![]() Better control of morning glucose levels has been demonstrated by increasing the amount of exercise in the evening and by increasing the protein to carbohydrate ratio of the evening meal. Lifestyle modification is an important component to be considered. Management of morning hyperglycemia should be a part of the overall diabetes control strategy. If insulin adjustments are made based on early morning fasting glucose levels, a larger dose of insulin might be administered than would be appropriate if the dawn phenomenon magnitude was considered. For type 1 diabetes, tight control with insulin must take into account the dawn phenomenon to avoid nocturnal hypoglycemia before the onset of early morning glucose elevations. The ability for a continuous infusion to provide a bolus in the early morning hours to counteract the dawn phenomenon is a possible explanation, as long-acting insulin preparations have no ability to achieve this. In studies that have demonstrated superior glycemic control with continuous insulin infusion as opposed to long-acting insulin formulations, the dawn phenomenon is likely the reason. Oral hypoglycemic agents have failed to show adequate control of the dawn phenomenon, while insulin therapy has been shown to be much more effective.Ĭhoosing an insulin regimen must, of course, be individualized for each patient, but research has indicated that the presence of the dawn phenomenon must be considered in selecting the type of insulin and the mechanism of delivery. Optimal insulin therapy is important in type 1 diabetes, but also in type 2 diabetes. The prevention of long-term sequelae by minimizing exposure to hyperglycemia is key early in the disease process. When the presence of the dawn phenomenon is detected, especially when associated with the extended dawn phenomenon, an individual patient should be considered for earlier and more aggressive control of glucose. The magnitude of the dawn phenomenon can then be calculated by using the equation 0.49X +15. By measuring blood glucose pre-breakfast, pre-lunch, and pre-dinner, then taking the difference between the pre-breakfast glucose and the average of the pre-lunch and pre-dinner glucose values to determine “X”, the presence of the dawn phenomenon in an individual, which has been defined as an upward variation in glucose of 20 mg/dl, can be detected with 71% sensitivity and 68% specificity. This has enabled the development of a formula to calculate the magnitude of early morning hyperglycemia without CGM. A strong correlation between pre-meal glucose values and the change in glucose with the dawn phenomenon has been identified. An alternative to CGM has been described by Monnier et al., utilizing intermittent glucose monitoring to quantify the magnitude of the dawn phenomenon. The dawn phenomenon is quantified by subtracting the overnight glucose nadir from the glucose value observed just before breakfast. In addition to documenting elevated early morning glucose levels, CGM ensures no associated nocturnal episodes of hypoglycemia have occurred, which could indicate a Somogyi effect rather than a true dawn phenomenon. Diagnosis of the dawn phenomenon is most effectively achieved by the use of continuous glucose monitoring (CGM), which in recent years has become more widely available to clinicians.
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