Diabetesnet.com
12-14-2009, 06:50 PM
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John,
I am working with someone on a study in adults with Type 1 and 2 who have gastroparesis, in some cases pretty severe with constant vomiting. In the study they will all use pumps and sensors and I am sure many extended and combination boluses. I was just wondering if you have any experience with CGM findings in patients with gastroparesis and if there are any therapy guidelines you give them (ex: when to stop an extended bolus based on CGM trend and BG data etc... Do you suggest earlier treatment of lows due to delayed gastric absorption and if so what is your BG threshold?). Any advice is greatly appreciated!
Best,
J
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Hi J,
In our clinic, I only see a few patients with gastroparesis and none with continuous vomiting. Vomiting is more common with celiac than with gastroparesis. In diabetes, it is easy to confuse the two, so celiac should be ruled out first. See this study (http://journal.diabetes.org/clinicaldiabetes/V17N41999/pg188.htm) for a discussion of one such case that includes diagnostic options.
With ANY stomach complaints, I start patients on acidophilus caps (2 caps two or three times a day for 1-2 weeks until symptoms improve and then as needed for symptoms). Hyper and hypoglycemia both disrupt normal intestinal bacterial balance, so re-establishing normal bacterial flora and digestion with acidphilus and similar bacteria that assist us in digesting foods and that are key to improving stomach symptoms. I have used this single treatment with hundreds of my patients with excellent results. Diagnosis and treatment are easier once symptoms are minimal.
For the damaged nerves of gastroparesis, I focus on glucose control, and try to rebuild nerve conduction with alpha lipoic acid and evening primrose oil or flax seed oil as primary interventions (2 cups of one or the other twice a day). Repairing nerves is a very slow process and sometimes impossible if nerves are badly damaged. I keep hoping one of the drug companies will get a nerve growth factor approved by FDA, but don't see anything on that horizon.
The best advice on what to eat for gastroparesis: Complex carbs and a low GI, low fat diet are very helpful. Be sure to stop intake of artificial sweeteners, especially sorbitol, in case they are worsening the problem.
Per the more relevant questions, how early you treat pending lows depends on the CGM's lag time as well as accuracy. Better ability to detect lows and less lag time (Dexcom (http://www.diabetesnet.com/diabetes_technology/dexcom.php)) means less need to intervene when the glucose is still high. Other CGMS have hypo predictions that can help, as you are aware.
The best way to treat lows or pending lows is with fast simple carbs like glucose tabs. These have the greatest chance of entering the blood stream after quick digestion. Combo boluses are a big plus (I like to have patients give at least some of each meal bolus beforehand) but it takes the CGM feedback to individualize how to give combos for different meals. You won't know if a combo bolus may need to be stopped or when to do it without some personalized CGM feedback. But at least you can tell the participants that much.
The decision on whether and when to stop a combo bolus will depend on their experience with the same food in the past – pizza may require no stoppage at all, while regular ice cream may..... Ask the participant if they know how different foods affect them, and if they don't, ask them to start tracking this. If they don't know, I would start with 30% of the bolus before the meal and 70% over 1.5 hours for moderate cases, and maybe 70% over 2.5 to 3 hrs for those with more advanced gastroparesis. I would stop the rest of a carb bolus if their CGM reads 180 mg/dl and shows a steep decline, or at 140 mg/dl with a moderate fall in their glucose trend.
Remember that most people with gastroparesis have a long history of high glucoses before they were diagnosed, and be more fearful of hypoglycemia. Once the CGM data starts to roll in, you will be able to give them clearer guidelines for improving their glucose levels with less risk of hypos.
Let me know how it goes,
John
Visit our Ask John Q&A Blog (http://www.diabetesnet.com/ask_john/) for more entries and leave your comments (https://www.diabetesnet.com/ask_john/?p=78#respond).
John,
I am working with someone on a study in adults with Type 1 and 2 who have gastroparesis, in some cases pretty severe with constant vomiting. In the study they will all use pumps and sensors and I am sure many extended and combination boluses. I was just wondering if you have any experience with CGM findings in patients with gastroparesis and if there are any therapy guidelines you give them (ex: when to stop an extended bolus based on CGM trend and BG data etc... Do you suggest earlier treatment of lows due to delayed gastric absorption and if so what is your BG threshold?). Any advice is greatly appreciated!
Best,
J
-------
Hi J,
In our clinic, I only see a few patients with gastroparesis and none with continuous vomiting. Vomiting is more common with celiac than with gastroparesis. In diabetes, it is easy to confuse the two, so celiac should be ruled out first. See this study (http://journal.diabetes.org/clinicaldiabetes/V17N41999/pg188.htm) for a discussion of one such case that includes diagnostic options.
With ANY stomach complaints, I start patients on acidophilus caps (2 caps two or three times a day for 1-2 weeks until symptoms improve and then as needed for symptoms). Hyper and hypoglycemia both disrupt normal intestinal bacterial balance, so re-establishing normal bacterial flora and digestion with acidphilus and similar bacteria that assist us in digesting foods and that are key to improving stomach symptoms. I have used this single treatment with hundreds of my patients with excellent results. Diagnosis and treatment are easier once symptoms are minimal.
For the damaged nerves of gastroparesis, I focus on glucose control, and try to rebuild nerve conduction with alpha lipoic acid and evening primrose oil or flax seed oil as primary interventions (2 cups of one or the other twice a day). Repairing nerves is a very slow process and sometimes impossible if nerves are badly damaged. I keep hoping one of the drug companies will get a nerve growth factor approved by FDA, but don't see anything on that horizon.
The best advice on what to eat for gastroparesis: Complex carbs and a low GI, low fat diet are very helpful. Be sure to stop intake of artificial sweeteners, especially sorbitol, in case they are worsening the problem.
Per the more relevant questions, how early you treat pending lows depends on the CGM's lag time as well as accuracy. Better ability to detect lows and less lag time (Dexcom (http://www.diabetesnet.com/diabetes_technology/dexcom.php)) means less need to intervene when the glucose is still high. Other CGMS have hypo predictions that can help, as you are aware.
The best way to treat lows or pending lows is with fast simple carbs like glucose tabs. These have the greatest chance of entering the blood stream after quick digestion. Combo boluses are a big plus (I like to have patients give at least some of each meal bolus beforehand) but it takes the CGM feedback to individualize how to give combos for different meals. You won't know if a combo bolus may need to be stopped or when to do it without some personalized CGM feedback. But at least you can tell the participants that much.
The decision on whether and when to stop a combo bolus will depend on their experience with the same food in the past – pizza may require no stoppage at all, while regular ice cream may..... Ask the participant if they know how different foods affect them, and if they don't, ask them to start tracking this. If they don't know, I would start with 30% of the bolus before the meal and 70% over 1.5 hours for moderate cases, and maybe 70% over 2.5 to 3 hrs for those with more advanced gastroparesis. I would stop the rest of a carb bolus if their CGM reads 180 mg/dl and shows a steep decline, or at 140 mg/dl with a moderate fall in their glucose trend.
Remember that most people with gastroparesis have a long history of high glucoses before they were diagnosed, and be more fearful of hypoglycemia. Once the CGM data starts to roll in, you will be able to give them clearer guidelines for improving their glucose levels with less risk of hypos.
Let me know how it goes,
John
Visit our Ask John Q&A Blog (http://www.diabetesnet.com/ask_john/) for more entries and leave your comments (https://www.diabetesnet.com/ask_john/?p=78#respond).