# Nocturnal Hypo's



## grainger (Feb 6, 2013)

Hey all,
Yet again I have more questions... sorry!

I have finally (yay) been referred to a hospital in London, Chelsea and Westminster which I'm happy to say seem really good. 

However, I've been having a few problems recently with serious highs in the mornings.
Turns out I'm having nocturnal hypos and not waking up  - this morning was a beauty of 18.2 . This has left me feeling really shaky today and if I'm honest pretty scared. I knew something was up and this was a possibility but I really thought I'd wake up?! (My only clue has been waking up really sweaty - sorry not a pleasant thought).

I'm reducing my background insulin evening dose tonight but I was wondering if anyone else has experienced this (without waking) and if they have any tips/advise etc?

Hope all is good with everyone!

H x


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## DeusXM (Feb 6, 2013)

Best thing you can do is some middle-of-the-night testing to see how rapidly your BG is shifting. You'll then just need to adjust your basal accordingly. Once you get it sorted though, you'll feel a LOT better - it's never fun waking up with BGs that high at the best of times, and your body's procedure for fixing a hypo in your sleep will make you feel like you've got a bad hangover!


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## Caroline (Feb 6, 2013)

Can't offer any advice but don't appologise for asking questions, every question is important.


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## everydayupsanddowns (Feb 6, 2013)

How are you taking your levemir Grainger?

It might be worth taking in two doses (splitting) so that you can have less working overnight and more during the day of you need it.


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## rachelha (Feb 6, 2013)

everydayupsanddowns said:


> How are you taking your levemir Grainger?
> 
> It might be worth taking in two doses (splitting) so that you can have less working overnight and more during the day of you need it.



Grainger

I used to have a lot of problems with nocturnal hypos.  I was put on to a split dose of levemir and had 12 units in the morning and just 4 in the evening.  This helped a bit, but eventually I got a pump to help with this problem.

I was hypo when I woke up this morning which was a bit weird.  I think I might have been low for a while as I had a dream which involved a big banquet of pastries and 3 birthday cakes!


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## grainger (Feb 6, 2013)

I'm already on split dose at the moment -Levemir - 11 in the morning and 9 at night. 
Reducing to either 7 or 5 tonight as suggested by the consultant today, we'll see what happens I guess.

I think the main thing that's freaking me out is the not waking up. Is that common?


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## DeusXM (Feb 6, 2013)

Depends on how deep you sleep! I tend to wake up but I have slept through a few. Evidently you've enough glycogen in your liver to keep you safe. So it might not necessarily be common but it's also not rare, if you see what I mean.

However, you don't want to have a lot of 'nypos' where you don't wake up - it may mean your body gets used to having them and it's never good to lose your hypo awareness.


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## bennyg70 (Feb 6, 2013)

Def do some mid night testing too see whats going on. I do believe its not always the case but its certainly my nurses favourite to blame high morning readings on hypos during the night. I knew it wasnt the case for me, as when I have suffered hypos in the night I wake! I did some testing and it wasnt hypos. I then realised it was all down to what I ate the night before / My diet. Ie Id go to bed after eating a carb laden fat laden meal (Eaten at 7pm or 8) at say 11 or 12pm, then during sleepy time, the carbs would release as the fat had slowed them down so much till then and I would be high all night and wake up high.

Im not saying its not rebounds from hypos but do the testing first (At least a couple of nights worth) before changing anything!!


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## bev (Feb 6, 2013)

DeusXM said:


> Depends on how deep you sleep! I tend to wake up but I have slept through a few. Evidently you've enough glycogen in your liver to keep you safe. So it might not necessarily be common but it's also not rare, if you see what I mean.
> 
> However, you don't want to have a lot of 'nypos' where you don't wake up - it may mean your body gets used to having them and it's never good to lose your hypo awareness.



Hi DeusXM,

There have been many studies on this issue and it is not at all proven that the liver kicks in to 'save' you. Using CGM it has been shown that many people simply sleep through their hypo's and have very prolonged ones which if they hadnt been woken up could have been in danger of a fit or worse - and no signs of the liver kicking in for many in the studies.

Hi Grainger,

It always concerns me when a team talk about high BG's as being the results of a liver dump. How do they know? They dont. They are making an educated guess but that just isnt enough. It could be other reasons like DP (dawn phenomenon) or your LA running out. The only thing you can do I'm afraid is to do some night testing - we usually do 3am as this is when levels naturally drop and long enough after the last evening meal to be able to understand the readings. Unless you know what the reason is for chaotic levels you cant possibly rectify it. Have you ever used a CGM? If not you might find this a useful way of identifying what is happening throughout the night. Whilst it is good to test at random times - having a CGM gives you a much more detailed picture of what is going on every minute.Bev


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## Lauras87 (Feb 6, 2013)

Are you knocking back your fast acting too?

I have the same problem but I do most times wake.


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## Josco (Feb 6, 2013)

It turned out I had been having overnight hypos that I was not waking from for many months and I had not realised that it was them that was causing me to feel really ill for much of the next day.  I did two hourly overnight profiles of my BGs and eventually I stopped taking Levermir at night as even just two units was dropping me too low.  I recently started on a pump and have three different basal settings overnight (I have only been using a pump for two weeks) and that is helping to sort out the overnight drops although I still need more adjustments yet.  I am doing two hourly profiles every night to try and get the basal rates right.  But you are not alone in being unaware of overnight hypos.  I can reassure you by saying that I am still here to tell the story


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## DeusXM (Feb 7, 2013)

> There have been many studies on this issue and it is not at all proven that the liver kicks in to 'save' you. Using CGM it has been shown that many people simply sleep through their hypo's and have very prolonged ones which if they hadnt been woken up could have been in danger of a fit or worse - and no signs of the liver kicking in for many in the studies.



I never said it was proven to happen in all people all the time. I'd like to see those studies, got a link? If this were the case, with people having very prolonged hypos, wouldn't they also have abnormally low A1Cs?



> The only thing you can do I'm afraid is to do some night testing - we usually do 3am as this is when levels naturally drop and long enough after the last evening meal to be able to understand the readings. Unless you know what the reason is for chaotic levels you cant possibly rectify it.



But given you've already ruled out the possibility of hypos causing a Somogyi  rebound, why then give this advice? If we accept that the liver doesn't dump glucose to recover from a hypo, then evidently by the logic you're using, the only possible solution is to take more insulin!

Unless of course we accept the possibility that actually, yes, the liver does kick in from time to time and dump a large amount of glucose. A rise from normal to 18 is a phenomenal amount of glucose and I think it would be extremely difficult to attribute this to either a failure of long-acting (very unlikely as the OP is on a split bolus) or dawn phenomenon. So where does this glucose magically appear from then, if it's not the liver either? 

I completely agree that there needs to be some nighttime testing to see what's going on but I strongly suspect on the evidence presented so far, we're seeing plain ol' hypo rebounding. But yes, the final piece of the puzzle is a night time reading, although a CGMS is probably overkill. A couple of nights testing at 3-4 hourly intervals would probably be sufficient to see what's going on.


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## megga (Feb 7, 2013)

I should do some testing overnight as stated and keep the data.
I had a problem with morning highs, i tried spliting my basel, then tried just having it in the morning, but nothing worked. My DSN then advised me to go on the pump.
It may be worth seeing your DSN with some B/S data, see if she thinks the pump could help you.


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## bev (Feb 7, 2013)

DeusXM said:


> I never said it was proven to happen in all people all the time. I'd like to see those studies, got a link?Yes - but cant get it at the moment as the person who has it is going through a family crisis - but will ask her when things are a little calmer. If this were the case, with people having very prolonged hypos, wouldn't they also have abnormally low A1Cs? Obviously the HBA1C would be impacted - but unless they were having one every single night then I doubt they would have an abnormal result.
> 
> 
> 
> ...



I will post the link once it is made available to me.Bev


p.p.s Here is one of the links.

Arch Intern Med. 1984 Apr;144(4):781-7.

The Somogyi phenomenon. Sacred cow or bull?
http://www.ncbi.nlm.nih.gov/pubmed/6370162
Raskin P.

Abstract
Posthypoglycemic hyperglycemia (Somogyi phenomenon) occurs infrequently in insulin-treated diabetic patients. When it occurs it is often in children and adolescents, or patients with a short duration of diabetes. Marked hyperglycemia (greater than 220 mg/dL) after hypoglycemia results from a large meal to relieve the symptoms of hypoglycemia. Posthypoglycemic hyperglycemia correlates with falling plasma insulin levels, rather than increasing concentrations of counterregulatory hormones, whose secretion may be defective. Asymptomatic nocturnal hypoglycemia is common but subsequent fasting hyperglycemia is not necessarily the result of "rebound." More likely, fasting hyperglycemia is due to a falling predawn insulin level. Nocturnal hypoglycemia is dealt with by a readjustment in the timing and dose of insulin. The failure of the Somogyi phenomenon to occur puts insulin-dependent diabetic patients at increased risk to potential lethal consequences of nocturnal hypoglycemia.

PMID:

6370162

[PubMed - indexed for MEDLINE]


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## DeusXM (Feb 7, 2013)

> Because you need to understand the full picture of what is going on! The OP needs to know when the rise is starting otherwise she has no idea whether it is DP or the LA running out or both.



But either way, it makes no difference. 

If it's caused by DP, then there isn't enough circulating insulin to meet her blood sugar requirements.

If it's her basal insulin running out, then there isn't circulating insulin to meet her blood sugar requirements.

Either way, the treatment regime is broadly the same.



> I have not said this never happens - the issue is that there is no real evidence to prove that it does and certainly no evidence to prove that it 'saves' people - otherwise how would so many Type 1's die in their sleep? 2 teenagers die per week sadly - clearly their livers arent 'saving' them.



Where on earth is this statistic that 2 teenagers die in their sleep each week from nighttime hypoglycaemia? That is a heck of a lot of people. I am not in the slightest disputing that people can and do die in their sleep from hypos but every report I have ever read about when this happens always either seems to include alcohol or happens in an individual with a history of going in and out of hospital for both DKA and hypoglycaemic collapse. Obviously no-one should ever rely on their liver alone to save them from nighttime hypoglycaemia. Obviously everyone should work to ensure that they avoid it. But do you not agree that we should consider the possibility that liver dumps can and do happen and that this might be the cause of elevated blood sugar in the OP in the morning? I'm not saying it isn't DP or basal running out; I'm saying let's consider all the options instead of just blithely assuming one of these options isn't an option.

In any case, citing a report from 1984, before we had modern insulins or even modern blood sugar testing methods, is hardly compelling proof that the Somogyi effect cannot possibly happen. Particularly when you follow the links to the right of the page which lead to more recent reports which suggest the Somogyi effect definitely exists!



> The use of a CGM is not overkill at all - a CGM gives the full picture of what is really going on and unless the OP is up for testing every few minutes it makes it difficult to see the bigger picture of what is really going on. Gary Schnieder (think like a pancreas) describes lack of a CGM as trying to read a book but only reading the first line of every page (normal testing) - whereas with a CGM you get to read the whole page so understand the whole story. Many teams have a CGM available for temporary use for these sorts of issues.



But why bother? You don't need to know what your BG is doing every minute of the night. You test before you go to bed, you test in the middle of the night, you test in the morning. That'll show you in the first instance if your BG is going up or down as a general trend. For instance, if you go to bed at 11pm at 6.5, a 3am test shows your BG is also 6.0, but then your morning at 8am is 18.0, then clearly something happens between 3 and 8am. So the next night you can then test at say 4am. Then you might find your BG is at 4.1...and you can infer a hypo must probably be taking place. Or perhaps it's at 12 - in which case it's either DP or the basal running out. Yes, a CGMS will give a more complete picture but given the option of either waiting for the clinic to sort this out, or just having a couple of nights of interrupted sleep, I'd take the interrupted sleep quicker option every time.


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## bev (Feb 7, 2013)

DeusXM said:


> But either way, it makes no difference.
> 
> If it's caused by DP, then there isn't enough circulating insulin to meet her blood sugar requirements.
> 
> ...


 My suggestion was for the OP to ask for a CGMS at clinic as a temporary measure - whilst also testing through the night. CGMS are not just for spotting one-off hypos/hypers - they are much more than that as they help with patterns and overall good control. Alex is on full-time sensors and we wouldnt do without them so unless you have used them full-time it is difficult for anyone to give an informed decision as to thier benefits.


It is your choice whether you believe it or not - but the latest thinking by the worlds experts in Type 1 (who I have met) do not believe it happens and refer to it as a 'myth'.Bev


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## Josco (Feb 7, 2013)

Can someone tell me what OP stands for please?!  I know the other abbreviations.  Thanks.


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## Steff (Feb 7, 2013)

Josco said:


> Can someone tell me what OP stands for please?!  I know the other abbreviations.  Thanks.



Original poster


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## everydayupsanddowns (Feb 7, 2013)

Interesting discussion. Leaving night time aside... Is the suggestion that low blood glucose never results in a release of glycogen from the liver/muscles? I have read impassioned posts from parents before (following a DUK article about nocturnal hypos), but does the liver NEVER dump under CGM observation? I only ask because I believe I have seen it happen in myself (albeit without the benefit of CGM) and consequently would not basal test if I had been hypo that day. Indeed I think that was a Scheiner recommendation in the basal test sticky in the pumping section. 

If it is thought to happen at some times of day, why not at night? Or is it just never thought to happen by some experts/specialists now?

Confused!


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## HOBIE (Feb 7, 2013)

It isnt easy at times  Sometimes i just dont want to know problems with T1. Good luck finding out


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## DeusXM (Feb 8, 2013)

> Testing throughout the night will help to understand whether it is DP or LA running out and the specific timing of this is paramount so the more tests the more information is provided. If its DP there may be a need for a pump - if LA there may be a need to alter the timings - so it is important and will make a difference to treatment.



I suspect it's very unlikely the basal is running out as the OP is already splitting their dose. I also don't think DP always requires a pump to treat (although granted, it makes it easier). I still think we need to rule out nypos though before we start messing around with insulin doses.



> This is the point I was trying to make - saying that the liver 'saves' people is not always an accurate reflection of what actually happens as this ability is mostly lost the longer one has diabetes.



Hang on.

Your previous position is that the liver DOESN'T dump glucose into the blood in the event of an untreated hypo, and that this particularly affects young people.

Now you seem to be saying that actually the liver DOES dump glucose, but this ability fades the longer you have diabetes. 

These statements contradict each other completely - if we now accept that that the liver does dump glucose in response to low BG levels AND this ability diminished the longer you have diabetes, then logically you can't then claim that teenagers are disproportionately affected by the failure of the liver to respond! Particularly as I'm not seeing a source for the original point the first place - simply saying "Diabetes UK say so" isn't actually good enough. I'm sorry, I know I'm coming across as rude and I really don't mean to. But what I want is facts, not hearsay and conjecture. Otherwise it sounds more like a diabetes myth. Let's base this discussion on evidence.

But now I'm interested - why would having diabetes for a certain length of time diminish the liver's ability to response to low glucose? What's the biological basis for this?



> The best paediatric teams in the UK do not believe in somoghyi. If it existed why would Medtronic have made the VEO that cuts out if levels automatically rise?



Umm...that's very, very defective logic there. That's like saying 'why do cars come with impact bars and airbags?'. Relying on your liver to tackle nighttime hypoglycaemia is not safe and I don't think at any point I implied it was. All I was suggesting is that the liver has the capability to respond to low blood glucose levels while you sleep and this can and does happen. Having a pump that can respond to dropping BG levels is no bad thing - all it's doing is mimicking what a normal pancreas would do. Just because there is a pump that can reduce its insulin output in accordance with blood glucose levels is nowhere near proof that the liver has no ability to response to low blood glucose level. As for whether or not the best paediatric teams in the UK do not believe in the Somogyi effect, I think all of us here are familiar with knowing more than our doctors about the condition and in any case no paediatric team in the country could be seen to endorse such an effect as it might encourage irresponsible diabetes control. And this is before we even get to the elephant in the room which is that children have smaller livers and thus smaller glycogen stores than adults, which could mean that even if their livers do release glucose to combat a hypo, they might simply not have enough in the tank. This would also then explain your currently unsourced stat that young people are disproportionately affected by fatal nighttime hypoglycaemia. 

Unfortunately, we're not talking about a child here. As you've pointed out before, I shouldn't necessarily apply to children what works for adults. Perhaps now would be a good time to make the point that this logically works both ways?



> As the parent of a child who uses full-time CGMS it is clear to me that somogyi does not happen - at best levels will rise to 9ish - but not the 18's that is reported. There are hundreds of children on CGM's on the CWD list and their data shows no such effect either - we cant all be wrong?! The somogyi was named after its founder in 1938 and has not actually been proven with any studies to happen - the latest data does not support it.



And I guess I've now addressed this too - you can't apply children's data to adult circumstances. Where is this data anyway? Where is this data conclusively proving somogyi doesn't happen in adults?



> the latest thinking by the worlds experts in Type 1 (who I have met) do not believe it happens and refer to it as a 'myth'.



And that's fine...but can we at least test to rule it out first? Most 'world experts' in T1 are still pedlding the line that we need to stuff ourselves with carbs every day - they can and do get things wrong. I know Bernstein doesn't believe in it but there are also plenty of T1s out there (myself included, I must stress) who have experienced this. Statistically, that's just as valid as you saying because it doesn't happen in your child, it never happens.


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## bev (Feb 8, 2013)

Hi DeusXM,

Clearly we have different opinions on this subject.I am not particularly interested in using my energies to prove to you what I know to be right - there is little point as we are all on the same side trying to battle this condition daily. If you choose to believe that somoghyi exists then that is your choice - I dont believe it does (apart from newly diagnosed and those who are in the honeymoon period) and is so infrequent that it cannot be relied on to save anyone. I think we should agree to differ.Bev


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## Adrienne (Feb 8, 2013)

everydayupsanddowns said:


> Interesting discussion. Leaving night time aside... Is the suggestion that low blood glucose never results in a release of glycogen from the liver/muscles? I have read impassioned posts from parents before (following a DUK article about nocturnal hypos), but does the liver NEVER dump under CGM observation? I only ask because I believe I have seen it happen in myself (albeit without the benefit of CGM) and consequently would not basal test if I had been hypo that day. Indeed I think that was a Scheiner recommendation in the basal test sticky in the pumping section.
> 
> If it is thought to happen at some times of day, why not at night? Or is it just never thought to happen by some experts/specialists now?
> 
> Confused!



Hiya how's you?    

I think the word 'never' cannot be applied.  It is proven (and I'm ill so can't be bothered to go and get any studies etc sorry  that generally the Somghiyklshfd (can't spell it so added a few letters of my own here) is not relied upon anymore and has been dispelled as good thinking.   I imagine the liver does in some people dump some lovely stuff every so often and that is fab for some.   But others, using CGM, can see very clearly that no it does not happen.  

There are also studies that show out of x amount of kids that the majority will not wake up when hypo at night, it is nothing to do with their bodies getting used to hypos, they just don't wake up.   I was actually talking to the real live consultant who was part of this particular study just the other week funnily enough.   

My thoughts (and these are purely my thoughts) that if the said 'dumping liver' worked well and indeed rose anyone up to 18 then this would happen day and night and there would be absolutely no need to treat hypos day or night.   Makes sense doesn't it.   With my daughter it never happens and I can see this with the CGM.

I think someone said CGM was overkill - mmmmm not my take it on it but each to their own.   The nearest thing on the market to a fully working normal pancreas is, at this moment in time, the Medtronic VEO with fully integrated full time use of CGM with its low suspend.  This low suspend function does save lives, there can be no argument on this.    Where I have been obviously far too knackered to hear my alarm clock the low suspend has kicked in twice now for the full 2 hours and one of those times it suspended again for a further two hours so that my daughter's levels rose slowly out of a hypo.  Phew.   I thank my lucky stars that we live in the right postcode to get full time CGM.   

Anyway hope you are well and now I must get on being ill


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## Robster65 (Feb 8, 2013)

A very interesting thread and one that makes me want to learn more. 

My education on this is about 30 years out of date so not a bad thing to find out what my liver may or may not do. I wonder if it has a minimal effect in us oldies, in that it squirts a little bit of glucose out to get us out of (or into) trouble sometimes.

One of the problems with getting hold of CGM is whether your support team actually have one to lend you. I tried and was met with a resounding no. They don't use them because they didn't find them reliable (I presume this meant they didn't know how to calibrate/interpret result).

Best thing as always is to test when there's a grey area and see what you find out. I've had some surprising results from late meals and delayed spikes that show in the mornings. It's one reason why i'm always cautious about dawn phenomenon. It does happen but sometimes it's just caused by what we eat the night before.

Rob


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## DeusXM (Feb 8, 2013)

But Bev, all I'm asking for is evidence for your opinion. As you say, we're fighting against the same enemy, diabetes. At the moment, the evidence I've seen suggests to me that the Somogyi effect happens, and this influences how I manage my diabetes. If you have evidence that demonstrates the Somogyi effect doesn't happen, I'd really appreciate it if you could share it as this would have a significant affect on how I manage my personal battle with diabetes. Agreeing to disagree isn't enough. This is our health and lives at stake here. I'm still trying to work out whether we fundamentally disagree on whether the effect happens or not because your position keeps changing - on the one hand, you say it doesn't exist. Then you say it only affects the newly dxed and honeymooning. And then you say it's just infrequent and can't be relied to save people - the latter part being exactly my position all along. So at the risk of drawing more of your energy, what is it? I'm now pretty confused.



> My thoughts (and these are purely my thoughts) that if the said 'dumping liver' worked well and indeed rose anyone up to 18 then this would happen day and night and there would be absolutely no need to treat hypos day or night. Makes sense doesn't it.



To an extent. My thoughts (and these are purely my thoughts) is that any liver dump is your body's inequivalent of the Alamo - after all else fails, this is the last gasp to try and resolve the situation and would only happen after the individual has lost consciousness. My feeling is it's similar to your body's response to hypothermia - just because your body can shut off vital parts of your body to retain temperature doesn't mean there's no need to keep warm!


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## everydayupsanddowns (Feb 8, 2013)

Hi Adrienne 

Lovely to hear from you  Sorry to hear that you are feeling a bit under the weather. 



Adrienne said:


> I think someone said CGM was overkill - mmmmm not my take it on it but each to their own.   The nearest thing on the market to a fully working normal pancreas is, at this moment in time, the Medtronic VEO with fully integrated full time use of CGM with its low suspend.  This low suspend function does save lives, there can be no argument on this.    Where I have been obviously far too knackered to hear my alarm clock the low suspend has kicked in twice now for the full 2 hours and one of those times it suspended again for a further two hours so that my daughter's levels rose slowly out of a hypo.  Phew.  * I thank my lucky stars that we live in the right postcode to get full time CGM*.



I'm almost always a non-waker myself for nocturnal lows so I know just what you mean (not that I've had a full on night hypo for years). My interest in the discussion is partly fired by that. When I get an unusually high reading in the morning I know I need to evaluate whether it is post hypo or general rise. For me that means waking and testing. Of course I would not dream of blithely assuming my liver would 'fix' any hypo automatically (no one is suggesting that) but I am another person who has seen weirdly elevated levels in the hours/day after a lower low. Not always immediately by any means, not very predictably and sometimes not at all but if I'm having lots of highs, one of the first things I look to fix (if it exists) is an increase in hypos (even just mild ones in the mid 3's). More hypos tends to equal more highs for me - and not, I hasten to add, just because of overtreatment. Learning about the liver being prompted to release glucose to regulate BG levels (which happens in non-Ds too I believe) was a lightbulb moment for me. It explained a lit of seemingly bonkers BG chaos in my D experience up to that point.

As far as I can see from reading the thread, when Deus said he thought that CGM was 'overkill' it was more from a point of view that while CGM would of course offer additional detail, it was not necessarily the _only_ way forward - and that to do *nothing* while waiting for a clinic to arrange a stint of CGM was not a good plan.

Personally I would LOVE access to a CGM, but as many times as I have requested it from my hospital, I have always been turned down. And self funding is not a viable option. I am pleased that you and Bev have access to the technology, but you do need to remember that for most of us any CGM at all _let alone_ full time coverage is simply not going to happen. We can only look on with a few pangs of envy 

In that sense I think the suggestion to run a couple of overnight tests to rule out a hypo rebound was entirely sensible.


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## DeusXM (Feb 8, 2013)

> Deus said he thought that CGM was 'overkill' it was more from a point of view that while CGM would of course offer additional detail, it was not necessarily the only way forward - and that to do *nothing* while waiting for a clinic to arrange a stint of CGM was not a good plan.



Thanks Mike for putting it far better than I did!

Yes, I'd love a CGMS and the VEO system too...I just don't think it's essential for solving the OP's problem. Incidentally Grainger, how's your detective work going?


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## bev (Feb 8, 2013)

everydayupsanddowns said:


> Hi Adrienne
> 
> Lovely to hear from you Sorry to hear that you are feeling a bit under the weather.
> 
> ...




Hi EDUAD,

I have not said not to do any testing! In fact I suggested it as that is the only way to find out what is happening so not sure where the wires have got crossed. I did say a CGM would be helpful as a temporary measure and the OP should ask at next clinic but nowhere have I said not to test.

As far as CGM's is concerned - it really does give us so much more information than normal testing which is probably why both Adrienne and myself can see what is really happening - testing every couple of hours just isnt enough as you cant get the full picture so we speak from years of experience. I did pass a link to DeusXM but it has been dismissed as its too old. What I would say is that can someone show me a link that categorically proves that somoghyi does exist? Giving BG results isnt enough - seeing a graph or data that shows it would be helpful. I could show you thousands of graphs that show that Alex and hundreds of other children dont have the luxury of the liver dump and I dont rule it out completely because we have also been told by a top chap that it does happen just after diagnosis - but it does also start to fail after a year or so - sometimes longer it depends on the person - but I asked him point blank 'DUK tell me that my child wont die in the night because the liver will save him - can you confirm this happens'? His reply was 'the liver initially will play ball and kick out glucose - but after a while it gets a bit fed up of doing that because it was never geared up to do on an on-going basis so it will one day stop and for some people it never happens and for others it might be months or a couple of years at most but eventually it gets tired and just stops'. 

I cant remember his name as this was over 4 years ago at a JDRF talk and he was guest speaker. I remember feeling devastated all over again because DUK had promised me that children dont die in their sleep at a DUK weekend - and they were talking nonsense.

I wish everyone had access to CGM - it really isnt fair - but the knowledge that parents like Adrienne and myself have gained should not be dismissed as we can see much more using CGM and have no reason to be making any of this up - clearly we would love our childrens livers to dump when needed - but they just dont - and not because they have bad control - it just simply doesnt happen for the reasons mentioned above. DeusXM - as I said earlier I think its best we agree to disagree and accept that we have different ways of managing this condition and what suits one person wont necessarily suit another - but we are all on the same side - diabetes is such a drain and I dont want to waste anymore time debating this issue as you clearly dont accept my view.Bev


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## Adrienne (Feb 8, 2013)

Robster65 said:


> A very interesting thread and one that makes me want to learn more.
> 
> My education on this is about 30 years out of date so not a bad thing to find out what my liver may or may not do. I wonder if it has a minimal effect in us oldies, in that it squirts a little bit of glucose out to get us out of (or into) trouble sometimes.
> 
> ...



Hiya Rob

I agree always test, its in theory the only thing we have (except CGM) to know what is going on.   However even those meters can be 20% out, we've just changed to the One Touch Verio IQ which is fabulous so far and boasts to only ever (if ever) being a maximum of 15% out !

It does make me laugh when I hear about old school consultants (generally) who say catergorically that CGM doesn't work or isn't accurate enough.   mmmm wish I could do a presentation to all these people.   They don't know because they don't use them.   Using one for a week when you have neither the experience nor wherewithal to read the reports (talking about consultants here by the way not you) is not going to give you any sort of indication.   

It is soooo hard for an adult to get CGM at all, although I do know a few with full time funding for CGM and they wouldn't give it up for anything.   Neither would any parent and this is because we all (collectively all, parents and adults) know it works and know how to use it and know that most of the time it is accurate.  Who knows whether the CGM is right or the glucometer !  I mean if the glucometer is allowed (by law or whatever it is) to be up to 20% inaccurate, who says that the CGM reading is not closer to a true blood reading,   food for thought eh !     I think an open mind by some of these consultants is needed.

I don't necessarily think it is adults that maybe the liver dumping process may or may not work for.   It certainly doesn't work for many children (which their parents can see by using a CGM).    For many once they are low, they stay low until user intervention.  Its frightening stuff.   When I say children I am talking up to about the age of 20 odd here as well.  

Anyway who knows, as with everything diabetes it is not all clear cut.


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## Adrienne (Feb 8, 2013)

everydayupsanddowns said:


> Hi Adrienne
> 
> Lovely to hear from you  Sorry to hear that you are feeling a bit under the weather.
> 
> ...



Hiya

Absolutely I agree, test test test test always, even with CGM to be honest.  I have no idea what the NICE guidance is on CGM for adults, I only know about kids and young adults as its the same and its they need to be offered the use of one for a week ish or so, or something like that.     

Self funding if possible is a must as well in my view but only of course if you can afford it, it is not cheap.   I do know some parents who go without other things (like a social life ) to just buy a kit as they know it works.   Hard if you are providing for a family.

In the absence of CGM then of course test test test, absolutely 100% agree.   just don't agree that CGM and overkill can ever be put in the same sentence in regard to anything as it isn't, plain and simple, it is the best tool on the market but I absolutely appreciate that most cannot afford it and that it is a postcode lottery as tor funding for children let alone for adults.  Nightmare really.

Right have to leave the computer now as I seem to have a house full of pre teens wanting to play the Wii so I am escaping upstairs with my bedroom door firmly shut whilst they have the run of downstairs, mistake ?  Possibly


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## Adrienne (Feb 8, 2013)

DeusXM said:


> Thanks Mike for putting it far better than I did!
> 
> Yes, I'd love a CGMS and the VEO system too...I just don't think it's essential for solving the OP's problem. Incidentally Grainger, how's your detective work going?



I agree it is not essential or the only way as it is not possible to get it for many many people.   

(it is not overkill though  and if someone does have it, it is absolutely the only way forward as it works). 

For the original poster the only answer for now is the test and to test probably hourly for 3 nights if possible (or 2 hourly) to establish what is happening or even better if the original poster has an other half then to get them to test whilst asleep as that way you would know what is going on whilst asleep.    Not sure how possible that would be though.


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## AlisonF (Feb 8, 2013)

While randomised controlled trials are always the best evidence to work from, in the absence of an up to date one, I find anedotal experience a useful help in informing decisions. 

Having used CGM for the past 6 years, I have seen no evidence at all of me experiencing the Somogyi effect either at night or during the day. That's not to say it categorically doesn't exist, but it certainly doesn't seem to for me.


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## Adrienne (Feb 8, 2013)

bev said:


> Hi EDUAD,



hahahahaha this made me laugh to myself.   Took me ages to work out that your name wasn't Eduad, thought it was unusual but that it was the initials of your Everydayupsanddowns.   !!!   What a numpty eh !


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## Adrienne (Feb 8, 2013)

AlisonF said:


> While randomised controlled trials are always the best evidence to work from, in the absence of an up to date one, I find anedotal experience a useful help in informing decisions.
> 
> Having used CGM for the past 6 years, I have seen no evidence at all of me experiencing the Somogyi effect either at night or during the day. That's not to say it categorically doesn't exist, but it certainly doesn't seem to for me.



Hiya Alison

Well my friend you were one of the adults I was of course talking about.  Hope all ok with you x


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## DeusXM (Feb 8, 2013)

> I did pass a link to DeusXM but it has been dismissed as its too old. What I would say is that can someone show me a link that categorically proves that somoghyi does exist?



Well, it's not categorically proven to exist, but at the very least, it's not a closed case that it doesn't.

Endokrynol Pol. 2011;62(3):276-84.
The dawn phenomenon and the Somogyi effect - two phenomena of morning hyperglycaemia.
http://www.endokrynologia.polska.viamedica.pl/en/zamow_art_pdf.phtml?id=43&indeks_art=607



> Research supporting the existence of the Somogyi effect includes the experiment carried out by Matyka et al. [42]. Their study involved two groups of 29 type 1 diabetic and non-diabetic children. The aim of the study was to determine the response of insulin-antagonistic hormones to hypoglycaemia. The results revealed a small increase of plasma GH and a rise of plasma epinephrine during nightly hypoglycaemia compared to a night without hypoglycaemia. The levels of norepinephrine, cortisol and glucagon were the same after a night with or without hypoglycaemia. Furthermore, the above
> mentioned study found a significant increase in plasma insulin concentration  between 11 p.m. and 3 a.m. among type 1 diabetic children, but not in non-diabetic children [42]. Perriello et al. [43] showed that fasting and post breakfast plasma glucose levels were significantly higher after nocturnal hypoglycaemia than when hypoglycaemia was prevented. Moreover, fasting levels of plasma glucose in their study correlated directly with overnight plasma levels of epinephrine, GH and cortisol. Bolli et al. [44] drew similar conclusions, and indicated that hypoglycaemia can cause rebound hyperglycaemia in the absence of insulin waning in patients with type 1 diabetes, and that this results primarily from an excessive increase in glucose production due to activation of glucose counterregulatory systems. In another study [45], the authors observed the presence of the relationship between the Somogyi effect and the exuberant counterregulatory release of GH caused by nocturnal hypoglycaemia among patients with type 1 diabetes.



The article then discusses the counterarguments to the Somogyi effect happening but concludes:



> the existence of the Somogyi effect has not been definitively proven. However, science supposes it to exist, and it is supposed to be present in clinical practice among large number of patients with morning hyperglycaemia. With regard to the impact of the excessive dose of insulin on the Somogyi effect, it is highly probable that this phenomenon can occur not only among patients with type 1 diabetes, but also among patients with type 2 and secondary types of diabetes, provided patients have been intensively treated with insulin.



Another pretty comprehensive report (also from 2011) can be found at http://emedicine.medscape.com/article/125432-overview#a1



> Although no data on frequency are available, Somogyi phenomenon is probably rare. It occurs in diabetes mellitus type 1 and is less common in diabetes mellitus type 2.



And here's where it gets really interesting for the OP.



> Patients with Somogyi phenomenon present with morning hyperglycemia out of proportion to their usual glucose control. Nocturnal hypoglycemia is missed or asymptomatic, and posthypoglycemic hyperglycemia is not considered or is confused with the dawn phenomenon.
> 
> The most common cause of morning hyperglycemia is hypoinsulinemia. Patients have an increased need for insulin in the early morning primarily due to the release of growth hormone, which antagonizes insulin action. Cortisol may play a supporting role.
> 
> ...



So yes, not proof that the Somogyi effect definitely happens. But certainly evidence to suggest it shouldn't be discounted until further testing's been done.



> His reply was 'the liver initially will play ball and kick out glucose - but after a while it gets a bit fed up of doing that because it was never geared up to do on an on-going basis so it will one day stop and for some people it never happens and for others it might be months or a couple of years at most but eventually it gets tired and just stops'.



I would politely suggest you've misunderstood his meaning. Think about it - if you go for years without ever having a liver dump to ward off nighttime hypoglycaemia, and then suddenly have a one-off, how could your liver possibly get 'fed up'? What this says to me is that the liver does in fact release glucose but that repeated undetected nighttime hypoglycaemia will eventually dull this response (presumably in much the same way that repeated hypos dull hypo awareness). In other words, this doctor was being absolutely responsible by reiterating to you that there is no substitute for good glucose control and nighttime hypo prevention - which is precisely what I said earlier!


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## bev (Feb 8, 2013)

DeusXM said:


> Well, it's not categorically proven to exist, but at the very least, it's not a closed case that it doesn't.
> 
> Endokrynol Pol. 2011;62(3):276-84.
> The dawn phenomenon and the Somogyi effect - two phenomena of morning hyperglycaemia.
> ...




Hi DeusXM,

I would politely reply that I did not misunderstand the meaning! You seem hell-bent on believing what you have been told by the Medical Profession for years so not sure why you want me to 'prove' differently! Fair enough - your the one who knows your diabetes best - as do parents who do all the night-testing - but please dont assume that our experience is not of any value simply because you dont believe it. I would also add that us parents do attend the latest conferences from JDRF and others (FFL) and are  up to date with the latest theories - as do our Medical teams who also (in our case) one of the main speakers due to their high standing in the diabetes community. Like I have said before - lets agree to disagree - you wont convince me that somorghyi exists and I wont convince you that it doesnt - check mate - he he!Bev


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## DeusXM (Feb 8, 2013)

> You seem hell-bent on believing what you have been told by the Medical Profession for years so not sure why you want me to 'prove' differently! Fair enough - your the one who knows your diabetes best - as do parents who do all the night-testing - but please dont assume that our experience is not of any value simply because you dont believe it.



I'm not hellbent on anything apart from keeping options open. My position has always been the same - the Somogyi effect may exist, and if it does, doesn't necessarily happen in everyone. I'm basing this on the research I've found and my own personal experiences of actually having it happen to me, and indeed, anecdotal evidence from other adults with diabetes.

You are welcome not to believe in the Somogyi effect, but given it is theorised as a cause of morning hyperglycaemia, do you not agree that the OP should at least do the testing to rule it out rather than just assume it couldn't possibly be a factor?

You're arguing that the Somogyi effect NEVER happens - despite the fact it HAS happened to me! It's not ME assuming another person's experience isn't of value. I'm certainly not telling you that your child or anyone else's has had the Somogyi effect happen to them, but you do seem to be telling me that something that happened to me, didn't happen, because it hasn't happened to anyone you know. Is my experience not of value then because you don't believe it?


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## Northerner (Feb 8, 2013)

Difference of opinion and experience noted people, lets not make this a circular argument


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## Robster65 (Feb 8, 2013)

Getting back on topic, would be interestign to know from Grainger what her BGs have been before bed, what time she ate and any overnight and mornign BGs since the thread started.

(get well soon Adrienne!)

Rob


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## Josco (Feb 9, 2013)

Steff said:


> Original poster



Ah.  Thank you.  Thinks make much more sense now


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## Phil65 (Feb 9, 2013)

Grainger, I hope you find an answer.....maybe this thread might have added to the confusion, to me though this thread has been fascinating reading......and very passionate......love it! 
I have to say though that I do agree with a lot of what Deux has said, I definitely suffer from the somogyi effect, I've had cgm and this supported this, also DP has always been a big problem for me. The pump has really helped me and those problems could not really have been alleviated with MDI (unless lots of work and lots of corrections)


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## everydayupsanddowns (Feb 11, 2013)

What I find most interesting is that the posters who are most convinced that hypo rebounds (let's not use the S word) don't happen in the D they know best - their own or their child's are the ones with most access to CGM data.

I have *never* had the benefit of CGM, but I have had seemingly random highs after a hypo that bear no relation to food I have consumed, or active insulin levels. When I learned about the possibility of a 'liver dump' post-hypo, it was easy for me to put these two things together and draw a conclusion.

This thread makes me wonder if perhaps Alison (for example) believed in post-hypo-liver-dump-highs before she secured CGM and was able to watch that graph line *not* reacting enough times after a hypo to convince her that any unexpected post-hypo highs must be being caused by something else.

If post hypo-counterregulatory-hormone-highs don't exist I shall really miss them, as they have provided a valuable safe haven for many frustrations over the years.

Still confuses my though why generally basal testing is supposed not to be done after a hypo... From Gary Scheiner's 2008 basal testing sticky in the pumping section...



> *Your liver should be producing its ?normal? amount of glucose*
> Do not run the test if you have had a low blood sugar within the previous 4 hours; hypoglycemic episodes tend to result in over-secretion of glucose by the liver.



http://diatribe.us/issues/13/learning-curve

Is it just that this advice is old? Has he changed his postion? 

TBH it would make my life much easier if I felt I could basal test even after a 3.7 during the day as when my basals are out it can be very frustrating having to wait for a _valid_ opportunity!


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## Phil65 (Feb 11, 2013)

everydayupsanddowns said:


> What I find most interesting is that the posters who are most convinced that hypo rebounds (let's not use the S word) don't happen in the D they know best - their own or their child's are the ones with most access to CGM data.
> 
> I have *never* had the benefit of CGM, but I have had seemingly random highs after a hypo that bear no relation to food I have consumed, or active insulin levels. When I learned about the possibility of a 'liver dump' post-hypo, it was easy for me to put these two things together and draw a conclusion.
> 
> ...




.....and so irritating that you have to abort your basal testing, especially when the testing period hasn't long to run! I do wonder why my liver does dump during the night and doesn't during the day as a result of a hypo, is it because my nightime hypo goes on for longer without self correction?


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## HelenM (Feb 11, 2013)

> This thread makes me wonder if perhaps Alison (for example) believed in post-hypo-liver-dump-highs before she secured CGM and was able to watch that graph line *not* reacting enough times after a hypo to convince her that any unexpected post-hypo highs must be being caused by something else.
> 
> If post hypo-counterregulatory-hormone-highs don't exist I shall really miss them, as they have provided a valuable safe haven for many frustrations over the years.



I've never had morning highs that I can relate to overnight lows. If I have a high the next morning I can usually relate it to later meals the night before, particularly  high fat meals.

 I used to go to bed with a 'normal' level (maybe in the 5s) and woke up at a similar level but  I sometimes woke  during the night with hypo symptoms  When I tested though I wasn't low.  I wasn't certain whether it was my age ie menopause related or if I really was going low.
 I was able to borrow a CGM . It was very interesting, I was woken by the alarm and my glucose was low according to the monitor but  when I tested my glucose was 6 -7.  I then watched the monitor show the level rising again . Remember there is a time lag on the monitor.
My glucose levels were falling to hypo levels, presumably my liver intervened and released some glucose but not enough to cause a high next morning.  On a couple of nights this happened more than once. My liver was compensating but not over compensating and it was doing it quickly (certainly doesn't work that fast during the day). The rest of the night my glucose levels were almost a flat line.

After discussing this with my doctor I agreed (somewhat reluctantly) to reduce my bolus for my evening meal and go to bed with a slightly higher level rather than trying to adjust the basal overnight. She was concerned that though my liver was doing what it should do that it might not continue to do so. I believe that there is evidence that the glucagon response diminishes both when there are a lot of hypos and also when people have had diabetes for a number of years.
It worked and when I used the CGM again achieved a very gradual slope towards the morning.

 (as long as I didn't eat high fat, late meal . Then BG starts to rise in the early hours. That only started when I stopped running so many miles a week. I suspect I no longer had to 'fill up' my glycogen stores. I found out that was happening after a later session with a cgm)


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## AlisonF (Feb 11, 2013)

everydayupsanddowns said:


> This thread makes me wonder if perhaps Alison (for example) believed in post-hypo-liver-dump-highs before she secured CGM and was able to watch that graph line *not* reacting enough times after a hypo to convince her that any unexpected post-hypo highs must be being caused by something else.



Spot on Mike, I always believed in it, but after using the CGM I've never seen the evidence that they exist in me.


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## Abi (Feb 11, 2013)

Generally if I'm high after being hypo- or suspected hypo and not tested, been asleep etc- it's either overtreatment of hypo or ignoring symptoms for too long so that Mr Liver decides to intervene, or me and Mr Liver intervening together- so we both raise levels by a few points-need to communicate more with each other!


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## pgcity (Feb 11, 2013)

My theory for what it is worth is that post hypo highs are caused by either over correcting or by the release of adrenalin and that is why you shouldn't basal test after one. I am surprised there is no evidence showing the somogyi exists but I have only read the wiki page.


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## grainger (Feb 11, 2013)

*I'm back - sorry for delay in replying*

Hi all,

Apologies for silence, manic few days as usual.... very interesting read though! Not convinced I have a clue what's going on with me... so... I'll take some advice... post my bs levels, food, exercise levels etc and you guys can draw some conclusions.

Will say this... I cannot and will not test every hour throughout the night, I start work at 7.30am, am up at 6 and need to be able to concentrate. I'm also rubbish at not letting life get in the way so there are nights this week I've had a drink (or several etc) which I realise will not make working anything out easy...So I apologise in advance. I plan to have a sensible week until Friday when I fly to Thailand so hopefully I'll be able to give better readings then.

Should also mention, my sugar levels through the day are good - generally between 4.5-6 before lunch and maybe slightly higher 5-8 before dinner. Finally, I test in the morning after I've showered etc before drying hair (just incase you were interested!)

OK...
4th Feb
Dinner 19:45 BS 5.4 
Home made Lasagne, garlic bread and homemade smoothie (strawberry, raspberry and banana). 
CPs = 9. Novorapid = 9
Bed 22:31 BS 5 
Ate 1xCP (digestive biscuit 10.1g) and didn't inject for it.
Levemir = 9Units

5th Feb
Waking BS 6:15 = 18.3
Workout before dinner - 30 mins intensive circuit type training
Dinner 18:30 BS = 8
Pasta with homemade mint pea pesto, smoothie (this time blueberry and banana) 
CPs = 6.5. Novorapid = 4.5
Bed 22:16 BS = 8.4
Levemir = 9Units

6th Feb
Waking 6:20 BS = 13.2 
Hypo at 13:47 
Workout before dinner - 30 mins intensive circuit type training
Dinner 19:30 BS = 11.6 (figure I over ate after hypo)
Homemade fish curry with rice and green beans
CPs = 6. Novorapid = 6
Bed 23:05 BS = 10.4
Levemir = REDUCED TO 7. 

7th Feb
Waking 6:19 BS = 7.8
Hypo before dinner (one of those things) at 18.57
Out for dinner 19:05 BS = 4.2
Pasta with tomatoes, various other veg type sauce. 1/2 bottle of red wine
Then another large glass of red wine.
Bed 00:05 BS 18.5 (I forgot to inject for dinner all together - no concentration after hypo!)
Levemir = 7


8th Feb
Waking 6.20 BS = 17.4
Workout before dinner - 30 mins intensive circuit type training
Hypo at 20:15 (ops)
Dinner 20:30 BS = 4.5
Thai takeaway (starters, then shared a red thai curry with rice), 1/2 bottle of prosecco.
CPs = 10 Novorapid = 10
Bed 00:36 BS 10.4
Levemir = 7

9th Feb
3.00am - hypo 
Waking 9:33 BS = 13.3
Dinner 18:22 BS = 7.4
homemade cottage pie + veg, 1/2 crispy creme doughnut
CPs = 4 Novorapid = 4
Bed 23:50 BS 14.4 (completely underestimated dinner!)
Levemir = 7

10th Feb
Waking 9:10 BS = 8.3
Dinner 19:55 BS = 6.9
Chicken baguette, pork pie.
CPs = 8 Novorapid = 8
Bed 22:22 BS 6.6
Levemir = 7

11th Feb
Waking 6:24 BS = 15.7

So there you have it - to me it still doesn't make any sense. Although the days I wake up really high I wake up very sweaty and tired. 

What do you think??? Sorry for the essay!

Hannah


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## grainger (Feb 11, 2013)

Should also add, I massively summarise my conversations with consultants - we do go through a lot!
And he has said if we can't solve it the way I'm trying to now they have no issues with me having CGM for a week to see.


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## fencesitter (Feb 11, 2013)

Glad it was a home made lasagne


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## fencesitter (Feb 11, 2013)

Sorry for flippant remark ... I do feel for you, very hard to see what's going on there. You have had a few better mornings with the reduced Levemir dose, but was it like that on the higher dose too (ie some good and some not so good)? I wouldn't have thought every hour was necessary for night time testing, maybe just once a night to see if you can find out when the rise starts, but easy for me to say that when I don't have to get up at 6am. As you say the wine might have interfered a bit too so perhaps you should do a really squeaky clean week of testing weighing all your food to make sure the carbs are really accurate, avoiding the booze and so on. Something to look forward to after your holiday


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