Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath
This week, we continue with Part 3 of our special series of case discussions.
Ms. ME was referred to an endocrinologist and diabetes educator by her GP. Ms. ME is a 28-year-old woman who has had Type 1 diabetes since she was 10. She has good control on Novolin 70/30 (Mixtard 30/70) twice a day and her latest HbA1c is 6.0%. Most of her home tests range between 72 and 108mg/dL(4 and 6 mmol/L.). She exercises regularly and follows an appropriate diet. She reported frequent hypos but said she could cope with them. Her insulin dose was reduced and she was referred to the dietitian. She is very weight and clothes conscious….
We have an experienced, possibly obsessive person here, so it is unlikely that she does not understand diabetes and only needs re-education. It is imperative that we stop the hypoglycemia. Pre- and postprandial testing around meals could help determine the duration of action of her rapid-acting insulin and whether we need to reduce her basal insulin to stop nocturnal hypos.
I would initially check her eating pattern, carbohydrate intake and amount, duration, and timing of exercise and include a little supper until the nocturnal hypoglycemia stops. She may not reduce her insulin enough on the days she does heavy exercise and experiences delayed hypoglycemia from the exercise. Hypoglycemia can occur many hours after exercise. Usually basal bolus regimens and adjusting the insulin dose and carbohydrate on exercise days improves the situation.
Ms. ME exercises regularly, which improves insulin sensitivity, so she is likely to need smaller doses of insulin. She may have been given inappropriate education regarding exercise and insulin in the past and need re-education about sport, diet, including carbohydrate intake such as the amount, type, GI effect, meal distribution during the day, when to eat, and insulin dose adjustment on high exercise days, as well as delayed hypoglycemia.
I would consider referring her to a psychologist. She is weight- and clothes- conscious. She may have a disordered body image and may have an eating disorder, which needs to be explored by assessing her diet history, which may not be accurate initially. There is also a need to consider how she lives, with whom she lives and what she means when she says she ‘copes’ with hypos. She may be seeking attention.
Diabetes clinical nurse consultants see many young women such as Ms. ME who need understanding and support. I would complete an education assessment and find out what she hopes to achieve. The assessment would include the usual demographic details, living situation, work and lifestyle, diabetes and treatment status, blood glucose testing practices, activity levels, weight history, eating, alcohol consumption, and smoking status (see Figure 3.1). Asking about stress and using a Likert scale to assess how Ms. ME copes with diabetes could be helpful. Other health history includes the number and frequency of hypoglycemia and ketoacidosis events, and medications. I would ask about over-the-counter treatments and complementary therapies because people may not volunteer such information. The assessment will determine mutual actions to be achieved from the consultation, plans for the next consultation, and what resources and referrals to other team members might be required (see Figure 3.1). Teaching checklists can save time and repetition.
Several consultations will enable a rapport to be developed and time to discuss Ms. ME’s interests such as the latest colors and fashions. Initiating a basal bolus regimen using a peakless long-acting insulin before bed does not seem to have prevented nocturnal hypoglycemia. Ms. ME may have been brought up by her parents to keep her diabetes under ‘tight control’ for fear of complications such as blindness and amputation and perhaps not being able to have a family. The benefits of psychological counseling should be discussed with her.
I would download her blood glucose test results from her meter, but would be prepared for few episodes of hypoglycemia to be recorded. While she may carry her meter with her, the hypoglycemic autonomic symptoms of sweating, trembling, anxiety and nausea and the fact that the hypos occur at night may mean she is not able to test her blood glucose until she recovers, which could be some hours later, when the blood glucose is high due to the counter-regulatory response or returned to normal.
Continuous glucose monitoring (CGM), involving a small device clipped to the belt connected to a small sensor electrode inserted under the skin, could provide useful information about her blood glucose pattern. The meter is worn continuously, usually 72 hours, and interstitial glucose is measured every 5 minutes. The insertion process only takes a few minutes but an initial 1-hour calibration period is required.
I would also discuss the possible benefits of an insulin pump. The pump is attached to an infusion line inserted under the skin. The basal rate delivers insulin continuously and several different rates can be programmed over the course of the day. Bolus doses are delivered by pressing a button to deliver a specific amount of insulin at each meal, taking into account carbohydrate intake, blood glucose level, and exercise. Correction boluses can be given when the blood glucose levels are too high and during illness.
There are several ways to work out the best formula for each person’s pump and to deliver the appropriate insulin dose. Frequent blood glucose testing is needed initially to enable insulin and other adjustments to be made. The pump is disconnected for showers and the spa, some sports and sometimes during intimacy. Alarms alert the person to pump malfunctions such as the infusion tubing disconnecting from the pump or low batteries. Meticulous insertion technique is necessary and the cannula and tubing should be changed every 2-3 days. Insulin pumps can improve lifestyle by enabling greater flexibility. In addition, Ms. ME may regain her ability to detect hypoglycemia symptoms. I would refer her to a dietitian, especially if she chose to use a pump, and suggest a dose adjusted for normal eating.
Diabetes Educator 2
I agree with most of these suggestions, but two other issues are worth exploring: these include whether the hypoglycemia is related to alcohol intake or sexual activity. Both are very sensitive issues and need to be discussed tactfully and in a non-judgmental way. She might also benefit from blood glucose awareness training (BGAT) (Cox et al. 2001). Islet cell transplantation could be considered if all the suggested options do not improve the situation.
It is likely that Ms. ME is suffering from two inter-related challenges. First, she may have lost her sensitivity to hypoglycemia (hypoglycemia awareness), which is not uncommon among people with longstanding diabetes, especially those who have managed to maintain good control of their diabetes. This means that she may be having any mild hypoglycemic episodes without being aware of them, which might explain the good HbA1c despite the episodes of DKA. The second challenge is her anxiety over having hypoglycemia, and subsequent running of high blood glucose values. Combined, these two challenges can provide an interacting spiral that drive the person down emotionally and drive the blood glucose levels high.
One traditional way to address hypoglycemia unawareness is to support individuals running their blood glucose levels high for an extended period of time, until they regain their sensitivity to mild hypoglycemia. However, if someone has microvascular complications, this period of elevated blood glucose levels may exacerbate the progression of complications. An alternative approach would be to help people learn to regain their awareness through a focused self-management program. Blood glucose awareness training (BGAT) (Cox et al. 2001) and its derivatives such as hypoglycemia awareness training (HAT) (Kinsley et al. 1999) have demonstrated remarkable efficacy in helping people regain their hypo awareness. Some of the studies have indicated that these programs do more than re-skill the individual to identify his/her hypo symptoms more readily, and may facilitate the recovery of neuroendocrine responses to low blood glucose levels (Kinsley et al. 1999).
Running programs such as these with demonstrable efficacy may be difficult to implement in practice — due to lack of training, difficulty accessing the program and insufficient resources. In addition, people may not want to take part in such intensive programs. Key aspects of the program could be evaluated in individual consultations. Although no trials have been published using this approach, it may be of real value to combine the body scan and error grid analysis with individual patients. Patients scan their body for any symptoms they notice at that time. Based on this and their knowledge of their insulin, diet and activity over the day, they then estimate their blood glucose values. If they do this repeatedly, they can learn to identify those symptoms consistently related to high blood glucose values and those related to low glucose values. This, in theory, along with self-management education around how to adjust insulin levels proactively for food and activity levels, could have a substantial impact on Ms. ME’s anxiety and diabetes glucose regulation.
The aims of the book are to: (1) address commonly encountered diabetes management problems; (2) develop comprehensive responses from a range of relevant health professionals who suggest management approaches relevant to their area of practice. The speciﬁc health professionals who provide comments about each case depend on the speciﬁc clinical issue; and (3) stimulate thought and discussion.
The target readership is health professionals from a range of professional backgrounds and general as well as specialist professionals such as general practitioners, nurses, dietitians, and podiatrists. The book will be particularly useful for beginner practitioners specializing in diabetes. In addition, it will provide suggestions or food for thought for more experienced practitioners. The cases will be excerpts from the book are all real and are presented exactly as the information was received from the person making the referral. General practitioners, diabetes educators and people with diabetes referred most of the cases; some were self-referrals by people with diabetes. They represent referrals to various diabetic health professionals and concern commonly encountered clinical issues.
Next Week: Another Case Discussion
For more information on the book, just follow this link to Amazon.com, Managing Clinical Problems in Diabetes
Copyright © 2008 by Blackwell Publishing Ltd, UK
Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath