Hypoglycemia + Heart = Things You Need To Know ASAP

 

Does this illustration scare you?

It should.

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I first encountered this slide during an academic lecture given by Dr. Mikhail Kosiborod, MD when I attended the International Hospital Diabetes Meeting in May. He was sharing data about cardiovascular events and outcomes. (If you’re not an academic, the smart people begin to sound like Charlie Brown’s teachers after a while.) But when this illustration came onto the screen, I frantically scribbled the study’s authors down.

This slide was the first time I saw so plainly what was happening to me when I had a moderate hypoglycemic episode. (Dr. Kosiborod said that a “moderate” hypo was 57 mg/dl or less.) Not just the “I feel like I’m dizzy and not all here and let’s concentrate on something insignificant and is it hot in here?” reaction. This was what was going on inside without me feeling most of it. 

Complications are not always from high blood glucose levels

We all know the long-term implications of high blood sugars. It’s that same old “-Opathy” chant that everyone sings loudly: “Retinopathy-neuropathy-nephropathy” with the back-up singers humming: “Don’t forget about stroke and amputation and arteriosclerosis and…big finish, everyone! Gum disease!”

But with lows, it’s a quick ditty: “Unconciousness, seizure, death.” It’s not a chart-topper, but it can be #1 with a bullet if you’re hypoglycemic. When I had those times of “Whoa…let’s stand in the kitchen and daze off into space,” it didn’t feel like I was doing any damage to my body. Sure, I felt like my head had been run over by Gravedigger and I was treading in molasses for several hours after some lows, but I recovered. Or so I thought. Now?

I am setting myself up for long-term complications with repeated moderate low blood sugars. So are you. 

Here’s what happens (you can follow along with the slide, but I’ll break it down in terms we all understand):

Inflammation

Every moderate hypoglycemic reaction sends out wonderful proteins to increase inflammation in our body. (I’ll cut to the chase. We don’t want that.) They are:

Vascular endothelial growth factor (VEGF ), is a signal protein that helps to promote the growth of new blood vessels. We need VEGF as we grow in a womb (to create the blood vessels), after exercise or injury, and VEGF can help create new blood vessels when there is an obstruction. But, much like really good food, it’s only good in moderation. Too much of it (“overexpression”) can contribute to asthma, retinal problems, and  cancers.  The levels go up when we have a moderate hypoglycemic episode.

C-reactive protein (CRP) is a protein released in response to inflammation. Some of our organs, like colons, show a greater risk of cancer when they’re chronically inflamed. This lovely protein also raises our risk for heart disease, high blood pressure, and coronary artery disease.

Interleukin 6 (IL-6) is an interleukin (No, I’m not a medical professional or a biology whiz, so I had to look it up. Fancy word for protein) that does double duty: it promotes inflammation and can help with healing in certain situations. In this case, when we have a low, it’s under the inflammation category. And it gets busy.

“IL-6 stimulates the inflammatory and auto-immune processes in many diseases such as diabetes,[22]atherosclerosis,[23]depression,[24]Alzheimer’s Disease,[25]systemic lupus erythematosus,[26]multiple myeloma,[27]prostate cancer,[28]Behçet’s disease,[29] and rheumatoid arthritis.[30]” – Wikipedia

Endothelial Dysfunction

Vasoconstriction, the narrowing of blood vessels, is not something you want unless you need to stop a massive bleed. But, when you don’t need to stop a hemorrhage, it’s not often something super to have going on. Vasoconstriction raises blood pressure (which is why vasoconstrictor medications are given to people with low blood pressure) and can cause erectile dysfunction. You know what else causes vasoconstriction? Caffeine. Sigh.

Time for a breather. Here’s a picture of a bunny, because this stuff is pretty heavy. Warning, after the bunny, there are no more cute things. 

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Abnormal Blood Coagulation

If it’s a medical term and it starts with “abnormal”: uh-oh.

Factor VII is another protein in our body that helps the clotting process. Too little Factor VII = hemophilia. Too much Factor VII = clotting when there shouldn’t be. Moderate hypoglycemic episodes increase this protein in the body.

Neutrophils are white blood cells. When inflammation starts, neutrophils head towards the area of inflammation. Because our body is doing the inflammation dance when we’re having a moderate low, neutrophils show up for the party, too.

Platelet Activation – platelets help to staunch bleeding by clumping and clogging a blood vessel. Great for stopping bleeding, of course, but lousy when the result is thrombosis. We increase platelet activation when we’re low.

Sympathoadrenal Response

We release adrenaline, epinephrine and norepinephrine as our blood sugar sinks into the basement. It’s that “fight or flight” feeling; that “out-of-control and my heart is racing” feeling. It’s our body’s adrenal response to get us to do something.

When we have multiple hypos, we can developed a suppressed sympathoadrenal response – and that’s hypoglycemic unawareness. Clinicians talk about raising a target blood glucose level because a person with diabetes has hypo unawareness to retrain the body to have that adrenal response again.

But your nervous system also factors into play here. Your autonomic nervous system. Your heart is part of this system. A moderate hypo causes your heart to beat faster (“Thud-thud-thud”) and can cause long-term issues with the timing of your heart (arrhythmia). We’re making our hearts work harder.

It’s Not Over When You Think It’s Over

Your blood glucose level comes up and the hypo is over. But what happened to your body is not over. Not by a longshot. This is what I learned at the symposia at ADA’s 75th Scientific Sessions on Hypoglycemia.

And it’s this:

Vascular issues can last up to two days and blood coagulation issues for up to a week. 
Every moderate hypoglycemic episode builds up inflammation and coagulation responses in my body. One sucky hypo a week was not uncommon for me, even with a Dexcom.

What Am I Doing Now?

I’m doing everything to prevent a moderate or severe low blood sugar. The research I did shows me that I can change the way I react to my lows and help prevent these “issues” from happening.

My CGM is constantly on my body and I’ve set it to alarm at 80mg/dl so that I’m still in my right mind to look at it and take action if I need to do so. Has this helped?

Yes. 

Instead of alarming at 70, when I often tell myself that I’m invincible and that my blood sugar will go back up on its own (I’ve said this to myself a lot…Yes, I know. False.), I’m catching that low. It also has prevented the response of eating everything in the kitchen because I’m in “fight or flight” (or “stuff your face or pass out”) mode. My stress level is lower and I feel more in control.

And that is what this post is about… giving you the info and giving you the opportunity to help yourself, because while you can’t control having diabetes, you can control how you manage it. And hypos are not so innocent.

 

Diabetes Diagnosis Increases Psychiatric Disorder Risk

KONICA MINOLTA DIGITAL CAMERAI understand that scientific studies must be completed so that it can become more than anecdotal evidence. These studies need to be published in reputable academic journals, showing the researchers have followed the proper protocols to get to the conclusion.

But for this latest study, I could have saved everyone a lot of time and money.

This starkly titled study was published on February 3, 2015 in ADA’s Diabetes CareRisks of Psychiatric Disorders and Suicide Attempts in Children and Adolescents With Type 1 Diabetes: A Population-Based Cohort Study.

A large study in Sweden assessed children diagnosed with T1 diabetes and their healthy siblings over a longitudinal study (and also combined a comparison to the general population). Upshot? Here it is:

Children with type 1 diabetes are at high risk of psychiatric disorders, which seems to be a consequence of the disease rather than due to a common familial etiology. The results support recommendations on comprehensive mental health surveillance in children with type 1 diabetes, especially in recently diagnosed children.

In their research, the investigators found the risk for psychiatric morbidity tripled in the first six months of diagnosis. Even long-term, it was still twice as high for the entire observation period compared to the control subjects. I could have told them that.

No Surprise

For a child, a Type 1 diabetes diagnosis is traumatic. (Yes, it’s traumatic for the whole family. Let’s focus on the kid right now and what she/he thinks.) You go from being fine (or your concept of fine) to being told that you have an incurable disease that you can, at best, manage well enough to avoid major complications. Of course, you’ll have to be diligent, stab yourself with needles and lancets, and despite your best efforts, you may still get complications. You tell me if that would send you to your happy place…

I was diagnosed in 1983. Less than 24 hours after my Type 1 diabetes (it was called juvenile diabetes back then) was confirmed, I was in Joslin Clinic’s inpatient Diabetes Treatment Unit where I spent 11 days being indoctrinated. I was too busy learning about insulin and exchanges and sick day rules to really think about what the long-term impact on my life would be.

When it overwhelmed me, it wasn’t in the first six months. In my experience, my medical team and my family worked hard to prepare me for the long slog ahead to the best of their abilities. I know that I was loved and that I was educated in my disease. It took a year and a half, away from my family for an extended period of time on my own.

After the “novelty” of this diagnosis wore off, my head went to very dark places. I would have gone spelunking because I was a teenage girl, but diabetes gave me exclusive entry to depths that most kids don’t reach. Instead of crying over a crush, I was crying over a shortened life span and all those complications that everyone’s grandmother had. Guilt over blood sugars and A1Cs and feeling judged had me questioning my self-worth. My inability to get my blood glucose levels under control (thank you, puberty) for very long played a part in how I felt day-to-day. How the hell was I going to do this every day for the rest of my life?

We Can’t Do This Alone, But We Are Alone

898781_96304223I’ve never kept my bouts of depression a secret. It is liberating to talk about the things that scare you, as long as you know you feel safe. I have had some incredible medical professionals who have led me out of the dark places. I have some wonderful fellow T1 talkers who shine the light on the strong connection between T1 and depression. We can’t do this alone. It’s exhausting. And terrifying.

You can have the best cheerleaders on your team, but they’re not going to win the game for you.  (That’s as close to a sports metaphor as you’ll get on this blog. Go team!)

 

Parents go through their own private hells when a child is diagnosed and I encourage any family to get counseling to talk through the tough times. (Think about the siblings who can become jealous because the T1 kid gets all the attention. I’m grateful that my brother wasn’t like that – at least that I know about.)

But in the end, it’s us. We are alone. The Type 1 child, no matter how protected, loved, educated, watched over… when we close our eyes at night, we think. And dream. And wonder. Sometimes, we travel to dark places. Some of us don’t want to come back. And that’s when it’s crucial that we have people who help us.

Researchers needed to do the studies to tell the medical community what we’ve been telling them for years. It’s not all in our heads. We are at risk simply because we have diabetes. We need a holistic medical team for every T1 child (and dare I say it, T1 adult): someone to teach us how to use insulin and count carbs and someone to teach us how to live our lives with diabetes in a healthy way – body and mind.

If you (or someone you know with Type 1 diabetes, especially those who are newly diagnosed) need help, please… talk with your medical team about your thoughts. There are options and support groups and professionals… For your children who have been diagnosed, please understand that no matter how much love you show them, they may need outside help that you can’t give. That’s OK. Really, it is. 

Creeper

723890_942368176.3%.

6.5%

6.8%

The last three A1Cs.

My CDE asked a simple question:

“What do we need to do?”

I love that she thinks she can help. That she can do something. But I know better.

I’m a creeper. And I know why I’m creeping up, but I’ve been ignoring it.

I’m ignoring the beeps and buzzes of my Dexcom. John will hear it go off – in the other room, because I can ignore it more effectively if it’s not near me – and he’ll say: “Your diabetes is going off.” I’ll nod, say: “It’s high.” or “It’s low.”

Actually look at it? Well…

Take action on it? Well…

Sometimes it takes someone else to point out that you’re creeping. After I went to my latest appointment, John told me that he’s noticing that I’m not doing anything after I see my blood glucose level on a screen.

“Why? What’s stopping you from doing this when you know it will help you?”

The lows are scaring the hell out of me, because I’m not feeling them until they are so bad that my heart is pounding and I’m in panic mode. The highs are safety. And when they’re too high for too long, my action is to SWAG to bring it down, but never so much that I’ll be at 100. I want to feel safe. And I also know that I don’t have to be as vigilant if I know I’m high . And that’s dangerous.

“What do we need to do?”

It’s what I need to do.

Take action. Take care. Listen to the technology that I do have to help. Do it.

I’m not burned out, but I’m in that headspace where my own diabetes becomes a distant hum of a gnat I can’t swat, so I let it buzz.

And creep.

My CDE and I upped my basal rate, looking at the graphs that were in front of us, and I’m hoping that the highs will stop being so high – and I’ll work on listening to the Dexcom.

It takes listening to others sometimes to make a change happen. Listening to your medical team, your family and friends, and the DOC. (Because, DOC, knowing that I am not the only one who does this makes me feel not so alone.)

And then doing it.

So, thank you to my CDE and John and the DOC for being the “we”.

I’m done creeping for now.

Type 1Diabetes + No Insurance? How Little Can You Pay To Live?

Money

You are an adult with T1 diabetes living in the United States. You have no health insurance – or worse, health insurance with such a high deductible that everything you need is out of your own pocket. This is today’s reality for so many people.

Want to know how much having diabetes and paying out of pocket will cost? How little you can pay? Read on…

Ground Rules

This is the bare minimum standard of care, which means I’m not trying to NOT use test strips or avoid tests or health care visits.

When I say “bare minimum”, it means that there are no insulin pumps, no continuous glucose monitors, no conveniences, no latest on the market medications, and forget the latest insulin analogues. The insulin you’ll be using is the same formulation that I started with in 1983 – Regular and NPH (except you get recombinant DNA and I got a mix of beef and pork). 

You should take this as a “If I am to follow what the ADA says I need to do at the very least, this is how much it would cost me for my diabetes.”

This does NOT take into consideration if you have to see additional health care professionals or have additional tests if it’s been determined that you have complications.

I am using the American Diabetes Association’s Standards of Care 2014 as the guiding document.

Most of the items listed can be purchased at Wal-Mart. Why Wal-Mart? Because ReliOn items, sold at Wal-Mart, are the cheapest on the market. I can’t vouch for their accuracy, efficacy, or their overall comfort and convenience. With the exception of the ReliOn glucose tabs that I purchased in an emergency once, I’ve never used these items. But here goes…

Insulin

PR-052_1280x580The least expensive insulin that you can purchase in the United States is at Wal-Mart. Remember that these particular insulins are not the latest or fastest insulins on the market. You will need to work with your health care professional to create your dosage plan, because if you are switching from different insulins (Humalog, Novalog, or Apridra for fast-acting or Lantus, Levemir for slower-acting/basal insulins) your dosage, timing, and when these drugs peak will be completely different.

The ReliOn brand insulin is manufactured by NovoNordisk, just so you know.

That being said, once your have your dosage, let’s pretend calculate:

If you take a total of 30 units per day (hey, adjust for more or less, this is a hypothetical Type 1 adult weighing 60kg), you will take about 900 units per month. As there are 1,000 units per vial, you’ll need at a minimum 2 vials per month.

  • $24.88 ReliOn®/Novolin® Human Insulin N
  • $24.88 ReliOn®/Novolin® Human Insulin R
  • $24.88 ReliOn®/Novolin® Human Insulin 70/30

Total cost per month: $49.76 

Total cost per year: $597.12

Syringes

PR-038_1280x580You have insulin, but you need the vehicle to get the insulin into you: syringes.

  • $12.58 ReliOn Insulin Syringes (100 syringes in each box)

If you use the ReliOn insulin, you’ll most likely take two shots per day (minimum, remember?), so that’s 60 syringes per month. You can only buy them a box at a time.

Total cost per month: $12.58

Total cost per year: $100.64 (8 boxes, for 720 syringes each year, hoping that every single one works properly)

Blood Glucose Monitoring

You need 1 meter. Here you go:

Total cost (let’s just call it per year, OK?): $16.24

Now, this is where it begins to get tricky. You need strips and lancets.

According to the ADA, for Type 1s, self-monitoring of blood glucose (SMBG) is key to diabetes management. They recommend 6 – 8 times per day as a minimum of blood glucose testing. When you read the Standard of Care document, they state:

“…prior to meals and snacks, occasionally postprandially, at bedtime, prior to exercise, when they suspect low blood glucose, after treating low blood glucose until they are normal glycemic, and prior to critical tasks such as driving.”

That is waaayyyy more than 6 times per day, but I’m going with the bare minimum.

So,  6x/day = 180 strips per month. Wal-Mart sells their ReliOn strips in counts of 50, so you’ll need 4 boxes per month.

Total cost per month: $36.00

Total cost per year: $432.00

Now, you have to have a lancing device to get that blood.

Total cost per year: $5.84 

0007874202646_180X180.jpg-5678a538e37caabcaab7cedf6058410c726dc3e5-optim-180x180You are supposed to use a new, sterile lancet for each blood glucose check. (Ahem.) Following the guidelines, it would be 6 new lancets each day for a total of 180 lancets per month. Buy the bigger box and you’ll save a penny per lancet.

Total cost per month: $5.84

Total cost per year: $64.24 ( you only have to buy 11 boxes if you buy the larger box each month). 

Miscellaneous Supplies:

You hope that you’ll never be sick, under stress, or have a blood glucose over 240 mg/dl, because then you could possibly have ketones. But you need to have the ketone strips on hand, just in case. These do expire, so at a minimum, you’ll need one vial of these per year.

Total Cost per year: $6.64

If you are following the guidelines, you’ll need to use an alcohol swab for every time you use a syringe or a lancet.

  • $3.74 ReliOn Alcohol Swabs, 400ct

You’ll use a whopping 2,920 of these each year. Minimum.

Total Cost per year: $29.92

Hypoglycemia? According to Diabetes Care:

Individuals with type 1 diabetes average 43 symptomatic episodes annually; insulin-treated individuals… As for severe hypoglycemic episodes, patients with type 1 diabetes experience up to two episodes annually…The risk increases with a history of hypoglycemia and an increased number of years of insulin treatment.

So, figure on one hypo per week. (You and I both know there are more, but again, we’re bare boning this.)

Hypoglycemia treatment options? Well, you could use glucose tabs or gels; they are the most effective in treating hypoglycemia. Still need something, so you can purchase juice or candy that can treat hypoglycemic reactions for less, but won’t be as effective or as portable or convenient.

  • $3.98 50 ct. ReliOn Glucose Tablets (with an average of 4 tablets for each episode, but you may have to buy something on the fly so this cost may be higher)

Total cost per month (average): $3.98

Total cost per year (average): $47.76 (not counting extra items purchased if you don’t care the glucose tabs with you at all times)

 Lab Tests/Vaccines

Standard of Care states:

Type 1s should have their A1C tested twice per year if you are under 7.0% and quarterly if not meeting goals. The least expensive option is… yes, you guessed it: Wal-Mart.

  • $8.98 ReliOn A1c Test – must mail test to lab to get results.

Total Cost per year: $17.96 – $35.92

Influenza vaccine annually (remember, this is Standard of Care recommendations) You can try and get a free one at a health fair or county health department

Total Cost per year: free to $25.00, depending on where you go without insurance.

Now, often you’ll have to see a health care provider to get this test, but there are some places that you can walk in and get this done without insurance or a prescription. I chose Any Lab Test Now for pricing (obviously this can vary around the country).

Fasting lipid panel annually, regardless of history. If you’re on a statin, then more frequently.

Total Cost per year: $49.00 (minimum) 

Microalbumin test to measure albumin excretion (levels will determine your kidney function)

Total Cost per year: $49.00 (minimum)

Health Care Visits

797188_84253664One visit (minimum) to a health care provider to do physical exams, etc. If there is any evidence of complications or comorbidity, additional visits may be requested.

Total cost per year for a single non-specialist: $95 to $215 (depending on location, according to this 2014 article)

One visit (minimum) for a dilated comprehensive eye exam. (This cost referenced is for a standard eye exam. It may be more based on dilation.) Remember if the health care provider finds evidence of retinopathy, additional visits, treatment, and tests will be needed.

Total cost per year for an eye exam: $50 to $114 (depending on location, according to this website)

 

$1561.36

This is the bare minimum cost annually without insurance (or out of pocket if you have horrible insurance options, not counting the amount you are paying for premiums), if you are not eligible to use free services or patient assistance programs.

Remember The Ground Rules

This amount assumes you are not using an insulin pump, a CGM, any brand name products besides ReliOn, the latest analogues or medications, or using any resources that may cost extra. You are essentially using the same technology that I started with over 30 years ago when I became Type 1, except the blood glucose testing is less expensive and results are faster.

That amount assumes that you are eating a healthy diet (oh, wait… it costs more to eat healthy, so factor that in…).

That amount assumes you are without ANY complications from diabetes or have ANY comorbidities.

That amount assumes you do not take a statin or an ACE inhibitor (recommended by ADA for many patients).

That amount assumes you do not take ANY other medications – or gosh, need a Glucagon Low Blood Sugar Emergency Kit.

That amount assumes you do not have periodontal disease, heart disease, depression, hypothyroidism (which is the most common autoimmune disorder associated with T1 – up to 30% of us have it), kidney disease, neuropathy, frozen shoulder or trigger fingers, foot issues…

That amount assumes you will not be admitted to the ER, the hospital, need specialists (nephrologists, podiatrists, orthopedists, ophthalmologists, cardiologists, gastroenterologists) or have to take time off of work due to diabetes.

If you do need assistance, there are resources available for U.S. individuals with diabetes that meet certain criteria.  

Are you getting what I’m saying here?

607166_81443036If those assumptions are wrong (and most of the time, they are) there are additional thousands of dollars to be spent out of pocket. You can’t get those services at Wal-Mart prices.

This is not a blueprint for how to manage your diabetes.

This is showing you the cheapest, but often substandard treatments, for diabetes. How many people with diabetes must make decisions that impact our life due to the cost of living with this disease? TOO MANY.

I haven’t even started on the emotional cost. The psychological cost. The cost on families, coworkers, employers, friends…

It’s not how little we can pay…

I’ve figured that out: $1561.36 per year, give or take thousands of dollars.

It’s about how much we can’t afford to lose, which is much, much more. 

 

 

Thanks (And No, Thanks)

1101220_85751092Thank you. Yes, you.

I asked for your ideas and your input and your help, and you commented. You made a difference.

The less than stellar appointment I had with the surgeon last week over my trigger finger had been roiling around in my brain and I was confused. Was I wrong in wanting to have a conversation? Was I incorrect in thinking that I shouldn’t have to have three fingers done if only one is triggering? Why don’t they sell Halloween Fun Size candy all year? (Wait. You didn’t answer that. I’m still asking.)

I read your comments and I talked with John… both actions got me to make a second opinion appointment, which I had today. The new surgeon was courteous, looked at my chart before speaking, and talked WITH me, not at me.

One finger will get de-triggered next week. One. Not three. One. (His eyebrow went up when I told him that the other surgeon wanted to do three at once and he had a micro expression that screamed out: “The other surgeon must need to make a payment on his Maserati.”)

On my way from the appointment with the new surgeon, I called the other doctor’s office and gave my “No, thanks” to their surgery option.

So, this is a quick thanks to you (and no, thanks) to the first surgeon. This is why I love the diabetes online community. You help others by sharing your experiences and your opinions. (And my finger still hurts, so I can’t type much more.)

Thank you.