When the glucose levels appear disorganized and without an obvious pattern, consider these possible explanations:
- Hypoglycemic events during the night, causing rebound hyperglycemia
- Check the glucose level at 2am
- Reduce the nocte dose of basal insulin by 10-20%
- Constipation
- Very common in people with diabetes, particularly during acute illness
- It causes gastrointestinal dysmotility, erratic GI absorption and glucose levels
- Treat with regular aperients.
- Faecal impaction will require an enema
- Gastroparesis
- Can be due to hyperglycemia or underlying autonomic neuropathy
- Erratic GI absorption causes erratic glucose levels
- Frequently coexists with constipation, so treat the constipation too
- Treat constipation before promotility agents given
- Promotility agents include: Metoclopramide, erythromycin syrup, domperidone, amitriptyline. Perform a 12-lead ECG before and after commencing these, looking for prolongation of QTc interval and arrhythmias
- Snacking in between meals – and no insulin to cover it
- Avoid snacks or give non-sugar or low-carbohydrate options that will not raise glucose levels
- Eating sugar or high-GI carbohydrates at meals
- Avoid this, because rapid-acting insulin is not quick enough to match these foods and control glucose levels
- Malabsorption eg. coeliac disease, pancreatic exocrine insufficiency
- Investigate and treat appropriately
- Coeliac disease: anti-TTG antibody result will be positive
- Pancreatic exocrine insufficiency – faecal elastase is low
- Poor insulin injection technique
- Observe technique
- Avoid areas of lipohypertrophy