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Clinical Practice:

10 commandments to better glucose control.

10 Effective steps/habits to achieve optimal glycemic control.

  • Aim for good glycemic control, defined as HbA1c <6.5%*
  • Monitor HbA1c every 3 months in addition to regular glucose self-monitoring
  • Aggressively manage hyperglycemia, dyslipidemia and hypertension with the same intensity to obtain the best patient outcome.
  • Refer all newly diagnosed patients to a unit specializing in diabetes care where possible
  • Address the underlying pathophysiology, including treatment of insulin resistance
  • Treat patients intensively so as to achieve target HbA1c <6.5%* within 6 months of diagnosis
  • After 3 months, if patients are not at target HbA1c <6.5%* consider combination therapy
  • Initiate combination therapy or insulin immediately for all patients with HbA1c 3 9% at diagnosis
  • Use combinations of oral antidiabetic agents with complementary mechanisms of action
  • Implement a multi and interdisciplinary team approach to diabetes management to encourage patient education and self-care and share responsibility for patients achieving glucose goals

*Or fasting/preprandial plasma glucose <110 mg/dL (6.0 mmo1/L) where assement of HbA1c is not possible.

Reference
14 Del Prato S, et al. Int J Clin Pract 2005:59:1345-1355

Adjustment of insulin dose for travel between several time zones15

Overview:

A person who travels between several time zones may need to adjust the total daily dose of insulin for the day of travel. This is to take into account the shortening or lengthening of the day due to the change in time.
Number of time zones = (current military time for starting city) - (current military time for arrival city)
If the person travels westward (for example from New York to Los Angeles), the number of time zones is positive, since the day is prolonged.
Total daily insulin dose for day of travel = (usual daily dose of insulin) *(24 + (number of time zones))/24 If the person travels eastward (for example from New York to Paris), the number of times zones is negative, since the day is shortened total daily insulin dose for day of travel = (usual daily dose of insulin) * (24 - number of time zones)/24
It probably should be unnecessary to adjust the dose for the change in 1 time zone.
These adjustments will need to be modified if there are long layovers in interim destinations.

References:
15. Koda-Kimble MA, Carisie BA, Chapter 48. Diabetes mellitus. Pages 48-1 to 48-92 (page 48-40). IN: Koda-Kimble MA, Young LY. Et al (editors). Applied Therapeutics: The Clinical Use of Drugs, Seventh Edition, Lippincott Williams & Wilkins-2001.

Hospital admission guidelines for diabetes*

These guidelines are to be used for determining when a patient requires hospitalization for reasons related to diabetes. Inpatient care may be appropriatein the following situations:

  • Life-threatening acute metabolic complications of diabetes.
  • Newly diagnosed diabetes in children and adolescents.
  • Substantial and chronic poor metabolic control that necessitates close monitoring of the patient to determine the etiology of the control problem, with subsequent modification of therapy.
  • Severe chronic complications of diabetes that require intensive treatment or other severe conditions unrelated to diabetes that significantly affect its control or are complicated by diabetes.
  • Uncontrolled or newly discovered insulin-requiring diabetes during pregnancy.
  • Institution of insulin-pump therapy or other intensive insulin regimens.

Modification of fixed insulin-treatment regimens or sulfonylurea treatment is not, by itself, an indication for hospital admission. Guidelines for hospital admission are given below. Guidelines are never a substitute for medical judgment and each patient's total clinical and psychosocial circumstances must be considered in their application. Therefore, there may be situations in which admission is appropriate, although the patient's clinical profile does not comply with these guidelines. For example, inadequate family resources may dictate admission of newly diagnosed type 1 diabetic patients who otherwise do not meet the admission guidelines.

Acute metabolic complications of diabetes -

Admission is appropriate for the following:

Diabetic ketoacidosis:

Plasma glucose >250 mg/dl (>13.9 mmol/l) with
1) arterial pH<7.30 and serum bicarbonate level <15 mEq/l and
2) moderate ketonuria and/or ketonemia.

Hyperglycemic hyperosmolar state

Impaired mental status and elevated plasma osmolality in a patient with hyperglycemia. This usually includes severe hyperglycemia (e.g. plasma glucose>600 mg/dl (>33.3nmol/l)) and elevated serum osmolality (e.g., >320 mOsm.kg) (>320 mmol/kg).

Hypoglycemia with neuroglycopenia

  • Blood glucose <50 mg/dl (2.8mmol/l) and the treatment of hypoglycemia has not resulted in prompt recovery of sensorium; or
  • Coma, seizures, or altered behavior (e.g., disorientation, ataxia, unstable motor coordination, dysphasia) due to documented or susptected hypoglycemia; or
  • The hypoglycemia has been treated but a responsible adult cannot be with the patient for the ensuring 12 h; or
  • The hypoglycemia was caused by a sulfonylurea drug.

Uncontrolled diabetes -

Poor metabolic control of established diabetes as defined herein justifies admission if it is necessary to determine the reason for the control problems and to initiate corrective action. For admission under these guidelines, documentation should include at lease one of the following:

  • Hyperglycemia associated with volume depletion.
  • Persistent refractory hypergcemia associated with metabolic deterioration.
  • Recurring fasting hyperglycemia 300 mg/dl (>16.7 mmol/l) that is refractory tooutpatient therapy or an A1C level>100% above the upper limit of normal.
  • Recurring episodes of severe hypoglycemia (i.e., 50 mg/dl) (2.8 mmol/l) despite intervention.
  • Metabolic instability manifested by frequent swings between hypoglycemia (<50 mg/dl) (<2.8 mmol/l) and fasting hyperglycemia (<300 mg/dl) (<16.7 mmol/l).
  • Recurring diabetic ketoacidosis with out precipitating infection or trauma.
  • Repeated absence from school or workdue to severe psychosocial problems causing poor metabolic control that cannot be managed on an outpatient basis.

Admission for complications of diabetes or for other acute medical conditions:

Chronic cardiovascular, neurological, renal, and other diabetic complications may progress to the stage where hospital admission is appropriate. In these situations, the needs governing admission for the complication per se (e.g., management of end-stage renal disease) are the primary guidelines for determining whether impatient care is required. However, in applying such guidelines, the fact that diabetes is present must be considered; this may result in patients requiring admission who otherwise might be managed on an outpatient basis. The same is true for other medical conditions (e.g., infections) and treatments (e.g., surgery, chemotherapy) in which 1) diabetes is a confounding factor, 2) rapid initiation of rigorous control of diabetes can improve outcome (e.g., pregnancy), 3) the primary medical problem or the therapeutic intervention (e.g., large doses of glucocorticoid) can cause a major deterioration in diabetes control, or 4) there is actue onset of retinal, renal, neurological, or cardiovascular complications of diabetes.

Originally approved 1990. Most recent review/revision, 2000.
*Currently, there is a committee considering a major revision of this position statement.
© 2004 by the American Diabetes Association.

Travelling with diabetes

Even though Diabetes maybe a life altering condition, it need not cost you your entire traveling lifestyle. Diabetes doesn't have to keep you grounded. You can follow your passion anywhere, as long as you bring the right supplies and plan ahead.

Here are some important things to keep in mind, before you take insulin with you on your next vacation.

Getting ready:

  • If you're traveling to a different time zone, talk to your healthcare provider about when you should take your insulin shots.
  • Ensure that you carry written prescriptions for your insulin and Diabetes pills, in case you need to get more while you're away.
  • If you're travelling to another country, get a list of International Diabetes Federation groups in that country. They should be able to help you fill a prescription and find a healthcare provider in an emergency.
  • If you are travelling to a country where the locals don't speak a language that you know, then learn how to ask the following incase of a Diabetes emergency: "I have Diabetes.", "Sugar or orange juice, please."

Tips on packing your diabetes medication and insulin:

  • You are permitted to carry on your liquid and gel prescription medications, even if they are in containers greater than 3.4 ounces.
  • Be sure that your medications are labeled, so they are identifiable.
  • Pack at least twice as much medicine and blood-testing supplies. Pack at least half of these in your carry-on bag and keep it with you.
  • Remember to pack your oral medications, blood testing supplies and a blood glucose meter-plus extra batteries for the glucose meter.
  • If you're spending time in the sun or if you are holidaying in a warm country, take a travel pack to keep your insulin cool.
  • Carry snacks-sugarless biscuits and cheese, a juice box, and some hard sugar candy-in case you need to raise your blood sugar quickly during an emergency.

How to handle your medication during airport screening:

  • Before going through a security check at the airport, inform the screener that you have Diabetes and that you're carrying supplies with you.
  • It would be recommended that you request a visual screening of your insulin materials, rather than scanning them. You can also request a visual body screening, if you are carrying an insulin pump.
  • The name on your prescription medications should match the name on your boarding pass. If they do not match, the security officers will demand for an explanation for the same.

Steps to take before you fly and after you land:

  • When you make your reservation, you can request the airline you are traveling by to arrange for a special meal for you, which is low in sugar, fat and cholesterol.
  • Keep snacks handy in your carry-on bag, incase the airline is not able to arrange for the special meal you requested.
  • Check your blood sugar level as soon as you land because jet lag can make it hard to tell if your sugar level is very high or very low.

Once you arrive from your trip:

  • Check your blood sugar often, especially if you're more active or eating more than usual.
  • Keep snacks in you handbag and carry them with you everywhere. Food might not be available everywhere you go.
  • Vials and cartridges of Lantus® don't have to be refrigerated while you're away (for up to 28 days). However, ensure that they aren't stored in a place that's very hot or very cold.
  • Be alert to changes in the appearance of your insulin or changes in your insulin needs. If needed, contact your doctor for advice about this.

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