3 ms·

>Such should be done only with great care, as a false low reading can harm and even kill the patient (who eats a high-sugar-content item while glucose in the bl

by pixl97 11mo ago

>Such should be done only with great care, as a false low reading can harm and even kill the patient (who eats a high-sugar-content item while glucose in the blood is, in fact, not low). I've been a type I diabetics for over 25 years and I don't quite understand this one. Low blood sugar is an immediate life or death situation, but high blood sugar killing people? Just how high was it and for how long? As someone that has a CGM I still calibrate it by using a blood test every couple of days because the CGM sensors can wander on accuracy.

bonsai_spool 11mo ago
It depends on what the true blood sugar value was: if someone were already at the high end of normal and a 'brittle diabetic', you can end up in 'diabetic ketoacidosis' for T1DM individuals or—less likely—'hyperosmolar hyperglycemic state' generally. See https://www.mayoclinic.org/diseases-conditions/hyperglycemia/symptoms-causes/syc-20373631 https://www.mayoclinic.org/diseases-conditions/hyperglycemia... for a discussion of both (in Emergency conditions)
- SkyPuncher 11mo ago
  [flagged]
  - slowking2 11mo ago
    You can die on the order of hours to days not of high blood sugar per se, but of the low insulin causing diabetic ketoacidosis parent comment mentions. It would be odd for a faulty sensor to cause an otherwise bad day into dka and death though. The sensor would need to be wildly off for hours and the user to not notice. Insulin delivery would need to be paused or greatly reduced for many hours. There are additional therapies like SGLT-2 that could make this more likely but they usually aren’t used with T1D precisely because they break the normally very strong correlation between inadequate insulin levels (leading to dka) and high blood glucose. Even though I can’t think of an easy way for a false low(s) to turn into lethal DKA, that doesn’t mean it didn’t happen. Abbott sells a lot of CGMs. It could have been a contributing factor to several deaths even if the fault would almost always not be a significant issue.
  - bonsai_spool 11mo ago
    > Sorry to be crass, but this type of argument is exactly why non-experts shouldn't be talking about topics > I myself am not a doctor. I love to learn from my wife. I suggest that you speak to your wife before correcting my unimpeachable explanation of why someone might die from being told, incorrectly by their CGM, that their blood glucose is low. I say this as someone doesn't need to rely on a spouse but have actually received my own medical education. And I've had my own HHS patients—it's not even clear if your wife (!!) works in this area. As the sibling commentator shares, we don't really expect these patients to show up after a day of bad data, but we also have no idea how many days of bad data occurred.
    - pixl97 11mo ago
      As someone that experienced DKA when I was young I'm still not sure how that happens unless there were a lot of other confounding factors. Having hypoglycemia that high for a while will make everything start smelling like varnish. Also you start physically hurting especially your kidneys which is not something you can ignore. If there were other confounding factors then I'm wondering what their endo told them, unless this is one of those countries you could buy it without a prescription? Any endo with any training would have a fragile diabetic using more than one monitoring method and have them doing regular blood tests.
      - bonsai_spool 11mo ago
        I responded to your sibling post: https://news.ycombinator.com/item?id=46395603 https://news.ycombinator.com/item?id=46395603 DKA is a common presenting symptom for new T1DM patients but that's definitely not the only time it occurs. And we also have HHS which can occur in T1DM and T2DM.
    - SkyPuncher 11mo ago
      Thank you for offering your credentials. By nature of this being an internet, tech-focused forum there just aren't many doctors here. Without a reference to credentials, I made a (poor) assumption about your authority on the matter. I was very clear that I probably know more than the average person, but I'm certainly not an authority. I do think my underlying point is generally, correct, though. And, implicitly supported by your retort. Low and high blood sugar are emergencies of different acuity. To be clear, by the time either of them turns into an emergency, they are both emergencies. However, the time frame for going from "my blood sugar is managed" to "I need emergency intervention" is generally different (and longer for high blood sugar emergencies).
  - mlyle 11mo ago
    Don’t be the guy who lectures the MD/PhD— who gave an outside source— about being not an expert, by citing conversations with your spouse.
    - SkyPuncher 11mo ago
      The MD/PhD did not offer any credentials. Citing an outside source does not make one more correct. My point still remains. Low and High blood sugar are different acuity of emergencies.
      - bonsai_spool 11mo ago
        I have to say that I don't talk about credentials because they really are an inappropriate source of authority on the internet. I instead link to authoritative references.
      - mlyle 11mo ago
        It seems like you're missing the distinction being drawn between high blood sugar (but adequate levels of insulin to prevent ketosis) and very very lowlevels of insulin. The former is bad over longer time scales; the latter can become ketosis/acidosis/an emergency quickly. But neither that, nor is whether he should offer credentials the point. The point is you said this: > > > Sorry to be crass, but this type of argument is exactly why non-experts shouldn't be talking about topics they aren't experts on. I think there's a little recalibration necessary if the person you said this to turns out to be pretty well educated and capable in the subject.
bdcravens 11mo ago
That seemed odd to me as well (also diabetic). When I'm not being responsible, I can ride out a BG of 300-400 for hours and mostly I'm just lethargic. That said, my mother in law, who had worse diabetes than me, went without her pump during mine and her daughter's wedding (a bit of vanity about the pump showing through her dress). She was at 600+, and started feeling pretty ill that evening.
nashashmi 11mo ago
I’m bound to get type 2 some day. So I learned quite a bit about diabetes now. And low sugar is very bad. So a false low sugar tells the patient to eat sweet things. A high sugar causes lots of damage, but I have never heard of it causing death. Usually something gets amputated first. This finding was strange. Let’s remember this writer is someone who has diabetes and an axe to grind. This is not news. This is a rant.
- layla5alive 11mo ago
  [flagged]
  - dvfjsdhgfv 11mo ago
    > Your comment was Dunning Kruger. Did you stay at a Holiday Inn Express last night? I know nothing about the subject, just wanted to say your comment is exactly one I'd prefer to filter out - it adds nothing to the discussion, I haven't learned anything from it and reading it makes me feel like wasting my precious time on Reddit rather than on one of the very few remaining quality forums like HN.
jeremyjh 11mo ago
Actually its pretty straightforward. This article was written by a witless clown.
wanderingmoose 11mo ago
High blood sugar should be considered a symptom. High blood sugar can be caused by: 1) Having enough basal or "baseline" insulin but eating too many carbohydrates. This will lead to a high blood sugar reading but no immediate danger (this will cause long term health issues like kidney failure, blindness, etc if you run a high average blood sugar over time.) 2) Not having enough insulin which is incredibly dangerous. This will often presents with high blood sugar but not always. Your cells are not getting enough glucose. Your body responds by releasing lots of short term energy stores. The stores that become glucose still can't enter your cells since there is not enough insulin so your blood sugar will often read high. Your body also breaks fat into ketones which use a different mechanism to enter the cells and don't require insulin. Ketones can provide the energy your body needs and keep you alive for the short term, but they are acidic and will kill if the concentration gets too high (diabetic ketoacidosis -- your blood pH changes enough that it interferes with the normal chemical reactions your body requires) So the real test for dangerous situations when experiencing high blood sugars is to test your urine for ketones. From the FDA article, it sounds like the CGMs were incorrectly reporting low blood glucose values for extended periods of time. The closed loop pumps respond to a low blood glucose by lowering the basal rate of insulin. The is dangerous if done for too long a time. Also note that insulin response varies wildly by individual. From the pumps I use, there is a maximum basal rate adjustment allowed before the pump alarms and kicks you out of the "insulin auto-adjust mode". This was with both medtronic and tandem pumps. I haven't used the abbot cgm or pump. I would expect there would also be limits to how much the pump will lower your basal insulin rates before alarming. I haven't seen any specifics, but I bet the software bug is allowing a lowered basal rate for too long under continued false low glucose readings and patients going into DKA. (IMHO bad sensors should be accounted for in software and user alerted under any suspicious circumstances) Needless to say, this is a horrible situation and my heart goes out to everyone impacted.
mmmmbbbhb 11mo ago
The actual issue with the sensors was that they'd report highs as lows, and lows as highs.
- jrflowers 11mo ago
  That’s not true at all. It only reported false lows, not false highs. False lows and false highs are only equivalent if you do not understand the basics of diabetes management.

by pixl97 11mo ago

bonsai_spool 11mo ago

It depends on what the true blood sugar value was: if someone were already at the high end of normal and a 'brittle diabetic', you can end up in 'diabetic ketoacidosis' for T1DM individuals or—less likely—'hyperosmolar hyperglycemic state' generally. See https://www.mayoclinic.org/diseases-conditions/hyperglycemia/symptoms-causes/syc-20373631 https://www.mayoclinic.org/diseases-conditions/hyperglycemia... for a discussion of both (in Emergency conditions)

SkyPuncher 11mo ago
[flagged]
- slowking2 11mo ago
  You can die on the order of hours to days not of high blood sugar per se, but of the low insulin causing diabetic ketoacidosis parent comment mentions. It would be odd for a faulty sensor to cause an otherwise bad day into dka and death though. The sensor would need to be wildly off for hours and the user to not notice. Insulin delivery would need to be paused or greatly reduced for many hours. There are additional therapies like SGLT-2 that could make this more likely but they usually aren’t used with T1D precisely because they break the normally very strong correlation between inadequate insulin levels (leading to dka) and high blood glucose. Even though I can’t think of an easy way for a false low(s) to turn into lethal DKA, that doesn’t mean it didn’t happen. Abbott sells a lot of CGMs. It could have been a contributing factor to several deaths even if the fault would almost always not be a significant issue.
- bonsai_spool 11mo ago
  > Sorry to be crass, but this type of argument is exactly why non-experts shouldn't be talking about topics > I myself am not a doctor. I love to learn from my wife. I suggest that you speak to your wife before correcting my unimpeachable explanation of why someone might die from being told, incorrectly by their CGM, that their blood glucose is low. I say this as someone doesn't need to rely on a spouse but have actually received my own medical education. And I've had my own HHS patients—it's not even clear if your wife (!!) works in this area. As the sibling commentator shares, we don't really expect these patients to show up after a day of bad data, but we also have no idea how many days of bad data occurred.
  - pixl97 11mo ago
    As someone that experienced DKA when I was young I'm still not sure how that happens unless there were a lot of other confounding factors. Having hypoglycemia that high for a while will make everything start smelling like varnish. Also you start physically hurting especially your kidneys which is not something you can ignore. If there were other confounding factors then I'm wondering what their endo told them, unless this is one of those countries you could buy it without a prescription? Any endo with any training would have a fragile diabetic using more than one monitoring method and have them doing regular blood tests.
    - bonsai_spool 11mo ago
      I responded to your sibling post: https://news.ycombinator.com/item?id=46395603 https://news.ycombinator.com/item?id=46395603 DKA is a common presenting symptom for new T1DM patients but that's definitely not the only time it occurs. And we also have HHS which can occur in T1DM and T2DM.
  - SkyPuncher 11mo ago
    Thank you for offering your credentials. By nature of this being an internet, tech-focused forum there just aren't many doctors here. Without a reference to credentials, I made a (poor) assumption about your authority on the matter. I was very clear that I probably know more than the average person, but I'm certainly not an authority. I do think my underlying point is generally, correct, though. And, implicitly supported by your retort. Low and high blood sugar are emergencies of different acuity. To be clear, by the time either of them turns into an emergency, they are both emergencies. However, the time frame for going from "my blood sugar is managed" to "I need emergency intervention" is generally different (and longer for high blood sugar emergencies).
- mlyle 11mo ago
  Don’t be the guy who lectures the MD/PhD— who gave an outside source— about being not an expert, by citing conversations with your spouse.
  - SkyPuncher 11mo ago
    The MD/PhD did not offer any credentials. Citing an outside source does not make one more correct. My point still remains. Low and High blood sugar are different acuity of emergencies.
    - bonsai_spool 11mo ago
      I have to say that I don't talk about credentials because they really are an inappropriate source of authority on the internet. I instead link to authoritative references.
    - mlyle 11mo ago
      It seems like you're missing the distinction being drawn between high blood sugar (but adequate levels of insulin to prevent ketosis) and very very lowlevels of insulin. The former is bad over longer time scales; the latter can become ketosis/acidosis/an emergency quickly. But neither that, nor is whether he should offer credentials the point. The point is you said this: > > > Sorry to be crass, but this type of argument is exactly why non-experts shouldn't be talking about topics they aren't experts on. I think there's a little recalibration necessary if the person you said this to turns out to be pretty well educated and capable in the subject.

bdcravens 11mo ago

That seemed odd to me as well (also diabetic). When I'm not being responsible, I can ride out a BG of 300-400 for hours and mostly I'm just lethargic. That said, my mother in law, who had worse diabetes than me, went without her pump during mine and her daughter's wedding (a bit of vanity about the pump showing through her dress). She was at 600+, and started feeling pretty ill that evening.

nashashmi 11mo ago

I’m bound to get type 2 some day. So I learned quite a bit about diabetes now. And low sugar is very bad. So a false low sugar tells the patient to eat sweet things. A high sugar causes lots of damage, but I have never heard of it causing death. Usually something gets amputated first. This finding was strange. Let’s remember this writer is someone who has diabetes and an axe to grind. This is not news. This is a rant.

layla5alive 11mo ago
[flagged]
- dvfjsdhgfv 11mo ago
  > Your comment was Dunning Kruger. Did you stay at a Holiday Inn Express last night? I know nothing about the subject, just wanted to say your comment is exactly one I'd prefer to filter out - it adds nothing to the discussion, I haven't learned anything from it and reading it makes me feel like wasting my precious time on Reddit rather than on one of the very few remaining quality forums like HN.

jeremyjh 11mo ago

Actually its pretty straightforward. This article was written by a witless clown.

wanderingmoose 11mo ago

High blood sugar should be considered a symptom. High blood sugar can be caused by: 1) Having enough basal or "baseline" insulin but eating too many carbohydrates. This will lead to a high blood sugar reading but no immediate danger (this will cause long term health issues like kidney failure, blindness, etc if you run a high average blood sugar over time.) 2) Not having enough insulin which is incredibly dangerous. This will often presents with high blood sugar but not always. Your cells are not getting enough glucose. Your body responds by releasing lots of short term energy stores. The stores that become glucose still can't enter your cells since there is not enough insulin so your blood sugar will often read high. Your body also breaks fat into ketones which use a different mechanism to enter the cells and don't require insulin. Ketones can provide the energy your body needs and keep you alive for the short term, but they are acidic and will kill if the concentration gets too high (diabetic ketoacidosis -- your blood pH changes enough that it interferes with the normal chemical reactions your body requires) So the real test for dangerous situations when experiencing high blood sugars is to test your urine for ketones. From the FDA article, it sounds like the CGMs were incorrectly reporting low blood glucose values for extended periods of time. The closed loop pumps respond to a low blood glucose by lowering the basal rate of insulin. The is dangerous if done for too long a time. Also note that insulin response varies wildly by individual. From the pumps I use, there is a maximum basal rate adjustment allowed before the pump alarms and kicks you out of the "insulin auto-adjust mode". This was with both medtronic and tandem pumps. I haven't used the abbot cgm or pump. I would expect there would also be limits to how much the pump will lower your basal insulin rates before alarming. I haven't seen any specifics, but I bet the software bug is allowing a lowered basal rate for too long under continued false low glucose readings and patients going into DKA. (IMHO bad sensors should be accounted for in software and user alerted under any suspicious circumstances) Needless to say, this is a horrible situation and my heart goes out to everyone impacted.

mmmmbbbhb 11mo ago

The actual issue with the sensors was that they'd report highs as lows, and lows as highs.

jrflowers 11mo ago
That’s not true at all. It only reported false lows, not false highs. False lows and false highs are only equivalent if you do not understand the basics of diabetes management.