"You have gotten to the point where you have to take insulin" - Type 2 Diabetes Mellitus (Part III)

In the third episode of our type II diabetes series, our patient Tabby joins us to speak about her experience with insulin, monitoring blood glucose, and lifestyle modifications. We wrap up the mini-series with some specific advice from both our patient and expert interviewees.

Share your reactions and questions with us at Speak Pipe . We might feature you on a future episode!

=== Outline ===

1. Introduction
2. Chapter 9 - Starting Insulin
3. Chapter 10 - Day-to-Day Management
4. Chapter 11 - Hypoglycemia and Difficult Conversations
5. Chapter 12 - Lifestyle Changes
6. Chapter 13 - Advice to Patients and Practitioners
7. Conclusion

=== Learning Points ===

1. When adding a new insulin therapy, consider factors such as cost, the patient’s eating habits, and their attitude toward injections
2. The ADA recommends starting insulin if the A1c is over 10% when symptoms of hyperglycemia are under poor control, or in patients with ESRD. 
3. When teaching patients how to monitor their own glucose, take the time to teach them how to use a glucometer and record their blood sugars
4. Educate patients and loved ones on how to identify hypoglycemia and how to treat it.

=== Our Expert(s) ===

Dr. Tracy Rabin is an Internist and Pediatrician who joined the Yale faculty in 2011 as a member of the Section of General Internal Medicine (YSM Department of Internal Medicine), and currently serves as the  Associate Program Director for Global and Community Health in the Yale Primary Care Internal Medicine Residency Program (YPC). She attends and teaches on the medical wards at the St. Raphael's Campus (SRC) of Yale-New Haven Hospital; directs care and precepts residents in the SRC Adult Primary Care Diabetes Clinic.

=== References ===

1. [American Diabetes Association] Standards of Medical Care in Diabetes—2022 Abridged for Primary Care Providers: https://diabetesjournals.org/clinical/article/40/1/10/139035/Standards-of-Medical-Care-in-Diabetes-2022  
2. HUSKY Health Program | Providers | Continuous Glucose Monitors (CGM) Policy: https://www.huskyhealthct.org/providers/provider_postings/policies_procedures/Continuous_Glucose_Monitors_Policy.pdf 
3. [American Diabetes Association] Hypoglycemia: https://www.diabetes.org/healthy-living/medication-treatments/blood-glucose-testing-and-control/hypoglycemia 

=== About Us ===

The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible medical education podcast episodes that center on a patient's lived experience with a disease.

Hosts: Katie Gielissen, Maisie Orsillo
Post-Production Assistant: Christina Liu
Logo and name: Eva Zimmerman
Theme music and Editing: Josh Onyango
Other background music: The Tides, Yen, Joel Cummins, Underbelly & Ty Mayer, Bobby Richards, DJ Williams, Dan Henig, Surviving the Asteroid Belt

Instagram: @pcpearls
Twitter: @PCarePearls
Listen on most podcast platforms: linktr.ee/pcpearls

Transcript

Introduction

[00:00:00] Maisie: Hi, my name is Dr. Maze Orcillo and I'll be one of your hosts today. Welcome to primary care pearls. A podcast made by learners for learners and led by our patients' stories. Today.

[00:00:13] Tabby: You need to do better with your sugars. You need to do better with drinking, um, your juices and sodas and sugary juices. but I didn't do it. And then It was just told to me you have diabetes. Got in the car and cried. And I'm like, you have gotten to the point where. You have to take insulin. 

[00:00:39] Maisie: We're talking about diabetes, part three in our three part diabetes series on type two diabetes.

[00:00:48] Katie: Type two diabetes mellitus is associated with insulin resistance and slowly progressive beta cell failure. By the time type two diabetes is diagnosed up to one half of their beta cells are not functioning properly. While many patients will benefit from an oral or injected medication, other than insulin for management of type two diabetes, others benefit from insulin due to their potency and other health issues such as chronic kidney disease.

[00:01:15] Maisie: During our discussion today will be joined by Tabby, a patient. Living with diabetes

[00:01:20] Tabby: Okay. Hi. I tabbed with a blunt. My age is 32. I go by Tabby 

[00:01:27] Maisie: we'll also be joined by an expert from the Yale school of medicine

[00:01:31] Rabin: my name is Tracy Raven, and I'm a med peds physician. I'm the associate program director for global and community health in the Yale primary care internal medicine residency program. And I'm also the director of our diabetes clinic within our resident and faculty practice.

[00:01:48] Maisie: With the conversation facilitated by our resident interviewer, Dr. Alissa Chen

[00:01:53] Alissa: Alyssa Chan, you know, me, I'm a third year resident in internal medicine and the Yale primary care program and will be chief next year.

[00:02:02] Maisie: I'm a second year resident in the Yale primary care internal medicine residency program and dr. Gillon and I will be co-hosting this episode 

[00:02:09] Katie: I'm Katie Gillon. I'm an assistant professor of medicine and pediatrics, and I also will be co-hosting this episode. We hope through this discussion, listeners will become more familiar with insulin therapies and some of the basic principles of blood glucose monitoring.

[00:02:24] Unlike some of our other medications for diabetes, insulin often carries with it, assumptions, both on the part of the provider and the part of the patient today. We'll be exploring how to select and initiate insulin as well as the impact that insulin can have on patients' lives. I know for you, Maisy, uh, insulin therapy is sort of a personal topic.

[00:02:44] Maisie: Oh yeah. I've had my fair share of experiences wearing an insulin pump for almost 20 years. And I can say that it's had its challenges, but I'm overall a big fan of insulin 

[00:02:55] Katie: before we get started, please know that this content is meant for learning and entertainment purposes only, and should not be used to serve as medical advice.

[00:03:04] If you or a loved one is suffering from anything covered in today's episode, please be sure to discuss it with your medical provider while specific brand names may be mentioned during the discussion. Please note, we do not endorse any specific brand or brands. Now onto the show. 

Chapter 9: Starting Insulin

[00:03:22] Maisie: So let's begin by hearing a bit about the initiation of insulin. 

[00:03:29] Katie: when your doctor brought up, starting on insulin. How did you respond to that? Or how did you feel about that? 

[00:03:36] Tabby: So of course I had my poker face on and I'm like, oh yeah, sure. Oh, okay. Got in the car and cried. And I'm like, you have gotten to the point where. You have to take insulin. Now, it was told to you, you need to do better with your sugars. I cannot sit here and say that I wasn't told that you need to see a nutritionist but I didn't do it. 

[00:04:05] Maisie: For some patients starting insulin can be perceived as a personal failure that they didn't do enough. As we heard from Tabby, her initial reaction to the recommendation was to have a strong emotional response. This is an important factor when thinking about the initial conversation and whether they're ready to hear about the practicalities of starting insulin

[00:04:26] Alissa: what things about a patient and their journey with diabetes make you start thinking, oh, I should really start insulin on this patient.

[00:04:36] Rabin: I think about people who who we might meet for the first time or some member of the team might meet for the first time in the hospital, coming in for the first time with diabetic ketoacidosis or severe hyperglycemia that's symptomatic, and they may have an A1C that's very high.

[00:04:58] We think about A1C of 15, 16 those are the patients where we say, okay, there are other medicines that will be beneficial to this person, undoubtedly, but what we really need is the insulin so that we can get these sugars down. And then we can move on from there. And when I have the opportunity to work with patients in that situation, I like to talk with them about the fact that in many situations like there's we start insulin and then we're usually able to reduce the dose.

[00:05:27] We reduced the dose of insulin, and many people will actually even come off of insulin. There's this phenomenon of pancreatic stunning from the hyperglycemia. And if you can just get the sugars under better control, then you may see improve beta cell function and people may actually do better And transition just fine over to oral medications.

[00:05:44] So I think, so those are, that's one category of folks. Then I also think about folks who've had diabetes for a while and we've been escalating therapy and we've been trying different oral regimens, maybe adding a GLP one. And really just, no matter what they do, no matter what we are suggesting in terms of meds, they're not able to to get to their personalized goal. So those would be folks that I would think about insulin as sort of an escalation of therapy or intensification of therapy.

[00:06:14] Maisie: The American diabetes association lays out some specific criteria for initiating insulin. Though. As with all medications, this choice should be individualized to the patient. Insulin should be considered. If there is evidence of ongoing catabolism, such as weight loss. When A1C levels are greater than 10% or blood glucose levels are above 300 milligrams per deciliter. There are symptoms of diabetes such as excessive thirst, or excessive urination. And if those symptoms are becoming, uh, significant in one's life, or if the patient has, uh, end stage renal disease,

[00:06:52] Alissa: And what factors do you think about when you're considering a type of insulin regimen for.

[00:06:57] Rabin: Cost is the first one. So thinking about costs. But then the other piece has to do with the burden on the patient of adding insulin to their regimen. I like to think about, what is their daily schedule? Are they somebody who works the night shift? Are they somebody who works days?

[00:07:13] When do they eat? Are they somebody who eats only once a day for any host of reasons? Are they somebody who eats three times a day plus snacks in between? thinking about how do they feel about injections? If they're really uncomfortable with the idea of injections, then it's really not fair to try starting more than one injection a day off the bat.

[00:07:32] If there's someone who has been doing injections, perhaps with a GLP one agonist in the past, and it really doesn't seem to phase them if they need it, then we may even consider starting with basal insulin and then adding, once daily mealtime dose, if if necessary.

[00:07:47] But I usually like to only add sort of one type of insulin at a time, I feel it's important for people to feel comfortable and feel confident with what it is that they're doing before you make things more complicated.

[00:09:21] Rabin: starting with basal insulin is really the way to go. That's the recommended way to go is to start with with basil insulin and try to try to normalize or try to bring down any way the the fasting blood sugar as your first step a different way to think about it as if you started with a mealtime insulin.

[00:09:39] And then you start adding the basil insulin after that. You're probably gonna end up needing to bring down your dose of the mealtime insulin as your Basal starts to increase. So if you at least start by trying to mimic, typical physiology for somebody who doesn't have diabetes thinking about, having some Bazell amount of insulin.

[00:09:56] Then it'll allow your titration of any additional doses to be more sophisticated. The other piece too is now, moving towards this recommendation of starting with basal insulin and then using a GLP one agonist as sort of the addition, allowing patients to have their own endogenous, mealtime insulin bolus, if you want to think about it that way.

[00:10:16] That's also another fantastic combination that I love, especially when you think about the weight implications of the different meds. If you think about insulin as something that often makes people gain weight and then the GLP ones as something that helps people lose weight. So you can kind of balance things out a little bit.

[00:10:31] If you go with a regimen like that, 

[00:10:33] Katie: So how do we decide what type of insulin to start and what dose should we start? The ADA recommends that we start basal long-acting insulin at 10 units per day, or alternatively, you can prescribe 0.1 to 0.2 units per kilo, per day. So Maisie, what are some examples of long-acting or basal insulins?

[00:10:55] Maisie: So first we have glargine that includes, um, meds such as Lantus Semglee or Basaglar there's Detemir uh, or Levemir and there's Degludec, which is a U 200 formula, and that's Tresiba 

[00:11:11] Katie: yeah. And a U 200 means basically that in each one ML of insulin, there are 200 units and that's distinct from our, other types of insulin, such as glargine and Demir, which are U 100 or a hundred units per one ML of fluid.

[00:11:27] So the other thing I like to make sure to teach my residents about and make sure that I do when I prescribe a new insulin prescription is to make sure to prescribe the right needles for each of the, prescriptions that I'm doing. So if I'm prescribing a pen, typically I'm gonna be prescribing a pen needle. That's typically a 32 gauge, uh, as short as I can find them. So, you know, a half inch or less, usually like more closer to a quarter of an inch in length. And I usually pretty liberally prescribe those because I don't want my patients reusing their needles in order to conserve them. So I'm giving boxes of 100, 200 from the get go. The other thing is if you're prescribing a vial, um, um, make sure that you prescribe the correct syringes. So if you're doing a U 100 preparation, which we talked about earlier, make sure to prescribe a U 100 syringe that administer enough of the medicine that you prescribe.

Chapter 10: Day-to-Day Management

[00:12:25] Maisie: So along with giving patients practical advice for taking their medication, when starting insulin, it is also important to discuss glucose monitoring. 

[00:12:33] Katie: what's it like to check your sugars at home? 

[00:12:36] Tabby: So I'll tell you this, you have to get into a groove because there's certain parts of your finger that you just do not stick because it hurts.

[00:12:47] I started to learn that going around the sides of it and not directly in the middle, made a difference. You have to really find what works for you because. I learned that having the finger stick, the part that sticks you actually comes in numbers. It ranges from one to five and that's how far the needle comes out.

[00:13:12] So I had it at five and I poked my finger for the first time. And I hollered doing this Herb's I'm not can't do that. I can't do that. So it wasn't. I couldn't do it. I just wasn't educated on how to do it. And so I started to read with this thing as numbers. What's that mean? And that's how I started to realize that, oh, okay.

[00:13:32] Five sticks you the hardest. And then I started to realize where or my fingertips to stick myself. So it's, it got, it was a little bit trial, but we got it. 

[00:13:46] Katie: You know, I think that is such a helpful tip that the Lancet device can be adjusted to increase the blood flow, but it also increases the pain that occurs when you're checking your sugars.

[00:13:58] Um, so every single Lancet device has that you'll often see either numbers or blood drops on the side that can be adjusted and you can show patients how to do that

[00:14:08] I think one of the really tough parts. You can tell me if this is true, but like you have to carry around a bunch of stuff like the glucometer and the pen.

[00:14:17] And just tell me a little bit about like how you juggle all that stuff throughout your day, trying to live your life. 

[00:14:23] Tabby: So I went from not carrying a bag to carrying a bag and in that bag has everything that I need. I can tell by the start of my day, how and what I need for the day, depending on my sugar number And that's how I really go off about my day.

[00:14:45] If I know of my sugars are high for today I know that I can't have really juice. I know that I need my sugar, my crystal light. I know that I'm, I can't have any starch for the day. I need to maybe have a salad or half a sandwich or something like that. When. I will say this. The, because the insulin is in a pen, it's a lot easier.

[00:15:13] To carry around then it would be, if you were back in the day with a whole kit, thing it makes traveling a lot easier. And especially if you have to take the insulin multiple times a day just as long as you have your your kit, the glucometer kit, and You have to remember your pins, go on your insulin.

[00:15:33] I've been out plenty of times. It's time to take my insulin. I forgot the needle. So I'm looking at the insulin, no needle. And what I do is as I get  a ziploc bag, I put everything in a ziploc bag, one of the freezer bags, and I make sure that it's full and I bring it up.

[00:15:51] Katie: so Tabby talks a lot about what it's like to carry around all that equipment and stuff. When she's monitoring her blood sugars in order to stay safe at home and outside the home. So Maisie as somebody who's had to check her sugars for many years, how did that resonate with you? 

[00:16:08] Maisie: Oh yeah. The supply bag game is real and my Mine has evolved over the years. I used to have a small black nap sack. It was one of those, you know, across the chest bags and I had everything kind of loose in there. that I realized it wasn't very organized. So then I got those special multi compartment bags. And I would have my pen needles and one compartment, my insulin and another, even though it's supposed to be refrigerated, you can get refrigerated packs.

[00:16:38] So some people will carry around little cool packs with their insulin. 

[00:16:41] Just as a quick aside, I just traveled recently for vacation and invariably, a quarter of my luggage is diabetes supplies, alcohol pads, glucagon. I mean, you name it. It's it's in there. So yeah, I, I really empathize with Tabby on that one. 

[00:16:59] Alissa: I know in clinic you love teaching about diabetes supplies, just like maybe one of my favorite pre-clinic didactics. Why is this so important for doctors to know the diabetes supplies?

[00:17:12] Rabin: Oh man. Yeah, no, I love teaching about supplies. So first I mean this was something that I never really learned about in my training. And so it was really only once I started working as an attendings or working in our diabetes

[00:17:27] clinic, that I started to realize how little I understood about what it means to be a person living with diabetes and having to deal with all of these things.

[00:17:36] Patients would be coming into clinic saying my glucometer isn't working. Okay that's a black, that was a black box, okay. The glucometer isn't working, I'll write you a prescription for a new one. There's a lot of troubleshooting that can be done. And and some of it is maybe your patient wasn't educated in using the glucometer

[00:17:51] And so there's such room for improvement. And I think even just thinking about that, teaching somebody how to use their glucometer appropriately and having them realize that their doctor understands what they have to go through. Every time we ask them to check their blood sugar, I feel like that's actually very it's confidence inducing for the patient because now they actually understand the tool.

[00:18:13] But it also enhances the therapeutic Alliance between the provider and the patient.I'm not asking you to check your blood sugar three times a day because I don't think it's a big deal. I actually think it is a big deal. I don't want you to be a human pin cushion. So I'm only going to ask you to do that if we are going to do something with those numbers, and I'm going to explain to you why we need those numbers.

[00:18:34] And if it turns out that it's too much for a patient to, to manage, I'm also pretty explicit to say, if you can't do it every day, that's fine. But we do need these numbers sometimes because that's going to be the best way for us to really help, figure out how to safely titrate things.

[00:19:38] So I think I loved talking about those things because it's so practical. And if you have knowledge of those things, it just helps your patients know that like you care about what their life is like, that you understand a little piece of what they're experiencing, navigating living with diabetes. 

[00:19:55] Alissa: Yeah. So when you have that appointment with a patient and you're starting insulin How do you counsel them and starting this process?

[00:20:06] Rabin:. I think the most important thing from my perspective is to show them what it is they're going to do.we have all these sort of dummy supplies and clinic. We have insulin pens, we have vials, we have syringes. We have needle tips for the pins. We go into the room and we have all of the equipment that we are going to be prescribing for the patient because we want to show them what it is that they're going to be taking home from the pharmacy.

[00:20:32] And then walking through with them, how they're going to be using whatever it is, showing them, and then ideally having them then demonstrate the same thing back. I feel like that that's such an important piece. And often if patients feel uncomfortable with that, we'll say, okay we've done the demonstration here.

[00:20:48] Why don't you go to the pharmacy, pick up your supplies and then we'll have you come back in a week and two weeks, and we can do your first injection here. We can of walk you through it. And that might boost your confidence as well. So I think the more that you can do to give people a realistic sense of what it is that you're asking them to do at home the better it's going to be for them.

[00:07:59] Tabby: I don't know if I'm considered old school, but I really thought it was going to be a vowel with the needle and you had to flip it up and you had to draw it out. But I, it came in a pen. He came in a pen and all you have to do was put your needle on there and you click it to whatever dose that you're supposed to take.

[00:08:22] And it wasn't that bad. 

[00:21:06] Maisie: So that's a great segue. Um, let's talk about some practical components of starting insulin. So, Dr. Gillen, can you just go through in a little more detail, how you. Uh, do that with patients in the office? 

[00:21:17] Katie: Well, one of the first things I do is show them the needle very explicitly because I think that's one of the biggest hurdles for patients to start injecting themselves. And oftentimes when patients see how small the needle is, it really is a game changer for them. And I hear a lot from patients. That's it, that's how big it is. So I think that's really helpful. Um, the next thing that I do is I help them understand that when you screw that needle on, um, for the first time there's usually a little bit of air, uh, stuck into the system.

[00:21:46] So I teach them about something called priming, which basically means I ask them to dial their insulin pen up to about two units and expel a little bit of insulin out to remove the air from the system. Um, and so they should see some medicine coming out of the tip and that helps to assure them that medicine will be delivered when they actually go to give their.

[00:22:06] I tell them to dial it up to the number that they want to, uh, use. So we're starting at 10 for most patients and set that aside and then prep the area for injection, which usually means that they're gonna select a par, uh, area on their belly. Um, most typically that doesn't include the area around their belly button.

[00:22:25] I tell them not to inject around their belly button, cuz it's actually pretty painful to inject around there. 

[00:22:30] Um, but anywhere else, basically from the group cage down to the, uh, pelvic area is fair game. Um, they're gonna want to use a little bit of alcohol to prep the area, clean it a little bit. They'll wanna squeeze the area to get it ready.

[00:22:44] Grab their insulin pen and make sure the numbers are facing up so that they can see and make sure that the medicine's actually going in. They're gonna inject the insulin pen, perpendicular to their skin, and they're gonna press the button down until they see the number go down to zero. And then I tell them to count to 10 and literally do the one Mississippi two Mississippi whole thing before they remove the, uh, uh, needle from their skin.

[00:23:10] After that, I tell them to unscrew the needle and then in the state of Connecticut, at least, uh, the way that they can dispose of, uh, needles is to put it in a hard sided plastic container. And once that filled up, they can just screw on the top and throw it in the regular trash. But each state might have its own regulations on how to dispose of needles.

[00:23:28] you know, you've been doing insulin for a long time though. Ma do you have any pro tips for how to give insulin? 

[00:23:33] Maisie: You know, there are other injection options, but I agree that the abdomen is, is one of the more comfortable it's where we tend to have a little bit of extra Tissue to inject into. When I was younger, I used to do the back of the arm especially if they wanna give their abdomen a break. Uh, another, I think super important thing is just rotating sites. I do see a lot of people, they. Uh, you know, have their, their favorite spot. That's just easy to get to, and it's tempting to go there all the time. But, uh, from personal experience, uh, the scar tissue game is real. And over time you can start to develop that even with good site rotation, believe it or not, you're a little more prone to it actually, when you wear an insulin pump because the insulin is accumulating under the skin, in that area over a number of days.

[00:24:24] Um, so rotation is key to prevent bruising and, scar tissue formation, 

[00:24:29] I think the, uh, disposal piece is key. Making sure that people are really safe and not throwing their needles directly into the garbage. But you can use a good old laundry detergent container and fill it up and it takes a lot to fill those and then you just throw 'em in the garbage.

[00:24:46] Katie: So we've started someone on insulin and now we have to kind of give them instruction for how to check their sugars at home. So when I'm starting insulin, typically I'm starting a basal insulin, a type two diabetic patient. Um, and so typically I'll recommend that they check their sugars once a day in the morning, uh, that fasting sugar can really tell us how well that insulin is working. so I think it's great to check the sugars at home, but how do we keep track of them? Maisie do you have any tips or ways that you like to counsel your patients on keeping track of blood sugars at home? 

[00:25:23] Maisie: Oh, definitely. The log book thing, I, I think works for some folks, uh, other people want a freestyle in a notebook. That's fine. if people are more into, electronic assistance, especially because everything is on our phones, now there's a lot of different apps that people can use to input their blood glucose values. And Then they can just, they have their phone with them at the appointment. 

[00:25:44] Katie: Yeah. The other tip that I often ask patients to do, if they have a hard time remembering their glucose log, they write down the numbers, but they forget the glucose log. I ask them to take a picture of their log once a week, cuz they always remember their phone.

[00:25:56] Continuous glucose monitors are now more commonplace than they used to be. Although coverage can vary based on insurance and state 

[00:26:04] Rabin: so continuous glucose monitors, something that I'm very excited about because starting January 1st, 2022, Connecticut Medicaid is now covering continuous glucose monitors for patients who are on only one injection per day of insulin. This is a game changer for our practice.

[00:26:22] So I can say that I personally have not had the opportunity to use continuous glucose monitors up to now. Primarily because the rules governing insurance coverage for CGMs has been so restrictive and. And I don't remember if you have anyone in our practice who you've been trying to get a CGM for, but thinking about patients needing to demonstrate that they're taking at least three, three injections a day of insulin, that they're checking their blood sugar three to four times a day, and that they're making treatment decisions based on those blood sugar numbers.

[00:26:54] And you need to submit records to demonstrate this. This is thinking about patients with type two diabetes. So we have very few patients who were able to to actually either, meet those criteria and then also gather that data and submit the data.

[00:27:12] I think those were the three, three things. there are a couple of patients in our practice who I know were able to navigate that with their primary care providers, but very few. With more complicated patients, especially folks who may need an insulin pump who might be going on continuous glucose monitors in conjunction with insulin pumps are thinking about that.

[00:27:32] Those are patients that we tend to refer out to endocrine. So we haven't really had those more complicated patients in the practice. But I was in diabetes clinic, literally yesterday talking with our fantastic APRN Jayna about a patient who we are starting a continuous glucose monitor on.

[00:27:48] So we sent him with a prescription and we're having him come back in two weeks. And we're going to go through with him how to start. And I'm just so excited for him.

[00:27:57] Katie: stay tuned for a future episode focused on continuous glucose monitors.

Chapter 11: Hypoglycemia and Difficult Conversations

[00:28:02] Katie: Have you ever had a low blood sugar? And what did that feel like for you? 

[00:28:06] Tabby: I remember it like it was yesterday - my mom came to visit and she said to me, you're going to need to start taking your. I said, yes, mom was a drive slightly, have not been on my insulin at that point for almost a month and a half.

[00:28:28] So what do I do? I get up, I go to the kitchen, I get the insulin pen. I put it to what I'm supposed to, what I was supposed to take. I put it, I took it five minutes later. I'm sick. My sugar's dropped so fast and I'm in the bathroom. I'm nauseous, I'm gagging. And I kept saying, mama, something is wrong.

[00:29:00] And so she says let's take your sugars before I took it. It red high on the machine. When I took it again, it was a hundred and something when I felt sick. So I now realized that was my sugars were maybe five or 600 in a drop to a hundred. I was sick. I was so sick. And my mother just said just lay back on the couch and put this rag over your head.

[00:29:27] And I kept saying, I can't kick it. I can't take it. I felt horrible. Wasn't it. The next day I went to the grocery store with my wife and I was out of it. I was stumbling over words. I asked her to reach for something and I'm like, no, blah, blah, blah, blah, blah, blah, blah. And she's what is wrong with you?

[00:29:50] And I'm just spaced out. I don't know what's going on. And we ended up having to go to the emergency room that night. And they thought that I was having a stroke because I could not speak, I could not, I couldn't. I couldn't say anything didn't remember anything. And so my wife had said, oh she had took her insulin and it dropped.

[00:30:13] And the only thing that I remember them saying to me was what's today's date. And I remember sitting there and I'm thinking, oh my God, all the date, I don't know the date. I don't know the date. And I looked up and it was on the TV. It's February, and I sit back knowing good dog on I didn't know what the date was.

[00:30:38] Didn't even know what the year was. And so I'm like, yeah, it's February you. I sit back, I aced it. They ended up letting me go, but that was very dangerous for me to do. And I didn't realize, I didn't remember that whole day until the following day. 

[00:30:57] Katie: so here Taby describes an episode of perceived hypoglycemia or commonly called pseudohypoglycemia. So when she checked her sugar, it was around 100. Typically we define hypoglycemia as less than 70. Um, but here she felt low, even though her blood sugar was above 70.

[00:31:14] Why does this happen? Well, one thing that we know about type two diabetics in particular is that when your blood sugar is persistently high for a long period of time, a sudden drop in blood sugar can be perceived by your brain as a low blood sugar. And so what she felt was very real. And, uh, can be very uncomfortable. 

[00:31:36] It doesn't necessarily have to be treated as a hypoglycemic event, but typically what I do when patients are experiencing this is take it a little bit slower and slowly bring those blood sugars down over time so that the brain slowly adjust to normal blood sugars, um, a blood sugar less than 70 should definitely be treated.

[00:31:57] so that sounds like a scary experience with insulin.

[00:32:00] So now you're taking it though. So what allowed you to get over 

[00:32:05] Tabby: that hump? Because I was scared, right? I realized that I don't want to feel that way again. So in order for me not to feel that way again, you have to take it. So I went to my primary care doctor. We started off slow again, and then we inched our way back up.

[00:32:21] I realized that I'm not my doctor, even though we all want to be our own doctor. And I realized that this is serious. I still don't have any symptoms, but war. What was that? So now I'm sitting up now, when I'm what'd you say again, two months ago? What you say? I'm now I'm really interested in finding out what's going on because I was sick and I didn't like.

[00:32:50] Katie: So maze. What are some strategies or things that you tell your patients to do if they are low? 

[00:32:56] Maisie: Yeah, so I think some ways that I counsel patients around hypoglycemias of course going through what are the, the typical symptoms. So when people can feel it, the shaking, the sweating Potentially changes in vision weakness. it's just as from someone who's experienced it a lot, it's a very unpleasant feeling. Then the second piece I like to talk about is preparedness for how to manage the hypoglycemia. And discussing, what are the different options you can use? Uh, anything from juice to soda, there are glucose tabs, fruit snacks, all sorts of options. I think that, um, it's important too, to actually talk about the amount that you wanna use to treat the sugar because the symptoms are so unpleasant that a lot of times we want to consume something until we feel better.

[00:33:44] And in my experience often when you do that, you actually are overtreating. And by the time you're feeling better, your sugar is already a hundred and fifty one eighty, you're, you're starting to really climb up quickly. So I really try to counsel patients around having four to eight ounces of juice and waiting 15 minutes.

[00:34:05] And then after you've waited about 15 minutes, check your sugar again. And if it's not coming up above 70, then having another, the old 15 grams of carbs and 15 to 15, 15 rule is the old standard. And it really does work. Um, and it helps people, I think, to avoid overtreating the hypoglycemia.

[00:34:26] And then the third thing to think about in addition to oral options is to always have glucagon on hand. The older version of glucagon was a syringe. It came usually in a, in a red box. So it was easy to identify. And it came with a, a vial of saline and then the actual glucagon tablet you'd mix them together and then inject them. And of course at that point, you're typically unable to do this yourself. So I, I encourage patients to, uh, talk with loved ones about where their glucagon kit is, and open it up. And there's instructions inside usually printed right on the, the plastic itself of how to use it, even more convenient. Now we have nasal glucagon. 

[00:35:12] Katie: yeah. And that's another thing that I will often have a family member come in to learn about how to give glucagon if they're not comfortable, cuz you can get a test kit, uh, basically for the clinic to do teaching. And that's one thing that could be really life saving for patients. If they're having recurrent, especially, recurrent asymptomatic hypoglycemia

[00:35:30] Alissa: Tammy told us a story, which I think is so common to our patients where she stopped taking her insulin and then started taking it again and had a hypoglycemic episode. And how do you address periods of like intermittently not taking medicines and then what complications may be at hypoglycemia or other things that might happen?

[00:35:49] How do you address that with your.

[00:35:51] Rabin: Yeah. I mean, I think this it's a great question. I think this goes back to trying to create a safe space where patients will even talk about it. I've certainly had experiences where a patient will come in with a glucose log where the numbers are almost exactly the same for every single day and they're written in the same pen and, and you're thinking like, gosh, I'm, I'm wondering if you're feeling uncomfortable about telling me that you didn't check your blood sugar for the last three weeks, those kinds of situations.

[00:36:18] So again, so the first thing is creating a space where, I just need to know what you've been doing because that's going to help us move forward. And then if people have had those experiences like hypoglycemia, where they truly just feel terrible. And they relate it to the medication.

[00:36:33] We'll, let's talk about why, what was happening that day. Was it a day where you were running late? You forgot to eat breakfast, but you took basal insulin that morning. And and then, then things were crazy and you didn't have lunch and now you were hypoglycemic in the afternoon okay. So let's see what we can do to strategize around that.

[00:36:51] It may be that there are, interventions around having snacks available or thinking about planning your day that could be put into place. But if not, it may be that we just need a lower Joseph insulin and we need to come up with other strategies to help you with your sugar that are not just insulin.

[00:37:06] Katie: monitoring glucose levels takes a significant amount of time and effort for our patients. It's important to monitor for hypoglycemia in patients on insulin and create a space for them to share the struggles they're having with checking and maintaining safe blood glucose.

Chapter 12: Lifestyle Changes

[00:37:21] Maisie: let's transition to discussing lifestyle interventions in patients living with diabetes. 

[00:37:27] Alissa: So how do you tackle counseling on lifestyle interventions?

[00:37:33] Rabin: Yeah. I mean, I think a lot of it starts with so tell me what you're already doing. Tell me about, how you move throughout the day. Do you feel like you spend most of your day sitting in a chair, do you feel like you get up and walk around or you're trying to do anything specific for for exercise, [00:37:49] And and then we can move from there into recommendations. And similarly, it's the same strategy with diet, what did you eat in the last 24 hours? And again, starting from there and and then moving forward to thinking about how to maybe optimize either of those either of those things.

[00:38:09] Katie: Like it's not just about the medicines, right? It's about what you eat and drink. Can you tell me how, the way you think about meals and eating has changed? 

[00:38:19] Tabby: So I've never counted. Calories, never, ever. I've never counted calories. I never said that's too much starch.

[00:38:30] I never said I'm not going to have that. With my. Sugars. My diabetes has pushed me into learning about food because I'd feel sick if I sat down and I had a whole plate of steak and I'm a big baked potato and all those things I started to feel sick because my sugars are too high and it's okay, Tag on it.

[00:38:56] I'm taking the medicine. Now I have to watch what I eat. Are you guys crazy? I'm drinking the sugar-free juice. Isn't that? Good enough. It's not. And I'm still learning to this day that your insulin, your sugar intake, what you drink and what you eat all holds together. It all goes together.

[00:39:17] And try some of that sugar-free stuff in a surprise yet. You'll never know. You're like, oh, that's a sugar-free. I surprised myself quite a few times. 

[00:39:27] Katie: So Tabby mentioned sugar, free juice and other sugar free products. I think this is one of the big misconceptions patients have surrounding diet and being healthy with diabetes. I think in particular juice can be one of those things that can be misleading when you see no sugar added, especially if you're really trying to work hard to bring down how much you're drinking in terms of, um, carbohydrates. A lot of patients think that juice is really healthy and necessary part of their diet.

[00:39:58] So I typically tell patients to turn that, jug or can, or whatever, uh, product around and look at the label and look to see, how many carbohydrates are in that drink. And I don't necessarily expect my patients to, count carbs, especially if they're living with type two diabetes.

[00:40:15] But what they're looking for is zero sugar, or zero calories, for those sugar, like sweetened beverages. Um, if they truly do want like a sweetened beverage without any added carbohydrates. Do you have any other tips, Maisie? 

[00:40:29] Maisie: Yeah, no, I'm really glad you, you brought this up because I think that the biggest piece is talking about carbohydrates and also talking about, where carbohydrates come from, because oftentimes things like juice or candies or sodas is what a lot of patients bring up to me.

[00:40:46] They say, well, I, I don't really drink soda. I don't really, eat a lot of desserts, but they may be eating a lot of breads and pastas. And so we really talk about how your body metabolizes all of this into sugar and this raises your blood glucose levels. And this is a big contributor to, one's A1C.

[00:41:04] I tell people, honestly, if they want to enjoy something with real sugar in it in a small amount, I would honestly them rather do that 

[00:41:13] Katie: yeah. And I, I like to also, acknowledge all our humanity when we're, talking about eating because I think eating is so much part of our culture and family. And, I think it's very hard to change that part of yourself and there's a lot of pressures to eat in a certain way. So I think oftentimes working around, portion control and other things so that, my patients can still enjoy the foods they love while also attending to their diabetes at the same time. It's just about working together as a team and acknowledging that food is a really powerful motivator for some people um, and, uh, making sure that you acknowledge that and work with your patient for what works for them. 

[00:41:54] Tabby: in the African American household, we fry everything, everything. Bacon everything's fried. We have cornbread that we fry, in a skillet on the stove. Okay. So I went grocery shopping. I didn't buy any oil. What am I going to do now?

[00:42:09] That was my accident. I'm like, I have chicken and French fries here. What am I going to do with it? And I had no choice, but to put it in. I put it in the oven. I seasoned it. Well. I stopped salt. I don't use any salt anymore. I found alternative seasonings that still tastes gourd. That makes it flavorful, but it doesn't have any salt or anything in it.

[00:42:32] I bought myself an air fryer. I just upgraded my air fryer. The best thing that's ever happened to me. You can put things in there. It comes out like it's crispy. I don't remember the last time I even used oil. So with me baking and boiling and my air fryer, it changed it for me. it has taught me to cook differently. 

Chapter 13: Advice to Patients and Practitioners

[00:42:56] Maisie: Let's hear some final words of wisdom from our patient and expert. 

[00:43:01] Tabby: If you have diabetes, please take it serious. And this is coming from a young lady that was once in health care field that had a full-time job. I worked over time to the point where I can't work

[00:43:20] all because. I don't want to take my medicine because I don't feel anything. I have been going through this through years. Take your medicine, listen to your primary care doctor. If you feel like your primary care doctor is not for you find a another one. There are everywhere. Do not stick with someone you're not comfortable with find someone that you're comfortable with.

[00:43:45] That suits you. That will help. Diabetes is not just something that you deal with. It's something everybody deals with. It affects everybody. It affects your friends. And it's okay to tell someone, because oftentimes you forget sometimes. they will help you because they love you and they want you to be okay. 

[00:44:08] Alissa: Is there anything else you want trainees to know about treating patients with diabetes?

[00:44:13] Rabin: One of the benefits of being a primary care doctor is the opportunity to have longitudinal relationships with patients over time and to be able to work with them as circumstances change in their lives.

[00:44:24] And there's so much that you need to take into account with respect to people's lives in order to come up with good patient centered plans for managing their diabetes, thinking about how. Culture and tradition and emotion, and is bound up in what you eat and when you eat and the type of activity that you do and how you're supported by your community.

[00:44:45] So I think it's just it's so rewarding to be able to walk with people in that journey and acknowledging that there will be bumps along the road and, it's not going to always be sort of a forward moving direction, but it's incredibly rewarding. So I just would hope that trainees listening to this would would take that and also be excited to help folks manage their. 

[00:45:05] Alissa: Well, Thank you so much. I really enjoyed this time. I think I also have to liberate my husband and my two-year-old from the bedroom.

[00:45:09] Rabin: Thanks so much for having me Alyssa.

[00:45:11] Katie: So Maisie I learned a ton just by talking with you as usual and I learned a lot by listening to Dr. Rabin expertise 

[00:45:20] Maisie: Mm-hmm yep. And really a ton from our patients. Right. that's, what's so valuable about hearing Tabby's experience and every patient we talk with about their diabetes, they have some wisdom to share and it's, uh, a really important part of the care that we provide. 

[00:45:36] Katie: I agree. And that's why I enjoy taking care of diabetes so much, cuz it creates a space where I can be creative and work with the patient and also where we can make things better.

[00:45:46] I've seen a lot of patients really improve just by making efforts in diet exercise. And some of these newer medications can be really, really effective in bringing down that A1C and preventing those long term things that we're worried about. 

Here are some key points that I took away from the show and I hope that you will too. 

Some patients do require insulin as part of their type II diabetes management, which should not be considered a failure. 

The ADA recommends starting insulin if the A1c is over 10% when symptoms of hyperglycemia are under poor control, or in patients with ESRD. The ADA also recommends starting patients on basal insulin at either 10 units per day or 0.1 to 0.2 units per kilogram per day. 

In addition to proper insulin prescribing, it’s important to take into consideration the logistics of glucose monitoring and management, being sure to prescribe the appropriate equipment and having the patient bring the equipment into the office to learn and demonstrate their technique when they’re about to use insulin for the first time.

 It is also important to help them establish a plan on how to keep a record of their blood sugar measurements. 

Lastly, it’s really important to educate both patients and their loved ones on how to identify hypoglycemia and how to treat it when it occurs, with either oral agents or glucagon.

[00:46:52] we hope you enjoyed this episode, which was made possible by contributions from our patient Tabby, our resident interviewer, Dr. Alyssa Chan and Dr. Tracy Rabin who provided faculty peer review for the project and served as our expert. Special thanks to Keval Desai, one of the key writers for this episode and our producers, August Allocco, Helen Cai and Joshua Onyango as well as our faculty advisor Dr. Katie Giellisen 

[00:47:16] Katie: Be sure to follow us at PC pearls on Instagram, where you can expect to get sneak, peeks, additional learning content and the most up-to-date details on show release times. Thanks again for joining us today. Farewell from all of us here at the primary care pearls podcast. And we'll catch you in the next one.