Acute Complications Diabetes Flashcards
Importance of checking BG levels
Very little impact alone
- Has to be associated with meaningful activity
When to check BG
- To avoid Hypoglycemia
- Confirm a low if symptoms are present
- Assess response to medication changes
- Assess response to food
- Changes in routine
- During acute illness
- During Pregnancy
Blood Glucose Monitoring Recommendations
- Using insulin more than once a day
Check 3 times a day
- Include pre and postprandial measurements
Blood Glucose Monitoring Recommendations
- T2DM using once a day insulin
Check at least once per day at variable times
Blood Glucose Monitoring Recommendations
- T2DM not using insulin
Depends on type of antihyperglycemic agent, A1c levels, and risk of hypoglycemia
- Not at A1c target = Structured CBG Checks
- At A1c target + Not using antihyperglycemic agents with risk of hypoglycemia = Daily CBG Checks not recommended
Blood Glucose Monitoring Recommendations
- All individuals with diabetes when A1c is not in target OR episodes of hypoglycemia
Check frequently to determine most effective approach to improve BG management
- Check 4 times a day (May include overnight checks)
When to use Real Time Continuous Glucose Monitors / Intermittently Scanned Continuous Glucose Monitoring
- T1DM using basal/bolus therapy / Continuous subcutaneous insulin infusion
Benefits of Real Time Continuous Glucose Monitors / Intermittently Scanned Continuous Glucose Monitoring
- Increases time in range
- Reduces duration and incidence of hypoglycemia
Principles of Check Smart
What does the numbers mean
Why did I get that number
What could I do differently next time
Controlling Insulin
- More Carbs = More Blood Glucose
- More Protein/Fat = Less Blood Glucose
- Intense Exercise = Less Blood Glucose
- Sports Drinks = More Blood Glucose
- Increase Insulin = Less Blood Glucose
- Decrease Insulin = More Blood Glucose
Consideration of Exercise and Blood Glucose
- Before
Do not exercise if Blood Glucose is too low or too hight
- Low = Exercise will exacerbate it
- High = Add to uncontrolled episode
Ensure levels is between 4.0-14.0
Consideration of Exercise and Blood Glucose
- During
Will fluctuate differently depending on the person and the exercise regimen
Consideration of Exercise and Blood Glucose
- After
Can fluctuate up to 24 hours later
- Delayed hypoglycemia 6-12 hours after exercise
–> Caused by muscle cells absorbing glucose to replenish glycogen stores
- Make sure to check BG when changing exercise regimen
- May have to add extra bedtime snack
Consideration of Exercise and Blood Glucose
- Low Intensity
Ex. Shopping, Walking, Stretching
- Decrease Bolus Dose by 25-50%
Consideration of Exercise and Blood Glucose
- Moderate Intensity
Ex. Brisk walk, swimming, tennis, mowing the lawn, riding a bike
- Decrease Bolus Dose by 50-75%
Consideration of Exercise and Blood Glucose
- High Intensity
Ex. Competitive sports, shoveling snow, aerobics, jogging, soccer
- Decrease Bolus Dose by 75-100%
Consideration of Exercise and Blood Glucose
- Duration of Exercise
May have to consume a 15 gm carbohydrate every 30 mins
Consideration of Exercise and Blood Glucose
- Timing of Exercise
Reduce Dose if exercise:
- Is planned and will occur within 1-2 hours after meal-time insulin
Consumes Carbohydrate Snack, repeat if needed
- Is planned and will occur 2 or more hours after meal-time insulin
- Is unplanned and occurs within 1-2 hours after meal-time insulin
Consideration of Alcohol and Blood Glucose
- Immediate Effects
Some drinks like beer and coolers have carbohydrates
- Will immediately increase blood glucose
Some drinks like hard alcohol, dry wine, and light beer do not have carbohydrates
- No immediate effect
Consideration of Alcohol and Blood Glucose
- Delayed Hypoglycemia (Cause)
Happens with all type of alcohol up to 24 hours post consumption
- MOA: Inhibits glucagon production by liver, means less hepatic glucose production
Increased risk of nocturnal hypoglycemia
Consideration of Alcohol and Blood Glucose
- Delayed Hypoglycemia (Prevention)
Eat food while drinking and have a bedtime snack
Check blood glucose at night
Check blood glucose the next day and be aware of potential lows the next day
Consideration of Travel and Blood Glucose
- Storage
Keep supplies on you as they can freeze in storage
Keep supplies cold in a refrigerator
Consideration of Travel and Blood Glucose
- Dosing (North-South)
Days are same duration
- No adjustments to basal/bolus
Consideration of Travel and Blood Glucose
- Dosing (Travel East)
Day is shorter –> Reduce basal dose on travel day
Within North America (3 hr time difference)
- Decrease by 1/4 to 1/3
North America to Europe (7 hr time difference)
- Decrease by 1/3 to 1/2
Consideration of Travel and Blood Glucose
- Dosing (Travel West)
Day is longer –> increase bolus dose on travel day
Have an extra snack and extra bolus dose once you arrive at location
Consideration of Travel and Blood Glucose
- Dosing (Time Zones)
Switch to new time zone (mealtimes and waking hours) ASAP after arrival
Consideration of Driving and Blood Glucose
- Checking
If Blood Glucose is less than 4 mmol/L
- Treat hypoglycemia (Successful treatment if BG is greater than 5 mmol/L)
- Wait 40 minutes before driving
If Blood Glucose is 4-5 mmol/L
- Consume carbohydrate before driving
Check Blood Glucose every 4 hours
Consideration of Fasting and Blood Glucose
- Concerns who?
People with Type 1 Diabetes
People with Type 2 Diabetes on Insulin or on an antihyperglycemic agent associated with hypoglycemia
Consideration of Fasting and Blood Glucose
- Actions
Adults with Type 1 or Type 2 Diabetes requires an assessment 1 to 2 months before fasting
- Allows a management plan for fasting
Diabetes and Sick Day Management
- Relationship
- Blood glucose can fluctuate during a common illness
- Over the counter medication used for treating symptoms can affect glucose levels (Decongestants or sugar in syrup)
Diabetes and Sick Day Management
- Goals
- Avoid large fluctuations in blood glucose
- Avoid dehydration
- Avoid ketoacidosis
- Avoid the need for urgent care
Diabetes and Sick Day Management
- What causes Increased Glucose
Cortisol, Glucagon, and other hormones released
- Increased insulin resistance
- Increased hepatic glucose production
Diabetes and Sick Day Management
- Checking
Check Blood Glucose 4 times per day
OR
Check Blood Glucose every 2 hours if high or continuing to rise
Check urine or blood for ketones if Blood Glucose is above 14 mmol/L
Diabetes and Sick Day Management
- Management
Drink plenty of water to avoid dehydration
Drink electrolytes if there is a significant loss of fluids
If using insulin increase dose
- Blood glucose will rise even when not eating
- May need to use a correction bolus
Diabetes and Sick Day Management
- OTCs
Dextrose and other carbohydrates are found in liquid cough and cold products. Try to use sugar free products or for people with diabetes products
- Small effect, but, just best to avoid
Decongestants can increase blood glucose
- Try to avoid oral products, use topical for short period of time if absolutely needed
Avoid NSAIDs (SADMANS)
Diabetes and Sick Day Management
- SADMANS
Sulfonylureas
ACEi
Diuretics + Direct Renin Inhibitors
Metformin
ARB
NSAIDs
SGLT2 Inhibitors
Diabetes and Sick Day Management
- Ketoacidosis
For Type 1 Diabetes
If experiencing 2 or more of these symptoms patient should seek urgent care:
- High Blood Glucose (Greater than 14)
- Moderate to high ketones in urine/blood
- Dehydration
- Anion Gap Metabolic Acidosis
- Electrolyte Imbalance
- Increased Respiratory Rate
- Acetone (Fruity) odour to breath
- Abdominal pain
- Decreased level of conciousness
Diabetes and Sick Day Management
- Hyperosmolar Hyperglycemic State
Type 2 diabetes
Similar symptoms to DKA
- Frequent urination, thirst, dry mouth, dehydration, leg cramps, weakness, lethargy, unconciousness
Unlike DKA:
- Much higher blood glucose (greater than 25 mmol/L)
- Elevated serum osmolarity
- Little to no ketonuria or ketonemia
Diabetes and Sick Day Management
- SGLT2
SGLT2 inhibitors can produce symptoms of DKA at blood glucose levels of 13 or above
Diabetes and Sick Day Management
- Hyperosmolar Hyperglycemic State Treatment
Need IV replacement therapy
Symptoms of DKA
Frequent Urination
Thirst
Dry mouth
Dehydration
Leg cramps
Weakness
Lethargy
Unconsciousness
Diabetes and Sick Day Management
- When to seek help
2 or more of the following:
- Not retaining fluids (Diarrhea, vomiting)
- Gastroenteritis with fever of 38.5 or greater for 2 days or more
- Abdominal pain
- Blood glucose is greater than 14 mmol/L and continues to climb even after therapy
- Ketones
–> Blood (>3mmol/L)
–> Urine (4-16mmol/L)
