Insulin resistance at night time

[MisterMints]

Hi all,

I seem to have developed a bit of a problem, and I’m at a loss about what to do about it. Hopefully, someone here might be able to help!

Firstly, the basics:

• Type 1
• On MDI, not pump
• NovoRapid and Tresiba
• Libre and MM as CGM
• I:C ratio tends to be around the 1:10 to 1:15 range depending on meal

I have developed in the last few weeks a real resistance to insulin in the evening. This usually happens fairly late in the evening (after 9pm) and will continue until morning where its as if everything resets.

Tonight for example, I injected 11u of NovoRapid, and it had no effect whatsoever for about 90 minutes. This was a little earlier than usual, but I was going to inject then eat 15 minutes later than usual, but with nothing happening with my BG level I decided to wait. In the end I went for a 10 minute walk to see if I could kick start the insulin into action, and it worked slightly but then BG started rising again.

The above is a bit of a one off and extreme example, but the below is fairly typical of what happens;

Eat evening meal around 7pm, inject NovoRapid on about a 1:12 or 1:15 ratio depending on what I’m eating, BG rises as expected, then falls as expected about 2 hours later. Then around 10:30/11pm BG shoots up - it will go from 6.5 mmol (117 mg/dl) to 12 mmol (216 mg) and I’ll inject 2u NovoRapid to try and stop that rise. Usually that doesn’t do anything and it’ll continue to rise, so I’ll inject more. Keeps going up to 15, 16, 17, 18 mmol (270 - 325 mg)

Quite often I can inject more insulin than I had with my evening meal, and it will have no effect and bear in mind, I have had nothing to eat or drink since 7pm.

When I wake up in the morning its not uncommon for my BG to still be in double digits (in mmol), usually around the mid-teens so if I take a corrective dose at breakfast time (but without actually eating) I can get myself back down to ideal levels with no fuss.

I’ve spoken to my consultant and specialist nurses about it, and they don’t seem too bothered. I’m getting very frustrated by these unexpected spikes and it is causing me a whole load of stress and anxiety, especially since they don’t really seem to understand what is happening or how to deal with it. But I’m also getting next to no sleep as I’m still up at 2 or 3 am trying to get my BG down to acceptable levels with little luck, or sleeping high and feeling like crap (sleeping high feels like sleeping drunk to me, and waking up with that heavy hangover head)

It is a very recent thing (started happening in the last few weeks) and nothing has changed. No other stress in life like kids or work. I’ve previously done some basal calculations and I’m pretty confident I have my Tresiba at the correct dose, but I’m at a complete loss as to what is happening and why.

Does anyone have any pointers, tips, experiences of this kind of thing? Why would I become super resistant to insulin just between the hours of 10pm and 7am?!

[CatLady]

Sorry you are having such a tough time. I am sure someone here with more experience than I have) will be able to offer some insights. Glad you found your way to the forum!

[mike_g]

What are your meals like? High Fat/Low Carb? Any changes to your meals in recent days? If low carb, proteins can take 4 hours or more to register on BG as they are digested.

I’ve had troubles with evening/night BGs before, but for me, it is an issue of slow digestion, especially if I eat a lot of fat/protein with the evening meal. In this case, BG will be fine or will require a slight correction at bedtime (100-120 mg/dL) , and then will be about 200 mg/dL or higher at 6 AM. In this case, my meal is likely digesting for 5-6 hours. I’ve dealt with this by eating dinner sooner, and less fat/protein with dinner. Also, I’ve needed to bump my basal, which can be done differently for PM basal vs AM basal, since I’m on Levemir 2x daily.

[MisterMints]

I’m not sure really how to describe my meals @mike_g!

Typically they will be something like a carb element (usually wholemeal rice, pasta or sweet potato), a veggie element, and sometimes a meat element (usually chicken, occasionally beef).

I’m having the same issue right now with my BG going up, and tonight dinner was really simple - sourdough and rye bread (toasted) with scrambled eggs.

Other examples might be bean chilli with brown rice, or sweet potato baked wedges with chicken breast and greens (usually peas, broccoli or asparagus tips). These would also usually contain a tin of chopped tomatoes for a bit of liquid.

[T1john]

I have the same problem. I tend to eat dinner late and spike and roller coaster untill around 3 or 4am untill i finally stay down. But i am on pump so a little diffrent, but i incressed my basal rate from 7 to midnight. Do a temp basal increase of 25% also incresed my carb ratio and do a square wave bolus of 75% and 25% for 30 minutes then a 1unit bolus every 1 1/2 hrs (that is my action time) untill i see it change course. It usually works quite well. But sometimes still get to 200 before it changes course.
Hope mabey you can take something from this, and good luck and glad to see you here.

[ClaudnDaye]

Have you considered switching to a pump if this is a viable option for you? The ability to set ‘temp basal’ rates is a critical feature of pumps that may help you in your situation. I know we utilize this feature multiple times daily for our son.

[Chris]

Can you split the basal doses so you can get more at night?

[MisterMints]

@ClaudnDaye this is something I’m looking into, but the process is quite slow where I am. I’m waiting to get onto a DAFNE course as a prerequisite of pump therapy, then I have to run through a load of consultations to make sure it’s suitable for me and so on. I think it’ll be at least 6 months before I can get one at the current rate. But once I am pumping I’m hoping to close the loop which I think will have other benefits (for example, stopping the extreme spikes I get after exercise)

@Chris splitting the Tresiba is not something I’ve looked at to be honest. It is rated as a once per day injection (infact, my consultant reckons it stays in the body for up to 48 hours) so I don’t really see how splitting it will have any impact. Happy to hear more though if people have other/better ideas.

@T1john I do adjust my basal doses to try and compensate, but it has other impacts. I’m fairly active (running 4-5 times per week) so any basal increase plays havoc with my hypos when I am active. When I’m having a rest day though, an increase of 15-20% has next to no impact, but this may be because my body is still working through yesterday’s exercise, or because I’m only really supposed to make adjustments to my Tresiba dose every 3 days to see if there is an impact. I don’t know.

[Trying]

@MisterMints

Eat evening meal around 7pm, inject NovoRapid on about a 1:12 or 1:15 ratio depending on what I’m eating, BG rises as expected, then falls as expected about 2 hours later. Then around 10:30/11pm BG shoots up - it will go from 6.5 mmol (117 mg/dl) to 12 mmol (216 mg) and I’ll inject 2u NovoRapid to try and stop that rise. Usually that doesn’t do anything and it’ll continue to rise, so I’ll inject more. Keeps going up to 15, 16, 17, 18 mmol (270 - 325 mg)

As several others mention, I, too, experience this, and do various strategies similar to @T1john, more or less successfully. Yes, I agree w/ @ClaudnDaye, that a pump could really be helpful because you can adjust the basal w/ a temp basal to compensate for the increased insulin requirements, as well as automate the square bolus / extended bolus. I use both, sometimes in combination.

For example, last night I originally did an extended bolus for me dinner since I was already on the low side, BG 60s. I took 1/4 of the bolus immediately, then extended the rest over 2 hours. An hour after taking the extended bolus, I was going up according to the Dexcom CGM trend line, very fast, so I suspended the extended bolus, and then gave myself the rest of it, plus 1U, as a regular bolus. This stabilized the rise, and I never went above BG 100. Just a lucky outcome but the key is to monitor your CGM, and use a combination of bolus types - temp, extended/square, and super bolus depending on the BG and ongoing trend.

I see that you already take a delayed NovoRapid correction bolus around 10:30 PM. Maybe you could take it earlier before your BG rises to that level, assuming this is a consistent, repeat experience?

And as everyone else mentioned, meal content is also key! I myself am unable to change my dinner content successfully to prevent these delayed BG increases. I’m vegetarian (not vegan) so II suspect my dinner has too much fat content like olive oil. So, instead I use the pump bolus combo I just described!

[docslotnick]

@MisterMints You might want to take a look at this thread

Are you insulin-resistant and slow to respond at night?

[mike_g]

@MisterMints: Have you ever been diagnosed with gastroparesis (delayed stomach emptying)? This is a complication of diabetes which might be involved here.

Alternatively, it may be some basal-related phenomenon. Maybe the Tresiba is quitting early? The 42 hours claimed by Tresiba is based on a dosage of 0.4 Units/Kg, a fairly high dose for a T1 (for me, that’d be 37 units, as opposed to my current total daily dose of 26 Units Levemir). I suspect that lower doses don’t last 42 hours, but can’t find studies to validate this.

I recall someone switching their 1x daily dose of Tresiba to a different time (evening instead of morning, or vice-versa). I’ve also heard of people having success with 2x daily. This is likely dependent on several factors which influence basal performance in individuals: diet type, exercise, calorie consumption, among others (neglecting female-specific basal related variables here).

Another approach may be to add in a dose of NPH in the evening, or Regular, as supplemental basal. Regular only lasts around 5-7 hours, so is more of a bolus insulin. NPH lasts around 12 hours. @Eric has used NPH as a supplemental bolus, per some threads on this site.

If you do intend to try Regular and or NPH, they can be purchased over the counter at WalMart for $25/vial.

[MisterMints]

@Trying Taking the NovoRapid correction earlier is a possibility, but the problem is my rises are just too unpredictable. Sometimes I can see a rapid rise (such as my BG reading doubling over the space of 60-90 minutes) and other times it may be a slow creep upwards where I’ll then go to bed and get a sudden jump around 2-3am. The jumps are never the same either, so I just don’t know how much correction to take and often end up taking 2 or 3 injections of around 1-2u until I feel have flattened the line and comfortable going to bed.

@docslotnick thanks for that link. Some great information there and familiar experiences!

@mike_g I’ve never been diagnosed with gastroparesis but certainly something to ask about with my care team. Thanks for the suggestion.

If the 0.4u/Kg figure is correct (and assuming I’ve done my sums right) by dose of Tresiba should last about 32 hours, so I would think that even if it was beginning to tail off at night time, I’d still have enough left in me. I inject my Tresiba around 10pm each night, simply because I know I will always be doing the same thing at that time (if I did it in the morning for example, there’s work during the week - meetings, presentations etc - or sports at the weekend - running races on a Sunday would all tend to start around the 9 or 10am mark and I may be running for 2 hours or more).

I don’t know what NPH or Regular is, but as I’m not in the USA I won’t be able to buy it over the counter like that anyway. Unless there is something available in the UK via the NHS that I could try.

[mike_g]

Regarding 32 hours vs 42 hours: I don’t think it is a simple calculation to determine length of action. See below for an excerpt from the dosing instructions. They don’t say anything about performance below 0.4 u/kg - if studied, I haven’t seen it published. It still may last >24 hours for a lesser dose, but I don’t know for sure. Even if we did have a labratory curve for lower doses, there is still person to person variability to consider.

As far as changing dose time or moving to 2x daily - those were just suggestions to try. Some have had success playing with these.

NPH is sold as Novolin N or Humulin N: Wikipedia

Regular is available as Novolin R or Humulin R: Wikipedia

[MisterMints]

Cheers @mike_g I’ll have a play around with the possibility of 2x injections and see if I can make it work.

Unfortunately, in the UK at least, insulin is not able to be bought over the counter so to try out NPH or Regular I’d have to get my doctor to prescribe them, and they won’t do that unless there’s a proven clinical need. Thanks for the suggestion though.

[Trying]

@MisterMints

the problem is my rises are just too unpredictable.

Yes, being on MDI makes this tough. When I was on MDI w/ Humalog and Lantus I had the same issue. I would have the delayed rise in the evening 3-4 hours after a bolus. I basically did what you are doing. I’d take 1U a couple hours after dinner, and then another maybe 1/2 hour later, all the while monitoring my BG, and just repeat, as you do. My evening BG rise is pretty predictable though, probably because I eat mainly the same types of food each night. If I eat out, all bets are off though! Maybe you could try eating the same dinner for a few nights and see if you get consistent rise in BG. If so, then you can make a more well informed correction based on the food content. Then try another dinner type, and so on 'til you have a more clear “library” of responses. Maybe this won’t work, but you could try it.

Also, if you are a runner, then I bet that has a huge effect on your evening BGs, too, I’m afraid. At least it does me. I am more insulin sensitive on a run day, so evening BGs do not rise as much, and in fact, I usually have to reduce my basal (I’m on a pump). But this may occur to you, too, and hence causing your BG rises to be unpredictable!

[Scotteric]

Even if you can’t get a pump right now, you may be better off switching to an insulin you can adjust every night based on your needs. I like Levemir because I can take more or less of it every 12 hours without a lingering effect. If I eat closer to bed time, a big/multi-course meal or a meal high in carbs, fat or protein, it will cause a huge delayed spike during the night. I’ve learned to take a bigger dose of Levemir when eating like this and a smaller dose at night when eating earlier or less. You can’t do this with Tresiba.

[MisterMints]

@Trying I seem to have the opposite problem to you! On run days I’m too sensitive, and need very little. Repeated meals are a good idea - we kind of do that already in making enough to microwave later in the week (great for a quick meal after running) but nothing to stop me trying eating it 2-3 days on the trot.

@Scotteric I used to be on Levemir. In fact, I switched about 8 months ago because I couldn’t get my dawn phenomenon under control at all with Levemir. Another thing to add to the list when I next see my doctor.

[Trying]

@MisterMints

On run days I’m too sensitive, and need very little. Repeated meals are a good idea - we kind of do that already in making enough to microwave later in the week

Oh, I meant that I’m also insulin sensitive on run days so my BGs do not rise in the evening as much! So we are the same, I think.

Yes, I do the same, make enough food for the week, and then warm up during the week. Saves time! I hope you are able to see a trend with food and BGs!

[Michel]

@MisterMints, my son gets insulin resistant at night, as do some other teens on the forum.

There are several options with this:

• We use different ICRs at night, that are, right now, double the ones we use in the evening. For instance, at 125 we would give a 1.25U correction, but we give a 2.5U instead

• For us, insulin timing is much slower at night. From 45 minutes activation during the day it goes to 75 minutes, sometimes longer. So make sure you check your activation timing

• We also use an addition temp basal (pump) between 10 and 20 more.

You don’t have a pump so you can’t do the latter. But you could use, as has been suggested, human insulins that have a longer activation and duration: NPH (N in the UK I think) and R. You do have a clinical need since you need to resolve this insulin resistance issue! So I urge you to ask your doctor. NPH and R activate a bit more slowly than Humalog, but the tail effect is stronger for R, and NPH is kinda half way between Humalog and Levemir for us: it lasts about 4 hours, very convenient to use. But you need to experiment though. You can find activation curves for all insulin made by @kmichel by searching on this site.

As far as I have read, Tresiba is flat enough that changing your injection timing won’t work—but I could be wrong about that.

I strongly urge you NOT to stay up to solve your dosing problem. I face the issue all the time with my son. I can become totally sleep deprived after a few days when I do that. And we have established that my son gets insulin resistant when he is short of sleep, so I am pretty sure this is a vicious circle for you. I would strongly recommend that you set up 90 minute snooze alarms for high BG if you use a CGM, or schedule a 90 minute regular alarm check up after going to sleep so that you get a full sleep cycle in every time. I think there is a good chance that part of your issue is now sleep deprivation!

I would not hesitate to insist with my doctor if I were you. Btw, most pharmacies in France will sell you insulin without prescription FYI. So in the worst case try a run across the border. Hope you can figure this out!