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Glucose (blood sugar) levels
Both low blood sugar (hypoglycemia) and high blood sugar (hyperglycemia) are of concern for patients who take insulin. It is important, therefore, to carefully monitor blood glucose levels. In general, patients with type 1 diabetes need to take readings four or more times a day. Patients should aim for the following measurements:
Pre-meal glucose levels of 90 - 130 mg/dl
Bedtime levels of 110 - 150 mg/dl
Different goals may be required for specific individuals, including pregnant women, very old and very young people, and those with accompanying serious medical conditions.
Finger-prick test. A typical blood sugar test includes the following:
A drop of blood is obtained by pricking the finger.
The blood is then applied to a chemically treated strip.
Monitors read and provide results.
Home monitors are about 10 - 15% less accurate than laboratory monitors, and many do not meet the standards of the american diabetes association. Most doctors believe, however, that they are accurate enough to indicate when blood sugar is too low.
To monitor the amount of glucose within the blood a person with diabetes should test their blood regularly. The procedure is quite simple and can often be done at home.
Some simple procedures may improve accuracy:
Testing the meter once a month.
Recalibrating it whenever a new packet of strips is used.
Using fresh strips; outdated strips may not provide accurate results.
Keeping the meter clean.
Periodically comparing the meter results with the results from a laboratory.
Supplementary monitoring devices. Other devices are available for monitoring blood glucose. These devices are used in addition to traditional fingerstick test kits, and glucose meters but do not replace them:
Continuous glucose monitoring systems (cgms) use a needle-like sensor inserted under the skin of the abdomen to monitor glucose levels every 5 minutes. In 2007, the sts-7 system was approved. Using a disposable sensor, the sts-7 measures glucose levels for up to a week. An alarm will sound if glucose levels are too high or low. The older minimed system measures glucose over a 72-hour period and has wireless communication between the monitor and an insulin pump.
Glucowatch is a battery-powered wristwatch-like device that measures glucose by sending tiny electric currents through the skin, a technique called reverse iontophoresis. It is painless and has a warning device when detecting high glucose levels. It takes 2 hours to warm up, and the sensor pads need to be changed every day. Glucowatch measures glucose levels three times per hour for up to 12 hours. About a quarter of the time, the results differ significantly from actual fingerstick tests, however.
Hemoglobin a1c (also called hba1c, ha1c, or a1c) is measured periodically every 2 - 3 months, or at least twice a year, to determine the average blood-sugar level over the lifespan of the red blood cell. While fingerprick self-testing provides information on blood glucose for that day, the hba1c test shows how well blood sugar has been controlled over the period of several months. For most people with well-controlled diabetes, hba1c levels should be below 7%. Home tests are available for measuring a1c but they tend not to be as accurate as the laboratory tests ordered by doctors.
Urine tests are useful for detecting the presence of ketones. These tests should always be performed during illness or stressful situations, when diabetes is likely to go out of control. The patient should also undergo yearly urine tests for microalbuminuria (small amounts of protein in the urine), a risk factor for future kidney disease.
Insulin like supplementary drugs for hyperglycemia
Pramlintide (symlin) is a new type of injectable drug that can help control postprandial hyperglycemia, the sudden increase in blood sugar after a meal. Pramlintide is injected before meals and can help lower blood sugar levels in the 3 hours after meals. Pramlintide is used in addition to insulin for patients who take insulin regularly but still need better blood sugar control. The fda approved this drug in 2005 for adults with type 1 and type 2 diabetes. Pramlintide and insulin are the only two drugs approved for treatment of type 1 diabetes.
Pramlintide is a synthetic form of amylin, a hormone that is related to insulin. Side effects may include nausea, vomiting, abdominal pain, headache, fatigue, and dizziness. Patients with type 1 diabetes have an increased risk of severe low blood sugar (hypoglycemia) that may occur within 3 hours following a pramlintide injection. This drug should not be used if patients have trouble knowing when their blood sugar is low or have slow stomach emptying (gastroparesis).type diabetes
Insulin pumps. An insulin pump can improve blood glucose control and quality of life with fewer hypoglycemic episodes than multiple injections. The pumps correct for the “dawn phenomenon” (sudden rise of blood glucose in the morning) and allow quick reductions for specific situations, such as exercise. Many different brands are available.
The typical pump is about the size of a beeper and has a digital display. Some are worn externally and are programmed to deliver insulin through a catheter in the skin or the abdomen. They generally use rapid-acting insulin, the most predictable type. They work by administering a small amount of insulin continuously (the basal rate) and a higher dose (a bolus dose) when food is eaten.
Many adults, adolescents, and school children use insulin pumps. Studies indicate that even very young children (ages 2 - 7 years) can successfully use insulin pumps and that the pumps may help improve blood sugar control.
The catheter at the end of the insulin pump is inserted through a needle into the abdominal fat of a person with diabetes. Dosage instructions are entered into the pump's small computer, and the appropriate amount of insulin is then injected into the body in a calculated, controlled manner.
Learning to use the pump can be complicated, although over time most patients find the devices are fairly easy to use. To achieve good control, patients and parents of children must undergo some training. The patient and doctor must determine the amount of insulin used -- it is not automatically calculated. This requires an initial learning period, including understanding insulin needs over the course of the day and in different situations and knowledge of carbohydrate counting. Frequent blood testing is very important, particularly during the training period.
Insulin pumps are more expensive than insulin shots and occasionally have some complications, such as blockage in the device or skin irritation at the infusion site. In spite of early reports of a higher risk for ketoacidosis with pumps, more recent studies have found no higher risk.