Acute Complications Diabetes

Question 1

Importance of checking BG levels

Answer 1

Very little impact alone
- Has to be associated with meaningful activity

Question 2

When to check BG

Answer 2

• 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

Question 3

Blood Glucose Monitoring Recommendations
- Using insulin more than once a day

Answer 3

Check 3 times a day
- Include pre and postprandial measurements

Question 4

Blood Glucose Monitoring Recommendations
- T2DM using once a day insulin

Answer 4

Check at least once per day at variable times

Question 5

Blood Glucose Monitoring Recommendations
- T2DM not using insulin

Answer 5

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

Question 6

Blood Glucose Monitoring Recommendations
- All individuals with diabetes when A1c is not in target OR episodes of hypoglycemia

Answer 6

Check frequently to determine most effective approach to improve BG management
- Check 4 times a day (May include overnight checks)

Question 7

When to use Real Time Continuous Glucose Monitors / Intermittently Scanned Continuous Glucose Monitoring

Answer 7

1. T1DM using basal/bolus therapy / Continuous subcutaneous insulin infusion

Question 8

Benefits of Real Time Continuous Glucose Monitors / Intermittently Scanned Continuous Glucose Monitoring

Answer 8

1. Increases time in range
2. Reduces duration and incidence of hypoglycemia

Question 9

Principles of Check Smart

Answer 9

What does the numbers mean
Why did I get that number
What could I do differently next time

Question 10

Controlling Insulin

Answer 10

• 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

Question 11

Consideration of Exercise and Blood Glucose
- Before

Answer 11

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

Question 12

Consideration of Exercise and Blood Glucose
- During

Answer 12

Will fluctuate differently depending on the person and the exercise regimen

Question 13

Consideration of Exercise and Blood Glucose
- After

Answer 13

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

Question 14

Consideration of Exercise and Blood Glucose
- Low Intensity

Answer 14

Ex. Shopping, Walking, Stretching
- Decrease Bolus Dose by 25-50%

Question 15

Consideration of Exercise and Blood Glucose
- Moderate Intensity

Answer 15

Ex. Brisk walk, swimming, tennis, mowing the lawn, riding a bike
- Decrease Bolus Dose by 50-75%

Question 16

Consideration of Exercise and Blood Glucose
- High Intensity

Answer 16

Ex. Competitive sports, shoveling snow, aerobics, jogging, soccer
- Decrease Bolus Dose by 75-100%

Question 17

Consideration of Exercise and Blood Glucose
- Duration of Exercise

Answer 17

May have to consume a 15 gm carbohydrate every 30 mins

Question 18

Consideration of Exercise and Blood Glucose
- Timing of Exercise

Answer 18

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

Question 19

Consideration of Alcohol and Blood Glucose
- Immediate Effects

Answer 19

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

Question 20

Consideration of Alcohol and Blood Glucose
- Delayed Hypoglycemia (Cause)

Answer 20

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

Question 21

Consideration of Alcohol and Blood Glucose
- Delayed Hypoglycemia (Prevention)

Answer 21

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

Question 22

Consideration of Travel and Blood Glucose
- Storage

Answer 22

Keep supplies on you as they can freeze in storage
Keep supplies cold in a refrigerator

Question 23

Consideration of Travel and Blood Glucose
- Dosing (North-South)

Answer 23

Days are same duration
- No adjustments to basal/bolus

Question 24

Consideration of Travel and Blood Glucose
- Dosing (Travel East)

Answer 24

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

Question 25

Consideration of Travel and Blood Glucose - Dosing (Travel West)

Answer 25

Day is longer --> increase bolus dose on travel day Have an extra snack and extra bolus dose once you arrive at location

Question 26

Consideration of Travel and Blood Glucose - Dosing (Time Zones)

Answer 26

Switch to new time zone (mealtimes and waking hours) ASAP after arrival

Question 27

Consideration of Driving and Blood Glucose - Checking

Answer 27

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

Question 28

Consideration of Fasting and Blood Glucose - Concerns who?

Answer 28

People with Type 1 Diabetes People with Type 2 Diabetes on Insulin or on an antihyperglycemic agent associated with hypoglycemia

Question 29

Consideration of Fasting and Blood Glucose - Actions

Answer 29

Adults with Type 1 or Type 2 Diabetes requires an assessment 1 to 2 months before fasting - Allows a management plan for fasting

Question 30

Diabetes and Sick Day Management - Relationship

Answer 30

- 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)

Question 31

Diabetes and Sick Day Management - Goals

Answer 31

- Avoid large fluctuations in blood glucose - Avoid dehydration - Avoid ketoacidosis - Avoid the need for urgent care

Question 32

Diabetes and Sick Day Management - What causes Increased Glucose

Answer 32

Cortisol, Glucagon, and other hormones released - Increased insulin resistance - Increased hepatic glucose production

Question 33

Diabetes and Sick Day Management - Checking

Answer 33

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

Question 34

Diabetes and Sick Day Management - Management

Answer 34

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

Question 35

Diabetes and Sick Day Management - OTCs

Answer 35

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)

Question 36

Diabetes and Sick Day Management - SADMANS

Answer 36

Sulfonylureas ACEi Diuretics + Direct Renin Inhibitors Metformin ARB NSAIDs SGLT2 Inhibitors

Question 37

Diabetes and Sick Day Management - Ketoacidosis

Answer 37

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

Question 38

Diabetes and Sick Day Management - Hyperosmolar Hyperglycemic State

Answer 38

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

Question 39

Diabetes and Sick Day Management - SGLT2

Answer 39

SGLT2 inhibitors can produce symptoms of DKA at blood glucose levels of 13 or above

Question 40

Diabetes and Sick Day Management - Hyperosmolar Hyperglycemic State Treatment

Answer 40

Need IV replacement therapy

Question 41

Symptoms of DKA

Answer 41

Frequent Urination Thirst Dry mouth Dehydration Leg cramps Weakness Lethargy Unconsciousness

Question 42

Diabetes and Sick Day Management - When to seek help

Answer 42

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)