus peak and maybe I could use that to help with the spike around 11-12. At first it seemed to help a little. I also tried backing off on the lantus a little around then as it seemed like she wasn't needing as much and so the nights were a bit smoother for a couple weeks. Then she got sick and we were on vacation so it was a mess again. Now she seems back to baseline health and so I am trying to adjust. During her illness and after I increased the lantus gradually again. A couple months ago she was up to 3.2 which seemed almost too much and we weaned down to 2.8. Now in the past couple weeks I have crept her up to 3.4 which is the highest she has ever had.

    On a typical night she eats around 6:30 or 7. She has a small peak if any and occasionally drops low or borderline about 1.5 to 2 hours after humalog then starts to rise sharply after 3 to 3.5 hours. Since I have been increasing the lantus I had held off correcting her highs at night as much lately and we were seeing her go from around 70-100 at bedtime to 250 to 280 for most of the night and then trending down around 5am so that by the time she eats which is often late like 9am, she might be 150-220 or so. If I correct her (lately) around midnight with .5 unit of humalog then she drops to about 65-70 in the morning (5-6am). Sometimes I have to treat her but sometimes she hovers there then starts to rise at 6;30 so that she might be 120 or more by breakfast. A couple months ago the corrections at 11 didn't do much for several hours but lately she seems more sensitive to it again.

    I have been wanting to do basal testing but wanted to have her healthy etc before doing it so haven't done a real basal test yet. But a couple days ago she had a pretty low carb/low fat dinner of grilled plain chicken and berries (blueberries, strawberries and raspberries) and maybe a bite of cauliflower at 6:30 She had minimal spike and stayed at 115 for a few hours after that until about 6 hours after her humalog and meal when she rose to about 185-200 for 4-5 hours then drifted down to 129 around 8am. So from what I read about basal testing you want to start and end up within about 40 points of each other. She was 115 at about 4 hours after humalog and 129 in am so that seems good but is it typical and expected that she will rise to nearly 200 for so many hours in between the end points even with a dinner like that?

    I'm just trying to figure out what to adjust next and if she is on the right lantus dose or maybe we need to split lantus dose. When I look at her CGM date she runs much higher between midnight and noon that she does between noon and midnight. She has this slow prolonged high at night then a big breakfast spike then after lunch she has a tiny spike and skips along borderline low in the afternoons and a small spike with dinner until she reaches 11pm or so. I could try increasing the lantus but I would have to back off the humalog doses as she is already often 65 to 75 before her lunch and dinner which I was thinking was due to the lantus since it happens just as the next meal is due.

    I'm sorry this is still a long and rambling post. I know a pump offers much more options in changing basal rates but I know plenty of people manage well on MDI so if any of the above makes sense to anyone then I would love suggestions on dealing with the prolonged rise at night and how to tweak things.
     
  2. sszyszkiewicz

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    so what are her ratios? are they different by meal? and her correction factor is what?
     
  3. nebby3

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    A couple of thoughts -- when my dd was young she would often rise sharply soon after falling asleep. Sometimes even during naps. I attribute this to growth hormones and those are really hard to combat. For my dd she was pumping at the time but since she didn't fall asleep at the same time every night, we couldn't prepare for the spike with basal changes.

    I think timing the lantus park such as it is to just after bedtime is your best bet. And if you need to correct every night do that too. You could also consider splitting lantus into 2 doses though it doesn't sounds like that it your main problem at the moment.

    Basal testing can be helpful but often I think they need more insulin -- even basal-- when eating carbs plus they need different amounts at different times of day and there's not much you can do about that on MDI. I still think one can get decent control on MDI you just need to realize that you may have some times of day when you are supplementing the basal insulin with higher boluses or corrections and some times when basal is covering carbs. Set a lantus dose that keeps her safe at night and then deal with the days.
     
  4. bamaboyd82

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    My 4yo son has those same surges in BG after falling asleep. We've been told they are likely the result of growth hormones. They happen most nights, but of course, not every night (that would make them far too easy to deal with!). We actually do what I guess might be considered a preemptive correction...we did it on MDI before and do it on the pump now. Once he has fallen asleep, we watch the Dexcom to see whether big jumps in BG start up (10 points or so every five minutes for a couple of readings) and if they do, then we give 0.5 units to blunt the rise. Sometimes it ends up being too much. More often, it keeps him in the low 200s and we have to do a very small correction a few hours later. Without it, he ends up in the 300s in short order and takes hours to come down.
     
  5. kail

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    Well my post was certainly not understandable and succinct as I look at it now. I apologize and thank everybody for trying to respond. Yes I am assuming we are battling growth hormones but how frustrating. Every night I chastise myself for not being brave enough to dose her when it first starts to spike but a few days ago I tried dosing when she was 186 and rising around 11:30 and she was low at 4.

    Her breakfast ratio is 1:25
    Lunch about 1:42 but trying 45 lately
    Dinner is about 1:42 also

    1 unit seems to drop her around 240 to 250.

    Lantus is 3.4 and her total daily dose is about 6.5 to 8.

    She weighs about 39 lb or 19 kg
     
  6. sszyszkiewicz

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    Since dinner is near bedtime I would try dosing dinner after the meal and dose a little extra. We were lucky that t1d waited 11 years before my son was diagnosed so I don't have any experience with toddlers. Can you dose in 1/10th of unit increments?
     
  7. Lakeman

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    Does this pattern only happen during sleep? Is it possible that she is digesting slowly which would cause a low then when the food is finally digested it causes a high?
     
  8. nebby3

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    Even if it's only during sleep it could still be growth hormones. My dd had yrs of that pattern on and off as a toddler. As I said it could even happen for naps but never till she was asleep. IMO that's just when the body decides to do it's growing. In my dd's case I don't see how it could just be slow digestion because it wouldn't happen at other times and it hang continued as she aged.
     
  9. kail

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    Well it looks like my last post didn't go through so I will try again and ignore if you see similar answer twice.

    I should remember how ridiculous it looks when I say things like I am giving her 3.4. I am certain that we are not giving her exactly that or even exactly the same dose each time. Her endo does not even believe we can reliably dose in .25 units. But in real life we do our best. When I give 3.4 I shave a hair off the 3.5 line and call that 3.4. A few weeks ago we were giving her 3.2 and she kept going low all day but when we tried 3 she was running in the 150-200s all day long. So we do our best to dose in between knowing it is not exactly the same each day and may not be exactly the dose that I am naming it. Its just what you do when you have a little one without a pump. Her doctor laughs at me every time I tell him her doses at our appt. it is what it is.

    I wish her dinner was earlier like 5:30 or 6 but we just can not manage it consistently. We used to dose every meal after she ate but after we put her on dexcom we were more comfortable with prebolusing. We realized she rarely refused to eat her meal and usually the problem would be controlling her second and 3rd helpings and so we switched to prebolusing or sometimes a few minutes into the meal. She was lingering over her meals and it was causing huge spikes if we bolused after. For dinner though it may make sense. We do sometimes bolus late with something I know is slow like beans or tortilla.

    The food absorption may still be a problem. I think we have improved on gluten free diet but I am sure that she is not normal. We were having severe lows at night sometimes that did not respond much to treatment. we used to treat lows with 2 ounces of juice but all of a sudden at night I would give 4 ounces of juice and retest in 20-30 and she would be the same and usually in 40's. It would take 3 or more juice boxes and sometimes some candy before she would come up. those episodes seem to be gone but I suppose her absortption might still vary and I wonder about some of the gluten free foods that she eats now as I don't really know what to expect from them. On the other hand I would think that a simple meal of chicken and fruit might be digested quickly and not cause a prolonged high starting 6 hours later.

    I am assuming it is growth hormones or maybe cortisol surge that happens an hour or two after going to sleep. She doesn't nap so I don't know if it would happen in daytime but yes this is the only time she has prolonged highs. She spikes high and hard after breakfast but down again in a couple hours. Lunch she has smaller peak then skips along usually close to going low like skipping pebbles on the pond then a small peak at dinner and a steep long rise around 11.

    Last night oddly was a very different pattern that I am not sure I have seen before. She had a late snack of popcorn-5g as we were going out and knew dinner would be late and was a bit high at dinner 185 at about 7:30. She was dosed first and then cut herself so ate about 10 minutes later. She stayed right about 190-200 for more than an hour then gradually dropped and leveled off at about 75. Dex indicated low once (59) but meter said 76 and then she started a very gradual climb and ended up with a high of 150 around 5:30 am before drifting down. She was 119 when I left at 6:45 and she was still sleeping. I don't know if it was giving her medications so late or what she ate or just a fluke but it was a great night.
     
  10. sszyszkiewicz

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    Do you have the special needles that allow you to see in 1/10th increments? I know they are available. Since she is so sensitive you need that accuracy.

    It's good you have a Dex. It allows you to try and observe.
     
  11. funnygrl

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    If you're not considering a pump right now you could ask about diluted insulin to help with accurate, fine tuned dosing.

    Edited: I just realized that 3.4 units is the Lantus dose, not the dinner dose like I thought, and Lantus can't be diluted so disregard above.
     
    Last edited: May 2, 2015
  12. wilf

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    What about giving the Lantus in the morning instead?
     
  13. kail

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    I don't know. I wondered about that but then I thought that if there was any peak effect of the lantus which I thought was usually about 6 hours later then perhaps I could leverage that to work on my stubborn night highs rather than have it kick in around 3pm when she typically drops low if we aren't watching closely and giving a snack. Plus if it wears off in the hours just before we dose around 6-7 or the first couple hours after the dose at least its during the time of the day when she runs lower. That was my thinking but perhaps I'm not looking at it right.
     

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