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January 3, 2012

Hyperglycemia and DKA, Insulin

Question from Staines, United Kingdom:

My nine-year-old daughter was diagnosed with type 1 about a year ago and went on a Medtronic MiniMed Veo pump in July. Three weeks ago, she became really lethargic quite quickly and her blood sugar was elevated constantly, day and night. We ended up in the Emergency Room where they did laboratory blood work but nothing came back so we were told it was viral. After a week off, she went back to school but her blood sugar was hardly ever below 14 mmol/L [252 mg/dl] even after raising her basal rates and a temporary basal rate running between 140 to 180%.

Last week, she developed a cold and became even more lethargic and her blood sugar was again elevated so I increased all basal rates again. Friday, the symptoms of the cold disappeared but the lethargy has her off school again, barely moving and feeling quite low. After speaking with her SDN, I have raised her basal rates again but she is still requiring a temporary basal, too, of about 140%. Should I be concerned? This is all still new and not how she has reacted before when she has caught bugs. What should I do?


From: DTeam Staff

When you are new to caring for diabetes mellitus (and sometimes when you are not so new), I think that somehow we, as clinician educators, do not make it clearer from the beginning that management recommendations are to HELP MANAGE glucose levels. Families, understandably, want consistency and glucose levels may not be…even when they are. By this, I mean that too often folks lose perspective: a TARGET glucose for your child somehow becomes a “NORMAL” glucose. When the target is not being reached we appropriately look for explanations. So, I go to the beginning: blood glucose hinges on many, many, many, many factors and variables and conditions. At the foundation of blood glucose control are three key parameters: insulin, food, and exercise. When these are matched with one another, blood glucose is more often in target. This means, of course, that sometimes one will still be out of target. Why? Well, for starters, some of the other myriad of variables may be playing a role.

As an example, when we are ill or otherwise “stressed”, our physiology has mechanisms that normally lead to the breakdown of stored sugar (called glycogen) into glucose and the liver will begin chemical processes to synthesize glucose. Why? Because the body sees “stress” as a state whereby extra “fuel” may need to be available in case one needs to go without eating or one needs to be active (like running away from danger).

You have probably noticed that it does not take much exercise to affect the serum glucose. Exercise initially will raise glucose (by helping to breakdown glycogen) but then ultimately will lower the serum glucose because the muscles and organs become more insulin sensitive. This leads to the mismatch of insulin-to-food-to-exercise. People rarely eat exactly the same amount of calories daily or have exactly the same amount of calorie expenditures daily.

Another factor includes the duration of time one has diabetes: commonly, in the first months of type 1 diabetes management, the patient will experience the diabetes “honeymoon.” This can last weeks, to months, to a couple of years. During this diabetes honeymoon, one’s own pancreas is still producing insulin in response to food and making insulin in conjunction with the insulin you are providing as the outside source. But when the diabetes honeymoon ends, then more insulin will need to be provided by the outside source.

There are factors that impact the body’s sensitivity to insulin: once again, stress hormones (such as cortisol and adrenaline) can inhibit the effects of insulin, but so can puberty hormones.

My general advice for pumpers would be this: when glucose levels are becoming more consistently and persistently off target, go back to the beginning and look at the variable with an unbiased eye: Has the patient been ill? Is the patient dosing appropriately for meals with “boluses” of insulin? Are the two hour after-meal glucoses in target? If not, then the insulin-to-carbohydrate ratios for meal planning were off (either counting carbohydrates inadequately or calculating inadequately). Make corrections with the “correction formula;” if that doesn’t lead to target glucoses, then the sensitivity factor or variable may need to be changed.

By all means, give insulin as needed. I’d estimate that if your basal rates are now 140% of previous, this won’t last long. If it is maintained, then this is the new requirement based on food and activity, etc.

On rare occasions, if, despite this, glucose levels continue to rise, then your own diabetes team may suggest special testing for other conditions (e.g., chronic, indolent infections) that lead to higher insulin needs or bring the patient into hospital for monitoring.