There's a thread where I have a question re diabetes mgmt that I don't think will get answered as it's off topic and buried in the thread so..
If a patient is controlling their type 2 with diet alone, not taking any diabetic meds, is asymptomatic but has a glucose of 70-85, is the proper thing to treat with juice?
With the same scenario, how is the patient at risk of developing critical hypoglycemia if not treated with juice?
Would juice cause an insulin spike in an insulin sensitive diet controlled type 2?
That's ridiculous. Many non-diabetics have fasting, and even post-prandial BGs in the 70s, or even 60s, and are perfectly fine. I would refuse the treatment if I were at your hospital
Remember the thread by the school PDN? I think it would be great if we could copy some excerpts and make a sticky in the diabetes forum, that was the most educational thread.
-- Do you normally have a bedtime snack? Would you like one tonight?
If this isn't a newly admitted pt, I also look at the chart; what were their numbers last night vs this morning?
That's reasonable, but I hope you realize that a type 2 diabetic on no meds is not going to "bottom out." It's physiologically impossible if the patient has any glycogen whatsoever (that would be almost all alive people).
Also, an infection or corticosteroid is likely to raise her blood sugar, not drop it.
Rebound hypoglycemia is a risk for diet controlled type 2 diabetics when on a course of corticosteroids or infection. The BS will trend up after eating, most likely, but the rebound hypoglycemia, which can drop pretty low and often unexpectently for the patient, will also be a symptom. That's what I would be looking for with the low numbers, if it were lower than the patient's baseline, I'd expect the numbers to go higher as well. I'd be on the look out for destabilization in general. Not unusual for inpatient, in my experience.
Since I don't know what the patient was being treated for, it's really just theoretical information. Whatever the illness that brought the patient into inpatient would shine a lot of light on the rest of the question (s). It's hard to answer without the rest of the information from my point of view. It seems like maybe it was on another thread, but I didn't read that thread so I'm just throwing out common reasons a diet controlled type 2 might get destabilized.
I was taught that it was part of the circadian rhythm for blood glucose to drop in the early AM and to give all diabetics, regardless of blood glucose levels and antidiabetics, a snack of complex carbs and protein before bedtime.
I was taught that if you didn't, the patient would either have a reflexive glucose release and wake up with an elevated BG, or wouldn't have the release and would be hypoglycemic. This was taught by our instructor who worked with an endocrinologist.
Maybe the hospital policy was based on something similar. I know that some units are required to check 2am blood glucoses, perhaps this is why.
That protocol is going to produce some yo-yo blood sugars.
If you must give juice, give no more than 4 ounces and follow with some protein (an ounce of cheese is good). If they're asymptomatic, just keep an eye on them during the night.
As has also been pointed out, keep an eye on trends. If you're in LTC, make a note in the 24 hour book regarding it-that way, you know that the Managers have seen it in Stand Up (or whatever the daily conclave is called where you are lol).
Rebound hypoglycemia is a risk for diet controlled type 2 diabetics when on a course of corticosteroids or infection. The BS will trend up after eating, most likely, but the rebound hypoglycemia, which can drop pretty low and often unexpectently for the patient, will also be a symptom
Why does/would this occur in diet controlled DM but has a hyperglycemic effect when on diabetic meds?
Okay, so no other factors withstanding, all you do by giving juice at 70-80 is induce hyperglycemia. Normal people without diabetes run down into the 60s occasionally. If the pt is asymptomatic, has eaten normally throughout the day, and consistently has had normal readings, juice is unnecessary.
I was taught that it was part of the circadian rhythm for blood glucose to drop in the early AM and to give all diabetics, regardless of blood glucose levels and antidiabetics, a snack of complex carbs and protein before bedtime.
I was taught that if you didn't, the patient would either have a reflexive glucose release and wake up with an elevated BG, or wouldn't have the release and would be hypoglycemic. This was taught by our instructor who worked with an endocrinologist.
This sounds like the Somogyi effect, which is when blood sugar drops over night due to an intervention and regulatory mechanisms cause it to spike. It's rare and, according to the evidence, exclusive to people taking medication that can cause hypoglycemia.
The dawn phenomenon, on the other hand, affects as much as half of T2DM, but isn't a response to hypoglycemia. It's caused by a release of hormones that stimulate glucose release (growth hormones), and is found regardless of the use of antidiabetics. This article is a great summary of 30 years of research. The treatment for the dawn phenomenon is insulin.
Rebound hypoglycemia is a risk for diet controlled type 2 diabetics when on a course of corticosteroids or infection. The BS will trend up after eating, most likely, but the rebound hypoglycemia, which can drop pretty low and often unexpectently for the patient, will also be a symptom.
Do you have any citations for this? I ran a bunch of queries through Ovid and couldn't find any articles. The reason this doesn't make sense to me for a patient who isn't on an antidiabetic medication is that patients with T2DM typically have elevated glucagon, which is a buffer against hypoglycemia. Of course, since patients who control T2DM through diet alone are rare when compared to those who use medications, it's kind of hard to find research that looks exclusively at them. Articles that reference the hyperglycemic effects of corticosteroids/glucocorticoids are a dime a dozen, but again, don't generally look at only diet controlled patients.
This sounds like the Somogyi effect, which is when blood sugar drops over night due to an intervention and regulatory mechanisms cause it to spike. It's rare and, according to the evidence, exclusive to people taking medication that can cause hypoglycemia.
The dawn phenomenon, on the other hand, affects as much as half of T2DM, but isn't a response to hypoglycemia. It's caused by a release of hormones that stimulate glucose release (growth hormones), and is found regardless of the use of antidiabetics. This article is a great summary of 30 years of research. The treatment for the dawn phenomenon is insulin.
Cool. Perhaps the treatment I was taught is the same kind of prophylaxis as SCD's & pepcid.
@dogen, just as a curiosity, as a T1D who experinces Dawn Phenomenon, is Dawn Phenomenon exclusive to diabetics, or is it a mechanism that happens to certain people and not others and the only reason we notice it in diabetics is due to their impaired glucose metabolism?
Also, can I just fangirl @dogen for a minute? I am only a graduate nurse, no boards yet, but I do do some speaking and writing about diabetes, as well as some volunteer advocacy work, and in your post I: A) learned something I did not know about T2D and elevated glucagon, B ) read a well reasoned and appropriately cited respones, with links so I could learn more. I love that type of post! In fact, I may even talk about elevated glucagon in a piece I'm kicking around about things nobody tells you about your diabetes.
VANurse2010
1,526 Posts