Dr. Steven Edelman on Hypoglycemia + Glucagon

This content originally appeared on Beyond Type 1. Republished with permission.

By Alexi Melvin

Dr. Steve Edelman, MD, is a diabetes specialist as well as the Founder of Taking Control of Your Diabetes (TCOYD) — an organization focused on empowering those with diabetes and encouraging them to “take a more active role managing their diabetes, and being self-advocates.”

Dr. Edelman recently took the time to chat with Beyond Type 1 about the importance of glucagon, among other key issues around hypoglycemia.

BT1: Thanks so much for speaking with us today Dr. Edelman — to start, can you talk about your personal background with type 1 diabetes?

Dr. Edelman: When I turned 15, I came down with all the drastic signs and symptoms and was diagnosed with type 1. 1970, they really were in the dark ages. So, my doctor put me on one shot of insulin and regular in the morning and we had urine testing and that was it. Could you imagine being on regular insulin just with breakfast?

And then eventually when I was an undergrad at UCLA, I ran into some really good diabetes doctors and they got me on the right track, but I did have really poor control for a long time. I didn’t really realize the importance of it. Unfortunately, as a result, I do have complications, but the good news is they’re stable.

What inspired you to create TCOYD?

It dawned on me that the education to people with diabetes was really quite lacking way back to 1995. I went to the Joslin clinic for my training. I went to UCSC to do clinical research, and I realized, all of the education was just going to healthcare professionals.

Not that it wasn’t good, but that’s the only direction it was going. I decided to put on a conference for people with diabetes at the San Diego convention center in September of 1995 and that was the beginning of TCOYD. And I was just going to do one conference here. I had two young kids and so I was just going to do it once a year. And that was a lot of work. But the feedback was so powerful, and people were, it’s a great phrase, so thirsty for information that I just said, “you can’t just stop at one a year” and then slowly spread. And then we started putting them on around the United States.

I felt that it was still important to educate healthcare professionals and about 15 years ago I kind of gave up on healthcare professionals. They were really stuck in the mud, really hard to change their practice habits, so that’s why I focused on patients. Then about 15 years ago, we started this program called Making the Connection, where we brought people with diabetes and healthcare professionals together in the same learning environment. The healthcare professionals got their own lectures in their own room at the convention centers and patients got their own, but in parts of the day, we brought them together. It was all in an effort to improve the doctor-patient relationship because our system is pretty broken. People are pretty pissed off at their caregivers. And if you don’t have trust in your caregiver and if the caregiver doesn’t have empathy back, it’s a bad combination.

So now we do our CME programs in parallel with our patient programs, and now we converted to virtual and I think we did a really good job. I don’t get much credit myself. If you’ve seen some of the crazy videos we do to try to keep education entertaining. I think we have a combination of good content and entertaining. I think the future’s going to be virtual learning for us. We have a conference on Saturday and we have people signed up from 60 different countries, about 3000 people across the United States, every state.

What sparked your desire to bring awareness to hypoglycemia and the need for glucagon options in particular?

A lot of people do not remember that in the old days there were people dying of hypoglycemia and it still occurs. Thanks to the continuous glucose monitor (CGM), it has gone down dramatically. I haven’t had any patients recently pass away from hypoglycemia, but I’ve had 10 people through the years, and they all were the same. They all had really good control. They were told a zillion times that they need to avoid complications, get their blood sugars down, but we didn’t have tools to prevent severe hypo. After having type 1 diabetes for 10 years, you kind of lose your response to hypoglycemia and you lose your symptoms. It’s really a sad thing.

What are some of the main issues that lead to severe hypoglycemia today?

Being a diabetes specialist, I see some pretty serious stuff all the time including people who failed at using the old glucagon kit, which delayed therapy and caused unbelievable hassles. I also have an uncle who had type 1 and he died from hypoglycemia and he had severe hypoglycemia unawareness. He had no complications of diabetes. He was treated at the Joslin Clinic when he was diagnosed, but he was so strict. I could not get him to back off like my other patients. And he basically got low and didn’t realize it. And that was it.

How have glucagon options progressed?

With the old glucagon kits, you had to be almost like a chemist to put these things together. And think about it, the person administrating and getting the glucagon ready to give, they’re typically not medically oriented. They’re the mother, the sister, coworker. And you’ve got to squirt diluted fluid into a little vile of powdered glucagon, mix it up, make sure it’s all dissolved. Then you got to suck it back out into the syringe. Then you got to take the syringe and jab it into someone on the ground that’s typically having a seizure or biting their tongue or rolling over, or demonstrating pretty bizarre behavior, which can occur. And when someone’s like that, time is of the essence. Anything that could make the quick administration of glucagon in an easy way for almost anybody, no matter what type of background is, is so important.

What would you say is the biggest obstacle around glucagon access today?

I think the biggest issue today is people do not have a valid prescription for it. I always have this analogy, if you have a house or an apartment and it gets robbed and they steal everything that’s important to you, what do you do next? You get an alarm system on your house. And I always say that same analogy. If someone’s had a bad hypo, they always have glucagon with them, but they did not have one at the time that they really needed it when they had a bad hypo. So, we have to really say, “Yeah, it can occur even if you’re on CGM, especially if you’re a type 2 on insulin as well,” cause that happens. And you got to have a valid glucagon kit with you, a valid meaning unexpired. These new glucagon kits last much longer. They don’t expire as fast as the older ones do, so that’s also helpful.

What are some ways that the CGM can most effectively help avoid hypos?

Well, one of the things I do in clinic is to really check where people set their upper and lower alerts. I had a patient yesterday in clinic who has had type 1 for 60 years. Her A1C is unbelievable, but she does have hypo unawareness and her lower alert was 65. You have to convince people that the extra alerts are worth it to you.

A lot of people said they put their lower alert at 65 and they don’t realize this situation called the “lag time.” So, when your blood sugar is dropping, even if you have a diagonal arrow down compared to, even worse, one arrow down or two arrows down, looking at the Dexcom arrows, they don’t realize that the glucose in your circulation is probably much lower than it appears on the Dexcom monitor or your phone. Because the Dexcom sensor and other sensors too, they measure the glucose in the subcutaneous tissue, and there’s a lag between the subcutaneous tissue and the circulation.

When your Dexcom goes off or when your CGM goes off at 65, and if your trend arrow’s going down, you could be 45 or 40. So that’s really an important issue, especially for people that their symptoms aren’t as obvious anymore. You could be caught off guard. And I had multiple patients that has occurred with. And then unfortunately, as you know, the majority of T1Ds in this country do not wear a CGM and that’s the topic of a whole other story.

Does this lag time issue apply to a regular glucometer as well?

Yes. If your blood sugar is dropping, your meter or CGM may be perfectly accurate of the subcutaneous tissue at 65. If you checked your blood sugar with a meter, it’s still going to say 65, but your circulation that’s going to your brain might be 45. So, the lag time is key. You could have the most accurate meter or CGM in the world, it doesn’t affect the lag time.

Is there anything else that you would want people to know about glucagon options that you don’t think is discussed enough?

I would say this, people have to ask their caregiver for it because in a busy clinic, it’s typically the last on the list and it’s important that they ask for a glucagon prescription.

I think they need to know that there’s two now that are just as easy to use as an EpiPen. Obviously, one is the nasal spray (BAQSIMI). But these devices aren’t for them, they’re for people who are going to be around them and that they should get more than one if they’re going to be at work or out of the house a significant part of the day. And have their best friend or their coworker be on the cautious side because when you least expect it, it can happen.

Source: diabetesdaily.com

Hypoglycemia Preparedness: How to Know Before You Go Low

This content originally appeared on diaTribe. Republished with permission.

By Lorena Bergstrom

A new awareness campaign helps people with diabetes recognize and plan for low blood sugar with emergency toolkits, discussion prompts, journaling, and a support network  

Low blood sugar can be a scary thing – it often sneaks up when people least expect it, quickly shifting from a minor annoyance to a potentially dangerous situation. In fact, a Canadian study found that people with diabetes (type 1 and type 2) experience severe hypoglycemia an average of 2.5 times each year. While type 2 diabetes typically presents a lower hypoglycemic risk than type 1, insulin and oral medications can still cause low blood sugar. However, you can take many steps to protect yourself.

We spoke with endocrinologist Dr. Gregory Dodell (with Mount Sinai in New York) and singer Crystal Bowersox about Lilly’s new Know Before the Low campaign, an important initiative to raise awareness about hypoglycemia. Bowersox and Dr. Dodell hope this program will empower people with diabetes to recognize signs of low blood sugar, start conversations with their peers, and prepare for emergencies before they happen.

Dodell

Image source: diaTribe

Know Before the Low offers information about managing hypoglycemia; it includes a chart of physical and cognitive symptoms, a tip list for emergency planning, and a guide for building a support network. Dr. Dodell said that unfortunately most diabetes literature focuses on controlling high blood sugar – even though low blood sugar can be more dangerous. He said that the campaign aims to address this information gap by “helping people and healthcare professionals talk about low blood sugar and prevent future episodes.”

To start, every person with diabetes should build an emergency toolkit, including:

  • Glucose tablets or sugary snacks
  • Glucagon – read about emergency nasal glucagon (Baqsimi) and ready-to-use autoinjector pens (Gvoke)
  • Glucose monitor (continuous glucose monitor or fingerstick blood glucose meter)
  • Emergency contact information

Bowersox makes her emergency pouch easily accessible to her friends and family: “My family, including my 11-year-old son, knows what to do if I have a hypoglycemic episode or emergency. I think it’s important for an individual’s entire support network to be aware of this.” Of course, it may seem inconvenient to carry around an entire toolkit when going out, but many of the new glucagons (like Gvoke and Baqsimi) are much more portable and easier to use than the glucagon previously available.

Keep in mind that for many people with diabetes, nighttime is both the most dangerous and the most common time to experience hypoglycemia. Dr. Dodell shared some useful advice: “If you see a downward trend before bed, you should eat a snack. It’s better to wake up high and correct during the day than have a low blood sugar episode overnight, which could cause many more complications and inconveniences. It’s also important for people with diabetes to know the triggers that can cause lows at night.” In short: check blood glucose before bed, play it safe, and know your risk factors. Additionally, daily routines have changed during COVID-19; you may be eating different foods, exercising more or less, and experiencing higher stress. All these factors may affect your blood sugar, especially at night.

Everyone’s body is different, but common risk factors for hypoglycemia include:

  • Exercise
  • Too much insulin
  • Fasting or low carbohydrate intake
  • Alcohol
  • Medications
  • Stress
  • Hormonal fluctuations
  • Illness

For a full list, check out Adam Brown and diaTribe’s 42 factors that affect blood glucose from his book Bright Spots & Landmines.

Hypoglycemia is different for everyone, so it is essential to be aware of your own body. Try to observe the symptoms you experience, and make note of potential triggers. Bowersox recommended keeping track of patterns: “Keeping a log or journal of things such as physical or emotional activity and comparing it to your blood sugar data could be a good way to see if there are trends that are causing you to go low. Ultimately, it’s important to share that information with your support network.” Know yourself – there are many factors that can lead to hypoglycemia, so it’s important to learn your own patterns of low blood sugar so that you can avoid these experiences.

KBTL

Image source: diaTribe

Perhaps the most critical part of Know Before the Low is its emphasis on connecting with your support network – family, friends, coworkers, teachers, and others. Bowersox said that she once had to ask her audience for candy to raise her blood sugar; fans were supportive and thanked her for raising awareness about diabetes. However, it can sometimes be difficult or uncomfortable to start conversations about diabetes and hypoglycemia with the people around us. Dr. Dodell explained that keeping the dialogue casual yet informative can be an opportunity to teach people something new: “You’re not putting a burden on them, but just explaining how diabetes affects your life. By broaching the topic casually, you can treat the conversation as more of a heads up than bestowing a responsibility. Just make sure to explain that you are carefully managing your diabetes, but there is a chance of an emergency. Not everyone has met someone with diabetes, but just explaining it and educating them can be a great preventive step.”

By sharing information about hypoglycemia signs, symptoms, and treatments, you can empower your peers to step in during an emergency. As Bowersox said, “Knowledge is power! When your network has information, they are empowered to help you, especially with low blood sugar. When I travel, my quality of life is improved by just educating and speaking up. Practice with your mirror, practice with your pet, but make sure your support network is there for you.”

As this project raises awareness of hypoglycemia, we hope it encourages people with diabetes, their healthcare professionals, and their support networks to engage in valuable discussions. As Dr. Dodell so perfectly concluded, “This campaign is one of the first to address the dangers of hypoglycemia. It is groundbreaking, and allows people to get needed resources. Diabetes experts and endocrinologists know that high blood sugar can sometimes be better than low blood sugar.”

For more information, read diaTribe’s article on hypoglycemia unawareness.

Source: diabetesdaily.com

Why Glucagon Is a Must for Sick Days

This content originally appeared on Beyond Type 1. Republished with permission.

By Jordan Dakin

Common Knowledge

Becoming sick when you have type 1 diabetes can easily complicate things. When you have the flu or a serious bacterial infection, your blood sugar levels can quickly become harder to manage, as they typically trend higher because of your body’s automatic, hormonal response to being sick. Because of this, you might find yourself needing more insulin than usual and needing to check for ketones more often to prevent diabetic ketoacidosis (DKA). Having a plan for sick day management when you have type 1 diabetes is crucial.

It’s important to be mindful of the possibility of high blood sugar when you’re sick. But it is also important to realize that sick day lows are a definite possibility as well! Especially if you’re taking more insulin than normal to combat highs when sick, you have to be mindful of resulting lows. You also run the risk of encountering a severe low if you are either unable to keep food down or lack an appetite when you’re sick, which are common realities when you have a cold or flu.

Enter Glucagon

Whatever the reason for a low, keeping glucagon handy to combat severe bouts of hypoglycemia on a sick day is definitely a must. Severe hypoglycemia is a dangerous complication of type 1 that can result in seizure, loss of consciousness, or death, and there is peace of mind in having a safety net to prevent any one of those outcomes. Glucagon is the first line treatment for severe hypoglycemia because it is the main counter-regulatory hormone to insulin. Parents and caretakers of those with type 1 can especially benefit by having an immediate safeguard against the dangers realities of a severe low.

The standard of care has been to keep a glucagon emergency kit handy. Historically, these emergency kits came equipped with an injectable form of glucagon, that requires mixing powder and liquid with a syringe by whoever is administering the shot. While this can definitely be an effective form of glucagon, having to mix the shot prior has made the procedure complicated and intimidating for some.

Next Level Options

Luckily for those of us affected by type 1 diabetes (T1D), glucagon has been approved in two new forms over the last year: nasal glucagon and pre-mixed steady state.

Baqsimi is the first and only nasal, non-injectable form of glucagon, offering a slight variation on what most people with diabetes are used to. It is administered like a nasal spray, but does not require inhalation, so even if a patient is unconscious (a frequent cause of severe hypoglycemia), anyone can administer Baqsimi and it will work.

Gvoke is the first liquid stable form of glucagon, meaning though it is an injection, it comes ready to use and requires no mixing on the part of whoever is administering the shot. Gvoke also comes in two forms: a pre-filled syringe (called Gvoke PFS) that is available to patients now and an auto-injector pen (the Gvoke HypoPen) that has yet to become officially available.

Neither Gvoke nor Baqsimi require refrigeration, and both have an impressive shelf life of up to two years if kept at room temperature. Another added benefit of these next generation iterations of glucagon is that these tools can likely prevent an ambulance trip to the hospital, saving time and resources. (Editor’s Note: This is especially important during the current COVID-19 pandemic, as it is not advised to visit hospitals unless absolutely necessary.)

How to Get Glucagon

Lilly currently offers a Baqsimi coupon patients can use to get up to two devices for as little as $25.

Through the end of April 2020, Xeris is offering a Gvoke co-pay card with which some patients can pay as little as $0 with eligible insurance to get their Gvoke PFS. Patients can also opt to request their prescription through the website and have Gvoke PFS delivered by PillPack at no additional cost.

Keeping glucagon handy is the best defense against unexpected lows when you’re not feeling well. Being sick might come with some uncertainties and cause some worry, but you can rest easier knowing you’re prepared and equipped with the necessary tools to take on whatever comes your way.

For step by step instructions on how to use each type of emergency glucagon, click here.

Source: diabetesdaily.com

Search

+