Calling diabetes experts

[Libby1987]

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?

[Dogen]

@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?

I don't know about being exclusive to diabetics, but early in the article synthesizing 30 years of research* they discuss continuous monitoring of glucose and insulin in diabetic and non-diabetic healthy controls, and that in non-diabetic patients they see a spike in insulin but not a spike in glucose in the dawn hours. So it appears that healthy controls have the same hormone release, but they have the mechanisms in place to keep from getting a blood sugar spike. There's even a little table, Figure 1, that shows the two measures over time.

* I tried to edit my previous post, but it's too late. So here's a link that should actually work.

[RainMom]

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).

Haha true. I totally based this off the fact that at my facility the docs rx sliding scale to almost all diabetics regardless of whether diet controlled or not. Most are postop with D5 1/2NS & decadron rx so invariably are running higher than their norm.

[defying.gravity]

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.

Good question (s), Dogen and Libby.

Here is something that might help you with your questions: https://www.netcegroups.com/1024/Course_34651.pdf

Diane Thompson is definitely a solid resource for any questions and concerns regarding diabetic care.

[defying.gravity]

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.

Dogen, I would like to adjust the word "will" in my post to "can". Hypoglycemia can be a symptom, not will be a symptom. I should have been more careful in my post, there is a big difference between "will" and "can" and "can" is more appropriate. Not every patient will experience it, but some can.

I, personally, am one of the dm2-diet controlled-patients who do get the rebound hypoglycemia on corticosteriods. I don't like using my personal point of view, though, because it blurs the boundaries of my objectivity when discussing professional topics, but that is something I've experienced personally more than once. Needless to say, I try to stay away from them as much as I can ....

[MLSTTS2015]

I was one of those that said would have treated in that original post. I will admit that I skimmed the post and did not read that the patient was not taking any insulin or other hypoglycemics; So at 85 I probably would have asked the patient if she usually dropped at night and would have left it up to the pt. as far as my hospital protocol they are very very strict, for those that are diabetics treat under 80 non diabetics treat under 70. we also must recheck 15min after we treat. our glucometers record everything and if we do not follow this it is investigated and we are usually written up.

[RNKPCE]

Curious what, if any intervention would you do on a non diabetic whose glucose is 73 on a routine chem panel?

Would your intervention be different in same scenario on a diet controlled diabetic?

[llg, PhD, RN]

Good question (s), Dogen and Libby.

Here is something that might help you with your questions: https://www.netcegroups.com/1024/Course_34651.pdf

Diane Thompson is definitely a solid resource for any questions and concerns regarding diabetic care.

Seems like a good review of standard information ... but I don't see any discussion in the resource about patients who are not on medications. The fact that the OP's original questions relates to a patient not on any medications changes things considerably. This patient has successfully managed his/her glucose and should be asked what about his/her usual patterns and allowed to make the decision as to whether to eat or drink anything herself.

I am a patient who has been borderline Type 2 / Insulin resistant for several years. I test 2x per day. When I get a reading in the 80's in the morning, my doctor and I am VERY happy about it. In such a similar situation, if a nurse tried to coerce me into drinking a sugary drink I didn't want or need, I might just throw it at her.

[Twinmom06, ASN, APN]

Twinmom, juice in an insulin sensitive person will just drop them again, why not with something like peanut butter and crackers?

its usually for AM sugars and tides them over till breakfast. If its not nearly a meal time then yes I get them crackers (no PB in the hospital anymore)

[defying.gravity]

I am a patient who has been borderline Type 2 / Insulin resistant for several years. I test 2x per day. When I get a reading in the 80's in the morning, my doctor and I am VERY happy about it. In such a similar situation, if a nurse tried to coerce me into drinking a sugary drink I didn't want or need, I might just throw it at her.

lol .. indeed, Ilg ... barring the throwing juice at a nurse, I'm right there with you. I'm pretty sensitive to pt baseline as well due to my personal experience. I added some examples in with my previous insights (which were as you say, check baseline) that were questioned, which is why I redirected the questions to someone with expertise. The author I referenced has rather extensive information in terms of diabetic care for nursing, that particular article is just a small part of her expertise. A good direction to point in, at least I think.

It does highlight a need for more studies for the diet controlled type 2 patients, if you ask me. Hopefully one day we can start to populate that particular section of the research.

I'm laughing at throwing the juice. I almost did that precise thing during one of my pregnancies with the GTT. I tested marginal with the GCT and went on to the GTT. A couple sips in and I realized how stupid I was being, I knew I was going to spike, I didn't need a test to tell me. Insurance did, according to the nurse. lol ... I threw it away and called my physician and said, "look, we know this isn't going to work, how do I get past this without being non-compliant". We just used my personal BG charting to submit to insurance. I wish I was nicer to that nurse, I know she was only doing her job. That wasn't one of my nicer days, and I blame myself. I knew better to mess with my BG like that just to prove what we already knew. Strange rules sometimes.

[Been there,done that, ASN, RN]

Certainly agree not all have the same nursing judgement. I was not saying throw protocol to the wind. I was saying ...nursing judgement must also be applied when following a set protocol.

When the nurse decides protocol is for the birds, s/he most certainly needs to consult/ notify the physician as to WHY protocol is for the birds... get an order to cover the change in protocol.