Type I Diabetes Mellitus Management In the Athletic

PopulationKelly Bachus, Danielle Violette, Patrick Violette,

Kim Anderson, Matt Whitesell

Purpose

• Type I Diabetes is typically diagnosed before the age of 30, and would be the most common type among high school and intercollegiate athletes that VSM provides coverage for

• We wanted to research the most up to date standard of care for Type I diabetic athletes to create an evidence based Diabetic Care Plan for all of VSM to utilize

Research Methods

• 30 literature review articles used to find the most current information about Type I Diabetes Mellitus and how it affects athletes’ participation

• Used guideline for our Diabetic Care Plan from Jimenez, et al in the ‘National Athletic Trainers’ Association Position Statement: Management of the Athlete With Type 1 Diabetes Mellitus’ article from the Journal of Athletic Training

• Consulted with Dr. Alex Diamond and Dr. Kristina Wilson in Vanderbilt Sports Medicine, and Dr. Bill Russell and Dr. Amy Potter in Vanderbilt Endocrinology

Pre Participation Examination and Clearance• History Questionnaire must include:

– Do you have frequent urination?

– Do you have excessive thirst?

– Do you have frequent hunger?

– Have you had any unexplained weight loss?

– Do you have unexplained fatigue?

– Do you have blurred vision?

– Do you have a family history of diabetes? What type?

– Do you have diabetes?

• ***If they answer yes, consult with team physician and refer to endocrinologist

• Existing Diabetes Type I Diagnosed Athletes must submit medical records documenting:

– HbA1c testing (desired <7% for adolescent, <6% for adult)

– Yearly dilated eye exam

– Yearly kidney function exam

– Yearly neurological exam

– If they have been diabetic for >15 years, a graded exercise stress test should be performed

– Type (s) and delivery method of daily insulin:

• Insulin to carbohydrate ratio at meals

• Sliding scale (correction factor) for high glucose

• Pump basal rate(s) or long acting injected insulin

Pre Participation Examination and Clearance

• During Pre-participation Exam evaluate and discuss:

– Diabetes self care skills

– General physical exam

– Educate athlete on effect of their sport on their diabetes

– Make sure they have a medical alert tag

– Athletes need to establish a relationship with a local endocrinologist

– Complete a diabetes information sheet to keep in their chart and travel folder (see below)

– Educate on proper foot care and foot wear for their sport

• Inspect feet daily for blisters, abrasions, lacerations

• Cut toe nails straight across

• No walking barefoot

• Avoid poor fitting shoes

– Be aware of training limitations

Pre Participation Examination and Clearance

Blood Glucose Monitoring and Insulin Therapy

• Pre exercise blood glucose should be 110-250 mg/dl

– Check 2-3 times before exercise at 30 min intervals

– Decrease the insulin bolus dose up to 50% at the pre exercise meal

• During exercise >1 hour blood glucose should be checked every 30 min

– ≥250 mg/dl with ketones present—no activity allowed

– ≥300 mg/dl no activity allowed

Blood Glucose Monitoring and Insulin Therapy

• Post exercise

– Shortly after exercise, they should eat a snack or meal

– If they tend to experience late onset hypoglycemia, measure blood glucose 2-4 hours post exercise and again before going to bed

– Check once during the night if they experience nighttime hypoglycemia

– If nighttime hypoglycemia reoccurs decrease the evening meal insulin bolus by 50%

Blood Glucose Monitoring and Insulin Therapy

• Insulin pump Use in Athletes

– Decrease basal rate 20-50% 1-2 hours before exercise

– Decrease bolus dose up to 50% at meal prior to exercise

– Decrease bolus dose up to 50% one hour prior to activity

– Disconnect the pump prior to exercise for no longer than one hour and monitor blood glucose frequently

– Pump can be worn during non-contact sports. It is recommended you secure and pad the pump to decrease jostling during impact activities

– Re-connect the pump immediately after competition

– Check blood 30 minutes after reconnecting the pump to ensure proper function

Blood Glucose Monitoring and Insulin Therapy

• Strategies to optimize Insulin Therapy

– Know the athlete’s type of insulin used (both fast and long acting)

– Know their dosages during the day

– Know their corrections for high blood sugar (carb ratio, should be established between the athlete and their endocrinologist/nutritionist)

– Know adjustment strategies for planned activities

– Rotate injection sites for most effective insulin absorption

– If having trouble with insulin therapy document blood sugar and insulin dosages for a week to have more information to relay to the endocrinologist/nutritionist

Emergency Situations: Hypoglycemia– Signs and Symptoms

• Early: hunger, irritability, drowsiness or confusion, rapid heart rate, sweating, dizziness, or loss of color, typically develops when the blood glucose is below 70 mg/dl

• Late: brain neuronal glucose deprivation occurs and causes blurred vision, fatigue, difficulty thinking, decreased motor control, aggressive behavior, seizures, convulsions, and loss of consciousness

– Prevention

• Frequent blood glucose monitoring

• Carb intake adjustment pre-exercise or fast acting carb supplement during exercise

• Insulin dose adjustments

• Avoid exercising during peak of insulin

• Prevent dehydration

Emergency Situations: Hypoglycemia• Treatment

– Check if they are alert and able to eat or drink without assistance

– Administer 15 g of fast acting carbs (4 Dex4 tabs, 15 gm sports gel, 4 oz juice or soda)

– Repeat glucose check every 15 min until blood glucose returns to normal range

– Once glucose is up, give complex carbohydrate snack (bagel, sandwich)

– If athlete is unconscious keep athlete on their side (hypoglycemia and glucagon can often cause nausea)

– Call 911

– Inject 1 mg glucagon in the upper thigh muscle (see instructions below)

– Check glucose after 15 min

– If still unconscious give a second glucagon dose if available

– If consciousness is regained and athlete is able to swallow, provide food

– Monitor closely for 2 hours, checking their glucose every 15-20 min

Emergency Situations: Hyperglycemia– Signs and symptoms

• Nausea, dehydration, decreased cognitive performance, decreased visual reaction time, sluggishness, fatigue

• Ketosis: Also may have rapid breathing, fruity odor to breath, unusual fatigue, sleepiness, inattentiveness, loss of appetite, increased thirst, and frequent urination

– Prevention

• Frequent blood glucose monitoring

• Pre-exercise insulin dosage adjustments

• Frequent blood glucose testing

– Treatment

• Administration of small bolus of rapid acting insulin

• When blood glucose is ≥250 mg/dl, test urine or blood for ketones; if ketones are moderate or high, exercise is contraindicated

• When blood glucose is ≥300 mg/dl no activity is allowed

Sick Day Plan (VUMC Division of Pediatric Endocrinology)

• Check blood glucose (BG) every 4 hours around the clock until they are well

• Give BG correction (sliding scale) every 4 hours even if your child is not eating. Use novolog, humalog or apidra

• Test every urine for ketones or test blood ketones every 4 hours

• Offer fluids every 15 minutes while awake. If BG under 200, offer liquids with carbs. If BG over 200, offer sugar-free fluids.

• Call 615-322-7842 for any ONE of these reasons:

– Persistent vomiting (more than 3 times) with moderate to large urine ketones (or blood ketones greater than 1.5 mmol/l)

– Altered behavior

– Persistent rapid breathing

Sick Day Plan (VUMC Division of Pediatric Endocrinology)

• When you call, be prepared to provide:

– The past 48 hours of blood sugars

– Ketone levels

– Any other symptoms your child may be experiencing

• For pump users:

– If blood sugar over 240 and moderate or large ketones, give a correction for elevated blood sugar with a syringe and change site

– Always continue the basal rate

• For shot takers:

– Always give the basal insulin (lantus, NPH, or levemir)

• Follow these critical steps to keep your child’s diabetes in control when they don’t feel well!

Items to Have Access to at all Times• Emergency contact information

– Family members– Physicians-emergency help line to nurse and nutritionist

• Consent for treatment if they are a minor including consent to perform glucagon injection

• Have the athlete’s diabetes information sheet (see Diabetes Care Plan)• Athlete wears medical alert tag at all times• Blood glucose monitoring equipment including extra blood glucose test strips• Supplies to treat hypoglycemia including glucose tablets, fruit juice, carbs,

glucagon• Supplies for urine or blood ketone testing• Sharps container to properly dispose of needles and lancets• Insulin and extra supplies (spare batteries, spare infusion sets and reservoirs

for insulin pumps)• A copy of the diabetes care plan

Performing a Glucagon Injection on a Diabetic Athlete

INJECTION OF GLUCAGON:

• Glucagon (1 mg) is the white powder in the vial.

• The appropriate dose for all adults is 1 mg.

• The syringe contains only water.

• Pop the cap from the glucagon vial

• Remove the cover from the needle on the syringe.

• Inject entire contents of the syringe into the vial (do not remove syringe)

• Gently mix (as indicated on the inside lid)

• Draw back the entire contents of the vial into the syringe

• Inject the entire contents into the upper thigh muscle

• Insert the full length of the needle

Conclusion

• Be aware of the signs and symptoms of diabetes mellitus

• Have good communication with and understand the uniqueness of the diabetic athlete

• Be prepared for diabetic emergencies

• Utilize the Vanderbilt Diabetic Care Plan as a guideline in your supervision

Acknowledgements

• Thanks to Dr. Diamond, Dr. Wilson, Dr. Russell and Dr. Potter for their help and input!

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