Hypoglycemia Prevention & Treatment
Gary Scheiner MS, CDEOwner, Integrated Diabetes Services333 E. Lancaster Ave., Suite 204Wynnewood, PA 19096877-SELF-MGT (735-3648)(610) [email protected]
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 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 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
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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
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