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Troubleshooting: Hypo and Hyperglycemia

This article reviews causes of hypo and hyperglycemia and briefly highlights possible solutions for patients on insulin pump therapy. 

Causes of Hypo / Hyperglycemia Not Specific to Insulin Pump

Situations

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HypoHyperPossible Solutions

Situations

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Psychosocial considerations		 Hypox Hyperx Possible SolutionsConsider asking "What's the hardest part about taking insulin?" or "How do you feel..." e.g. about new doses, giving insulin in general, etc. 

Situations

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Insulin storage or expiry		 Hypo  Hyperx Possible Solutions 

Situations

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Missed doses. Also consider diabulimia. 		 Hypo  Hyperx Possible Solutions 

Situations

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Incorrect dosing - unintentional or intentional. 		 Hypox Hyperx Possible Solutions 

Situations

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Incorrect target (mmol/L) or incorrect use of formula. 		 Hypox Hyperx Possible Solutions 

Situations

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When bolus is taken (adequate, too much ac or pc)		 Hypox Hyperx Possible Solutions 

Situations

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Dose needs adjusting secondary unknown changes in diabetes. 		 Hypox Hyperx Possible Solutions 

Situations

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Exercise changes		 Hypox Hyperx Possible SolutionsTemp basal if on pump

Situations

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Incorrect carb counting		 Hypox Hyperx Possible Solutions 

Situations

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Diet Changes

Glycemic Index

Protein & fat intake. 

Low Carb or Ketogenic Diet 

 Hypox Hyperx Possible Solutions
  • Query if patient would change diabetes meds/doses or food portions.
  • Query appetite, possibility of gastroparesis. Note in the case secondary diabetes requiring insulin due to total pancreatectomy the patient may be at greater risk of severe hypoglycemia. (They may also present with GI symptoms similar to gastroparesis which suggests they may need adjustments to enzyme replacments. Alert endo to address this. Refer to RD.) 
  • Try temp basal; dual/square bolus if on pump.
  • Some people with type 1 diabetes may benefit from working with their healthcare team to try different algorithms for giving insuiln for protein and/or fat. 
  • If low carb or ketogenic diet, query treatments for hypoglycemia. If no or ineffective treatment, with the patient's permission, review rationale for using fast carbs noting that untreated hypo may increase risk of hypo unawareness which could impact driving. Encourage a referal to RD so the patient may continue their desired diet safety. 

Situations

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Menstrual cycle		 Hypox Hyperx Possible SolutionsAlternate basal profile; temp basal if on pump

Situations

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Puberty		 Hypo  Hyperx Possible Solutions 

Situations

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Weight changes		 Hypox Hyperx Possible Solutions 

Situations

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Gastroparesis		 Hypox Hyperx Possible SolutionsDual/square bolus; temp basal if on pump

Situations

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Drug/drug interactions		 Hypox Hyperx Possible Solutions See summary of drug interactions and Drug Product Database

Situations

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Exercise injection/infusion site		 Hypox Hyper  Possible SolutionsTemp ↓basal if on pump

Situations

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“Virgin” sites		 Hypox Hyper  Possible SolutionsTemp ↓basal if on pump

Situations

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Lipohypertrophy
 Hypox Hyperx Possible SolutionsRotate injection/infusion sites for more reliable insulin absorption.

Situations

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Intramuscular injection		 Hypox Hyper  Possible SolutionsReview pinch method and injection sites if very lean

Situations

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Stacking corrections		 Hypox Hyper  Possible SolutionsCorrect to 8-10 mmol 2 hr pc or read pump calculations

Situations

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Pregnancy (early)		 Hypox Hyper  Possible Solutions 

Situations

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Pregnancy (late)		 Hypo  Hyperx Possible SolutionsFor pump: Daily set changes. Active insulin time in pump may need to be reduced to 3 hr.  

Situations

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Breastfeeding (as well as possible mastitis)		 Hypox Hyperx Possible Solutions(Potenital lows with breastfeeding. Potential highs if mastitis)

Situations

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Alcohol		 Hypox Hyper  Possible Solutions 

Situations

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Adrenal insufficiency		 Hypox Hyper  Possible Solutions 

Situations

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Renal disease		 Hypox Hyper  Possible Solutions 

Situations

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Bariatric surgery		 Hypox Hyper  Possible SolutionsPost-bariatric hypoglycemia can occur typically 1-2 hours pc meals even in those not on insulin or secretatogues. This may occur up to few years after surgery. Refer to an RD to discuss management. 

Situations

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Pen not working or used incorrectly.		 Hypo  Hyperx Possible SolutionsSyringe for corrections with ketones!

Situations

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Spoiled insulin with heat (summer)		 Hypo  Hyperx Possible Solutions

During heat waves:

  • Keep current vial of insulin in the fridge
  • Try not to spend extended hours exposed directly to sun e.g. sunbathing (for overall health and for insulin in pump). Use an umbrella if laying on beach.
  • Consider smaller “fills” e.g. replacing pods (or reservoirs if other pumps) sooner than 3 days.
  • Never store safety kit in the car, where can overheat the “safety” insulin quickly
  • Can get a small Frio pack to keep a pen vial of insulin cool in a safety kit if on a beach.

Situations

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Illness/stress/silent MI		 Hypo(x) Hyperx Possible SolutionsTemp basal if on pump if appropriate. Occasionally a person responds to stress with hypo. 

Situations

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Medication Changes 		 Hypox Hyperx Possible SolutionsCheck with pharmacisty regarding any drug-drug interactions if blood sugars changed after starting new medications.

Situations

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Hydroxyurea 		 Hypo  Hyper x Possible SolutionsHydroxyurea can falsely elevate sensor glucose readings in Medtronic and Dexcom sensors (2021). Not Libre. Hydroxyurea is found in some drugs to treat some cancers, sickle cell anemia and other conditions. It is found in Hydrea™, Apo-Hydroxyurea™, Mylan-Hydroxyurea™* and hydroxycarbamide.

Situations

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Corticosteroids

 Hypo  Hyperx Possible Solutions

Increase insulin or addition of insulin to address peak rise of glucose values; Increase temp basal if on pump;

Situations

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Inaccurate glucose meter or sensor		 Hypox Hyperx Possible SolutionsRefer to product user manuals

Insulin Pump Programming

SituationsHypoHyperPossible Pump Solutions
SituationsEarlier temp basal used Hypox Hyperx Possible Pump Solutions 
SituationsEarlier square wave/extended bolus used Hypox Hyperx Possible Pump SolutionsNormal bolus may have been needed or % normal/extended needs changing
SituationsMixing up a.m. and p.m. when programming. Hypox Hyperx Possible Pump Solutions 
SituationsBasal rate mistakenly changed. Hypox Hyperx Possible Pump Solutions 
SituationsTime on clock wrong from travel or daylight savings time Hypox Hyperx Possible Pump SolutionsSign up for Pump Pointers as reminders are sent when daylight savings time changes.
SituationsActive insulin time too short HypoX Hyper  Possible Pump SolutionsStandard time is 4 hours. See note below.
SituationsActive insulin time too long Hypo  HyperX Possible Pump SolutionsStandard time is 4 hours. Active insulin time may be shortened in occasional situations eg. 3 hours in the third trimester of pregnancy e.g. in those who are confident their basal is set but at 3 hr pc when in target, their IOB indicates they would drop further, but they don't. e.g. at 3 hr pc BG occasionally elevated, pump advises no correction as IOB, but patient remains at the same BG level by 4 hr pc.
SituationsTargets programmed into pump (specifically low end) Omnipod information clarified with Omnipod IT via phone 2017 Hypo  Hyperx Possible Pump SolutionsIF BLOOD GLUCOSE UNDER TARGET: Animas will make two subtractions from meal bolus. One as a reverse correction to keep person in target and the second to subtract ALL the insulin on board. This may lead to severe under insulinization at times. To avoid, consider setting target of 4-7 which would read 5.5 +/- 1.5 if appropriate. Then it will subtract all IOB if under 4 mmol. Omnipod will subtract using a reverse correction (if turned on) and will always subtract previous insulin given for correction regardless if reverse correction is turned on. It will not subtract previous insulin (IOB) given for meal bolus. Omnipod distinguishes between IOB from correction or meal bolus. Medtronic will subtract using a reverse correction. No IOB is subtracted from meal bolus.
SituationsMax bolus reached and second "make-up" bolus not delivered. Hypo  Hyperx Possible Pump SolutionsReprogram for bigger max bolus (max possible is 30 units for Omnipod)
SituationsSuspend is on Hypo  Hyperx Possible Pump SolutionsOmnipod requires pump be suspended before making basal changes, and resumed after.

Cannula and Infusion Site

SituationsHypoHyperPossible Pump Solutions
SituationsInsertion close to muscle mass Hypox Hyper  Possible Pump SolutionsTemp ↓basal; Change site; Use angled infusion sets manually adjusted for muscular areas as can insert shallower
SituationsIntramuscular insertion Hypox Hyper  Possible Pump SolutionsChange site
SituationsCannula left in too long Hypo  Hyperx Possible Pump SolutionsChange q 2-3 days (q 1 for third trimester or q1-2 for large TDD). If infusion sites are hard to reach query frequency of set changes (eg. shoulder, back love handles, buttocks). If on Apidra insulin, change reservoir and set every 2 days. Metal cannulas change q 1-2 days.
SituationsKinked cannula Hypo  Hyperx Possible Pump SolutionsTry angled set (manually adjust angle) so not bumping muscle mass; try metal cannula; try different insertion method (device or manual); change if notice pain after bumping
SituationsTunneling (click for image in 30 degree set or here for Omnipod) Hypo  Hyperx Possible Pump Solutions
Change set/pod when notice wet material (see left to click for images). Look for tunneling often, especially if corrections aren't working as well as anticipated. It can occur with movement, sleeping on pod/set, large boluses. Try:
  • Extended boluses or slower insulin delivery
  • Changing set or pod more freqently
  • Different infusion sites with less movement
  • Try taping to reduce movement (e.g. Tegaderm)
SituationsToo shallow insertion near skin surface so “bumps” out with bolus Hypo  Hyperx Possible Pump SolutionsAssess sites; instruct on angle of insertion 20-45 degree for angled sets.
SituationsUnknowingly set ripped out Hypo  Hyperx Possible Pump SolutionsInstruct on a safety loop; Pull tubing twice daily to ensure connections
SituationsAdhesive sweats off Hypo  Hyperx Possible Pump SolutionsTry Skin-Tac product (buy from pump company, pharmacy or Blain MacLean Pharmacy & Surgical supplies); unscented hypoallergenic antiperspirant; tape/dressing like Tegaderm or IV3000.
SituationsSite irritation/tape irritation may impact insulin absorption secondary inflammation. Hypo  Hyperx Possible Pump SolutionsUse new site; Try Skin-Tac liquid or wipes on skin first; Tegaderm or IV 300 on skin first with hole cut for cannula; choose sites carefully to avoid those by pant line, bra/underwire.
SituationsCannula not inserted as needle guard not removed using a set with a serter. Hypo  Hyperx Possible Pump Solutions 

Reservoir and Infusion Set Tubing

SituationsHypoHyperPossible Pump Solutions
SituationsPriming tubing issues (primed when connected to body or forgot prime) Hypox Hyperx Possible Pump SolutionsRead screen instructions when filling/priming.
Situations“Fill cannula” amount is set incorrectly or cannulas not filled Hypox Hyperx Possible Pump Solutions 
SituationsTubing not fully connected to cannula at the site. Hypo  Hyperx Possible Pump SolutionsPull tubing twice daily to ensure connections
SituationsLeaking at hub/connection Hypo  Hyperx Possible Pump SolutionsReview tightening; be sure dry when connect
SituationsBubbles in reservoir/tubing Hypo  Hyperx Possible Pump SolutionsUse room temp insulin; prime tubing with reservoir held vertically (top facing ceiling); prime tubing until visible bubbles are out of tubing; change reservoir earlier if noticed many champagne bubbles when filling – they can “clump” to make big bubble when close to empty reservoir; do not disconnect tubing from reservoir until set is changed
SituationsOcclusion or other no delivery alarm Hypo  Hyperx Possible Pump SolutionsWhen filling reservoir, lubricate it by pulling plunger up and down a few times prior to filling with insulin; load reservoir vertically especially if not using full reservoirs
SituationsTubing/reservoir re-used too many times, or on Apidra. Hypo  Hyperx Possible Pump SolutionsUse new reservoir and tubing each set change. If on Apidra insulin, change reservoir and set/tubing every 2 days.

Physical or Mechanical Insulin Pump Problems

SituationsHypoHyperPossible Pump Solutions
SituationsCasing cracked and water inside; insulin leaked inside Hypox Hyperx Possible Pump SolutionsAdvise no exposure to water if cracked casing. Advise when remove pump for medical procedures arrange pump so that insulin being delivered is not being directed into/onto the pump (eg. if in baggie may need "zero" temp basal)
SituationsPump dies, screen fails, pump buttons stop working Hypo  Hyperx Possible Pump SolutionsCall 1-800#. Often replaced within hours. Review “Coming off pump” handout with client to prevent DKA. Http://ucalgary.ca/cdm/handouts
SituationsMagnet at theme park ride affect pump function Hypox Hyperx Possible Pump Solutionsunknown if pump function would result in highs or lows.
SituationsPressure changes with roller coaster or scuba diving affect pump function Hypox Hyperx Possible Pump Solutionsunknown if pump function would result in highs or lows. Expect lows moreso with g-forces forcing insluin out potentially
SituationsLiquid gets on the top of the reservoir or inside the tubing connector when connecting the tubing to the reservoir Hypox Hyperx Possible Pump SolutionsThis is for Medtronic: Liquid can temporarily block the vents. This may result in the delivery of too little or too much insulin.