Level 1 - Hypo, Sick Days, Monitoring & Tech (Class 6) Flashcards
(TRUE or FALSE)
GLP-1 RA can exacerbate hypos if they are also on insulin, sulfonylureas, and megitinides?
TRUE
List symptoms of hypoglycemia.
-Shaky
-Fast HR
-Sweating
-Dizzy
-Anxious
-Hungry
-Blurry vision
-Weakness/fatigue
-Headache
-Irritable
(TRUE or FALSE)
50% of hypos occur at night?
TRUE
(TRUE or FALSE)
BG levels determine severity of hypos.
FALSE
The response is individual. People have different thresholds
What should you consider for those having hypos?
1) Consider using other class of medications, that don’t cause lows
2) Try CGM
Neuroglycopenia
A shortage of glucose in the brain which affects functions of the neurons; occurs with BG ~ 30-40s
Considered severe with BG of 10-20s
What are the symptoms of neuroglycopenia?
-Irritability
-Drowsiness
-Dizziness
-Blurred vision
-Difficulty with speech
-Confusion
-Feeling faint
(TRUE or FALSE)
Those with neuroglycopenia can take glucose tabs.
FALSE
Simple tasks like getting to the fridge or chewing, might be unavailable
Name 5 major clinical/biological risk factors for hypoglycemia.
1) Recent level 2 or level 3 hypo episode within the past 3-6 months
2) Intensive insulin therapy
3) Impaired hypo awareness
4) ESRD
5) Cognitive impairment or dementia
Name 4 major social/cultural/economic risk factors for hypoglycemia.
1) Food insecurity
2) Low-income status
3) Homelessness
4) Fasting for religious or cultural reasons
Level 1 hypoglycemia
-BG?
-Recommended action by the patient?
BG <70 mg/dL
15/15 rule and contact provider to make needed changes. Now, at increased hypo risk
Level 2 hypoglycemia
-BG?
-Provider recs?
BG <54 mg/dL, indicates serious hypo
Reassess BG goals, consider med decrease, predictive of level 3 hypo, needs glucagon emergency kit
Level 3 hypoglycemia
-BG?
Severe hypoglycemia
AMS, altered physical functioning, requires external assistance
Under what 3 scenarios should a patient get a glucagon emergency kit?
All T1DM
Those in insulin
Those experiencing level 2 hypos
What causes hypoglycemia unawareness?
Autonomic symptoms adrenergically based (stress hormones)
When can hypoglycemia unawareness start?
After 2-5 years of T1DM (as glucagon secretion is impaired and epinephrine secretion becomes the primary mechanism to restore BG levels)
Since over time, the epinephrine response is diminished or delayed
For those with hypoglycemia what is the minimum BG target to increase the glucose threshold?
100 mg/dL for a few months
What are signs of nocturnal hypoglycemia?
-Vivid dreams
-Waking up with headaches
-Night sweats
-Waking up hungry
-Elevated (rebound) or low morning BG (called the Somogyi effect)
Somogyi effect
aka posthypoglycemia hyperglycemia
A phenomenon where BG levels rise significantly after a period of low BG. A hypo during the night, will cause the body to release stress hormones, thus increasing BG
15-20 grams of carb should rise the BG by how much?
30-45 mg/dL
What are the two recommended treatment options for severe hypoglycemia?
1) If they can swallow w/out risk of aspiration = gel, or honey, inside their cheek
2) If unable to swallow = Glucagon injection
What is the dosing for glucagon emergency kit, for adults? **
Adults = 1 mg
What is the dosing for glucagon emergency kit, for kids? **
Kids <20 kg = 0.5 mg
(TRUE or FALSE)
After a glucagon injection, the person does not need to eat.
FALSE
They must intake carb, as soon as possible to help replace their glucose stores
What is a common reason for new hypoglycemia episodes?
Worsening GFR function
A BG level of X, would indicate having a snack or decreasing medications before bedtime, to prevent hypo?
<110 mg/dL
For those on insulin or secretagogue what is the recommended bedtime BG range?
110-180 mg/dL
Name 6 reasons for BG self monitoring?
1) Feel better everyday - have sense of control
2) Fewer missed work/school days
3) Avoid unwanted weight gain
4) Avoid hospital admissions
5) Avoid hypoglycemia situations / safety
6) Enhanced athletic performance
How often should someone with T2DM on oral meds, check their BG? **
Medicare covers 100 strips for 3 months = 1 test daily
(TRUE or FALSE)
The ADA states that there is no great evidence to support that regular BG monitoring for those with T2DM on oral meds provides a benefit as far as A1c.
TRUE
But it might give them more information to how to make behavioral changes
What is the most common reason for inaccurate BG results on a glucometer?
User error
What is the best way to check the accuracy of your glucometer?
Bring it with you to a blood drawn and do a test at the same time they are drawing blood
You can also call the 1-800 # and ask if the device is within the limits of accuracy
What is the limit of accuracy for glucometers, for home use?
+/- 20% accuracy
How long does the CGM lag behind a glucometer reading?
~ 15 minutes
Higher oxygen tensions, like higher altitude, may affect glucose readings, how?
May result in false low glucose readings
Name some interfering substances for glucose readings.
-Uric acid
-Galactose
-Xylose
-Acetaminophen
-L-dopa
-Ascorbic acid
Under which 2 scenarios will Medicare cover a CGM?
1) On insulin therapy
2) Level 2 hypos
(TRUE or FALSE)
CGMs are indicated during pregnancy.
TRUE
CGM indication has been expanded to include pregnancy for Dexcom G7, FreeStyle Libre 2, Libre 3, which will enhance care in this population
Name 3 benefits of wearing a CGM.
1) Generally reduce A1c if they are regularly worn
2) Significantly reduce hypos in Type 1
3) Significantly reduce hypos in Type 2
(TRUE or FALSE)
People using CGM devices must also have access to BGM at all times.
TRUE
For which patients, should AIDS (Automated Insulin Delivery Systems) be offered?
1) T1DM including youth and adults
2) T2DM on multiple daily insulin injections
Name some pump complications.
-Dislodgement or occlusion (DKA)
-Lipohypertrophy
-Lipoatrophy
-Pump site infection
Digiceuticals
FDA approves and monitors clinically validated, digital, usually online, health technologies intended to treat a medical or pyschological condition
(TRUE or FALSE)
Sick day guidelines recommend discontinuing diabetes medications.
FALSE
Continue to take diabetes medications, but we may need to adjust doses.
Call your MD on advice for taking SGLT-2s
(TRUE or FALSE)
When we are sick we release a lot of corticosteroids that cause an increase in BG levels.
TRUE
What are the general sick day guidelines? (8)
1) Continue to take diabetes meds
2) Test glucose every 4 hours
3) Drink plenty of liquids
4) Rest
5) Call MD
6) Plan ahead
7) Check urine ketones, if BG > 240 - call MD or go to urgent care
8) If at risk of dehydration, hold metformin
Name reasons to call your MD when sick.
1) Vomiting more than once
2) Diarrhea
3) Difficulty breathing
4) BG > 300 mg/dL on 2 readings
5) Temperature > 101 F
6) Positive ketones in urine
(TRUE or FALSE)
A PWD should avoid sugary beverages when they are sick.
TRUE
Unless they are not able to eat (vomiting, for example)
(TRUE or FALSE)
If a person has ARF, metformin can build up in the blood causing lactic acidosis.
TRUE
What is the sick day guideline for those taking SLGT-2s?
Avoid or decrease the dose, until you are able to discuss it with your MD
If a person is admitted to the hospital with a BG of XXX, then you should recommend that they have their A1c checked.
> 140 mg/dL
(TRUE or FALSE)
For those with or without diabetes, hyperglycemia is associated with increased morbidity and mortality in hospital settings.
TRUE, including:
-MI
-Stroke
-Cardiac surgery
-Infection
-Longer LOS
When is it appropriate to start insulin therapy on a hospitalization patient?
If BG 180 or higher on two different occasions within 24 hours
What is the BG goal for hospitalized patients?
110-140 mg/dL while in the ICU
100-180 mg/dL in non-ICU
When are SGLT-2 recommended in the hospital setting?
Those with T2DM and HF
Initiate use or continue during hospitalization and upon discharge
When would you avoid SGLT-2 inhibitors during hospitalization?
-Severe illness
-Ketonemia or ketonuria
-Prolonged NPO status
-Undergoing surgical procedure
For a patient undergoing surgery, when should SGLT-2 inhibitors be stopped? What about Ertugliflozin?
Hold SGLT-2s 3 days before surgery
Hold for 4 days for Ertugliflozin
What is a very common cause of hypos in the hospital?
Too much basal insulin
Others include: Insulin correction scale mismatch; frail, older person with reduced appetite and low GFR; patient is improving and thus requiring less insulin
What is the A1c goal for elective surgeries?
A1c < 8.0%
What is the perioperative BG goal?
BG 100-180 mg/dL
(TRUE or FALSE)
Diabetes medications should be held the day of surgery.
TRUE
When should SGLT-2 meds be held for surgery?
3-4 days
What are the recommendations for insulin management, in preparation for surgery?
NPH - cut dose by 50% (T2DM)
Basal insulin - give 75-80% of dose (consider individuals, like T1DM may need 100%)
What are 3 usual critical barriers?
1) Perceived worthlessness
2) Too many perceived obstacles
3) Absence of support and resources
