#I need to bolus for food still and correct high bgs | Explore Tumblr Posts and Blogs

mcatmemoranda · 5 years

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Notes I took from a lecture on Fluids:

Mon, Sep 30, 3:45 PM

Lactate is converted to bicarbonate, so lactated ringers solution can cause alkalosis if used long enough. Not to be used with ceftriaxone, because it will precipitate. Not to be used in pts with liver failure because lactate is metabolized by the liver.

Dextrose D5W - may help in elderly pts who are NPO. Monitor BG in diabetics with finger sticks q4-6 hrs. Can cause hypokalemia because water goes towards sugar and body responds by holding onto Na+ and getting rid of K+.

Saline - monitor for hypernatremia.

1/2 Normal Saline (NS) shifts fluid into cells.

Hypertonic saline is used in severe hyponatremia.

4-2-1 rule.

For women add 40 to total ... I missed what he said :( But I posted about maintenance fluids before and how to calculate it.

Ins & outs = I&Os, oliguria, polyuria. If I&Os not matching, something is wrong.

Bolus = quick dose of saline. "Everyone can use a liter."

CHF = try to avoid a bolus; if needed, give half or 1/4 of a liter, monitor for crackles in lungs. Check pulse ox & vitals; check pt. Put order in for 1/2 bag. Cirrhosis - kidneys start failing, but no reason to give a liter because pt has low albumin, kidney damage. Give albumin, high protein diet, steroids to get liver functioning again. Peds - depends on weight; give dextrose w/ K+. AKI - kidney damage; do FeNa score, get urine sodium & potassium; less than 1 is pre-renal, greater than 1 is post renal. Anything between is intrinsic AKI. Basically (if I recall correctly) the fact that the fractional excretion of sodium in the urine is less than 1 means that the problem isn't with the kidneys themselves, since they're still able to reabsorb Na+ and thus there is less sodium in the urine. Ergo, the problem must be before the kidneys. If the kidneys are failing, they won't be able to reabsorb sodium, so there will be more sodium in the urine and thus the problem is intrinsic to the kidneys.

Hyponatremic - too much fluid. Know duration, severity, coexisting medical conditions. Chronic condition pts show fewer symptoms. Monitor for neurological sxs. Correct with 4 to 6 mEq/day. Correct chronic hyponatremia slowly. Serum and urine osmolarity, salt they're putting out. 600 (I'm assuming that's urine osmolality) means osmotic diuresis. Restrict fluids.

Mild hyponatremia (Na+ of 129 mEq/L), add urine sodium & K+ and divide by serum sodium. If ratio greater than 1, it's SIADH.

SIADH - small cell lung cancer can cause it, psych drugs cause it, brain damage, nicotine.

Most common cause of hypernatremia is dehydration; can also be due to DM or meds. D5W is given because it doesn't contain sodium.

Hypokalemia - tired, cramps, cardiac changes. Replete K+. PO is better than IV. IV K+ hurts/burns and messes up veins. When repleting K+, 10 mEq K+ raises serum K+ by 0.1 mEq.

Hyperkalemia - Salt substitute is KCl, so people using it get hyperkalemia. K+ likes to be inside the cells. It over polarizes the membrane when there is too much. Then you get cardiac problems. Calcium will help raise the threshold. Give insulin, Ca2+, hemodialysis. Beta agonists and insulin put K+ into cells. Insulin will take Na+ out of cells. Basically, insulin, NaHCO3, and beta-2 agonists make K+ go into the cells. Ca2+ is given if you see EKG changes in hyperkalemic pts (peaked T waves and widened QRS complexes). Ca2+ protects the heart and prevents dysrhythmias. But you also need to give something that will actually lower total body K+; you do that with furosemide, Kayexalate, or hemodialysis.

Hypomagnesemia is due to poor PO intake or GI loss of Mg2+. It causes torsades de pointes.

Hypermagnesemia-> weakness

Hypophosphatemia-> rickets

Refeeding syndrome - giving too much food too fast to someone who has been starving for a while--> insulin is released in too high an amount and then they get electrolyte abnormalities; particularly important to remember that refeeding syndrome causes hypophosphatemia.

Refeeding syndrome is precipitated by rapid refeeding. The hallmark electrolyte disturbance of refeeding syndrome is hypophosphatemia, which leads to widespread dysfunction of cellular processes. This can be characterized by cardiac instability leading to arrhythmias, congestive heart failure, acute respiratory failure, and even death. Other electrolytes are also deranged, including sodium and potassium, as well as thiamine, protein, glucose, and fat metabolism.

Hypocalcemia - use corrected calcium; sxs: twitch, tetany, Trousseau sign, Chvostek sign. When blood calcium is low, PTH is released-> bones break down.

Hypercalcemia - "stones, moans, groans, thrones, psychiatric overtones;" work up for malignancy (granulomatous diseases cause hypercalcemia).

#fluids #IV fluids #IVF #lactated ringers #D5W #maintenance fluids #electrolytes #electrolyte abnormalities

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type2diabetestreatments-blog · 7 years

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The Scoop on Novo's New Faster-Acting FIASP Insulin

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The Scoop on Novo's New Faster-Acting FIASP Insulin

There's a new ultra fast-acting insulin on the market internationally, and hopefully before long it will become available to us here in the U.S. too.

You may have heard mention of FIASP, or Faster-Acting Insulin Aspart, that recently hit the market overseas and in Canada -- and been wondering what the deal is with this new super-fasting insulin. We put our ears to the ground to learn more about it, what PWDs (people with diabetes) who've started on this med are saying online, as well as what its manufacturer Novo Nordisk has to say about this new product that was just recently re-submitted to the FDA for consideration as a new type of medication.

Here's what we've heard:

Getting to Know FIASP

What exactly is Faster-Acting Insulin Aspart? Remember, insulin aspart is the official scientific name for the synthetic insulin analog that sells under the brand Novolog here in the States and NovoRapid internationally.

What's in a Name? OK, so maybe FIASP is not the most creative branding (sounds like a variety of wasps?), but the name certainly fits. Whether it will carry a new brand name here States when launched remains TBD.

By Vial or Pen? Internationally, FIASP is available by vial, Penfill, and FlexTouch insulin pen. Interestingly, we see that in Europe it's approved for insulin pumps but it's not pump-approved in Canada. Hmm. Here in the U.S., Novo tells us FIASP will only be available in pen form.

Timing Flexibility: FIASP can be taken anywhere from 2 minutes before a meal or up to 20 minutes after the start of a meal, and apparently works just as well as NovoRapid/NovoLog that is taken before mealtime. While Novo officially still recommends taking FIASP before the meal, overall they're touting more flexible dosing, mentioning “earlier, greater and faster absorption, thereby providing earlier insulin action." This something that Novo has also pushed with its new Tresiba basal insulin that can last as long as 42 hours.

Faster Absorption: It's twice as fast as regular NovoLog or NovoRapid. Getting into the science, that's because two "excipients" have been added to FIASP’s formulation -- Vitamin B3 (niacinamide) to increase the speed of absorption, and a naturally occurring Amino Acid (L-Arginine) for stability.

Better Post-Meal BGs: Clinical trial data in which more than 2,000 PWDs with type 1 and type 2 were tested using FIASP showed the new insulin was linked to a lower spike in post-meal BGs and was determined to be just as safe as NovoLog.

More Hypos?! However, data also shows patients had more hypos in the first two hours after eating a meal -- most likely, as the result of not being used to the quicker action.

A1C Effect: Yes, data also show that patients lowered their A1C levels. This remains important, despite the fact that PWDs have been saying for years (and the FDA has recently acknowledged) that A1C is not the end-all, be-all guage for diabetes care. So it will be interesting to watch how FIASP proves itself with other measures like time in range.

The FDA actually sidelined FIASP in Fall 2016, asking the company for more detailed information about the "assay for the immunogenicity and clinical pharmacology data." On March 29, Novo just re-submitted their FDA application for review, so it's TBD how quickly it moves from there. The company expects to hear back from regulators by year's end.

Real-Life Feedback on FIASP

How are patients liking FIASP? It's pretty early to tell still. And of course "fast-acting" is often a subjective term just like everything else in this pancreatically-challenged universe of ours; Your Diabetes May Vary.

One of the best visual explanations we've seen on FIASP to date comes from diabetes nurse specialist in London, UK, Ines Parro, who created this infographic for her informational site Daybetes:

And here's a sampling of some of the online feedback we've seen around the global Diabetes Online Community (shared with their permission, where applicable):

"I have been using FIASP for 30 days. I was using NovoRapid/NovoLog before. FIASP doses the same for me. I find that it starts to work faster than NovoRapid and it stops working a little faster as well around the 3-hour mark. It is too early to see results in my A1C. I did find some injection site discomfort the first few days, nothing serious. That has subsided now and I don't feel a thing with a bolus. I have tight control, 5.8% A1C last time. I think it will make a difference as I can stop a rising high post-meal BG much more effectively than with NovoRapid. I do notice that when I bolus there is a sensation similar to what I felt when injecting Lantus before I switched to the pump."

-- Steve, a Canadian in an OmniPod group on Facebook, who also mentions that insulin is available over the counter in his country.

"Have been on FIASP for a week now, and holy smokes -- what a difference that has made for my blood sugars and overall control. I barely have words to describe my gratitude. For my fellow pancreatically-challenged friends, cannot say enough about how much this has helped with meal-time dosing and corrections. Game-changer!! #fiasp #gamechanger #insulin"

- Sandy Struss in Canada

"Someone who has tried it said the initial drop is fast, so make sure you are eating and the tail is shorter... so far she likes it but she is also using it with a closed loop system."

-- from the Women with Diabetes group on Facebook

- Liz in Europe, discussing FIASP on Diabetes UK forums

"I've got some in my Omnipod right now. I don't find it works any faster or shorter acting than the Apidra that I had been using before (but Apidra was a lot faster and shorter-acting for me than Humalog and Novolog). What it did do though, was drop my BG way more than I expected, so I guess it is more effective. My very first meal with it I bolused the same 4 units that I normally would for the lunch I eat everyday, and my BG fell to 2.9 mmol/L (52 mg/dl) around 90 minutes after eating, where as normally, from the 6.5 I started at, Apidra or Humalog would have brought be down to 5.5 or 6.0 after eating. I've had to lower my basal rate as well, because I woke up three times last night to the low alarm from my Dexcom. I am using fewer units per day, but I find its effects less predictable than Apidra for me. There is probably going to be a descent length adjustment period to learn the idiosyncrasies of it."

- Vicka Plume in Canada, as posted on the TuDiabetes forums

We're also following our UK D-friend Tim Street over at DiabetTech, who's been experimenting and chronicling his FIASP experience since starting on it in March -- from his first 48 hours and initial impressions, to wondering if "this is, in fact, the next-gen insulin we've been waiting for?" He was initially enthusiastic, but ran into some snags later, as noted in his latest Further FIASP Insight blog post:

"At first it was a joy, with massively reduced bolusing time and huge efficiencies, however as the month has progressed, our friendship has soured somewhat. I’ve been needing more and more of it and it’s not been much fun trying to work out what’s been going on."

Specifically, Tim notes that while FIASP appears to work faster, it has also increased his insulin sensitivity and he's observing that it seems less effective per unit as time goes on. He wonders whether that could be a long-term issue for this product across the board, or maybe just an effect personal to him.

He also notes: "For meals with a slow absorption profile, there is a real risk of hypoing here if the upfront bolus is too high. It looks like it will be beneficial in the use of a square wave or dual wave/combi bolus though. I think these factors will need to be considered in changing to this insulin. People may need to re-learn their bolusing strategy dependent on the foods that they eat. Something for both PWDs and HCPs to be aware of when looking at changing."

We're happy to see Tim inviting others from around the D-Community to share their own experiences with FIASP, to help everyone better understand how it works in real life. Great idea, Tim!

Access and Affordability?

Of course, any new insulin product these days brings critical questions of access and affordability.

No matter how great the innovation, it doesn't much matter if people can't afford it or get access through their insurance plans. So what's the status of cost and coverage for FIASP?

We're told that in the EU and Canada, FIASP carries the same cost as existing Novolog insulin, whereas U.S. pricing has not yet been finalized, according to Novo.

That's a little unnerving given the complicated drug pricing and insurance coverage system we're faced with here in the States, where insurance plans have no real incentive to let patients change to newer or different medication varieties if they cost more. In fact, the payers are notoriously pushing patients to cheaper alternatives these days (i.e. non-medical switching), which gave birth to the #PrescriberPrevails advocacy campaign calling for physicians (and patients) to have the freedom to select the best treatment for the individual.

At the moment, we can only cross our fingers that PWDs will have reasonable access to any insulin they need, up to and including exciting faster-acting varieties that could improve results.

Disclaimer: Content created by the Diabetes Mine team. For more details click here.

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This content is created for Diabetes Mine, a consumer health blog focused on the diabetes community. The content is not medically reviewed and doesn't adhere to Healthline's editorial guidelines. For more information about Healthline's partnership with Diabetes Mine, please click here.

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type2diabetestreatments-blog · 7 years

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Ask D'Mine: Teens and M&Ms, Dealing with Um... ED

New Post has been published on https://type2diabetestreatment.net/diabetes-mellitus/ask-dmine-teens-and-mms-dealing-with-um-ed/

Ask D'Mine: Teens and M&Ms, Dealing with Um... ED

Hello again and welcome to our new diabetes advice column, Ask D'Mine:

Send us your diabetes questions! We don't mind a bit if they're weird, slightly angry, or something you might consider embarrassing. Really. We love that stuff.

"Need help navigating life with diabetes? Email us at [email protected]"

Jumping right in, say hello to your host, veteran type 1, diabetes author and community educator Wil Dubois:

Julie from Colorado, type 3, writes: I could kill our endo. He told my 14-year-old boy that he could eat anything he wanted to so long as he bolused for it. Now my son is eating M&Ms and his blood sugar is a wreck! When I try to call him on it he just tells me the endo says it's OK. What should I do?

Wil @Ask D'Mine answers:

Oh yeaaaaaaaaaah.........

What? Oh! Sorry! I drifted off into fantasy there for a moment. I was picturing your endo leaning against a stained and pot-marked wall, smoking his last cigarette, contemplating blindfold or no blindfold, while a squad of infuriated mothers load their rifles.

All right, so first to the medicine side of this equation. Technically speaking, the endo is right: you can eat anything if you bolus correctly for it. Yeah, and technically speaking, you can swim in bloody water with great white sharks without using a shark cage — if you do it correctly. But that doesn't make it a good idea.

Even when using advanced pump features, super-bolus techniques, a Symlin pen, and perfect timing to make a marching band proud—many adults have trouble bolusing for some kinds of foods. Our fastest insulin is not nearly fast enough for many of the foods in our environment. On top of that, type 1 teens are smaller ecosystems, which are harder to control than larger ones. And teens often lack the...ummmm... focus... needed to make complex boli work. And don't even get me get me started on the whole hormone thing.

So does technically correct advice make for good advice? Uh, no. I think most of us would agree that telling a teenage kid that they can do anything they want, "just so long as..." is a really bad idea.

I'm sure you wanted to tear that endo apart, and I applaud your restraint in not doing so. You could try "talking" to the endo, but I think you'd probably be wasting your breath. Endos don't get continuing education credits talking to moms (although it would be a good idea). My experience with docs is that the more specialized they are, the less open to outside advice they are. And changing endos wouldn't remove the hall pass your kid just got. Worse, even if your endo changed his tune, the kid will still stick with the original statement because it validates behavior he wants.

So, at this point, the die is cast. The train has left the station. The ship has sailed. You get the idea...

Now what?

The core problem here is that a Medical Authority—note capital letters—has given your son permission to do something against your rules/desires. And in the pediatric type 1 universe, Medical Authority can trump parental authority. After all, if mom and dad know it all, there's no reason to go to the doctor, now is there?

I think your only alternative here is to appeal to a higher authority than the endo: King Teststrip.

I propose you make a deal with your son: Fine. The endo is correct. You can eat anything, as long as you bolus. But the endo also gave you glucose targets you have to keep inside of. The latter rule trumps the former.

With apologies to sci-fi author Isaac Asimov, here are my Three Laws for employing this advice from the endo:

You must first keep your blood sugar in target.

You must take insulin when you eat.

You may eat anything you want, so long as you don't break rule number one and rule number two.

Say to your son: if you can stay under your high target, fine, you can eat it. If you can't keep your numbers in target, sorry, you can't eat it. Now, let's test those M&Ms.

Test-bolus-eat-test.

I'm guessing the M&Ms will have a hard time passing the test.

Good luck, and be sure to let us know how it all works out for you!

Robert from New York, type 2, writes: I'm 54 years old and my last A1C was in the high 8s. Lately I've been having some trouble in the bedroom. I'm wondering if my diabetes is the cause, and what I should do about it. Should I ask my doctor for the little blue pill? Will it work for me?

Wil @Ask D'Mine answers: I think you should ask your doctor if a prescription for five prostitutes is right for you. But seriously, now that I've offended half the readers with my off-color humor, erectile problems are common for middle-aged guys. They are also common for PWDs with elevated blood sugar. I won't bum out all of you guys with the statistical odds for middle-aged PWDs with high blood sugar, as it's much too nice a day out to go there. Let's just say your odds are long. On second thought, that's a really bad choice of words on my part. Moving on...

There are lots of causes of what we now like to call Erectile Dysfunction, or ED. Some are physiological—body stuff. Some are psychological—emotional stuff. But, yeah, I'd be willing to bet that your diabetes has a part to play in your bedroom problems.

The first thing you should do is get your damn blood sugar down where it belongs. High blood sugar can cause ED, and getting your diabetes in control might be all it takes to get you up and running again (if you know what I mean).

Also, beyond the bedroom, an A1C in the high 8s puts you on the doorstep of kidney damage, which will make your bedroom problems look pretty small by comparison. So a lot of good things will come from getting your blood sugar better controlled.

I think that should be your first step. If you continue to have trouble in the bedroom after your BG is in control, then one of the several prescription meds for ED is very, very likely to work for you. The clinical track record for these meds is excellent.

Not long ago I asked a patient if the Cialis that one of our docs had prescribed for him had done the trick. "Works great," he told me with an ear-to-ear grin.

"Too well!" spat his wife.

Ah....

It's at times like this that I actually don't know what to say.

And, of course, in keeping with the perverse nature of the heathcare universe, ED meds are usually better covered by insurance than diabetes meds and supplies. But that's a subject for another day...

One last note for the guys only: Don't be selfish bums. If you are having some ED issues, please remember that there are other ways to make your partner happy and satisfied until you are up and running again. Be creative about it. Be open about it. Be a man about it.

Don't forget to ask YOUR questions. Go ahead. You know you want to...

This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.

Disclaimer: Content created by the Diabetes Mine team. For more details click here.

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type2diabetestreatments-blog · 7 years

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First-Ever Guidelines on Safe Exercising with Type 1 Diabetes!

New Post has been published on http://type2diabetestreatment.net/diabetes-mellitus/first-ever-guidelines-on-safe-exercising-with-type-1-diabetes/

First-Ever Guidelines on Safe Exercising with Type 1 Diabetes!

As a person with type 1 diabetes who exercises regularly, I can tell you it's pretty much of a guessing game. I have some strategies that I use to keep my glucose in range for my spin class, aerobics, kick box, hiking and other workouts, but they are far from fool-proof -- and I've yet to find any really solid advice on BG management during these sweat-fests.

So I for one am really intrigued to see the first-ever official guidelines on managing exercise with T1D published in The Lancet journal last week as a 14-page report titled “Exercise management in type 1 diabetes: a consensus statement.” This comes on the heels of the ADA's sweeping 2017 Standards of Diabetes Care, which we just reviewed yesterday.

The new info-packed paper honing in on exercise was compiled by an international team of 21 researchers and clinicians, including some familiar names like JDRF's Artificial Pancreas lead Aaron Kowalski, and Drs. Bruce Bode of Atlanta Diabetes Associates, Anne Peters of USC Keck School of Medicine, and Lori Laffel of Joslin Diabetes Center.

Image Attribution

Source: SparkPeople URL: http://www.sparkpeople.com/resource/fitness_articles.asp?id=1497

It offers "guidelines on glucose targets for safe and effective exercising with T1D, as well as nutritional and insulin dose adjustments to prevent exercise-related fluctuations in blood sugar."

So what did these experts come up with? Well, let me just say that it's a comprehensive and informative paper -- explaining everything from the physiology of diabetes and exercise and the body's differing metabolic responses to aerobic vs. anaerobic activity, to sports energy drinks and the relative benefits of a low-carb, high-fat (LCHF) diet.

Disclaimers, and a Green Light

The authors are careful to make a few important disclaimers, first and foremost that one-size recommendations do not fit all, so strategies should be built around exercise types and individual aims, and should take into account "various factors including glucose trends, insulin concentrations, patient safety, and individual patient preferences based on experience."

The other main disclaimer is the simple fact that there are VERY FEW studies from which they were able to draw. "Several small observational studies and a few clinical trials have been published to date that help to inform the consensus recommendations presented here. More studies are needed to determine how to best prevent exercise-associated hypoglycemia... and how to manage glycemia in the recovery period after exercise."

They also state what seems obvious to most of us: "In general, aerobic exercise is associated with reductions in glycemia, whereas anaerobic exercise might be associated with (an) increase in glucose concentrations. Both forms of exercise can cause delayed-onset hypoglycemia in recovery."

Still, they make a big point of saying that despite concerns around fluctuating BG levels, exercise is highly recommended! "Active adults with type 1 diabetes tend to have better chance of achieving their (target A1C) levels, blood pressure targets, and a healthier BMI than do inactive patients... (and experience) less diabetic ketoacidosis and reduced risk of severe hypoglycemia with coma."

"The overall cariometabolic benefits outweigh the immediate risks if certain precautions are taken."

Gotcha, good news.

"However, older women who are active appear to have higher rates of sever hypoglycemia with coma than those who are inactive." (well, crap! bad news for me)

Which Exercise, and How Much?

The authors note that all adults with diabetes (either type) should be getting in 150 minutes of accumulated physical activity per week, with no more than two consecutive days of no activity.

They make detailed mention of aerobic activities (walking, cycling, jogging, swimming, etc.), resistance or strength training (free weights, weight machines, elastic resistance bands), and "high-intensity interval training" that involves intervals of exercise and rest.

But the consensus is: "It is unclear what the most effective forms of exercise for improvement of cardiometabolic control in type 1 diabetes are."

A few specifics they could provide are:

Exercise can increase glucose uptake into muscle by up to 50 times

Hypoglycemia develops in most patients within about 45 minutes of starting aerobic exercise

Individuals who are aerobically conditioned have lower glucose variability than do those who are unconditioned

The risk of hypoglycemia is elevated for at least 24 hours in recovery from exercise, with the greatest risk of nocturnal hypoglycemia occurring after afternoon activity

Weight lifting, sprinting, and intense aerobic exercise can promote an increase in BG that can last for hours; although a conservative insulin correction after exercise might be prudent in some situations, over- correction with insulin can cause severe nocturnal hypoglycemia and lead to death

High-intensity interval training has been associated with a higher risk of nocturnal hypoglycemia than continuous aerobic exercise in some cases

Starting Glucose for Exercise

Again with a lot of disclaimers about taking all the personal variables into consideration, the report recommends the following for kicking off exercise:

Starting BG below target (<90 mg/dL)

Ingest 10–20 grams of glucose before starting exercise

Delay exercise until blood glucose is more than 5 mmol/L (>90 mg/dL) and monitor closely for hypoglycemia.

Starting BG near target (90–124 mg/dL)

Ingest 10 g of glucose before starting aerobic exercise

Anaerobic exercise and high-intensity interval training sessions can be started

Starting BG at target levels (126–180 mg/dL)

Aerobic exercise can be started

Anaerobic exercise and high-intensity interval training sessions can be started, but beware that BG levels could rise

Starting glycemia slightly above target (182–270 mg/dL)

Aerobic exercise can be started

Anaerobic exercise can be started, but beware that BG levels could rise

Starting glycemia above target (>270 mg/dL)

If the hyperglycemia is unexplained (not associated with a recent meal), check blood ketones. If blood ketones are modestly elevated (up to 1·4 mmol/L), exercise should be restricted to a light intensity for only a brief duration (<30 min) and a small corrective insulin dose might be needed before starting exercise. If blood ketones are elevated (≥1·5 mmol/L), exercise is not recommended and you should be treating your high with the help of your HCP

Mild to moderate aerobic exercise can be started if blood ketones are low (<0·6 mmol/L) or the urine ketone dipstick is less than 2+ (or <4·0 mmol/L). BG should be monitored during exercise for further increases. Intense exercise should be initiated only with caution as it could promote further hyperglycemia

These are primarily aimed at maximizing athletic performance, the authors explain, and "are based largely on studies done in highly trained healthy individuals without diabetes, with few studies done in people with type 1 diabetes."

Basically, for intense exercise, they say that various carbohydrate and insulin adjustment strategies can be used, including reducing your pre-exercise bolus insulin dose by 30–50% up to 90 minutes before aerobic exercise, and/or consumption of high-glycemic (fast-acting) carbs during sport (30–60 grams per hour).

The optimal recipe here will vary by individual, but a general rule of thumb for "nutritional distribution of the total daily energy intake" is:

45–65% carbohydrate

20–35% fat, and

0–35% protein, with higher protein intakes indicated for individuals wanting to lose weight

The authors state: "The major nutrients required to fuel performance are carbohydrates and lipids, while the addition of protein is needed to help foster recovery and maintain nitrogen balance."

For protein intake, they suggest:

Eating 1-2 to 1-6 grams per kilogram of body weight per day, varying with training type and intensity

Eating ~20-30 grams of protein in addition to carbs immediately following exercise to promote muscle protein synthesis

They also point out that low glycemic index foods are a better choice before exercise, whereas high glycemic foods after exercise can enhance recovery. They even cite a study with proof of that, in which adults with T1D who ate low-GI carbs two hours before a high intensity run did better than those who ate more sugary stuff.

When it comes to low-carb, high-fat diets in people with T1D, they simply state that "long-term studies have yet to be done on the health, glycemia, or performance effects... (and) a concern with these diets is that they could impair the capacity for high intensity exercise."

Recommended Liquids for Exercise with Diabetes

They even have a lot to say on what we should be drinking.

Water is the most effective drink for low intensity and short-duration sports (ie, ≤45 min), as long as BG is at 126 mg/dL or higher.

Sports beverages containing 6–8% carbs and electrolytes "are useful for athletes with type 1 diabetes exercising for a longer duration (and) as a hydration and fuel source for higher intensity exercise, and for prevention of hypoglycemia. However, over-consumption of these beverages can result in hyperglycemia." Ya think?

Milk-based drinks containing carbs and protein "can assist with recovery after exercise and prevent delayed hypoglycemia"

Caffeine intake in athletes without diabetes has shown improvements in endurance capacity and power output.85 Caffeine intake (5–6 mg per kg body mass) before exercise attenuates the decrease in glycemia during exercise in individuals with type 1 diabetes, but it might increase the risk of late onset hypoglycemia.

Insulin Dosing Strategies for Exercise

And what about adjusting insulin? Should you be tweaking your bolus or basal doses?

Here's a rundown of what the paper says on that:

Bolus dose reductions "require planning in advance and are probably only appropriate for exercise with a predictable intensity performed within 2–3 hours after a meal"

Reduction in the basal insulin dose for patients on multiple daily insulin injections "should not be routinely recommended but can be a therapeutic option for those engaging in considerably more planned activity than usual (eg, camps or tournaments)"

Where practical, a basal rate reduction, rather than suspension, should be attempted 60-90 minutes before the start of exercise

An 80% basal reduction at the onset of exercise helps mitigate hyperglycemia after exercise more effectively than does basal insulin suspension, and appears to be associated with a reduced risk of hypoglycemia both during and after the activity; optimal timing is yet to be determined

We propose a time limit of less than 2 hours for insulin pump suspension on the basis of rapid-acting insulin pharmacokinetics (meaning how the drug moves through your body)

To address nocturnal hypoglycemia, the consensus statement recommends about a 50% reduction of bolus insulin dose for the meal following exercise, "along with consumption of a snack with a low glycemic index at bedtime."

"Consumption of a snack alone, without changing basal insulin therapy, does not appear to entirely eliminate the risk of nocturnal hypoglycemia, and alcohol intake might increase the risk," they add.

... All very useful tidbits for managing this incredibly complex condition! And doing so while also concentrating on your workout, for God's sake.

So, all you athletic types with diabetes out there -- what are your thoughts here?

Disclaimer: Content created by the Diabetes Mine team. For more details click here.

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Type 2 Diabetes Treatment Type 2 Diabetes Diet Diabetes Destroyer Reviews Original Article

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type2diabetestreatments-blog · 7 years

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Ask D'Mine: How to Stack Insulin, and a Mystery Diagnosis

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Ask D'Mine: How to Stack Insulin, and a Mystery Diagnosis

Welcome to another edition of our weekly Ask D'Mine column! But before we get started, we want to wish Amy a very Happy Birthday today!

We hope Amy has a fabulous and relaxing day with her family and friends. She deserves it!

And now, back to our regularly scheduled programming...

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Too much insulin, too little insulin... Goldilocks had nothing on PWDs! This week, our host Wil Dubois, diabetes author and community educator and also a veteran type 1 himself, helps two readers figure out how to get their insulin doses just right.

Need help navigating life with diabetes? Email us at [email protected]

Robin from New Jersey, type 1, writes: I'm a recently diagnosed Type 1, and my insulin requirements seem to change pretty often. Even when I eat the same healthy meals and have roughly the same activity level, my BGs suddenly start jumping higher for a few days. And then they'll drop. I've had various changes in my dosing, but I feel like I'm chasing the wind trying to get an MDI plan that works. I can't change my bolus calcs or basal dose every time I have one high or low day, but I hate having high BGs for hours on end. If I'm careful about insulin already on board, how often can I give a small correction dose of fast-acting insulin to get back in line?

PS—I LOVE your Q&A column. Your good humor and down-to-earth approach really make a tangible difference for me and many others!

Wil@Ask D'Mine answers: Thank you for the vote of confidence on the column! Much appreciated. Ahem...

So what we are talking about here is strategic stacking. Or maybe it's tactical stacking. Hmmmm.... Fun question.

OK, so in a test tube, our modern fast-acting insulins last up to six hours. In most folks, the realistic effect tapers off at the four hour point, but that said, a lot of endos prefer to use a three-hour duration of action when figuring these things out. At any rate, the smart money says the insulin will last between three and four hours. The common wisdom invested in the smart money says not to bolus more than every four hours to avoid a stack-and-crash.

But let's think about this for a moment.

The whole "avoid stacking" thing assumes that you've actually taken enough insulin to get the job done, but the job just isn't done yet. It's an approach that counsels patience. But what if you didn't take enough insulin? Then it wouldn't matter how long you wait, you'll still need to add more insulin. So the question becomes, how do you know when it's safe to assume you don't have enough insulin on board to finish the job?

My vote: two hours.

For me, I find that I do get a solid four hours out of a shot of fast-acting, based on the fact I sometimes get hypos right around the four-hour mark. Hey, if the insulin had worn off at three hours, it wouldn't be able to force my head underwater an hour later, right? So I think if, half way through the insulin's run at two hours, you're not yet half way to where you want to be, you can—and should—take some more insulin.

In short, you need to do some math, and if the job is less than half done at two hours, get some more workers on the case!

Sooooo...practice time! Let's pretend you were at 300 when you corrected, and want to be at 100. If two hours downstream you're at 200, should you take more insulin? No! You're half way through the insulin's duration of action and you're half way to your destination. Things are going perfectly! (Going from 300 to 200 is a one-hundred point drop and, in a perfect world, you'd expect to be half-way home in two hours.)

If you are, say, at 250, you could go ahead a take a sip of insulin. Not as much as you would take for 150 points high—you've still got insulin in play for 100 points worth of drop—but you could take some more for the extra 50 points that you're still above target.

Of course, in two more hours, your original correction dose for the 300 is gone, but you still have half the insulin you took for the 50 points over target. If you're not down to 125 at this point you can take a third correction (remembering, of course, that you have half a 50-point correction still in the pipeline).

And if you're going to do much of this, may I suggest a notebook and pen?

Now, word of warning before all the endos and techno freaks start flaming me. The system I just advocated for suggests a linear duration and method of action for the insulin in your bod, which it isn't. It's really curvilinear. That is to say the insulin in your body isn't like sand flowing through an hour glass. Insulin takes a little while to ramp up in your body, and at peak action it has more punch than it does towards the tail end. So using a straight line approach, in theory, under-estimates the first hour of insulin and over-estimates the last hour. But as we are playing the averages anyway, and because diabetes and blood sugar have more in common with chaos theory than normal math, I think you'll find my approach not only "good enough," but practical and usable without needing an advanced degree in mathematics.

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Christy from Missouri, type ??, writes: I was hospitalized in the middle of November. The doctor diagnosed me as type 2 and put me on 500mg of Metformin twice a day. He told me I had ketones in my blood and urine but was not acidotic. Later, in December, I began seeing a nurse practitioner. She did a metabolic panel and my A1C came back 14.3. She told me I was type 1, and within a few visits I was shooting 20 units of Lantus before bed, and 4 units of Novolog before each meal. Plus the metformin twice a day. The insulin, while very effective in controlling my postprandial spikes, presented a whole new set of challenges. I quickly learned that if I didn't have enough carbs in my meal, I would go hypo. I would shake, then sweat, followed by a headache. I feel like I'm a walking experiment. I don't know what to make of all of this. If I respond so strongly to the insulin, am I a type 2 like the doctor said, or a type 1 as the nurse told me?

Wil@Ask D'Mine answers: One if by land, two if by sea... Sorting out who's a type 1 and who's a type 2 is not as easy as you would think it would be. Virtually every test in our arsenal is subject to false positives or false negatives under some circumstances.

So I'm not sure either which type you are. Type 2s generally don't have ketones, but they can. Type 2s are generally more insulin resistant, but not always. Both type 2s and type 1s can respond to metformin. What a mess! But you know what?

It really doesn't frickin' matter.

And that's because what kind of diabetes you have is not likely to change how you, Christy Q. Mystery Diabetic, will control this illness. Here's why: first we know that metformin, all by its little lonesome, did a miserable job of controlling your diabetes, leaving you at dialysis-friendly A1C level of 14.3. We also know that most oral meds will only lower A1C by one point or less. To get you from 14.3 to 6.3 on oral meds alone would require at least eight different pills. Screw that. Better to break out the insulin.

Insulin, wonderful insulin, is infinitely scalable. You use as little or as much as you need to get the job done. But you should be taking.

Novolog to cover your food, not taking food to cover your Novolog. I was disturbed to hear you have to eat "enough carbs" in your meals to keep from going low.

I think this is because you're using flat-rate dosing, which isn't the best way to use the med. A flat dose of Novolog requires a flat dose of food. Flat-rate dosing is simple, but it's likely to give too much insulin for some meals, and too little insulin for others. Your medical team should take some time to help you figure out your insulin-to-carb ratio. This will let you vary the size of your mealtime shot depending on the size of your meal. Some meals might need only two units, others might need ten. You'll also need to learn how to count carbs so in order to determine the right amount of insulin to take.

As you do seem pretty insulin sensitive based on your Lantus and Novolog volume, you should also talk to your medical team about whether or not you still need the metformin at all.

Hopefully some med changes will convert you from a walking experiment to a walking success story, even if still a mysterious one.

Disclaimer: Content created by the Diabetes Mine team. For more details click here.

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Type 2 Diabetes Treatment Type 2 Diabetes Diet Diabetes Destroyer Reviews Original Article

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type2diabetestreatments-blog · 7 years

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D-Blog Week: One Thing to Improve

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D-Blog Week: One Thing to Improve

We are in the third day of the annual Diabetes Blog Week, hosted by Karen Graffeo over at Bitter-Sweet Diabetes.

The topic today is One Thing to Improve. As Karen instructs: "Yesterday, we gave ourselves and our loved ones a big pat on the back for one thing we are great at. Today, let's look at the flip side. We probably all have one thing we could try to do better. Why not make today the day we start working on it? No judgments, no scolding, just sharing one small thing we can improve so the Diabetes Online Community (DOC) can cheer us on!"

In deciding which of our team at the 'Mine would write this one, Mike quipped: "Only ONE thing to improve? Geez." So, that won him the honor of penning our entry for today!

While we sometimes joke that no Person With Diabetes (PWD) is perfect, my motto is that I'm "pretty perfect at being imperfect" when it comes to my own D-management — a little by choice, and some by simple lack of willpower. You could actually say I'm the epitome of anti-willpower when it comes to handling some of the basics of diabetes management that they teach us back at diagnosis time. You name it, I'm probably able to improve it. And there's no shame on my part in admitting that.

But one thing that clearly rises to the top of my improvement list is my ability to slack on my carb counting and insulin dosing in the evenings. See, I tend to do all the right things during the day. Routine is key, but so is the fact that in an office setting, there's less temptation to just go "grab something."

Once I'm at home and dinnertime rolls around, though, all bets are off. That's when my slacking begins, from not accurately measuring the food and dosing accordingly to idly munching on snacks throughout the evening. Obviously, that leads to higher BG readings at night. Sometimes so high that it impacts my ability to sleep. Then I need to give myself a correction (or a rage bolus) to start coming down by morning, although I'm often still in the 200s until mid-morning. That of course spills into the rest of my day, sometimes creating a chain reaction on the glu-coaster where Lows and Highs smack me upside the head!

Now that I'm working from home, the costly vending machines or store-bought options have made way for whatever might be in the cupboard or refrigerator — meaning less obstacles on the path to eating, if my willpower is taking a nap.

So, that's my item to improve on. I know I can start by making better use of the digital scale we bought a few years ago, but haven't utilized as much as we should. I can also focus on checking the carb counts for home-cooked meals and finding the necessary nutritional info when we dine out. When at home in the evenings, whether I'm online or hanging with the family, that means resisting the urge to snack. If I am that hungry or need to eat something, the scale and ONE portioned bowl needs to be the limit.

Simple concept: do what I'm supposed to, and use the tools that I already have.

Measuring food, dosing correctly, testing to ensure I'm staying in range or closer to it, and balancing that food with exercise and all the rest of whatever might be happening in life. Simple, right? Maybe so, for those textbook PWDs. But I'd say for me, all that is easier said than done.

With my history of slacking, I know one post is not enough. I'll have to keep writing and tweeting about this, and hopefully lean on the cheerleading DOC to help keep me accountable! (thanks in advance, for the likely swarm of messages on this...)

And then, I'll worry about all those other items that should be on my improvement list...

We'd love your input: Do you all have any tricks or tips to stay accountable on carb counting and insulin dosing?

Disclaimer: Content created by the Diabetes Mine team. For more details click here.

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Type 2 Diabetes Treatment Type 2 Diabetes Diet Diabetes Destroyer Reviews Original Article

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