Let's go on to another case. A 42-year-old man comes to his primary care physician for a follow-up
visit. He has type 1 diabetes for 19 years for which he takes insulin. He complains of frequent
episodes of waking up in the middle of the night. When he wakes up, he feels excessive sweating,
hand tremors, and weakness. His morning blood glucose is high on repeated measurements. What
is the optimal intervention for this patient's condition? This patient has longstanding type 1
diabetes. He is awoken at night with symptoms of hypoglycemia. The symptoms of excessive sweating,
tremor, and weakness are closely correlated with low blood glucose. The conclusion here is that
the patient has the Somogyi effect. Ask the patient to have a small
carbohydrate snack before bedtime to mitigate the drop in glucose that he is experiencing in the
middle of the night and this will reduce the symptoms of hypoglycemia.
Hypoglycemia while the patient is sleeping due to a high insulin dose at night
stimulates the release of counter-regulatory hormones. These generally come from the adrenal
gland in the form of cortisol, glucagon, and cathecholamines. This leads to morning hypoglycemia
which is a rebound post the hypoglycemic effect of these counter-regulatory stress hormones.
A simple way to detect this is also the treatment. You ask the patient to have a small carbohydrate
snack at bedtime to keep the blood glucose up overnight and in the morning the blood glucose levels
have normalized and the Somogyi effect can be diagnosed. Daily insulin doses based on this should
be reduced in the long term.