Lecture 26 - Acute Complications of Diabetes

what are meaningful reasons to check blood glucose

avoid hypoglycemia

confirm a low if someone is felling symptoms of hypoglycemia

assess the response to medication changes

assess response to food

during changes of normal routine

during an acute illness

during pregnancy

how often is it recommended that people using insulin more than once a day check capillary blood glucose

at least 3 times per day and include both pre- and post-prandial measurements

how often is it recommended that people with type 2 diabetes using once-daily insulin check capillary blood glucose

at least once per day at variable times 

how often is it recommended that people with type 2 diabetes not using insulin check capillary blood glucose 

individualized depending on type of antihyperglycemic agents, A1c, and risk of hypoglycemia  

how often is it recommended that all people with diabetes with A1c not at target or episodes of hypoglycemia

4 times per day, may include overnight checks

when are real time continuous glucose monitors or intermittently scanned continuous glucose monitoring recommended

people with type 1 diabetes using basal-bolus insulin or continuous subcutaneous insulin infusions

what are the benefits of real time continuous glucose monitors and intermittently scanned continuous glucose monitoring 

increases time in range

reduces duration and incidence of hypoglycemia 

what should blood glucose be before exercise

>4 and <14 mmol/L

what happens to blood glucose during exercise 

levels will fluctuate 

individuals will respond differently to exercise 

changes in exercise regimen (intensity, aerobic vs resistance, duration, timing) change blood glucose profile 

what are considerations for blood glucose after exercise 

delayed hypoglycemia may occur 6-12 hours after exercise 

caused by muscle cells absorbing glucose to replenish glycogen stores 

important to keep checking blood glucose, especially if exercise regimen changed

may need to consider extra snack at bedtime 

how should insulin be adjusted for low intensity exercise (walking, golf with a cart, stretching)

decrease bolus dose by 25-50%

how should insulin be adjusted for moderate intensity exercise (brisk walk, mowing the lawns, riding a bike, raking leaves, golf without a cart, swimming, tennis, downhill skiing)

decrease bolus dose by 50-70%

how should insulin be adjusted for high intensity exercise (competitive sports, shovelling snow, aerobics, jogging, hockey, soccer, basketball)

decrease bolus dose by 75-100%

what should a patient do if planning on exercising within 102 hours of a meal-time insulin

adjust insulin dose

what should a patient do if planning on exercising >2 hours from a meal time insulin

consume a carbohydrate snack before the activity and repeat as needed

what should a patient do if they have unplanned exercise that occurs within 1-2 hours after mealtime insulin 

consume a carbohydrate snack before the activity and repeat as needed

what are the immediate effects of alcohol on blood glucose

some alcoholic drinks have carbohydrates → immediately increase blood glucose levels

• e.g. beer, coolers, sweet white wine, sweetened mix

some alcohols have little-no immediate effect

• e.g. hard alcohol, dry wine, low carb/light beet

what might people using insulin when consuming alcoholic drinks with carbohydrates

substituting carbohydrates in meal plan (1 beer = 1 piece of bread)

adjusting insulin dose

what is delayed hypoglycemia from alcohol 

can happen up to 24 hours post consumption with all types of alcohol 

caused by reduced hepatic glucose production 

+++ increases the risk of nocturnal hypoglycemia 

how can delayed hypoglycemia from alcohol be avoided

eating food while drinking and having a bedtime snack

check blood glucose during the night

check blood glucose more often the next day or be aware of potential for lows

what should a person do if their blood glucose is < 4 mmol/L before driving

treat the hypoglycemia → successful if glucose rises to >5 mmol/L

wait at least 40 minutes before driving

what should a person do if blood glucose is 4-5 mmol/L before driving 

ingest carbohydrate before driving 

how often should a person check blood glucose while driving

every 4 hours

what should a person with diabetes know about driving

check blood glucose before driving

always have hypoglycemia treatment within reach (glucose tabs, sugar packets, jellybeans, lifesavers, juice box)

driver’s medical should be conducted at least every 2 years

where should insulin be packed when traveling 

carry-on 

how should insulin be adjusted when traveling north-south

no adjustment to basal or bolus insulin

how should insulin be adjusted when traveling east

day is shorter → reduce basal insulin dose on travel day

within north america (e.g. edmonton to halifax 3hr time difference) → decrease by ¼ to 1/3

from north america to europe (e.g. edmonton to londor 7 hr time difference) → decrease by 1/3 to ½

how should insulin be adjusted when traveling west 

day is longer → have an extra snack and an extra bolus insulin dose once you arrive at your destination  

how soon should a person with diabetes switch to new time zone mealtimes and waking hours when traveling

ASAP

how should Ramadan and periods of fasting be considered for adults with type 1 or type 2 diabetes

should receive individualized assessments 1-2 months before doing so to determine sustainability for fasting and to formulate a management plan

what can happen to blood glucose during common illnesses

fluctuate and become unpredictable

OTC medications used to treat symptoms can affect blood glucose 

glucose release from the liver is increased

insulin resistance increases during illness

what are the goals for sick day management for diabetes

avoid large fluctuations in blood glucose

avoid dehydration

avoid ketoacidosis

avoid need for urgent care

what should a person with diabetes do when sick

check blood glucose ≥4 times per day or every 2 hours if high or continuing to rise

check urine or blood for ketones if blood glucose is > 14 mmol/L

drink fluids to avoid dehydration (include electrolytes)

if using insulin may need more than normal (correction bolus)

what OTC for cough and cold should people with diabetes be cautious of 

liquid products → contain dextrose and other carbohydrates 

• use formulations that have artificial sweeteners, labeled sugar free, labeled for people with diabetes 

decongestants (pseudoephedrine) → can increase blood glucose levels

• avoid if possible, topical products have less systemic effect, ok to use for short period

NSAIDs should be avoided because of renal complications  

what medications should be avoided on sick days

SADMANS

sulfonylureas, ACEi, diuretics/direct renin inhibitors, metformin, ARBs, NSAIDs, SGLT2i

what are s/s of diabetic ketoacidosis

high blood glucose (>14)

moderate-high ketones in urine or blood

dehydration

anion gap metabolic acidosis

electrolyte imbalances

increased respiratory rate

acetone (fruity) odor to breath

abdominal pain

decreased level of consciousness

what is hyperosmolar hyperglycemic state 

seen in type 2 diabetes, triggered by heart attack, stroke, severe infection

evolves over several days to weeks (DKA develops within hour-days)

symptoms similar to diabetic ketoacidosis but presents with much higher blood glucose (>25), elevated serum osmolality, little to no ketonuria or ketonemia 

SGLT2i can produce symptoms of diabetic ketoacidosis at blood glucose >13

when should a person with diabetes seek urgent care when sick

when 2 or more of the following occur:

• not retaining fluids (vomiting, diarrhea)

• gastroenteritis with fever for > 48 hours

• abdominal pain

• blood glucose > 14 or continues climbing despite corrective measures

• ketones (urine 4-16 mmol/L) blood (>3 mmol/L)