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Gary Scheiner MS, CDE Owner, Integrated Diabetes Services 333 E. Lancaster Ave., Suite 204 Wynnewood, PA 19096 877-SELF-MGT (735-3648) (610) 642-6055 www.integrateddiabetes.com Gary@integrateddiabetes.com
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Gary Scheiner MS, CDE Owner & Clinical Director, Integrated Diabetes Services LLC Hypoglycemia Hypoglycemia Prevention & Treatment
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A little bit about me… Certified Diabetes Educator for 15 years Written four books and dozens of articles on intensive insulin therapy, including Think Like A Pancreas Serve on numerous faculties and advisory boards Type-1 Diabetes for 25+ years Utilize pump, CGM and Symlin Once went low when lecturing on hypo prevention
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A little bit about our practice Team of Diabetes Educators w/Personal Connection to Diabetes Provide Advanced Education & BG Management Coaching Full Remote Access (phone, e-mail, skype, text, etc.) Type-1 Diabetes Focus, Children & Adults
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Todays Hot Topics Hypoglycemia: Definitions & Causes Problems Caused by Hypoglycemia Preventive Strategies Proper Treatments
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Hypoglycemia: Definitions Mild: Adrenergic (BG<70) (<4mmol) Moderate: Cognitive (BG<50) (<3mmol) Severe: Unconscious (BG ???)
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Hypoglycemia: Cause Imbalance between factors raising and lowering blood glucose levels Blood Glucose FoodInsulin/Oral Meds Counterregulatory Hormones Physical Activity
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Hypoglycemia The Greatest Limiting Factor In Diabetes Management
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The Great Limiting Factor Performance Impairment
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The Great Limiting Factor Accident Risk
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The Great Limiting Factor Anxiety / Embarrassment
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The Great Limiting Factor Lasting Damage? Spatial memory / performance (if before age 5)
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The Great Limiting Factor Diminished Symptoms (Hypoglycemic Unawareness)
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The Great Limiting Factor Rebound
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The Great Limiting Factor Accelerated Gastric Emptying Post-Meal Spike
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The Great Limiting Factor Weight Gain
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Hypoglycemia: Targets/Goals Unable to recognize & verbalize lows: >80 (4.5 mmol) Able to recognize & verbalize lows: >70 (4 mmol) Pregnancy: >60 (3.3 mmol) <10% of readings below target at each time of day No severe lows
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Hypoglycemia Prevention Strategies 1. Insulin Program Setup (background/basal)
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Hypoglycemia Prevention Strategies 1. Insulin Program Setup (background/basal)
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Hypoglycemia Prevention Strategies 1. Insulin Program Setup (background/basal)
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Hypoglycemia Prevention Strategies 1. Insulin Program Setup (background/basal) Basal insulin should hold BG STEADY in the absence of food, exercise and bolus insulin!
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Hypoglycemia Prevention Strategies 1b. Insulin Program Setup (Meal/Bolus) Only rapid analogs work when needed – right after eating!
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Hypoglycemia Prevention Strategies 2. Meal/Snack Timing Major issue w/a.m. NPH/Lente Minor issue w/Lantus or Levemir Not usually an issue with pump use
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Hypoglycemia Prevention Strategies 1500-Rule (aggressive) (83 rule) 1800-Rule (conservative) (100 rule) (Total Daily Ins.)/1500 or 1800 May vary day vs. night (nighttime often 50% more than day) 3a. Proper Correction Doses
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Hypoglycemia Prevention Strategies Premeal: 100 (5.5) (aggressive) 120 (6.7) (typical) 140-150 (7.6-8.3) (cautious) 3b. Appropriate BG Targets Postmeal (1-2 hrs): <160 (9) (aggressive) <180 (10) (typical) < 200 (11) (cautious)
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Hypoglycemia Prevention Strategies Severe lows are more common the day after: –Erratic BGs –Hypoglycemia –Intense exercise 3c. Use Floating Targets Adjust TODAYs target based on yesterdays events! + 10 (.5) if lows + 10 (.5) if heavy exercise - 10 (.5) if neither* *(never set target below 100!)
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Hypoglycemia Prevention Strategies I:C Ratio that matches pre-meal BG 3-4 hours (not 2!) after eating I:C Ratio often varies from meal to meal (bkfst dose > lunch & dinner) 4. Proper Meal/Bolus Doses
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Hypoglycemia Prevention Strategies 5. Account For Unused Insulin* Time since meal insulin 1 Hr2 Hrs3 Hrs4 Hrs Conservative Approach 70% left40% left10% left0% left Aggressive Approach 67% left33% left0% left * Newer pumps figure this automatically based on the insulin duration you set.
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Hypoglycemia Prevention Strategies 5. Account For Unused Insulin Example: Gave 6.0 units at 7pm, BG 200 at 9pm. Conservative approach: 40% remaining (6 x.4) = 2.4 units left Aggressive approach: 33% remaining (6 x.33) = 2 units left Subtract the unused insulin from your usual correction dose!
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Hypoglycemia Prevention Strategies 6. Carb Counting Accuracy Proper Portion Measurement Look Up Unknown / Restaurant Foods Use Carb Factors Subtract 100% of Fiber Subtract 50% of Sugar Alcohols
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Hypoglycemia Prevention Strategies 7. Extend Meal Insulin When Necessary Use 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
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Hypoglycemia Prevention Strategies 8. 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
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Hypoglycemia Prevention Strategies 8. 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: o lower basal insulin for 8-12 hours o low-G.I. Snacks o lower mealtime boluses
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Hypoglycemia Prevention Strategies 9. 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
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Hypoglycemia Prevention Strategies 10. Frequent Monitoring Before All Meals & Snacks Pre/Post Exercise Bedtime 3 a.m. (occasionally)
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Hypoglycemia Prevention Strategies 11. Recording & Analysis Record all pertinent data BGs Carb Activity Insulin Use an organized form (multiple days on single page, if possible)
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Hypoglycemia Prevention Strategies 11. 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
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Hypoglycemia Prevention Strategies 12. Continuous Glucose Monitoring Alarms to alert user/family of pending lows
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Hypoglycemia Prevention Strategies 12. Continuous Glucose Monitoring
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Hypoglycemia Treatment Mild/Moderate Low –Check BG First –Treat w/High-Glycemic Index Food –Treat w/Proper Amount –Re-Check in 15 Minutes High-GI Foods Glucose Tablets Dry Cereal Pretzels Graham Crackers Vanilla Wafers Jelly Beans Gatorade
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Hypoglycemia Treatment Use 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
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Use of Glycemic Index (contd) Hypoglycemia Treatment
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Always Carry Rapid-Acting Carbs!
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Hypoglycemia Treatment DEXTROSE Rules! Glucose Tablets Sweet Tarts Smarties Spree Air Heads Nerds Runts
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Hypoglycemia Treatment Wt-lbs (BG rise/g) BG 70s (4) BG 60s (3.5) BG 50s (3) BG 40s (2.5) BG <40 (2) <40 ( 9-10) (.5) 6g7g8g9g10g 40-70 ( 7-8) (.4) 7g8g10g11g13g 70-100 ( 5-6) (.35) 8g10g12g14g16g 100-160 ( 4) (.3) 11g13g16g19g21g 160-220 ( 3) (.2) 14g17g21g24g27g >220 ( 2) (.15) 20g25g30g35g40g Once BG has risen, give rapid-acting insulin to cover any overtreatment!
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Hypoglycemia Treatment Treatment amt. for insulin on board Treatment amt. for recent exercise Treatment amt. for previous low-G.I. foods Idiosyncracies
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Hypoglycemia Treatment Severe Low –Unconscious / Unresponsive –Seizure –Uncooperative
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Take-Home Messages Quantify Your Lows Strategize to Minimize Plan for Proper Treatment
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Questions? Thank You For Participating in Type-1 University! www.type1university.com www.integrateddiabetes.com US (877) 735-3648
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