If you’re a parent or spouse of a person with type 1 diabetes, are you a member of the “3 AM Club”? I’m not talking about a late night out on the town with your friends, but the “witching hour” when low blood sugars are more likely to happen. Scary movies often portray 3AM as a time when mysterious or supernatural things occur to people. In diabetics taking insulin, 3 AM can become a “perfect storm” of sorts where the sugar lowering effect of the insulin, excessive physical activity or less food intake collide at a time when a blood sugar “low tide” naturally occurs.

Being a 3 AM clubber means you’re someone who sets your alarm clock during the middle of the night to check your child or loved one for a surprise low blood sugar. Your membership ritual occurred on that night your child or spouse had that severe low blood sugar during sleep, maybe even a seizure. After ceremoniously witnessing a severe low sugar or even calling 911 for help, you take the vow to not let this happen again, even at the cost of your own physical and mental well being.

3 AM clubbers are everywhere. In my practice I try to find them and offer a way out. Most are not hard to find: just look for the bags under the eyes and the burned out looks on their faces. That’s what years of 3 AM club membership will do for you. One family I know of had her aunt sleep on the floor every night in her niece’s bedroom for 10 years after a low blood sugar when the girl was a toddler.

But first they must be willing to leave and that takes some effort to change. Being the nighttime BG checker is a noble and selfless act, but it takes a dangerous toll on this family member, beginning with sleep deprivation, chronic stress and anxiety, and even eventually problems with marital relations. Many feel it’s a duty and to do anything less would be wrong. They often see no way out. Now in most cases I’m talking about moms, but dads are often found wandering around in this club too.

But unlike the “Hotel California”, you can check out AND leave the 3 AM club. The first step is to carefully review the insulin doses taken in the evening. They might just be too much. Different insulin types peak (work strongest) in relation to the time when they’re injected. If that peak happens during the middle of the night (like with NPH insulin taken at suppertime, or 75/25 or 70/30 premixes), talk to your doctor about changing the time the shot is taken. Since most children and teens today are on basal bolus insulin regimens, the peaking effect of the basal insulin preparations (glargine and detemir) is less pronounced and can be managed by prudent adjustments in most cases.

Adjust the bedtime snack to provide a source of long-acting carbohydrates into the body to allow a steady source of sugar for getting a good night’s sleep. Excessive physical activity the day before can cause post-exercise hypoglycemia and can be offset by increases in the bedtime snack carbohydrates on that night only. In general, proper meal and snack planning can be as helpful as insulin adjustments for reducing the chances of middle of the night low blood sugars.

High tech exits from the 3 AM club include the insulin pump and/or the continuous glucose sensor. Rates of insulin delivery may be lowered at night to avoid aggravating the natural tendency for middle of the night low sugars. Remember to time the rate change to happen about 2 hours before the time you really need less insulin action.

Continuous glucose monitoring sensors now measure blood sugar levels minute to minute and have alarms that go off at night when sugars start to get too low or too high. Add a baby monitor to your toolkit and you’ve got a high tech solution for remote monitoring. These new CGMs require a level of commitment by the family and patient to wear them consistently, which is not insignificant (for help with reimbursement you might try CGMSCentral). Also, these units are pricey and require a doctor’s prescription, but they can get be an express ticket out of the 3 AM club for many.

So just how much BG checking is too much? That’s debatable. Those of you with CGM devices may glance at them every hour or more. But monitoring hourly blood samples is excessive for all but the most obsessive compulsive folks and not a practice compatible with good mental well being. It’s all about what you do with the data you get. Going to the 3AM Club now and then is fine and a very good idea especially for those days outside of normal or even as a planned test for a few days. But when you find yourself trapped in the 3 AM club, start looking for the exits.

Last 5 posts by Steve

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This entry was posted on Tuesday, December 23rd, 2008 at 10:48 am and is filed under Behavioral, CGMS, type 1. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.