October 02, 2019 Stay safe while sick and living with type 2 diabetes
Diabetes can often be hard to manage on its own, let alone when you are sick.
In this webinar, Susie Jin will provide insight into the strategies for individuals living with diabetes to staying safe while you are sick. Susie will cover how to prevent low blood sugars, what do if you are using insulin and the importance of being vaccinated for the influenza virus.
Susie Jin is a pharmacist, certified diabetes educator, certified insulin pump and continuous glucose sensor trainer, board certified geriatric pharmacist and certified fitter for compression therapy. Her professional experience in Diabetes Education includes a variety of practice settings such as her local hospital Diabetes Education Program, her local Community Health Centre, within a medical clinic, and now, primarily, in her community pharmacy.
This webinar is proudly presented by
[00:00:01] Welcome everyone to Diabetes Canada's 2019 Type 2 webinar series. My name is Jeneni Jude and I will be your host today. We are delighted that you are able to join us today for the webinar entitled "Staying safe while sick and living with type 2 diabetes". To start off, I would like to draw your attention to the survey below the video. In order to best serve your needs, we kindly ask that you provide us with your input by completing the short survey towards the end of the presentation. We thank you in advance for your input. Today's presentation will be about 25 to 30 minutes in length. We would like to take a moment to thank our sponsor. This webinar series is presented by Sanofi Pasteur. Now I would like to welcome our speaker Susie Jin and thank her for joining us today. Before turning it over to Susie, I'd like to give you a brief introduction. Susie is a community pharmacist, diabetes educator, and certified fitter of compression therapy. She is a chapter author for Diabetes Canada's 2018 Clinical Practice Guidelines, a key message lead for Diabetes Canada's Dissemination and Implementation Committee of the 2013 and 2018 Clinical Practice Guidelines, and has written best practice recommendations for Wounds Canada. Recently, Susie contributes on committees for Health Quality Ontario, including the Diabetes Quality Standard Advisory Committee. While Susie practices diabetes education in a variety of practice settings, including primary care offices,, diabetes education centers and in her community pharmacy, she is most excited about this opportunity to share her knowledge with you through diabetes education in the form of a webinar. So without further ado, I present to you Susie Jin.
[00:02:11] Thanks Jen. I'm the pleasure to be here with everybody today so thank you for joining me for our webinar on "staying safe while sick". As Jen had said, this is part of the webinar series for individuals living with type 2 diabetes but many of the concepts actually apply for people also with type 1 diabetes. So it's something to consider that- that this could actually be speaking to somebody equally who has Type 1 diabetes. OK so let's get started. What I'd like to do is put this in context of the whole guideline dissemination strategy. So really what I'd like you to do with I invite you to follow along use your phone or use your computer and open up guidelines that diabetes dot see. So when you go to visit that Web site you're going to see this screen is going to appear. And today's presentation is on "staying safe while you're sick" and you're going to see on the left hand side that that that's the- one of- you'll see the key messages there. And what I like about putting this stay safe while sick within the grand scheme of things is that hopefully you'll be able to appreciate everything else all the tons of tools and resources that are available to you. So for example, if I want to know how can I reduce my risk of diabetes complications, well I can click on that middle of the button there on reducing my risk of diabetes complications and a whole bunch of tools and resources will open. You'll see there are some that are designed for the health care provider but we also have several patient tools. And so if I wanted to know what do I need to do to reduce my risk of complications, well at any time, take your time, go through those and any questions you have, take those to your health care provider and find out that's the why. Why do I need to do this. It's because essentially we're if I can check up all those boxes and do all this and make sure I meet my screening and make sure I get my target, then I have successfully reduced my risk of developing complications as much as I can. You'll see the next one is keeping patients safe. And so that's where today's presentation falls under. And then also just to give you an idea there's tons of tools and resources designed for people living with diabetes to support you and self-management. OK so let's get started. I'm going to introduce you to Lai Kuen. Lai Kuen is- is possibly a friend of yours or maybe hopefully somebody that is similar to you. And these are the medications she's on. And I've also given up just a little bit more information about her. So when we look at Lai Kuen and trying to keep her keep her safe and don't let her get sick, well the first thing to do is to prevent sickness. So one of the most important things we can do is make sure we get our vaccinations in. So there's the annual influenza vaccination, so that's the annual flu shot. And why. Why do we get it? Because it has been proven to reduce hospitalizations and death. So you know really when it comes to caring for ourselves and we want to do everything we can to- to prevent and keep our safe is- well we want to make sure we're getting our annual flu shot. And you can imagine many times you can get that through the primary care provider, you can get ir through community clinics, you can get it through community pharmacies. So that's done annually and you'll see it coming out towards October ish actually, the end of October. But certainly if you don't get in right at the middle to the end of October, go for it in November. It's not too late to get your annual flu shot. The other vaccinations that you could consider to help prevent sickness is the pneumonia shot. And there are two different pneumonia shots. And I'm going to leave it with making sure that you are aware of the pneumonia vaccination and you'd want to speak to your health care provider about which one is appropriate for you, at what timing is it appropriate for you because there's certain- if you get one you have to wait a certain time before you get the other one and vice versa. But just making you aware of you know checking off your check boxes. I know if I want to stay healthy I need to get my annual flu shot and I need to get a pneumonia shot that's more generally once or twice in your lifetime. But again, this depends on you and all your different medical conditions and things like that. So I've just wanted to make sure that you have a- you're aware of it and you have a conversation with your health care provider. And the last- or the other vaccination to consider would be the herpes zoster vaccination. So that would be the shingles vaccination. And again there's actually two different ones on the market and we'd recommend one versus another based on access to resources and so forth. So again if you don't know about it or if you haven't had it, you'd want to make sure you have a conversation with your health care provider as to when is that appropriate for me and which one should I get at that time. OK so now that we've considered for Lai Kuen what she can do to help prevent herself from getting sick. The next thing to do is if you're sick what can you do to prevent it from actually getting worse. And so I invite you to follow along, use your phone or use your computer or your laptop and go to guidelines.diabetes.ca, and when you open that website you'll see on the left hand side under the drop down menu the appendices. And when you open the appendix eight, the six day medication list opens and this one is the one that many health care professionals might be familiar with. You'll see on the left hand side there's instructions for health care professionals and on the right hand side, there's some instructions for people with diabetes. I'll bring your attention to the sad man. These are the classes of medications that we would recommend that people would hold in the event that they are sick. But truthfully this tool isn't entirely helpful for people living with diabetes because how many of us know what classes of the medications there are. So I'm going- we'll move on to the next slide and that's the one that's really more designed for people with diabetes. OK so this is a tool and I think what's most important, I think is that, I want you to be able to find this tool because while this was designed for people affected by diabetes, truthfully there's a lot of intricacies that go into making this particularly relevant to you. So we want to individualize it. So in many ways I'm going to walk you through how to find it and then encourage you to print it off and take it with you to your next health care provider appointment. So to find that page to have that in front of you so you can follow along with me I read- I welcome you to follow along with your- use your phone or again your laptop or your computer and go to guidelines.diabetes.ca and from the home screen your- this is what your home is going to look like and you'll see that we are talking about how do we stay safe when we're sick. So that's the middle one. How do we keep patients safe. And after you click on that the resources for people with diabetes will open and you'll see the middle one there staying safe when you have diabetes and are sick or at risk of dehydration will open. OK. And so now when we have this open I'm just going to make it bigger and you can see from the out from the top part, when you have diabetes or are sick or are sick and at risk and are sick at risk of dehydration, I think it's important that we actually recognize when or what does it mean by to be at risk of dehydration. And so we have you know when you're vomiting when you have diarrhea, if you have fever so whenever you're fluid depleted, right, if you're feverish you're kind of sweating a lot. And so you're technically at risk of dehydration and certainly when you're vomiting and diarrhea, well you're definitely losing fluids. So what do we do in that situation. Well the first thing we need to do is make sure that we are replenishing the fluid we have lost. So certainly there we have drink plenty of fluids. Now it's kind of, we have some caveats built into this- this resource in that if you are being told to limit your fluids, so if your kidneys are, you have chronic kidney disease on top of diabetes and whatnot, then technically this tool is not for you. And what you can do is use this tool go to your health care provider and find out what do you mean by. OK. I need to replenish with something but what should I do. Can you give me more information. And when I say go to a health care provider not every health care provider is going to know the answer to that. It might be your nephrologist or your renal dietician or so forth. But the truth is is that if you make a start go to somebody go to your health care provider they will either be able to help you themselves or they will direct you to how you can find the help. So that's really what we're saying is just make sure you know the answer for you. Right. Drinking plenty of fluids. And you'll see there's a whole list of different ideas, suggestions so electrolyte replacement solutions, clear soups or broth, water, diet soda, watered down apple juice. And they're kind of in the order of best, better and anything's better than nothing kind of thing. And so we really tried to. It kind of depends on your level of kidney function. Your underlying care. So you know if you have an- and, and it also depends on the extent of vomiting and diarrhea that you're going through. So again it's not really prescriptive as to this is what you must do. But any of those choices if possible if you're really dire. Start with the electrolyte replacement solutions and kind of work your way down as in better top is the best first choice second choice third choice option. And certainly limiting caffeine is important. OK so then don't forget Lai Kuen is on glycoside. So for her I need to make sure that if she cannot eat her usual foods, that I have to give her some suggestions as to what she could have so that she doesn't have low blood sugar. But truthfully in this case Lai Kuen is our patient and she is on glycoside. So then I do have to worry about hypoglycemia. On the other hand there are several people who actually aren't on medications that can cause lows. And so if you're not on a medication that can cause lows, well then truthfully this is not really I don't have to worry about lows for you because you're not on meds that cause lows. Right. So what medications cause low's, that would be things like glycoside or glyburide or repaglinide. If you're on any of those or if you're on insulin of any sort. So then if you are then that's relevant to you and if you're not on any of those agents that actually can cause lows then you know what. Let's just move on. Keep this tool simple that pertain to you. Talking about moving on Lai Kuen is not on insulin and so you know what I'm going to tell her if she's in my office I'm going to tell her "Let's not worry about this because you're not on that let's just go to the next bullet point" and the next bullet point is if you are eating less than normal and the symptoms last more than 24 hours you should temporarily stop. In this case it's her glycoside. And so what we why we tried to be give a little bit more information in this tool is that in this case we I guess in this case if she's- if the vomiting and diarrhea is kind of mild and going over several days but she's actually able to keep eating like you know then then technically she can still continue to take her glycoside in that case. I'm going to draw your attention, even though I know we've been talking about Lai Kuen as our patient. I just want to draw your attention to the fact of if you are using insulin so she is not usually insulin, but you on listening to this webinar you might be using insulin so I do want to have a little bit of a conversation here about for those who are using insulin, you would need to check your blood sugar more often because you are at risk of lows right, and you might need to adjust the amount of insulin you inject. So that's a whole conversation that you need to have with your health care provider and you need to know how to adjust your insulin. This tool we tried to keep it simple. And so because there's so many different forms of insulin that people could be on, they could be on the once a day, they could be on the once a day plus mealtime insulin or they could be on the mixed insulin. So because there's so many different types of insulin we'd left it that if you don't know how to adjust your insulin make sure you speak to your health care provider who should be able to give you the information as to how you should adjust your insulin and if they don't know then of course we just ask them to make sure that they can refer you. So if they don't know then I would be an expert. I'd be like Do you know who who would be able to help me answer this question so that's just all about supporting you in your own self care.
[00:16:18] All right. So now if we flip over the tool to page two or the back of PAGE ONE this is where I am and this is hopefully where we're together there. So this is the list of the different medications that we would ask you to temporarily stop in the event that you are sick or at risk of dehydration. And you know one thing you could do is literally go through this and try to find the names of which medications you're on but truthfully I'll draw your attention to the bottom where it says note the list above does not include the names of medications that come in combination. So for example these are the meds that are single source items. So for example if you look at certain diabetes pills they're the SGLT2 inhibitors can come single as in Invokana or they can be in combination with metformin and then it's called invokamet. Well that might be simple to sort of get the fact that oh I have to stop my invokamet as well if I happen to be on that agent but if you're on the combination of Forxiga with metformin. That one the name becomes xigduo. So it's not something that is easy for somebody living with diabetes to figure out all the different intricacies. Similarly jardiance and when you put it in combination with metformin the name becomes synjardy. So again tricky. The other ones that we also need to consider are the ones that are have metformin in combination with a DPP-4 inhibitor. So for example some people are on Januvia. Well that's not on the list. And if you were on Januvia, you could actually continue Januvia in the event that you were at risk of dehydration. But Januvia, if it was mixed with metformin you have the name of the medication being janumet. So janumet you'd want to consider holding in the event that you have dehydration. And similarly we have jentadueto or combo glys and those are different agents that are all in combination with metformin. So again there's a little bit of intricacies that we have to think about. So that brings us down to who do we ask for help. So while this tool does say ask your pharmacist and the idea behind that is that many times medications are changing all the time and so pharmacists being easily accessible that that's one person you could ask, but really and truly ask any health care provider because we want to make sure that this list is provided to you. But what does that mean to you. So in this case if we can actually think about Lai Kuen if I was filling this out for her I would be telling her that the medications that she needs to temporarily stop when she's eating less than normal would be glycoside. Right now mind you I emphasize it's only if she's eating less than normal. So technically if she's able to continue eating the same amount that she normally would then she can continue if she's keeping things down it's not all vomiting and coming up or going straight through her, then really she is fine to stay on her glycoside. When she is at risk of dehydration or when she can't keep you know which is fluid and so forth, vomiting and stuff, then for her would be metformin, canagliflozin, and the telmisartan or you know we might actually write it out in the form that she might be familiar with it and she would be I guess in that case metformin, invokana, and the telmisartan. And then you know we don't- we always want to have the date that it was reviewed and who reviewed it with you just so that when you go from one health care provider to another, everybody speaking the same language everybody knows what you're what you're on. Or when that information was updated. The other thing I'd like to point out is the other part underneath it says note, restart these medications when you are eating and drinking normally. And that's actually very important part because, so for example in this case Lai Kuen is on telmisartan and there are several people this happens to where you have an incident maybe you come down with pneumonia or some sort of thing you end up in the hospital because your kidneys have had some complications and they kind of were affected due to the dehydration of the pneumonia and so forth. But then what happens is in the hospital we stop it because that's what we want- what's on- that's on the list. That's what we've- that's the right thing to do. But once the kidney function normalizes there should be a conversation about when do we restart. And so for some people it's you know this is done not even in a hospital setting you actually stop it for two or three days and then you restart it. No problem but I think that it was worth- a worthwhile conversation to have with your health care professional if telmisartan or what not is actually indicated for you for protecting your heart and your kidneys. So in long term actually protect your kidney right. If it's there to protect your heart and kidneys and it's indicated for you, we don't stop it for the rest of your life. If it was only a short term needing to protect your kidneys for short term. So I hope that makes sense that we want to make sure that this conversation if you had stopped it short term for in the event that you were sick the conversation should be had as to when do you restart it. And the last thing that is important about this tool is the very bottom part that tells you when should you seek additional help. So for example when is this tool not enough for you to support you in self care. Right. So for example if you cannot drink enough fluids. Right so the very first part says I'm dehydrated I need to drink fluids, but if for whatever reason you know maybe you've been told you're not supposed to drink so many fluids or maybe you're drinking but it's just still going straight through you can't seem to keep it down. This tool you need to seek more help. Right. If you don't know which medications to stop, even though they're there you can see it's still pretty complicated. So this this list does not make sense to you, go to your health and engage your health care team and find out which medications should I need to stop and I need to understand this tool. Right. If I don't know how to adjust my insulin again I need to seek help. So again this just kind of gives you an idea of the fact that it's not enough. OK So that concludes the first part of the webinar which really just walks people through how this tool can be used for you. The second part of the webinar was really the thought process that went into designing this tool and it's a little bit more advanced. But you know it might be relevant to you or for you to appreciate why we made certain decisions and how we wrote certain things. So when we created this tool we really had to, the committee had to say it ourselves well really what are we worried about when people are sick. What's the point of what- what are the issues that we have to think of. And so I welcome you to pause this video read through those and see if any of that makes sense to you and see if any of that if you know which is the answer which is the best response as to which is the most true. And so let's see if you. If you pause it you'll see that these answers are that the first one, patients are at risk of hypoglycemia when they cannot eat or drink sufficiently. Well I kind of shaded that because that's half true. So the one that's most true is the third comment. The third line down which is patients are at risk of acute kidney injury due to dehydration and impaired blood flow to the kidney. So truthfully there are other risk factors that put us at risk of acute kidney injury. Certainly the infection itself puts us at acute kidney injury so that's one of the risk factors and so that's what's important vaccinations to help prevent getting sick. There's other things like if you have underlying chronic kidney disease there's other things that put us at risk of acute kidney injury. But with respect to these four different statements which one is the most correct. Well when we are sick we are worried about the hydration status and maintaining the blood flow to the kidneys. So let's go over each different statement and try to make it correct. Try to understand what do we need to make it correct and how did we develop the tool to address these things. So the first one, patients are at risk of hypoglycemia when they cannot eat or drink sufficiently and to make that more correct, we really need to recognize if they are at risk of hypoglycemia. So truthfully, patients are at risk of hypoglycemia when they cannot eat or drink sufficiently. If they are on medications associated with hypoglycemia. The reverse, therefore if they are not on medications that are associated with hypoglycemia then they're not technically at risk of hypoglycemia. And truthfully I wouldn't even worry about the risk of hypoglycemia and somebody who's not on medications associated with hypoglycemia. I would just move on to the next part. The next statement. So let's just take a minute and review which medications are associated with hypoglycemia, which pe- who is associate- who has a higher risk of hypoglycemia. And those are people who are on either glycoside such Lai Kuen is or glyburide right to the [00:25:45]self honorary [0.3s] such as that. Insulin of generally any sorts whether long acting insulin or whether the mealtime insulin. Both of those or whether you're on a mixed insulin, insulin of any sort puts you at higher risk of hypoglycemia and then of course we also have rarely it's possible or less it's the meglitinide known as repaglinide which we would've told you to stop anyway because no how they often tell you you know you're not eating don't need to take it. So that's probably less. But having said that certainly if you're not on any of those agents that I just listened. But glycoside, glyburide or any form of insulin, then really we're not really at risk of hypoglycemia and quite honestly more concerned about the hyperglycemia, the high blood sugars which we'll talk about. Our second statement does address that patients are at risk of hyperglycemia, so high blood sugars, due to the decreased counter regulatory hormone release during sickness. So let's look at what's wrong with this. Well it's not that it's a decreased counter regulatory hormone release but rather an increased counter regulatory hormone release. So let's try to understand what that means. Certainly the counter regulatory hormone release is another way of just calling it stress hormones. So when you're sick, you- you have stress hormones released and that kind of makes sense. Just sort of think about it. I'm under you- when you're not feeling well you're when you're sick and you're you're under stress you know you're not feeling well you're vomiting and diarrhea you're just you're under so much stress that your sugars actually go up due to that stress hormone release. And so that's kind of also explains why is it that when you're sick and you're actually not even eating as much cause you're just not feeling like you want to eat but your sugars are going up and you say what's going on. I'm not even eating as much of my sugars are going up and that is because of that stress hormone release that is increased which causes your sugar to go up. And so that factors in two or more main concern about you know I'm not I'm only worried about hypoglycemia, lows, if they're on medications that can cause lows. For the most part, I'm actually really worried about the sugars that are going up that we need to control. We need to take care of that.
[00:28:14] OK and so when it comes to this the third statement. Well we've already said that it is correct. Right we've already said that patients are at risk of acute kidney injury due to dehydration and impaired blood flow to the kidneys. But what does this mean. So essentially when you're sick in order when we were thinking about the tool, well to counter the risk of dehydration the first thing we tell you to do is drink plenty of fluids. And that certainly was the first thing on the tool right. The other thing we should tell you is to hold or temporarily stop your diuretic, that's the water pill. Right. Because the water pill is causing you to become dehydrated to cause you to pee out liquid or fluid urinate. So we- we- we- we try to mitigate. We try to slow down or try to prevent or reduce the dehydration by saying you know what we don't need to take this diuretic right now for these next couple of days until we can re-establish our balance in our bodies. The other one we'll tell you to hold is your SGLT2 receptor inhibitor so those are the- the sodium glucose lowering transport inhibitors. But regardless it's on the list but that's what we're doing. That's how we're countering the dehydration when we created the tool. The other thing we're doing is we're actually trying to mitigate or reduce the impaired blood flow to the kidneys. And so how do we do that. Well again the diuretic is slowing down or causing dehydration and reducing the blood flow to the kidney. So we again hold that. And then the other agents which also affect blood flow to the kidneys NSAIDs and again the list is on that tool so you can look at the different NSAIDs. We also tell you to stop or hold the ACE or ARBs and stop the SGLT2 inhibitors. Now I just wanted to explain one thing because many of you may be on an ACE or ARB and you were told you need to take these because these are going to help protect your kidneys. And so if we just look at that almost screenshot it you go whoa, why am i stopping these two agents that actually can cause impaired blood flow to the kidneys. And I just wanted to explain that to you. OK so just a little bit to understand what's happening is the kidneys have a pressure inside the kidneys. And we want to be green. Green is good right. But what happens over time just like blood pressure goes up, well the glomerular pressure, the pressure in the kidneys can slightly go up. And so what we do is we put you on agents so that ACEs and the ARBs and the SGLT2 class, we actually tell people oh let's put you on these and that's going to reduce the glomerular pressure and hopefully bring us back into the green. The nice green is good right. But what can happen in acute kidney injury or an acute illness, so you know it's a situation where either you've had a, goodness, heart attack or some sort of illness like the pneumonia that puts pressure on the kidneys. And when the kidney pressure goes down well we don't want you to be all those agents that are further lowering pressure. And so to protect the kidneys in that state we just stop them temporarily. OK. And then so then looking at the last statement let's try to understand that. So I'm going to just move it up. So we have a little bit of working room patients are at risk of D.K. A. And I've crossed that part out because that part is a part that's wrong. So let's just discuss this a little bit. Patients are at risk of D.K.A. Well let's just think about it because everybody here on the webinar is everybody at risk of D.K.A And that's not entirely true. So again is just kind of like the same kind of thing. Are you all at risk of hypoglycemia. Not entirely and so we need to know who is at risk of D.K.A. Who do we need to be a little bit more cautious about and who can we just say you know move on you're not at risk of D.K.A., and let's just not exaggerate things and make things worse than they really are. This doesn't pertain to you. So let's take a look at who is at risk of D.K.A. So what is D.K.A. due to? Well D.K.A. is and you see I crossed off due to ongoing based ones one because that's not correct. What is the correct statement. People who are at risk of D.K.A. It's due to a relative insulin deficiency in comparison to an elevated stress hormone release. So again what we have is it's always our bodies supposed to be in balance right. The amount of insulin is supposed to be related to our stress hormones and everything supposed to flow nicely. Well sometimes when we're sick we have issues where the gap between the amount of insulin we have in our bodies is too low in comparison to the stress hormone release. So the stress hormones are going up right. Remember we talked about that they're going up because we're sick. So we actually want to make sure we are maintaining our insulin. And so that's why some people will say well I'm sick and I'm not eating as much. Why do I still need the same amount of insulin or you know that type of thing and so it's because the stress hormones are causing your sugars to go up we need to make sure your insulin is not down at zero. But we have to make sure that it is countering and balancing as much as possible. And so many times that's why we actually keep you on the insulin and we don't stop the insulin. Right. The other thing to think about is again who is at risk so therefore who is at risk of D.K.A. Are the people who have lived with diabetes for longer, so don't forget Lai Kuen has lived with diabetes for twenty five years. So she is really kind of on- her insulin production may have been reduced kind of down and as we get lower and lower, her ability to produce insulin is lower so that some thought about well could her gap of insulin production to stress hormone release speak wider and quite possibly yes. That's something I'm thinking about in the back of my head. Right. People who use insulin. Well they are meeting the support and since of course they have they are at higher risk of D.K.A. And particularly when we're thinking about type 2 diabetes if you're on an SGLT2, so don't forget Lai Kuen is. She is on an SGLT2 inhibitor so she may have exhibiting signs of D.K.A. at possibly at lower than expected blood sugar levels and so that's just something to consider because many times we used to think "oh well the sugars aren't elevated she can't be in D.K.A, but it's something to consider and it's not always lower than expected. Sometimes it is still up to 14 and 16 and higher that we would expect to see D.K.A. in. D.K.A Is very complicated. As a caveat, you know it looks different in type 1 and type 2 often. So having said that it's just something to think about when we are creating the tool. If you're at risk and what would you do to mitigate the risk of D.K.A. Well certainly it's the replenishing of fluids, staying hydrated, which in this case because they're at risk of D.K.A if you really are at risk of D.K.A. the more important ones. Remember I started saying that in order of importance with the electrolyte replacement solutions they are even more important for somebody who is at risk of D.K.A. versus just water. Right. Similarly what's the other thing we'll do, is we'll make sure we actually don't stop the insulin and we'll be making sure we're checking sugars as well as ketones and we'll be making sure those people who are at risk of D.K.A. are given a proper insulin adjustment chart based on the presence of ketones. So again that's something that if you don't know how to do, nobody's actually gone over that with you, that's a conversation you'd want to have. Mag- maybe asking them, your health care provider. Am I at risk of D.K.A. And if so. OK. And so this is a summary slide that just corrects all of the bullet points but again remembering that not everybody is at risk of hypoglycemia and not everybody is at risk of D.K.A. So the two ones in the middle are more relevant to everybody. And the other ones on the extremes the number one and number four are kind of more knowing. You want to know your risk. OK. So that concludes our webinar on staying safe while sick. I thank you very much for joining me. I thank you for helping me care for Lai Kuen and I hope that this has engaged you and empowered you to care for yourself and to get you to know what you need to do to stay safe while you're sick, which pretty much means if you don't know all the answers to that particular tool that we- that we discussed. Print it off take it to your health care provider and hopefully it will all make sense once you're actually speaking with somebody to help support you in your own care. Thank you very much and I'll pass it over to Jen.
[00:37:23] And that concludes our webinar for today. I'd like to sincerely thank Susie for speaking on behalf of Diabetes Canada. It had been a great learning experience. And for those of you looking for more support and resources for living well with diabetes, feel free to call our toll free line at 1 800 Banting. So that's 1 800 226 8464. If you have any questions about today's presentation please send us an email at firstname.lastname@example.org and we will get back to you as soon as possible. Thank you for joining us today. We hope that you've enjoyed this learning experience with Diabetes Canada and look forward to your participation in the future.