Next Challenge

Woohoo!  I finished my first half-marathon. It was slow but I did it and raised $1380 for St. Jude's Children's Cancer Research Hospital.  What do you want to do but haven't tried yet?

Your Diabetes shouldn't keep you from living the life that you dream.

What NOW?

I told you I was training for my first half-marathon.  Well next weekend, I run it!  It won't be pretty and I won't be fast but I'll be proud to finish!  Furthermore, I'm super excited that I've raised $1225 for St. Jude's Children Cancer Research Hospital!

What NOW?  Well, let me get through next weekend before I make any future goals.

What about you?
What is your goal?
And what is stopping you?



Hugs and Love,
Nanci

What is Success?

When it comes to Diabetes--success is whatever the person with diabetes says that it is.  One week it may be waking up without lows. The next week it could mean not skipping any meal boluses.  This is just how it has to be when you are dealing with a chronic illness.  Furthermore, there has to be a moving target because once you get the A1c you want--if you are still having lows, that trumps the A1c.

According to Winston Churchill, "Success consists of going from failure to failure without loss of enthusiasm."  In other words, if you didn't have a good day, if you ate the cookie, forgot to exercise, drank sweet tea--just do better the next hour, or if the sun has set, the next day--but do, DO better. 

If you don't feel like you can lose 10 pounds, then set your goal on 2 pounds and DO it! 

If your a1c is 10 and you don't feel like you can achieve an a1c of less than 6.5%, then set your goal on an a1c of 8% and DO it. 

If you don't think you can exercise for 30 minutes a day, then set your goal on 15 minutes and DO it!

"Our greatest weakness lies in giving up. The most certain way to succeed is always to try just one more time." -Thomas Edison

Oh, and if you can't do it for yourself--make a goal for your mom/dad, a charity and/or for someone you love.  As I've mentioned--I am not a runner but I've signed up to run my first half-marathon in honor of my friend Jill, that died of breast cancer. By collecting donations, I'm raising money for St Jude Children's Research Hospital. My half-marathon jersy came in the mail recently and its a nice reminder of why I'm getting out of bed so early 3 mornings a week. :) When I even consider complaining...I simply think of children with cancer undergoing chemo, radiation and surgery and I jump out of bed with enthusiasm.  Although cancer is a sad reality for some, it reminds me that I certainly have nothing to complain about ever!  And by the way, I ran 6 miles on Saturday. It wasn't fast and it wasn't pretty but it was a mile farther than last week, so I'd call it a Success.

Come on--Make a goal and then go DO it!

Hugs and Love, 

Nanci

I am NOT a Runner!

Ok, so I'm training for my first half marathon.  I hate to run but I need a goal to get in shape.  Lets just say that 80 degree weather is not comfortable running weather!

Speaking of running...Europe is ahead of the game when it comes to Diabetes Care.  They were first to get a implantable sensor and a faster insulin.

• Europe has just approved a sensor that is implanted under the skin and last for 90 days! Eversense will be the "world's first long-term sensor."  This device uses a 90-day implanted sensor that is placed in the upper arm in a 5-10 minute in-office procedure. It has a rechargeable transmitter device worn on top of the skin, directly over the sensor, which powers the implant and sends the current glucose value and trend arrow to a smartphone. The transmitter is removable (off and on) depending on activity. Although, it has to be on to get glucose readings.

• Novo Nordisk also has a faster insulin.  It is called NovoRapid and it works to improve post prandial blood sugars--so the blood sugars after a meal. It also works great in pumps!  The insulin starts to work to lower blood sugars 10-20 minutes after you inject it, a maximum effect occurs between 1 and 3 hours and lasts for 3-5 hours.

Diabetes management is changing all of the time!  We need to keep changing too!  We can't become stagnate in our health.  So...Have you made your goal?  Want to walk 2 miles without stopping? Get your a1c down? Eat healthy?  Make a goal and then make it happen!

Hugs and love,

Nanci

Long TIME Over DUE

Long time overdue...

Well, I've been off the grid for a while.  I started a new role in my job and it required a lot more of my time and attention. Then I got sick with the flu and pneumonia, which because of my asthma--I still haven't fully recovered from but I'm on the mend.

To get into shape and to rehabilitate my poor lungs...I signed up for my first half marathon!  Yes, I'm "crazy".  I hate running but I had to have a goal to get myself moving again and I'm running to raise money for St. Jude's Children Cancer Research Hospital. So see, it wasn't enough to do it for me--but I can do it for the children!!  I've commited to raising $500-1000 by the race in July.  Say a prayer for me! :)

This is what life does, it throws you curve balls and sends you back a few steps but a goal can't often times get you back on track.  So, if you've been off the wagon for a while...not eating like you should, not exercising.  If you aren't happy with your 7 pound weight gain and you haven't been to the gym in 3 months.  Make a goal--and make it achievable--so you can stick with it and accomplish it!  Then...make a new one.

All the Best,
Nanci

To all my Nephrology Providers who want help with their ESRD patients...

For all of the providers that often ask me what to do when patients start dialysis or have kidney disease...I've made you a little suggestion sheet to help you begin.  As always, please remember you have to look at each patient as an individual and adjust their care accordingly and there is more than one way of doing things so this is only meant as an option--not a step by step guideline.  You know your patients best--talk to them and work with them to determine what is the best approach.

1.    Diabetes requires the whole team approach.  No it isn’t always easy and we don’t have the time but what you do may save someone’s life.

2.      Even if the person has an Endocrinologist or is seeing there PCP for DM, it is important that we asked the pt. if they are having highs (over 250) or lows (less than 70) at every interaction.  Highs will take a person out of this world eventually whereas lows can take someone out of this world immediately.  There is no reason people should die from a low bg because the only reason they are having them is because we/providers have them on too much medication. 

3.      When pts go from CKD to ESRD—be sure to look at their medication list. 

a.       Insulins should usually be reduced by 25-50%.  This means basal and bolus insulin.

                              i.      Example—if pt. is on levemir 30 units and Humalog 10 units with each meal, do 15 units of levemir and 5 units with each meal to start and ask them to bring bg logs and make an appt to f/u with the provider that is following their Diabetes.

                               ii.      The normal bg range for patients with DM is 80-180 so don’t shoot for everything to be 80-120.

                              iii.      Never increase insulin more than 10% at a time.  For pts with reduced renal function it is best to start low and go slow.  In pts with normal function, we can usually increase by 20%.

b.      Long acting insulin such as levemir/lantus/toujeo—monitor its success by the first morning bg.  If pts are waking up 100-180, this is good.  If less than 100, reduce the dose by 20%, if over 200, add 10% to their dose.  You can re-evaluate every week if they bring you bg logs.  These meds are dosed once a day and can be given at night bc they work to cover the pt. when they are not eating.  Does not have a peak.

                            i.      Tresiba has a long half-life and can last up to 42 hours in pts that do not have ESRD so I would recommend it not be used in pts on dialysis unless they just come to you on it and are doing great with no lows.  If on it, they will likely be on a very tiny dose.

c.       Short acting insulin such as Humalog u100/Novolog u100—is rapid acting and covers meals.  Usually it is 50% of the daily needs.   This med should never be given before bed and should only be given at the start of a meal or for people with satiety, immediately after the meal so that they don’t take more insulin than they really eat bc they got full too fast.  Peaks in 1-2 hours.

                             i.      For example—if the pt. is on 15 units of long acting, the total short acting will also equal 15 units (5 units at each meal).   However, a lot of pts with ESRD, unless they are type 1 do not need meal insulin.

d.      NPH/Humulin N/Novolin N/Intermediate Insulin:  should be dosed twice a day. Usually 2/3 in the AM and a 1/3 in the PM. However, in ESRD some pts can get away with just one injection a day.  This injection should be given only if pts are eating because it will peak around 8-10 hours.   

e.       Regular/Humulin R/Novolin R: Should be given with food and usually twice a day, with breakfast and dinner.  The patient should not take without food.  This drug does peak in 2-4 hours.

f.       Mixed insulin can be 50/50, 75/25, 70/30 and should only be given with food. This insulin is best used in patients that are regimented and do the same routine every day.  It is long/short insulin mixed together.  Peaks vary.

 4.      Low bgs:  If over 70, I tell pts never have a bg less than your age—or an a1c less than your age.  It keeps them safer.  Remember lows can kill pts and every time a person has a low bg, less than 70, they lose brain cells and are at risk for falls/injury etc.

a.       Treat lows with 15g carbohydrates—6 skittles, 4 glucose tabs, ½ cup of juice

b.      Recheck bg 15 minutes after low bg; usually it will have gone up by 30 points, if not over 70 repeat 15g carbs and recheck in another 15 minutes.

 5.      Oral meds and ESRD.

a.       If pts are on sulfonylurea—reduce it by at least half.  I prefer 2.5mg dose. These drugs are notorious for causing pts to have low bgs—falls/syncope etc.  If on sulfonylurea be sure it is glipizide or glimepiride.  Do not use glyburide.

b.      Metformin is not safe in ESRD but most CKD pts can tolerate it with a GFR over 30. 

c.       TZDs (pioglitazone) requires no dose adjustment but can cause edema so use these with caution and stop at the first sign of swelling. (Yea, it can be hard to tell—and that is why I would not use them in these patients.

d.      Victoza has been used in CKD and with ESRD but I’d recommend you let someone experience manage this—it can be tricky but if they are doing fine and someone is watching them—I’d leave it alone bc it is a great drug.

e.       Bydureon—don’t use in ESRD. CKD with GFR over 30.

f.       Tradjenta—safe in CKD and ESRD, no dose adjustment

g.       Januvia—25mg if GFR less than 30, 50mg if GFR 30-50 and 100mg if GFR over 50.

h.      Meglitinide—prandin—start with 0.5mg with meals


6.      As of right now, we do not get dinged for elevated A1Cs—but primary care MDs do and it is likely that Endocrinologists will eventually.  Therefore, be sure to communicate with the pts provider and let them know if A1C is not in good control. It really does take all of us to make a difference.

 7.      If the pt. feels shaky, jittery, clammy, hungry and/or is acting irritable—check a bg while the patient is in the chair be sure we don’t send pts out with low bgs.  They are at risk of falls, seizures, coma and death from lows.

 8.      Pts may complain of blurry vision, headaches or fatigue with high bgs.  They can bring their insulin with them if they are going to eat at the clinic.

 9.      Check feet.  I encourage you to talk to the patients about their feet.  If they are not showing them to you, it is because their toenails need cut, they are hiding a sore or they can’t reach their feet and haven’t changed their socks in a while. Gangrene is a serious complication.

 10.  If pts don’t seem to need their DM meds and they are on insulin and they have a small frame/low bmi…I caution you against stopping all of their insulin bc they may be a type 1 and/or LADA (latent auto-immune of adulthood) and not know it.  Therefore, be sure you confirm with a cpeptide before stopping all insulin.

All the Best,
Nanci


What you are will show in what you do. Thomas A. Edison
 
copyright.nsb10.13.2016.

 

This is a life changer for all type one patients!!!

A pump that adjusts for you!!!

http://www.medtronicdiabetes.com/blog/fda-approves-minimed-670g-system-worlds-first-hybrid-closed-loop-system/

Hugs and Celebrate!
Nanci