Acute Complications of Diabetes

Question 1

Why Should People with Diabetes Check Their

Blood Glucose?

Answer 1

• First of all, try to avoid using the term
blood glucose ‘test’
…we are checking the blood glucose level
• Checking blood glucose levels has very little impact on glucose control
– 20+ controlled trials in type 2 diabetes
– 5+ systematic reviews & meta-analyses1-3
• A1c difference at 6 months -0.3% (-0.5% to -0.2%)
• A1c difference at 1 year -0.1% (-0.5% to 0.1%)
• Strips and lancets can be very expensive
• Checking NEEDS to be associated with a meaningful activity

Question 2

Meaningful Reasons to Check Blood Glucose

Answer 2

• Avoid hypoglycemia
– e.g., multiple daily insulin injections, using drugs that cause hypoglycemia
• Confirm a low if someone is feeling symptoms of hypoglycemia
– Also important with hypoglycemia unawareness or if someone is unable to communicate
• Assess the response to medication changes (addition / dose adjustment)
• Assess response food (amount, composition)
• During changes in normal routine
– Exercise
– Alcohol
– Travel, Driving
• During an acute illness (sick day management)
• During pregnancy

Question 3

Self-Monitoring of Blood Glucose

Answer 3

• Regular SMBG if an individual is…
– Using ≥4 daily insulin injections or an insulin pump2,3
• Check blood glucose ≥4 times daily and include both pre- and postprandial
measurements3
– Using <4 daily insulin injections
• Individualize the frequency of blood glucose checks, may require ≥4 times daily
– Starting a medication known to cause hyperglycemia (e.g., steroids) or
experiencing an illness known to cause hyperglycemia
• Individualize the frequency of blood glucose checks, may require ≥2 times daily

Question 4

Increase the frequency of SMBG if…

Answer 4

– Using drugs known to cause hypoglycemia
– Occupation requires strict avoidance of hypoglycemia
– Not meeting glycemic targets or newly diagnosed
– Changes to diet, exercise, or pharmacologic treatment
• Daily SMBG not usually required if…
– Glycemic targets are maintained with lifestyle alone
– Prediabetes

Question 5

Check Smart
– What does the number mean?
– Why did I get that number?
– What could I do differently next time?

what 3 things influence bg?

Answer 5

diet, physl activity, diabetes regimen

Question 6

Exercise and Blood Glucose
• What is the blood glucose level
Before - During - After
• How intense is the exercise
• What is the duration of the exercise
• When is the exercise in relation to meals, insulin, and other
drugs that can cause hypoglycemia

Answer 6

• Before: Exercise not recommended if blood glucose is too low or too high
– should be >4 mmol/L and <14 mmol/L
• During: levels will fluctuate
– Individuals will respond differently to exercise
– Changes in the exercise regimen (intensity, aerobic versus resistance, duration, timing, etc) will also create changes in blood glucose profile
• After: can still fluctuate up to 24 hours later
– Delayed hypoglycemia may occur 6-12 hours after the exercise
Cause: Muscle cells are absorbing glucose to replenish glycogen stores
• Important to continue checking blood glucose, especially if the exercise regimen changed
• May need to consider an extra snack at bedtime

Question 7

how to adjust dose of insulin based on intensity of exercise

Answer 7

Low: walking, golf with a cart, light gardening, stretching, shopping
• ⇓ bolus dose by 25-50%
Moderate: brisk walk, mowing the lawn, riding a bike, raking leaves, golf without a cart,
swimming, tennis, downhill skiing
• ⇓ bolus dose by 50-75%
High: competitive sports, shoveling snow, aerobics, jogging, hockey, soccer, basketball
• ⇓ bolus dose by 75-100%
\
Duration of the exercise ⟹ may need to consume a carbohydrate (15 gm) every
30 minutes

Question 8

Timing of the exercise in relation to meals, insulin, and other drugs that can cause
hypoglycemia (e.g., sulfonylureas)

Answer 8

if exercise is planned and will occur within 1-2 hrs of meal time insulin, adjust insulin dose

if planned but will occur > 2 hrs of meal-time, consume a carbohydrate snack before activity and repeat as needed

unplanned and occurs within 1-2 hrs after meal time insulin, eat snack

Question 9

Alcohol and Blood Glucose

immediate effects

Answer 9

Symptoms hypoglycemia = symptoms drunkenness
• Immediate effects…
– Some alcoholic drinks have carbohydrates that can immediately increase blood glucose levels
• Beer, coolers, sweet white wine, liqueurs, sweetened/sugared mix
• People using insulin may consider
– Substituting for carbohydrates in meal plan (1 Regular Beer = 1 piece of bread)
– Adjusting insulin dose
– Some alcoholic drinks have little or no immediate effect on blood glucose
• Hard alcohol, dry wine, low carb or light beer

Question 10

Alcohol and Blood Glucose

delayed effects

Answer 10

Delayed hypoglycemia (up to 24hrs post consumption)
– Can happen with all types of alcohol
– MOA: reduced hepatic glucose production
(possibly by inhibiting the effects of glucagon on the liver)
– +++ risk nocturnal hypoglycemia
– Avoid by…
• Eating food while drinking and have a bedtime snack
• Check blood glucose during night (set alarm, have someone wake you)
• Check blood glucose more often next day OR be aware of potential for lows

Question 11

Travel

Answer 11

• Take supplies in carry-on
• Insulin storage
• Insulin dosing
– Travel North-South (duration of day remains the same, meal times are similar)
• No adjustment to basal insulin or bolus insulin
– Travel East (day is shorter ⟹ reduce the basal insulin dose on the travel day)
• Within North America (e.g., Edmonton to Halifax 3hr time difference): may consider decreasing by 1/4 to 1/3
• North America to Europe (e.g., Edmonton to London 7hr time difference): decreased by 1/3 to 1/2
– Travel West (day is longer)
• Have an extra snack and an extra bolus insulin dose once you arrive at your destination
– Switch to new time zone (meal times and waking hours) ASAP after arrival

Question 12

Driving

Answer 12

• Check blood glucose before driving
– If blood glucose <4 mmol/L
• Treat the hypoglycemia ⟹ successful treatment if blood glucose >5 mmol/L
• Wait at least 40 minutes before driving (for brain)
– If blood glucose 4-5 mmol/L • Ingest carbohydrate before drive
– Check blood glucose at least every 4 hours
• Always have hypoglycemia treatment within reach
– glucose tabs, sugar packets, jelly beans, lifesavers, juice box
• Driver’s medical should be conducted at least every 2 years
– Glycemic control from blood glucose logs
– Frequency and severity of hypoglycemic events
• Awareness of hypoglycemia
– Identify presence of diabetes related complications
• Retinopathy, Neuropathy, Amputation, Cardiovascular Disease

Question 13

Ramadan and Periods of Fasting

Answer 13

• Concerns for hypoglycemia and hyperglycemia during fasting
– Type 1 diabetes and people with type 2 diabetes using insulin, or non-insulin antihyperglycemic
agents associated with hypoglycemia (e.g., sulfonylureas)
• Many healthcare providers have limited knowledge about the specifics of fasting during
Ramadan
• Adults with type 1 or 2 diabetes who intend to fast should receive individualized assessments 1 to 2 months before doing so to determine their suitability for fasting and to formulate a management plan
– Diabetes Canada Healthcare Provider Tools & Resources
• Ramadan and Diabetes Recommendations
– Diabetes and Ramadan Alliance
• www.daralliance.org

Question 14

Sick Day Management

goals

Answer 14

• Common illness (influenza, gastroenteritis, and sometimes a common cold) can affect blood glucose control
– Blood glucose levels can fluctuate and become unpredictable
– Over-the-counter medications used to treat symptoms can also affect blood
glucose levels
• Goals
– Avoid large fluctuations in blood glucose
– Avoid dehydration
– Avoid ketoacidosis
– Avoid the need for urgent caree
• A good management strategy should be created before getting sick!

Question 15

Sick Day Management
how does bopdy respond

how often to check bg and ketones

Answer 15

• The body responds to an acute illness by releasing cortisol, glucagon, and other hormones*
• Glucose release from the liver is increased
• Insulin resistance increases during an illness
Ø Both actions lead to increased blood glucose levels
• Check blood glucose often, ≥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 plenty of fluids to avoid dehydration
• Include electrolytes (e.g., using a sprots drink) if there is significant gastrointestinal or urinary loss of fluid
• If using insulin, may need MORE than normal
• Blood glucose will rise, even if not eating
• Correction bolus (small amount of short acting or rapid acting insulin)

Question 16

Sick Day Management

Over-the-Counter Products

Answer 16

• Liquid cough and cold products contain dextrose and other carbohydrates
• Affect on blood glucose when using the recommended doses for a short period of time
may be small, but best to avoid
• Use liquid formulations that have artificial sweeteners, are labelled as “sugar free”, or
labelled “… for people with diabetes”
• Decongestants (e.g., pseudoephedrine) can increase blood glucose levels
• Avoid if possible
• Topical products have less systemic effects than oral, and only use for a short period of
time at the recommended dose and interval
• Non-steroidal anti-inflammatory drugs in OTC products should be avoided
because of the renal complications (SADMANS)

Question 17

Sick Day Management

Ketoacidosis (Type 1 Diabetes)

Answer 17

• High blood glucose (>14-20mmol/L)
• Anion gap metabolic acidosis
• Moderate-to-high ketones in urine or blood
• Symptoms:
– Nausea
– Vomiting
– Abdominal pain
– Rapid breathing (remember: this is a respiratory alkalosis in response to
metabolic acidosis)
– Fruity breath
– Extreme tiredness, drowsiness, weakness
– Coma

Question 18

Sick Day Management

Hyperosmolar Hyperglycemic State (Type 2 Diabetes)

Answer 18

Typically evolves over several days to weeks
– Diabetic Ketoacidosis (DKA) that can develop within hours to days
• Triggered by illness (heart attack, stroke, severe infection)
• Symptoms similar to DKA
– frequent urination, excessive thirst, dry mouth, dehydration, leg cramps, weakness, lethargy,
unconsciousness
• Unlike DKA, HHS will present with extraordinarily high blood glucose (>25 mmol/L),
elevated serum osmolality, and little to no ketonuria or ketonemia
• NOTE: SGLT2 inhibitor use can produce symptoms of DKA at lower blood glucose levels (>13
mmol/L)
• Need treatment in hospital (IV fluid replacement and correct electrolyte imbalances)

Question 19

Sick Day Management

how much water to drink

Answer 19

• Check blood glucose often
– ≥4x/day or q2hrs if blood glucose is high or rising
• Check urine or blood ketones every 2-4 hours
– If blood glucose >14 mmol/L
– If unable to keep food or fluids down
• Drink lots of liquids
– 1 cup per hour
– dehydration common with high blood glucose (>14 mmol/L) and ketones
– helps flush out ketones
• If taking insulin, use a correction bolus as needed
– Take small bolus of short acting or rapid acting insulin q2-3hrs
– 1 unit of insulin will ↓ blood glucose 2-3mmol/L
• In illness = insulin resistance = may not ↓ this much

Question 20

Sick Day Management

When to seek urgent care

Answer 20

• In general, when 2 or more of the following occur
– Not retaining fluids (vomiting, diarrhea)
– Gastroenteritis with fever (>38.5C) for >48hrs
– Abdominal pain
– Blood glucose >14-20mmol/L or continues climbing despite
corrective measures
– Ketones
• Urine moderate to high (4mmol/L-16mmol/L)
• Blood (fingertip) >3mmol/L

Question 21

Sick Day Management

sadmans

Answer 21

Hold medications that have reduced clearance or increased risk of
adverse effects during the illness SADMANS
S sulfonylureas
A ACE inhibitors
D diuretics, direct renin inhibitors
M metformin
A angiotensin receptor blockers
N nonsteroidal anti-inflammatory drugs
S SGLT2 inhibitors