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©2009 by the American Diabetes Association, Inc. All Rights Reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including duplication, recording, or any information storage and retrieval system, without the prior written permission of the American Diabetes Association.
Printed in the United States of America
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The suggestions and information contained in this publication are generally consistent with the Clinical Practice Recommendations and other policies of the American Diabetes Association, but they do not represent the policy or position of the Association or any of its boards or committees. Reasonable steps have been taken to ensure the accuracy of the information presented. However, the American Diabetes Association cannot ensure the safety or efficacy of any product or service described in this publication. Individuals are advised to consult a physician or other appropriate health care professional before undertaking any diet or exercise program or taking any medication referred to in this publication. Professionals must use and apply their own professional judgment, experience, and training and should not rely solely on the information contained in this publication before prescribing any diet, exercise, or medication. The American Diabetes Association—its officers, directors, employees, volunteers, and members—assumes no responsibility or liability for personal or other injury, loss, or damage that may result from the suggestions or information in this publication.
The paper in this publication meets the requirements of the ANSI Standard Z39.48-1992 (permanence of paper).
ADA titles may be purchased for business or promotional use or for special sales. To purchase more than 50 copies of this book at a discount, or for custom editions of this book with your logo, contact the American Diabetes Association at the address below, at booksales@diabetes.org, or by calling 703-299-2046.
American Diabetes Association
1701 North Beauregard Street
Alexandria, Virginia 22311
Library of Congress Cataloging-in-Publication Data
Fox, Larry A.
Diabetes 911 : how to handle everyday emergencies / by Larry A. Fox and Sandra L. Weber.
p. cm.
Includes index.
ISBN 978-1-58040-300-9 (alk. paper)
eISBN 978-1-58040-378-8
1. Diabetes—Complications. 2. Medical emergencies. I. Weber, Sandra L. II. Title.
RC660.F688 2008
616.4’62025—dc22
2008024026
This book is dedicated to all of the patients and families who have taught me so much about diabetes.
—Larry A. Fox
To my family, with love.
—Sandra L. Weber
CONTENTS
8: Severe Weather and Natural Disasters
I would like to graciously acknowledge the members of the diabetes team and my colleagues and the endocrine staff at Nemours in Jacksonville, all of whom have made immeasurable contributions to the care of children with diabetes. I am especially indebted to Dr. Nelly Mauras, a wonderful friend, colleague, and mentor, whose support over the years has been invaluable.
I am grateful to the American Diabetes Association and its editorial staff for the opportunity to enhance the education and care of patients with diabetes and their families.
Last, but certainly not least, I am forever thankful to my wife, Mary Louise, and my daughters, Erin and Megan, for the endless support and love they have given me.
—Larry A. Fox, M.D.
I wish to thank all who have contributed to a lifetime of learning: my patients, who have shared their joys, frustrations, successes, and struggles; my colleagues, who have provided an environment in which to think and grow; my students, who have kept the desire to learn fresh; and my family, who have always been there, encouraging me to grow and explore and reach.
I am grateful to the American Diabetes Association for their commitment to those with diabetes and to Greg Guthrie for his guidance in preparing this manuscript.
—Sandra L. Weber, M.D.
People with diabetes have to deal with the same day-to-day emergencies in life as those that occur for people without diabetes. Unfortunately, they also have to deal with a number of diabetes-related emergencies—ones that are not experienced by most people. These include potentially life-threatening events, such as reactions to low blood glucose levels (hypoglycemia) or insulin pump failure, but also include less severe emergencies, such as travel-related diabetes issues. It goes without saying that the best way to deal with any emergency, diabetes-related or not, is to be prepared. That’s why we wrote this book.
Diabetes 911 will help you prepare for the emergencies that creep up if you have diabetes. It is a valuable reference for children and adults with diabetes (regardless of whether you have type 1 or type 2). People who are friends or family members of a person with diabetes will also find Diabetes 911 to be a helpful resource.
Diabetes 911 covers both general emergencies and extreme emergencies. General emergencies are those day-to-day, common pediatric and adult situations. Extreme emergencies are those rare dangerous situations for which you need to be prepared, such as severe weather and power outages. For easy reference, each chapter ends with a summary of its important points.
Chapter 1 Preparation and Prevention
People with diabetes experience unique, day-to-day emergencies specific to their condition. Because you have diabetes, you need to be prepared to deal with these emergencies. Alexander Graham Bell, the famous inventor, once said, “Before anything else, preparation is the key to success.” Preparing for diabetes emergencies is no exception—expect the unexpected. Many diabetes-related problems can be prevented with proper preparation. Here are some beginning steps in preparing for (and hence preventing) a variety of simple but common problems in day-to-day diabetes care.
DIABETES SUPPLY KIT
Scouts are not the only ones who should be prepared. Everyone should. There are many situations when simply having another diabetes supply kit readily available can save you a lot of aggravation and time. Many of these emergencies can be avoided by having all of the necessary diabetes supplies ready and waiting for you. The list above shows the supplies that should be in your kit. You may need additional items depending on your specific situation or if you are preparing for a specific circumstance (for example, a standard kit might not include a flashlight, but it should if you are preparing for a severe weather event).
YOUR DIABETES SUPPLY KIT INVENTORY
Diabetes medicines (such as unopened insulin vials and diabetes pills)
Blood glucose test strips
Lancets
Alcohol wipes
Urine and/or blood ketone strips
Items to treat mild or moderate low blood glucose levels (hypoglycemia)
Glucagon emergency kits (2), if you are at risk for severe hypoglycemia
Insulin syringes and/or pen needles
Extra blood glucose meter and batteries
Insulin pump supplies—infusion sets, reservoirs, batteries, transparent medical dressings (if used)
Written instructions from your diabetes team regarding an insulin regimen to follow when off pump therapy (be sure to include the right kind of insulin)
A list of emergency contact phone numbers for your diabetes team (weekday and evening/weekend numbers), primary care physician, and pharmacy.
Things to Know about
Your Diabetes Supply Kit
1 Keep a diabetes supply kit at home and at other places you frequent (such as work, school, or relatives’ houses). Also, if your child has diabetes and is in daycare or with a babysitter, be sure to keep a backup kit there as well.
2 Remember that unopened insulin should be refrigerated. Opened vials, on the other hand, do not have to be refrigerated. We do not recommend putting opened vials in your diabetes supply kit because opened vials have a shorter shelf life (usually two to four weeks). So, if your diabetes is managed with insulin, your emergency supply kit would have to be kept in the refrigerator.
3 Don’t forget to check the expiration dates on all medicines and supplies in your kit. Even blood glucose test strips and lancets expire. We suggest checking the expiration dates on items in your kit every month. Set a routine, so it becomes habit and you don’t forget (for example, the first day of every month).
4 Your kit must include items for treating low blood glucose levels. Most cases of hypoglycemia are treated using 15–20 grams of carbohydrate in the form of simple sugar (also called fast-acting carbohydrate). Glucose tablets are a small and convenient option. Some people prefer other sources of carbohydrate, such as glucose gel or small juice boxes or pouches (usually 4–6 ounces); these, however, can take up more space in your kit. Glucagon should also be included if you are at risk for severe hypoglycemia (see ARE YOU AT RISK FOR SEVERE LOWS?). Glucagon kits are meant to be given by someone else (i.e., not the person having the hypoglycemic reaction), so remember to teach others how a glucagon kit is used beforehand.
5 Last, but not least, if your diabetes self-care management changes in any way, make sure you update your kit to reflect these changes. So, for example, if a new medicine is added to your management, go back and add that medicine to your kit.
Other Recommendations
EXTRA INSULIN
Bottles of insulin may break when dropped on hard floors. We’ve had countless calls from frantic patients or parents who need a new insulin prescription called in to the pharmacy because their last vial is now spread across the kitchen floor (and this invariably happens late at night, when most pharmacies are closed). There are many other circumstances in which your time and stress level can be reduced by simply keeping extra insulin available at all times.
PRESCRIPTION REFILLS
Don’t wait until the last minute to call your diabetes team for medicine or supply refills. Plan on calling refills in at least one week in advance. You want to be sure that the diabetes team has enough time to review your medical records and take care of your request before you actually run out of insulin, other medicines, or supplies. Remember, diabetes centers treat hundreds—sometimes thousands—of patients and may receive many emergency calls every day. There is no guarantee that they’ll be able to get to your request as soon as you need it.
INSULIN PUMP ISSUES
Pump failures can happen, although, luckily, not too commonly. If they do, you may be off your pump for a day or longer. Because the “smart pumps” in use today have the bolus calculations and basal rates programmed into the pump, you may not remember this important information. Avoid being stuck without knowing your insulin doses and keep a written copy of your insulin pump settings, including basal rates, bolus calculations (i.e., meals and high blood glucose boluses), sensitivity factors, target numbers or ranges, and alarms, so pump therapy can be restarted immediately after receiving your replacement. Most insulin pump companies have software that may simplify this process by allowing you to download pump setup information to your home computer. Having this information readily available will make the transition between injections and pump therapy seamless and easy.
ARE YOU AT RISK FOR SEVERE LOWS?
You are at risk of severe hypoglycemia if any of the following apply to you:
you are taking insulin or taking a pill that causes your pancreas to make insulin
you have neuropathy
you have frequent lows
you cannot recognize the warning signs of hypoglycemia
you have had a prior severe low blood glucose reaction This is discussed in greater detail in chapter 2.
Knowing your bolus calculations may also be necessary if you use injections until the pump is replaced. It is also useful to have a vial, cartridge, or pen of long-acting insulin available. The kind and amount of insulin you use should be discussed with your diabetes team, written down, and placed in your diabetes supply kit. For more details about switching to injections while waiting to restart pump therapy, see chapter 4.
SICK DAY SUPPLIES
If you become ill, you’ll need extra supplies to ensure that you have a safe and speedy recovery. Make sure that the items for sick day management are at home all the time. If you are vomiting, stay hydrated by taking frequent sips of clear fluids, such as ginger ale, sports drinks, or water (plain or flavored). Popsicles or other frozen fluids are sometimes easier to take in if you are nauseated. Keep both regular and sugar-free fluids on hand: regular for when blood glucose levels are low or in your target range and sugar-free for when you have high blood glucose levels. Be sure your refrigerator or pantry is stocked with these items. You do not want to have to run to the grocery store at the last minute.
Your diabetes team may want you to keep limited amounts of medicines on hand to treat vomiting. Being prepared can help minimize your risks of dehydration and avoid a visit to the emergency room. If your team suggests this, be sure of a few things: 1) the supply is kept up to date (not expired), 2) you know how to use the medicine correctly, and 3) contact your diabetes team before taking the medicine. Also, call or go to the emergency room if, despite the medicine, you are still not able to keep fluids down or your condition worsens.
SUMMARY:
PREPARATION AND PREVENTION
YOUR DIABETES SUPPLY KIT INVENTORY
Diabetes medicines (such as unopened insulin vials and diabetes pills)
Blood glucose test strips
Lancets
Alcohol wipes
Urine and/or ketone strips
Items to treat mild or moderate low blood glucose levels (hypoglycemia)
Glucagon emergency kits (2), if you are at high risk for severe hypoglycemia
Insulin syringes and/or pen needles
Extra blood glucose meter and batteries
Insulin pump supplies—infusion sets, reservoirs, batteries, transparent medical dressings (if used)
Written instructions from your diabetes team regarding an insulin regimen to follow when off pump therapy (be sure to include the right kind of insulin)
A list of emergency contact phone numbers for your diabetes team (weekday and evening/weekend numbers), primary care physician, and pharmacy.
YOUR RISK OF SEVERE HYPOGLYCEMIA IS HIGHIF ANY OF THE FOLLOWING APPLY TO YOU
you are taking insulin or taking a pill that causes your pancreas to make insulin
you have neuropathy
you have frequent lows
you cannot recognize the early warning signs of hypoglycemia
you have had a prior severe low blood glucose reaction
RECOMMENDATIONS FOR HOW YOU CAN LESSEN THE RISK OF SOME COMMON DIABETES PROBLEMS
Put together a diabetes supply kit and review it monthly. Such a kit should be available at home and in other places where you spend a lot of time (work, school, daycare, and relatives’ houses).
Keep at least one extra bottle or cartridge of insulin available, not only at home but also in other frequented places.
Give at least one week’s notice to your diabetes team or pharmacy when asking for medicine and/or supply refills. For mail-order prescriptions, you may need three weeks.
Make a backup copy of all insulin pump settings and alarms.
Keep sick day supplies on hand.
Hypoglycemia (low blood glucose) is probably the most common emergency in children and adults with diabetes. With the use of more intense insulin regimens, improved blood glucose control comes at the risk of more frequent hypoglycemia. Whether mild, moderate, or severe, hypoglycemia can leave a lasting impression on someone with diabetes or his or her caretaker (especially a parent). In severe cases, hypoglycemia can sometimes have devastating consequences, such as death related to hypoglycemia while driving. Therefore, people with diabetes, and others who spend a lot of time with them (parents, other relatives, school personnel, teachers, co-workers, friends, etc.), need to know how to properly handle this emergency.
This chapter covers recognition and treatment of hypoglycemia. It focuses not only on mild and moderate low blood glucose levels, but also proper treatment of severe events. One of the keys to success with nearly everything is planning ahead—hypoglycemia is no exception. Thus, this chapter also addresses the prevention of hypoglycemia, including when playing sports or exercising. Lastly, this chapter reviews how medications and alcohol influence the development and recognition of hypoglycemia.
SYMPTOMS OF HYPOGLYCEMIA
Hypoglycemia is generally classified as mild, moderate, or severe. This is based on the symptoms of low blood glucose levels (how you feel when your sugar is low). The classification is not based on actual blood glucose numbers. The symptoms of hypoglycemia can vary significantly from person to person and do not entirely depend on the blood glucose level. For example, there can be no symptoms at all, even with a very low blood glucose level (under 40 mg/dl). Or a person can have moderate or severe symptoms with a slightly low blood glucose or a level that is not even low (more than 70 mg/dl).
Many of the symptoms of low blood glucose levels (see SIGNS OF MILD OR MODERATE HYPOGLYCEMIA) are manifestations of the body’s response to the low sugar level. Low blood glucose levels activate the sympathetic nervous system, causing early warning signs of hypoglycemia, many of which people recognize. Such symptoms indicate that the body is trying to raise its blood glucose level. These early symptoms are also what you feel when blood glucose drops rapidly but may not be considered low. It is not just the blood glucose level that determines whether someone has symptoms or not—it is also dependent on how fast the blood glucose level is falling.
Other symptoms, however, indicate that the brain is not getting enough of the glucose it needs to function properly. These are the late signs of hypoglycemia and occur if early symptoms are not sensed or recognized or are ignored. The symptoms of mild or moderate hypoglycemia can vary from person to person. Even one person may have different symptoms one day compared with another, depending on surrounding circumstances.
A severe low blood glucose level is much worse and indicates that the brain is severely deprived of the glucose it needs to function properly. Hypoglycemia is always considered severe if it is accompanied by unconsciousness or a seizure (convulsion). It is also severe if you are still conscious but unable to correct the hypoglycemia yourself, whether it is because you cannot recognize it or because you need the help of another person. In infants, toddlers, and young children, this definition does not always apply because they always require someone else’s help to treat hypoglycemia, regardless of severity, just by virtue of their young age. It is important to treat severe hypoglycemia immediately to prevent brain damage, but even more important to prevent it altogether.
WHEN DOES HYPOGLYCEMIA OCCUR?
Hypoglycemia occurs when the balance between your insulin levels and the amount of available glucose is disrupted. If your body does not have enough food or is unable to make enough glucose (causing an insufficient amount of glucose available for your body to use for energy), blood glucose levels will decrease. Low blood glucose levels may occur if:
you skip meals or snacks or eat them much later than usual (if a fixed insulin regimen is used)
you are not eating enough or eating much less than usual
you are getting more insulin than you need
you are getting a lot of exercise or activity
your liver is unable to make enough glucose
Several diabetes medicines can cause low blood glucose levels, including, of course, insulin. There are other diabetes medicines that can cause relatively high amounts of insulin in the body, which can cause low blood glucose, including a class of drugs called sulfonylureas. Examples of sulfonylureas include chlorpropamide (Diabinese), glyburide (Diabeta, Micronase, and others), glipizide (Glucotrol), and glimepiride (Amaryl). Meal-time agents such as Starlix and Prandin have lower risks for hypoglycemia, but still present some risk. Other diabetes medicines generally do not cause hypoglycemia unless they are taken in combination with medications that increase your risk.
A common drug associated with hypoglycemia is alcohol. Alcohol has a number of effects that can contribute to low blood glucose levels, and these effects are often delayed up to 12 hours after drinking. Alcohol inhibits the body’s defenses against low blood glucose levels: it blocks the liver’s ability to make glucose, blocks the effects of chemicals (or hormones) in the body that increase glucose production in the liver, blocks the action of insulin (its effectiveness), and impairs your ability to recognize hypoglycemia. Special precautions need to be taken whenever someone with diabetes consumes alcohol. Alcohol consumption and its relation to hypoglycemia are described in depth in Alcohol.
TREATMENT OF
HYPOGLYCEMIA
All low blood glucose levels need to be treated quickly, although the treatment for the different levels of severity (mild or moderate versus severe) varies. If you think you are experiencing hypoglycemia, you should always test your blood glucose level before treating it (unless the low is severe, with unconsciousness or seizure; such cases should be treated before blood glucose is tested).
Mild or Moderate
Hypoglycemia
Confirm mild or moderate hypoglycemia with fingerstick testing (under 70 mg/dl). We recommend using the Rule of 15 to treat mild or moderate hypoglycemia. Treat with 15 grams of carbohydrate; then check the blood glucose level 15 minutes later. Take another 15 grams of carbohydrate if the blood glucose level is not above 70 mg/dl. Depending on a number of factors (such as your actual blood glucose level, plans for exercise, or past experience), you may have to start with 20–30 grams of carbohydrate rather than 15.
AVOID OVERTREATING HYPOGLYCEMIA
This is a common mistake for a few reasons. First, people become nervous about a mild or moderate low turning into a severe one. This is especially true for someone who has experienced a severe low event. It can be very scary, not only for the person with diabetes but also for friends and relatives (especially parents of children with diabetes) who witness the event. Plus, if the severe low is experienced in a public place or at work, it can be very embarrassing. People will do anything to avoid this happening again, including over treatment of low blood glucose or intentionally keeping glucose levels higher than goal.
Second, people have a tendency to treat the symptoms rather than the blood glucose level itself. Sometimes the symptoms take a little longer to recover than the blood glucose: blood glucose levels may be back in the target range (or even above it) after treatment, but some of the symptoms will not have disappeared. If this happens, continuing to take carbohydrate will raise blood glucose levels too high. So remember, it is important to treat the blood glucose level, not the symptoms.
SIGNS OF MILD OR MODERATE HYPOGLYCEMIA
You may feel one or more of the following:
Shaky
Sweaty
Rapid heart beat
Heart palpitations (feeling like your heart is pounding very hard)
Headache
Hungry
Irritable or combative
Tired
Confused
Nervousness or anxiety
Dizzy or lightheaded
Another reason why people overtreat hypoglycemia is because they eat whatever is available without counting carbohydrates. Doing this is much easier than making sure you only get 15 grams of carbohydrate, especially if you are scared, but it can lead to high, fluctuating blood sugars and contributes to poor diabetes control. The overwhelming appetite that accompanies hypoglycemia can sometimes be hard to ignore. Having a plan ahead of time can help control the amount of carbohydrate eaten. An easy solution is to always have a few sources of 15 grams of carbohydrate handy, such as glucose gel or tablets.
Severe Hypoglycemia
The treatment of severe hypoglycemia is different from that for mild or moderate lows. Because the severe low indicates that the brain has very little of the glucose it needs for energy, it is critical to treat these incidents much more aggressively. In these situations, treat first, ask questions later.
If the person experiencing severe hypoglycemia is conscious and able to swallow safely, give 30 grams of glucose immediately and then check his or her blood glucose level. Stay with the person, as the situation may change.
SIGNS OF SEVERE HYPOGLYCEMIA
Unconsciousness
Seizure (convulsion)
Confusion
Inappropriate conversation/word choice
Inappropriate behavior
Sweating
THE RULE OF 15
After confirming that the blood glucose is low via fingerstick:
Give 15 grams of carbohydrate (e.g., 4 ounces juice, 3–4 glucose tablets, or 4 ounces regular soda).
Recheck blood glucose 15 minutes later.
Repeat process until blood glucose is over 70 mg/dl.
If someone is unconscious or having a seizure, avoid using oral treatments. This person cannot swallow correctly and may suffocate or choke if food or liquids go into the windpipe.
GLUCAGON
Glucagon is used to treat severe lows. Glucagon is a hormone produced by the pancreas that helps the liver make and release glucose into the bloodstream. When injected, glucagon tells the liver to quickly release its stored glucose into the bloodstream. Glucagon comes in small vials or easy-to-use emergency kits. Make sure your close relatives or anyone else with whom you spend a lot of time (spouse, other family members, friends, coworkers, etc.) understands when and how to give a glucagon injection. Your diabetes team can teach anyone how to give glucagon. Glucagon, like insulin, does expire, so you’ll need to check the expiration dates for glucagon kits in your diabetes supply kits.
Glucagon is injected into the muscles of the thigh or arm. Adults should use the whole vial (1 mg, or 100 units on an insulin syringe). The amount of glucagon used for children is different than that for adults (see GLUCAGON DOSING FOR CHILDREN AND ADOLESCENTS for dosing in infants, toddlers, children, and adolescents). As soon as the glucagon is given, check blood glucose levels, and, if necessary, repeat it in 15 minutes. Be sure to notify your diabetes team of the severe low because changes to your insulin regimen may be required.
If no glucagon is available, call 911 immediately. Glucose gel (or even cake icing) can be used to treat a severe low if glucagon is not available. Squirt the glucose gel or cake icing into the mouth between the cheeks and gums. Carbohydrate is absorbed here, but not as rapidly as desired in an emergency.
Glucagon can also be used in children or adults who have low blood glucose levels and are not able to eat or drink because of vomiting or other reasons. Talk to your diabetes team about using glucagon in these circumstances.
GLUCAGON DOSING FOR CHILDREN AND ADOLESCENTS
The amount of glucagon used for young children and adolescents with diabetes is based on age, as indicated in the chart below, or by weight. Use an insulin syringe to draw up the glucagon and inject it. Talk to your diabetes center for their recommendations on glucagon dosing.
| Age | Amount of glucagon | ||
| 4 years old or younger | 0.1 mg (10 units) | ||
| 5–10 years old | 0.2 mg (20 units) | ||
| 11 years old or older | 0.5 mg (50 units) |
CALLING 911
There are differing schools of thought regarding if and when to call 911. Some recommend only calling 911 if the glucagon does not work, you cannot find it, or you forget how to use it. Others suggest calling 911 immediately. This way there will not be a delay in the paramedics’ arrival if you cannot find the glucagon or if you panic when trying to use it. Talk to your diabetes team about when you should call 911.
PREVENTION OF HYPOGLYCEMIA
Most of the time, with proper planning, hypoglycemia can be prevented. This section covers the prevention of the most frequent causes of low blood glucose levels, including nighttime hypoglycemia and exercise-related hypoglycemia.
Nighttime Hypoglycemia
If you take insulin, one of the most concerning times to have a low blood glucose level is during the night, when you are sleeping. Recent research has shown that a good way to help minimize the chance of nighttime hypoglycemia is to make sure your blood glucose is over 100 mg/dl at bedtime. Before going to sleep, check your blood glucose. If it is under 100 mg/dl, take 15–30 grams of carbohydrate. If a bedtime snack is a part of your self-care regimen and your blood glucose level before the snack was under 100 mg/dl, make sure you check after the snack is finished to be sure that the blood glucose level has risen over 100 mg/dl.
Knowing what your blood glucose level is doing while you are asleep is important. This is especially important for people taking insulin or taking medicines that increase insulin production overnight. We recommend testing blood glucose between bedtime and awakening a couple of times per week, varying the time when the blood glucose check is done. Insulin levels peak at different times; knowing when these peaks occur helps you know the best times to test blood glucose levels. Knowing your blood glucose pattern during your sleep time will guide you in deciding whether any insulin or medicine changes need to be made before low blood glucose levels occur. This will help prevent hypoglycemia (and high blood glucose levels) during sleep hours.
Insulin and Exercise
The important role of exercise in managing diabetes cannot be overemphasized, but with the benefits come the risk of hypoglycemia. Regular exercise improves the way insulin works in the body and helps you maintain a healthy weight. Exercise also allows the body to use sugar faster, decreasing how much insulin is needed. Thus, exercise can cause hypoglycemia because there is a high amount of insulin in your system relative to the amount of glucose from the liver or from the food you ate. Exercise continues to improve how your body uses glucose, even after you stop exercising. The more frequently and more intensely you exercise, the longer the effects of exercise can last (as long as 24 hours after the activity is over). Therefore, if you are exercising, you may need to take less insulin than usual for up to the next 24 hours.
RECOMMENDATIONS FOR PREVENTING EXERCISE-RELATED HYPOGLYCEMIA
The following recommendations will help minimize the chances of experiencing hypoglycemia related to exercise.
Check your blood glucose before exercising and every 30–60 minutes during the activity, depending on the intensity of the exercise.
You may have to take 15–30 grams of carbohydrate before exercise, depending on your blood glucose level before exercise and the intensity of the exercise you plan to undertake. Experience will tell you what blood glucose levels work best for you before a particular activity. Some people want their blood glucose to be over 100 mg/dl, some over 120 mg/dl, and others over 180 mg/dl before exercising. One recent study in children, however, showed that having a blood glucose level over 130 mg/dl before exercise decreased the chance of experiencing hypoglycemia during exercise. This study was done in children on insulin pumps, so these results may not apply to everyone. Nonetheless, try using 130 mg/dl as a starting level, and if you are below that level, take some extra carbohydrate before exercise. Be sure to talk to your diabetes team for guidance.
Make sure sources of carbohydrate (such as a juice box or glucose tablets or gel) and a glucagon kit are available at all times, including when you are exercising.
Be sure to check your blood glucose during the activity period. During exercise, if your blood glucose begins to dip below your cutoff point—or if it seems to be dropping quickly—take 15–30 grams of carbohydrate. Recheck your blood glucose level 15 minutes later to be sure it has not dropped further.
Insulin dose changes may be required during the activity and possibly even later, because the effects of exercise on insulin needs can last up to 24 hours.
If you use an insulin pump, changes in your basal rates may be required. Many people disconnect their pump before starting exercise. Some research has shown that hypoglycemia is much less likely during exercise if the basal rate is stopped. However, we recommend not being disconnected from your insulin pump for more than two hours at a time because this may leave the body without insulin for too long. You can also decrease your basal rate through your insulin pump using the temporary basal rate features. Talk to your diabetes team about changes to your insulin pump regimen during and after exercise.
Knowing your needs and your response to exercise is critical. Different exercise routines, regimens, or even times of day can give very different responses. The key is to be proactive and learn your patterns by monitoring, reviewing, and adjusting to your needs.
As a reminder, the effects of exercise on insulin needs can last up to 24 hours after the exercise is over. Because of this, it is not uncommon to experience hypoglycemia in the middle of the night after a day of activity. This is obviously a time when lows need to be prevented. Be sure to check blood glucose levels frequently after exercising, including during late night or early morning hours.
Alcohol
Several precautions need to be taken when it comes to having diabetes and drinking alcohol (see RECOMMENDATIONS FOR PREVENTING ALCOHOL-RELATED HYPOGLYCEMIA). Alcoholic beverages can contain carbohydrate and may cause blood glucose levels to initially rise. However, alcohol impairs the body’s response to low or decreasing blood glucose levels. This effect can be quite delayed, up to 12 hours after drinking. Additionally, alcohol impairs judgment, so your ability to recognize and treat hypoglycemia will be reduced. When slightly intoxicated or drunk your ability to think straight is altered; you may not recognize hypoglycemia when it happens and may not treat it properly even if you do. Alcohol is metabolized (broken down) by the liver, and during this process, the liver does not make as much glucose as normal. Thus, alcohol impairs one of the body’s key responses to low blood glucose—releasing stored glucose from the liver to raise blood glucose levels.
