April 7, 2009
Daily Care, Hyperglycemia and DKA
Question from Altona, New York, USA:
My 15-year-old son switched from twice daily Lantus to twice daily Levemir in November 2008. Dosing with Lantus provided variable blood sugar results and required different insulin-to-carbohydrate ratios throughout the day and evening, thus the choice to move to a basal insulin that initially provided consistent blood sugar control. For the first two months, blood sugar control was excellent. For the past two months, we have been seeing elevated morning fasting blood sugars in spite of steadily increasing evening doses of Levemir. His bedtime, 10 p.m., blood sugars are in the 90 mg/dl [5.0 mmol/L] to 110 mg/dl [6.1 mmol/L] range and his wake up numbers are in the 220 mg/dl [12.2 mmol/L] to o 275 mg/dl [15.3 mmol/L] range. I have done nighttime checking at 1 to 2 a.m. and his numbers are in range at this point. Short of getting up at 4 or 5 a.m. every day to correct this with a shot of Humalog, what can you suggest? The blood sugar does correct in about two to three hours following the morning dose of Humalog.
Answer:
Any chance that there are nocturnal lows being missed at 3 to 5 a.m.? Could you get up and check a few nights to see if this can be answered? If so, then the higher Levemir dose would obviously need to be cut back. If there were a steady rise towards dawn, then increasing the dose at night of Levemir would solve this problem. Sometimes giving the bedtime Lantus or Levemir dose much later also solves the problem since it would mini-peak near dawn/pre-breakfast, exactly where it seems needed. Lastly, eating a high fat bedtime snack sometimes does not show up as high sugars until many hours later and if this were the case, then stopping such a choice would also solve the problem.
SB
