“And sometimes honestly, patients have had diabetes or hyperglycemia for so long and they haven't noticed it that they'll tell me, ‘Oh, this has only been happening for a few days.’ And I promise you it's been happening for longer, but it's come on so slowly that they just don't notice.”
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In today’s episode, we will be talking to Dr. Alexanian who is the Director of Inpatient Diabetes Program at the Boston Medical Center, she specializes in inpatient management of diabetes. In this episode we will discuss several life-threatening complications of diabetes called diabetic ketoacidosis (DKA) and hyperosmolar hypoglycemic state (HHS). We will also discuss hospitals should create guidelines to manage these complications and how diabetes care has evolved over the years.
Dr. Sara Alexanian is an Endocrinologist at Boston Medical Center, which is the largest safety-net hospital in New England. She directs the Inpatient Diabetes program, and is also involved in quality improvement and resident education.
Shireen: In today's episode, we will be talking to Dr. Alexanian, who is the director of inpatient diabetes program at the Boston Medical Center, where she specializes in inpatient management of diabetes. In this episode, we will discuss several life threatening complications of diabetes, like diabetic keto acidosis, and hyperosmolar or hyperglycemic state.
We will also discuss hospitals. And how they're going about creating guidelines to manage these complications and how diabetes care has evolved over the years.
Podcasting from Dallas, Texas, I am Shireen and this is the Yumlish podcast. Yumlish Is working to empower you to take charge of your health through diet and exercise and reduce the risk of chronic conditions like type two diabetes and heart disease. We hope to share a unique perspective and a culturally relevant approach to managing these chronic conditions with you each week.
Dr. Sarah Alexanian is an endocrinologist at Boston Medical center, which is the largest safety net hospital in New England. She directs the inpatient diabetes program and is also involved in quality improvement and resident education. Welcome Dr. Alexanian.
Alexanian: Thank you so much.
Shireen: An absolute pleasure. So, Dr. Alexanian, will you tell us a little bit about your background and why you decided to specialize in diabetes in particular.
Alexanian: Sure, I'd be happy to. So I did my internal medicine training in Boston. I actually, thought when I started out that I was gonna go into geriatric medicine, taking care of older patients. To the chagrin of many of my older family members, I made a change and went into endocrinology which I found really just fascinating in terms of the hormonal changes and the treatments we had available.
And then when I was working as a fellow in the hospital, taking care of patients with hyperglycemia and diabetes, I found it really interesting to work in that situation, to work with the other physicians and to be part of the care team, taking care of patients in this really urgent setting.
Shireen: So, can you help us understand a couple of different concepts?
First, can you tell us what diabetic keto acidosis is and hyperosmolar hyperglycemic state?
Alexanian: Sure. So those are the two types of hyperglycemic crisis that we take care of in patients hospitalized with diabetes. So diabetic keto acidosis is probably the one people have been more likely to have heard about.
It's sometimes abbreviated DKA and there's many names in medicine that often don't mean anything in endocrinology. We have graves disease, we have Hashimoto's disease. And the name tells you absolutely nothing about the condition, but diabetic keto acidosis tells you, really everything you need to know about making that diagnosis.
The person comes in with diabetes or hyperglycemia per se. Keytones, elevated keytones in their blood and in their urine and a low pH as a sign of acidosis. So it really just falls under the name as you would expect. And then hyperglycemic hyperosmolar syndrome often called HHS is less common, but those patients have severe hyperglycemia and they develop
such high levels of glucose and sodium and other substances in their blood that they become. What's called hyperosmolar and severely dehydrated, which can lead to significant complications.
Shireen: Can you speak to some of those complications for both DKA and HHS?
Alexanian: Sure. So many of the times patients with one of these conditions, and in fact, you can add a end up with a combination of the two will end up in the ICU.
They may suffer from an infection which is not uncommon in patients admitted in this situation. The infection may be part of what their presentation is, or it may actually be the cause of their hyperglycemic crisis. They may have severely high acid levels that require treatment. They may require intubation if they're not able to breathe well.
And again, they often have significant other medical problems that present at the same time, if not infections, sometimes stroke or heart attack or other issues as well.
Shireen: I need to ask to qualify this. Is there a difference between DK and HHS as far as type one versus type two is concerned and also do these complications,
are they associated with diabetes? Do they affect a certain age group? Any, anything there?
Alexanian: Sure. So great question. So traditionally we've thought of patients with type one diabetes as developing DK and patients with type two diabetes, developing HHS. You really need to be substantially insulin deficient to, to generally go into DKA, but we've found that that's not always the case anymore.
We do see patients In particular with type two diabetes. Now come in with DKA and occasionally patients with type one coming in with HHS, and sometimes again, an overlap between the two. It depends a little bit what the patient's underlying situation is. In terms of most common demographics of patients presenting, we don't really have a lot of great data for HHS.
There is national data available for DKA. The most recent numbers are, are always a little out of date for these. Of things, but generally the highest mortality rate for patients with DKA tends to be in the late thirties, but it can happen across all age groups and spectrums. The patients at most risk for really adverse consequences are those who are very young and very old, as you might expect.
Shireen: What are some of the treatments that can be used to help minimize the risk of DKA and HHS, and then what are some contributing non-medical factors as well?
Alexanian: Sure. So. There's a number of things that lead our patients to come in, in DKA or HHS. Sometimes it's that they never knew they had diabetes several times a year. I'll see someone in the ICU who often hasn't seen a physician in years. And they just didn't know they were sick. And they had no one to call and they finally ended up in the hospital in the ICU.
So sometimes it's a situation where the patient just really hadn't been receiving medical care. Sometimes what can happen is if patients already know they have diabetes, they may lose access to their medication. Either due to problems with their insurance or problems paying for their medication.
And this can end them up in the situation of hyperglycemic crisis, because they're unable to access their medication. And finally, if they get again, very sick with something else, like an infection or occasionally some medications we prescribe that can cause hyperglycemia, this can also tip them over into being in an unstable state.
Shireen: Being that you're in a hospital system, how have hospitals reevaluated their management for treating these life threatening conditions?
Alexanian: Yeah. So the, the story of, of treatment of diabetes is really a long and very interesting one. We actually just last year here as sort of a, a geeky diabetes medicine holiday celebrated the anniversary of a hundred years of insulin being discovered. Which happened in 1921. So that was a big deal, obviously in the world of diabetes.
And for those of us who take care of patients with this condition. And so it's been a hundred years now that we've had insulin. Actually, before insulin was discovered, the rate of death with patients with DKA was more than 90%. So it was almost universally a fatal condition. And after we had insulin available, initially they used to treat patients with very low doses of insulin.
Cuz there simply wasn't a lot to go around. And in the 1950s, they started to be able to give people fluids and antibiotics. And the death rate was gradually improving down to about 10% in the 1950s. And then it wasn't really until the 1970s that they started doing a lot of. Saying, what is the best way to treat patients with this condition?
So they did what we consider to be the gold standard of, of studies, which is a randomized controlled trial. And they did a number of those and they asked different questions about how to best, best manage patients, very high doses of insulin, or our lower dose is okay, what can we use to treat the acidosis?
Should we do that differently? And those studies in the 1970s really still form the basis of how we take care of patients in DKA and HHS today. And so I think really what's happened over the past few decades is not so much that we've had a lot of new information, but that. There's been a growing recognition that there's so many conditions now and so many medications.
And so, so much evidence that hospital systems really need to develop protocols and guidelines to help the doctors manage patients in the best way to assure we always follow best practice. And so instead of when I was an intern and a resident, it was my job just to know how to manage DKA and to look it up and to read about it and to know what to do.
Now we have protocols and guidelines that really show the physicians, what are the best steps to take in this situation to make sure patients get the best care.
Shireen: What would some of the steps include within this patient care? Not to create guidelines right now on this podcast, but what's some just summary, broad strokes.
Alexanian: Yeah. Yeah. So again, they've remained very simple. And since, since all these studies have been done, the, the main tenants are really insulin therapy, which can be given intravenous or subcutaneous giving appropriate IV fluid hydration. These patients will be dehydrated less so in DKA, actually, patients with HHS may need six to 10 liters of fluid.
That's how severely dehydrated they are. So hydration is critically important. And then they may have some problems with their electrolytes such as their sodium or potassium. And again, in many situations, patients have another underlying problem that either triggered the DKA or HHS or as a result of it.
And we need to treat that underlying condition we've done really well in the past number of years, treating patients with DKA. As I mentioned before, before we had insulin, it was nearly a hundred percent fatality. The most recent rates in the United States, looking at mortality are about 0.4%. So if patients seek medical care promptly they, they generally do really well now.
The same we have seen the, some improvements in HHS as well, but the mortality for that, although again, it's less common is much higher. It's about 10 to 20%. And the reason for that is these patients tend to be older. They tend to be sicker and they don't pass away from the diabetes per se, but really.
Something else that made them sick to begin with.
Shireen: Next, what I'd like to do. Dr. Alexanian is talk a little bit about your study. One, can you tell us a little bit about the study and then also in, in your study, patients had a high percentage rate of hypoglycemia. How were you able to reduce the rates without affecting the DKA?
Alexanian: So, yeah, so what we had done is a number of years ago, as a group, we sat down and were looking at our, our treatment guideline and protocol and asking if we could do anything better here.
I've now been at my current institution more than 10 years. And when I started here, we already had a guideline for managing patients in hyperglycemic crisis. And that guideline had been built off of papers and evidence and best practice. And so we followed it but looking at it as a group, we felt that perhaps the rates of hypoglycemia or low blood sugar were just higher than they needed to be.
One of the main challenges in working with insulin therapy is of course accidentally giving too much insulin more than the patient needs and the blood sugar's too low. And so, again, that's really one of our main challenges in the hospital and we looked, and there was really no good published data to.
How much hypoglycemia was expected in treating patients with hyperglycemic crisis. But again, we wondered if we could do better. So at our hospital, like many other hospitals, again, we have a group whose job is to really work as a committee to make sure the guidelines are updated and, and any new information or, or changes that could be, could be a potential improvement are put into place.
And so what we did is we look back at all the original studies that have been done in patients with DKA, we collected protocols from other institutions. And then we sat down and really just took a hard look at our protocol and we have a, a nice multidisciplinary group of endocrinologists. We have doctors in training, we have nurses, IT specialists, pharmacists, and everyone really put their heads together and said, can we make some changes here that would improve this?
And we found just with making some small changes in the way we adjusted the insulin while we were treating patients. That the rate of hypoglycemia significantly decreased. And so this was really a comparison to our own results from before and trying to improve on what we were doing. 'Cause we, again, we have guidelines based on best practice, but sort of the devil can be in the details here.
And, and like I said, we stayed aligned with the best practice in the studies, but still found that we could make a difference.
Shireen: And so tell us a little bit more about what you saw and what the results of the study looked like.
Alexanian: Sure. So again, we often found that it was really more towards the tail end or the end part of the treatment of hyperglycemic crisis that patients tend to become more sensitive to insulin therapy.
And that's when we saw the low blood sugars and it was a challenge because the patients would be almost out of hyperglycemic crisis. They'd be getting insulin through an IV and we'd have to shut it off. 'Cause the blood sugar was too low and there was a bit of a scramble to try and bridge the patient over to the standard therapy.
Once we finished with IV insulin. And it was just a recurrent problem that we had, we found in particular, this happened to patients with either acute or chronic kidney disease because insulin the effects of insulin will really be affected by how well the patient's kidney is working. So in particular in patients whose kidneys were not working normally, we saw they were more prone to hypoglycemia.
So we had, again, this protocol that the nurses followed to titrate the insulin. And by looking at certain case examples, and specifically with patients whose blood sugar had gone low, in many cases, again, with chronic kidney disease, we adjusted how quickly the, how high the insulin doses could be titrated and then how the doses could be titrated down if the blood sugar were falling.
So just minor changes, but still within sort of the general recommended dosing guidelines for patients with hyperglycemic crisis. You know, when they first were doing those studies, I mentioned in the 1970s It was recognized that patients in hyperglycemic crisis have what we call insulin resistance, which is just sort of what it sounds like you give insulin.
And it doesn't work that well, you're resistant to the effects of it. And that happens when people are sick. So they were often treating patients with up to a hundred units, an hour of insulin, and anyone who has taken insulin before recognizes that to be an extremely high amount. And it wasn't until they did these studies that they found what we call now, low dose insulin.
What's now really compared to that low dose insulin therapy was equally effective. And as you might imagine, safer in taking care of patients with hyperglycemic crisis, but it was really quite amazing to look back as someone who had obviously not practiced in the 1970s to see really the truly massive doses of insulin patients used to be treated.
Shireen: Of course, a lot of that has come quite a long ways here. Besides the treatments given by medical professionals, is there anything else people with diabetes can do themselves, a special diet?
Alexanian: Sure. Yeah. So there's not much specifically in terms of, of diet for patients in this situation, but I think a lot of prevention really is around patients, making sure they're staying up to date with their regular medical care, which can be a real challenge. One of the things we do when we see patients in the hospital, again, sometimes it may have been a new diagnosis of diabetes, but sometimes it was a situation where they knew they had diabetes and for whatever reason had not been accessing the medical system or taking their medications and looking at what barriers they had to these types of, to these products and to these systems. So did they lose their insurance? Did they change jobs? Was something unaffordable. Did the formulary change in the, the type of insulin they needed to take change? Did they lose their doctor? Were they out of network? Did they move. Can we help connect them to the system.
So I think for patients really and this can be so hard the way our medical system is, but trying to stay on top of making sure that they're connected to the healthcare system, if possible, to have health insurance and to make sure they can take their medications regularly and to, to be monitoring their blood sugars.
I know it's not a fun thing to do. It's it's frankly can be quite miserable. I don't prescribe it because I'm, I'm aware that, you know, it isn't fun to do, but really it's the best way to know in many situations what's going on. So taking medication regularly, checking your blood sugar, and if you don't feel well, reach out to your provider, tell them what's going on.
Say my blood sugars are high and I don't feel well. And, you know, try not to wait until you get very sick and, and and stay at home until you're just really miserable. So reach out when you're not feeling well.
Shireen: And what are some of the symptoms that people should keep in mind, especially those who aren't on top of checking their blood sugar levels.
Alexanian: So often the classic symptoms that we think of with uncontrolled diabetes are the ones that patients will mention. So that means being very thirsty are urinary urinating frequently. And sometimes honestly, patients have had diabetes or hyperglycemia for so long and they haven't noticed it that they'll tell me,” oh, this has only been happening for a few days.”
And I promise you it's been happening for longer, but it's come on so slowly that they just don't notice. And sometimes what I find is helpful is to ask people, are you getting up at night to urinate? Well, yeah, I get up five or six times a night to urinate. Okay. Well, that's, that's generally not normal.
You know, it's not always diabetes, it can be another problem. But oftentimes that's something they notice. Well, you know, I, I have had trouble sleeping because I do get up frequently to urinate. So they may not notice how much they're urinating. Because again, it's been going on for a while, but those are a couple things to look for.
Unexplained, weight loss. Is another issue. So what happens is glucose is of course, one of our main energy and food sources. And if people have very uncontrolled diabetes, the body's way of getting rid of that sugar is to pee it out through the urine. One of the things we can do to protect ourselves from that uncontrolled hyperglycemia.
And so those are calories that are coming out in the urine. And so patients may experience weight loss as well. So, those are sort of the chronic symptoms we see more acutely patients can experience nausea or vomiting, abdominal pain. They can become confused. They can have a fever. So again, they tend to be fairly concerning signs that that can happen when patients are developing one of these situations.
Shireen: Thank you for sharing that Dr. Alexian with that we are toward the end of the episode. At this point, can you tell our listeners how they can connect with you and just learn more about your work?
Alexanian: Sure. So they can visit our webpage and Boston Medical Center, endocrinology to learn about the services we can provide for patients with diabetes.
We have a comprehensive outpatient system here. So please feel free to visit our website and see, see what we do here. I'm also available on LinkedIn. Most of my time is spent in the hospital taking care of patients. I'm sure many of them hope, hope, never to see me in that capacity. I hope your listeners can, can avoid that.
That's where I spend most of my time. But again, those other places you can learn more about what we do.
Shireen: Lovely. Thank you so much for your time and to our listeners out there, who are listening, hope there were [tips] in here that are useful for you. Look out for those indicators of those symptoms and definitely get your checkups done routinely as you need to.
And so next we'll cover the we'll move the conversation over onto Facebook, onto Instagram, head over there. Find this podcast post and answer this very simple question. How do you manage your diabetes today? For yourself or even a love or loved one. The question is how do you manage your diabetes today for yourself or a loved one head over to Facebook or Instagram on Facebook.
We are @Yumlish, on Instagram @yumlish_. We'll see you there after this episode. Thank you again, Dr. Alexanian.
Alexanian: Thank you so much. It's been my pleasure.
Shireen: In today's episode, we will be talking to Dr. Alexanian, who is the director of inpatient diabetes program at the Boston Medical Center, where she specializes in inpatient management of diabetes. In this episode, we will discuss several life threatening complications of diabetes, like diabetic keto acidosis, and hyperosmolar hyperglycemic state.
We will also discuss hospitals. And how they're going about creating guidelines to manage these complications and how diabetes care has evolved over the years.
Podcasting from Dallas, Texas, I am Shireen and this is the Yumlish podcast. Yumlish Is working to empower you to take charge of your health through diet and exercise and reduce the risk of chronic conditions like type two diabetes and heart disease. We hope to share a unique perspective and a culturally relevant approach to managing these chronic conditions with you each week.
Dr. Sarah Alexanian is an endocrinologist at Boston Medical center, which is the largest safety net hospital in New England. She directs the inpatient diabetes program and is also involved in quality improvement and resident education. Welcome Dr. Alexanian.
Alexanian: Thank you so much.
Shireen: An absolute pleasure. So, Dr. Alexanian, will you tell us a little bit about your background and why you decided to specialize in diabetes in particular.
Alexanian: Sure, I'd be happy to. So I did my internal medicine training in Boston. I actually, thought when I started out that I was gonna go into geriatric medicine, taking care of older patients. To the chagrin of many of my older family members, I made a change and went into endocrinology which I found really just fascinating in terms of the hormonal changes and the treatments we had available.
And then when I was working as a fellow in the hospital, taking care of patients with hyperglycemia and diabetes, I found it really interesting to work in that situation, to work with the other physicians and to be part of the care team, taking care of patients in this really urgent setting.
Shireen: So, can you help us understand a couple of different concepts?
First, can you tell us what diabetic keto acidosis is and hyperosmolar hyperglycemic state?
Alexanian: Sure. So those are the two types of hyperglycemic crisis that we take care of in patients hospitalized with diabetes. So diabetic keto acidosis is probably the one people have been more likely to have heard about.
It's sometimes abbreviated DKA and there's many names in medicine that often don't mean anything in endocrinology. We have graves disease, we have Hashimoto's disease. And the name tells you absolutely nothing about the condition, but diabetic keto acidosis tells you, really everything you need to know about making that diagnosis.
The person comes in with diabetes or hyperglycemia per se. Keytones, elevated keytones in their blood and in their urine and a low pH as a sign of acidosis. So it really just falls under the name as you would expect. And then hyperglycemic hyperosmolar syndrome often called HHS is less common, but those patients have severe hyperglycemia and they develop
such high levels of glucose and sodium and other substances in their blood that they become. What's called hyperosmolar and severely dehydrated, which can lead to significant complications.
Shireen: Can you speak to some of those complications for both DKA and HHS?
Alexanian: Sure. So many of the times patients with one of these conditions, and in fact, you can add a end up with a combination of the two will end up in the ICU.
They may suffer from an infection which is not uncommon in patients admitted in this situation. The infection may be part of what their presentation is, or it may actually be the cause of their hyperglycemic crisis. They may have severely high acid levels that require treatment. They may require intubation if they're not able to breathe well.
And again, they often have significant other medical problems that present at the same time, if not infections, sometimes stroke or heart attack or other issues as well.
Shireen: I need to ask to qualify this. Is there a difference between DK and HHS as far as type one versus type two is concerned and also do these complications,
are they associated with diabetes? Do they affect a certain age group? Any, anything there?
Alexanian: Sure. So great question. So traditionally we've thought of patients with type one diabetes as developing DK and patients with type two diabetes, developing HHS. You really need to be substantially insulin deficient to, to generally go into DKA, but we've found that that's not always the case anymore.
We do see patients In particular with type two diabetes. Now come in with DKA and occasionally patients with type one coming in with HHS, and sometimes again, an overlap between the two. It depends a little bit what the patient's underlying situation is. In terms of most common demographics of patients presenting, we don't really have a lot of great data for HHS.
There is national data available for DKA. The most recent numbers are, are always a little out of date for these. Of things, but generally the highest mortality rate for patients with DKA tends to be in the late thirties, but it can happen across all age groups and spectrums. The patients at most risk for really adverse consequences are those who are very young and very old, as you might expect.
Shireen: What are some of the treatments that can be used to help minimize the risk of DKA and HHS, and then what are some contributing non-medical factors as well?
Alexanian: Sure. So. There's a number of things that lead our patients to come in, in DKA or HHS. Sometimes it's that they never knew they had diabetes several times a year. I'll see someone in the ICU who often hasn't seen a physician in years. And they just didn't know they were sick. And they had no one to call and they finally ended up in the hospital in the ICU.
So sometimes it's a situation where the patient just really hadn't been receiving medical care. Sometimes what can happen is if patients already know they have diabetes, they may lose access to their medication. Either due to problems with their insurance or problems paying for their medication.
And this can end them up in the situation of hyperglycemic crisis, because they're unable to access their medication. And finally, if they get again, very sick with something else, like an infection or occasionally some medications we prescribe that can cause hyperglycemia, this can also tip them over into being in an unstable state.
Shireen: Being that you're in a hospital system, how have hospitals reevaluated their management for treating these life threatening conditions?
Alexanian: Yeah. So the, the story of, of treatment of diabetes is really a long and very interesting one. We actually just last year here as sort of a, a geeky diabetes medicine holiday celebrated the anniversary of a hundred years of insulin being discovered. Which happened in 1921. So that was a big deal, obviously in the world of diabetes.
And for those of us who take care of patients with this condition. And so it's been a hundred years now that we've had insulin. Actually, before insulin was discovered, the rate of death with patients with DKA was more than 90%. So it was almost universally a fatal condition. And after we had insulin available, initially they used to treat patients with very low doses of insulin.
Cuz there simply wasn't a lot to go around. And in the 1950s, they started to be able to give people fluids and antibiotics. And the death rate was gradually improving down to about 10% in the 1950s. And then it wasn't really until the 1970s that they started doing a lot of. Saying, what is the best way to treat patients with this condition?
So they did what we consider to be the gold standard of, of studies, which is a randomized controlled trial. And they did a number of those and they asked different questions about how to best, best manage patients, very high doses of insulin, or our lower dose is okay, what can we use to treat the acidosis?
Should we do that differently? And those studies in the 1970s really still form the basis of how we take care of patients in DKA and HHS today. And so I think really what's happened over the past few decades is not so much that we've had a lot of new information, but that. There's been a growing recognition that there's so many conditions now and so many medications.
And so, so much evidence that hospital systems really need to develop protocols and guidelines to help the doctors manage patients in the best way to assure we always follow best practice. And so instead of when I was an intern and a resident, it was my job just to know how to manage DKA and to look it up and to read about it and to know what to do.
Now we have protocols and guidelines that really show the physicians, what are the best steps to take in this situation to make sure patients get the best care.
Shireen: What would some of the steps include within this patient care? Not to create guidelines right now on this podcast, but what's some just summary, broad strokes.
Alexanian: Yeah. Yeah. So again, they've remained very simple. And since, since all these studies have been done, the, the main tenants are really insulin therapy, which can be given intravenous or subcutaneous giving appropriate IV fluid hydration. These patients will be dehydrated less so in DKA, actually, patients with HHS may need six to 10 liters of fluid.
That's how severely dehydrated they are. So hydration is critically important. And then they may have some problems with their electrolytes such as their sodium or potassium. And again, in many situations, patients have another underlying problem that either triggered the DKA or HHS or as a result of it.
And we need to treat that underlying condition we've done really well in the past number of years, treating patients with DKA. As I mentioned before, before we had insulin, it was nearly a hundred percent fatality. The most recent rates in the United States, looking at mortality are about 0.4%. So if patients seek medical care promptly they, they generally do really well now.
The same we have seen the, some improvements in HHS as well, but the mortality for that, although again, it's less common is much higher. It's about 10 to 20%. And the reason for that is these patients tend to be older. They tend to be sicker and they don't pass away from the diabetes per se, but really.
Something else that made them sick to begin with.
Shireen: Next, what I'd like to do. Dr. Alexanian is talk a little bit about your study. One, can you tell us a little bit about the study and then also in, in your study, patients had a high percentage rate of hypoglycemia. How were you able to reduce the rates without affecting the DKA?
Alexanian: So, yeah, so what we had done is a number of years ago, as a group, we sat down and were looking at our, our treatment guideline and protocol and asking if we could do anything better here.
I've now been at my current institution more than 10 years. And when I started here, we already had a guideline for managing patients in hyperglycemic crisis. And that guideline had been built off of papers and evidence and best practice. And so we followed it but looking at it as a group, we felt that perhaps the rates of hypoglycemia or low blood sugar were just higher than they needed to be.
One of the main challenges in working with insulin therapy is of course accidentally giving too much insulin more than the patient needs and the blood sugar's too low. And so, again, that's really one of our main challenges in the hospital and we looked, and there was really no good published data to.
How much hypoglycemia was expected in treating patients with hyperglycemic crisis. But again, we wondered if we could do better. So at our hospital, like many other hospitals, again, we have a group whose job is to really work as a committee to make sure the guidelines are updated and, and any new information or, or changes that could be, could be a potential improvement are put into place.
And so what we did is we look back at all the original studies that have been done in patients with DKA, we collected protocols from other institutions. And then we sat down and really just took a hard look at our protocol and we have a, a nice multidisciplinary group of endocrinologists. We have doctors in training, we have nurses, IT specialists, pharmacists, and everyone really put their heads together and said, can we make some changes here that would improve this?
And we found just with making some small changes in the way we adjusted the insulin while we were treating patients. That the rate of hypoglycemia significantly decreased. And so this was really a comparison to our own results from before and trying to improve on what we were doing. 'Cause we, again, we have guidelines based on best practice, but sort of the devil can be in the details here.
And, and like I said, we stayed aligned with the best practice in the studies, but still found that we could make a difference.
Shireen: And so tell us a little bit more about what you saw and what the results of the study looked like.
Alexanian: Sure. So again, we often found that it was really more towards the tail end or the end part of the treatment of hyperglycemic crisis that patients tend to become more sensitive to insulin therapy.
And that's when we saw the low blood sugars and it was a challenge because the patients would be almost out of hyperglycemic crisis. They'd be getting insulin through an IV and we'd have to shut it off. 'Cause the blood sugar was too low and there was a bit of a scramble to try and bridge the patient over to the standard therapy.
Once we finished with IV insulin. And it was just a recurrent problem that we had, we found in particular, this happened to patients with either acute or chronic kidney disease because insulin the effects of insulin will really be affected by how well the patient's kidney is working. So in particular in patients whose kidneys were not working normally, we saw they were more prone to hypoglycemia.
So we had, again, this protocol that the nurses followed to titrate the insulin. And by looking at certain case examples, and specifically with patients whose blood sugar had gone low, in many cases, again, with chronic kidney disease, we adjusted how quickly the, how high the insulin doses could be titrated and then how the doses could be titrated down if the blood sugar were falling.
So just minor changes, but still within sort of the general recommended dosing guidelines for patients with hyperglycemic crisis. You know, when they first were doing those studies, I mentioned in the 1970s It was recognized that patients in hyperglycemic crisis have what we call insulin resistance, which is just sort of what it sounds like you give insulin.
And it doesn't work that well, you're resistant to the effects of it. And that happens when people are sick. So they were often treating patients with up to a hundred units, an hour of insulin, and anyone who has taken insulin before recognizes that to be an extremely high amount. And it wasn't until they did these studies that they found what we call now, low dose insulin.
What's now really compared to that low dose insulin therapy was equally effective. And as you might imagine, safer in taking care of patients with hyperglycemic crisis, but it was really quite amazing to look back as someone who had obviously not practiced in the 1970s to see really the truly massive doses of insulin patients used to be treated.
Shireen: Of course, a lot of that has come quite a long ways here. Besides the treatments given by medical professionals, is there anything else people with diabetes can do themselves, a special diet?
Alexanian: Sure. Yeah. So there's not much specifically in terms of, of diet for patients in this situation, but I think a lot of prevention really is around patients, making sure they're staying up to date with their regular medical care, which can be a real challenge. One of the things we do when we see patients in the hospital, again, sometimes it may have been a new diagnosis of diabetes, but sometimes it was a situation where they knew they had diabetes and for whatever reason had not been accessing the medical system or taking their medications and looking at what barriers they had to these types of, to these products and to these systems. So did they lose their insurance? Did they change jobs? Was something unaffordable. Did the formulary change in the, the type of insulin they needed to take change? Did they lose their doctor? Were they out of network? Did they move. Can we help connect them to the system.
So I think for patients really and this can be so hard the way our medical system is, but trying to stay on top of making sure that they're connected to the healthcare system, if possible, to have health insurance and to make sure they can take their medications regularly and to, to be monitoring their blood sugars.
I know it's not a fun thing to do. It's it's frankly can be quite miserable. I don't prescribe it because I'm, I'm aware that, you know, it isn't fun to do, but really it's the best way to know in many situations what's going on. So taking medication regularly, checking your blood sugar, and if you don't feel well, reach out to your provider, tell them what's going on.
Say my blood sugars are high and I don't feel well. And, you know, try not to wait until you get very sick and, and and stay at home until you're just really miserable. So reach out when you're not feeling well.
Shireen: And what are some of the symptoms that people should keep in mind, especially those who aren't on top of checking their blood sugar levels.
Alexanian: So often the classic symptoms that we think of with uncontrolled diabetes are the ones that patients will mention. So that means being very thirsty are urinary urinating frequently. And sometimes honestly, patients have had diabetes or hyperglycemia for so long and they haven't noticed it that they'll tell me,” oh, this has only been happening for a few days.”
And I promise you it's been happening for longer, but it's come on so slowly that they just don't notice. And sometimes what I find is helpful is to ask people, are you getting up at night to urinate? Well, yeah, I get up five or six times a night to urinate. Okay. Well, that's, that's generally not normal.
You know, it's not always diabetes, it can be another problem. But oftentimes that's something they notice. Well, you know, I, I have had trouble sleeping because I do get up frequently to urinate. So they may not notice how much they're urinating. Because again, it's been going on for a while, but those are a couple things to look for.
Unexplained, weight loss. Is another issue. So what happens is glucose is of course, one of our main energy and food sources. And if people have very uncontrolled diabetes, the body's way of getting rid of that sugar is to pee it out through the urine. One of the things we can do to protect ourselves from that uncontrolled hyperglycemia.
And so those are calories that are coming out in the urine. And so patients may experience weight loss as well. So, those are sort of the chronic symptoms we see more acutely patients can experience nausea or vomiting, abdominal pain. They can become confused. They can have a fever. So again, they tend to be fairly concerning signs that that can happen when patients are developing one of these situations.
Shireen: Thank you for sharing that Dr. Alexian with that we are toward the end of the episode. At this point, can you tell our listeners how they can connect with you and just learn more about your work?
Alexanian: Sure. So they can visit our webpage and Boston Medical Center, endocrinology to learn about the services we can provide for patients with diabetes.
We have a comprehensive outpatient system here. So please feel free to visit our website and see, see what we do here. I'm also available on LinkedIn. Most of my time is spent in the hospital taking care of patients. I'm sure many of them hope, hope, never to see me in that capacity. I hope your listeners can, can avoid that.
That's where I spend most of my time. But again, those other places you can learn more about what we do.
Shireen: Lovely. Thank you so much for your time and to our listeners out there, who are listening, hope there were [tips] in here that are useful for you. Look out for those indicators of those symptoms and definitely get your checkups done routinely as you need to.
And so next we'll cover the we'll move the conversation over onto Facebook, onto Instagram, head over there. Find this podcast post and answer this very simple question. How do you manage your diabetes today? For yourself or even a love or loved one. The question is how do you manage your diabetes today for yourself or a loved one head over to Facebook or Instagram on Facebook.
We are @Yumlish, on Instagram @yumlish_. We'll see you there after this episode. Thank you again, Dr. Alexanian.
Alexanian: Thank you so much. It's been my pleasure.
Shireen: Thank you for listening to the Yumlish Podcast. Make sure to follow us on social media @Yumlish_ on Instagram and Twitter and @Yumlish on Facebook and LinkedIn. For tips about managing your diabetes and other chronic conditions and to chat and connect with us about your journey and perspectives. You can also visit our website Yumlish.com for more recipes advice and to get involved with all of the exciting opportunities Yumlish has to offer. If you like this week's show, make sure to subscribe so you can hear more from us every time we post. Thank you again, and we'll see you next time. Remember your health always comes first. Stay well.