How to manage nocturnal hyperglycemia in diabetes type one?

From the Guidelines

Nocturnal hyperglycemia in type 1 diabetes is best managed by adjusting basal insulin doses or timing, and using continuous glucose monitoring, as recommended by the most recent guidelines 1. Managing nocturnal hyperglycemia in type 1 diabetes requires a combination of insulin adjustments, meal timing strategies, and monitoring. The most effective approach is to adjust basal insulin doses or timing, particularly for those using multiple daily injections. For patients on long-acting insulin like glargine (Lantus) or detemir (Levemir), increasing the evening dose by 1-2 units or splitting the daily dose to administer a portion before bedtime can help. Those using insulin pumps should consider adjusting overnight basal rates by 10-15% during the problematic hours, typically between 2-4 AM. Some key points to consider when managing nocturnal hyperglycemia include:

• Consuming a bedtime snack containing protein and complex carbohydrates (such as 15g of carbs with 7-10g of protein) can prevent overnight lows while avoiding high-glycemic foods that cause blood sugar spikes.
• Regular blood glucose monitoring at bedtime and around 2-3 AM helps identify patterns, with continuous glucose monitoring being particularly valuable for detecting the "dawn phenomenon" (early morning hormone-induced rises in blood sugar) 1.
• Physical activity earlier in the day rather than late evening can also help maintain more stable overnight glucose levels.
• Automated insulin delivery systems should be offered to all adults with type 1 diabetes, as they have been shown to improve glycemic outcomes and quality of life, and minimize hypoglycemia 1. These strategies work by providing appropriate insulin coverage during nighttime hours when hormones like growth hormone and cortisol naturally increase glucose production. It is also important to note that early use of continuous glucose monitoring is recommended for adults with type 1 diabetes to improve glycemic outcomes and quality of life, and to minimize hypoglycemia 1. Overall, a comprehensive approach that includes insulin adjustments, meal timing strategies, monitoring, and the use of automated insulin delivery systems can help manage nocturnal hyperglycemia in type 1 diabetes.

From the FDA Drug Label

CLINICAL STUDIES The efficacy and safety of LEVEMIR given once-daily at bedtime or twice-daily (before breakfast and at bedtime, before breakfast and with the evening meal, or at 12-hour intervals) was compared to that of once-daily or twice-daily NPH human insulin or once-daily insulin glargine in non-blinded, randomized, parallel studies of 6004 patients with diabetes (3724 with type 1, and 2280 with type 2). In general, patients treated with LEVEMIR achieved levels of glycemic control similar to those treated with NPH human insulin or insulin glargine, as measured by glycosylated hemoglobin (HbA1c) Type 1 Diabetes – Adult In one non-blinded clinical study (Study A, n=409), adult patients with type 1 diabetes were randomized to treatment with either LEVEMIR at 12-hour intervals, LEVEMIR morning and bedtime or NPH human insulin morning and bedtime. Insulin aspart was also administered before each meal At 16 weeks of treatment, the combined LEVEMIR-treated patients had similar HbA1c and fasting plasma glucose (FPG) reductions to NPH-treated patients

The condition of sugar spikes at night in diabetes type one is referred to as nocturnal hyperglycemia. To manage nocturnal hyperglycemia in diabetes type one, the drug label suggests administering LEVEMIR at bedtime or in a twice-daily regimen (morning and bedtime) in combination with insulin aspart before each meal 2. Key points to consider:

• LEVEMIR can be administered at bedtime to help control nocturnal hyperglycemia
• Twice-daily regimen (morning and bedtime) can also be effective
• Administration of insulin aspart before each meal is recommended in combination with LEVEMIR
• LEVEMIR has been shown to achieve similar HbA1c and FPG reductions compared to NPH human insulin in patients with type 1 diabetes 2

From the Research

Nocturnal Hyperglycemia in Diabetes Type 1

Nocturnal hyperglycemia, or high blood sugar levels at night, is a common issue in diabetes type 1 management. The following points outline the condition and its management:

• Nocturnal hyperglycemia can occur due to various factors, including the dawn phenomenon, which is caused by the release of growth hormone and other hormones that raise blood glucose levels in the early morning hours 3.
• Insulin therapy is the primary treatment for type 1 diabetes mellitus (T1DM), and typically involves multiple daily injections of short-acting or rapid-acting insulin analogues, along with one or more daily separate injections of intermediate or long-acting insulin 4.
• The choice of insulin regimen should be individualized and aim to closely resemble a natural physiologic state, avoiding wide fluctuations in glucose levels 4.
• Studies have shown that insulin glargine can be effective in reducing nocturnal hypoglycemia and improving glycemic control in patients with type 1 diabetes 5.
• Other insulins, such as insulin detemir, have also been shown to improve glycemic control with less hypoglycemia and no weight gain in patients with type 2 diabetes, although their effectiveness in type 1 diabetes may vary 6.
• A meta-analysis comparing insulin lispro protamine suspension with insulin glargine and detemir found no significant difference in change in HbA1c level, but noted that nocturnal hypoglycemia occurred more frequently with insulin lispro protamine suspension 7.

Management Strategies

To manage nocturnal hyperglycemia in diabetes type 1, the following strategies can be considered:

• Adjusting the insulin regimen to include a basal insulin that provides a steady level of insulin throughout the night, such as insulin glargine or insulin detemir 4, 5, 6.
• Using a continuous glucose monitoring system to track glucose levels throughout the night and adjust the insulin regimen accordingly 4.
• Implementing a bedtime snack or adjusting the timing of insulin injections to help regulate glucose levels during the night 4.
• Regularly monitoring blood glucose levels and adjusting the insulin regimen as needed to achieve optimal glycemic control 4.