- AACE PATIENT SAFETY EXCHANGE -

-->

AACE Patient Safety - Ask the Experts - Patient's Corner Q&A

Some assembly required

Question from "M.L.":
Yesterday I was in my doctor’s office. I am on an insulin pump. My blood sugars had been too high and my doctor wanted to change the basal rates of insulin, but I could not remember how to do this and the doctor also did not know how to do this. We finally found a nurse in the office who did know, and I also called a help number from the company and together they helped me find the doses so they could be changed. Is this a common problem?

Answer from Richard Hellman, MD, FACP, FACE:
Unfortunately, it is becoming an increasingly common problem. As the insulin pumps become more sophisticated, we are seeing, nationwide, more problems resulting from pumps that are not understood by either the patient or the doctor. Many patients are being put on insulin pumps after only a few hours of initial education, and they do not realize the potential risks to them if they make a serious mistake in the use of their pump.

The American Association of Clinical Endocrinologists holds an annual hands-on teaching session for our endocrinologists just finishing their training. But we need to provide even more educational and re-education opportunities for our doctors. Unfortunately, many non-specialist physicians have neither the time nor the support staff to provide this service for the patients.

Likewise education needs to be tailored to the needs of the patient and their family. Re-education is essential, but since only some patients will benefit from the on-line tutorials, which are generally available, I recommend that much of it be face-to-face. Coordination of care for the patient with diabetes on an insulin pump in many countries, such as in France, is done primarily by expert multidisciplinary teams of diabetes specialists. There are examples of such programs available in the United States, and they do an outstanding job of educating both the team and the patient and their family. There needs to be more of these multidisciplinary diabetes groups in order to provide better protection for our patients. Unfortunately, policy planners and payors have not yet understood that it is not enough to provide an insulin pump, they also need to pay for both your education and re-education; It is essential that your pump use can be completely integrated into your care so the pump can be used both safely and effectively to keep your glucose levels in the optimal range.

Short-acting and long-acting insulin

Question from "L.G.":
Sometimes I accidentally give short-acting insulin instead of long-acting insulin and my blood sugar gets too low? What should I do?

Answer from Richard Hellman, MD, FACP, FACE:
The first thing to do is to check your glucose level to see whether it is too high, in the normal range, or too low. If it is already low, I would give glucose tablets or another rapidly absorbed carbohydrate dose immediately and call your doctor for advice. Your doctor will decide, based on how sensitive you are to the effect of insulin, how much insulin you gave, the time of the day, your calorie intake and activity, as to how much replacement carbohydrate to take, how many hours to continue checking, and when it is safe to take your long-acting dose. If your glucose is elevated, you can call your doctor first. But is your glucose is in the normal range, taking some carbohydrate and then calling is also prudent.

After the episode is successfully treated, we then need to examine why this happened, so as to prevent it from happening again. Sometimes the mistake happens when people are in a hurry and don’t look closely at the bottle of insulin. It is always good to make a habit of rechecking the label of bottle and the dosage of insulin at least once. Sometimes the mistake may be due to the lighting being poor, or it may indicate your vision may not be as good as it has been. Please discuss this with your doctor or other health professional. It is very important to make it very unlikely that this mistake ever occurs again. Insulin is a very powerful drug, and safety matters.

Leave a Comment

There are 2 comments

Trisha – TX

May 02, 2009 - 13:04

Subject: hyperthyroid-Graves Disease

I have recently been diagnosed with hyperthyroid, probable Graves Disease and was given the option of three separate treatments. 1.) medication (PTU-with a recent mention of serious risk of liver failure & Tapazole-with health risks), 2.) surgery to remove the right thyroid gland (risk of being Hypo and on Rx for the rest of my life) 3.) radiation treatment (risk of being HYPO and on Rx for the rest of my life).

I am wanting to become pregnant and have been advised by my GYN and Endocronologist to regulate my thyroid prior to conceiving due to the risks of miscarriage. My concerns are that the thyroid medication available for hyperthyroid has been said to cause probable birth defects in the case of pregnancy. Are the risks of remaining untreated for my Graves Disease greater than the risks of Rx? Which is more concerning... HYPO- or HYPER- thyroidism during and after pregnancy since it appears that I will need to be on Rx either way.

Reply to Trisha

Dr. Hellman

May 11, 2009 - 16:27

Subject: Dr. Jeffrey R. Garber, MD, FACP, FACE comments:

With the understanding that his comments are general in nature and are not a substitute for a careful evaluation including a history and physical examination, and review of specific laboratory data, Dr. Jeffrey R. Garber, MD, FACP, FACE further comments on PTU in response to Patient Safety Exchange visitor's comments.

***

Controlling your thyroid condition prior to becoming pregnant and while pregnant generally outweighs the risks of each of the therapies outlined by your physician.

PTU has NOT been associated with birth defects and is therefore preferred to methimazole during pregnancy. Although there is a risk of serious liver problems with PTU it is unusual. Both can be avoided by having surgery or receiving radioactive iodine prior to becoming pregnant.

Since an underactive thyroid is usually easier to treat than an overactive one, most practicing endocrinologists feel that making someone with an overactive thyroid underactive is a reasonable approach.

We recommend discussing your specific concerns as well as learning more about your thyroid condition, however, with your treating physician.

***