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diabetes management during the COVID-19 pandemic and other emergencies

Content provided by the Diabetes Research Institute's Education and Nutrition Service

Whether you have type 1 or type 2 diabetes, during times of stress and illness, blood sugars may change rapidly leading to extreme high or low blood sugars. Visits to the Emergency Care Center may be avoided if you are prepared for sick days and monitor your situation closely. In order to prevent this from happening, there are important steps you can take:

Monitor your blood sugar frequently, as often as every hour, if not using a continuous glucose monitor (CGM).

Continue your diabetes medications as usual. If you have type 1 diabetes, you should continue taking your insulin and can adjust according to your situation (*more below). Sometimes patients with type 2 diabetes take medications called Sulfonylureas (glipizide, glyburide, glimepiride), which may increase the risk of having a low blood sugar, especially if you are not eating normally. If you are not eating, you may decrease or stop this medication to reduce the risk of low blood sugars

Stay hydrated! Drink at least one glass of fluid every hour. If your sugar levels are high, stick to drinking water. If your blood sugars are low, you need to drink beverages that contain carbohydrates, such as fruit juice, Gatorade/Powerade or Pedialyte.

Provide accurate information to health care providers. Upload any device that you use so your provider has access to the most accurate information.

Preparation kit for sick day guidelines
Should include at least 2 months’ worth of the following:

• Blood sugar test strips

• Diabetes and blood pressure medications/insulin

• Pump/CGM supplies

• Charger or batteries

• Sugar-free and sugar fluids (water & Gatorade)

• Glucagon (Kit, pre-filled/pre-mixed, or nasal – check that it is not expired)

• Ketone test strips

• Medication for nausea or vomiting, medication for diarrhea

• Medications to treat fever-Acetaminophen (Tylenol)

• Your health care team contact number
(If you are a patient of the treatment facility at the Diabetes Research Institute, call 305-243-3636 or contact the DRI's Education and Nutrition Service at 305-243-3696)

Note: Ensure all your prescriptions are current and you have a maximal number of refills available. Also, consider contacting your pharmacy to see if you are able to refill your prescription even if is before the typical 30-day time window as some state and/or health insurance companies are waiving refill restrictions because of COVID-19.

Ketones
If you have type 1 diabetes or are insulin dependent and you are feeling sick, check ketones every couple of hours (urine – Ketostix, or blood – ketone meter). If ketones are “moderate or large,” or if you can’t tolerate any liquids by mouth, call your healthcare provider.

Diabetic Ketoacidosis (DKA)
DKA is a dangerous condition that demands immediate medical attention, and can be fatal if left untreated. Symptoms of ketoacidosis may include symptoms of high blood sugar and/or:

  • “Fruity” smelling breath
  • Nausea
  • Vomiting
  • Stomach cramps
  • Confusion
  • Unconsciousness
  • Extreme weakness

Insulin Adjustment Guidelines During Illness or Stress

  • Use your prescribed insulin supplemental/correction scale (sensitivity) for rapid acting insulin.

  • If you have moderate ketones, you may give 110% of the calculated dose (Example: If your correction dose is 5 units, give 5.5 units of rapid-acting dose. If unable to give half units, round up to next whole unit, example 6 units.)

  • You may increase your basal rate also. Change by small increments, +/- 10 - 20%
    Example: If you are on 20 units of Lantus, increase your dose to 22 or 24 units.

  • Pump users: Use Temp Basal feature to increase your basal insulin temporarily.
    • Example: Increase basal to 10-20% of your standard basal rate for 4-6-hour duration.
    • Medtronic & Tslim will show 110-120%.
    • Omni Pod will show 10-20%.
    • Monitor blood sugars frequently during this time.
    • You can CANCEL the temp rate if/when blood sugars return to target range.

    If you suspect a pump site malfunction:
    • Disconnect from pump, give correction dose (may use pump calculator to determine dose) with a manual injection (pen or syringe).
    • Change infusion set (cartridge, tubing, & site on body).
    • Write down somewhere that you gave a correction as to prevent insulin stacking (overdose).
           >Manual injection dose will not be IOB on pump

    If you suspect pump failure:
    • Disconnect from pump, give correction dose (may use pump calculator to determine dose) with a manual injection (pen or syringe).
    • Inject with long-acting insulin (total dose of daily basal insulin pump or dose given to you by your provider) and then give at same time every day.
    • Once you receive the pump, restart it at the time that long-acting insulin is due so you do not have double the dose of basal insulin.
    • Use the correction factor & carb ratio doses that are in the pump to determine your dose of rapid-acting insulin when eating and/or when correcting a high blood sugar.

*Contact your diabetes specialist if you are unsure about your dose adjustments*

Hypoglycemia Symptoms and Treatment

Hypoglycemia symptoms

  • Treatment
    • ~15 grams of a fast-acting carbohydrate (4 oz juice or 4 glucose tabs or 4 oz regular soda)
    • Recheck blood sugar after 15 minutes
    • Repeat if blood sugar below 70 mg/dl
    • Follow with protein/fat if not eating within an hour

If your blood sugar is so low that you pass out, someone with you needs to know what to do. If that ever happens, the treatment is Glucagon.

  • Glucagon - Emergency kit comes with a syringe filled with saline (salt water) and a vial containing the Glucagon powder (new: nasal powder or pre-filled syringe).

  • You must mix the saline and the powder together first before you give the injection (pre-filled syringe does not require this step).

  • Nasal powder – click device twice once inserted in person’s nose.

  • After you have given the injection or powder spray, call 911. It takes about 10-15 minutes for the Glucagon to fully kick in.

  • You can download ahead of time a Glucagon app for iPhones that walks you through the steps.

  • If you are ever unsure of what to do, please call the doctor’s office.

  • Double check the expiration date; Glucagon is good for about a year. Call the doctor’s office to get a new prescription if it’s expired.

Situation Crisis Management

Diabetes Technologies: Keep contact numbers on hand

Dexcom> 1-844-607-8398
Who do patients contact if they have questions about their Dexcom products and supplies?
Dexcom will continue to process re-orders but asks that patients only contact the Customer Sales Support and Technical Support teams at 844-607-8398 with urgent requests at this time.

Medtronic> 1-800-646-4633
Online Tool to Manage Your Supply Needs 24/7 – www.Diabetes.Shop

Insulet (Omnipod)> 1-800-591-3455

Tandem Diabetes> 1-877-801-6901

Cleaning Your Pump
One of the CDC's recommended practices to help prevent the spread of respiratory illnesses is cleaning frequently touched surfaces and objects daily. Insulin pumps are kept close to the body and touched often out of necessity. We suggest cleaning your pump along with your other frequently handled objects. When cleaning your pump, use a damp lint-free cloth. Do not use household or industrial cleaners, solvents, bleach, scouring pads, chemicals, or sharp instruments. Never submerge the pump in water or use any other liquid to clean it. Do not place the pump in the dishwasher or use hot water to clean it. If needed, use only a very mild detergent, such as a bit of liquid soap with warm water. When drying your pump, use a soft towel.

Wipe the outside of your Dexcom transmitter with a damp lint-free cloth or isopropyl alcohol wipe between uses.

Insulin Help
There are three insulin manufacturers who offer immediate assistance and long-term solutions. This is the fastest way to get help. Be sure to have all of your information ready before you call. Available options are based on your income, insurance, and the type of insulin you need.

1) Before you call, plan to spend 20–30 minutes and be prepared to answer personal/insurance/financial questions.
2) Find out who your manufacturer is by checking the company logo on your insulin vial or pen, and call using the numbers provided below. A customer service representative will confirm your eligibility and explain your options.
• Lilly Diabetes Solution Center 1-833-808-1234
• Novo Nordisk NovoCare® 1-844-NOVO4ME 1-844-668-6463
• Sanofi Patient Assistance Program 1-888-847-4877
https://insulinhelp.org/

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