Hypoglycemia
and Hyperglycemia
Hypoglycemia and hyperglycemia are two
terms to get to know and remember. Knowing how to treat low blood
glucose episodes (hypoglycemia) and high blood glucose episodes
(hyperglycemia) is important in your management of diabetes. In my
last blog, some numbers were given for goals in blood glucose
management and they are important.
Hypoglycemia is considered for BG
readings below 70 mg/dl (3.9 mmol/L). Most people get noticeable
symptoms when BG goes below 80 mg/dl (4.4 mmol/L), but others do not
until BG gets lower. Readings of 70 mg/dl and above are normal for
most people and generally of no concern. Trends below 80 mg/dl need
to be watched carefully if they get near the 70 mg/dl level. Why do
I use the mg/dl behind the numbers? This is what the meters are set
to read in the USA. All other countries use the mmol/L.
Symptoms of hypoglycemia vary by
individual, but may include extreme hunger, nervousness, excessive
perspiration, rapid heartbeat (tachycardia), headache, fatigue, mood
changes, blurred vision and difficulty concentration and completing
mental tasks. Extremely low glucose levels can lead to disorientation
and convulsions, even coma and death
People with type 2 diabetes still need
to be concerned about readings heading downward from 80 mg/dl and
especially if on insulin or Sulfonylureas as they can cause
hypoglycemia very easily. Although Metformin will not cause
hypoglycemia, in combination with Sulfonylureas, hypoglycemia can
become a problem. Many doctors are not aware of oral medications
causing hypoglycemia and this may lead to problems. Be especially
aware of this if you skip a meal or if you are becoming ill. Test
and if you are below 70 mg/dl, then take a glucose tablet, wait 15
minutes and test again. If you are below 60 mg/dl (3.3 mmol/L) take
two glucose tablets and repeat. If you are below 45 mg/dl (2.5
mmol/L), and having a hard time thinking, have someone call 911 as
you need treatment immediately unless you have a glycogen pen and can
have someone inject you. Most people with type 2 seldom have these
available unless they are on insulin and have had serious
hypoglycemia previously.
Hyperglycemia is difficult to detect
for most individuals. There is much disagreement as to where
hyperglycemia starts. Irrespective of what number you choose to
believe, the American Diabetes Association (ADA) has set the upper
limit for A1c's at 7.0 percent. This equates to 154 mg/dl (8.6
mmol/L). I have also seen ADA use the number of 180 mg/dl (10.0
mmol/L). It is known that complication damage occurs at an A1c value
of 7.0% and higher. Some will argue that damage occurs above 140
mg/dl (7.8 mmol/L). I prefer using the 140 mg/dl as the starting
point for complication damage and as the starting point for
hyperglycemia.
Most people can only detect
hyperglycemia by testing. When your blood glucose levels are above
200 mg/dl (11.1 mmol/L) it may be several days before you may notice
any signs. Some people do not notice frequent urination and
increased thirst, even then. This is another reason to test
regularly. If you are a person that exercises regularly, a blood
glucose reading of 240 mg/dl (13.3 mmol/L) means you must not
exercise until your BG is below 200 mg/dl. It is always advisable to
talk to your doctor about the amount of medication to use to bring
high BG numbers down. Unless you have previously discussed this with
your doctor and know what to do, it is always wise to talk with the
doctor.
Both hypoglycemia and hyperglycemia can
cause death and it is important to know what to do and how to treat
both. Many people with type 2 diabetes don't think this will happen
and ignore the signs for hypoglycemia or think it is not important to
test regularly for hyperglycemia. People with type 1 diabetes know
the value of testing because they are on insulin, but people with
type 2 diabetes are often not even told about this until they are
prescribed insulin. I lay this problem at the feet of doctors
because they do not stay current with oral medications and often do
not understand what the combined side effects are for multiple oral
medications. I also believe the ADA is responsible because they
promote stacking (using more than one oral medication) of oral
medications and do not give appropriate warning of the dangers. Read this article on the Joslin website
for a chart of oral medications and the side-effects. It does not
cover the problems when using combinations or stacking. More on this
in another blog.
Doctors and
the Different Types of Practice
Doctors and those in the medical
profession are mostly like you and I. The one difference is the
amount of education they have and the type of experiences is what
sets them apart. Some excellent doctors always work for the patient
and strive to give the highest quality service. Like any profession,
there are the “bad apples” and we need to avoid them as they give
medicine a bad reputation. In between there is all types and
variations. Do not forget the physician practitioners and physician
assistants. We must also include the nurse practitioners. When I
use the term medical profession I mean to include all of them.
Doctors work with the other medical professionals, but many do not
like them as part of their practice while other doctors welcome them.
Read a blog I wrote in May 2010 on
patients and doctors. Also follow the links provided, as the
information is still applicable and appropriate for this discussion.
I do need to add a few new types of medical operations that exist
today and are very important. For diabetes these can add value to
the appointment and save many problems from developing. A few
practices are beginning to see the value also. I am talking about
shared medical appointments (SMAs). If you are a patient that
insists on keeping your diagnosis a secret, they are not for you.
You must be ready to talk and listen to others and have them know
you. How many people participate in SMAs? This will vary by how
much room a doctor has, how many patients are willing to attend, the
size of the staff available, and how much preparation is needed.
Doctors that are old hands at this and have the room have been known
to have 25 or more patients. Others limit it to 10 to 15 patients.
In my limited discussions with a few doctors using SMAs, they only
have room for the smaller numbers. They utilize private rooms to
talk with those patients unwilling to have the doctor tell them test
results in the group setting or for someone receiving information
that the doctor wants to share in private.
Most doctors use SMAs to dispense the
same information to everyone at the same time. Examples include
importance of testing, medication side effects, goal setting,
lifestyle changes, foot care, and other information. Questions are
answered and discussions on some points do happen. One
endocrinologist uses this to mix new to diabetes patients with old
hands with diabetes to breakdown the panic the new patients are
experiencing. Other groups include people by experience, and some
are with groups that want to stay together. Some doctors have
registered dietitians (RDs) and certified diabetes educators (CDEs)
assisting. Others use physician assistants and nurses. Other
combinations also exist for the medical staff.
Concierge medicine is also gaining in
popularity and doctors can spend varying time with the patients.
Appointments can vary from a half hour to an hour and a half
depending on the need. Some will have a secretary/receptionist and
others will have no one but themselves. Some practices may be two or
more doctors. For more information I suggest reading my blog here
and follow the links to more on the topic. Investigate this site,
which also is about concierge practices. I am aware of one husband
and wife team in concierge practice that is investigating the use of
shared medical appointments (SMAs) for different diseases, diabetes,
cancer, multiple sclerosis, and one other disease.
Something being talked about and
possibly happening is telemedicine. This study is the first I had
read about it, but I think this will have a place in rural areas. By
using nurses or nurse practitioners in the field, telemedicine may
reach patients that otherwise would not have access to doctors
because of the distance to be traveled and especially those no longer
able to drive. It will be interesting to see this develop over the
next few years.
An area of medical practice that is
operating is retail clinics and pharmacy medicine. They are not
quite as sophisticated as neighborhood or a few other inner city
clinics that are staffed by doctors on a voluntary or small fee
basis. The retail clinics are normally staffed by nurse
practitioners, physician assistants, or pharmacists. There is
opposition to these clinics, but they may have their place because of
the coming shortage of primary care physicians. They may have a
place to serve to take the pressure off primary care and emergency
room medicine and they are more economical when compared to emergency
room services. Patients rate most very high for service and
satisfaction. Read about these services here and here.
In some states, actions are underway to
regulate heavily many of the above practices and the state of
California wants to force all doctors back into the practices or
hospitals. The state hospital association is lobbying hard for this.
Series 3 of 12
No comments:
Post a Comment