Optimizing Insulin Therapy in Diabetes - Episode 8
Robert Hood, MD: The most common reasons why people get hypoglycemia with diabetes are related to giving insulin without eating food properly; giving insulin and not making adjustments for exercise; or giving insulin that has not been adjusted properly because they’re not monitoring, or they’re doing the monitoring and nothing has been done with the blood sugars. Insulin therapy has to be continually adjusted for people with diabetes. Blood sugars should be reviewed at least weekly; ideally, patients can be taught to self-titrate, and that will help not only get rid of high blood sugars but also minimize the risk of low blood sugars.
The patient also has to understand what a low blood sugar feels like. Some people can’t feel blood sugars adequately. So there should be emphasis from the education standpoint on perception and response to hypoglycemia. Another mistake people make is that they treat hypoglycemia inappropriately and make it last longer. You don’t want fat and protein with your sugar when you’re treating hypoglycemia. So eating a Snickers bar is not what you do. You should be eating pure glucose with very little fat and protein.
Finally, medications can interfere with perception and recovery from hypoglycemia that increase its rate. We want to be as physiologic as possible with insulin so that the insulin reduces the risk of hypoglycemia. We want the patient’s lifestyle to cope with the insulin from the standpoint of making the right adjustment for food and intake. Patients should be well versed in how to recognize and treat hypoglycemia and should, if appropriate, have glucagon at home and, if appropriate, wear a medical alert as well.
The final thing is, if patients are more prone to hypoglycemia using insulin, please adjust your A1C [glycated hemoglobin] goals. A goal of 6.5% is not for everybody. A goal of 7% is not for everybody. The target A1C should be customized, especially in a patient with diabetes in the context of hypoglycemia, because there is a risk-benefit analysis there, not just a cost-benefit analysis.
Davida F. Kruger, MSN, APN-BC, BC-ADM: Hypoglycemia is one of the biggest concerns patients and the providers have when we start insulin. They’ve seen someone who has had a hypoglycemic event, and they don’t feel well when they have a hypoglycemic event. So we really want to be proactive and prevent hypoglycemic events as best we can. A couple of things we talk to patients about regard the timing of their insulin, making sure that if they’re taking a basal insulin that they take it the same time every day; that if they’re taking mealtime insulin, they take it 10 to 15 minutes before the meal; that they check their blood glucose.
In 2018, we must have continuous glucose monitoring for patients who are taking insulin. Those patients benefit by it because they can see the direction their blood glucoses are going. “Don’t take your insulin and then miss a meal. If you’re going to be more active, we can adjust your insulin down.” Patients will say, “Oh, I have low blood sugar because I was shopping and I missed the meal and I forgot to eat; I walked around the mall, and all of a sudden, I had low blood glucose.” So talk to them proactively. “This insulin is dosed based on your activity level here. If you’re going to increase it, then we can lower your insulin before that activity, or we can give you a pre-exercise or activity snack.”
Also tell patients to always carry 15 to 30 grams of carbohydrates with them. If they think they have low blood sugar, treat it with 15 grams of carbohydrates. Recheck their blood glucose. If they’re still low, they can take another 15 grams. They can follow it up with protein. But be proactive so that their insulin is timed appropriately and they check their blood glucose, they don’t miss meals; and if they’re going to be more active, we adjust their insulin or their food intake.
Patients will call and say they were at the mall, they missed a meal, they were more active because they were out shopping, and they had a low blood sugar. They’re very concerned about that low blood sugar. If we don’t take it very seriously, the problem is that patients will lower their insulin on their own or they will stop taking it.
We need to talk to them about strategies. “If you’re going to be more active, we can lower insulin before that activity. We can give you an activity snack. But if you’re going to be out walking around, don’t take your insulin and miss a meal. Also, be aware to carry something to treat low blood sugar.” We tell patients who are on insulin to always carry 15 to 30 grams of carbohydrates with them. You don’t want to be running to a store and saying, “I’m having low blood sugar. Can I have something to drink?”
We do not want them to overtreat low blood sugar either. So use 15 to 30 grams of carbohydrates for a low blood sugar. Recheck your blood sugar in 15 minutes. If it’s still low, take another 15 grams of carbohydrates and then follow it up with protein. But the key things are, don’t take your insulin and not eat. If you’re going to be more active, we can lower your insulin for those activities or give you an activity snack. Check your blood glucoses more often if you’re going to be more active.
Serge Jabbour, MD: When patients complain of hypoglycemic events, I do a few things. I do my own teaching in the office, but I also send my patients to my diabetes educator because they need formal training on how to prevent and manage hypoglycemia at the same time: first how to prevent by using drugs that don’t cause hypoglycemia and also by teaching patients how to prevent hypoglycemia on a daily basis. For example, if patients tell me they become hypoglycemic when they go to the gym, I tell them what adjustments they need to make to prevent hypoglycemia. If they’re on insulin, I tell them how much they need to cut back on the insulin to prevent low blood sugars or whether they need to have a snack before they work out. Preventing hypoglycemia is key through teaching and education and adjusting the medications they’re on.
One other important aspect is how to treat hypoglycemia the right way. Many patients panic when they become hypoglycemic, and I do understand it. Patients might open the fridge and eat whatever carbs they have in the fridge. Then an hour later, their blood sugar is 400 or 500 mg/dL. These patients, when they become hypoglycemic, should eat typically 15 to 25 grams of carbs—that’s 4 to 6 oz of juice—and that’s all they need. Wait 15 minutes and recheck their sugar. If it’s normal, they’re fine; if it’s still low, repeat the same thing.
One easy way to deal with this is to carry glucose tablets they can buy from a store. They can always keep them in their car, at work, at home, or at the gym. They can pop 3 or 4 tablets when they become hypoglycemic. So the key is not to overreact and overtreat hypoglycemia.
Transcript edited for clarity.