Zoning in on Sick Day Management: Practical Tips, Strategies, and Advice

By Dr. Francine Kaufman

Pediatric endocrinologist Dr. Fran Kaufman shares tips for managing illness and diabetes: make a sick day plan, have supplies on hand, log your data, modify your insulin doses, and call your healthcare team. 

Everyone with diabetes who takes insulin needs to have a sick day plan. This is something you develop with your healthcare professional to help you manage the high and low sugar levels that can be associated with an illness. The following advice applies to people with type 1 diabetes and people with type 2 diabetes who take insulin – the advice may be different if you have type 2 diabetes and do not take insulin.

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When you get sick, you are at risk of becoming dehydrated from poor intake or from excessive loss of fluids due to nausea, vomiting, diarrhea, and fever (your body may lose more water when you have a high temperature). In addition, dehydration is common in diabetes because high glucose levels (above 180-200 mg/dL) cause sugar to enter your urine, dragging an excess amount of fluid with it. Illness also puts you at risk of developing ketones, which when coupled with high glucose levels can lead to diabetic ketoacidosis (DKA), a very serious condition. How do you know if you have ketones? Good question, click here!

The purpose of your sick day plan is to try to keep your glucose levels in a safe range – to avoid dehydration and to prevent ketones from rising to a dangerous level. When you get sick, you should contact your healthcare team to describe your symptoms, determine if they want to evaluate you or send you to a lab (for testing), and most important, to share the numbers that you will collect as you fill in your sick day log (more on this below). It is possible that no matter what you do, you might need to go to an emergency department or be hospitalized – but acting quickly, obtaining the right data, and doing your best to manage your glucose and hydration will minimize risks.

So what illnesses are we talking about? It turns out just about any common bacterial or viral infection – such as the flu (influenza), a cold (upper respiratory virus), tonsillitis, strep throat, an ear infection, stomach flu (gastroenteritis), a bladder infection, and even a skin infection, such as an abscess – can interfere with your diabetes management. However, right now, the greatest concern is COVID-19. An infection with COVID-19 can lead to very high glucose and ketone levels, putting someone at risk for DKA. Acting quickly to start your sick day plan, even if you end up needing to be hospitalized, is important.

When you get sick, your body needs energy to fight the infection and repair damaged tissue. The infections listed above, particularly those that lead to vomiting, diarrhea, fever, and dehydration, cause your body to release certain hormones (called stress or counterregulatory hormones) that tell your liver to release stored glucose and tell your fat cells to release free fatty acids that form ketones. In someone without diabetes, the body releases more insulin to control the rise in glucose and ketones; because you have diabetes, you have to take additional insulin to manage the high glucose and ketone levels. You want to get your sugar levels between 100-180 mg/dL. Blood sugars below 180 mg/dL will prevent excess urination that can dehydrate your body. Staying above 100 mg/dL helps keep you from dipping too low and risking severe hypoglycemia.

If your glucose level is above 180 mg/dL, you need to consider increasing basal insulin doses, using an increase in basal insulin with the temp basal feature on your insulin pump, or giving repeated corrections of bolus insulin with a syringe, pen or pump. Usually, correction doses should not be given more often than every two to three hours to avoid “stacking” insulin, which could lead to low blood sugars. By having a plan for illnesses that starts your modified care early and by keeping in touch with your healthcare team, you are more likely to keep your glucose values in the 100-180 mg/dL range.

But you also have to be concerned about hypoglycemia. Low sugar occurs, particularly in children and the elderly, if the illness affects calorie and carbohydrate intake by decreasing appetite or by causing vomiting or diarrhea. Although low glucose is usually considered to be less than 70 mg/dL, during illness there is concern if glucose levels are below 100 mg/dL. If your infection or illness leads to low glucose levels, reducing basal insulin and not taking bolus insulin doses should be considered. If suspension of insulin is required, you should not suspend or delay taking the next dose of basal insulin for more than 60 minutes, because this increases your risk of developing ketones. Start sipping a sugar-containing drink, one tablespoon at a time. If hypoglycemia continues and you cannot make it better by ingesting sugar, consider the administration of low-dose glucagon. Low-dose glucagon can increase glucose level by 50-200 mg/dL in 30 minutes. To learn about whether low-dose glucagon is right for you, and at what dose, talk with your healthcare team.

To follow what is happening in your body, it helps to start a log of your glucose levels, ketones, fluid intake, and insulin doses. This sick log can be shared with your health care team. It should show improvement from one time period to the next (see below). Note: the biggest concern is vomiting; if you vomit more than twice in a time period or across two time periods, call your healthcare team.

The log shows only two days, because you should be better after 24 hours and completely on the mend after 48 hours. If you are not getting better, call your healthcare team.

Table

Image source: diaTribe

Here’s how to keep track (and why to keep track!) of these important numbers:

1. Glucose Levels: Check glucose levels every 1-2 hours. You may have to change this and check your glucose every 30 minutes if your levels are changing quickly. CGM trend data should be looked at every 10-15 minutes. Watch for rapid changes by looking at numbers and arrows. The goal is to keep your glucose between 100-180 mg/dL and without wide swings in values.

2. Ketone Levels: Urine ketones are often detected using a urine ketone strip. A small patch on the strip changes color depending on your level of ketones, representing negative, small, moderate, large and very large levels of ketones. Moderate, large, and very large levels are of concern. Ketones can also be measured with a fingerstick and a special ketone meter. The readings for blood ketones are more accurate and range from 0.0 to 3.0 mmol/L or greater. Blood ketone levels below 0.6 mmol/L are considered normal. Between 0.6 and 1.5 mmol/L ketones are high and show that your fat has broken down to form excess ketones. This puts you at risk of DKA if glucose levels are also elevated. Ketone levels above 1.5 mmol/L are serious, and you should contact your healthcare professional. Signs of elevated ketones:

  • Nausea and vomiting (which may also be present because of the infection)
  • Shortness of breath and labored breathing (your body is trying to eliminate the ketones through your breath so you can also smell them, they make your breath smell fruity)
  • Weakness
  • Altered level of consciousness and trouble staying awake (this is most concerning; call your healthcare professional immediately if this is happening)

Ketones should be tested at the onset of an illness and then every four hours.  If ketone and glucose levels are both elevated, your healthcare team might advise you to increase correction insulin doses further, by an additional 10-15%. If ketone levels are high and glucose levels are not high (less than 150 mg/dL), oral glucose and some insulin – reduced by about 50% – will help clear your ketones. Drinking water will also help reduce ketones as they are removed in the urine. To learn more about ketones, including what they are and how to measure them, click here.

3. Temperature: High fever can help show the severity of your illness, particularly if it is persistent.  We have learned that COVID-19 is associated with persistent high fever. Use the log sheet to document any medications you take to lower fever so that you can report this to your healthcare team.

4. Fluid Intake, with and without Sugar: Consuming liquids is critical if there is risk of dehydration. Fluids with sugar should be taken if glucose levels are between 100-150 mg/dL, and fluids without sugar should be taken if glucose levels are between 150-180 mg/dL. If you have vomited, wait 30-60 minutes before trying to drink, and then start with teaspoons of water or ice chips, progressing to tablespoons and ounces. The goal is to retain 4-6 ounces of fluids (or 2-4 ounces for young children) every 30-60 minutes until you can drink without risk of vomiting and as your thirst dictates. Food is much less important after vomiting; don’t try to eat food until you are on the mend.

5. Urination: Noting frequency and amount (small, medium, or large) is important to understand the ongoing risk of dehydration. As glucose levels reach the target of 100-180 mg/dL, you should see a decrease in both frequency and amount of urination, as well as less dehydration.

6. Vomiting, Diarrhea and Dehydration:  Vomiting and diarrhea can lead to dehydration. The signs of dehydration include dry mouth, sunken eyes, weakness, loose skin, rapid heart rate, and low blood pressure. Vomiting is also of great concern because it occurs not only from the illness, but as a result of DKA. That’s why vomiting that occurs throughout one time period or spans two time periods in your log means it is time to call your healthcare professional.  However, if you feel weak after vomiting only once or twice, it is always better to call earlier than later.

7.  Insulin, Amount and Time: One of the most important things to remember is that during an illness, you still need to take insulin. Even if you are not eating or drinking at the beginning, you need to have insulin in your body. Insulin allows sugar to enter your body’s cells to be used for energy, and you need more energy to fight off an illness. Insulin also reduces ketone formation and stops excess urination by lowering glucose levels. If you have high glucose, you might need 25-50% more insulin than you usually take, due to insulin resistance created by the extra stress or counterregulatory hormones in your body. If you have low glucose, you might need to take 25-50% less insulin than you usually take, but you still need some basal or background insulin on board.

8. Medications: At the beginning of an illness, you should consider calling your healthcare team to determine if you should avoid taking any of your routine medications while sick. This includes glucose-lowering pills or injections, such as SGLT-2 and GLP-1 drugs, or medications for blood pressure and cholesterol. In addition, it is important to write down any medications you take (name, dosage, time) to treat fever, vomiting, diarrhea, or other symptoms of your illness. Anti-vomiting medications may be helpful but should only be taken after discussing with your healthcare professional.

Key Messages:  

  • Know your sick day plan before you become sick.
  • Have supplies on hand. These include supplies to measure glucose, a way to measure ketones, a thermometer, sugar-containing fluids, glucagon, extra-rapid (or short) acting insulin, and medication to treat fever. Discuss with your healthcare team whether you should have medication for diarrhea and vomiting on hand.
  • Have all the contact information for your healthcare team available, and call them sooner rather than later.
  • Before you call your healthcare team, have the data listed on your log sheet written down, plus your symptoms.
  • Take insulin at modified doses to address both high and low glucose levels. You still need to have some insulin in your body, even if you are not eating.
  • Let someone help you while you are ill. It is too big a job to be done alone.

About Fran

Dr. Fran Kaufman is the Chief Medical Officer of Senseonics, Inc. She is a Distinguished Professor Emerita of Pediatrics and Communications at the Keck School of Medicine and the Annenberg School of Communications at the University of Southern California.

Source: diabetesdaily.com

Making the Most of CGM: Uncover the Magic of Your Ambulatory Glucose Profile

This content originally appeared on diaTribe. Republished with permission.

By Cindy Takigawa and Frida Velcani

What’s an AGP report, and what does it show? Why does my AGP matter? How can I use an AGP report to improve my blood glucose levels and time in range?

Having diabetes is a full-time job: you have to simultaneously monitor your diet, activity, stress, and even sleep. On top of that, you need to calculate and manage the number of carbs you consume in each meal, and keep careful tabs on your blood sugar levels. The Ambulatory Glucose Profile (AGP) report, developed by the International Diabetes Center, is a tool that provides a simplified way to look at data on your blood glucose patterns and trends. It has been recognized as a standard of care for reporting continuous glucose monitor (CGM) data by the American Diabetes Association. In this article, we explain what an AGP report is and how you can use the information to help you navigate your diabetes management.

CGM App

Image source: diaTribe

What is an ambulatory glucose profile report?

An AGP report is a standardized, single-page report that includes glucose statistics like time in range, a summary glucose profile, and daily glucose graphs. It converts blood glucose readings from a CGM device into a detailed picture, allowing you to quickly visualize the time you spend above and below your target range. The report is based on at least seven days of CGM data, with 14 days of data (or more) considered ideal. Currently, many CGMs include a version of the AGP report in their devices and reporting software.

An AGP report that summarizes data provided by self-monitoring of blood glucose (SMBG) is currently being developed. This article focuses on CGM AGP reports.

Why does my ambulatory glucose profile matter?

The AGP report is the same no matter what device you use – it allows your healthcare team to assess blood glucose levels and trends in a standard way for everyone they see. Below you’ll find sample AGP reports from Abbott, Dexcom, and Senseonics.

The AGP report shows patterns in a user-friendly way so that people with diabetes can easily identify the times of day when glucose levels are consistently low, high, or fluctuating. The general goal for people with diabetes is to have their glucose levels stay within the target range of 70 to 180 mg/dL for at least 70% of the day, spending less than 4% of their time in hypoglycemia (under 70 mg/dL). The information from an AGP report can help you have a discussion with your healthcare team about goals for your diabetes management and ways you can achieve them. The data offered by this report can help make your care far more precise and effective.

What exactly does your AGP show?

The standard AGP (designed by the International Diabetes Center and shown above) will show your data like this:

  • Glucose Statistics and Targets: This section displays metrics including average glucose, glucose variability, and Glucose Management Indicator (GMI), which can be thought of as your predicted A1C. It also includes the dates and number of days in the report, as well as the percent of time that the CGM was used to collect data. While time in range goals can be individualized, the expert-defined goals for various groups of people with diabetes can be found in this section. You can read more about time in range targets here.
  • Time in Ranges: This color-coded bar chart helps you visualize the percentage of time spent above and below your target range.
  • Ambulatory Glucose Profile: This graph combines all of your glucose readings over time to display your trends across a 24-hour period. At the end of this article you can find examples of what this will look like for your specific CGM.
    • Black line: the median of all the readings. Half of your glucose values are above the middle black line and half are below.
    • Green lines: this is your target glucose range.
    • Dark blue area: 50% of glucose values lie in this area.
    • Light blue area: 90% of glucose values lie in this area. This percentage may differ between AGP reports. The International Diabetes Center report includes 90% of glucose values, while the Eversense report shows 80% of glucose values.
    • Dotted blue lines: 5% of the highest and lowest glucose values are above and below this line, respectively.
  • Daily Glucose Profiles: Each box shows your glucose pattern from a single day.
    • Yellow area: instances of high glucose (hyperglycemia).
    • Red area: instances of low glucose (hypoglycemia).

How can I interpret an ambulatory glucose profile report?

An AGP report combines several days of blood glucose readings into one snapshot. Once you have identified daily patterns, you can work with your healthcare team to adjust your medications and insulin dosing to spend more time in range. You may also discuss timing of food or physical activity, what you are eating, or ways to reduce stress. Here are some steps you can take to understand your data:

1.     Look at your time in range. The goal is to shift the numbers into the 70 – 180 mg/dl target range while having fewer lows and extreme highs. Each AGP report includes a bar chart of your time in range; one way to see this goal in action is to aim for more “green” and less “red” on the bar chart.

2.    Keep track of the usual times you wake up, go to sleep, eat meals and snacks, and are physically active. Food, activity, medication doses, and dozens of other factors can affect your blood glucose levels. Recording these activities and their timing will help you understand your AGP report and the patterns you see.

3.    Identify times when your glucose levels are lowest and highest, and look for times of more variability. Speak with your healthcare professional about what factors may be causing highs, lows, and variability in your AGP and how you can reduce them. The wider the shaded blue areas on your report, the more variability there is in your glucose levels.

4.    If you can, compare your current and past AGP reports, and create an action plan with your healthcare team. What strategies did you use previously to make changes? Identify a few steps to improve your glucose patterns moving forward.

To learn more about how people with diabetes and healthcare professionals can use AGP, click here. For more resources on time in range, check out diaTribe’s comprehensive library here.

Abbott AGP

CGM App

Image source: diaTribe

Dexcom AGP

Dexcom

Image source: diaTribe

Eversense AGP

AGP

Image source: diaTribe

Source: diabetesdaily.com

What’s Coming and What’s Delayed in Continuous Glucose Monitoring?

This content originally appeared on diaTribe. Republished with permission.

By Albert Cai

Updates and delays from Abbott, Dexcom, Medtronic, and Senseonics

With several clinical trials on hold due to the COVID-19 pandemic, we’re bringing you a roundup of the latest updates on future continuous glucose monitors (CGM). Understandably, the FDA also announced a few months ago that it would focus its efforts on devices related to COVID-19. With the disclaimer that it’s impossible to know exactly when the pandemic will subside, when trials might resume, and how FDA reviews might be affected, here is the latest news we’ve heard from companies.

Click to jump to a product, which are organized alphabetically.

Abbott FreeStyle Libre 2

CGM

Image source: Abbott FreeStyle

What’s new? FreeStyle Libre 2 keeps the same “scanning” feature as the original FreeStyle Libre, but adds Bluetooth connectivity. This is important because it enables optional high and low glucose alerts. Users who enable these alerts will be able to get a notification on their reader or phone whenever their glucose reading goes above or below their specified ranges. Looking ahead, the Bluetooth feature will also allow FreeStyle Libre 2 to be part of automated insulin delivery systems (AID), like Insulet’s Omnipod Horizon.

Like the original FreeStyle Libre, FreeStyle Libre 2 has 14-day wear, is factory-calibrated (no fingerstick calibrations required), and can be scanned with either a phone or a reader device (the reader for FreeStyle Libre 2 is blue, instead of black). Importantly, FreeStyle Libre 2 will be offered at the same price as the original FreeStyle Libre.

When’s it coming? The FreeStyle Libre 2 has already launched in a few European countries (we know of Germany and Norway) and will launch in others soon. In the US, FreeStyle Libre 2 has been under FDA review for over a year. In March, Abbott said that it was working through “some finishing items” and was “very confident” the device would be cleared soon.

Dexcom G7

Dexcom

Image source: Dexcom

What’s new? Dexcom’s G7 will be fully disposable (the transmitter and sensor are combined and thrown away together) and have longer wear (we believe somewhere around 14-16 days). Remember that the Dexcom G6 sensor lasts for 10 days but has a transmitter that is re-used for 90 days. The G7 will be considerably slimmer than G6 and will have a lower cost of manufacturing in bulk, though consumer pricing is not yet determined – we imagine it will be similar. The G7 will keep the same accuracy, no fingerstick calibrations, and Bluetooth connectivity as the G6.

Dexcom has been developing G7 in partnership with Verily, the division of Alphabet formerly known as Google Life Sciences. There has been mention from Verily that an accelerometer may also be built-in to the G7 device, but we aren’t sure if that feature made it into the final version of G7. Having a built-in accelerometer could allow the G7 to also track physical activity, like a Fitbit or other fitness tracker.

When’s it coming? Dexcom planned on launching G7 in “early 2021,” but with most clinics placing new trials on hold, Dexcom is expecting a “minimum delay of approximately six months.” It’s difficult to know when clinics will be able to conduct trials (and when people will feel comfortable enrolling in trials), but assuming a six-month delay, G7 could be on the US market sometime in the second half of 2021.

Medtronic “Project Zeus” CGM

Abbott FreeStyle

Image source: Medtronic

What’s new? Medtronic’s next CGM, referred to as “Project Zeus,” will reduce the number of required fingerstick calibrations and have improved accuracy (compared to its current offering, Guardian Sensor 3). The new CGM will require day-one calibration (unclear on the number of fingersticks that will be required on day one), compared to Guardian Sensor 3, which requires at least two fingerstick calibrations every day. Medtronic expects Project Zeus to launch with a “non-adjunctive” indication, meaning users will be able to bolus insulin based on CGM reading alone, and not have to perform a confirmatory fingerstick. the new CGM will keep the same seven-day wear, size and shape, and reusable transmitter component as the Guardian Sensor 3 (pictured above).

When’s it coming? The trial for Project Zeus began in June 2019 and is expected to wrap up within the next month. Medtronic expects to submit the CGM to the FDA by the “end of the summer.”

Senseonics Eversense XL (180-day)

Eversense XL

Image source: Eversense XL

What’s new? The “XL” extended life-version of Senseonics’ Eversense in the U.S. will have the same size and features as the original Eversense, but the Eversense XL is implanted for 180 days, rather than the 90-day Eversense. As a reminder, the Eversense sensor is implanted in the users’ upper arm in a clinic and remains there for the sensor duration; a silver-dollar sized on-body transmitter is worn on the outside of the arm to deliver readings to a smartphone. Senseonics is targeting reducing calibrations from 2 per day to 1 per day with same non-adjunctive indication.

When’s it coming? Eversense XL is already available in Senseonics’ European markets. The trial for Eversense XL in the US wrapped up in late March, and Senseonics has previously aimed for FDA clearance in “late” 2020. We aren’t sure whether that timeline has been pushed back due to COVID-19, but the fact that the trial has already completed is encouraging.

Source: diabetesdaily.com

New Implantable Device Gains Attention

We have seen major advancements in the world of continuous glucose monitors in recent years, including Eversense, the first implantable device. This implanted device is able to monitor blood glucose, as well as alert the person when their levels get too low or high. One issue with implantable devices is how to continuously power them. Excitingly, a new prototype was recently developed that can power itself by using our own glucose.

With implantables being the way of the future, having to remove the device to charge is counterproductive. Researchers at King Abdullah University of Science and Technology (KAUST) created this device that is able to directly utilize the energy within our bodies. It is made up of n-type semiconducting polymer along with the enzyme glucose oxidase. When the glucose oxidase detects glucose in its surroundings, it removes electrons and transports them through the connected polymer. The device can detect glucose levels in saliva and likely other bodily fluids, while the same polymer also helps convert glucose and oxygen into electrical power, which runs the device.

While more research is needed to see if this method is practical and safe, so far it has shown to be promising. According to the recent press release,

“This fuel cell is the first demonstration of a completely plastic, enzyme-based electrocatalytic energy generation device operating in physiologically relevant media,” says Sahika Inal, principal investigator of the study. “Glucose sensing and power generation are only two examples of the applications possible when a synthetic polymer communicates effectively with a catalytic enzyme-like glucose oxidase. Our main aim was to show the versatile chemistry and novel applications of this special water-stable, polymer class, which exhibits mixed conduction (ionic and electronic).

Have you considered an implantable device? If insertions were minimal due to this new technology, would it pique your interest?

Source: diabetesdaily.com

How to Use FreeStyle Libre Trend Arrows to Adjust Insulin Doses

This content originally appeared on diaTribe. Republished with permission.By Jimmy McDermott, Maeve Serino, and Adam Brown New Endocrine Society guidelines for FreeStyle Libre users to adjust insulin doses based on trend arrows. Plus, additional guidelines on scanning time and frequency The Endocrine Society recently published guidelines on adjusting insulin dosing based on FreeStyle Libre continuous glucose monitor […]
Source: diabetesdaily.com

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