3. If the lows take place when no bolus was given at bedtime, reduce the basal insulin from bedtime to morning (if using a pump) or the dose of long-acting insulin (if taking injections).
Unfortunately, predicting when, or if, a rebound is going to occur after typical garden-variety low blood sugars is difficult. Some people find that they only experience a rebound following
symptomatic lows, complete with the shakes, sweats, and so on.
If you detect a pattern and know when to expect a rebound to occur, give yourself a small dose of rapid-acting insulin once you’ve recovered from the low.
If you use an insulin pump, consider raising your basal insulin by 50 percent for the next three to four hours.
For example, if your blood sugar always rebounds to the 300s (17, 22) following readings below 50 (3), you might benefit from a basal increase once your blood sugar has returned to normal.
Speaking of treatment, another way to prevent a significant rebound is to refrain from overtreating the low. Eating excessive amounts of food when you are low is like throwing gasoline on a fire. We will discuss proper treatment of lows in the next chapter.
Steroids
Steroid medications such as cortisone and prednisone are used to treat asthma, arthritis, emphysema, and muscle and joint inflammation. These drugs create significant insulin resistance and raise blood sugar levels, sometimes dramatically. Inhalers (containing albuterol) and topical steroids (in cream or ointment form) can also raise blood sugar levels.
The Adjustment: For those using a steroid medication on a temporary basis, an increase in the usual insulin doses will almost certainly be necessary. Likewise, if you use a steroid medication on a regular basis but have your dosage increased, an insulin dose increase will also be needed.
Some steroids are more potent than others, and their onset and duration of action can vary.
Ask your physician about the specific medication that you plan to use.
Oral steroids tend to have relatively short courses of action, having maximum effect several hours after taking them and less effect twelve to twenty-four hours later.
Increasing the basal insulin dose by 50 percent to 100 percent for twelve hours usually works nicely.
Injected steroids, such as cortisone (for knee, shoulder, or elbow inflammation, for example) will raise the blood sugar starting a few hours after the injection and last as long as four to eight days.
The peak insulin resistance usually takes place two to three days after the injection.
The following basal insulin adjustment has worked well for many of our patients
Day 1: 1.5 times the usual basal dose
Day 2: 2, 3 times the usual basal dose*
Day 3: 2, 3 times the usual basal dose*
Day 4: 1.5, 2 times the usual basal dose
Day 5: 1.5 times the usual basal dose
Note that many pumps will not allow a basal increase of more than 200 percent (double) the usual settings. It may be necessary to set up a secondary basal profile with the necessary basal increase.
Those who use a hybrid closed-loop system that automates the basal insulin delivery often benefit from switching back to manual mode until the effects of the steroid wear off. If your system takes the past several days of total insulin delivery into account in determining your needs, it might overdeliver following a period of steroid use. It’s best to keep the system in manual mode for several days following a return to your usual basal settings.
AWOL Thyroid
Having diabetes means that we’re at risk for a host of other health problems.
One of them is low production of thyroid hormone (hypothyroidism), also called Hashimoto’s thyroiditis.
This condition is caused by the same autoimmune defect that attacks the beta cells of the pancreas and causes type 1 diabetes.
In this case, the attack is on the thyroid gland and causes inflammation and stress to occur to the cells that produce thyroid hormone.
Approximately one out of six women and one out of eighteen men with type 1 diabetes have hypothyroidism, as do one out of twenty people with type 2 diabetes.
When insufficient amounts of thyroid hormone are produced, the body’s metabolism slows down, and blood sugar levels tend to go up.
The Adjustment: Treatment for hypothyroidism involves taking a pill to provide extra thyroid hormone. The dose is usually very low to start and is increased gradually until normal thyroid levels are achieved. Until this happens, both basal and bolus doses will likely need to be increased. Take the basal settings, insulin-to-carb ratios, and correction doses up by 10 percent every couple of days until satisfactory fasting and premeal blood sugar levels are achieved.
Other Medications
Diuretics, Dilantin, estrogen, testosterone, epinephrine, cough and cold remedies that contain epinephrine, certain antibiotics (fluoroquinolone versions), lithium, and many beta blockers can cause a short-term rise in blood sugar levels. See Appendix E for a more complete list of drugs that can cause a rise in blood sugar levels.
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 your bolus or basal insulin or both. It’s best to wait several days after starting any of these medications to see how your blood sugar patterns are affected, and ask your prescribing physician for advice on the proper course of action.
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, in all likelihood, 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 or when your blood sugar is elevated. Here’s a quick guide to help you manage.
1. If you use an insulin pump, stay connected to the pump before, during, and after the procedure. 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. If your blood sugar is elevated prior to the procedure, cover with a standard correction bolus, and bolus as usual for your after-surgery meals and snacks. If you find that your blood sugar remains elevated for more than a few hours after the procedure, consider raising your basal by 50 percent by using the pump’s temporary basal feature.
2.
If you inject long-acting insulin in the morning or at night, or NPH at night, take your usual dose.
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 your blood sugar remains elevated for several hours following the surgery, talk with your physician about increasing your dose of long-acting or NPH insulin by 25 percent until you have fully recovered and resume your usual activities.
3. 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, check your blood sugar every two to three hours, and administer correction insulin as needed.
The Other Stuff That Can Lower Blood Sugar Levels
Prior 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 call it) 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 every unit of insulin will cover a greater amount of carbohydrate and have a greater blood sugar, lowering effect following hard workouts. 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: If you use a hybrid closed-loop system, it should work nicely to help prevent most episodes of D’OH.
If not, here’s a phrase you’ve seen before: If you can predict it, you can prevent it.
Keeping detailed records of your workouts should allow you to figure out which types of activities induce a delayed drop and when.
For example, since discovering 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.
Options 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
• having a slow-digesting snack prior to the time of the expected drop (without any bolus or with a reduced bolus)
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-to-carb ratios, and the sensitivity factor. For those trying to lose weight, reducing insulin doses is absolutely necessary, as repeated bouts of hypoglycemia will hinder 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 their doses by 5 to 10 percent across the board.
Aging
The older I get, the harder it is to define what is meant by “advanced age.” My kids think people in their thirties are old and those in their fifties (like me) are older than dirt. As we age, our bodies start to produce fewer hormones that raise blood sugar (such as growth hormone). This is rarely seen in middle age. It usually starts to rear its ugly head after age sixty-five and can result in falling blood sugars during the night and between meals.