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ОглавлениеPart III
Monitoring Diabetes
CHAPTER 6
Basics of Blood Glucose Monitoring
• How Often You Should Monitor
Monitoring your blood glucose is an important tool for taking care of yourself and your diabetes. Your health care provider will perform tests to measure your average blood glucose level at most visits, as discussed in more detail in chapter 2. However, the blood glucose monitoring that you do every day—on your own—will form the backbone of your diabetes management plan.
Blood glucose readings help you understand how you respond to different situatixons: food, exercise, illness, and even stress. Readings also help you make informed choices for treating your blood glucose with insulin or other medications, food choices, and physical activity. Ultimately, these choices help you feel better each day and prevent complications down the road.
This chapter will explain some of the basic guidelines for monitoring blood glucose, such as who should monitor, how often you should monitor, and when to do extra checks. Keep in mind that blood glucose monitoring is up to you. You will be the person most responsible for keeping tabs on your diabetes and making adjustments to fit your lifestyle and health goals.
Who Should Monitor?
The simple answer is . . . you.
People with diabetes who take insulin should always monitor their blood glucose. People with type 2 diabetes who take diabetes pills should check with their health care providers about whether and how often to monitor. Insulin and other diabetes medications are powerful drugs that lower blood glucose. You can tell how well they are doing their job by keeping track of your blood glucose. Also, when you use these medications, you are at risk for low blood glucose (hypoglycemia). Monitoring will tell you if your blood glucose is low, so that you don’t have to guess. It can also guide you in deciding how much and which foods to eat at meals.
People with type 2 or gestational diabetes who manage their blood glucose with exercise and meal plans do not need to worry as much about low blood glucose levels. However, monitoring may be helpful. It gives you feedback on how well your diabetes care is working. Positive feedback may be a wonderful source of encouragement for you. You can see the effects of your exercise program or food choices. For pregnant women, it guides the treatment adjustments that will help keep you and your baby healthy.
The best way to lead a healthy life is to take charge of your diabetes. You can do this by managing glucose levels with food, physical activity, and medication. The single most important thing you can do for yourself is to keep track of the amount of glucose in your blood on a regular basis.
Monitoring is the only way to know how your body responds to food, medication, activity, and stress. Without knowing this, you can’t make changes in your diabetes care plan. Trial and error—and a little patience—will help you reach your glucose goals.
Instead of saying “I feel good” or “I feel terrible,” take measurements and keep records. These records will tell you how well your diabetes plan is working.
Why Should I Bother?
• If you take insulin or certain diabetes pills and your blood glucose level swings too low over the course of the day, you could develop hypoglycemia. For example, if you take insulin and your blood glucose level drops too low and you don’t treat it, you could fall unconscious.
• High blood sugar may not cause an immediate emergency but may lead to severe complications over time. People with a history of chronic high blood glucose can develop debilitating eye disease, kidney disease, circulation problems, or nerve disease. They can also be at risk for dehydration.
How Often You Should Monitor
Of course, how often you monitor your blood glucose is highly individual. It depends on: whether you have type 1 or type 2 diabetes, your blood glucose goals, how often you’re willing to prick your finger, and what supplies you can afford. How often you monitor also depends on your reasons for checking your blood glucose.
If you have type 1 or type 2 diabetes and you use the results to adjust your next insulin injection or food intake, then you may need to check your blood glucose level each time before you inject or eat a meal (3–4 times a day). You might also monitor after meals to see if you gave the right insulin dose.
If you aim for a blood glucose level close to normal, it’s essential to monitor at least four, and sometimes eight, times a day. You would check before and after each meal and before bedtime every day and in the middle of the night (around 3 a.m.) about once a week. Studies in type 1 diabetes have shown a relationship between the number of blood checks a day and blood glucose control. You’ll hear more about setting goals for keeping your blood glucose levels as close to normal in chapter 9.
However, you may only be taking one or two insulin shots each day or oral medications, so you may decide to monitor just two times each day. Blood glucose levels in people with type 2 diabetes are often more stable over the course of a day. If you take oral diabetes medications, you may not need to monitor as often because you can’t use the results to fine-tune your dose.
People with type 2 diabetes who manage their blood glucose without medications might monitor once or twice a day, three or four times a week, or not at all. However, checking your blood glucose levels regularly will help you keep track of your diabetes and see how all of your efforts are working. One approach is to routinely measure your fasting or pre-breakfast blood glucose levels. It can also help to check your blood glucose at different times of the day: before and after exercise, before and after meals, and at bedtime. This gives you a better idea of what is happening with your blood glucose levels.
Monitoring Goals
Your goal is to understand the pattern of your blood glucose in response to your daily lifestyle. However, you may also need to capture unusual highs and lows.
Standard Times to Check Blood Glucose
• Before breakfast, lunch, dinner, or an especially big snack
• Before you go to bed
• 1–2 hours after breakfast, lunch, dinner, or an especially big snack
• At 2 or 3 a.m.
Sometimes you may not feel quite right, and you may not know why. Monitoring your blood glucose may help you pinpoint the problem. For example, if you feel sweaty and a little shaky after a three-mile run, you may just be tired from the workout or you could be having a low blood glucose reaction. You simply don’t know without monitoring. You may decide to eat because you think your blood glucose is low, but it could actually be high. Only monitoring will give you the information you need to make the right decision about treatment.
Over time, you will gain confidence in your ability to manage your diabetes. You may think it’s okay to monitor less often. Beware! It’s tempting to think you can tell what your glucose level is by the way you feel, but research shows that most people cannot guess their glucose levels reliably. Guessing is dangerous, especially if your blood glucose level tends to swing with little warning.
When to Do Extra Checks
There are times when you’ll need to monitor your blood glucose more often, particularly when you’re trying to decipher how new situations affect your blood glucose. In general, changes in medication, food, physical activity, stress, and illness will affect your blood glucose. So, you’ll need to perform extra blood glucose checks during these situations. These checks will help you respond to and treat your blood glucose properly. Remember, you should always monitor your blood glucose when you suspect that it is too high or too low.
Extra Checks for Meals
Put most simply, some foods make your blood glucose go up. However, there are quite a few nuances to keep in mind. The amount and type of carbohydrates in certain foods, as well as the amount of food you eat during a meal, will affect your blood glucose level. Sounds complicated, right?
Well, the best way to take charge is to begin to learn how the food you eat affects your blood glucose levels. You’ll want to monitor your blood glucose more closely when you eat new foods or eat special meals. You may be surprised at how your glucose level responds to different foods. Measure your blood glucose 1–2 hours after you eat particular foods. Do you find that your blood glucose rises faster after you eat rice or pasta? Does it rise faster after a cookie or a granola bar? By figuring out how your body responds to specific foods, you can have a plan so that your blood glucose will not rise too high, too fast. You can read more about managing your diabetes and food in chapter 10.
Extra Checks for Physical Activity and Exercise
In general, physical activity, including exercise, will lower your glucose and make your body more sensitive to insulin. During exercise, your muscles work harder and use up the glucose they have stored for fuel. Your body uses glucose from the blood when the glucose stored in muscles becomes low. Exercise can help use up some of the glucose that builds up in the blood.
You need to take special precautions when you exercise. You want to make sure that your blood glucose levels don’t drop too low too fast. This can happen in the hours after exercise when your muscles take glucose from the blood to restore their glucose reserves (this is more common in type 1 diabetes). Make sure to check your blood glucose immediately after exercising as well as several hours later.
Doing extra checks before and after physical activity will help you decide if you need to eat a little more or inject a little less insulin. Some people with type 2 diabetes find that they no longer have to take insulin or other diabetes medications once they start a regular exercise program. However, to be safe, talk over your blood glucose readings and exercise program with your health care team before you make changes to your diet, insulin, or other medications. Read more about managing your diabetes and physical activity in chapter 11.
High Blood Glucose and Exercise
It sounds strange, but people with type 1 diabetes will also need to check their blood glucose to make sure that it isn’t too high during exercise. If your blood glucose level is over 250 mg/dl, exercise may cause your blood glucose level to go up rather than down.
Hard exercise with too little insulin can make the liver release stored glucose. Someone with type 1 diabetes whose blood glucose is greater than 250 mg/dl should test for ketones (read about how to test for ketones in chapter 7). Do not exercise if ketones are present. Use caution if your blood glucose is greater than 300 mg/dl, even if no ketones are present.
Extra Checks for New Medications or Insulin
If you have type 2 diabetes and take oral medication, finding the best dose can be tricky. You will need to monitor frequently when you are starting a new medication or trying to find the best dose of medication. Check your blood glucose once or twice a day (before breakfast and one other time during the day) to avoid low blood glucose. Occasionally you may want to check 2 hours after meals to see how well the medication works with your meal plan. Your monitoring records will help you and your health care provider decide what changes, if any, are needed.
Starting or changing an insulin plan will also mean more blood glucose monitoring. Read up on the specifics of insulin in chapter 13.
Other Times for Extra Checks
• Before you drive (if you take insulin)
• When you are more physically active than usual
• When you have lost or gained weight
• If you start taking a medication for another condition that affects blood glucose levels or your ability to recognize low blood glucose warning signs
• If you have hypoglycemia at night or wake up with high blood glucose levels
• When your levels have been outside your target range more often than in your range
• If you don’t feel well. Checking helps you determine whether your glucose level needs attention
• If you’re pregnant
Extra Checks during Stress
Everyone seems a little stressed out these days—and living with diabetes can add even more stress to your life. Stress can produce hormones that raise blood glucose levels. Stress can also be a hidden contributor to unexpected swings in blood glucose levels.
Therefore, you’ll want to check your blood glucose more often when you’re experiencing stress. The effects of stress on your blood glucose can’t be measured as easily as units of insulin or calories burned during exercise. However, stressful situations could be throwing your blood glucose out of range (for example, if you have a bad day at work), so make sure to check your blood glucose when you feel stressed.
When you can’t figure out why your blood glucose level is so high despite “doing everything right,” think about the stresses in your life and how you respond to them. Do you eat when you are under stress? These extra calories, plus stress hormones, could raise your blood glucose.
Extra Checks during Illness
Being sick is another kind of stress on your body that can raise blood glucose. Your body releases hormones to fight the illness, but these hormones also counteract the effect of insulin and raise blood glucose. Sickness can cause your diabetes to go out of control. Extremely high blood glucose levels caused by illness can also lead to diabetes emergencies, including coma and death.
Blood glucose monitoring is especially important during any illness. Even if you have type 2 diabetes and only monitor once a day, you may want to check more often during times of illness. In general, you’ll want to check your blood glucose every 3–4 hours. Read more about handling sickness under the “Illness” section in chapter 8.
Tips on Using Results of Self-Monitoring
Throughout the book, you’ll find more advice about using the results of self-monitoring. Your results will help you develop your diabetes management plan, including your goals for meals, physical activity, and treatment.
Sometimes, you’ll need to take immediate action based on a blood glucose reading, while many other times you’ll use the information to interpret a pattern and make future adjustments. This is particularly true for people who are not taking multiple, daily injections of insulin.
Self-monitoring is also important for identifying blood glucose emergencies. Chapter 8 will describe some common blood glucose emergencies and how to handle them.
CHAPTER 7
Self-Monitoring Tools
• Lancets
• Logbooks
Now that you’ve read about the importance of monitoring your blood glucose, you probably want to know exactly how to measure your blood glucose. There are a handful of tools that will help you accurately and easily measure your blood glucose every day. These tools are now smaller and more sophisticated than anyone would have dreamt of 30 years ago.
New products are always being developed, so keep in mind that this chapter just covers the most essential tools. Every year the American Diabetes Association’s magazine Diabetes Forecast publishes a Consumer Guide for patients that describes the latest devices, as well as most devices currently on the market. The Consumer Guide is published in print and online, and it is a patient’s best resource for researching blood glucose monitoring tools (http://forecast.diabetes.org/consumerguide).
Essential Tools
Lancet: A device that pricks the skin with a small needle to obtain a blood sample.
Test Strip: A strip (with a blood sample) that is inserted into a blood glucose meter.
Blood Glucose Meter: A small, portable machine used to display blood glucose readings on a digital display.
Blood Glucose Log: A record of your blood glucose readings over time. Some people prefer a paper log, whereas others prefer a digital log.
Lancets
Lancets allow you to take a sample of blood with minimal discomfort and optimal discretion. The spring-loaded device contains a needle or lancet, a way to select how deep the needle goes, and a release button. You’ll want to use the shallowest poke possible to draw blood. This hurts less and causes less scarring on your fingers.
Many blood glucose meters come with lancing devices. However, there are quite a few lancets on the market, so shop around if you don’t like the one that came with your meter or if you want more than one. Some allow you to prick sites other than your fingers. Others are designed for people who have trouble drawing blood or who have sensitive or calloused skin. Still others have retractable needles or easy disposal systems. Different lancets produce different sizes of blood drops. Make sure the device you are considering will help you get a drop of blood that is large enough for your meter.
Lancets are sterile the first time only, so don’t share lancets or lancing devices. Lancets can become dull after multiple uses, making future fingersticks more painful, so change them when needed to fit your comfort level.
Not all lancets fit all devices, so do your homework. Make sure that you can easily get replacement lancets to fit your device. Check the prices for replacement lancets as you compare devices.
Test Strips
Test strips are disposable strips that take a sample of blood. You insert a test strip into a meter to get a digital reading of your blood glucose level. Test strips are made to work with specific meters, so you’ll need to buy the appropriate brand and type.
Here are some things to consider when purchasing a meter and test strips. Some test strips are designed with a curve to help patients guide their fingers more easily to the application site. Other test strips are extra large to make them easier to handle. The packaging of the test strips may also be an important consideration for you. Some come packaged in a vial, whereas others are individually wrapped in foil. The foil wrappings can be more portable, but also more difficult to open. Some meters take a testing “disc” (containing enough room for multiple blood samples) or a drum with preloaded strips.
You’ll want to research the price of test strips as you consider which blood glucose meter to purchase (see more on this topic below). Test strips usually come in boxes of 50 or 100, and you can buy them online or in stores. The box of test strips will have an expiration date, and individually packaged strips usually last about 2 years. In the past, the U.S. Food and Drug Administration uncovered schemes to distribute counterfeit test strips. Always buy your strips from a reputable retailer, and check the FDA website (www.fda.gov) for updates on test strips or call the manufacturer if you have any concerns.
Sometimes, in rare cases, people who take certain medications containing sugars that aren’t glucose or who are undergoing medical procedures may receive false high readings with certain strips. Be sure to discuss your strips with your health care provider if you are put on a new medication or if there is a change in your health status.
Generic Test Strips
You can also buy generic brands of test strips that are manufactured to work with specific meters. Make sure that the generic brand lists your meter on the packaging or in the product information.
Test Strip Storage
Test strips should be stored in their covered container and kept in a dry area. Not keeping your strips safe and dry could affect their accuracy. For example, keeping strips in the bathroom with the container uncovered may result in false blood glucose readings.
Blood Glucose Meters
If your doctor has told you that you need to frequently self-check your blood glucose, then a blood glucose meter is an essential tool for taking care of your diabetes. Only by keeping close tabs on your blood glucose levels and recognizing when they are out of range can you take steps to remedy the situation.
The meter measures an electric current in the blood that depends on the amount of glucose present. A sample of blood is placed on a small area of a test strip or disk. A special enzyme transfers electrons from glucose to a chemical in the strip, and the meter measures this flow of electrons as current. The amount of current depends on how much glucose is in the blood. This weak current flows through the strip and is measured in the meter. The meter produces an electronic reading of blood glucose levels in milligrams per deciliter (mg/dl).
There are also several meters that check more than blood glucose. One meter measures blood glucose and ketones (a byproduct that can indicate a serious medication problem). Another meter measures blood glucose, ketones, and lipids (including HDL and LDL cholesterol and triglycerides).
Plasma Versus Whole Blood
Meters measure the amount of glucose in whole blood, which is the complete composition of the blood flowing through the body. More simply, whole blood is the blood that is directly drawn from the body without further treatment. Several blood-glucose testing methods, however, measure the glucose contained in blood plasma. Plasma is a yellow liquid component of whole blood that has to be separated from blood using laboratory methods. The issue is that tests yield different blood glucose results when performed on whole blood versus blood plasma. Plasma test results tend to be 10–15% higher than results from whole blood.
Even though they measure the glucose levels in whole blood, today’s meters are adjusted to provide results in the plasma glucose equivalent, so blood glucose test results are consistent among all testing measures.
The sheer number of blood glucose meters on the market can be overwhelming. But the good news is that consumers now have more choices than ever in finding a device that fits their budget and lifestyle. Considerations for a blood glucose meter break down into roughly three categories: cost, performance, and your lifestyle. The following section will explore each category in detail.
Considerations for Buying a Blood Glucose Meter
• Cost: Insurance coverage, price of test strips
• Performance: Accuracy, batteries, and meter replacement
• Lifestyle: Meter size, your vision and language, test site, user-friendliness, meter memory, and data management system
Cost Considerations
The cost of your blood glucose meter should be a consideration as you research different brands. Your health insurance may cover the cost of a meter and maybe the test strips. Meters are usually deeply discounted by the manufacturer through rebates and coupons, but you’ll want to analyze the long-term costs of any meter and the strips before you purchase it.
Insurance Coverage
Check with your insurance plan or company health program before you invest in a meter. For example, Medicare covers the cost of meters, strips, and lancets. Your insurance may pay for only specific meters or have a cost allowance. Also find out if you are covered for the test strips and how many you are allowed per year. Your insurance may cover more of the cost of meters and strips through a mail-order program. However, you will need to get a prescription to be reimbursed.
Price of Test Strips
In the long run, your meter’s test strips will cost you much more than the meter itself. You may be surprised by the cost when you go to buy replacement strips for your meter. The meter that seemed like a bargain at the time of purchase may turn into a major expense when it comes time to pay for strips (especially if you don’t get reimbursed for them by your insurance). Make sure you check the cost of the strips your meter uses before you buy it. Check Diabetes Forecast’s Consumer Guide and ads for lists of companies that sell discounted strips.
Performance Considerations
The U.S. Food and Drug Administration (FDA) regulates all meters made and distributed in the United States. Manufacturers are required to list devices with the FDA, as well as follow guidelines for marketing, labeling, safety, and efficacy. However, you—as the primary user—will be responsible for checking the performance of your meter over time.
Accuracy
Some machines require that you code each new batch of test strips with your meter in order to maintain accuracy (some do not). Test strips can vary from batch to batch. There may be differences in the amount of chemical on the strips in each batch. So you must standardize (or code) your meter to make up for these small differences when you open a new batch of strips. If you don’t code, all your results with the new strips may read higher or lower than they really are. Instructions for coding are included in every new package of strips. Some meters automatically code themselves—you don’t have to do anything when you open a new batch of strips or the disk.
You’ll also want to check the accuracy of your meter from time to time. You can do this one of three ways: perform an electronic check, use a “control” solution or strip, or compare your meter with a laboratory meter.
Your meter should perform an electronic check every time you turn it on. It will give you an error code if something is wrong. You can check the owner’s manual for instructions for correcting errors.
Meters often provide a standard solution, known as a “control” solution. This solution contains a known amount of glucose to help check for accuracy. Other meters use a control strip to check for accuracy. If you measure the amount of glucose in this standard solution or strip in your meter and your meter shows a reading that is too high or too low, your machine may be giving you a faulty reading. The manufacturer’s instructions will tell you how often to check with the control solution or strip for the best accuracy.
Write the date on your control solution when you open it and remember that it is usually good for one to three months, depending on the manufacturer.
If you are having a problem with accuracy, first check to see if your problems are being caused by old or damaged test strips. Then call the manufacturer of your meter. There may be something wrong with your meter. You can usually order a vial of standard glucose solution by calling your meter’s manufacturer.
In some cases, your health care provider can help you check the accuracy of your meter by using a laboratory meter in his or her office. Your health care provider might ask you to perform a blood glucose test just as you would on your own. Then, he or she might check your blood glucose using the laboratory machine. If the two results match, your meter is probably accurate.
Other factors can affect the accuracy of your meter. Altitude, temperature, and humidity can have unpredictable effects on glucose results.
In some cases, you, not the meter, may be giving inaccurate results. Researchers have found that practice, at least in the area of blood glucose monitoring, does not make perfect. Fresh from training by a diabetes educator, people start off getting accurate results. But as time goes by, people begin to get sloppy. Accuracy usually decreases over time.
Take your meter with you for checkups, and ask your health care provider to observe your technique from time to time. Or measure your blood glucose level with your own meter when your blood is drawn for laboratory glucose tests. Record your results. The two readings are best compared when you are fasting. When your lab-tested blood results are available, compare the numbers.
Comparing Home and Lab Results
• Make sure that you are comparing plasma blood readings (not whole blood) from your meter to your lab results.
• If your result was off by more than 5–10%, go over your technique with your diabetes educator or provider. If he or she can’t find any problems with your technique, it’s time to consider whether something may be wrong with your meter.
Monitoring: Problem Areas to Watch
• Your blood. Are you getting enough blood on the test strip? To increase blood flow, wash your hands in warm water, hang your hand down, and massage your hand from your palm out to your fingertip before pricking. You may find it less painful to prick the side of your finger rather than the fleshy pad. For some strips, once the drop is on the strip, you can’t add more blood. Washing your hands will also help prevent any perfumes or food residue from affecting your test results.
• Test strips. Are your strips fresh? Be aware of the expiration date. Avoid exposing the strips to light and moisture. Are you coding your meter to each new batch of test strips? Variations occur from one batch to another, even when made by the same manufacturer.
• Your meter. Check your meter regularly with the control solution specified by the meter’s manufacturer. Look in the instructions that came with the meter if you’ve forgotten the technique. If your meter can be cleaned, do it periodically. You may find a buildup of blood, dust, and lint that can affect the readings.
Batteries and Meter Replacement
Meters run on batteries, but each model handles batteries differently. Find out what kind of battery your meter takes before purchasing it. Consider the cost and ease of replacing the batteries.
Some models allow you to buy the battery and insert it into the meter yourself. These batteries might be specific to the meter and therefore could be more expensive and difficult to find. Or these batteries might be standard batteries (such as AA or AAA) that run in devices like flashlights or remote controls and therefore are cheaper and easier to find. Still other meters have no replacement batteries.
Most manufacturers will tell you how long the meter’s batteries will last. Some meters tell you when the battery needs replacing. Some companies will replace batteries for you, and others simply replace the whole meter.
With daily use, batteries generally have to be replaced every 1,000 readings.
Lifestyle Considerations
Your lifestyle is one of the most important considerations for choosing a blood glucose meter. With so many meters on the market today, you are bound to find a meter with at least a few of your preferred features.
Size
Some glucose meters are so small that they fit on a vial of strips, while others are larger, so people with big hands can handle them easily. Small meters are easy to slip into your pocket or purse. However, if you have trouble with small hand and finger movements, you may want to consider a larger meter. Larger meters may be heavier and clumsy to carry around. Some meters have rubber grips that make them easy to hold.
Your Vision and Language
Whether you have severe visual impairment or just have a hard time focusing on small print, you may want to consider this when choosing a meter. Some meters completely talk users through monitoring with both voice set-up commands and readings. The meter may also have buttons with raised imprints. Others have a large screen to make reading the numbers easy. If you have any degree of colorblindness, test a few different models. Make sure that you have no trouble reading the digital display.
Some meters display or speak in different languages, such as Spanish. Others use symbols instead of words to display information.
Test Site
Alternative blood glucose monitoring, such as the upper arm, thigh, calf, and palm, is available with some meters. Make sure to check your meter for the availability of this feature before using alternate sites. Alternate sites will give you more options, but these sites may not be as consistently accurate as your fingertips. For example, readings from alternate sites may vary after eating, after taking insulin, or during low blood glucose periods.
User-Friendliness
Make sure your meter or monitoring system is easy to handle, especially if you have arthritis. Several features can make meters easier to use. Some models require a smaller-sized drop of blood. Ask how much blood is required for each model you might be considering. With some models, too little blood may give a faulty reading, and you may need to repeat the test. This can be inconvenient at best, but it could be a problem for people with poor circulation in their hands or those who must check their blood glucose in cold environments.
Other models may require more hands-on time than others. For example, stay away from devices that require too much time if you’re always in a hurry. Some meters can measure blood glucose just seconds after a drop of blood lands on the strip. These devices can be very useful when you test often or in work and social situations, where a few seconds here and there really make a difference. If you are always on the move, you may want to consider a meter and insulin pen combination.
Blood Contamination
Contamination can be a serious concern if you have an illness such as hepatitis or HIV infection. So, choose a system that will keep handling of blood samples to a minimum. Don’t share lancet devices or meters in which blood can contaminate the device. Always dispose of sharps properly.
Support System
If you are using a meter for the first time, consider one that offers a video that teaches you how to do the reading. A picture or visual image can make a seemingly complicated procedure crystal clear. Also make sure that the company has a 24-hour toll-free number to call for any questions about the meter. Sometimes a quick phone call clears up a simple problem. Also check that your health care team is familiar with the model you purchase and that supplies are easily available in your area or by mail order.
Meter Memory and Data Management System
Your meter can do much more than give you a blood glucose reading. It can also store and manage these readings and sometimes even make recommendations for food or insulin doses based on this information.
Some meters can store up to 3,000 glucose readings. A big memory can be helpful for people who carry their meters around with them during the day. Some models have one-button memory recall to review recent results.
Your meter’s data management system is also important to consider. Some models will help you upload the information to a web portal that only you and your health care provider can access. Some models come with software programs that you download to your computer to help you track and visualize your results. These programs can provide trend analysis, averages, graphs, printouts, and more. This can make it easier for you and your health care team to pinpoint any problem areas that might arise. You’ll read more about keeping records of your readings in the logbook section below.
Surprisingly, data management systems don’t cost too much more than regular meters. Before you buy a system, check to see if your health care team uses or recommends one system over another. Also call the manufacturer’s toll-free number, and ask them what you will be getting. They should answer any questions you may have.
Don’t buy a high-end blood glucose data management system unless you can afford the extra cost. Many people find that they can get along with a good logbook. This is especially true if you have type 2 diabetes and monitor less often.
How to Use a Blood Glucose Meter
Follow your meter manufacturer’s instructions for calibrating, setting date and time, and using control solutions. Check to make sure your strips are not outdated, and store them within the proper temperature limits. Strips can be ruined if they are kept outside the range of acceptable temperatures. If you have problems, there is a toll-free number on the back of the meter that you can call for help. Read the instructions for possible test sites.
Equipment
• Lancet
• Test strip
• Cotton ball or tissue
• Blood glucose meter
• Logbook
Instructions
1. Make sure your hands and skin are clean and dry. Soap or lotion on your skin can cause incorrect test results.
2. Puncture the skin where testing is to be done with the lancing device. If there is a problem with potential hypoglycemia, use your finger for testing.
3. Squeeze or milk out the amount of blood needed by the individual meter. With alternative sites, follow manufacturer’s instructions.
4. Follow instructions to see if blood needs to be dropped on the test strip or if the finger or other site should be held so the strip can absorb the blood.
5. Apply firm pressure with a cotton ball or tissue to the lanced site until bleeding stops.
6. Dispose of the lancet and test strip according to local waste disposal laws.
7. Record your test results in your logbook. See more about logbooks below.
Continuous Glucose Monitors
A continuous glucose monitor (CGM) is a small sensor inserted under the skin that measures the fluid between cells called interstitial fluid. This measure correlates to blood glucose. The monitor communicates wirelessly with a handheld device that displays your interstitial fluid level. The sensor must be changed every few days or so. The system can display real-time glucose levels at 1- and 5-minute intervals, and alarms can be set to alert patients of high or low glucose levels. Rapid rate of change can also be displayed. In addition, these systems come with data management software to help patients see readings in trend charts and graphs.
CGMs are more expensive than traditional meters. However, some insurance is beginning to cover these devices.
Although CGMs have not been widely studied, some initial studies have shown that they may beneficial for patients who wear the devices all the time and are highly motivated. For example, continuous glucose monitoring along with tight blood glucose management can lower A1C in adults with type 1 diabetes. Children, teens, and younger adults may benefit, too.
Currently, the FDA requires users to confirm CGM readings with readings from a traditional blood glucose meter before making treatment decisions because CGM devices are so new.
Logbooks
One of the most important tools in your diabetes toolbox is also the most overlooked. A logbook may not look like much, but it will help you and your health care providers understand your blood glucose levels. It will alert you to any red flags that could signal a serious problem and help you determine whether your treatments are working—and how to fine-tune them.
Your health care provider can provide you with a logbook or your meter may come with one. Call the toll-free number for your meter manufacturer to request more. Some manufacturers have logbooks that you can download to your computer and print.
If you like the idea of keeping a paper logbook, you can photocopy blank pages and compile them in a loose-leaf notebook or create your own custom logbook. You may want a lot of room to write in your logbook. Consider buying a spiral-bound notebook or using a loose-leaf notebook, where you can add pages as needed, to jot down extra notes. You may find it useful to have extra space to record different symptoms and situations that could be relevant to your health. Your logbook is an important tool that can help you spot patterns in your blood glucose control, so be sure that it is easy to use.
Some meters come with an electronic logbook that records your readings and allows you to enter comments about your meals or other situations. Some people may prefer the convenience of using an electronic logbook rather than paper. However, you should always keep some type of logbook rather then just storing readings in your meter’s memory.
Ask your health care provider which readings you should write down in your logbook. You should also bring your logbook with you during doctor’s appointments so that you can look over your readings together.
Ketone Tests
People with type 1 diabetes, and occasionally people with type 2 diabetes, can experience a dangerous condition called ketoacidosis. Ketoacidosis is a buildup of ketones in your urine. It can lead to a diabetic coma and death if left untreated. It can happen at any time, but may be more likely during illness, stress, or pregnancy. You can read more about ketoacidosis in chapter 8 about blood glucose emergencies.
Luckily, you can test the ketones in your urine with a urine test strip to make sure you don’t develop ketoacidosis. It’s important to detect ketones before they grow to large levels. Checking for urine ketones is especially important for people with type 1 diabetes who do not make any insulin. People with type 2 diabetes usually produce some insulin, so they are less likely to develop ketoacidosis. However, everyone with diabetes needs to know how and when to check for ketones. Read more about when and how to check for ketones in chapter 8.
Urine Ketone Test Strips
You put a test strip in your stream of urine or in a cup to test for ketones. Urine strips vary in how quickly they show a result, so read and follow the directions so you know how long to wait. A change in color will indicate the presence of ketones. Some strips will indicate ketone levels as 0, trace, moderate, or large, whereas others will give a specific reading. Some urine strips also measure glucose and have two test pads on each strip.
Where to Buy Supplies
People with diabetes now have more choices than ever about where to buy their diabetes supplies and devices. You can shop online, in a local or chain pharmacy, and through the mail. It’s up to you to decide which is the most convenient and cost-effective place to shop. Be wary of online marketplaces where people sell and auction personal items. It is not possible to know if testing supplies have been stored properly or have been altered in any way. Only buy from a reputable source.
Packaging
Individually foil-wrapped ketone strips are the most expensive up front, but they last longer. They may save you money because you are unlikely to need to test ketones very often. Ketone strips that come in a vial all spoil at the same time, probably 6 months after you open them.
Pharmacies
Some pharmacies offer a smaller selection of equipment, so check the aisles to see how your pharmacy stacks up. If you have a good relationship with your pharmacist, you may be able to ask him or her to order what you want. Although small pharmacies can be more expensive, establishing a good working relationship with your pharmacist can save you a lot of running around. Pharmacists can often give you information about the ins and outs of different products and models. Local pharmacists will know the products they sell and will be able to spend time training you to use the purchase. This is often a real, convenient advantage.
Most grocery store and chain pharmacies carry diabetes supplies, which might be convenient if you are shopping for other items.
Diabetes Supply Stores
Another shopping option is to visit a diabetes specialty store. To find one near you, call your local American Diabetes Association office or check in the phonebook under “Diabetes” or “Medical Supplies.” If you are lucky enough to have one nearby, you may be able to get many nonprescription items along with diabetes information and support in one easy stop. You may also find a selection of healthy foods, books, and information on local diabetes events and organizations. Many diabetes shops have knowledgeable staff who can help you compare models, answer questions, and provide training on new tools.
Mail Order
Purchasing your diabetes supplies, such as test strips, through a mail-order supplier can save you money. However, you’ll also have to calculate the extra time it will cost to ship supplies and perhaps the extra time to deal with insurance coverage.
Buying Supplies Online
When purchasing supplies online, make sure to look for an Internet site that is secure and reputable. The FDA recommends purchasing from websites that are located in the United States and provide clear ways to contact the company with questions or concerns.
Making Mail Order Work for You
• Pay extra attention to timing. Some orders will ship automatically, whereas others will take up to 2 weeks. Order your supplies far enough in advance that your current supply won’t run out before the new ones arrive.
• The mail-order company should confirm your insurance coverage before filling out your first order. If you use Medicare to help pay for supplies, note that the prices shown in advertisements or quoted over the phone may differ from the amount that Medicare will reimburse for that item.
• If you live in a warm climate or order during the summer, ask how perishable items will be shipped. Strips can spoil in excessive heat, so overnight shipping is best for these items.
• Compare prices by shopping around. Most mail-order firms have toll-free numbers and websites.
• Always keep copies of any orders you send through the mail. If you call in an order, be sure to write down when you placed the order and what you ordered.
• Check the expiration date on each item that arrives. If you’ll need the item in 6 months, make sure it doesn’t expire in 2 months. Send back all items with expiration dates that are just around the corner.
CHAPTER 8
Blood Glucose Emergencies
• Illness
Dealing with high and low blood glucose levels is a fact of life with diabetes, so you should be aware of possible emergencies that can occur. Emergencies include blood glucose levels that are too high or too low.
It is important that you learn to recognize the warning signs and have a plan for dealing with them. Discuss with your health care team what you should be on the lookout for and what you should do if you suspect an emergency situation may be developing. Also, talk to your family, friends, and coworkers about what to do in an emergency. If you are in danger, you may not always be able to handle the situation yourself.
Being prepared is your best bet, and frequent monitoring of blood glucose will alert you in time to prevent most emergencies.
Hypoglycemia
The most common emergency is low blood sugar, which is called hypoglycemia. It can be a problem for people who take insulin or certain diabetes pills, including chlorpropamide, glipizide, glyburide, glimepiride, repaglinide, and nateglinide. Hypoglycemia occurs when blood glucose levels get too low. At the beginning of a hypoglycemic reaction, you might feel dizzy, sweaty, shaky, or faint. If untreated, you could lose consciousness or have seizures.
Hypoglycemia is usually caused by insulin doing its job too well. In people without diabetes, the body stops releasing insulin before glucose levels fall too low. But if you inject insulin, your body has no way to shut it off. Another interesting, if frustrating, fact about diabetes is that the body uses insulin inconsistently. Even if you always give yourself the same dose of insulin or other diabetes medication, you could end up with more than enough insulin to handle the glucose in your blood. This can happen even when you are doing everything (including eating) the same as usual.
It’s impossible to control everything you do to manage your diabetes, no matter how hard you try. Insulin will do its job of clearing glucose from the blood even if it means that blood glucose levels fall too low. Hypoglycemia usually occurs just before meals, during or after strenuous exercise, or when you have too much insulin in your body. Sometimes you may even get hypoglycemia during the night when you are sleeping.
Causes of Hypoglycemia
• Too much insulin
• Too little food
• Too much exercise
• A delayed meal
• Alcohol on an empty stomach
Symptoms of Low Blood Glucose
It’s important that you learn your own signs of hypoglycemia. Different people may have different feelings, so it’s important to know what signals your body gives during a low glucose reaction. Hypoglycemia can occur at any time. The only sure way to know whether you have hypoglycemia is to check your blood glucose.
Symptoms of Hypoglycemia
• Shakiness
• Nervousness or anxiety
• Sweating
• Irritability or impatience
• Chills and clamminess
• Rapid heartbeat
• Lightheadedness
• Hunger
• Sleepiness
• Anger, stubbornness, or sadness
• Lack of coordination
• Blurred vision
• Nausea
• Tingling or numbness in the lips or tongue
• Nightmares or crying out during sleep
• Headaches
• Strange behavior, including delirium, confusion, or personality change
• Seizures
• Unconsciousness
Each person’s reaction to low blood glucose can cause a different set of symptoms. It is unlikely that you will have them all or that you will have the same ones each time.
Hypoglycemic symptoms can serve as important clues to whether you are having a low glucose reaction, but they are not always the full story. Sometimes the symptoms could be due to something else. Unless you check your blood glucose level, you could overtreat or overreact, causing glucose levels to soar.
Very often, hypoglycemia occurs when blood glucose levels fall below 70 mg/dl. However, many people have glucose readings below this level and feel no symptoms. Others may start to have symptoms of hypoglycemia when their blood glucose is higher than 70 mg/dl. All of this can be very confusing. To start, ask your provider or educator what glucose levels to look out for when you suspect hypoglycemia. Make note of the symptoms you are experiencing. You will soon learn what level is too low for you.
Hypoglycemia at Night
While it may seem difficult to figure out whether you’ve had hypoglycemia in your sleep, there are some clues.
• Pajamas or sheets are damp with sweat in the morning
• Restless sleep or nightmares
• A headache or feeling of tiredness when you wake up in the morning
• Ketones in your urine in the morning without a high blood glucose reading
You may want to check your blood glucose around 2 or 3 a.m. a few times to try to match your results with your food intake, physical activity, and medication doses from the previous day and evening. This will help you pinpoint what is really going on.
Hypoglycemia Unawareness
Some people have a hard time knowing when their blood glucose level has fallen to a dangerous level. People who tend to miss these early symptoms are said to have hypoglycemia unawareness. For them, the first symptom of low blood glucose can be impaired thinking.
Hypoglycemia unawareness seems to occur more frequently in people who have had a lot of low blood glucose episodes or who have had diabetes for a long time. In addition to unawareness, a person’s body may not respond properly. Someone with hypoglycemia unawareness may not respond immediately to treatment, and the hypoglycemia may last longer.
People with hypoglycemia unawareness are less likely to be awakened from sleep when hypoglycemia occurs at night, and they have less strong defenses against hypoglycemia during exercise. It is common in pregnant women and people who intensively manage their diabetes. There is some evidence that frequent episodes of low blood glucose can make someone have hypoglycemia unawareness.
This is a dangerous condition, and if you think you have hypoglycemia unawareness, you should consult with your health care team. Sometimes, just avoiding mild hypoglycemia can help restore a person’s awareness of the symptoms of hypoglycemia. Other times, the solution will be to increase blood glucose goals to higher numbers.
Some Safety Nets for Hypoglycemia Unawareness
• Increase the number of times you check every day or check at different times
• Always check before driving. If levels are under 100 mg/dl, eat and test again. If glucose levels are higher than that but falling, eat and test again before driving
• Discuss your hypoglycemic episodes with your health care team so you can look for patterns to use as warning cues
• Educate the people you’re with every day about hypoglycemia and how to help you
• Wear an ID bracelet that identifies you as a person with diabetes
• Ask for prescription glucagon, and be sure those around you know how to use it. (Find out more about glucagon later in this chapter.)
• Attend a class on blood glucose awareness training offered at a specialty diabetes clinic
Treatment of Hypoglycemia
Check your blood glucose level if you think you have hypoglycemia. Talk to your health care team about the blood glucose level at which you should begin treating for hypoglycemia. Although it’s best to check before treating, this may not always be possible. What if you don’t have your monitor with you? Should you wait until you get home? No! Eat or drink something immediately. Never wait until you get home, especially if you have to drive.
You need to eat or drink something that contains carbohydrate that can be rapidly absorbed from your digestive tract and into your blood. However, you shouldn’t go overboard. You’ll feel worse later on if you send your blood glucose levels soaring. There are many choices of fast-acting carbohydrates.
You’re best prepared for low blood glucose if you carry around a measured amount (15 grams) of “pocket carbohydrate.” The easiest and most convenient fast-acting carbohydrate is found in glucose tablets or gel, which come in a variety of flavors. Check the annual Diabetes Forecast Consumer Guide for a list of current over-the-counter products for treating low blood glucose. Usually, two to five glucose tablets or one package of glucose gel will bring quick relief, but check the instructions and dosing on the package to make sure.
Recheck your blood glucose 15 minutes after you’ve treated your low blood glucose. If you still have low blood glucose, you may need to take another dose of 10–15 grams. Check again in another hour. If blood glucose is low, you may need another 15 grams of carbohydrate.
Fast-Acting Carbohydrates for Hypoglycemia
Each has about 15 grams:
• 2–5 glucose tablets
• 1 gel tube
• 2 tablespoons raisins
• ½ cup regular soda (not diet)
• 4 ounces orange juice
• 5–7 Lifesavers
• 6 jellybeans
• 10 gumdrops
• 3 teaspoons sugar, honey, or corn syrup
• 6–8 ounces nonfat or 1% milk
After an episode of severe low blood glucose, readings may run high for some hours afterward, as a result of your body fighting back against the low blood glucose. High blood glucose readings immediately following a low reading can lead to a misinterpretation of the pattern. Talk to your health care provider about these patterns, because if you treat for the high readings, you may begin a dangerous cycle of fluctuating blood glucose levels.
Special Considerations for Hypoglycemia
Physical Activity
Exercise and other physical activity lowers blood glucose levels, so you have to be extra careful to avoid hypoglycemia during and sometimes after exercise (if you take insulin). When you first begin an exercise program, you will need to monitor your blood glucose levels after exercise to find out how your body responds. If you feel as though you are becoming hypoglycemic while you are working out, stop at once. Don’t say, “I’ll just do one more lap” or “Just 5 minutes won’t hurt.” Stop.
Treating Hypoglycemia during Physical Activity
• Check your blood glucose right away and treat hypoglycemia if you need to.
• If you want to continue your workout, eat a snack, take a 15-minute break, and check to make sure your blood glucose has come back up above 100 mg/dl before starting back. If you start too soon, your blood glucose may drop again, quickly.
• Studies show that hypoglycemia is even more likely to occur 4–10 hours after you exercise than during the activity or shortly after.
Sexual Activity
If you are prone to hypoglycemia when you work out or at night, you may also have a low blood glucose reaction following sexual activity. This can be especially true if you have sex at night. This is when your blood glucose levels typically dip, so you may need to adjust your insulin or have a snack before or after sexual activity. Be especially careful if you are combining sexual activity with alcohol.
Avoiding Lows During and After Sex
• If you use insulin, you need to be watchful for low blood glucose during or after sex.
• Check your blood glucose first. This may slow you down a bit, but it’s better than having to deal with low blood glucose at an inopportune moment.
• Eat just before or right after active sex, just as you would if you were exercising.
• Consider having a snack before going to sleep for the night.
• If you use an insulin pump, you may want to set a temporary basal or disconnect it during sex to avoid going low. See more about insulin pumps and plans in chapter 13. The length of time you can safely keep the pump off without an injection depends on how active you are. Ask your health care team for advice about this.
Heart Disease
Hypoglycemia can cause your heart to beat faster than normal. If you have heart disease, talk to your doctor about how hypoglycemia might affect you. You may need to keep your blood glucose levels a little higher to reduce the risk of developing hypoglycemia.
Alcohol
Alcohol lowers blood glucose levels. Normally, when your blood glucose levels begin to drop too low, your liver will convert stored glycogen to glucose. This helps protect you from a severe reaction temporarily and gives you time to recognize and treat hypoglycemia. But alcohol interferes with this process. If you drink alcohol, you may have a severe hypoglycemic reaction with little warning. Read more about alcohol and your meal plan in chapter 10.
Dawn Phenomenon
Your body has a normal mechanism that wakes you up and gives you energy to start the day. Your body responds to this wake-up call of hormones. These hormones depress the activity of insulin, allowing blood glucose to rise between around 4 and 8 a.m. This is called the dawn phenomenon. The dawn phenomenon can be one reason for blood glucose readings and ketone levels that are high when you wake up.
If high morning blood glucose levels seem to occur mysteriously, discuss the problem with your health care team and talk about the best way to treat it.
Severe Hypoglycemia
You could develop severe hypoglycemia if your symptoms of low blood glucose go unnoticed or are ignored. People who are elderly or who take diabetes pills, such as sulfonylureas, are more likely to develop severe hypoglycemia. You may lose consciousness if your brain has been deprived of blood glucose for too long. This is a real emergency. The best way to deal with severe hypoglycemia is to take precautions so that it doesn’t happen in the first place. Be alert to your symptoms and treat yourself right away. Don’t wait to see if it gets worse or put off treatment until a more convenient time.
You may become so confused and irritable that you refuse help during a hypoglycemic reaction. Those around you may have to be persistent to get you the help you need. They can save you from a coma and a trip to the hospital by insisting that you take some form of glucose quickly. Your life will be easier and safer if those with whom you spend the most time can spot a low glucose reaction and know what to do about it.
Someone else must take over if you become unconscious. You will not be able to eat or drink anything, but your blood glucose levels need to go up immediately. The safest remedy is to get a glucagon injection. Your helper should call for emergency help at once if he or she does not know how to inject glucagon. Glucagon will not work in someone who does not have enough glucose in the liver, which can occur with starvation, or in those whose liver does not effectively release stored glucose, which can occur with excessive alcohol intake.
Severe Hypoglycemia and Sleep
If you live alone, you may be concerned about having a severe hypoglycemic reaction while you are sleeping. Your best bet is to monitor your blood glucose levels before you go to sleep and occasionally during the night. If your blood glucose level is dropping, eat a small snack before going to sleep. Try mixing uncooked cornstarch into the snack or eat a product that contains slow-digesting carbohydrates. Many people who take insulin are able to reduce their risk of nighttime lows by switching to an insulin pump.
If you are prone to hypoglycemia, you’ll need to train someone you trust to inject glucagon. Talk to your provider about whether you should buy a glucagon kit, which is available by prescription. Ask your family members or friends to learn how to use glucagon, so they know what to do.
How to Inject Glucagon
1. Typically, glucagon kits are brightly colored and include step-by-step instructions.
2. A glucagon kit has a syringe filled with diluting fluid and a bottle of powdered glucagon. You must mix the diluting fluid with the powder immediately before it is injected. The instructions for mixing and injecting glucagon are included in the kit.
3. Inject glucagon into the buttock, arm, or thigh.
4. Turn the person on his or her side so if there is vomiting, he or she will not choke.
5. Feed the person with appropriate carbohydrate immediately when he or she wakes up and is able to swallow. Start with nondiet soda, juice, glucose tablets or gels, and then additional carbohydrate.
6. Check blood glucose. If the person does not wake up within 15 minutes, call for an ambulance. The dose may be repeated after 20 minutes.
7. Always call your provider and emergency personnel when a severe reaction occurs in order for help to arrive and appropriate care to be administered. Ask for instructions on emergency procedures when you get the prescription. Read the instructions that come with the glucagon and share them with friends, family, and coworkers.
8. Kits usually last a year before expiring (check the date on the box). However, premixing the glucagon and diluting solution will make the mixture last only 48 hours in the refrigerator.
Always let your health care providers know if you have taken glucagon and had a severe hypoglycemia episode. Also, tell them if you are having frequent bouts of even mild hypoglycemia. By working together, you might find a pattern in your insulin, meals, or activity routine that may be causing the hypoglycemia. With clues, you and your health care team can do some problem solving and decide on changes to prevent severe hypoglycemia.
Tell a Friend
Either you or a member of your health care team should instruct family, friends, or coworkers about the signs of severe hypoglycemia—and what to do if it develops.
Pregnancy and Severe Hypoglycemia
Many pregnant women, who have intensive blood glucose goals, may experience hypoglycemia unawareness. Thus, they are more likely to have mild and moderate bouts of hypoglycemia. Pregnant women should keep up a consistent blood glucose monitoring routine and check their blood glucose when hypoglycemia is most likely (between meals and in the middle of the night). You need to treat any blood glucose level below 70 mg/dl. You’ll have to take special precautions if you are pregnant and become unconscious.
Treating Severe Hypoglycemia during Pregnancy
• You may need only half the normal dose of glucagon at the beginning of a severe episode of hypoglycemia.
• After 15 minutes, if you do not regain consciousness or your blood glucose levels do not rise, you need another shot and someone should call 911 for emergency help.
• Make sure that those with whom you spend time know that you are pregnant and know what to do if you have a low blood glucose episode.
• Ask your health care provider about the dose of glucagon you need.
Hyperglycemia
High levels of glucose in your blood over time may lead to long-term complications. But blood glucose levels can also become dangerously high in the short term and cause a life-threatening situation that could result in coma or death. It is important to know the warning signs and treatments for hyperglycemia, which are different for people with type 1 and type 2 diabetes.
Type 1 Diabetes and Diabetic Ketoacidosis
Too little insulin in your body leads to too much glucose in your blood. A rare and serious—but often preventable—emergency can arise when blood glucose levels rise. Diabetic ketoacidosis, also called DKA, occurs when you don’t have enough insulin. It is mostly a problem for people with type 1 diabetes. A person with diabetes may have such low levels of insulin that his or her liver may produce unchecked levels of glucose and ketones, especially during illness or stress. It can occur in people with type 1 diabetes who have not yet been diagnosed.
Diabetic ketoacidosis can start innocently enough; you miss a dose of insulin, the insulin you’ve been using has gone bad, or your insulin pump tubing gets blocked. The lack of insulin leads to an undetected high blood glucose level, which can progress to a coma, shock, pneumonia, difficulty breathing, and even death.
Diabetic ketoacidosis can occur during periods of stress or illness, when the body releases hormones that promote the release of stored glucose and block the effects of insulin. Sometimes when you are sick and can’t eat, you may think, “I shouldn’t take insulin today.” But your body still needs insulin to cover its 24-hour insulin needs, even if you aren’t eating. Plus, you are likely producing extra glucose. So, in addition to your usual dose of insulin, you may actually need extra insulin. Drinking plenty of fluids will also help. Talk with your health care providers ahead of time about a plan of action for dealing with ketoacidosis and how to prevent it when you are stressed or ill.
Signs of DKA
• High blood glucose above 240 mg/dl and not falling
• Classic signs of hyperglycemia: intense thirst, dry mouth, need to urinate frequently
• Lack of appetite or pains in your stomach
• Vomiting or nausea
• Blurry vision
• Fever or warm, dry, or flushed skin
• Difficulty breathing
• Feeling of weakness
• Sleepiness
• A fruity odor on your breath
Testing for Diabetic Ketoacidosis
You can use a test strip to measure the amount of ketones in your urine. Urine test strips are available over the counter, and you can find out more about using them in chapter 7. Some blood glucose meters also check for ketones.
You’ll want to test your urine for ketones whenever your blood glucose is over 240 mg/dl or you feel ill. If your urine shows trace or small amounts of ketones, it’s a sign that you need more insulin or carbohydrate.
When to Test for Ketones
• If your blood glucose is over 240 mg/dl and not falling
• When you are ill, especially if you have a high fever, bouts of vomiting, or diarrhea
• When you have severe fatigue, fruity breath, breathing difficulties, or a hard time concentrating
• During pregnancy, if your blood glucose is over 200 mg/dl or as your health care provider recommends
How to Check for Ketones in Urine
Equipment
• Ketone test strip
• Cup or a clean container to contain the urine, if desired
• Watch or other timing device
Instructions
1. Dip a ketone test strip in a urine sample or pass it through the stream of urine.
2. Time test according to the directions on the package.
3. The strip will change colors if ketones are present. Compare test strip to package color chart.
4. Record the results.
5. Contact your provider as recommended based on your results.
If Your Urine Shows Moderate or Large Amounts of Ketones
• Call your health care team immediately or use the plan that you and your health care team have already put in place.
• You probably need to take extra rapid- or short-acting insulin right away.
• Drink plenty of sugar-free fluids to prevent dehydration.
• Seek emergency help at once if your ketones do not promptly go down or if you are vomiting and can’t stop.
• Make sure those who spend time with you know what to look for and what to do if you have signs of diabetic ketoacidosis.
Illness calls for more frequent blood glucose monitoring and urine testing for ketones. Do both at least every 4 hours until you’re feeling better. Check your urine for ketones any time you feel queasy or are vomiting (even if your blood glucose isn’t high). A buildup of ketones can cause nausea.
Pregnant women should also test for ketones frequently. Daily urine ketone testing can help detect elevated levels and prevent diabetic ketoacidosis, which can be very dangerous for the developing baby.
Blood Ketone Testing
Your doctor may prefer that you check for ketones in your blood rather than in your urine. Testing ketone levels in the blood actually yields more accurate results than checking ketones in urine. Usually, blood ketone levels are checked by drawing blood and testing the sample in a lab—obviously, this is something done at a clinic or hospital. However, some newer blood glucose meters can check blood ketone levels in addition to blood glucose levels, making this test easy to perform at home.
Type 2 Diabetes and Hyperosmolar Hyperglycemic Syndrome
People with type 2 diabetes have less dramatic swings in blood glucose levels compared with people with type 1 diabetes, in general. However, people with type 2 diabetes can sustain high blood glucose levels over prolonged periods without even knowing it. This can wear on the body and may cause diabetes complications. You can guard against chronic hyperglycemia by monitoring your blood glucose levels regularly.
Acute hyperglycemia can occur in people with type 2 diabetes and is life threatening. Hyperglycemia in people with type 2 diabetes does not usually produce ketones. But blood glucose levels can soar to over 600 mg/dl and even as high as 1,000 mg/dl. This sometimes happens before diabetes is diagnosed. Extreme hyperglycemia can cause a coma.
Hyperosmolar hyperglycemic syndrome (HHS) occurs almost exclusively in people with type 2 diabetes. It can happen to people who manage their diabetes with food and exercise only and those who take diabetes medications.
One-third of all cases of HHS are caused by undiagnosed diabetes. HHS results from stress, infections, heart attacks, strokes, corticosteroid medications, and even diuretics. Sometimes something as simple as not being able to get a drink of water can contribute to developing HHS. It occurs more often in people who have restricted mobility, such as the elderly, or in people who cannot take good care of their bodies. Also, as you age, your sense of thirst diminishes, and it’s harder to sense the need to drink enough fluids.
HHS occurs because rising blood glucose levels cause you to urinate more and become dehydrated. This process may go on for days and weeks. Extreme dehydration eventually leads to confusion and inability to get a drink or make it to the toilet. The blood gets thicker with more glucose and less fluid. Eventually, the severe dehydration leads to seizures, coma, and death.
Signs of HHS
• Dry, parched mouth
• Extreme thirst, although this may gradually disappear
• Sleepiness or confusion
• Warm, dry skin with no sweating
• High blood glucose. If it’s over 300 mg/dl on two readings, call your health care team; if it’s over 500 mg/dl and not falling, have someone take you to the hospital immediately.
If you experience any of the above signs of HHS, check your blood glucose levels at once and call your provider. Be sure those around you know what to do because you may not be able to react.
You’ll be alerted to high blood glucose levels well before HHS sets in if you check your blood glucose even once a day. To be sure, test your blood glucose levels three or four times a day when you are sick. It’s also very important to drink plenty of alcohol-free, sugar-free fluids. You may need to take insulin, even if you don’t ordinarily use it.
Special Precautions for HHS
• Ask your doctor or pharmacist if certain medications may increase your risk for HHS, such as glucocorticoids (steroids), diuretics, phenytoin (Dilantin), cimetidine (Tagamet), and beta-blockers (especially Inderal).
• HHS can occur in people having peritoneal dialysis or intravenous feedings, so you’ll need to check blood glucose frequently.
• About one-third of cases of HHS occur in people living in nursing homes. This can happen when residents are confused or have to wait for staff to offer them something to drink, leading to dehydration. Family members may have to educate staff of the patient’s needs and ask for regular blood glucose monitoring.
Illness
When you’re sick, your body releases hormones to fight the illness. These hormones also counteract insulin and raise your blood glucose levels. Extremely high blood glucose can lead to diabetic ketoacidosis and HHS.
So, when you’re sick, you’ll want to check your blood glucose more frequently than ever. Also, be sure to talk to your health care team before you get ill about what you should do in the event of illness. You and your health care team can work together to come up with a plan to help you handle common illnesses, such as colds or the flu.
Sick-Day Action Plan
You and your doctor may want to answer these questions when developing a plan for your next illness.
• How often should I monitor my blood glucose?
• When should I call the doctor?
• Should I test for ketones?
• What medication changes should I anticipate? How should I manage doses of my insulin or other medication?
• Which over-the-counter medications are safe to take?
• How should I choose appropriate foods and fluids while I’m sick?
Tips during Illness
• Monitor. Check your blood glucose and ketone levels about every 3–4 hours. If the levels are too high or you are pregnant, you may need to monitor more often.
• Food. Make substitutions for your usual food if nausea and vomiting make it difficult to eat. Try to eat or drink your usual amount of carbohydrates. Talk to your dietitian about ways to cover your basic eating plan. Prepare a sick-day plan before you even become sick. Try to keep some comforting foods, like soup, on hand, especially during the cold and flu season.
• Liquids. Drink plenty of caffeine-free liquids. You may need regular soft drinks or sports drinks with sugar or carbohydrate if you are losing fluids by vomiting, fever, or diarrhea. These drinks may help prevent the hypoglycemia caused by not eating or taking extra insulin. Try sipping 3–6 ounces an hour to keep your blood glucose even.
• On Hand. Keep a thermometer on hand and a small supply of common sick-day medications that are safe to take. Be sure to read the labels. Be sure to consult with your health care team to find out which medications are safe to use.
• Insulin. If you have type 1 diabetes, continue to take your insulin—even if you can’t eat. You may even need extra insulin to take care of the excess glucose your body releases when you are sick. Ask your provider about what blood glucose levels call for a change in your insulin dose.
Cold Medicines
Some cold medicines sold over-the-counter to treat colds and flu can affect your blood glucose level. Many cough and cold remedies labeled “decongestant” contain ingredients, such as pseudoephedrine, that raise blood glucose levels and blood pressure. Talk to the pharmacist or your provider before you take any over-the-counter medication.
In addition, some cough and cold remedies contain sugar and alcohol. Make sure you read the label and find out exactly what “active ingredients” as well as “inactive ingredients” any medication contains. A small amount of sugar or alcohol is probably fine, as long as you’re aware of it.
Pain medications are usually safe in small doses. You don’t have to worry about taking an occasional aspirin for a headache or fever. Many people with diabetes take a daily, coated “baby” aspirin to protect against cardiovascular disease. This is safe for people with diabetes, if it is recommend by their health care team. Check with your doctor to see if you can safely take ibuprofen.
Call the Doctor
You’ll want to call your health care provider if you experience any of the following:
• You have been sick for 1 or 2 days without improvement.
• You have experienced vomiting or diarrhea for more than 6 hours.
• You have moderate to large amounts of ketones in your urine or blood ketones are 0.6–1.5 mmol/l or higher.
• You are taking insulin and your blood glucose levels continue to be over 240 mg/dl or the level determined by you and your provider.
• You have type 2 diabetes, you are taking oral diabetes medication, and your pre-meal blood glucose levels are 250 mg/dl or higher for more than 24 hours.
• You have signs of extreme hyperglycemia (very dry mouth or fruity odor on the breath), dehydration, or confusion and disorientation.
• You are sleepier than normal.
• You have stomach or chest pain or any difficulty breathing.
• You have doubts or questions about what you need to do for your illness.
Keep records of your condition during your illness so that you’ll have the information ready when you call your doctor. These records will make it easier for your doctor to determine how sick you are and to keep track of your progress in getting well.
Things to Tell Your Health Care Provider
• Blood glucose levels and your urine ketone results—starting when you first realized you were ill
• Insulin doses and diabetes pills you have taken and when you took them, as well as any other medications you’ve taken
• The amount of time you’ve been sick
• Symptoms such as your temperature, your appetite and fluid intake, any weight loss, or any other problems
• Your pharmacist’s phone number
