High & Low B lood S ugars: Managing the Ups and Downs

1. High & Low Blood Sugars: Managing the Ups and Downs School Nurse Workshop September 2019 Mary Zornes, ARNP, CDE, MSN-FNP

2. Overview: Early recognition, treatment and prevention of hyperglycemia & hypoglycemia in the school setting • Why does glucose control matter? • Recognition of low and high glucose symptoms and the overlap of symptoms • Causes and treatment of hypoglycemia and hyperglycemia • Diabetic Emergencies • Severe hypoglycemia • Severe hyperglycema/DKA • Preventing low and high glucose • CGM use in schools • Case studies and addressing difficult situations

3. Why does glucose control matter?

4. Why does glucose control matter? Short Term Long Term Delayed/decreased growth and development Retinopathy Nephropathy Neuropathy Cardiovascular disease Dementia Decreased quality of life • Affects ability to concentrate and learn • Irritability, anxiety, and depressed mood • Increased inflammatory response

5. Diabetes control is a balancing act • Food intake • Insulin • Activity • Stressors/illness

6. Hypoglycemia = Low Blood Sugar • Frequent adverse effect of diabetes treatment/insulin use • Sudden onset, treat urgently • Impairs cognitive and motor functioning: may be mistaken for inattention or misbehavior, student may become combative. • Greatest immediate danger: may progress to seizure or unconsciousness if not treated, and can result in brain damage or death Not always preventable. Early recognition and intervention can prevent an emergency. Most cases are mild and can be treated by eating or drinking a fast acting carbohydrate. Diabetes Medical Management Plan (DMMP) should specify signs and action steps at each level of severity: Level 1 Mild (<70) Level 2 Moderate (<54) Level 3 Severe (Severe cognitive impairment)

7. Hypoglycemia Symptoms

8. Hyperglycemia = High blood sugar • Happens when the body has too little insulin or can’t use insulin effectively • Impedes a student’s ability to learn and participate • Greatest danger: may lead to diabetic ketoacidosis (DKA), coma, and/or death if not treated (mainly in type 1) • Can mimic flu-like symptoms • Fatigue, nausea, vomiting, listlessness, dehydration • Usual onset is gradual progression to higher glucose levels • More rapid onset hyperglycemia with pump malfunction, illness, or infection • Consecutive high readings are more concerning than a single high reading • The student’s DMMP should specify signs and action steps at each level of severity: • Mild, Moderate, Severe

9. Hyperglycemia Symptoms

10. Which symptoms may occur with both low and high blood glucose? A) Blurry vision B) Confusion C) Loss of consciousness D) Hunger E) Fatigue F) Weakness G) A, B, & E H) All of the above

11. Causes of Hypoglycemia • Too much insulin • Overestimated insulin for food/carbs • Stacking insulin: correcting high blood sugar too often • Basal insulin too high • Too little food • Didn’t finish meal/snack, or late/skipped meal • Unanticipated physical activity • Greater duration or intensity than usual • Illness/Stress

12. Causes of Hyperglycemia • Late, missed or too little insulin • Too much food/carbs for insulin • Decreased physical activity • Improperly stored or expired insulin • Failed insulin pump site • Illness, Stress, Injury • Hormone fluctuations, including menstrual periods • Other hormones or medications • Any combination of the above

13. Treating Mild to Moderate Hypoglycemia Intervene promptly; follow DMMP: • Check blood glucose or CGM sensor result if available. • If no meter is available or when in doubt, treat. If untreated may progress to more serious events. • Have an adult stay with the student. DO NOT send a student with suspected low blood glucose anywhere alone. • Consider “Rule of 15”

14. Hypoglycemia Treatment: The Rule of “15” General guidelines, follow student’s DMMP • Test blood sugar, if low • Give 15 g of fast acting carb-Examples: • 4-6 oz regular juice or pop (not diet/low cal) • 3-4 glucose tabs or gummies • 1 glucose gel or liquid • 2 Tbsp raisins • 1-2 Tbsp honey or 1 Tbsp table sugar • Recheck glucose in 15 min, if still low, treat again. • If symptoms continue, call parent/guardian per DMMP

15. Treating Mild to Moderate Hyperglycemia General action steps, follow the student’s DMMP: • Confirm high glucose with blood glucose check &/or review of CGM trends/pattern • Check ketones (urine or blood) • If using an insulin pump, check the infusion site and the pump for any alerts • Allow free use of bathroom and access to water • Administer insulin • Recheck blood glucose • Call parent/guardian per DMMP • Note any patterns, communicate with school nurse and/or parent/guardian

16. What appears to be “non-compliance” may actually be: • Diabetes distress or diabetes burnout for caregiver or student • Dr. William Polonsky, PhD, CDE has written helpful materials and resources on this. • Depression, anxiety, or history of trauma • Sensory issues or autism spectrum contributing to food aversions, “pickiness” • Eating disorders: twice as common in adolescent girls and women with type 1 diabetes • Diabulemia: Intentionally restricting insulin for weight loss • Financial hardship • Insulin and diabetes supply rationing due to cost • Food insecurity • Missing follow up appointments Need to assess for these in a non-judgmental, “curious” manner and connect patients/families to social services, counselling, and support.

17. Low Glucose Emergency-Unresponsive or seizure due to severe hypoglycemia Rare, but life threatening, if not treated promptly: • Place student on his/her side • Lift chin to keep airway open • If unconscious or seizure, do not put anything in student’s mouth • Inject glucagon (traditional glucagon requires reconstitution, GvokePFS-new as of Sept 2019 is premixed and stable in solution, ready to inject, and can be used in children as young as 2 years) or use intranasal glucagon (Baqsimi-new as of July 2019, glucagon nasal powder, does not require inhalation, can be used age 4 years and above), per student’s DMMP • Student may become nauseated and vomit after glucagon. • Call 911, then parent/guardian • Student should respond in 10-15 minutes • May repeat dose in 15 minutes if necessary • Remain with the student until help arrives

18. High Glucose Emergency-Severe Hyperglycemia, Diabetic Ketoacidosis (DKA)Life threatening, if not treated promptly: • Caused by insufficient insulin and excess build up of ketone acids in the body from burning fats • Usually develops slowly but can develop within a few hours if vomiting • Contact the parents/guardians and health care provider, plan to transfer to ER. • Do NOT exercise with high glucose levels and high ketones. • Warning signs & symptoms • Nausea & vomiting • Extreme thirst & fatigue • Fruity odor on breath and/or labored breathing • High levels of ketones in urine or blood • Difficulty paying attention or confusion

19. Preventing Highs and Lows • Accurate carb counting & insulin dosing • Balancing carbs with protein & healthy fats, and choosing high fiber/complex carbs to help stabilize glucose levels. • Monitoring that insulin matches the food eaten (watch for picky eaters or sneaking extra food) • Timing: Insulin, meals, physical activity; keeping to a schedule helps • Keep a glucose monitor or CGM with the student for early detection of highs and lows • Keep a fast acting carb on the student to prevent lows • Watch for patterns in highs and lows (stress, activity, food, etc.)

20. Benefits of Continuous Glucometers (CGM) in the School Setting • Shows real time glucose levels and trends, some models have personalized alerts to prompt a response when the glucose level is above or below the prescribed target range. • Trend arrows reflect a rise or fall in glucose, and the speed at which it is rising or falling. Some devices can predict hypoglycemia and provide alerts to avoid it. • Provide insight into cause and effect, and see how various foods, activities, stress, and other factors affect glucose levels. • Data reviewcan reveal patterns to inform changes to the treatment plan-prescribed insulin or behaviors (ie missed insulin doses, take insulin before meal versus post meal).

21. Figure 1 Dexcom G5 Trend Arrows and Change in Glucose- available via license: Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International Aleppo, Grazia & Laffel, Lori & Ahmann, Andrew & Hirsch, Irl & Kruger, Davida & Peters, Anne & Weinstock, Ruth & Harris, Dennis. (2017). A Practical Approach to Using Trend Arrows on the Dexcom G5 CGM System for the Management of Adults With Diabetes. Journal of the Endocrine Society. 1. 10.1210/js.2017-00388.

22. Guidelines for the use of Continuous Glucometers (CGM) in the School Setting “The student’s DMMP should ALWAYS be consulted before using CGM or Sensor data to make treatment decisions” (ADA, 2018). Dexcom G5 and Dexcom G6 are indicated for treatment decisions and FDA approved for persons with diabetes age 2 years and older. Medtronic Guardian 3 sensor is indicated for use in persons with diabetes age 14 and older, and for use with the MiniMed 670G system to automatically adjust basal insulin levels. Monitor blood glucose with a meter to confirm high or low glucose or for CGM calibration in accordance with the student’s DMMP. Newer CGM devices can share the CGM data to a smart phone and to caregivers remotely. Data sharing can improve care coordination for students with diabetes but may be viewed as intrusive by adolescents. “If the CGM falls off at school, the school nurse should help the student place all pieces into a sealable plastic bag to be sent home with the student. No portion of the CGM should be discarded while at school” (ADA, 2018).

23. Case Study 1 • 10 year old boy has a blood sugar of 95 before lunch. He took his lunch time insulin appropriately for carbs. Now in class getting ready for standardized testing, he feels tired, has blurry vision, and can’t focus well. 1. Do you think his blood sugar is: a) high b) low or c) can’t tell from the information provided? 2. What would you do first? Next? 3. Could anything be done to prevent this?

24. Case Study 1 part 2 • Today, this same student is having trouble estimating his insulin for carbs as the main dish is lasagna and no food label or portion size with carb count was made available to him by the food service staff. 1. What are the legal requirements? 2. What can be done to address this?

25. Case Study 2 • A high school girl comes in with a blood sugar of 260. She admits she forgot her breakfast insulin because she was “in a hurry”. • What are your top 3 priorities/concerns for this patient?

26. Case Study 2 part 2 • A high school girl comes in with a blood sugar of 260. She admits she forgot her breakfast insulin because she was “in a hurry”. • This scenario of forgetting or under dosing insulin is occurring on a regular basis and you notice the girl is also losing weight and getting attention for her weight loss. She also frequently “forgets” to bring her testing supplies and snacks. What other issues might you explore with this patient and parents/guardians?

27. Questions? Thank you! Mary Zornes, ARNP, CDE, MSN-FNP mzornes@cvch.org

28. References & Resources American Diabetes Association Guidelines for the use of Continuous Glucose Monitors (CGM) and Sensors in the School Setting, September 10, 2018 https://www.diabetes.org/sites/default/files/2019-06/CGM%20guidelines.pdf American Diabetes Association Safe at School Diabetes Training, Accessed September 2019 https://www.diabetes.org/resources/know-your-rights/safe-at-school-state-laws/training-resources-school-staff/diabetes-care-tasks-school American Diabetes Association DKA (Ketoacidosis) and Ketones, Accessed September 2019https://www.diabetes.org/diabetes/complications/dka-ketoacidosis-ketones Jackson, Crystal C. et al. Diabetes Care in the School Setting: A Position Statement of the American Diabetes Association Diabetes Care 2015 Aug; 38(8): 1610-1614. https://doi.org/10.2337/dc14-2898 Hirsch, Irl B. Glycemic Variability and Diabetes Complications: Does It Matter? Of Course It Does! Diabetes Care 2015 Aug; 38(8): 1610-1614.https://doi.org/10.2337/dc14-2898 The National Institute of Diabetes and Digestive and Kidney Diseases. Helping the Student with Diabetes Succeed: A Guide for School Personnel Accessed September 2019 https://www.niddk.nih.gov/health-information/communication-programs/ndep/health-professionals/helping-student-diabetes-succeed-guide-school-personnel?dkrd=hispt1099 NovoNordisk & JDRF Caring for Someone with Type 1 Diabetes. June 2016, PDF booklet. Accessed September 2019 https://www.novomedlink.com/diabetes-patient-support/disease-education/caring-for-someone-with-type1-diabetes.html Medtronic.MiniMed 670G Insulin Pump system. Accessed September 2019 https://professional.medtronicdiabetes.com/minimed-670g-insulin-pump-system Xeris Pharmaceuticals. Gvoke Now Approved! Webcast with the Diabetes Community September 13, 2019. https://www.gvokeglucagon.com/pdf/now_approved_gvoke_webcast.pdf Aleppo, Grazia & Laffel, Lori & Ahmann, Andrew & Hirsch, Irl & Kruger, Davida & Peters, Anne & Weinstock, Ruth & Harris, Dennis. (2017). A Practical Approach to Using Trend Arrows on the Dexcom G5 CGM System for the Management of Adults With Diabetes. Journal of the Endocrine Society. 1. 10.1210/js.2017-00388. Medtronic MiniMed.(2016) Getting Started with MiniMed 670G Continuous Glucose Monitoring.PDF booklet. Accessed Sept 2019 https://www.medtronicdiabetes.com/sites/default/files/library/download-library/workbooks/Getting%20Started%20with%20MiniMed%20670G%20Continuous%20Glucose%20Monitoring.pdf