Customizing hypoglycemia treatment

Posted by omnipod on Mon, 11/02/2015 - 09:53 in

Nobody likes being low.  Not only does it feel lousy, it can impair your thinking and make it hard to come up with a plan without “overshooting” and winding up way above target.  Lows impair your performance and can lead to accidents.  At best, they might leave you feeling a little bit awkward and embarrassed.

Over time, many people lose the ability to feel their lows.  The symptoms are your friend; they let you know that there is a problem that you need to fix.    Untreated lows are incredibly dangerous, to say the least.  Some people allow themselves to consistently run too high, preferring to risk complications rather than risk having lows.  Even if you don't over-treat a low, you may wind up with high blood sugar due to the effect of counter-regulatory hormones.  Lows can also cause your stomach to empty faster than usual, resulting in a BG (blood glucose) spike.  And the extra calories it takes to treat a low…that can lead to weight gain.  It can be quite the juggling act!

Let's start with the basics.  Insulin (and some oral medications) and exercise lower BG.  In larger quantities, alcoholic beverages eventually lower BG, although they may initially raise it.  Food and counter-regulatory hormones raise BG.  It's important that basal insulin be well-set, so that it keeps BG at a reasonable level rather than allowing it to rise or fall.  Generally a BG under 70 mg/dl is considered hypoglycemia, although in pregnancy this number changes to 60, and we often use 80 in those who have hypoglycemia unawareness and for whom lows are more dangerous.    While it is not realistic to have tight BG control without ever experiencing a low, we do want to make sure lows occur fewer than three times per week, and that there are no severe lows.  It becomes a big problem when a low BG cannot be treated without the assistance of someone else.  Severe lows need to be treated with an injection of Glucagon.  Lilly even has an app for Glucagon injection to make it easier for someone to help in an emergency: https://itunes.apple.com/us/app/glucagon/id553314007?mt=8 .

Preventing lows is an important first step.

Keep the following in mind:

  • If you are taking glargine or detemir, there may be a time of the day where it's necessary to have a few uncovered carbs to prevent lows--this is often the late afternoon.
  • Know how to navigate the effects of alcoholic beverages and exercise.
  • Make sure your correction factor/sensitivity is set properly, and realize that most people are more insulin sensitive in the overnight hours.  Set the I:C so the BG lands near your target 3-4 hours after the last bolus.  Typically different meals require different I:C ratios.
  • Have your BG targets set appropriately.
  • Account for Insulin on Board; pumps do this automatically, but with injections you must do this on your own (a good App is: RapidCalc Diabetes Manager https://itunes.apple.com/us/app/rapidcalc-diabetes-manager/id400469609?mt=8).
  • Make sure your carb counting is accurate.  Learn to use the extended bolus for slow-digesting foods or long duration meals (holiday time/picnics, etc).
  • Test frequently, or use a CGM.  Keep records that you can analyze for trends.
  • Pay attention to trends!  Repeated lows at the same time of day means that something isn't working, and it needs to be changed.

Assuming that you have taken reasonable steps to avoid lows and the inevitable happens, what's the best course of action to take?  That "Rule of 15" where you are told to eat 15 gm of carb, wait 15 minutes, test BG, and treat again if still low…that's not for Type 1s!  It's more of a one-size-fits-all, and this is about customizing treatment.  So…

First, check the BG with a fingerstick (if possible) to verify the low and see how low you really are.  Then treat with a fast-acting, high glycemic index food, such as glucose tablets or gel, or a dextrose-based candy like Smarties or Sweet Tarts.  If you don't have access to that, dry breakfast cereals, saltines and pretzels make for some of the better choices.  Milk and apple juice are actually lower on the glycemic index table and take longer to bring the BG up, despite what you may have been taught.  But…how many grams of carb do you need to use?  That's the million dollar question!  The more you weigh, the less a gram of carb will raise your BG, thus a larger amount of carb will be needed.  The less you weigh, the more a gram of carb will raise your BG, and so a smaller amount will do the trick.  And the lower you are, the more carb you will need.

In general,

  • If you weigh 60 lbs or less, a gram of carb will raise the BG about 6-10 mg/dl
  • For 60-100 lbs, a gram of carb will raise the BG about 5 points
  • For 100-160 lbs., a gram of carb is good for about 4 points
  • For 160-220 lbs., it's 3 points
  • If you are more than 220 lbs, assume 2 points

Remember, though, if you have insulin on board or have recently exercised, you will need to increase the treatment.  If you are low and are about to have a meal, simply enter the amount of carbs into your pump (preferably after the meal) along with the pre-meal BG value.  The pump will recommend an appropriate bolus, with adjustment made for the low BG.  The same holds true if you overtreat a low.  Collect all the empty food wrappers, count up all the carbs, and enter it into your pump along with the pre-treatment BG value to determine an appropriate bolus.

Checking your BG 15 minutes after treatment is a good idea, but don’t expect your BG to have returned to normal.  Even dextrose takes time to digest and absorb completely.  As long as your BG has begun to rise after 15 minutes, you should be fine.  No need to re-treat, as this will lead to overtreatment.

If you have a CGM (continuous glucose monitor), be sure to look at the trend.  If you are coming down slowly and not yet low, you can use a medium glycemic index food (which will digest slower, but prevent a further drop in BG), and use less of it.  On the other hand, a fast drop warrants aggressive treatment, so use the highest glycemic index food you can find, and make sure you take the full amount of carbs.

One more thing – don’t wait until you’re low to figure all this out.  Plan and prepare your treatments ahead of time so that it’s ready, willing and able to do the job when the time comes!

NOTE: Information posted on Podder Talk is not intended to be taken as medical advice. Always consult with your healthcare provider for questions and guidance on managing any health-related issues.