I am not 'Set Adrift on Memory Bliss', thank you.

(That's a reference to a P.M. Dawn song, for the young'uns.)

Dawn Phenomenon.

It sounds innocuous, doesn't it?

Dawn... That time when light gently filters through the window, peeking through the cracks in the curtains. Birds sing. The occasional early morning commuter's car rolls by. A gentle turn of the body in bed to get a few more precious moments of sleep. You can hear Morning Mood by Grieg, can't you?

Phenomenon... It's just, like, this thing that happens, man... </TheDude>

The reality - waking with blood glucose levels in hyperglycemic range. Here are the symptoms I experience:

• Vice-like headache
• Powerful need to urinate
• Dry mouth, eyes, nose... all mucus membrane areas. Yes, even there.
• Joint and muscle ache and inflammation
• Fatigue

For some PWD, this is an occasional thing. For me? Every. Single. Day.

This is what it looks like in a CGM representation. This was my morning on 05 Jul 18.



For the non-T1D folks, here's what you're looking at:

Ideal range for people with T1D is 70 mg/dl to 130 mg/dl. At night, the lower bound raises to 80 mg/dl to have a safety buffer in the event of the basal (background) insulin use profile causing a dip.

The upper limit is lowered overnight to prevent waking up with the symptoms of hyperglycemia.



For most PWD, Dawn Phenomenon isn't a thing. If their basal injection or pump rate is correct, they'll have that relatively flat line that you see between 0100 and 0400 all night long. Whatever they went to sleep at, they'll wake up +/- 25 mg/dl.

And then there's people like me...

I usually get about 6-7 hours of sleep a night. I fall asleep sometime between 1 and 2 am and wake between 7:30 and 9 am.

Last night, I was running high until about midnight due to a high carb/high fat lunch and dinner. The correction dose I took around 11pm kicked in fully a little after 1am.

In a 'normal' diabetic (hahahahaha!) this would have resulted in a waking BGL somewhere around 100-120 mg/dl.

I have finally realised that the sheer exhaustion I wake up with every day is the reason I tend towards afternoon naps. Part of it is that I am just tired by then, since the overnight sleep wasn't restful. The other part of it is that it's the one time I sleep where I generally don't wake out of range.

What's the solution?

1. Some people have had success with zero-carbs after 4pm. 
2. Others only have relief from being able to set differing basal rates by time with an insulin pump. 
3. Some people have had luck with the more modern basal insulins (Toujeo, Tresiba).
4. Some people on MDI (multiple daily injections) set an alarm and inject a correction dose before the rise happens and go back to sleep.

I've tried 1 and 3. Zero carb after 4pm reduced the peak of my Dawn Phenomenon,  but didn't eliminate it. Toujeo taken in the evening is what I'm doing now and resulted in this trace.

But the good news is that it looks like my basal dosage is good for the times when my body isn't busy telling me "I made you glucose, HERE!"

Basal Switching: Insulatard to Toujeo

I switched from Insulatard (an intermediate insulin) to Toujeo recently.

This was after having been on Lantus and being taken off (site reaction) and then Levamir (was like injecting water). I've been on Insulatard for the last two years. I have had a tolerable relationship with it. It was just barely doing its one job. It was time for a change.

Night 1:

Toujeo suggests an 80% reduction of the total daily for your intermediate/NPH insulin. So I went from 14u to 11u.

Unfortunately, Toujeo takes about five days to get fully entrenched and Insulatard is all 'fuck all y'all, I'm out' after about 10-12h. So my night was fun.

Once the Toujeo kicked in, it wasn't too bad, and I'm hoping it has a positive effect on my dawn phenomenon/foot on floor issues. I still woke up north of 350 mg/dl (19.5 mmol/l).

Day 1:

The weirdest sensation to wake up to so far as a person with Type 1 is having dry mouth, eyes that feel like they were rolled around in the desert and reinserted, a powerful need to wee... and being sticky because it's humid out. I'm not sure how there can be so much difference between internal and external but there we are.

Day 2:

I am forever in the Sahara. The wind never abates. I have always been thirsty, I will always be thirsty.

Day 3:

There's two days left of titration. I suspect the dosage is low. While the smart thing would be to wait until the full titration period is over, I am renowned for my impatience. Upping by 1u tonight.

Day 4:

Better, but not perfect. We've downgraded from the Sahara to southern Portugal in the dry season. It's an improvement.

Day 5:

WHY IS THIS NOT PERFECT YET?
I am blaming my frustration and desire to cry on high BGLs over the last five days. I just want to feel normal, thanks.

Day 6:

One more unit increase. Debated on jumping 2 units, but using the rule of 'no more than 10% of basal increase at a time', I'm trying to be good. Especially in light of Day 3's impatience.

Day 7:

Fuck this. Another unit up. Waking over 300 (16.6) is not what I signed up for with this new basal, thanks.

Day 8:

Did I... Did I just wake up in the low 300s? Okay, it was 311 mg/dl (17.2 mmol/l), but I'm going to take it as a good sign. Another unit up tonight. Yes, I know, I should be more patient, but waiting three days between increases means that I'd be at this for weeks to get sorted. I just can't.

Day 9:

Woke up at 249 mg/dl (13.8 mmol/l). Not perfect, but pretty close to my normal thanks to Dawn Phenomenon. One more unit, for luck.

Day 10:

Inadvertent basal testing in the afternoon (got distracted, forgot to get lunch) shows a nice flat line in the 150 mg/dl (8.3 mmol/l) range. This is an improvement from the flat lines that exist only because I maxed out my Dexcom.

Day 11:

Woke up in the morning at 216 (12), which is more in line with my usual. I'm hesitant to increase more without basal testing since yesterday lunchtime showed a pretty flat line. Would have been lower if I'd compensated for the Dawn Phenomenon (I can't abbreviate it to DP, my brain goes elsewhere) and the Foot on Floor rise - but without knowing if it was going to send me low during the day, I figured probably best to err on the side of not hypo.

Final dosage: 15 u.

So what's next?

Basal testing (again) and reworking my carb ratios, since the evening ones were compensating for the drop off with Insulatard.

The 'good' news is that it doesn't seem that any of the current basals will address my Dawn Phenomenon/Foot on the Floor issues sufficiently and the main solution for that is an insulin pump with programmable basal rates.

Manually being your own organ is a huge pain in the ass.