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

HypoglycemiaThe 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)

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Avg Basal Needs

NPH / Lente at Bed

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12am1am2am3am4am5am6am7am8am9am10am11am12pm1pm2pm3pm4pm5pm6pm7pm8pm9pm10pm11pm12am

Avg Basal Needs2526283032343534302419131099.510111212.5141618202224

NPH / Lente at Bed1216283846504638302015117766665555679

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

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NPH or Lente at Bed & Bkfst

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12am1am2am3am4am5am6am7am8am9am10am11am12pm1pm2pm3pm4pm5pm6pm7pm8pm9pm10pm11pm12am

Avg Basal Needs2526283032343534302419131099.510111212.5141618202224

NPH or Lente at Bed & Bkfst1424343734241586814223032302214854346812

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

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Ultra Lente at Dinner

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12am1am2am3am4am5am6am7am8am9am10am11am12pm1pm2pm3pm4pm5pm6pm7pm8pm9pm10pm11pm12am

Avg Basal Needs2526283032343534302419131099.510111212.5141618202224

Ultra Lente at Dinner16192224252626252422201816141312111099910111214

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

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Avg. Basal Needs

Morning Lantus or Levemir

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12am1am2am3am4am5am6am7am8am9am10am11am12pm1pm2pm3pm4pm5pm6pm7pm8pm9pm10pm11pm12am

Avg. Basal Needs2526283032343534302419131099.510111212.5141618202224

Morning Lantus or Levemir19202122232423222120202020202020202020191817161718

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

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

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Avg Basal Needs

Insulin Pump

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12am1am2am3am4am5am6am7am8am9am10am11am12pm1pm2pm3pm4pm5pm6pm7pm8pm9pm10pm11pm12am

Avg Basal Needs2526283032343534302419131099.510111212.5141618202224

Insulin Pump27272727333333333322221212121212121212122020202020

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

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Blood Sugar Rise After Eating Carbs

Analog (Humalog or Novolog taken with meal)

Regular (taken 30 min. pre-meal)

NPH / Lente (taken 4 hours prior)

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0.511.522.533.544.555.566.577.588.599.510

Blood Sugar Rise After Eating Carbs000000003103000000000

Analog (Humalog or Novolog taken with meal)00000000268632100000

Regular (taken 30 min. pre-meal)000000013566.565310000

NPH / Lente (taken 4 hours prior)000.250.40.711.52.12.83.33.53.63.53.22.72.11.61.20.90.7

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

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Night

Notes

Blood Sugar

Insulin Dose

Grams Carb

Phys. Activity

Date:

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Dinner

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Night

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Blood Sugar

Insulin Dose

Grams Carb

Phys. Activity

Date:

Breakfast

Snack

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Dinner

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Bedtime

Night

Notes

Blood Sugar

Insulin Dose

Grams Carb

Phys. Activity

Date:

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Night

Notes

Blood Sugar

Insulin Dose

Grams Carb

Phys. Activity

Date:

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Blood Sugar

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Grams Carb

Phys. Activity

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Night

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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

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Hypoglycemia

Complications

w/CGM

HbA1c

Risks

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Hypoglycemia107.35.64.53.52.72.11.51.10.80.60.5

Complications0.50.60.81.11.52.12.73.54.55.67.310

w/CGM107.35.64.53.52.72.11.51.10.80.60.50.40.3

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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

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2 hrs0.30.47

2.25 hrs0.10.45

2.5 hrs00.4

2.75 hrs2.75 hrs0.3

3 hrs3 hrs0.2

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3.5 hrs3.5 hrs0.05

3.75 hrs3.75 hrs0.025

4 hrs4 hrs0

High GI

Med GI

Low GI

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0 hrs.25 hrs.5 hrs.75 hrs1 hr1.25 hrs1.5 hrs1.75 hrs2 hrs2.25 hrs2.5 hrs2.75 hrs3 hrs3.25 hrs3.5 hrs3.75 hrs4 hrs

High GI00.51.30.50.30.100

Med GI00.10.30.50.70.80.70.50.30.10

Low GI000.050.10.20.30.40.450.470.450.40.30.20.10.050.0250

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!

Wt-lbs (BG rise/g)BG 70s(4)BG 60s (3.5)BG 50s(3)BG 40s (2.5)BG

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