A: There is not much point in testing your blood sugar several times a day if you don’t use the information to make the necessary changes. The value of blood glucose testing lies in helping you understand what happens to your blood sugars through the day. It also helps you and your diabetes team work out what changes are required.
People who have well controlled type 2 diabetes on diet or tablet (HbA1c < 7) would not expect to derive any great benefit from blood sugar testing.
If you are taking insulin and your control is poor, adjustments to your insulin dose will be needed. In order to adjust your insulin it is important to know what your levels are at different times of the day so that the right insulin dose is adjusted. A general rule would be if your blood glucose levels are high at a given time, the dose of insulin which requires adjusting is the preceding dose. In many people who make no change in their dose of insulin it makes no sense to test four times a day. The trends or patterns of blood sugar change are often established and do not vary a lot from day to day. When you attend the diabetes clinic an HbA1c test will give your doctor an idea of your overall control. However the HbA1c does not help to decide which of your insulin doses needs to be changed.
Test strips cost the NHS approximately 35p each. 4 tests a day for a year would cost in the region of £500. For one million people with diabetes this represents 500 million pounds on glucose test strips alone! This does not take into account the cost of lancets.
Q: When should frequency of testing be reduced?
A: Blood sugar testing can be reduced or stopped when:
Blood sugars are well controlled and regularly within normal range, HbA1c < 7
Type 2 diabetics who are not using the information to make changes
When there has been no change in dose of insulin for more than 3 months
Sore fingers
Q. Should I keep a record of my blood sugar readings?
A: Yes. Always keep a written record of your blood glucose concentrations. The readings are intended to show trends in blood sugars which will determine changes in insulin doses. Most modern meters will have a memory capable of retaining over 50 readings. This is not a useful way of storing your readings unless you plan to download them to a computer. When you attend the clinic it would be easier for the Nurse to analyse your readings if they are written down, so that the trends or patterns are clearly visible. Make sure the time of testing is clearly recorded. A diary, for recording readings, is available from the Diabetes nurse.
A:
Before breakfast – fasting blood sugar
2 hours after breakfast – postprandial blood sugar
before lunch
2 hours after lunch – post prandial
before your evening meal
2 hours after your evening meal
at bedtime
2-3 am to check for nocturnal hypos
Q: What should I do if I think I am having a hypo?
A: Mild hypoglycaemia where you are aware of your symptoms is easily treated by taking a sweet drink or glucose tablets. 15 g of glucose is more than sufficient. Avoid over treating, such as by taking an entire bottle of Lucozade or several Mars Bars as this only leads to wild swings of your blood sugar. Remember your body has its own mechanisms for dealing with a hypo which are also working away in the background. A carbohydrate meal is by far the best way of sorting out mild warning symptoms.
The following forms of quick acting carbohydrate may be used:
- half a glass of Lucozade, Coca-cola or lemonade
- 2-3 glucose tablets taken with water.
- 5 fruit pastilles
- Follow this up with a glass of milk and a biscuit or a sandwich.
If you are confused but still able to drink, a friend should give you a sweet drink. If you cannot or will not swallow, hypostop gel can be placed in your mouth. This should be absorbed from the lining of the cheek rather than swallowed. It is ideally placed between the jaw and the cheek. It should not be used if you are unconscious.
If you have lost consciousness, you may be given Glucagon, pending the arrival of the emergency services. See your Diabetes Nurse for information regarding the use of Glucagon.
Q: What if I have a hypo when my injection is due?
A: It is difficult to give precise advice about this situation as there are a number of factors which may be relevant. As general rules first make sure your blood sugar levels are restored to normal. You may then take a reduced dose of insulin and your usual meal. Do not miss your dose of insulin as this is likely to lead to a large 'swing' of your blood glucose concentrations.
Q: What should I do about recurrent hypos?
A: Recurrent hypoglycaemia can sometimes be a difficult problem to solve. Identifying the cause is important which may include one or more of the following factors
- skipping meals
- alcohol
- exercise
- hypoglycaemia unawareness (loss of warning symptoms)
Q: What should I do if I am driving?
A: If driving you should stop your vehicle as soon and as safely as possible.
Take a tablet of glucose or a glucose drink
Remove the ignition key and move to the passenger seat. If on the Motorway leave your car with hazard warnings on and move to a position of safety.
Refer to the leaflet Diabetes and Driving for more advice on diabetes and driving which is available from your Diabetes Nurse. Or visit Diabetes UK for more information.
Q: Can I go abroad if I am taking insulin?
A: Yes. There should be no reason why you should not be able to travel as long as you follow a few simple rules. Air travel is a common occurrence for people who receive insulin therapy.
These problems can be overcome by planning ahead for your journey.
Q: New Security Restrictions at Airports
A: People with diabetes can still take insulin with them onto aircraft despite new security restrictions. Those traveling should bring a letter from their doctor explaining their need to carry syringes/injection devices and insulin. The doctor’s letter explaining your need for insulin and injection devices should be presented to the airline staff, and if you do encounter any problems you should request to speak to a manager or senior member of staff. Some GPs will make a charge for writing a letter. If you travel frequently therefore, it would be a good idea to ask your doctor to phrase the letter in such a way that it can be used more than once.
A number of airlines bring in restrictions in emergency situations about what items can be brought onto their aircraft in hand luggage. This leads to concern about traveling with insulin and a number of people have been advised that they must put spare insulin in baggage in the aircraft's hold. Our advice based on information from insulin manufacturers has always been to avoid storing insulin in baggage which goes into the hold, as travelling at altitude may cause the baggage to freeze, which would damage the insulin. We have spoken to an insulin manufacturer and they have advised, in emergency situations, to place insulin that has to go in the hold, in an airtight container (such as a flask) in the middle of your suitcase. Alternatively, if an airtight container isn't available, wrap in bubble wrap, then in a towel and again place in the middle of your suitcase.
On arrival you must examine the insulin for crystals and discard the insulin if any are found. Even if it looks ok, you should test your blood glucose levels more frequently and if they appear abnormal, discard the insulin as it may be damaged and ineffective.
On some airlines, once on board the plane, cabin crew may request that medication be handed over for storage during the flight. For this reason it may be advisable to put insulin and syringes/needles in a separate carrier bag.
In addition to a doctor’s letter, a Diabetes UK Insulin user’s identity card may also help the cardholder to verify his/her need to carry syringes and medication. Please note however, that this card does not hold any statutory status at present, and police or customs are not required by law to recognise the card and the information printed on it. Nonetheless, they are aware of its existence and producing the card may ease any problems you might otherwise encounter.
Those traveling may wish to contact their airline in advance for the most up-to-date information on this issue.
A. Your diabetes supplies should be carried in your cabin bag. Cargo holds are subject to extremes of temperature which can cause insulin to deteriorate. Furthermore check-in baggage may get lost.
Ask your doctor to provide you will a letter explaining your need insulin and injection devices. You should present the letter to the airline staff, and if you do encounter any problems you should request to speak to a manager or senior member of staff. Security officials at airports may not always accept a written prescription or letter from your doctor, though it is recommended you carry one anyway Some GPs will make a charge for writing a letter. If you travel frequently therefore, it would be a good idea to ask your doctor to phrase the letter in such a way that it can be used more than once.
In addition to a doctor’s letter, a Diabetes UK Insulin user’s identity card may also help the cardholder to verify his/her need to carry syringes and medication. Please note however, that this card does not hold any statutory status at present, and police or customs are not required by law to recognise the card and the information printed on it. Nonetheless, they are aware of its existence and producing the card may ease any problems you might otherwise encounter.
According to aviation regulations all insulin vials/pens/cartridges should have a professional, pre-printed pharmaceutical company label affixed which clearly identifies the medication.
Lancets for blood glucose monitoring should be capped and clearly labelled.
Glucagon kits should also have the original preprinted labels attached.
You may wish to contact their airline in advance for the most up-to-date information on this issue.
Q. Are there any problems associated with Air Travel?
A.
- Yes. There is increased security at Airports. Needles and Lancets have to be ‘declared’
- Crossing time zones affects timing of injections
- Meals on board aircraft may not be suitable
- Dehydration is common
These problems can be overcome by planning ahead for your journey.
Q. I am flying to America. How will crossing time zones affect me?
A. If you are taking off from Heathrow Airport, traveling west to New York. The time at your destination is five hours earlier in the day. Therefore when you arrive you have five more hours to get through before it’s time for bed.
If you are on a twice daily isophane and soluble Insulin:
- Take your usual morning dose on the morning before you leave.
- Keep your wristwatch reading London (GMT) time.
- Time your evening meal at the usual time (approx 10 hours after the morning dose).
- Take the full dose of soluble insulin with half the dose of isophane at this time.
- At dinner time in New York (say 6pm which would be 11 pm GMT), take the remaining half of the isophane insulin with your full dose of soluble insulin.
- The next morning resume your usual daily dose.
If you are on a twice daily mixture e.g. Human Mixtard 30:
- Take your usual morning dose, the morning before you leave.
- Time your evening meal at the ‘usual time’ as above. Take half the dose of insulin at this time
- Take the remaining half of your dose, when it is dinner time in New York.
- The following morning resume your usual daily dose.
If you are on a basal bolus regimen:
- For example on three doses of Novorapid or Humalog with Glargine at bedtime.
- Take your usual dose of Glargine the night before you leave.
- Take your doses of pre-meal insulin as you normally would. Time your dose of Glargine for your usual injection time (say 22:00 h), taking half your dose at this time.
- Take the remaining half-dose of Glargine at bedtime in New York (i.e. 3 a.m. GMT). This way your 24 hour requirement of Glargine stays the same, though the dose is split to help deal with the time change.
- Use extra soluble insulin (humalog or Novorapid) to cover extra meals during the flight based on how much carbohydrate you eat.
These are simple illustration as there can never be a comprehensive account of insulin management to cover every travel itinerary.
Rule of thumb.
Travelling East will shorten your day and you may therefore need less insulin.
Travelling West will lengthen your day and you may therefore need more insulin.
This ‘rule of thumb’ does not always apply especially on long-haul flights. Advice can be obtained from your Diabetes Nurse.
What should I eat on the plane?Take the regular meal offered and supplement your carbohydrates if necessary with snacks.
Avoid alcohol
Drink plenty of fluids
Monitor blood sugars regularly (every 4 hours recommended)
Ideally take your insulin at meal time rather than half hour before
How should my insulin be stored while away?
Keeping insulin cool is a concern but there are various products on the market to help. Several, such as the Frio pack and Isobag, are available via Diabetes UK shop. You could also use a small cool bag from a camping shop or a wide mouthed thermos flask. Many hotels also have a fridge in the room, and you could check if this was the case before leaving home. Remember, if you are flying you should keep your insulin in your hand luggage as it may freeze in the hold. For more information about travel speak to your Diabetes Nurse or see the Diabetes UK Travel guide and country guides available via the Diabetes UK web site at www.diabetes.org.uk
Checklist for Journey.
- Insulin, pens/syringes, lancets and test strips to last your trip
- Blood glucose meter
- Sharps Box
- Glucagon kit
- Glucose tablets
- Medication for vomiting and diarrhoea
- Complex carbohydrates – e.g. breakfast bars, snacks in case meals are delayed
- Short acting insulin for sick day management
- Card or bracelet which identifies you as someone who has diabetes
- Insurance documents
- Letter from GP explaining reason for carrying insulin & needles