Going on holiday

We've just returned from a great two weeks away. This year we gave the kids the choice of three different holidays. Options included a fortnight by a beach, a short break in Switzerland, but the winner was a combo of a week in Ironbridge in Shropshire, followed by a week in the Lake District.

Holidays are always a bit of a juggling act diabetes-wise. You are completely out of routine, you eat out far more often, wine flows, ice creams and treats beckon.

Thankfully Lantus continued to behave itself back in its morning slot. Staying in the UK meant there were no pesky time-zone issues, though I did have to gradually shift my injection time to suit our more relaxed holiday breakfast timing. Thankfully my first blood test of the day was pretty much spot-on most days. I even managed a little experimentation with post-breakfast spikes. I've settled on a new slightly higher insulin:carb ratio taken 20-30 minutes before breakfast, depending on my fbg (pre-breakfast) level. An hour or two after breakfast was mostly in the 8-10mmol/l region which compared to some recent disastrous readings felt pretty good.

The other thing about holidays is all that great wandering about you can do. Ironbridge is absolutely packed with things to look around, and it's almost impossible to visit the Lakes without doing some kind of walking about. The benefit of this, of course, is that you can sneak an occasional ice cream or cake to keep your levels up, without having to worry about injecting. Either that or I just gradually worked my way through a pocketed packet of Fruit Pastilles during the day. At Blist's Hill (the Victorian Town museum close to Ironbridge) I even managed to win a Sherbert Fountain by knocking it off a shelf with a pop-gun at the Victorian funfair. Initially I was a bit disappointed that these now come in a plastic tube, rather than wrapped in yellow paper, but the benefit was it lasted in my pocket until a wander around Ambleside and Skelwith Force.

I'd forgotten all about Sherbert Fountains... Hypo prevention has rarely been so much fun. It was like being 8 again.

Lantus problems and going round in circles

And on and on and on...

When we began writing about our experiences of living with Diabetes it was, at least in part, in response to a nasty overnight hypo brought on (I suspect) by the action of Lantus glargine. From some reading I have done since it appears I am not alone in this. That there are other people with diabetes using Lantus and injecting their dose at night time (recommended by the manufacturer and for most people the best option) who find they sometimes go low overnight, or wake up low in the morning.

One of the difficulties in managing diabetes with MDI (multiple daily injection) basal-bolus is that if you don't get your basal (background) dose correct then everything else becomes incredibly difficult to manage. You have no firm footing on which to start your day.

I think the late-at-night injection timing is suggested because it puts Lantus's onset period (perhaps an hour two until full strength) at a time when you have finished eating for the day and are usually if not actually asleep, then pretty much at rest. When I moved my injection to the morning, though my overnight levels were suddenly very steady and reliable, I had problems with high blood glucose spikes after breakfast. In response I began to split the dose, morning and evening, having a little just before bed, and the rest at breakfast. My hope was that this would spread the activity more evenly over the day. Sadly though, after a few months I can see that this has caused more problems, and not really solved anything. I found I was waking up low again, or waking slightly clammy having gone hypo overnight. On several occasions my liver then took matters into its own hands and began dumping glucagon into my bloodstream as it's own emergency measure. I would wake high, inject rapid-acting insulin and wait until my levels dropped before eating breakfast. After 2 hours or so I would give in, my levels still stubbornly high, eat a fraction of my usual breakfast and wait to see how things were going at lunch. Not only that but if the smaller Lantus dose didn't send me hypo overnight, then it had run out of steam by breakfast anyway and I was heading for spike central again after breakfast. Smaller doses you see, tend to act over a shorter time. With no Lantus hanging around, and anything from 15-45 minutes for Humalog to get going even a fairly low GI breakfast was going to cause problems. What my neice might describe as an #epicfail.

So I've gone back to Lantus in the morning. Suppertime and pre-breakfast readings are more constant. The post-breakfast problem still exists, of course, but at least I've lost the overnight hypo and liver-dump double whammy. Last time I didn't spend much time experimenting with the timing of my breakfast bolus (rapid-acting) doses. My hope is that with enough time between injecting and eating I might be able to stay out of the teens between breakfast and lunch.

Maybe.

And there was evening, and there was morning...

Just a quick update on the ongoing Lantus experiment... If you've popped by before you may have read that I recently changed the timing of my Lantus injection to combat fairly frequent, low-level morning hypos.

After the initial euphoria of my new-found pre-breakfast bg stability had worn off, I began to notice an unfortunate side effect of the new system. True, I was no longer waking up hypo 3 times a week, but I began to find that after breakfast my blood glucose levels would 'spike' - rising steeply and peaking way higher than I'd like.

When I'd suggested shifting my Lantus dose to the mornings to the DSN at the hospital, she had said that in her experience it merely 'moved the problem'. While this wasn't exactly true in my case (as I wasn't having consistent late afternoon hypos) it did appear that I'd simply swapped one problem for another.

My overall control has always been pretty good. A few swings here and there, but on the whole, fairly respectable HbA1c's (the test that reveals how 'normal' your blood glucose levels have been over the previous 12 weeks or so - below 7% is the guideline). One of the things I'm noticing about my renewed focus on tighter control is that you quickly move your own goalposts. I know for sure that one of the ways I've kept my HbA1c's in check is by having rather too many low-level hypos to counteract the high readings over the same period. Good control is not about constantly swinging from high to hypo, but as with all average-based assessments the HbA1c can hide the true picture.

In short, I was not happy to constantly spike after breakfast especially since I was now missing all those pesky morning hypos that would have kept up the illusion of good control in my HbA1c.

So for the last week or so I've been splitting my Lantus dose, half at about 10pm and the rest at around 7am the following morning. My reasoning was this... Lantus takes a good 3-5 hours to get going (this is why it is often recommended that you take the dose last thing at night). It also lasts around 18-26 hours, depending on the person - I think it's around 20-22 hours for me. What I think was happening with my breakfast time dose was that yesterday's had run out, and today's wasn't kicking in until mid-morning at the earliest. This meant that my breakfast bolus was having to cover basal requirements as well as whatever I was eating. By injecting half and half I now have two activity curves running out of phase so that the onset of one is covered by the activity of the other.

I have to confess that the timings of the doses are based more on convenience and the likelihood that I'll remember them than any complicated graph-based calculation of perfect timings, but for the last week or so both fbg (pre-breakfast blood glucose level) and post breakfast readings have been pretty much bang on target.

Well apart from the day I forgot to inject that is... but that's another story.

Update: Basal driving me bonkers

Timing is everything

Injecting Lantus first thing in the morning... Just a quick follow up to my recent post about switching my Lantus dose to first thing in the morning. It works!

I've just looked back over some old bg readings for the last few years and they suggest I've been waking up to a low level hypo perhaps 2 or 3 times a week. Since switching the timing of the dose 10 days ago my levels have pretty much all been in the 3.9 - 7.5 mmol/l range with the majority between 4.4 and 6.7 mmol/l.

I got into an email conversation with Matt Jones who said he used to have a similar experience and had pretty much solved it overnight by injecting Lantus in the morning. I'd tried slightly altered doses (having got hold of a 1-unit Autopen) and having a small amount of slow-release carbs last thing at night to beat the morning lows but neither had been particularly effective.

I seems it wouldn't work for everyone - I mentioned switching the dose timing when speaking to my DSN and she had said that in her experience it just 'moved the problem', but for me the difference has been amazing.

Thanks Matt. I owe you one :)

Update: Morning and Evening

Morning person

I am not, as Jane will tell you, a morning person.

It's not, I hasten to add, that I am at all grumpy(!), rather that until something approaching 9 or 10am you are lucky if you get more than a grunt out of me. And then there's the sighing and yawning. Lots of that.

Over the last few years, mornings have also had an added complication in that it has not been unusual for me to wake up a little low. More often than not it's just a case of something sugary with my coffee and all is well, but it's never a good start to a day. A few times a year I am not only low, but my levels are dropping, and Jane has had to intervene.

Since we've been blogging about our experiences of living with diabetes this has been a nut I've been trying to crack. I've tried dropping 2 units of Lantus which seemed to throw my system into a high-sugar tantrum. I've tried dropping 1 unit of Lantus, which involved getting hold of a new, slightly different Autopen. I've tried various amounts of carbohydrate at suppertime to stave off the morning low.

None of these has been particularly successful.

So now I'm trying something something suggested by a commenter on this very blog. I've moved my Lantus injection to the morning rather than last thing at night.

Although Lantus is often said to have a 24 hour peakless profile in reality many Lantus users find the graph is a bit more complicated than that. Indeed this graph on lantus.com shows a slightly flattened version of what I believe happens in my case. It shows a period of onset rising to a mini-peak 4-6 hours after injecting; followed by a slight drop and levelling off; then a fall-off of activity at around 18-28 hours (which I believe can be more or less depending on the person). If my morning lows are due to Lantus's higher level of activity in the hours after injection - at the time when it appears I need less background insulin - then a move to a morning injection should match the fall-off of activity with my reduced need.

It's only been a few days yet and I've not had a chance to run any basal tests to see how things are going, but so far I've not had a pre-breakfast low and levels through the rest of the day have been pretty much what I'd expect.

So far so good. I'll let you know how things progress.

Update: Timing is everything