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Does this look like Somogyi?

Discussion in 'Parents of Children with Type 1' started by Theo's dad Joe, Jan 21, 2016.

  1. Theo's dad Joe

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    5 units Lantus at breakfast, and blood sugar 148 4 hours after dinner. I've been raising the Lantus to try to help with daily ratios rising but thinking he may have too much. ( I raise it and it helps for 3-4 days then the ratios regress again).

    Although the Lantus is AM he seems to always be most sensitive around midnight-1:00 am.

    The other alternative was that morning Lantus was weakening after midnight, but if his honeymoon could still get him from 148 4 hours after dinner bolus to 70s at midnight I doubt it would not be able to hold against dwindling basal. Rise from 1:00 am to 5:30 am. 5:30 am fingerstick was 145. Have not seen big early am rises like that before so does it look like Somogyi, and if so maybe its too much basal at night, or too much night time sensitivity. He doesn't trend down during the day though outside of meal bolus. Flat 5 hours after lunch or dinner.

    Thanks. I am really trying to figure out this rising bolus need, whether he needs more basal or if low stretches at night are the problem. We have not had sub 60 fingersticks at night, but sometimes 65s and occasionally several hours (3-5) between 70-80 on cgm, checked every 2 hrs by fingerstick.

    Edit: also does that look like another one at 9:00 pm? He was dropping 4+ hours after dinner and fingerstick read 81-gave carbs, just 7 grams. CGM tracked down to 60 but he was 78 30 minutes after carbs, then shot up to 160 (confirmed) so that's 80 points from 7 grams of carbs which is not typical, but maybe if coming from a true 60.

    Edit: the drop at 6:00 was a half unit correction at 5:30 am as he was 148 and trending up and I wanted to try to have that started on by breakfast. He came down so fast though (90 by 7:15) that I had him eat breakfast at bolus time and he still dropped fast, though fingerstick was 72 at the bottom.
     

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    Last edited: Jan 21, 2016
  2. mmgirls

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    No it does not look like Somogyi in the sense of a "rebound", a rebound usually indicates that the person went hyper after a hypo and usually there is insulin resistance for 5-10 hours afterwards, so the 5:30am correction would most likely not have been effective.

    I would say either that is when he fell into "deep sleep", was a Lantus peak from 4-6 hour prior to that time or a regular old "counter regulatory response" from the liver to boost bg.

    So where are you at now with settings? how big is you kiddo?
     
  3. mmgirls

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  4. Theo's dad Joe

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    The Lantus is now at 7:30 am, not at night. He can be 130-150 4 hours after dinner bolus but still come down and sit at 75 for hours in the middle of the night. Like last night. I checked at 11:00 pm, 12:30, and 2:00 am and he was 72-78 each time.

    Someone suggested a snack at bed, but he has a PEAK 3.5-4.9 hours after dinner or around 8:00 (granted just 137 yesterday) after running under pre-prandial (120) numbers for 3 hours. I THINK the peak is hormones and not a late dinner effect, but I have a hard time giving him a snack when he is topping out at 137 (or 160) 4 hours after dinner.

    Sometimes he will not have the late peak after dinner, and I will give him the snack. It will usually push him up to 120-130 and he will stay THERE most of the night, but if he is fairly low like 80 and dropping 4 hours after dinner which happens some times, the snack seems to rebound him more and he will go up to 150-170 which works for now, but when the honeymoon is over completely I don't want to stick him up at 160 all night.

    Anyway here is a cgm trace of the late dinner/bedtime hormone rise. He bolused for dinner at 4:25. At 8:25 he topped out at 137 but he almost looked like he was going low and if he was very active he would definitely go low after dinner before the rise. We just played in the pool at a hotel one night after dinner and he dropped from 100 to 47 in half an hour, and this was 2 hours after dinner. He only needed 6 grams of fast carbs to stay 100 for another hour, but he needed another 2 rounds of 6 carbs before bed because he kept trending down from the activity, but this is a 54 pound kid "playing" in the pool and he doesn't go low from two hours of sledding after breakfast or lunch.

    So Theo is almost 10. He is 54 pounds. He actually has a TDD of about 16 now (yesterday) and that was 6 morning Lantus and 10 bolus for only about 120 grams of carbs so an average of about 12:1 and when his Lantus was at 3 he was needing over 8:1 at breakfast and 10:1 at lunch and dinner (or even a little lower, maybe 7.5 and 9.5 if I really wanted to end up where we started.

    So he has enough honeymoon that when I fix basal, he gets a little recovery and then doesn't NEED as much any more, then I cut it back, and his pancreas works harder and he needs it again.

    We have a great average and time in target still in 3 weeks since back to school but I'd take 140 I think if I could get less stressful patterns (basically he will need a correction at school lunch one day (160 or so) , and he will come to lunch at 80 the next and go low while he's eating, but if I treat too aggressively he will be high at dinner because his meal time curves are long (not high but long probably from a little more fat in the mix). Then he will go low often after dinner only to have the bedtime rise sometimes happen and sometimes not. He also went low 2.5 hours after lunch yesterday, but with a ratio that had him RISING 25 points between lunch and dinner the day before. He got a small snack 7.5 grams pretzels, and went to 150 but suddenly he's clearing it off so makes me think basal is now too high again, though he was 9:1 at lunch and 12:1 at dinner and was higher at 4 hours for both of those meals.
     

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  5. Theo's dad Joe

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    My son's endo and also the Pink Panther book says that ideally you should be able to get to fasting numbers by 2 hours after a meal. Is this for real? Is it based on Non-Ds or is it actually possible? All of our meal time curves last 4 hours and the peaks are often after 2 hours. Is it because kids are small or do people see shorter curves on higher carbs? Also if you do happen to get to 100 within 2 hours won't you go low in the next 2 with 1/3 of your insulin still on board?

    Here are a couple examples of issues I am trying to figure out or troubleshoot.

    First, we get peaks occurring about 2.5 hours after breakfast. The endo told me that peaks occur between 1 and 2 hours and we should try to be in range withing 2 hours "by the book" but Gary Scheiner says in many articles that peaks are usually within 1-2 hours. What is more, during my son's early honeymoon, he did peak within 2 hours for breakfast, and he was often down to 90-120 a little after 2 hours, but that peak shifted later and later in the second 6 months of the "honeymoon" as bolused doubled or tripled.

    Am I alone here, or do other people see breakfast with no rise for an hour, then peaking around 2.5 hours?

    Then we often have "FLAT" dinner for 2-3 hours (unless I don't prebolus), but that 8:00 pm rise. This happened even at the beginning of the honeymoon when we were using 36:1, instead of 12:1 and when he ate much higher carbs. He would run flat at 70 at 1, 2 and 3 hours after dinner but go up to 130-190 at the 4 hours mark.
     

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    Last edited: Jan 21, 2016
  6. Theo's dad Joe

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    Thank you for the clarification about Somogyi having insulin resistance, so I should be able to rule that out. That leaves me thinking that some nights his AM Lantus is losing strength around 1:00 am OR that it is the beginning of the puberty hormone pattern where he used to get the 7:30 pm rise it sometimes isn't coming, and sometimes there is a clear rise starting around 1:00 or 2:00 am. So after a night of 75, and thinking he'd have the am rise, he woke up at: 71. Every day is the same, in that it is completely different right now. One day he comes to dinner and I know he needs 10:1, and another day I am sure he will run flat at 14:1.

    By the way, I read somewhere, perhaps in using insulin that rebounds can make you more sensitive to insulin because you use up all of your adrenaline and cortisol and glucagon counter-regulating the low and your body has to build those up again over 12-18 hours and so you don't have those hormones to balance your bolus, or your basal for that matter for quite a while. But I suppose the immediate effect of a rebound would be high counter regulatory hormone levels-but once the liver gets rid of them couldn't you run low for several hours?

    Even at worst, we are catching everything in the 70s, but I used to have meals where he would come down to 70-80 after 2.5 hours and then rise back up, so I didn't use to ever treat early 70s and 80s.

    I am literally taking a leap on carb ratios today. I also might have to have them bolus after eating at school.
     
  7. mmgirls

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    I think you are changing ratios way too much. And you are setting yourself up for problems later when the honeymoon wains, because I think that his body still has a good response to correcting for a fast falling BG if you have not seen numbers below 65. .
     
  8. wilf

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    Not Somogyi. You are doing fine. Most families would be thrilled to have numbers like these.
     
  9. Theo's dad Joe

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    I only gave him about 6-7 extra grams of carbs at breakfast because he was at 71 which has not happened in a long time. We have been getting 90-110 at breakfast, so it seemed to me that running 9 hours in the 70s last night may have indicated that he is back to doing more on his own. Anyway I guessed, and at least it worked today. He only went up to 130 at breakfast and was 96 at lunch versus 120 yesterday with 6 grams fewer carbs. It would be great to just get a month or two back to what we had before break so I can rest a bit. I would have not been so uptight the last year if I knew how easy I had had it. In the long run I see the rationale, but if I know that he ran higher late after breakfast and needed a correction I will sometimes factor that correction into dinner and watch, and usually it hold true right now.
     
    Last edited: Jan 21, 2016
  10. rgcainmd

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    Agree with this ^^^.

    If you are bothered by the degree of BG fluctuations you are seeing and by the uncertainty surrounding the causes of undesirable BGs to the extent that you seem to be, you should get your son on a insulin pump. Pumping probably won't answer enough of your questions regarding the "whys" (I don't think anything will), but it will allow you to make more adjustments that can have more immediate impact with less risk. Pumping can allow you to "back-pedal" more quickly on adjustments you've made that didn't work out the way you intended. An ending honeymoon unfortunately does not follow a smooth and predictable curve, and random residual endogenous insulin production makes it very difficult, if not impossible, to answer the "whys" and makes attempts to answer such questions pretty much exercises in futility a great deal of the time. Which is why I was relieved when my daughter's honeymoon ended; the questions and feasible answers made a lot more sense. And the data provided by experimenting with reasonable solutions were 100 times more consistent and trustworthy.
     
  11. Theo's dad Joe

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    Wilf and mm. Thanks regarding identifying rebound-or lack. I was worried that he was rebounding from too much Lantus at night. Otherwise I would be fine with him running in the upper 60s, but with Lantus it is still a little nerve wracking. He still responds to Lantus more like someone who is insulin resistant in that if I add a unit, he will tend to come down to a fasting level just a little bit lower, but not trend continutally downward. So if I take away a unit he would tend to settle in in the 90s rather than the 70s for example.
     
  12. rgcainmd

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    I'm not understanding how coming down to a lower fasting BG after increasing the dosage of long-acting insulin (rather than "trending continually downward") is indicative of insulin resistance (as opposed to a "simple" need for more insulin due to waning endogenous insulin production).
     
  13. mmgirls

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    I'm with you I am not sure what he is trying to say. "trending continually downward" would either indicate too high of Basal or endogenous insulin, either way settling down into the non-D fasting numbers of below 100 but not ever going below 70 is ok especially in a kiddo that is honeymooning and on a fairly low dose of basal insulin.
     
  14. Theo's dad Joe

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    I am not saying it indicates insulin resistance. I am saying that in this honeymoon, similarly to type 2s, my son has a margin of blood sugar management, just not enough insulin (or sensitivity) to manage it to an ideal level. Type 2s basically don't aim for flat basal. They titrate until the added insulin is getting them close enough to a good fasting number that what they have left can do the fine tuning.

    So he's not sitting on a flat basal situation where if he is at 170 he will stay more or less at 170. He will trend down to whatever marginal reserve he has left but he still has the "shut off" control for now on that last marginal bit.
     
  15. Theo's dad Joe

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    So I am curious about this because everything I read from Scheiner and others says that when you are completely insulin dependent you want to have a more or less flat basal and that if you stay flat, even a little high (say running flat at 170), you will stay around there if basal is correct. So my understanding is that once he has no control of that last bit of insulin, he will not have an equilibrium fasting blood sugar of say 90, but he will have a flat blood sugar and need corrections if he is higher to get to 90. Type IIS and people with some insulin left will still have their pancreas work to lower them to as normal a level as it has the ability too because their pancreas is effectively doing the correcting. My son has Lantus, and he has some of his own, but when he gets to a certain level his insulin is still shutting off.

    In fact when we first started dexcom he would have the exact same blood sugar curve and same final point (about 90) if I gave him 30 to 1, 20 to 1, 15 to 1 at each meal-I mean exactly the same peak, the same value more or less at 30, 60 and 90 minutes, 2 hours and 4 hours. He did not go low from 2.0 units for 30 grams for breakfast, but he ran the exact same curve with 1 unit so I stuck with 1 thinking it was safer if he got really active (while maybe his own pancreas would have lasted longer if I had gone higher). (It goes against what everyone else says about a honeymoon that you can go low easily) Now if I used a little extra Lantus he would flatten out at 60 instead of 85, or a little less and it would be 100 all night.

    Later on, his peaks started to go over 200, so I upped the ratios from 30:1 to 20:1, but he was at 85-100 in 4 hours either way. Then when the peaks rose again I upped them to 12-15:1 and the peaks came down, but again still he was at 85-100 in 4 hours either way. his own insulin just turned off when he had a higher bolus. This of course is not the case now because he is at the limit. If he doesn't get enough insulin he is higher at 4 hours, but still has enough to come down given maybe 4-6 hours.
     
    Last edited: Jan 21, 2016
  16. rgcainmd

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    I don't understand what you mean by the term "flat basal" in your sentence "Type 2s basically don't aim for flat basal." Do you mean a fairly steady BG (with infrequent and relatively small fluctuations in BG) over an extended period of time?

    Also, insulin sensitivity (as in ISF or ICF) and insulin resistance are two different things.
     
  17. rgcainmd

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    Joe, you said: "He still responds to Lantus more like someone who is insulin resistant in that if I add a unit, he will tend to come down to a fasting level just a little bit lower, but not trend continutally downward."

    Then you said: "I am not saying it indicates insulin resistance."

    These two statements seem to contradict one another.
     
  18. rgcainmd

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    This is correct. I verified, by speaking directly with Gary Scheiner, that a basal rate is "correct" if it results in a more or less steady BG if said BG is not influenced by other factors. In other words, if someone with T1D who has essentially no residual endogenous insulin production goes to sleep at night with a BG of 170 and their overnight basal rates are "correct" (and nothing else intervenes to change BG like a surge of growth hormone or exercise or ingestion of carbs or whatever), then they will wake up with a BG of 170. In this particular case, if a BG of 170 is not what you desire, then another variable or combination of variables (such as ICF or I:C or DIA, etc.) need(s) to be adjusted.
     
  19. Theo's dad Joe

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    I am saying that he responds like someone who has some of his own insulin like the way type IIs or insulin resistant individuals do to basal insulin because he still manages on the margin.
     
  20. rgcainmd

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    I'm not trying to be adversarial.

    But I can't follow what you post when I don't know what you mean by phrases or terms like "he manages on the margin". Can you please explain what you mean by this particular phrase? Thanks!
     

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