Hypoglycemia Prevention & Treatment

Gary Scheiner MS, CDEOwner, Integrated Diabetes Services333 E. Lancaster Ave., Suite 204Wynnewood, PA 19096877-SELF-MGT (735-3648)(610) 642-6055www.integrateddiabetes.comGary@integrateddiabetes.com

Hypoglycemia:DefinitionsMild: Adrenergic (BG

Hypoglycemia:CauseImbalance between factors raising and lowering blood glucose levels

Blood Glucose Blood GlucoseFood Insulin/Oral MedsCounterregulatory HormonesPhysical Activity

Hypoglycemia

The Greatest Limiting Factor In Diabetes Management

The Great Limiting FactorPerformance Impairment

The Great Limiting FactorAccident Risk

The Great Limiting FactorAnxiety / Embarrassment

The Great Limiting FactorLasting Damage?

Spatial memory / performance (if before age 5)

The Great Limiting FactorDiminished Symptoms (Hypoglycemic Unawareness)

The Great Limiting FactorRebound

The Great Limiting FactorWeight Gain

Hypoglycemia:Targets/GoalsUnable to recognize & verbalize lows: >80 (4.5 mmol)Able to recognize & verbalize lows: >70 (4 mmol)Pregnancy: >60 (3.3 mmol)

Hypoglycemia Prevention Strategies1. Insulin Program Setup (background/basal)

Hypoglycemia Prevention Strategies1. Insulin Program Setup (background/basal)

Hypoglycemia Prevention Strategies1. Insulin Program Setup (background/basal)

Hypoglycemia Prevention Strategies1. Insulin Program Setup (background/basal)

Hypoglycemia Prevention Strategies1. Insulin Program Setup (background/basal)

Basal insulin should hold BG STEADY in the absence of food, exercise and bolus insulin!

Hypoglycemia Prevention Strategies1b. Insulin Program Setup (Meal/Bolus)Only rapid analogs work when needed right after eating!

Hypoglycemia Prevention Strategies2. Meal/Snack Timing

Major issue w/a.m. NPH/Lente Minor issue w/Lantus or Levemir Not usually an issue with pump use

Hypoglycemia Prevention Strategies1500-Rule (aggressive) (83 rule)1800-Rule (conservative) (100 rule)(Total Daily Ins.)/1500 or 1800May vary day vs. night(nighttime often 50% more than day)3a. Proper Correction Doses

Hypoglycemia Prevention StrategiesPremeal:100 (5.5) (aggressive)120 (6.7) (typical)140-150 (7.6-8.3) (cautious)3b. Appropriate BG TargetsPostmeal (1-2 hrs):

Hypoglycemia Prevention StrategiesI:C Ratio that matches pre-meal BG 3-4 hours (not 2!) after eatingI:C Ratio often varies from meal to meal(bkfst dose > lunch & dinner)4. Proper Meal/Bolus Doses

Hypoglycemia Prevention Strategies5. Account For Unused Insulin** Newer pumps figure this automatically based on the insulin duration you set.

Time since meal insulin 1 Hr2 Hrs3 Hrs4 HrsConservative Approach70% left40% left10% left0% leftAggressive Approach67% left33% left0% left

Hypoglycemia Prevention Strategies5. Account For Unused InsulinExample:Gave 6.0 units at 7pm, BG 200 at 9pm.Conservative approach: 40% remaining (6 x .4) = 2.4 units leftAggressive approach: 33% remaining (6 x .33) = 2 units leftSubtract the unused insulin from your usual correction dose!

Hypoglycemia Prevention Strategies6. Carb Counting Accuracy Proper Portion Measurement Look Up Unknown / Restaurant Foods Use Carb Factors Subtract 100% of Fiber Subtract 50% of Sugar Alcohols

Hypoglycemia Prevention Strategies7. Extend Meal Insulin When NecessaryUse When: Portions are very large Meal is prolonged Food is low-glycemic index (pasta, legumes, dairy) Apply Via: Square/Dual/Extended/Combo bolus on pump Delayed or Split bolus on injections

Hypoglycemia Prevention Strategies8. Adjustment for Physical Activity

Exercise, recreation, chores: all count! Reduce meal insulin (25%, 33%, 50%) for after-meal activity Snack prior to before/between meal activity Lower long-acting/basal insulin during and after prolonged activity

Hypoglycemia Prevention Strategies8. Watch Out for DOH!(Delayed Onset Hypoglycemia)

Following High-Intensity Exercise Following Extended Duration Activity May Occur Up to 24 Hours After Adjustments to food/insulin after activity: lower basal insulin for 8-12 hours low-G.I. Snacks lower mealtime boluses

Hypoglycemia Prevention Strategies9. Adjustment for Alcohol

Alcohol reduces the livers output of glucose and masks hypoglycemic symptoms Delayed BG drops can occur Decrease basal insulin (or overnight long-acting insulin) after drinking

Hypoglycemia Prevention Strategies10. Consistent Monitoring

Before All Meals & Snacks Pre/Post Exercise Bedtime 3 a.m. (occasionally)

Hypoglycemia Prevention Strategies11. Recording & Analysis

Record all pertinent data BGs Carb Activity Insulin Use an organized form (multiple days on single page, if possible)

Gary Scheiner, MS, CDE

Integrated Diabetes Services

333 E. Lancaster Ave., Suite 204

Wynnewood, PA 19096

Phone: (610) 642-6055 Fax: (610) 642-8046

Name:

Weekly Diabetes Record

Date:

Breakfast

Snack

Lunch

Snack

Dinner

Snack

Bedtime

Night

Notes

Blood Sugar

Insulin Dose

Grams Carb

Phys. Activity

Date:

Breakfast

Snack

Lunch

Snack

Dinner

Snack

Bedtime

Night

Notes

Blood Sugar

Insulin Dose

Grams Carb

Phys. Activity

Date:

Breakfast

Snack

Lunch

Snack

Dinner

Snack

Bedtime

Night

Notes

Blood Sugar

Insulin Dose

Grams Carb

Phys. Activity

Date:

Breakfast

Snack

Lunch

Snack

Dinner

Snack

Bedtime

Night

Notes

Blood Sugar

Insulin Dose

Grams Carb

Phys. Activity

Date:

Breakfast

Snack

Lunch

Snack

Dinner

Snack

Bedtime

Night

Notes

Blood Sugar

Insulin Dose

Grams Carb

Phys. Activity

Date:

Breakfast

Snack

Lunch

Snack

Dinner

Snack

Bedtime

Night

Notes

Blood Sugar

Insulin Dose

Grams Carb

Phys. Activity

Date:

Breakfast

Snack

Lunch

Snack

Dinner

Snack

Bedtime

Night

Notes

Blood Sugar

Insulin Dose

Grams Carb

Phys. Activity

Hypoglycemia Prevention Strategies11. Recording & Analysis

Review every 7-10 days Look for patterns > 10% below target range @ given time Lows during/post-activity Lows on School/Work vs. off-day Lows Post-Menstrual

Hypoglycemia Prevention Strategies12. Continuous Glucose Monitoring

Alarms to alert user/family of pending lows

Hypoglycemia Prevention Strategies12. Continuous Glucose Monitoring

(

(

(

(

(

(

(

(

(

(

(

(

(

(

(

Hypoglycemia TreatmentMild/Moderate LowCheck BG FirstTreat w/High-Glycemic Index FoodTreat w/Proper AmountRe-Check in 15 MinutesHigh-GI Foods Glucose Tablets Dry Cereal Pretzels Graham Crackers Vanilla Wafers Jelly Beans Gatorade

Hypoglycemia TreatmentUse of Glycemic Index Lower GI foods digest & convert to glucose more slowly High-fiber slower than low Hi-fat slower than low Solids slower than liquids Cold foods slower than hot Type of sugar/starch affects GI

FastestGlucose

Dextrose

Starch (branched-chain)

Sucrose/Corn Syrup

Fructose

Starch (straight-chain)

Lactose

Galactose

SlowestSugar Alcohols

Use of Glycemic Index (contd)Hypoglycemia Treatment

Hypoglycemia TreatmentAlways Carry Rapid-Acting Carbs!

Hypoglycemia TreatmentDEXTROSE Rules! Glucose TabletsSweet TartsSmartiesSpreeAir Heads

Hypoglycemia TreatmentOnce BG has risen, give rapid-acting insulin to cover any overtreatment!

Hypoglycemia TreatmentTreatment amt. for insulin on board Treatment amt. for recent exerciseTreatment amt. for previous low-G.I. foodsIdiosyncracies

Hypoglycemia TreatmentSevere LowUnconscious / UnresponsiveSeizureUncooperative

Take-Home MessagesQuantify Your LowsStrategize to MinimizePlan for Proper Treatment

The Source of My Highs and Lows