1. 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

2. Gary Scheiner MS, CDE Owner & Clinical Director, Integrated Diabetes Services LLC Hypoglycemia Hypoglycemia Prevention & Treatment

3. 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

4. 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

5. Todays Hot Topics Hypoglycemia: Definitions & Causes Problems Caused by Hypoglycemia Preventive Strategies Proper Treatments

6. Hypoglycemia: Definitions Mild: Adrenergic (BG<70) (<4mmol) Moderate: Cognitive (BG<50) (<3mmol) Severe: Unconscious (BG ???)

8. Hypoglycemia: Cause Imbalance between factors raising and lowering blood glucose levels Blood Glucose FoodInsulin/Oral Meds Counterregulatory Hormones Physical Activity

9. Hypoglycemia The Greatest Limiting Factor In Diabetes Management

10. The Great Limiting Factor Performance Impairment

11. The Great Limiting Factor Accident Risk

12. The Great Limiting Factor Anxiety / Embarrassment

13. The Great Limiting Factor Lasting Damage? Spatial memory / performance (if before age 5)

14. The Great Limiting Factor Diminished Symptoms (Hypoglycemic Unawareness)

15. The Great Limiting Factor Rebound

16. The Great Limiting Factor Accelerated Gastric Emptying Post-Meal Spike

17. The Great Limiting Factor Weight Gain

18. 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

19. Hypoglycemia Prevention Strategies 1. Insulin Program Setup (background/basal)

20. Hypoglycemia Prevention Strategies 1. Insulin Program Setup (background/basal)

21. Hypoglycemia Prevention Strategies 1. Insulin Program Setup (background/basal)

22. Hypoglycemia Prevention Strategies 1. Insulin Program Setup (background/basal) Basal insulin should hold BG STEADY in the absence of food, exercise and bolus insulin!

23. Hypoglycemia Prevention Strategies 1b. Insulin Program Setup (Meal/Bolus) Only rapid analogs work when needed – right after eating!

24. 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

25. 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

26. 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)

27. 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!)

28. 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

29. 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.

30. 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!

31. 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

32. 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

33. 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

34. 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

35. 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

36. Hypoglycemia Prevention Strategies 10. Frequent Monitoring Before All Meals & Snacks Pre/Post Exercise Bedtime 3 a.m. (occasionally)

37. 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)

38. 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

39. Hypoglycemia Prevention Strategies 12. Continuous Glucose Monitoring Alarms to alert user/family of pending lows

40. Hypoglycemia Prevention Strategies 12. Continuous Glucose Monitoring

41. 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

42. 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

43. Use of Glycemic Index (contd) Hypoglycemia Treatment

44. Always Carry Rapid-Acting Carbs!

45. Hypoglycemia Treatment DEXTROSE Rules! Glucose Tablets Sweet Tarts Smarties Spree Air Heads Nerds Runts

46. 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!

47. Hypoglycemia Treatment Treatment amt. for insulin on board Treatment amt. for recent exercise Treatment amt. for previous low-G.I. foods Idiosyncracies

48. Hypoglycemia Treatment Severe Low –Unconscious / Unresponsive –Seizure –Uncooperative

49. Take-Home Messages Quantify Your Lows Strategize to Minimize Plan for Proper Treatment

50. Questions? Thank You For Participating in Type-1 University! www.type1university.com www.integrateddiabetes.com US (877) 735-3648