Think Like a Pancreas

by Gary Scheiner

  The Adjustment: Some steroids are more potent than others, and their onset/duration of action can vary. Ask your physician about the specific medication that you plan to use. In most cases single doses of a steroid medication (for example, an injection of cortisone for knee, shoulder, or elbow inflammation) will raise the blood sugar for anywhere from six to forty-eight hours. You may need to increase your basal insulin by as much as 50 to 300 percent until the steroid wears off.

  Other Medications

  Diuretics, Dilantin, estrogen, testosterone, epinephrine, and cough/cold remedies that contain epinephrine, certain antibiotics (fluoroquinolone versions), lithium, and many beta blockers can cause a shortterm rise in blood sugar levels. Thyroid medications (taken by those with an underactive thyroid gland) can also induce a modest elevation.

  The Adjustment: If you have been taking any of these medications over an extended period of time, no insulin dosage adjustments should be necessary. However, if you are starting or increasing a dose, you may need to increase the insulin bolus given after taking the medication. In the case of thyroid medication, you may need to make changes to your basal insulin when starting or increasing a dose.

  Surgery

  Medical procedures, ranging from oral surgery to a tummy tuck to cardiac bypass, have certain physiological and psychological consequences. Among these is a stress response by the body (in response to an invasion by “foreign fingers”) as well as the mind (in anticipation of the event). There is also a recovery period that involves bed rest and a certain degree of discomfort. What’s it all mean for your diabetes? Yep, high blood sugars—and at the worst possible time. A speedy recovery hinges on good blood sugar control. The body’s tissues heal better and with less risk of infection when the blood sugar is near normal.

  The Adjustment: If your surgeon offers to control your blood sugars for you during and after the procedure, take her up on it. The medical team will monitor your blood sugar frequently and infuse insulin directly into your bloodstream via an IV to keep your blood sugar as close to normal as possible.

  For outpatient procedures your doctor will probably ask you to manage your own diabetes. That’s okay—it’s not as complicated as it may seem. Because most procedures require you to fast beforehand, surgeons will typically schedule their patients with diabetes first thing in the morning. (Take advantage of it! We might as well get something for having this disease!)

  Even though you won’t be eating beforehand, you may need extra basal insulin to offset the effects of stress hormones prior to and during the procedure as well as lack of activity (and discomfort) after the procedure. You should give bolus insulin if/when your blood sugar is elevated. Here’s a quick guide to help you manage.

  If you use an insulin pump: Stay connected to the pump before, during, and after the procedure. However, make sure your infusion set and tubing will not get in the surgeon’s way. Keep your basal insulin at the normal level. Reducing your basal will almost certainly cause your blood sugar to run quite high. Cover your presurgery blood sugar with a standard correction bolus, and bolus as usual for your after-surgery meals/snacks. Following the procedure, if you find that your blood sugar remains elevated for more than a few hours, consider raising your basal by 50 percent by using the temp basal feature.

  If you take glargine, detemir, or NPH (at night): Take your usual dose of basal insulin. An hour or two prior to the procedure check your blood sugar and administer a correction bolus as needed. After the procedure check again and bolus as needed.

  If you take NPH in the morning: Give 50 percent of your usual dose of NPH the morning of the procedure. Include a dose of rapid-acting insulin if you wake up with high blood sugar. Cover all meals during the day (including lunch) with rapid insulin. If you are unable to eat, test your blood sugar every two to three hours and administer correction insulin as needed.

  The Other Stuff That Can Lower Blood Sugar

  Prior Heavy Exercise

  Have you ever finished a workout with a terrific blood sugar only to go low, out of the blue, hours later? Delayed-onset hypoglycemia (or D’OH, as Homer Simpson likes to say) is a blood sugar drop that occurs several hours after a high-intensity, long-duration, or exhaustive workout. It typically occurs six to twelve hours afterward, but it can take place up to twenty-four to forty-eight hours later. The timing of the drop varies from person to person and sport to sport. In my own case, playing full-court basketball in the evening usually results in a blood sugar drop the next morning before lunch.

  There are two reasons why delayed blood sugar drops take place. Heavy exercise makes muscle cells very sensitive to insulin, so following physical activity every unit of insulin will cover a greater amount of carbohydrate and have a greater blood sugar–lowering effect. Exhaustive exercise can also deplete the glycogen (sugar energy stores) in the muscles and liver, and as muscle and liver cells replenish their glycogen stores, blood sugar levels tend to drop.

  The Adjustment: The first step in dealing with D’OH is to determine when it happens and under what circumstances. Keeping detailed written records should allow you to figure out which types of activities induce a delayed drop as well as the timing. For example, since learning that nighttime basketball makes my blood sugar drop the next day at midmorning, I started reducing my breakfast bolus the morning after full-court hoops.

  So once again, if you can predict it, you can prevent it. Strategies for preventing D’OH include:

  •reducing your pump’s basal insulin leading up to the time of the expected blood sugar drop,

  •lowering the bolus at the meal preceding the expected drop,

  •reducing the long-acting insulin that will be active at the time of the expected drop, and

  •having a slow-digesting snack prior to the time of the expected drop.

  Weight Loss

  Just as weight gain increases insulin needs, weight loss reduces it. Losing as little as five pounds (2.4 kg) can enhance your insulin sensitivity and improve the overall effectiveness of your insulin.

  The Adjustment: All aspects of the insulin program will need to be adjusted with weight loss: basal insulin, insulin-carb ratios, and the sensitivity factor. For those trying to lose weight, reducing insulin doses as the weight begins to come off is absolutely necessary. Otherwise, repeated bouts of hypoglycemia will hinder further weight loss efforts. For example, someone who goes from 240 to 230 pounds (114 to 109 kg) and begins to experience below-target blood sugars should reduce his or her doses by 5 to 10 percent across the board.

  Aging

  With advanced age comes a reduction in hormones (such as growth hormone) that counteract insulin and stimulate the liver’s release of glucose.

  The Adjustment: Be prepared to cut back on basal insulin levels after age sixty. Hypoglycemia is particularly dangerous in the elderly due to impaired counter-regulation—the body’s hormones do little to help raise the blood sugar back toward normal in the event of a low—as well as the risk of falls and heart attacks when hypoglycemia strikes.

  Brain Work

  The central nervous system is one of the body’s major consumers of glucose. Brain cells rely almost exclusively on glucose for energy. Whenever the brain is working hard, blood sugar levels may drop. This can occur during periods of intense concentration (studying, multitasking), adjustment to new surroundings (new job, new home), and complex social situations (hosting a party, business networking, “working the floor”). Simply being in an environment that features lots of mental stimulation, such as a shopping center, supermarket, arcade, or casino, can make blood sugars drop.

  The Adjustment: Predicting when brain activity is going to be high enough to induce a blood sugar drop can be difficult. (In fact, trying to figure it out constitutes brain activity itself!) If you detect a pattern of blood sugar drops in certain situations, either reducing your insulin or increasing your food intake in anticipation of such events makes sense.

  For example, I have a tendency to “drop whi
le I shop” at the supermarket. In response, I try to go grocery shopping after dinner (real men shop at night) and then reduce my dinner bolus by about a third to prevent hypoglycemia. If I forget to make the adjustment, I’ll just graze on a few pretzel sticks while I shop.

  Climate

  Warm temperature and humidity have a tendency to cause blood sugar levels to drop. This is caused by heightened energy expenditure by the circulatory and respiratory systems as well as accelerated absorption of insulin from below the skin.

  The Adjustment: Seasonal changes may require modest (10 to 20 percent) changes in basal as well as bolus insulin doses. You may need short-term dosage adjustments when traveling to a climate that is warmer or more humid than what you are used to. When you move exercise from indoors to outdoors you may require a more significant preworkout bolus reduction than usual, particularly when the weather outside is very hot or humid. When taking injections of long-acting/basal insulin, try to inject into areas that will not be heated excessively by shower/bath water within a few hours of the injection; otherwise, the insulin may absorb and run out faster than desired.

  High Altitude

  Traveling to altitudes that are much higher than you are accustomed to can cause blood sugar levels to drop. At high altitudes the metabolism (heart rate, respiration) increases in order to deliver enough oxygen to the body’s cells. Luckily, the body usually adjusts to high altitudes within a few days, and metabolism returns to normal. Also, be careful when using your blood glucose meter at very high altitudes. Some meters do not give accurate readings above ten thousand feet (check your owner’s manual or call the meter manufacturer to see if your meter may be affected).

  The Adjustment: Be prepared to lower your basal insulin by 20 to 40 percent for the first couple of days when traveling to high altitudes. This will keep your blood sugar from dropping between meals and while you sleep. Exercising at high altitudes may require a greater dosage reduction than you are used to, as the body has to work extra hard to supply enough oxygen to your muscles.

  Nausea

  Any time your stomach is upset after eating and bolusing for a meal, you are going to be susceptible to hypoglycemia. When food sits (undigested) in your stomach or is later vomited, you will have taken bolus insulin for something that never actually reached your bloodstream.

  The Adjustment: If nausea is common or predictable (such as during early stages of pregnancy or chemotherapy), consider taking your bolus an hour or two after eating, once you are certain that your food will stay down.

  Otherwise, if your blood sugar is dropping and you are unable to tolerate ordinary food or beverages, there are a few ways to keep your blood sugar from bottoming out. First, try placing glucose tablets or dextrose-containing candy under your tongue or in your cheek. Even without swallowing, some of the sugar can be absorbed through the lining of the mouth. The stomach can sometimes tolerate low-sugar (but not sugar-free) beverages, such as sports drinks or diluted juice, when it cannot tolerate ordinary foods/drinks. Other options include turning the basal rate on your pump down by 80 to 90 percent for a few hours or giving yourself a small injection of glucagon, using an insulin syringe to inject it just below the skin. Ten to twenty units of glucagon are usually sufficient to reverse a downward trend in the blood sugar.

  Other Medications

  Certain medications, including MAO inhibitors, nicotine patches, antidepressants, and some antibacterial agents, may result in a temporary reduction in blood sugar levels. Starting an oral diabetes medication such as metformin can produce an ongoing need for less insulin, as the liver begins to secrete less than the usual amount of glucose throughout the day and night. The incretin mimetics—Symlin (pramlintide), Byetta (exenatide), and Victoza (liraglutide)—can have a blood sugar–lowering effect by suppressing the pancreas’s normal secretion of glucagon.

  The Adjustment: Speak to the physician who prescribed the medication to determine whether the dosage warrants any up-front changes in your insulin doses. Otherwise, take a wait-and-see approach. If you notice lower than usual blood sugar levels around the clock after starting (or increasing the dose of) the medication, cut back on your basal insulin in 10 percent increments until the problem is resolved. If the lower readings take place at a consistent time of day, reduce your bolus insulin prior to that time. For example, if you have been going low in the afternoon since starting on a nicotine patch, reduce your lunchtime bolus.

  Stuff That Can Make Your Blood Sugar Rise or Fall . . . or Both

  Just when you think you have it all figured out, along comes a factor or event that can cause blood sugars to both rise and fall, or vice versa. But don’t freak out—we can handle these.

  Alcohol

  Alcoholic beverages that contain carbohydrates, such as beer, table/dessert wine, wine coolers, hard lemonade, frozen/mixed drinks, will raise the blood sugar in the short term. Beer, in fact, is like liquid bread: It raises blood sugar pretty quickly. However, alcohol has a tendency to lower blood sugar levels several hours later by keeping the liver from secreting its normal amount of glucose into the bloodstream. As a result, hypoglycemia can occur after drinking. The fact that intoxication often masks the symptoms of hypoglycemia makes the problem worse. Neither the person with diabetes nor people around him/her are aware of the low blood sugar because the hypoglycemic symptoms take on the look, sound, and feel of being drunk. Consequently, preventing hypoglycemia is of paramount importance when drinking.

  The Adjustment: When drinking, you should bolus to cover the carbohydrates in your beverages. However, you need to make adjustments to prevent a delayed blood sugar drop from the alcohol. If you use an insulin pump, a temporary basal reduction of 30 to 50 percent for two hours per drink can work quite well because on average each alcoholic beverage needs about two hours for the liver to process it (the bigger you are, the less time it takes; the smaller you are, the longer it takes). In other words, if you have three drinks, lower the basal for six hours. Five drinks? Ten hours.

  If you take NPH at bedtime, consider lowering the dose by 10 percent for each drink you had that evening, up to an 80 percent reduction. If you take glargine or detemir, take the usual dose but have a modest snack (without bolusing) before going to bed. Ideally, the snack should be of the low-glycemic-index variety so as to provide a steady flow of sugar into the bloodstream for several hours. Examples include nuts, yogurt, chocolate, or carrots.

  Impaired Digestion

  Gastroparesis is a form of diabetic neuropathy in which the stomach is slow to empty into the intestines. Food digests much slower than usual, so the blood sugar has a tendency to rise several hours after eating rather than right after the meal. Those who take rapid-acting insulin to cover the meals sometimes see a drop in the blood sugar soon after eating, as the insulin begins working but the food doesn’t, followed by a sharp rise, as the food kicks in and the insulin wears off.

  The Adjustment: You can treat gastroparesis in a variety of ways. Facilitating the movement of food into the intestines is possible with oral medications, electrical stimulation, or modifications to the diet. If these prove to be ineffective, you will need to make mealtime insulin adjustments. Switching from rapid-acting insulin to regular insulin works for many people. Regular’s delayed peak (two to three hours after injection) and prolonged action (five to six hours) helps to match the absorption of sugars into the bloodstream for those with slow digestion. Another option is to delay the mealtime bolus until thirty or sixty minutes after the meal. Those who use insulin pumps can extend their bolus over a couple of hours to delay/blunt the peak and prolong the action curve of the insulin.

  Menstruation

  During various phases of the menstrual cycle, the body produces hormones that can raise or lower blood sugar levels. Many women find that their blood sugar levels are significantly higher for several days before the onset of their period and then lower for a day or two after menses begins. Although the effects of menstrual hormones last around the clock, morn
ing blood sugars seem to be affected the most.

  The Adjustment: Note the onset of your period in your selfmonitoring records for at least three months. Look for a pattern of consistently high or low blood sugars surrounding your menstrual cycle. Another way to detect this type of pattern is to download your blood glucose meter(s) to the computer and print out a long-term (two- to three-month) trend graph.

  In the figure below, menses that began at the end of January produced elevated glucose levels for several days prior (1/26 through 1/29).

  Figure 8-3. Trend graph showing a blood glucose rise prior to menses

  The Adjustment: If you find that you are waking up with high readings before your period begins, take your basal insulin dose up: As soon as premenstrual symptoms appear, raise the nighttime NPH or glargine/levemir dose by 10 to 20 percent or set a temp basal increase of 40 to 50 percent overnight if you use a pump. If your blood sugars run high around the clock prior to your period, raise the basal on your pump for twenty-four hours at a time, or set a secondary basal pattern that you can switch to at the start of your premenstrual phase.