DKA Awareness Week 2019 Resources

Hi friends! It’s been a busy time for me- after coming back from ADA Scientific Sessions and my cousins wedding I jumped right into helping with diabetes camp! Stay tuned for a post on ADA takeaways and Diabetes Camp but for now, enjoy these DKA Awareness Week Resources!

I was so excited to be asked by Beyond Type 1 to write a couple pieces for DKA Awareness Week 2019! I, fortunately, have never been in DKA (knock on wood), but I advocate for DKA Awareness to promote safety and prevent further loss of lives from a preventable component of living with diabetes. I have a couple friends who were diagnosed with T1D as adults and nearly lost their lives to DKA after (non-diabetes) healthcare providers missed the signs of adult-onset T1D. This seems to happen to many patients I’ve cared for as well. In fact, a large study in the UK found that 42% of T1D cases were diagnosed between ages 31-60! Takeaway- onset of T1D can occur at any age.

So, here we go. Here are the warning signs of diabetes (pre-DKA)!

  • Thirst
  • Frequent urination
  • In babies and toddlers, heavy diapers
  • In children with no previous concerns, sudden bedwetting- happened to me!
  • Weight loss (despite an increased appetite)- happened to me!
  • Decreased energy level
  • Blurry vision
  • Resource from Beyond Type 1

And the warning signs of DKA:

Early symptoms

  • High levels of ketones in urine
  • Very high blood glucose levels
  • Frequent urination
  • Dehydration
  • Extreme thirst

More extreme warning signs

  • Constant fatigue
  • Flushed skin
  • Nausea or stomach pain
  • Vomiting
  • Shortness of breath
  • Fruity smell on the breath
  • Disorientation
  • Resource from Beyond Type 1

And for further resources…

Loop Style Pattern Management: Tips for CDEs

If your clinic and patient’s healthcare provider support Loop, I challenge you to help the Looper with pattern management. But… if you haven’t dealt with Loop before, you might not know how to help these patients.

A key issue I have observed in the Loop community is people DO need help with insulin setting adjustments.

To increase time-in-range while Looping, one has to understand how to analyze patterns and adjust settings appropriately. For example, my first few days Looping, my time in range was around 70% but after making adjustments I’m over 90%!!! Just because the Looper’s CGM data appears great at first glance, sometimes a couple tweaks can still be made to optimize the system. Just because a Dexcom Clarity report says 80% time in range, that doesn’t eliminate the potential to take a further dive into the BG patterns and suggest adjustments. However, setting adjustment is different with Loop than with other insulin delivery systems.

Data & Reports

There are a few data sources for Looping but the one I find easiest to use that works with Loop (for my own pattern management with the CDE perspective) is Tidepool. Tidepool is free for all healthcare providers and people with diabetes. If you have Loopers at your clinic, I suggest checking with IT to confirm you can make a Tidepool account. Tidepool itself is pretty easy to use- it automatically syncs with Apple health data aka Dexcom data. Insulin pump data from the Loop app (for those who use Loop with Medtronic or Omnipod) can also sync to the Tidepool app.

What does the Tidepool report show? When logging in, it shows the typical ambulatory glucose profile.

But, what I find most helping in Loop adjustments (for myself) is viewing the daily reports under the Daily tab. I like how the report shows the CGM graph (blood glucose row), boluses (blue bars in the bolus & carbohydrates row), carbohydrates consumed (golden circles in the bolus & carbohydrates row) and the basal rates (basal rate row). The basals show the constant temp basal rates that Loop sets throughout the day. I print the daily reports to compare different days and look for trends that cannot be seen as easily on the ambulatory glucose profile page. An example of a daily report is below:

Interpreting the Data

So what is important to pay attention to for Loopers? First, take a peak for hypos. If there are a lot of hypos or any severe lows, take a peek to make sure the settings (target range, max basal) aren’t too aggressive. What else? Well, don’t worry about the basal to bolus ratio. The basal will be a much larger percentage of the total daily insulin dose than the bolus- this is how Loop works because it is heavily temp basals. Still assess carb ratios, in fact, that is one of the settings I changed the most. Another really important setting to pay attention to is the ISF. Loop delivers insulin based off of multiple factors- entered settings (pre-set basals, ISF, max insulin delivery, target range) carbohydrates on board and insulin on board. Overnight highs or lows are most likely attributed to ISF that needs adjustment and not just the pre-set basal. One way to tell if the ISF vs basal is off is to look at the basal row on the report- if BG drops after a high basal increase, that is likely an ISF that is too low. If Loop isn’t giving many temporary basals (unlikely!) and BGs are out of range, I would take a look at the basal instead of ISF. An example of an ISF that is too high overnight is displayed below:

Overall, it can be uncomfortable in the clinical setting if your clinic does not know how to support patients who Loop. Fortunately, I have found Tidepool very helpful in my own pattern management while Looping! Hopefully these tips are helpful for practice as well!