15Hypoglycemia: Targets/Goals Unable to recognize & verbalize lows: >80 (4.5 mmol/l)Able to recognize & verbalize lows: >70 (4 mmol/l)Pregnancy: >60 (3.3 mmol/l)<10% of readings below target at each time of dayNo severe lows
16Hypoglycemia Prevention Strategies 1. Insulin Program Setup (background/basal)
17Hypoglycemia Prevention Strategies 1. Insulin Program Setup (background/basal)
18Hypoglycemia Prevention Strategies 1. Insulin Program Setup (background/basal)
19Hypoglycemia Prevention Strategies 1. Insulin Program Setup (background/basal)Basal insulin should hold BG STEADY in the absence of food, exercise and bolus insulin!
20Hypoglycemia Prevention Strategies 1b. Insulin Program Setup (Meal/Bolus)Only rapid analogs work when needed – right after eating!
23Hypoglycemia Prevention Strategies 2. Meal/Snack TimingMajor issue w/a.m. NPH/PremixMinor issue w/Lantus or LevemirNot usually an issue with pump use
24Hypoglycemia Prevention Strategies 3a. Proper Correction Doses1500-Rule (aggressive) (83 rule)1800-Rule (conservative) (100 rule)(Total Daily Ins.)/1500 or 1800 (83 or 100)May vary day vs. night(nighttime often 50% more than day)
26Hypoglycemia Prevention Strategies 3c. Use “Floating” TargetsAdjust TODAY’s target based on yesterday’s events!+ 10 (.5) if lows+ 10 (.5) if heavy exer.- 10 (.5) if neither**never set target below 100 (5.5) or above 160 (9)Severe lows are more common the day after:Erratic BGsHypoglycemiaIntense exercise
27Hypoglycemia Prevention Strategies 4. Proper Meal/Bolus DosesI:C Ratio that matches pre-meal BG 3-4 hours (not 2!) after eatingI:C Ratio often varies from meal to meal(bkfst dose > lunch & dinner)
28Hypoglycemia Prevention Strategies 5. Account For “Unused” Insulin*Time sincemeal insulin 1 Hr2 Hrs3 Hrs4 HrsConservative Approach70% left40% left10% left0% leftAggressive Approach67% left33% left* Newer pumps figure this automaticallybased on the insulin duration you set.
29Hypoglycemia Prevention Strategies 5. Account For “Unused” InsulinExample:Gave 6.0 units at 7pm, BG 200 (11) at 9pm.Conservative approach: 40% remaining (6 x .4) = 2.4 units leftAggressive approach: 33% remaining (6 x .33) = 2 units leftSubtract the unused insulin from your usual correction dose!
30Hypoglycemia Prevention Strategies 6. Carb Counting AccuracyProper Portion MeasurementLook Up Unknown / Restaurant FoodsUse Carb FactorsSubtract 100% of FiberSubtract 50% of Sugar Alcohols
31Hypoglycemia Prevention Strategies 7. Extend Meal Insulin When NecessaryUse When:Portions are very largeMeal is prolongedFood is low-glycemic index (pasta, legumes, dairy…)Apply Via:Square/Dual/Extended/Combo bolus on pumpDelayed or Split bolus on injections
32Hypoglycemia Prevention Strategies 8. Adjustment for Physical ActivityExercise, recreation, chores: all count!Reduce meal insulin (25%, 33%, 50%) for after-meal activitySnack prior to before/between meal activityLower long-acting/basal insulin during and after prolonged activity
33Hypoglycemia Prevention Strategies 8. Watch Out for D’OH!(Delayed Onset Hypoglycemia)Following High-Intensity ExerciseFollowing Extended Duration ActivityMay Occur Up to 24 Hours AfterAdjustments to food/insulin after activity:lower basal insulin for 8-12 hourslow-G.I. Snackslower mealtime boluses
34Hypoglycemia Prevention Strategies 9. Adjustment for AlcoholAlcohol reduces the liver’s output of glucose and masks hypoglycemic symptomsDelayed BG drops can occurDecrease basal insulin (or overnight long-acting insulin) after drinking
36Hypoglycemia Prevention Strategies 11. Recording & AnalysisRecord all pertinent dataBGsCarbActivityInsulinUse an organized form (multiple days on single page, if possible)
37Hypoglycemia Prevention Strategies 11. Recording & AnalysisReview every 7-10 daysLook for patterns> 10% below target given timeLows during/post-activityLows on School/Work vs. off-dayLows Post-Menstrual
38Hypoglycemia Prevention Strategies 12. Continuous GlucoseMonitoringAlarms to alert user/family of pending lows
39Hypoglycemia Prevention Strategies 12. Continuous GlucoseMonitoringAlarms to alert user/family of pending lows
40The Value of Alerts: Minimizing the DURATION and MAGNITUDE of BG Excursions
42Setting Low Alerts Low alert thresholds are not BG target ranges Take “lag time” into account ( mg/dl)Predictive alerts lose value the further the advance warning (keep below 10 min)Rate of FALL alerts helpful for hypo prevention (>3 mg/dl/min)
43Hypoglycemia Treatment Mild/Moderate LowCheck BG FirstTreat w/High-Glycemic Index FoodTreat w/Proper AmountRe-Check in 15 MinutesHigh-GI FoodsGlucose TabletsDry CerealPretzelsGraham CrackersVanilla WafersJelly BeansGatorade
44Hypoglycemia Treatment Use of Glycemic Index (contd)
47Hypoglycemia Treatment Wt-lbs (kg)BG 70s(4)BG 60s (3.5)BG 50s(3)BG 40s (2.5)BG <40 (2)<40 (<19)6g7g8g9g10g(19-33)11g13g(33-48)12g14g16g(48-76)19g21g(76-105)17g24g27g>220 (>105)20g25g30g35g40gOnce BG has risen, give rapid-acting insulin to cover any overtreatment!
48Hypoglycemia Treatment “Idiosyncracies”Treatment amt. for insulin on boardTreatment amt. for recent exerciseTreatment amt. for previous low-G.I. foods
49Hypo Treatment Based on Trend Predictive Hypo Alert or Hypo Alert & recovering: Subtle Treatment50% of usual carbsMed-High G.I. foodHypo Alert & Dropping: Aggressive TreatmentFull or increased carbsHigh G.I. foodvsThird, REAL-Time Trend Arrows.One arrow up or down indicates a change of 1-2 mg/dl/min in the last 20 minutes.Two arrows up or down indicate a change of more than 2 mg/dl/min in the last 20 minutes.Arrows are only displayed if there has been at least a 1 mg/dl/min change in the last 20 minutes.Patients should think about where glucose may be in 20 minutes if it continues at the same rate.49
50Hypoglycemia Treatment For Severe LowUnconscious / UnresponsiveSeizureUncooperativeMay Use Lower DoseMay Inject SC
51Take-Home Messages Quantify Your Lows Strategize to Minimize Plan for Proper Treatment