Just wanted to share one of my periodic crazy periods trying to control my BG and my liver
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I wanted to share my latest experience of my erratic liver and the massive problems it causes me all the time trying to keep a steady BG - and how annoying/ depressing it can be - and if anyone has any bright ideas what the hell is happening (as it has happened before) !. I’ve been keeping an average on my CGM of 125 now for 3months and keeping within my range of 85-140 pretty successfully. All fell apart last night
(I have tresiba at 20 each day)
My normal erratic liver high activity usually ends at 3-4 pm each day so my constant monitoring and adjusting calms down at that point and I can eat some carbs for dinner - which I thought it had yesterday. My BG was 130 at 5.30pm so all good. Had dinner with a friend who had cooked coq au vin for 4 - it included half a bottle of wine, 3 tablespoons of flour no added sugar. With only other low carbs for the meal (cauliflower mash) I thought that it was OK and wouldn’t be too many carbs so I took 5 humalog at 5.30 - ate at 6pm. By 7pm my CGM was 200 which was way too high I assumed the wine sugar did that- by 8pm it was 140 though. I miscalculated a little and took an extra 4 units at 8.30am to get it back down to 90 for the night but didn’t realize the 5 was also still working. So I headed for a steep dive and had to eat a about 5g of sugar at 9.30pm. It wasn’t quick enough to correct the hypo so I dipped to 58 for ONLY 30mins and then rose back up to 130 by 12.30am which was when I expected the 8.30pm dose to stop (my bolus lasts 4hrs normally). Went to bed (unfortunately I hadn’t reset my alert at 140)
Woke up at 4am and it was 217 - and the CGM showed a steady climb from 12.30 to 4am. I took 7 units to correct the high and also as I knew the DP was starting soon anyway (3 dose at 7am normally) and went back to sleep. Woke up at 7.30am almost 4 hrs later and it was still 208 !! - CGM showed it had dipped to about 180 and then gone back again in the 4hrsso hardly a dent. Took another 6 units at 8.30am. Its now 10.30am and its still 180 but slowly going down I hope.
So to summarise, a hypo for 30mins at 9.30pm (Hence I can’t believe that it was the somogyi effect), no carbs from 6pm to now and I have been running an average of 200 and taken in total 23 units of humalog. This will no doubt throw me out for a couple of days. All my doctor can say is I have a sensitive liver and I’m taking too much homolog. For me its almost as if my liver is taunting me - give me some insulin I’m just going to ignore it and pump out even more…
The other thing it will give my doctor open field will be to zone in on that hypo and criticism me for going low that time - he loves to do that
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Some thoughts in somewhat random order.
1 - we deal with hormone highs a lot, since my son is a growing teenager, they suck. Sometimes they take a little insulin and other times they take a bunch, up to 3X the normal correction. It sounds like you are dealing with something akin to this.
2 - what are you using, pump or MDI. I ask, because on day 3 of a pump site we often have less effective insulin absorption. Enough that we are considering going to only 2 days on sites. If on a pump, you could be having similar issues.
3 - lows are part of the deal when using insulin for tight control. Tell whoever criticizes that to shove their thought where the sun don’t shine.
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Our son, Liam, experiences this quite often as well. Which is why our “nighttime” basal dosing is always a moving target and a work in progress. For Liam, he can stay relatively flat line from midnight through around 5AM, then he starts to creep upward very slowly…but it’s like a snowball. The increase starts slow, but as it continues to creep up it begin going faster and faster in the upward direction. If we don’t address it early (as soon as we see it ticking upward, check BG’s and give a little bolus bump), and if we sleep through the alarms, we can (and often do) wake up to well over 200…just sitting there for hours. It seems that, at least for us, the incline doesn’t continue going forever…it will eventually crest, but the cresting location is always between 200 and 250 where it is content with just sitting there flatlining and laughing at us. When it’s this high, it takes a lot more to get the downward movement to begin. And sometimes the result is a crash due to stacking. But , at least in my case, when I have to stack I just don’t go back to sleep…I wait it out in case I need to give a carb correction at the bottom.
Those nights suck and I’m sorry you’ve had this experience! I know how bad these nights suck!
For us, we just review/analyze and IF we see PATTERNS…that’s the key for us, then we adjust. If this means increasing basal at a certain time each morning, then that’s what we have to do. The key, though, is identifying a pattern. If you don’t have a pattern then it could have been anything, DP, growth hormone, sugar dump from the liver, a kid sneaking out of bed and getting a snack when mom/dad are sleeping, etc., etc., But if you can identify a pattern, you can work toward correcting it.
The “one off’s” I call them are just par for the course and I just grumble at the D-Gods and brush them off these days and try to make sure I wake up to address it earlier next time.
You’re doing great!
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@Robellengold, what a stellar record!
Ugly episode. However, like @Chris, we see those kinds of issues multiple times a week because of puberty – and, of course, when dealing with a sickness bout. So to us it has become unfortunately routine 
I would not worry about it, except to look out for possible sickness coming. Our T1 nurses have told us many times of how unreliable their diabetes is, as have other members in this community: when you think you are dialed in, all suddenly changes!
Instead, I would focus on what a great record you have!!!
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You didn’t mention drinking any wine, and it seems you would have if you did, so I’ll assume you didn’t (important to note that alcohol consumption can have effects - though wine used in cooking will have had the alcohol evaporated out so that wouldn’t be an issue here).
I don’t know what you normally eat, but I would consider this a VERY low carb meal (Bernstein low). Assuming you ate one fourth of the cooked meal you were consuming about: Wine 10g/4 = 2.5g; flour 18g/4 = 4.5g; cauliflower 6g (serving size?). A total of 13g carb. (or 18 if you include the small correction you took after eating). Thus, I don’t think you could possibly ascribe your BG response to the carbs you ate, which makes me believe that your response is more likely due to the protein you consumed. Especially since your BG was rising eight hours after you ate. Did you eat substantially more protein than you normally do - if so that could be what happened here.
I do not personally eat a diet anything like this low in carb, so I am probably not the best one to suggest how to balance this out. But I would suggest that you look to the protein and fat in your meal, rather than the carb you ate or your liver’s response.
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I do eat a very low carb high protein diet out of necessity - it just became easier for me - as I have to take 19 units of hunalog between 7am and 4pm ( 3 at 7, 5 at 9, 6 at 11 and 5 at 1.30) over and above th 20 units of tresiba I take each morning to keep my BG flat. I just can’t be bothered to insert carbs into that mix so I stick to eggs / avocados / salmon / skyr for breakfast so about 6g and then sashimi / cottage cheese / tuna salad / nuts for lunch so maybe 8g max
I’ve fasted during that period and also eaten the above and the humalog need doesn’t alter - so the protein doesn’t appear to impact it then
Dinner is my time for carbs as by 4pm I don’t need humalog after 4 for elevated basal unless I eat carbs so I can have a carb meal - like a piece of bread - maybe 20g at most
Perhaps your right - the lack of carbs for dinner maybe upset things - im hoping this is a one off - if it’s not then it’s probably the time to rise the tresiba as now I’m compensating with hunalog all day
Something is definitely up though as today I got to 4pm at 120 with the normal approach and then have fasted since but not injected humalog either and my blood sugar has risen up to 180 already in 3 hrs - will see what happens tonight I guess
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Are you skipping meals?
When we skip meals we get some liver glycogen release, so higher BG, typically in the 160s. I believe that is a common response to skipping meals.
Yes I’ve noticed that as well - fasting for me means a hard boiled egg instead of a meal - my girlfriend calls it fasting but it isn’t really - I find an egg is low enough in carbs and protein not to impact my BG so I can do an almost proper basal test as you can do overnight
It went up to 180 and then stayed there until 4am when my normal increase started so I think it probably means more tresiba but I’m going to keep at it for another few days to be sure
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How much time do you typically give before you change your basal, to be sure of the pattern?
A week or more - my doctor is the most sensitive about me changing my basal - for years I had it too high at 30 - that dealt with my 4am to 4pm rise nicely but it caused lows at night and evening -but my a1 was between 6.5’and 7 - so now I am down to 20 and using humalog for the 4am to 4pm period I’m loathe to increase as will he be - I came down from 30 to 20 by reducing it by 2 every 2wks
I’m sure I’m exposing my ignorance here, but just curious if you and your doctor have explored anything with a shorter action time that you could dose twice a day, higher amount to cover that 4am-4pm period and lower amount so you don’t drop low during the night? I’m not even sure such an option exists, though I know many people have to split their levemir twice a day to get better coverage, so seems it wouldn’t last the full 24 hrs?
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No definitely - that is my plan I am going to speak to him about next - which I got from those of you on this website - I’m going to ask to swap to either humlin and come off humalog or perhaps levemir - so I would take the tresiba in the am and also a dose of levemir and eliminate the humalog injections - and then maybe in the evening I take instead of humalog for my evening meal humiln again as I eat slow acting carbs and protein so it goes over 6 hrs instead of 3 like humalog
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I hope it works for you! Keeping up the kind of dosing schedule you’ve had to sounds exhausting.
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Have you considered metformin to help reduce the liver dumps ? I started this recently and needed to reduce my pump basal by 15%, and I get better results overnight.
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I started metformin recently as well to see if it would help with hormone-induced insulin resistance I get each month. I did have to reduce my pump basal slightly,but when hormones hit I still had to put my basal up be 60% as well as halve all my ratios. So it doesn’t seem to have helped that issue at all. I’m not sure that monthly hormones cause liver dumps so much as IR. if you are a woman, @Robellengold, this might be something to track.
I also eat low-carb and have intermittent problems with rising significantly overnight. I think it may be related to a combination of protein from dinner and pump sites when I push them to the end of day two and into day three.
If you have a dawn phenomenon problem, those can be frustrating to deal with on MDI. When I was using Lantau, I couldn’t get things set so that my (at the time) strong DP was covered, even splitting my Lantau dose into two shots per day. I had to wake up at 3:00 AM every morning to take a few units of Humalog. Ultimately, this was the main reason I chose to switch to a pump.
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My night results apart from this ananoly the other day are actually pretty good with tresiba once a day / I normally am 80-90 before I go to bed and then it stays like that until 7am - the 7am to 4pm rise I get each day is late enough for me to deal with it at 7am when I get up - it’s the taking multiple humalog injections that’s the issue
I’m not sure it is DP as it starts so late and lasts so long and I’m also beginning to think taking humalog may not be the right thing for me as I don’t need it on low carb diet
If my doctor agrees to levemir I’m going to take that at 7am and remove the hunalog and see what happens - if he doesn’t I might buy some regular insulin otc and try that as it would last 6-8hrs also and cover my 7-4 rise
I’m taking trulicity also not a metorfonin but similar impact on the liver right ?
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@Robellengold, do be conscious that the timing for Levemir is highly personal: yours could be very different from that of other people. It may last 12 hours for one person and 22 for another. So it will require a good bit of careful experimentation with a light hand 
[EDIT] particularly if you don’t share a bed with someone else who can notice if you get into trouble.
Good to know - maybe I need to go back to regular insulin - it peaks 3-4 hrs after and lasts up to 8 hrs - that profile perfectly matches my need - and it would be a lot cheaper
To get an idea of what your Levemir duration will be, convert your body weight to kilograms. Divide your Levemir dose by your body mass (in kilograms).
The more you are taking per kilogram, the longer it lasts:
Figure 2: Activity Profiles in Patients with Type 1 Diabetes in a 24-hour Glucose Clamp Study For doses in the interval of 0.2 to 0.4 Units/kg, insulin detemir exerts more than 50% of its maximum effect from 3 to 4 hours up to approximately 14 hours after dose administration.
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