My father is 87 and a type 1 diabetic of 40 years.. Recently after a stay in hospital they have changed the advice (under their own guidelines they say have come into force for everyone) from taking Novarapid if the glucose reading was 15 plus to ONLY taking it if ketones are showing in his urine (recommending to test at 17 plus). He was left with high readings (many in mid to high 20's) as they slowly adjusted his Insulin (10% every 48 hours). He was showing and still does when reading high all the symptoms of a Hypo - but they still say no Novarapid unless there are ketones. Surely this cannot be correct ?
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Novarapid / Hypo query
- Thread starter Richyok
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The official advice is to test for ketones when bg is on or above 13.9mmol/l or when unwell, leaving your father with levels of 20+ isn't good but if they are continuing to adjust his insulin doses to lower his bg then it's a case of wait and see.
I can't make out what you mean when you say your father is showing symptoms of a hypo when high, hypo's are when bg falls below 4mmol/l, if however his bg has been running considerably high for a long time he may experience 'false hypo's' as his medical team begin to reduce his bg levels, these 'false hypo's' are unpleasant but it's just the body's way of adapting to the lower bg levels and will disappear once his bg is stabilised.
Hope everything works out fine for you all, don't be afraid to ask his diabetes team any questions that you may have about his care.
I can't make out what you mean when you say your father is showing symptoms of a hypo when high, hypo's are when bg falls below 4mmol/l, if however his bg has been running considerably high for a long time he may experience 'false hypo's' as his medical team begin to reduce his bg levels, these 'false hypo's' are unpleasant but it's just the body's way of adapting to the lower bg levels and will disappear once his bg is stabilised.
Hope everything works out fine for you all, don't be afraid to ask his diabetes team any questions that you may have about his care.
Re: Novarapid / Hyper
Sorry - my above question should be about hyperglycaemia - so change hypo to hyper. I have got a copy of the guidelines and I read it as if showing + or ++ for ketones OR +15 (although they say 17) novarapid is to be taken - which makes sense to me - but the interpret it as +15 AND + or ++ ketones requires Novarapid - which makes no sense to me - leaving someone with overly high blood sugar for a continued period?
Sorry - my above question should be about hyperglycaemia - so change hypo to hyper. I have got a copy of the guidelines and I read it as if showing + or ++ for ketones OR +15 (although they say 17) novarapid is to be taken - which makes sense to me - but the interpret it as +15 AND + or ++ ketones requires Novarapid - which makes no sense to me - leaving someone with overly high blood sugar for a continued period?
Daibell
Master
Hi. I am simply amazed by the apparent advice form the hospital. May be I'm missing something. Most of us, I believe, on Basal/Bolus insulin regime do carb-counting for the Bolus and take enough to keep the blood sugar 2-3 hours after a meal at the less than 8-9 if possible based on the carb/insulin ratio we have measured works for us. In the long-term no diabetic should be left with bloods over, say, 10mmol 2-3hours after eating. If anyone is regularly in the mmol teens it will send their HBa1C into problem territory and be doing damage. Ketones and hyperglycemia are a sign of extreme blood sugar which no one should normally get anywhere near. I think you need further discussion with a good diabetic nurse or GP.
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Re: Novarapid / Hyper
No it's not good at all to be leaving your father with high bg, in order to bring his bg down he does need to take corrective doses of insulin otherwise his bg will continue to remain high, for most this means a corrective dose of insulin added to the next meal-time dose.
When ketones are present the DAFNE guidelines (this is structured education course for type 1's) says you should take 10 or 20% of your TDD of insulin depending on the level of ketones present, this is a small extract from the article to follow...
A positive ketone test means you need extra insulin as rapid acting e.g. NovoRapid.
You must test your blood glucose and ketones every 2 hours.
You will need to calculate 10% and 20% of your total daily dose (TDD). Add all your insulin doses together to get your TDD e.g. if you are on 30 units TDD then 10% is 3 units and 20% is 6 units.
If you have + or ++ (small to moderate) ketones then in addition to your insulin for CHO you should give an extra 10% as NovoRapid every two hours.
If you have +++ or ++++ (large) ketones then in addition to your insulin for CHO you should give an extra 20% as NovoRapid every two hours.
http://www.salforddiabetescare.co.uk/in ... nav_id=431
I would contact his diabetes team asap and express your concerns about your fathers bg, the line between prolonged high bg levels and DKA is a fine one and this has to be a worry for someone your fathers age.
Richyok said:
No it's not good at all to be leaving your father with high bg, in order to bring his bg down he does need to take corrective doses of insulin otherwise his bg will continue to remain high, for most this means a corrective dose of insulin added to the next meal-time dose.
When ketones are present the DAFNE guidelines (this is structured education course for type 1's) says you should take 10 or 20% of your TDD of insulin depending on the level of ketones present, this is a small extract from the article to follow...
A positive ketone test means you need extra insulin as rapid acting e.g. NovoRapid.
You must test your blood glucose and ketones every 2 hours.
You will need to calculate 10% and 20% of your total daily dose (TDD). Add all your insulin doses together to get your TDD e.g. if you are on 30 units TDD then 10% is 3 units and 20% is 6 units.
If you have + or ++ (small to moderate) ketones then in addition to your insulin for CHO you should give an extra 10% as NovoRapid every two hours.
If you have +++ or ++++ (large) ketones then in addition to your insulin for CHO you should give an extra 20% as NovoRapid every two hours.
http://www.salforddiabetescare.co.uk/in ... nav_id=431
I would contact his diabetes team asap and express your concerns about your fathers bg, the line between prolonged high bg levels and DKA is a fine one and this has to be a worry for someone your fathers age.
cally
Well-Known Member
Hi
You say your father has been a type 1 diabetic for more than 40 years? What kind of insulin treatment was he on before?
I think the main priority with doctors and the very elderly who are type 1 and need Insulin seems to be prevention of hypoglycaemia because of the risk of falls.
Unfortunately this often results in them being prescribed an Insulin regime which means that their blood sugar levels are too high all the time! I have even come across type 1's who have been taken off their fast acting insulin completely and are treated with just Lantus with very high blood sugars as a result.
You say your father has been a type 1 diabetic for more than 40 years? What kind of insulin treatment was he on before?
I think the main priority with doctors and the very elderly who are type 1 and need Insulin seems to be prevention of hypoglycaemia because of the risk of falls.
Unfortunately this often results in them being prescribed an Insulin regime which means that their blood sugar levels are too high all the time! I have even come across type 1's who have been taken off their fast acting insulin completely and are treated with just Lantus with very high blood sugars as a result.
He was and still is on Humulin M3 but he was previously told to take Novarapid if bg above 15. Now as you say they do not want him to take any unless ketones are showing - regardless of the high readings. He sat like a 'zombie' for over a week with readings mainly in mid to high 20's with all the usual symptoms of hyperglaecemia. The diabetic nurse is adamant that Novarapid is not to be given in case - as you say it creates a hypo/ fall - but there are district nurses coming in to monitor the insulin - and I'm trying to say that sustained high readings are detrimental to the body recovering from illness and the efficiency of the cells working correctly etc and that good insulin management is key!.......it's been so frustrating!
cally
Well-Known Member
It does sound as if they haven't got the dose right yet especially if his high blood sugars are causing him symptoms!
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robert72
Well-Known Member
The trick with biphasic insulins like Humulin M3 is to match your diet to the action of the insulin. If your father is recently out of hospital I would imagine he would be less active than normal, which would make him more insulin resistant as well as not burning off the carbs he is eating.
Is he on a set meal plan (same number of carbs for certain meals)? It might be worth him eating a bit less carbohydrates until his sugars are more level and he is more active. After my recent operation, the doctors became very concerned when my BGs went over 12 as they said it was very detrimental to the healing process.
Hope you manage to sort this out for him soon.
Is he on a set meal plan (same number of carbs for certain meals)? It might be worth him eating a bit less carbohydrates until his sugars are more level and he is more active. After my recent operation, the doctors became very concerned when my BGs went over 12 as they said it was very detrimental to the healing process.
Hope you manage to sort this out for him soon.
mentat
Well-Known Member
High blood sugars cause a lot of damage the body. Ketones damage it even more, but waiting until ketones arise is idiotic.
Modern medicine loves to deliver one-size-fits-all solutions. It's the easiest way for the medical professionals to absolve themselves of all responsibility in giving advice. They can become blind to patients who obviously don't fit the guidelines. Blind to patients whose suffering is staring them in the face.
I think part of the problem here is that when your sugars are at 13 for a few hours the guidelines make sense, but if your sugar hovers at 13 for days then a different situation is at hand, one that needs resolving.
If it were me I would take matters into my own hands, nobody can stop me injecting myself with what I believe is best for me. (That's my opinion, NOT advice.)
Modern medicine loves to deliver one-size-fits-all solutions. It's the easiest way for the medical professionals to absolve themselves of all responsibility in giving advice. They can become blind to patients who obviously don't fit the guidelines. Blind to patients whose suffering is staring them in the face.
I think part of the problem here is that when your sugars are at 13 for a few hours the guidelines make sense, but if your sugar hovers at 13 for days then a different situation is at hand, one that needs resolving.
If it were me I would take matters into my own hands, nobody can stop me injecting myself with what I believe is best for me. (That's my opinion, NOT advice.)
Everything everyone says on here makes sense - it just seems its the diabetic nurse team that don't understand diabetes! My father is seeing the consultant this afternoon - so hopefully some clarity and common sense will prevail. I will let you know later if that is the case!
Hi
I admit that your father's high bg levels would worry me a bit but as Robert has stated in his msg - Humulin M3 is a mixed insulin that is able to control bg levels just on its own as long as sufficient carb is eaten throughout the day in small amounts rather than large and the Novorapid is used as a back up to lower bg levels fairly fast when they have gone way too high. Caution has got to be used though as too much Novorapid could well cause bg levels to lower extremely quickly combined with the bg lowering action of the Humulin M3 so that is why the nursing staff are using the guideline that they have. They also, might not have the time to test your fathers bg levels too often which if he was at home, he would be able to do and eat some food to correct any undue lowering.
I suspect the cause of the high bg problem is - food. Hospital food is laden with too much carb and not enough vegetables or fruit for that matter and for the meals to be approved by Jamie Oliver - well I'm shocked to say the least. You need to ask the nursing staff what the carb count of the food they are dishing up to your father is. I doubt if they will know...
I admit that your father's high bg levels would worry me a bit but as Robert has stated in his msg - Humulin M3 is a mixed insulin that is able to control bg levels just on its own as long as sufficient carb is eaten throughout the day in small amounts rather than large and the Novorapid is used as a back up to lower bg levels fairly fast when they have gone way too high. Caution has got to be used though as too much Novorapid could well cause bg levels to lower extremely quickly combined with the bg lowering action of the Humulin M3 so that is why the nursing staff are using the guideline that they have. They also, might not have the time to test your fathers bg levels too often which if he was at home, he would be able to do and eat some food to correct any undue lowering.
I suspect the cause of the high bg problem is - food. Hospital food is laden with too much carb and not enough vegetables or fruit for that matter and for the meals to be approved by Jamie Oliver - well I'm shocked to say the least. You need to ask the nursing staff what the carb count of the food they are dishing up to your father is. I doubt if they will know...
Thanks - again what you say makes sense. But to clarify - he has been at home for 3 weeks and currently has carers visiting 4 times a day and district nurses coming in 2 x a day. I took him off the Complan diet! - which the diabetic dietician recommended as he has a swallowing problem (and which has 46.6% sugar) and put him on a balanced diet consisting of home made soups and avoiding sugary foods when his BG is/ was high.
Hi again
Humulin M3 is very similar to the action of Novomix 30/70 but its action on controlling blood glucose levels ok is dose determined on how much carb is being eaten (or needs to be) to keep bodyweight at an ok level as people who weigh more will need more insulin than people who weigh less and this has to be carefully balanced up with food to determine correct body weight as well.
How much carb is in the home made soup and is it also along with some bread? Soup can be high in carb according to the ingrediants put in it and bread is usually high in carb and cut bread - really alters according to how thick the slice is cut.
I think what you have got to do for your father is prepare food that is lower in carb so that the correction with Novorapid is not needed too much. In many respects as long as someone is of able mind and body and is able to test bg levels as and when they should, then its better to eat a small amount of carb to correct a low bg than it is to give correction insulin for a high bg.
Humulin M3 is very similar to the action of Novomix 30/70 but its action on controlling blood glucose levels ok is dose determined on how much carb is being eaten (or needs to be) to keep bodyweight at an ok level as people who weigh more will need more insulin than people who weigh less and this has to be carefully balanced up with food to determine correct body weight as well.
How much carb is in the home made soup and is it also along with some bread? Soup can be high in carb according to the ingrediants put in it and bread is usually high in carb and cut bread - really alters according to how thick the slice is cut.
I think what you have got to do for your father is prepare food that is lower in carb so that the correction with Novorapid is not needed too much. In many respects as long as someone is of able mind and body and is able to test bg levels as and when they should, then its better to eat a small amount of carb to correct a low bg than it is to give correction insulin for a high bg.
Daibell
Master
Hi having read the hospital guidelines you posted, I have a different interpretation from you. They are not saying ONLY give NovoRapid if Ketones are present. They talk about increasing normal insulin by X% as the blood sugar gets worse. I think this document says keep going with normal insulin BUT increase it as the blood sugar rises? It doesn't say to stop normal insulin so I think the staff may be misreading it?
No they have been raising them by 10% every 48 hours and it has eventually come more or less under control after several weeks, but it has been a long journey getting here.
I saw the consultant this afternoon and fully understand the theory of not wanting to give Novarapid (unless ketones present) - and avoid hypos and so it doesn't 'skew' the results, BUT the reality of that regime was that it left my father for literally days in a hyperglycaemic state - totally lethargic, thirsty with frequent urination and occasional loss of bladder control - the raised BG levels would indicate that any of the body's cells were not working to their potential and the recovery from pneumonia and other complications from his recent hospital stay would be slowed down.
Even though BG is thereabouts - the advice is still not to give Novarapid (unless ketones are present) even if high BG readings and hyperglycaemia returns on a short term basis. I cannot understand, if the Humulin doseage is considered correct, why if there is a tool to rectify any high rogue readings - why he cannot do so?
I saw the consultant this afternoon and fully understand the theory of not wanting to give Novarapid (unless ketones present) - and avoid hypos and so it doesn't 'skew' the results, BUT the reality of that regime was that it left my father for literally days in a hyperglycaemic state - totally lethargic, thirsty with frequent urination and occasional loss of bladder control - the raised BG levels would indicate that any of the body's cells were not working to their potential and the recovery from pneumonia and other complications from his recent hospital stay would be slowed down.
Even though BG is thereabouts - the advice is still not to give Novarapid (unless ketones are present) even if high BG readings and hyperglycaemia returns on a short term basis. I cannot understand, if the Humulin doseage is considered correct, why if there is a tool to rectify any high rogue readings - why he cannot do so?
