Preparing for Lows With Type 2 Diabetes

From diatribe.org

Key takeaways:

• People with type 2 diabetes commonly experience low blood sugar that can be fixed with a quick snack, but taking insulin or sulfonylureas raises the risk of more serious hypoglycemia.
• It’s important to regularly monitor your blood sugar and prepare for unexpected lows with a kit that includes a sugary snack, a medical alert identifier, and ready-to-use glucagon.
• Glucagon is an essential part of any kit, so if you haven’t had a conversation about it, bring it up with your healthcare team.

It’s scary to think about severe hypoglycaemia, but it can happen to anyone who manages their diabetes with insulin or sulfonylureas. 

If you have type 2 diabetes and use one of these medications, you should know what severe hypoglycemia is, how to avoid it when possible, and how to treat it when it occurs. Ideally, these conversations should be happening during check-ups with members of your healthcare team.

“Unfortunately, I think the data tells us that more often than not, conversations about hypoglycaemia are not happening,” said Dr. Rozalina McCoy, an endocrinologist at the Maryland School of Medicine.

This is part of the reason so few people at risk of severe hypoglycaemia are prepared for it if and when it occurs. One study found that only 3.5% of people who treat type 2 diabetes with insulin filled a prescription for glucagon between 2019 and 2023. If no one on your healthcare team has mentioned severe hypoglycaemia or ready-to-use glucagon, it’s a good idea to bring up at your next visit.

Defining severe hypoglycaemia

A hypoglycaemic event is a problematic dip in your blood sugar. All lows should be taken seriously and treated appropriately, but some are more severe than others. Level 1 hypoglycaemia, the mildest form, is typically defined as a blood sugar level below 70 mg/dL. 

Symptoms like dizziness, shakiness, sweating, hunger, and anxiety may occur during hypoglycaemia, but they become more common when levels drop below the level 2 threshold of 54 mg/dL. It’s important to note that some people have impaired awareness of hypoglycaemia and never experience symptoms, leaving them unaware of lows unless they’re using a monitor to track their blood sugar.

Level 3 or severe hypoglycaemia is when your ability to function is impaired, and you require assistance from another person to return to normal blood sugar levels. Often, this is thought of as something that occurs after you’ve reached level 2, but everybody has a different tolerance for lows.

“You can have someone have a blood sugar of 20 mg/dL, and yet they’re young and resilient and able to self-treat,” McCoy explained.

On the other hand, she said that older people, especially those who have developed additional chronic conditions that make daily life more difficult, may require medical attention for blood sugar levels as high as 70 mg/dL. 

When does severe hypoglycaemia occur?

Most cases of severe hypoglycaemia are associated with insulin therapy or sulfonylureas. These medications are very effective at helping your body manage blood sugar, but it’s still easy to run into unexpected circumstances (maybe a delayed or missed meal or strenuous physical activity) that leave you with lower blood sugar than you were anticipating.

“It’s a mismatch between insulin requirements and insulin presence in the body, but it doesn’t mean it was anyone’s fault,” McCoy added.

Monitoring for lows

According to the American Diabetes Association’s (ADA) Standards of Care, everyone who takes insulin should wear a continuous glucose monitor (CGM). These devices help track changes in your blood sugar over time and alert you when you start to go low.

You should discuss your target range with your healthcare provider. Generally speaking, most people with diabetes should be aiming to spend most of their time between 70-180 mg/dL, but McCoy said she advises her older patients who might have a harder time handling a low to treat 100 mg/dL as their lower bound.

If you worry about being overwhelmed by all the CGM data, McCoy suggested thinking about it as an alert for lows. Even if you’re not looking at it that often, a CGM will tell you if you’re consistently going below your target range and may need to adjust your insulin therapy.

A CGM can be helpful for anyone with diabetes, but if someone isn’t taking insulin, then monitoring their blood sugar with fingerstick tests can be sufficient.

“If they’re on a sulfonylurea, they should check whenever they’re not feeling well or whenever they think they might be having a low,” McCoy said.

Hypoglycaemia preparedness

When you go low, the ultimate goal is to get more sugar in your body. Even if you have a severe episode that requires a trip to the hospital, healthcare providers will be treating you primarily with oral carbohydrates or an intravenous (IV) drip of sugar.

If you’re alert and able to eat, then candy, soda, juice, and even honey and sugar packets can all be effective options for raising your blood sugar back to normal levels. Wherever you are, you should always have some sort of sugary drink or snack on hand.

Regardless, there may be times when you go too low too quickly to raise your blood sugar with food. In these cases, emergency glucagon is necessary. There’s also a chance that a hypoglycaemic emergency will move so quickly that you won’t have time to react to it on your own. It’s important to educate people you’re close to about hypoglycaemia and glucagon. 

In case none of them are around when you need help, you should also wear a medical alert necklace or bracelet that clearly states you have diabetes and may be experiencing a low. If you have a car, then you could also put a medical alert cover on your seatbelt. 

When to use ready-to-use glucagon 

The ADA recommends self-administering ready-to-use glucagon if 15 grams of sugar hasn’t resolved your low within 15 minutes, if you can’t keep food down, or if you feel yourself becoming confused or on the verge of passing out. 

If you do need to give yourself glucagon, be prepared to feel sick. Also, make sure to call your healthcare provider or 911. You may still need emergency medical attention or your diabetes medications adjusted.

The ADA also recommends using glucagon if you pass out, but someone else needs to administer it at that point. Make sure your diabetes emergency kit includes glucagon and is accessible and clearly marked for other people. Once again, you should start by making sure that people you’re close to know what glucagon is, how to use it, and where your supply is stored, but you also have to anticipate times when people you’re less familiar with will need to help you.

Make sure your glucagon is clearly labelled as something to use when you’re unresponsive. If you also carry insulin with you, store the two medications in separate containers and make sure the insulin is clearly labelled as something that should not be given to you while you’re unresponsive.

It’s possible that the person who finds you might not be comfortable giving you glucagon. However, McCoy said that a dose of glucagon is unlikely to cause much harm, even if hypoglycaemia isn’t ultimately the reason a person with diabetes has become unresponsive. 

Actual instructions for using glucagon will depend on what type you have. There are currently three options. A traditional mixing kit includes a vial of glucagon powder and a syringe of liquid, and the powder must be dissolved into the liquid at the time of administration. This takes time and creates the possibility for mistakes, so traditional mixing kits are not the best option for an emergency situation.

Instead, it’s better to have ready-to-use glucagon. When you talk to your healthcare provider, ask about Gvoke HypoPens and Baqsimi nasal powders, both of which are readily administered with no mixing required.

How to get glucagon

Glucagon is a prescription medication, so you’ll need to talk to a healthcare provider to get it. Ideally, when you receive a prescription for insulin or a sulfonylurea, you should also get one for glucagon. However, getting started on any new medication may involve a steep learning curve, and discussions about glucagon often slip through the cracks at early medical appointments.

“I’m not perfect. I run out of time, or I start insulin, and then I’m like, ‘Okay, I’ll talk about glucagon at the next visit,’” McCoy said.

If the clinician who prescribed you insulin or a sulfonylurea didn’t discuss glucagon, then ideally your pharmacist would bring it up when you go to fill your prescriptions. Pharmacists are legally obligated to offer consultations to anyone picking up medications, and they should know all of the risks and benefits of medications they’re dispensing. 

If your pharmacist sees your insulin prescription come in without a glucagon prescription, then they should ask you about it. Your pharmacist can also ask your clinician to prescribe glucagon without waiting until your next appointment.

Other members of your healthcare team, including diabetes educators and dietitians, can also get the ball rolling on a glucagon prescription, but if no one brings it up, don’t be afraid to initiate the conversation. For many people, pharmacists may be the best starting point for these conversations because you can walk into a pharmacy and request a consultation without an appointment.

For most people in the U.S., McCoy said that insurance will cover a new prescription of an autoinjector pen or a nasal powder, but coverage varies. If your plan doesn’t cover ready-to-use glucagon and you can’t afford it on your own, you may be eligible for patient assistance programs offered by Baqsimi and Gvoke. 

In general, insurance will cover a glucagon refill every year or after every use. Glucagon doesn’t last forever, so even if you haven’t used yours, make sure to check the expiration date and replace it when necessary. You’ll need a replacement every two or two and a half years depending on which option you choose.

The bottom line

Any person with type 2 diabetes may experience low blood sugar, but people who take insulin or sulfonylureas are particularly at risk for severe hypoglycaemia, which a person cannot resolve on their own without assistance from someone else. It’s important to regularly monitor your blood sugar and prepare for unexpected lows by carrying sugary snacks, a medical alert identification tag, and clearly labelled ready-to-use glucagon. 

Members of your healthcare team should discuss hypoglycaemia and prescribe glucagon if you’re taking insulin or a sulfonylurea, but if they don’t, initiate the conversation yourself. For many people, it may be easiest to start by talking to the pharmacist, who is often the most accessible member of your healthcare team.

https://diatribe.org/diabetes-management/preparing-lows-type-2-diabetes  

What's the worst thing you can do for sciatica?

From healthcentral.com

By Rosemary Black

Sometimes it’s just as important to know what NOT to do as it is to know what to do when you have sciatica. Avoiding these will cut your risk of sciatica symptoms 

Key Takeaways

• Sciatica pain can worsen when a herniated disc or bone spur compresses a nerve root in the lower back.
• Avoid hamstring-stretching moves like toe touches and downward dog; choose walking or swimming during painful flares.
• Warm up before heavy lifting and avoid high-strain machines like rowing, steep treadmill running, or high-resistance elliptical workouts.
• Don’t sit longer than 20 minutes or lounge on soft couches; get up often and use supportive seating with good posture.
• Limit bed rest to 48 hours, avoid bending or twisting while lifting, and take breaks during long car trips to reduce pressure.

Sciatica pain often comes on when a bone spur or herniated disc compresses a spinal nerve root in your lower back, causing excruciating discomfort in your back, leg, and butt. If you are living with sciatica, you may be trying everything to stop your pain: physical therapy, epidural injections, and various medications. But did you know there are some common, everyday things that can really aggravate your condition?

Here is what you shouldn’t you be doing if you are experiencing the pain that sciatica causes.

1. Avoid Exercises That Stretch Your Hamstrings

Stretching your hamstrings can worsen sciatica, says Ronald Tolchin, D.O., director of spine care at Baptist Health Miami Neuroscience Institute. Some exercises to skip? Straight-leg sit-ups, bending forward and touching your toes, squats with weights, and the yoga pose known as downward dog, he says. And, he adds, avoid doing leg circles where you lie on your back and make circles with your legs while one leg is down and the other one is raised.

What to do instead: When you are having pain, try walking, which warms up all your muscles, or swimming, which uses the buoyancy of the water to keep weight off your back, Dr. Tolchin says.

2. Avoid Lifting Heavy Weights Before Warming Up

Certain exercises with heavy resistance can aggravate your sciatica unless you have sufficiently warmed up your muscles first, says Adeepa Singh, M.D., a a pain management specialist and physiatrist with Brain and Spine Surgeons of New York.

“Weighted deadlifts, weighted squats, and Olympic lifts can increase loading and strain on your lumbar spine,” she explains. “If you do train with weights, be sure to stretch beforehand to warm up your muscles.”

What to do instead: Stretching and strengthening that start with gentle range of motion exercises, says Dr. Singh. “These alleviate inflammation of your back muscles and help improve your mobility to prevent further injury,” she says.

3. Avoid Certain Exercise Machines

For instance, rowing machines increase the strain on your lower back, especially if your core muscles are weak or not adequately warmed up, says Dr. Singh. Also don’t go on the elliptical trainer at high resistance or high incline, avoid higher impact running on the treadmill (sprinting or using a high incline), and bikes such as the Peloton (in certain situations), says Ai Mukai, M.D., a board-certified physical medicine and rehabilitation physician at Texas Orthopedics in Austin, TX.

                   Use caution and warm up extensively before heavy deadlifts or other exercises that work the posterior chain

“The Peloton bike can be OK for some people, but the flexion forward and possible twisting while on it can aggravate sciatica,” Dr. Mukai says.

What to do instead: Lower-impact aerobic machines and activities are fine and can even help sciatica, says Dr. Mukai. A recumbent bike is OK, too.

“But for a recumbent bike, I usually recommend a towel roll to support the lumbar curve,” she adds.

It’s fine to walk, not run, on your treadmill. But don’t power through if you are in pain.

“I would say sciatica pain or nerve pain is not a ‘good pain’ like sore muscles that people should power through,” Dr. Mukai says. “When a nerve is getting irritated by an activity and you are getting increased nerve pain and/or numbness or weakness, you should stop that activity.”

4. Avoid Sitting For Longer Than 20 Minutes

After 20 minutes or so, Dr. Tolchin says, get up and walk around for a bit before sitting back down. When you do sit, avoid bending forward. And don’t sit on a soft sofa, which is not supportive.

What to do instead: Staying active helps prevent stiffness that can result from being in pain.

“Walk around the house for 10 minutes every few hours,” says Dr. Singh. “Sitting or lying around can result in muscle spasms, stiffness, and the loss of mobility.”

And instead of that cushy sofa, sit in a supportive chair and pay attention to your posture.

5. Avoid Bed Rest

If you are really in a lot of discomfort, you can stay in bed but not for more than 48 hours, says Dr. Tolchin. When you are in the throes of acute sciatica, and you can’t find a comfortable position, there may be not much else you can do but rest, he says.

But after no more than 48 hours, you should plan to get out of bed.

“It is important to keep moving,” Dr. Tolchin says.

What to do instead: Get control of the pain with medication and then start moving. Try gentle stretching, walking, or even swimming.

6. Avoid Bending Over

“Bending forward to pick up an object increases shearing forces on the spine caused by the gravity that our muscles and ligaments have to resist while in the forward flexed position,” says Dr. Singh. “When this is combined with the weight of the object you are lifting, your ligaments, bones, and discs may become overloaded and you may get injured.”

What to do instead: Keep the spine straight (neutral) when you are picking up an object on the ground or when loading or unloading the dishwasher or clothes dryer, Dr. Singh advises.

“If you have to empty the dishwasher or clothes dryer, see if a family member can help,” says Laura Beck, M.S., P.T., vice president of rehabilitation at St. Charles Hospital in Port Jefferson, NY. "If not, go into a small squat, bending your knees slightly and keeping your back as straight as you can. Take smaller piles of dishes out of the dishwasher and don’t stack up a pile in your arms. Remove the utensil basket, set it on the counter, and unload it. This means you won’t have to bend as much.”

Keep your spine neutral and drive with the legs when lifting something off the ground.

7. Avoid Sitting in the “Wrong” Office Chair

“An uncomfortable office chair may not support your lumbar spine and can exacerbate your sciatica pain,” says Dr. Singh. “There is no one-size-fits-all for comfortable office chairs.”

What to do instead: While it is hard to recommend a particular chair, the goal is to keep your back supported and in a neutral position to prevent strain. While at your desk, take breaks every hour by standing and stretching for at least five minutes to prevent stiffness and to promote mobility of your back muscles, Dr. Singh says.

“Consider an ergonomic chair that helps you maintain a neutral position,” Dr. Singh says. “This means sitting up with your hips and knees at a 90-degree angle and with your feet flat on the floor. Adjustable lumbar support, arm, and seat height can make the chair more suited for your body based on your height and limb length.”

8. Avoid Twisting Your Spine

“You don’t need to avoid isolated twisting motions but when you combine twisting motions with other movements like forward or side bending, this can aggravate the joints and muscles in your lower back,” Dr. Singh says. A good example of what not to do is shovel snow or lift objects the wrong way, she says.

What to do instead: Learn the right way to lift objects. Make sure to do core strengthening exercises and stretch beforehand to improve your flexibility, range of motion, and prevent injury.

9. Avoid Lifting Heavy Objects

Follow your doctor’s recommendations but generally, in the acute phase of sciatica, avoid lifting objects that weigh more than 15 pounds, Dr. Singh says. And when you lift, do not attempt to lift an object that is far away from your body.

What to do instead: Stand close to the object with your feet shoulder-width apart. Bend your knees and squat down to the object. Lift the object by holding it with your hands on either side, Dr. Singh says. Make sure your head, back, and buttocks are aligned. Tighten your gluteal and abdominal muscles. Lift with your leg muscles by standing up from your squat position, keeping the object as close to you as possible and keeping your spine as straight as you can.

10. Avoid Long Car Trips

This isn’t always possible, of course, but if you are on a long ride, try to take frequent breaks to avoid sciatica pain from driving or being a passenger.

“And when you are in your car, get in the right position, without any slumping,” says Beck. Adjust your rearview mirror before you start driving so that it is in the right spot for you. If you have trouble seeing the mirror after you have been driving for a while, it may mean that you are slumping.”

What to do instead: Find a rest stop and walk around for a couple of minutes.

“Stand up straight so you will reduce that flexed posture,” Beck says. “Sitting is a more flexed posture that increases the pressure on your spine, so it is important to reverse that position.”

11. Avoid Worrying

“I would say that 90% of the time, a herniated disc will calm down,” says Dr. Tolchin. “If there are neurological deficits, that would be a reason for surgery. But most of the time, sciatica gets better.”

If you are worried that you may need sciatica surgery, it would most likely only be considered if you have numbness, weakness, incontinence, or the loss of reflexes.

“Surgery would only be considered if you have one of these or if you have exhausted all non-surgical options,” says Dr. Mukai.

What to do instead: Surgery can be a big deal and it’s completely natural to feel trepidation. If you’re concerned that one of your providers believes you need surgery, it’s not rude to get a second opinion.

https://www.healthcentral.com/condition/sciatica/what-to-avoid-if-you-have-sciatica