High Blood Sugar at Night: What to Do

This content originally appeared on diaTribe. Republished with permission.

By Eliza Skoler

Why do your blood sugar levels increase at night, and what you can do to prevent this? Learn strategies for managing high blood sugar levels overnight and in the morning, including healthy bedtime snacks.

For National Sleep Awareness week, we are focusing on how to regulate overnight blood glucose (sugar) levels. With the many factors that can affect your glucose levels, nighttime can be a challenge. Some people with diabetes experience high overnight levels while others fear or experience a glucose drop during sleep. Trying to keep glucose levels stable overnight will help you get more sleep and feel better – and a good night’s sleep will aid your diabetes management the next day. While this article focuses on overnight highs, you can learn more about preparing for and preventing hypoglycemia (low blood sugar) here.

Here are some tips and strategies for how people living with diabetes can get better sleep at night and avoid high blood sugar levels.

Click to jump down:
Symptoms of High Blood Sugar at Night
Is It Safe to Sleep with High Blood Sugar?
Why Does Blood Sugar Go Up at Night? 
What is the Dawn Phenomenon?
How to Stabilize Your Blood Sugar Overnight
Great Bedtime Snacks for People Living with Diabetes
What Should Your Blood Sugar be When You Wake Up?
How to Lower Morning Blood Sugar

Symptoms of High Blood Sugar at Night

If your blood sugar is high at night you may experience symptoms of hyperglycemia. Hyperglycemia, or “high glucose,” is not defined by one specific glucose level. While many people with diabetes aim to keep blood sugar levels below 180 mg/dl during the day, some people aim for the lower range of 120 or 140 mg/dl at night, when they are not eating.

At night, symptoms of hyperglycemia include:

  • Poor sleep
  • Waking up often to urinate or to drink water
  • Headache
  • Dry mouth
  • Nausea

Other symptoms of hyperglycemia that you may experience during the day or night include:

  • Frequent and excessive urination
  • Extreme thirst
  • Blurry vision
  • Confusion
  • Weakness
  • Shortness of breath

Is It Safe to Sleep with High Blood Sugar?

Glucose levels that are occasionally a little high at night generally don’t pose serious, immediate health concerns. Most people with diabetes cannot avoid some high glucose levels. However, frequent or long-term highs – particularly extremely high levels (above 250 mg/dl) – can be dangerous. It is important for people with diabetes to reduce high blood sugar as much as possible for two key reasons:

  1. Frequent hyperglycemia can lead to major health complications caused by damage to blood vessels and nerves, which can affect your eyes, heart, kidneys, and other organs. This occurs when glucose levels are too high over a long period of time.
  2. Very high glucose levels can be a sign of diabetic ketoacidosis (DKA, or high levels of ketones in your blood indicating that there is not enough insulin in your body). This occurs mainly in people with type 1 diabetes and can be life-threatening. For more information on DKA, read “Ketosis vs. Ketoacidosis: What’s the Difference.”

Why Does Blood Sugar Go Up at Night?

There are many factors that can cause your blood sugar to increase at night. For example: what food you ate during the day, how much and when you exercised, whether you ate snacks before bed, the timing of your insulin doses, and your stress level. You can experience different patterns of high blood sugar at night. You may start with high glucose when you go to bed, start the night in range but go high several hours later, or spend most of the night in range until the hours just before you wake up. By identifying your body’s patterns, you can figure out what is causing your high blood sugar and how to address it.

Common causes of a glucose increase at night include:

  • Eating too close to bedtime: whether you’re snacking or eating a late dinner, a post-meal glucose spike can lead to high glucose levels overnight. In particular, high-fat, high-carb meals (like pizza or pasta with creamy sauces) might delay glucose absorption causing an extended period of high blood sugar levels.
  • If you have type 2 diabetes, a treatment plan that doesn’t adequately address your nighttime insulin resistance or missed doses of your glucose lowering medication can cause high glucose levels at night (and often also during the day).
  • Over-correcting a low glucose level before bed. If you need to bring your glucose level back into range before you sleep, take just enough glucose to stabilize your blood sugar. Quantity-limited treatments (like glucose tablets or small candies) that will raise your glucose levels by a specific amount can be very helpful – learn more here.
  • If you take insulin, your insulin levels may be inadequate during the night. Depending on your dose and timing of basal insulin, the insulin may not last in your body until the morning. Learn about different types of insulininsulin pumps, and automated insulin delivery (AID) systems, all of which can be helpful for staying in your target glucose range overnight.
  • Taking less insulin before bedtime due to fear of low blood sugar overnight.

What is the Dawn Phenomenon?

Another reason for high nighttime blood sugar levels is the “dawn phenomenon.” The dawn phenomenon occurs early in the morning when the body naturally signals your liver to produce glucose, giving your body the energy it needs to wake up.

The hormonal changes associated with the dawn phenomenon happen to people with or without diabetes, though those without diabetes do not experience hyperglycemia. If you take insulin, you may need to try a new basal insulin or adjust the timing and amount of your basal dose (with injected insulin) or your nighttime basal rates (with an insulin pump) to cover an early morning rise.

How to Stabilize Your Blood Sugar Overnight

The most important thing you can do to stabilize your blood sugar is monitor your glucose levels at bedtime, during the night, and when you wake up to look for patterns. This will help you determine what’s going on in your body and how you can fix it. While there are many strategies people use to stabilize blood sugar at night, every person is different – you’ll have to look for trends in your body, experiment with ways to lower glucose levels over a period of time, and learn what works best for your body.

  • Check your blood sugar (or CGM) before bed. If it’s already high, your blood sugar levels may remain high throughout the night. To address this, you’ll want to start by adjusting when you eat your evening meal and what it consists of, and how much mealtime insulin you take to cover it.
    • Avoid eating lots of food close to bedtime. For diaTribe writer Adam Brown, the key to staying in range overnight is low-carb, early dinners, with no snacking after dinner.
    • Consider eating less food at night and taking more basal insulin to cover your evening meal.
  • Check your blood sugar (or CGM) during the night, between midnight and 3am. If you were in range before bed but have high glucose levels between midnight and 3am, you may need to adjust your basal insulin dosage and timing. If you are low during that time, you may experience a rebound high blood sugar later on – this is usually associated with overcorrecting the low.
    • Talk with your healthcare team about the optimal nighttime insulin regimen for you. You may need to adjust your insulin to avoid both early low blood sugar and later high blood sugar.
    • If you take basal insulin, see if you’re able to get an insulin pump or an automated insulin delivery (AID) system. AID systems will automatically adjust your basal insulin doses throughout the night to help keep your glucose levels stable.
    • For some people, a small snack before bed (with a small dose of insulin, if appropriate) can help stabilize glucose levels throughout the night and avoid an early morning high. Keep reading for a list of healthy bedtime snacks.
  • Check your blood sugar (or CGM) when you wake up. If you were in range before bed and between midnight and 3am, but have high blood sugar in the morning, you may be experiencing the dawn phenomenon or running out of insulin (or other medication).
    • If you take insulin, you may need to delay the timing of your basal dose to as close to bedtime as possible. Or, you may increase your basal rates with an insulin pump from around 3am on.
    • If you have type 2 diabetes, talk with your healthcare professional about your glucose-lowering medications to make sure that your treatment plan addresses overnight hyperglycemia.

It’s possible to experience a combination of these events – you may have high blood sugar levels at various points throughout the night. If you have a continuous glucose monitor (CGM, you’ll be able to better track your glucose levels throughout the night. You can use your CGM data to relate your behaviors to patterns in your nighttime glucose levels. Does the timing of physical activity affect your glucose levels overnight? What about food choices throughout the day, in terms of type, quantity, or timing of food? If you don’t have a CGM, the more frequently you can take a blood sugar readings the better. Learn how to get the most of your fingerstick blood sugar data here. It’s important to share your nighttime glucose observations with your healthcare team so that you can find the best ways to stabilize your blood sugar over the entire night.

For more advice on stabilizing nighttime glucose levels, read Adam Brown’s “The Overnight Blood Sugar Conundrum.”

Great Bedtime Snacks for People Living with Diabetes

For some people, a healthy bedtime snack helps to prevent glucose swings during the night. By eating a small snack that is full of protein and healthy fats (and low in carbohydrates), your body may be better able to avoid an overnight high – but if you take insulin, be sure to cover the carbohydrates in your snack even if it only requires a small dose of insulin.

Here are some snack ideas:

  • Plain nuts or seeds – try eating a small handful
  • Raw vegetables, such as carrots, celery, cucumbers, or tomatoes, with a small amount of hummus or peanut butter
  • Plain yogurt, and you can add berries or cinnamon (read about choosing a healthy yogurt here)
  • Chia seed pudding

Remember, a bedtime snack is only helpful for some people. To see if it works for you, you’ll have to carefully monitor your glucose before bed, during the night, and when you wake up.

What Should Your Blood Sugar Be When You Wake Up?

The goal of diabetes management is to keep your blood sugar levels as stable as possible. This means that when you wake up, you want your glucose to be in range and to stay in range throughout the day.

For many people with diabetes, the overall target glucose range is between 70 mg/dL to 180 mg/dL (3.9 to 10.0 mmol/L). To start the day strong, the American Diabetes Association recommends that you aim to wake up with glucose levels between 80 to 130 mg/dL. Talk with your healthcare team about your glucose targets.

How to Lower Morning Blood Sugar

Whether a morning high is caused by the dawn phenomenon or something else, here are a few things you can try to lower your blood sugar levels:

  • Physical activity when you wake up can help bring your glucose level down. Even going for a walk can be helpful.
    • To learn about exercise guidelines and glucose management strategies, click here.
    • Read Adam Brown’s take on walking – the most underrated diabetes exercise strategy.
  • Eating a light breakfast can help keep a morning high from increasing even more. Taking your mealtime insulin will help lower your blood sugar.
    • Adam Brown suggests eating a breakfast that is low in carbs, and notes that sometimes mealtime insulin has to be adjusted in the morning. One of his favorite breakfasts is chia pudding, since it has little impact on glucose levels; see what else he eats for breakfast here.
    • Catherine Newman has six popular, low-carb, delicious recipes in “The Morning Meal.”
  • Intermittent fasting and time-restricted feeding approaches to meal timing can also help people keep morning blood sugar levels in range. Read Justine Szafran’s “Intermittent Fasting: Stabilizing My Morning Blood Sugars” to learn more.
  • For additional ways to navigate mornings, read seven strategies from Adam Brown in “A Home Run Breakfast with Diabetes.”

Source: diabetesdaily.com

Rare Until It Happens to You: The Kycie Terry Story

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

By Jordan Jendricks

Jamie Terry doesn’t know what exactly it is about her daughter that resonates so deeply with people. But there’s something about the combination of her curly blond hair, striking blue eyes, and the circumstances around her unfortunate and preventable death that have incredible staying power, inspiring countless others to action.

“There have been many times that I’ve thought about that. There are sick children all over the world, why Kycie? But there’s something about her and I truly believe she was here on a mission. She’s still on a mission. I just think there’s a reason behind it all.”

Because even now, five years after her tragic passing, strangers from around the world still reach out to the Terry family about their little girl. They remember Kycie and her story, which has reached thousands and saved an untold number of lives. Kycie’s father, Josh, has lost count of how many other parents have thanked him, explaining they, too, might have lost a child if not for his daughter’s story.

“I don’t know why it went as viral as it did. I think she just has a face, too. And you can see how heartbreaking it was and how hard she worked to try and get back. If you lose a child or you lose a family member, to think that they died for nothing, it’s that much harder. To know that she’s made a difference in other people’s lives and helped save other people’s lives, and saved a lot of heartache and struggles, it’s more doable.”

Kycie Jai Terry was the second youngest of six children and the only girl. After four boys, Jamie remembers crying tears of joy over her fifth ultrasound and the realization she would finally have a little girl. She remembers her daughter as a vibrant child, who loved to dress up, ride bikes and catch lizards; who was a little bit of everything and unique, as her name suggests.

“I don’t think I realized at that time, but now I think there’s a reason that she has this unique name because you Google her and she pops up and it’s because she needed to make a difference in the world.”

Where Things Went Wrong

Kycie

Image source: Beyond Type 1

Kycie was diagnosed with type 1 diabetes on January 30th, 2015 while in DKA (diabetic ketoacidosis). Where her story differs from many who live with undiagnosed type 1 and go into DKA is that she ultimately experienced cerebral edema, a condition where fluid builds up around the brain, causing pressure and swelling. This complication was occurring unbeknownst to the healthcare providers treating her at the time, wreaking havoc on Kycie’s brain and nervous system as she slept in her ER room bed. Less than 1% of pediatric patients in DKA experience cerebral edema, making it rare, though this statistic was of little comfort to the Terry family. As Josh puts it, “It’s always rare until it happens to you.”

As he recalls, Kycie’s initial symptoms started with a headache, then a stomachache. It seemed like she might have had a stomach flu, then strep. But she didn’t get better with antibiotics; in fact, she worsened. She didn’t want to eat, she only wanted fluids, and she was suddenly remarkably skinny. The Terrys felt an urgency to take their daughter to the hospital as her condition only seemed to get worse. She was extremely lethargic once there, and Josh recalls her fruity breath, a tell-tale sign of ketones. Sure enough, the doctor quickly revealed the cause of the problem: “She has type 1 diabetes.”

But Kycie’s blood sugar was difficult to control. Later, the Terrys would learn that during this time in the ER, doctors were focusing solely on treating her diabetes without realizing that she had experienced any brain damage, or that it was growing worse. With blood sugar readings over 1,100 mg/dl (61 mmol/L), Kycie was in severe DKA and needed to be life-flighted to a children’s hospital five hours away. After landing, she suffered a seizure on the ambulance ride from the airport to the hospital. Four hours later, she was intubated, on a ventilator, unresponsive and in a diabetic coma.

An MRI was completed after Kycie was in a coma for over 24 hours, revealing for the first time the cerebral edema. Doctors told the Terrys that they didn’t expect her to live, but Kycie fought, ultimately coming to breathe again on her own before waking up. She spent the next 111 days in the hospital to relearn basic functions, after which she was able to go home and live with her family for another month and a half, though her life was entirely different. It was suddenly a feat for the five-year-old to hold her own head up, smile, or roll over by herself. Josh remembers feeling torn and heartbroken to see his daughter’s life suddenly so difficult.

“I remember sitting up there and thinking what a horrible situation she was in – a situation I wouldn’t want to be in. If I was in that place, I wouldn’t want to live that life,” he shares. “At the same time, she’s my little girl and it’s my job to protect her and my job to be there for her. It was a really hard place to be.”

Kycie

Image source: Beyond Type 1

The family continued on, taking care of their daughter and treasuring the few good times during otherwise long days. They documented their new normal, sharing feel-good moments and milestones on social media.

Kycie then caught a virus that led to pneumonia and another hospitalization, setting back some of her progress and making her less responsive. Though she was able to return home after growing stronger, in the early morning hours of July 11th, her oxygen levels were extremely low and her parents were poised to take her to the hospital yet again. Before they could leave the house, the second youngest Terry passed away peacefully in her father’s arms. She was a few months shy of her sixth birthday.

Her Legacy Lives On

Kycie is well-known now in the diabetes community, her story having touched so many all over the world. Beyond Type 1’s Warning Signs Awareness Campaign, which began in 2016, was inspired by her story and the reality that both misdiagnosis and missed diagnoses are problems that can be solved through education and awareness. Josh and Jamie both can’t underscore enough the importance of being able to recognize the signs and symptoms of type 1 diabetes.

“To get an early diagnosis is so critical. If you can catch type 1 before DKA, you’ve saved yourself the possibility of brain damage,” Josh explains. “And so that early recognition is so vital, not just because of the scariness of DKA, but because of the unknown that comes with it.”

Jamie reflects on her own lack of knowledge about diabetes in general and how Kycie’s situation truly opened her eyes to a chronic illness that affects so many on a daily basis.

“I knew nothing about it. And the thing that’s crazy with Kycie is it all happened so fast. Within five days, she had a traumatic brain injury,” she explains.

Jamie sympathizes with everyone who manages type 1 diabetes, having gotten a small taste of the complexity of the disease while caring for Kycie’s type 1 diabetes (T1D) the short time she was able: “That’s what is heartbreaking to me. Anyone that ever comes up to me and tells me they have type 1, the first thing I say to them is ‘I’m so sorry’ because it’s so much to take on. And we didn’t even get to.”

The Terry family now advocates for safe and early diagnoses of type 1 diabetes, sharing about Kycie whenever they can and working with local hospitals to help improve type 1 protocols. In Josh’s practice as an optometrist, he lectures others in his field on type 1 and the importance of recognizing changes in vision as potential signs. Their family is continually touched by the outpouring of love for their little girl and all they’ve been through, the community they’ve found through their loss and the surprising amount of good that has come out of an otherwise tragic situation.

As Jamie puts it, “There’s no greater title than ‘Kycie’s mom.’ It will always be hard to live without her, but part of the healing journey has been to know that she has saved and continues to save lives.”

Source: diabetesdaily.com

Survivor’s Guilt: Losing My Brother to Diabetes

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

By Katie Lesley

I was diagnosed with type 1 diabetes (T1D) when I was eight years old. I was about to attend a new school, and within the last few weeks of summer, I found myself learning to dose a medication responsible for being my lifeline. This diagnosis meant injecting needles I’d hope wouldn’t hurt every single time, and pricking my fingers at least four times a day. Although it was a heavy reality, I felt like I didn’t have time to react poorly. I just needed to learn how to keep myself alive every day. At eight years old, that’s a daunting task, but I tried to carry the responsibility with strong shoulders and usually had the perspective that it could’ve been worse. When I was diagnosed, I shared a hospital room with a girl about the same age. She was practically in a full-body cast from a tragic car accident. Later, I found out that her family had all died in the accident, but she didn’t know that yet. Learning how to inject myself didn’t seem so bad with my family surrounding me and knowing I’d be returning to the comfort of my home soon. I found myself thankful, and almost 30 years later, I often reflect on how T1D has changed my life in countless ways.

A Steep Learning Curve

My first experience with DKA (diabetic ketoacidosis) is still quite memorable. I had the flu and suddenly couldn’t stop throwing up in the middle of the night. I remember being in the dark, on my bed, with my mom holding a washcloth to my head and my older brother staring at me; he was there for support but also worried about me. I hadn’t been this sick since I was diagnosed, and I knew this wasn’t normal. Even though I felt so horrible, I was unwilling to go to the ER when my mom said it was time to go. I was just scared. After a lesson of what DKA was and its seriousness, I felt like it was my fault. I didn’t want to talk about it when I was finally released, and that guilt remained with me, resulting in not much conversation about it.

My family took the approach that they didn’t want me to feel abnormal or too different than any other children, and I felt like I had to be independent and take care of myself. That led to me not sharing too much about my T1D, and I just got used to managing it. Even though my brother and I shared an extraordinary relationship, I felt like my T1D separated us because he didn’t truly understand what I battled every day. That all changed, though, when he was diagnosed at age 22.

Ties That Bind

I vividly remember him calling me and saying, “I can’t believe my baby sister has been such a badass all these years, and I didn’t even realize what you had to do every day!” I laughed but was relieved I could share this flood of thoughts, feelings, and frustrations with my big brother. Even though I got to share all these conversations with him, I had such a mix of emotions learning he was diagnosed. I cried for him because I knew what he would have to live with, but I also felt like we could be each other’s strongest ally. We had a tradition of calling each other every time we left the pharmacy and joked about the insanity of costs associated with keeping ourselves alive. Nick’s sense of humor often saved me from negativity, something I’m always grateful for.

Healthy

Image source: Beyond Type 1

But DKA found its way to Nick, too. He had just recently fought off the flu, and I had told him to make sure to stay hydrated. The flu returned, and he called me on a Sunday, his normal routine. I was stuffing my wedding invitations with my best friend, and our call was short. He told me he didn’t feel good and was tired. I told him again to stay hydrated, I loved him, and to call me when he felt better. A couple of days later, that call came instead from my sister-in-law telling me Nick had suffered a heart attack and was in a coma. After an agonizing flight across the country to get to him, the doctors ultimately explained he suffered too much brain damage, that he had no brain activity, and told us the dreaded “there’s nothing else we can do.” His cause of death was DKA, which led to a heart attack and brain damage. Nick was only 28. He had two small children and his whole family were supposed to be at my wedding in just two months. He had a lifetime of happiness ahead of him, and DKA took him quickly, without any remorse.

I had severe survivor’s guilt. I felt it should’ve been me, I didn’t have kids to live for, and I had been hospitalized for DKA a few times and survived. I had T1D much longer than Nick, and I should’ve told him a billion times how important it was to be extra vigilant when he got sick. I couldn’t believe it took his life. I felt angry that we didn’t treat my disease differently when I was growing up; it should’ve been more of a topic of conversation rather than taking the tactic of protecting my feelings so I didn’t feel different. An emergency plan should’ve always been in place as opposed to having to just react to a bad situation. Nick’s lack of health insurance at the time shouldn’t have impacted any of his decision making. I should’ve told my sister-in-law over and over again how important it was to pay attention to his health and get him treatment immediately if he was sick. Death from DKA is preventable, and I knew that more than most.

Stronger Now

My 30-year milestone of living with T1D is upon me. I am now married and have a child of my own. Since Nick’s death, I made some dramatic changes to my management of the disease. After years of resistance, I committed to an insulin pump because I knew it would drastically help my overall health. I even dedicated myself to clinical trials for different devices and went beyond my comfort zone for the sake of improving T1D options. I found my way to the best endocrinologist I’ve ever had, even though her office is two hours away. I talk much more openly about my disease and share my frustrations with my incredibly supportive husband as I still try to balance the reality that T1D is mine forever, with no breaks, days off, or cures in sight. And even though Nick’s death may make it seem obvious that T1D and DKA are explicitly fragile, I’ve made sure to have emergency supplies and plans in place with my family. Nick will forever impact me and influence my choices. It’s easy to take so much for granted, but I promise you it’s sobering with just the mere memory of holding Nick’s hand in the hospital begging him not to leave us. Even though we are now separated by heaven and earth, T1D has made me stronger, and I have Nick to thank for that.

Source: diabetesdaily.com

What Are SGLT-2 Inhibitors and How Can They Help Your Heart?

This content originally appeared on diaTribe. Republished with permission.

By Mary Barna Bridgeman

SGLT-2 inhibitors can protect your heart! This type of medicine is recommended for people with type 2 diabetes who have heart disease or risk factors related to heart disease. Learn about the use of these medicines, including side effects, their effect on A1C, and their role in supporting heart health

Diabetes is a risk factor for heart disease: people with diabetes are twice as likely to have heart disease or a stroke compared to those without diabetes. Heart disease is often a “silent” condition, meaning that symptoms are not necessarily present until a heart attack or a stroke actually happens. It is important for people with diabetes to realize they may be at risk – click to read more about the link between diabetes and heart disease from Know Diabetes By Heart.

There are many ways to take care of your heart and to reduce the risk of heart disease while living with diabetes. New medicines, including sodium-glucose cotransport 2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) agonists, have been shown to protect the heart and reduce the risk of many specific heart-related outcomes. This article will focus on SGLT-2 medications, and our next article will focus on GLP-1 medications.

Heart diseases

Image source: diaTribe

Click to view and download diaTribe’s helpful infographic on preventing heart disease.

What are SGLT-2 inhibitors?

There are currently four medicines that are categorized as SGLT-2 inhibitors:

These medicines help people with type 2 diabetes manage their glucose levels: they work in the kidneys to lower sugar levels by increasing the amount of sugar that is passed in the urine. SGLT-2s increase time in range and reduce A1C levels while also lowering blood pressure and supporting weight loss. For people with diabetes who have had a heart attack or are at high risk of heart disease, or who have kidney disease or heart failure, these medicines could be considered regardless of A1C level. While SGLT-2 medications are expensive, some assistance programs are available to help with cost – see one of diaTribe’s most popular articles, “How to Get Diabetes Drugs For Free.”

What do you need to know about SGLT-2 inhibitors?

SGLT-2s have a low risk of causing hypoglycemia (low blood sugar levels). Because they increase sugar in the urine, side effects can include urinary tract infections and genital yeast infections in men and women. Dehydration (loss of fluid) and low blood pressure can also occur. Symptoms of dehydration or low blood pressure may include feeling faint, lightheaded, dizzy, or weak, especially upon standing.

Before starting an SGLT-2 inhibitor, here are some things to discuss with your healthcare team if you have type 2 diabetes:

  • How much water to drink each day
  • Ways to prevent dehydration and what to do if you cannot eat or you experience vomiting or diarrhea (these are conditions that may increase your risk of developing dehydration)
  • Any medicines you take to treat high blood pressure

When prescribed for people with type 2 diabetes, SGLT-2s rarely cause diabetic ketoacidosis (DKA), a serious and potentially life-threatening condition. For people with type 1 diabetes, DKA is a well-known risk when SGLT-2s are prescribed. Call your healthcare professional if you have warning signs of DKA: high levels of ketones in your blood or urine, nausea, vomiting, lack of appetite, abdominal pain, difficulty breathing, confusion, unusual fatigue, or sleepiness. When you are sick, vomiting, have diarrhea, or cannot drink enough fluids, you should follow a sick day plan – see Dr. Fran Kaufman’s article on developing your sick day management plan. Your healthcare professional may instruct you to test your urine or blood ketones and stop taking your medication until symptoms go away.

If you have type 1 diabetes or chronic kidney disease, depending on your level of kidney function, these medicines may not be for you. Additionally, SGLT-2s are associated with increased risk of lower limb amputation.

SGLT-2 inhibitors are usually taken as a pill once a day – often in the morning before breakfast – and can be taken with or without food.

What do SGLT-2 inhibitors have to do with heart health?

Results from clinical studies suggest SGLT-2 inhibitors may play an important role in lowering heart disease risks.

Jardiance was the first SGLT-2 inhibitor to show positive effects on heart health in the EMPA-REG OUTCOME trial. In this study, more than 7,020 adults with type 2 diabetes and a history of heart disease were followed. Participants received standard treatment for reducing heart disease risk – including statin medications, blood pressure-lowering drugs, aspirin, and other medicines – and diabetes care, plus treatment with Jardiance. Over a four-year period, results from the study showed that, compared to placebo (a “nothing” pill), Jardiance led to:

  • a 14% reduction in total cardiovascular events (heart attacks, strokes, heart-related deaths)
  • a 38% reduction in risk of heart-related death
  • a 32% reduction in overall death
  • a 35% reduction in hospitalizations from heart failure

Read diaTribe’s article on the results here.

Similarly, the heart protective effects of Invokana have been shown in two clinical studies, CANVAS and CANVAS-R. These two studies enrolled more than 10,140 adults with type 2 diabetes and a high risk of heart disease, randomly assigned to receive either Invokana or placebo treatment. In the CANVAS studies, treatment with Invokana led to the following:

  • a 14% reduction in total cardiovascular events (heart attacks, strokes, heart-related deaths)
  • a 13% reduction in risk of heart-related death
  • a 13% reduction in overall death
  • a 33% reduction in hospitalizations from heart failure

Read diaTribe’s article on the results here.

Farxiga may also reduce heart disease risks. In the DECLARE-TIMI 58 study, more than 17,000 people with type 2 diabetes received Farxiga; 40% of participants had known heart disease and 60% had risk factors for heart disease. Importantly, more than half of the people included in this study did not have existing heart disease. While Farxiga was not found to significantly reduce total cardiovascular events (heart attacks, strokes, heart-related deaths) compared with placebo, its use did lead to a 17% lower rate of heart-related death or hospitalization for heart failure. Read diaTribe’s article about the results here.

More recently, the DAPA-HF study evaluated the use of Farxiga for treating heart failure or death from heart disease in people with or without type 2 diabetes. The study included more than 4,700 people with heart failure; about 42% of those enrolled had type 2 diabetes. Farxiga was shown to reduce heart-related death or worsening heart failure by 26% compared to placebo, both in people with type 2 diabetes or without diabetes. Learn more about these results here.

All of the available SGLT-2 inhibitors have evidence suggesting benefits of this class of medications for people with established heart failure. Click to read diaTribe’s article on SGLT-2 Steglatro and heart health.

Other possible benefits of SGLT-2 inhibitors

InvokanaFarxiga, and Jardiance have also been shown to reduce the progression of kidney disease. Learn more about diabetes and kidney disease here.

SGLT-2s have been studied in people with type 1 diabetes, but are not yet approved for use by the FDA – you can learn about SGLT-2s for people with type 1 diabetes here.

What’s the bottom line?

You can reduce your risk of heart disease and promote heart health while living with diabetes. You and your healthcare team should develop a personalized plan to determine what ways are best for reducing your risk of heart disease. According to the latest evidence and treatment recommendations, SGLT-2 inhibitors may be most useful for people with type 2 diabetes and heart disease or at high risk of heart disease.

About Mary

Mary Barna Bridgeman, PharmD, BCPS, BCGP is a Clinical Professor at the Ernest Mario School of Pharmacy at Rutgers University. She practices as an Internal Medicine Clinical Pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.

This article is part of a series to help people with diabetes learn how to support heart health, made possible in part by the American Heart Association and American Diabetes Association’s Know Diabetes by Heart initiative.

Source: diabetesdaily.com

Ketoacidosis Rates Plummet with Continuous Glucose Monitoring Use (ADA2020)

Maintaining their target blood glucose levels as much as possible is critical to preventing various health complications for all people with diabetes. One deadly outcome of high blood glucose levels is diabetic ketoacidosis (DKA), which is a life-threatening emergency, but one that can typically be prevented with optimal glycemic management.

Checking blood glucose levels regularly and making the appropriate medication adjustments to keep in a safe blood glucose range is a challenge for many. Due to various factors, including sometimes a lack of access to a sufficient amount of test strips, patients may not be checking their blood glucose level as frequently as recommended.

Continuous glucose monitoring (CGM) technology is a relatively new development in diabetes care, but has already been shown to benefit many patients as related to glycemic management, mental wellbeing, and overall quality of life. By providing users with almost real-time data of their glucose levels, couples with the ability to set alarms to address blood sugar values that are out of range, prior to developing an emergency situation appears to be a critical tool to help people with diabetes better manage their condition and help safeguard against critical situations like severe hypoglycemia or DKA.

A new study conducted by a team of French researchers has just revealed striking results that underscore the benefits of CGM access for patients. The researchers just presented the major outcomes of the study at the American Diabetes Association (ADA) 80th Scientific Sessions this weekend.

Study Design

The researchers conducted a retrospective analysis of nationwide DKA records for patients with type 1 and type 2 diabetes one year prior to the initiation of the use of Abbott’s Freestyle Libre system and compared it to the recorded DKA rates one year after the initiation of CGM use in this population. Data from a total of 33,203 patients with type 1 diabetes and 40,955 with type 2 diabetes were included in the study.

Major Outcomes

The differences in the DKA rates before and after CGM use were striking. Overall, the rate of DKA decreased by 52% among those with type 1 diabetes and by 47% among those with type 2 diabetes. Furthermore, the researchers evaluated the impact of CGM technology on patients with different self blood glucose monitoring (fingerstick frequency) habits. The data revealed that the reduction in DKA rate was the most dramatic for those who do not check their blood glucose level daily, as well as for those who check their blood glucose more than five times per day. In fact, the baseline DKA rates were the highest for these two groups. This may seem counterintuitive, but it is likely that patients who check frequently may be doing so because of difficulty in managing their condition.

Roussel et al. (Presented at ADA 2020)

Conclusions

This retrospective analysis of data from a large cohort of patients prior to and after the use of CGM technology suggests that CGM use can help to dramatically decrease the incidence of DKA. The observed improvements in DKA rates were the most pronounced for those who check their blood glucose very little, but also for those who check frequently (more than five times per day). Overall, the study results highlight the potential health benefits of CGM use in preventing DKA in a very large group of patients. Unfortunately, today, access and affordability of CGM systems still remains a challenge for many patients.

Source: diabetesdaily.com

Build Your COVID-19 Diabetes Go Bag

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

By Jordan Dakin

When it comes to being hospitalized in the midst of the COVID-19 pandemic, it’s natural to worry about that possibility and while we hope we can stay home at all costs, being prepared for any scenario is the best course of action. As a result, packing a go bag in the case of a hospital visit during this time is crucial.

Most important? Pack your bag with 15 days of supplies to be on the safe side. The CDC recommends up to 14 days of quarantine in some cases for those who have been exposed or infected depending on the time it takes for symptoms to develop, so being prepared for a lengthy hospital stay just in case is advised.

The nature of COVID-19 is tricky because it requires isolation and even if you’re hospitalized for something diabetes-related, you run the risk of being exposed to COVID-19 in a hospital setting. Make sure you have all you need as it will be difficult for loved ones to get items to you if you are in isolation during a hospital stay.

Antiemetic or Anti-Nausea Medication

Zofran or any other antiemetic medicine is helpful to have on hand in case you do contract a mild form of COVID-19 to keep yourself from throwing up, as this can be dangerous and lead to DKA (diabetic ketoacidosis).

Carbs and/or Glucose Tabs

This may seem obvious, but it is so important. Be sure to pack some hard candy, fruit snacks, fruit juice, glucose tabs and gels, and any other preferred fast-acting carbohydrates.

Beverage(s) to Prevent Dehydration

This could include sports drinks, water, or a mix-in hydration powder with little to no carbs.

Ketone Strips and Glucagon

If you are sick, BGs are harder to manage and DKA can be a dangerous reality if you’re needing more insulin than normal while having trouble keeping carbs or fluids down. As a result, you should test for ketones more frequently when you are sick.

Insulin, Syringes, Pen Needles and Pump Supplies

Having backup methods to administer insulin is important in the event of a pump malfunction.

Testing Supplies Like a Blood Glucose Meter, Lancing Device, Lancet and Test Strips, Plus Sensors If Using Continuous Glucose Monitoring (CGM)

In some hospitals, it’s been difficult for patients to have their glucose levels checked hourly because healthcare workers don’t have enough personal protective equipment (masks, gloves, etc) to go in and out of patient rooms that often. Because of this, people with diabetes should be prepared to do their own testing and monitoring of blood glucose (BG). Bringing a backup method for testing aside from your CGM is also recommended in case sensors fail or other malfunctions occur.

Alcohol Swabs, Hand Sanitizer, Bandaids and Medical Tape

Disinfecting and keeping things clean and protected during this time is especially important.

Any Necessary Medications and Other Important Medical Details

This includes an itemized list of medications you’re currently taking, allergies to medications you might have, your physician’s information and emergency contact information.

Personal Protective Equipment

Pack your own gloves and masks or face coverings just in case. If possible, it might also be good to remember to wear PPE when entering the hospital to prevent excessive exposure to COVID-19.

Other Necessary Electronics and Chargers

Be prepared and bring any necessary cables to keep phones and tablets charged, especially if you’re using any kind of smart device to help monitor BGs.

A hospital stay during this time might sound scary, but it is important to take care of yourself and be prepared. If you are sick and have gone into DKA as a result and can’t keep down fluids, hospitalization becomes necessary and waiting only makes DKA more severe and life-threatening.

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

Advancements in Treatment: The Use of Adjunctive Therapies in Type 1 Diabetes

This content originally appeared on diaTribe. Republished with permission.

By Paresh Dandona and Megan Johnson

Read on to learn about the research around GLP-1, SGLT-2, and combination therapy use in type 1 diabetes. Dr. Paresh Dandona is a Distinguished Professor and Chief of Endocrinology at the University of Buffalo, and Megan Johnson is a fellow on his team

For people living with type 1 diabetes, new treatments are finally on the horizon. The University at Buffalo (UB) Endocrinology Research Center is helping to revolutionize the treatment of this condition. Among the most promising new therapies are two non-insulin medications currently used in type 2 diabetes, SGLT-2 inhibitors and GLP-1 receptor agonists.

SGLT-2 inhibitors, such as Farxiga, act the kidney to help the body excrete more glucose in the urine. Meanwhile, GLP-1 receptor agonists like Victoza work in several different ways: increasing the body’s natural insulin production, decreasing the release of the glucose-raising hormone glucagon, slowing the emptying of the stomach, and curbing excess appetite. Some people with type 1 diabetes take these medications as an addition to insulin treatment as an “off-label” drug. To learn more about off-label, check out the article: Can “Off Label” Drugs and Technology Help You? Ask Your Doctor.

Why consider these medications?

In people without diabetes, the body is constantly releasing more or less insulin to match the body’s energy needs.  People with type 1 diabetes do not make enough insulin on their own and have to try to mimic this process by taking insulin replacement – but it isn’t easy.

People with type 1 diabetes often have fluctuations in their blood sugars, putting them at risk for both low blood sugars (hypoglycemia) and high blood sugars (hyperglycemia). Many individuals are unable to manage their blood sugars in a healthy glucose range with insulin alone. In fact, less than 30% of people with type 1 diabetes currently have an A1C at the target of less than 7%.

Can GLP-1 agonists be safely used in type 1 diabetes?

Over the past decade, the endocrinologists at the University at Buffalo and other research groups have been conducting studies to see whether GLP-1-receptor agonists can safely be used in type 1 diabetes.

  • The first of these was published in 2011 and showed a decrease in A1C within just four weeks of GLP-1 agonist treatment. Importantly, people given GLP-1 agonists plus insulin also had much less variation in their blood sugars, as measured by continuous glucose monitors (CGM).
  • Another study involved 72 people with type 1 diabetes who took GLP-1 agonist or placebo (a “nothing” pil) in addition to insulin for 12 weeks. The GLP-1 group had decreases in A1C, insulin requirements, blood sugar fluctuations, and body weight. People in this group did report more nausea – a common side effect of GLP-1 agonists.
  • Since then, multiple studies, some involving over 1000 people and lasting up to 52 weeks, have shown that GLP-1 treatment in people with type 1 diabetes can reduce A1C and body weight, along with insulin dosages.

Many of these studies, but not all, have suggested that GLP-1 agonists can do this without increasing the risk for hypoglycemia or diabetic ketoacidosis (DKA). There is also some evidence that GLP-1 agonists can improve quality of life in type 1 diabetes.

Who should consider GLP-1’s?

The effects of GLP-1 agonists seem to be especially strong in individuals who are still able to make some insulin on their own, although it also works in people who do not.

In one notable study, researchers gave a GLP-1 agonist to 11 people with type 1 diabetes who were still able to produce some insulin. To get an estimate of insulin production, they measured levels of a molecule called C-peptide, which is produced at the same time as insulin. In these 11 individuals, C-peptide concentrations increased after GLP-1 treatment. By the 12-week mark, they had decreased their insulin dosage by over 60%. Incredibly, five people were not requiring any insulin at all. Even though the study was very small, the results were exciting, because it was the first study to suggest that some people with type 1 diabetes had sufficient insulin reserve and thus, could – at least temporarily – be treated without insulin.

Can SGLT-2 inhibitors be used in type 1 diabetes?

SGLT-2 inhibitors like Farxiga have also shown tremendous potential. In two large studies called DEPICT-1 and DEPICT-2, adults with type 1 diabetes were randomly assigned to take either placebo or SGLT-2 inhibitor in combination with insulin. Over 700 people from 17 different countries participated in DEPICT-1, and over 800 people with type 1 diabetes participated in DEPICT-2. At the end of 24 weeks, people taking dapaglifozin had a percent A1C that was lower, on average, by 0.4 compared to people who had received placebo, and it was still lower, by over 0.3, at 52 weeks. The number of hypoglycemic events was similar in both groups.

As with GLP-1 agonists, people taking SGLT-2 inhibitors had weight loss and decreased insulin requirements. People taking SGLT-2 inhibitor, however, did have an increased risk of diabetic ketoacidosis (DKA). If individuals consider this therapy, they should be cautious about not missing meals or insulin, and not drinking large amounts of alcohol, as these behaviors can lead to increased ketone production.

Several other research groups, in trials recruiting up to 1000 individuals, have seen similar results when using this class of medications.  Researchers have been conducting additional studies to try to determine how best to minimize the risks associated with them. Farxiga (called Forxiga in Europe) has now been approved as the first oral agent as an adjunct treatment for type 1 diabetes in Europe and Japan.

Promising Combination Therapy

Now, endocrinologists are also looking at whether GLP-1 agonist and SGLT-2 inhibitor combination therapy could increase the benefits of each of these treatments. A study conducted on a small number of people showed that GLP-1 agonists can help prevent ketone production, so it is theoretically possible that this medication could reduce the risk of DKA that was seen with SGLT-2 inhibitors.

In an early study involving 30 people with type 1 diabetes who were already on GLP-agonist and insulin were randomly assigned to take SGLT-2 inhibitor or placebo, as well. People who received both drugs saw an 0.7% reduction in A1C values after 12 weeks, without any additional hypoglycemia. People on the SGLT-2 inhibitor did make more ketones, though, and two individuals in the combination group experienced DKA. Larger studies are now being conducted to expand on these results and learn more about how to give these drugs safely. The hope is that non-insulin therapies will soon be approved for type 1 diabetes. By unlocking the potential of these therapies, we can do more than manage blood glucose levels – we can improve people’s lives.

Source: diabetesdaily.com

Diabetic Ketoacidosis (DKA) at 30,000 Feet

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

By PK Hrezo

Twist of Fate?

It’s coincidental, if not oddly poetic, that type 1 diabetes presented itself to my family and me for the first time just two weeks before National Diabetes Awareness Month — a time we won’t soon forget.

Until that night, I thought type 1 diabetes (T1D) was something that kids were born with. I never thought it could be presented at any stage of life. I’d participated in JDRF walks before for friends and charity, so I knew the bare minimum. It had never been suggested to me by medical professionals that T1D was something all parents should keep an eye out for. Perhaps I hadn’t consulted the Parent Handbook regularly enough. But face-to-face with T1D for the first time, it was clear, I was on the brink of full-on parental guilt.

T1D did not run in our family, but that was the first question the ER doctor asked me while my thirteen-year-old daughter Abby was lying on the ER stretcher, nearly comatose, during a severe DKA episode in Halifax, Nova Scotia on October 19th, 2019.

DKA

Image source: Beyond Type 1

I was far from home, away from my husband, family and friends, and I was shell-shocked.

The Backstory

Abby and I had been planning a girl’s weekend to Paris for years, just the two of us, and it was to be the weekend of October 18th. Abby was beyond excited, which now, looking back, is probably what propelled her through the symptoms that we ignored as pre-DKA indicators. But we didn’t know. All we knew was that Abby had been under the weather for about a week – not herself, more tired than usual, and her ear had been bothering her just enough to prompt us to see the family doctor before getting on a plane.

We saw a nurse practitioner who checked Abby’s vitals and said her throat was red, but no ear fluid, and that she’d be okay for travel with some Mucinex. That night, Abby didn’t sleep at all. She woke up and stayed up for most of the night with indigestion. When she looked exhausted the next morning, we chalked it up to a bad night’s sleep.

Once we got to our connection at Chicago O’Hare, Abby seemed to be even more exhausted than before. Looking back, I realize the altitude from the plane ride from Tampa to Chicago had an adverse effect on her already gradual decline into DKA. She was uncomfortable in any position, and very thirsty for sweet, juicy-type drinks. She had an apple juice, a smoothie, a sweet tea with honey – all of these, unbeknownst to me, were contributing to the high sugars that would send her into DKA. I thought I was keeping her hydrated to flush out the virus, but sadly, all I was doing was shoveling more sugars into her bloodstream.

When Abby looked at me during our long layover and said she thought Paris would be a bad idea, I was both glad she’d owned up to it and puzzled by her sudden change. Of course, I wanted to do what was best for her. She mentioned one of our backup destinations — somewhere closer where we could still have our mother-daughter weekend but relax without the hustle and bustle of a busy city. We were already part of the way to another place, so we chose a pleasant B&B in Halifax, where it’d be autumn and beautiful. I made our arrangements and we headed to the next gate.

In Hindsight

If I could redo that day, I wouldn’t have put her on a plane to Canada, but that doesn’t mean I wouldn’t have made a different mistake. I might have booked a room in Chicago, so we could rest and she could sleep it off, which could have been fatal, since I still didn’t know she was in near-DKA.

I called my husband and told him how Abby was behaving, and that we’d changed plans. He was surprised, but agreed she likely just needed rest. That was also about the time doubt squirmed its way into my mind. People were beginning to stare at her. She was stumbling to the bathroom, and she just kept saying she was tired and needed to sleep. I was eager to get out of the airport and settle down somewhere so we could get back to normal. Little did I know, that normal had left us for good.

We pressed on and boarded the aircraft, and after about thirty minutes into the flight, my mommy senses went full-on haywire. What had I done? Something was wrong with Abby — I had no idea what, only that something wasn’t right, and it was too late for us to turn around. Tears welled in my eyes and I stared out the window wondering how I could’ve made such a big mistake.

Completely in the Dark

Abby could hardly hold her cup of ice she’d been munching on. She was dropping everything, and I was getting frustrated, because I’d never seen her that way, and I knew something was happening that she wasn’t telling me. “Talk to me,” I kept saying to her. “I don’t understand what’s going on.”

But Abby didn’t understand what was happening to her either. She complained that her lungs were hurting. Her lungs? I didn’t know if she was exaggerating or if she was having an allergy attack. How did all of those symptoms measure up to exhaustion and a virus? It didn’t make any sense.

Abby got up to use the bathroom again and was gone for quite a while — this is what I now know as T1D’s excessive peeing symptom. I was just about to go check on her, when she returned to our seat and laid over me. Her voice was barely audible when she complained again of her lungs hurting.

“Is there a doctor here?” she asked me in hardly a whisper.

“No,” I told her calmly. “But we’ll find one when we land.”

My nerves spiraled. I was, without a doubt, the worst mom ever. I decided that as soon as we landed, I’d call 911. We were halfway there. I held Abby as she laid over me in the row. And then she began to breathe heavily and rapidly.

I rubbed my hand up and down her arm. The stark difference between my hand temperature and hers was so alarming that I knew I couldn’t put it off any longer.

“Wait here,” I told her, and I beelined for the back of the plane where the two flight attendants stood in the galley.

“Can you see if there is a doctor onboard?” I asked. “I think there’s something wrong with my daughter.”

Team Work

Without hesitation, the flight attendants sprung into action and all the lights on the aircraft came on. While everything was moving in a blur for me, I returned to Abby and a passenger seated behind us, Nick Wasser, popped up as the announcement was made and identified himself as a nurse.

I explained Abby’s symptoms and everything up to that point, and a minute later, two more professionals appeared: Dr. Peter Laureijs and his wife, Beth, also a nurse. The flight attendants had oxygen and medical kits and they moved the passenger from the bulkhead row, so that Abby could be laid there on the floor. The doctor and nurses attended to her with great care, administering oxygen and checking her vitals.

I whispered a prayer and asked God for courage to get through whatever was to come, and that He might save my daughter. I remember very well, the moment when the woman in the adjacent row, Nick’s wife, Johanna, reached her hand over and lay it on mine, with tears in her eyes and said, “If you need anything, I’m right here.” The flight attendants checked on me throughout the remainder of the flight and made sure I was okay. They were in communication with the flight deck, and the pilots opted not to divert, but instead speed up the plane to get us to Halifax sooner, where IWK Health Centre would know how to care for whatever was wrong with Abby.

DKA

Image source: Beyond Type 1

They’d administered an IV by then, and that’s what saved Abby’s life, because unbeknownst to me she was dehydrating by the minute, as her bloodstream was filled with all that sugar that couldn’t be processed.

An ambulance waited on the tarmac when we landed. I could see their flashing lights out the window, and an announcement was made for no one to move until the EMTs had boarded and retrieved Abby. We started moving through the airport and Border Patrol gave me temporary paperwork and told me to call later after we knew what was going on. They wanted to make sure Abby wasn’t contagious, rightfully so, and that we weren’t bringing disease into Canada. At that point, we still had no idea what was happening.

On the ambulance, the EMT said her glucose level was 30 mmol/L (540 mg/DL). That didn’t mean anything to me. I said she’d had a lot of sweet drinks and nothing really to eat, so it was no surprise they were high. I was so naïve to the symptoms of T1D.

Learning the Ropes

The EMTs and ER staff that met us at IWK were all top-notch professionals with such warmth about them, that I never once felt alone, nor judged for my epic mom fail. While Abby was transferred to a bed and hooked up to all kinds of tubes, the ER doctor asked me a ton of questions, one of which was if diabetes was in the family.

“No,” I said informatively.

This is diabetes,” he said. “I can smell the ketones from here.”

“Ketones? What the heck are ketones?”

A word I’d later come to be acquainted with on a much deeper level. T1D had just blindsided me in a T-bone collision. Welcome to your new life. How had I not known? How had the doctor back home not identified it? Did this happen to other kids Abby’s age? Why did it wait so long to show up?

I stepped out and called my husband, and he, too, was in denial at first, insisting she’d probably just had a lot of sugar. Then I mentioned what the doctor said about smelling ketones, and it hit Nate like an anvil.

“Holy cow!” he said. “That’s what I smelled yesterday, remember? I said you need to brush your teeth because your breath smelled, and I thought it was you. I can’t believe I didn’t recognize it!”

Nate is a fire chief in Tarpon Springs and has thirteen years of experience in the EMT/first responder profession, and he has run across T1D patients a number of times.

Abby was admitted to PICU a few hours later where she was tended to by sweet, caring nurses for the next forty-eight hours, and where I would begin googling words and terms I’d never known before, in hopes of learning a lifetime worth of information within a couple of days.

Every time an ICU nurse would come in, I’d fire off questions, one of which being: “Does this type of thing happen very often?” One of the nurses said that in the last three months, they’d had eight cases of pediatric DKA where the parents had no idea that their child was T1D. After ICU, we moved to a room on the children’s ward, where we were introduced to managing T1D on our own. I was trained to use a glucometer and give insulin injections, and how to count carbs.

Making Sense of It All

I posted on Facebook when we finally returned home to Tampa. Sharing the signs of DKA with other parents seemed a priority, in hopes others could learn from my mistake. After my Facebook post went viral, I was contacted by so many other T1D parents and patients who have similar stories. So many of whom were turned away from doctors and ERs who also thought nothing was wrong.

I was an anxious ball of nerves when Abby and I finally received the okay to travel home to Tampa, because I’d be in charge of her insulin doses on my own for the first time. Since I learned dosages and glucose readings in Canadian measurements, I had to retrain my brain to switch over.

DKA

Image source: Beyond Type 1

The IWK nurses stayed in close contact with me throughout our journey home and advised me on what dosage to give after each blood reading. We had a doctor’s appointment the following morning with our new Tampa-based pediatric endocrinologist, and after one delayed flight to Newark, and another delayed flight to Tampa, we muddled through our insulin injections, and were able to get home and begin our new normal.

Together, our family is planning healthier food options with fewer carbs. We are making Abby’s lifestyle change our lifestyle change, we’re all watching our sugar intake. Once at home, I realized how fortunate we were to get help when we needed it, and I realized I didn’t know one of the nurse’s names from the flight. I also wanted to find out the flight crew of UA5596 so I could thank them. I made a Facebook post one morning asking others to help me find them, and I received an overwhelming response.

The post received almost 6K shares from people eager to pass on Abby’s story. The T1D community embraced me in a way I’ll forever be grateful for. Instead of feeling alone with this condition, I feel a part of something so much bigger than a crummy auto-immune disease, and I know a wealth of resources and support are waiting online should I need it.

While Abby and my weekend had not been the one of culture and mother-daughter bonding we’d hoped for, we found something else equally important. We learned that we are both stronger than we think, and that love and faith will get us through anything. We gained a new respect for life and its fragility, and humanity proved it’s still full of compassion. Since that fateful October night, Abby and I have been invited into a community of fellow T1Ds we never knew existed, and we’re reminded that there is strength in numbers, and that people truly are eager to help when given the chance. We are not alone.

Source: diabetesdaily.com

DKA at Diagnosis May Affect Brain Development in Children

A recent study found that young children who experience one moderate or severe case of diabetic ketoacidosis (DKA) may be at risk for changes in their longitudinal cognitive and brain development. DKA is a life-threatening condition that is frequently observed in young children who are newly diagnosed with type 1 diabetes. The symptoms of DKA […]
Source: diabetesdaily.com

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