October 9, 2005
Hyperglycemia and DKA, Insulin Pumps
Question from New Lenox, Illinois, USA:
My daughter has been on the pump since late June. Her daytime numbers are pretty good, however, her nights have a strange pattern. She will have a good bedtime blood sugar level, 120 to 180 mg/dl [6.7 to 10.0 mmol/L]. She goes to bed between 8:30 and 9:00 p.m. By 10:30 to 11:00 p.m., she goes up to the low 300s mg/dl [16.7 to 17.5 mmol/L]. Without a correction, she comes down 80 to 100 mg/dl [4.4 to 5.6 mmol/L] by 3:00 a.m. By morning, she is back in a normal or low blood sugar range. She has her dinner bolus at around 5:30 or 6:00 p.m. Her basal rate all day is 0.3 until 9:00 p.m. when it goes up to 0.55, in an attempt to combat that early sleep high, then goes back down to 0.3 at 3:00 a.m.
Should her basal rate be higher in her early sleep period to keep her from spiking up and her 3:00 a.m. basal lower? Our pump trainer said this is very unusual, but seems to think what is happening is okay since her blood sugar is returning to normal with the pattern we have set. I think we should be able to control it to keep her from spiking up. Do you have any thoughts about how to stabilize her night time blood sugars?
Answer:
I think that either approach is okay. The first approach is the “forest-from-the trees” approach. If the overall levels are good and the A1c is very good, then you don’t need to make big changes. The other approach is the “look-at-all-the-effort-and-expense-we-put- into-getting-this-very-technical-piece-of-equipment-to-control-her- diabetes-and-we-should-be-able-to-utilize-it-even-better” approach. If you choose the latter, I would also increase the 9 p.m. to midnight rates and decrease the bedtime snack, but I would also be rather cautious and be ready to anticipate decreasing the basal rates from 3 a.m. to breakfast time.
Given that you might be at risk of inducing early morning hypoglycemia, then, and assuming that the A1c is, in fact, very good and the child receives no other medications that can affect glucose, you might really want to lean towards the first approach.
DS
