Diabetes management in the wilderness setting: WMS Guidelines

• Diabetes-specific medical conditions
• Individuals with pre-existing diabetes complications (including nephropathy, peripheral neuropathy, and retinopathy) should be counselled on minimizing additional risks to these organ systems with wilderness activity (Evidence grade: 1C).

• All individuals with diabetes planning high altitude travel should be up to date on yearly dilated fundoscopy. If any degree of retinopathy is present, ophthalmologic risks of wilderness travel should be discussed (Evidence grade: 1C).

SUPPLY PREPARATION

• Wilderness athletes should be counseled on a complete packing list of routine and emergency diabetes supplies (Evidence grade: 1C).

• Wilderness athletes should carry documentation of their medical history, basic diabetes management plan, and basic emergency action plan (Evidence grade: 1C).

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  • In insulin-dependent diabetes, blood glucose should be monitored before, during, and after intense and/or prolonged exercise (Evidence grade: 1B).
  • Those planning protocols for glucose monitoring and carbohydrate intake in exercise should understand how to adjust carbohydrate intake based on blood glucose and exercise. This plan should be individualized based on patients’ medical and exercise history and the environmental stressors to which they are exposed (Evidence grade:1B).
  • Individual hydration strategies should be developed prior to embarking on wilderness activities and should be adjusted based on real-time factors, including environmental temperature, altitude, and exercise type and duration (Evidence grade: 1C).
  • Wilderness athletes with type 1 diabetes should understand how to adjust insulin doses via either MDI or CSII. This should be individualized based on their medical and exercise history and the environment to which they are exposed. This should be discussed in detail with their primary care provider and/or endocrinologist prior to embarking on wilderness activities. Any device should be explained thoroughly prior to an expedition (Evidence grade: 1B).
  • Use of noninsulin diabetes medications should not be considered a contraindication to wilderness athletic involvement, though participants should be cautious regarding side effects. Particular attention should be paid to the individual risks of each specific class of medication (Evidence grade: 1C).
  • Wilderness athletes with diabetes should have a plan and carry supplies for treating hypoglycemia. They should be prepared to use a glucose repletion and glucagon strategy (Evidence grade: 1C).
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  • Wilderness athletes with diabetes should have experience with individualized methods for managing nocturnal hypoglycemia prior to wilderness activity (Evidence grade: 1C).
  • Those with insulin-dependent diabetes should know the signs and symptoms of ketosis, carry a serum and/or urine ketone testing kit, and know how to treat ketones during wilderness activities. It may be prudent to carry both as a contingency in the event of failure due to environmental conditions (Evidence grade: 1B).
  • Ketosis may be safely managed in the wilderness if an athlete with diabetes and the athlete’s healthcare provider are comfortable with a treatment protocol and if the patient is able to take oral hydration and nutrition and shows no signs of altered mental status (Evidence grade: 2C).

  • Both HHS and DKA should be considered medical emergencies managed by emergent removal or evacuation to definitive care (Evidence grade: 1A).

  • Healthcare providers covering events or expeditions in the wilderness should have the ability to monitor blood glucose and ketones and have a basic familiarity with how to treat and triage glucose abnormalities (Evidence grade: 1C).

  • There should be a plan for evacuation in the case of a hyperglycemic emergency (Evidence grade: 1A).
  • Those with insulin-dependent diabetes should understand how to adjust insulin doses when hyperglycemia occurs during activity. This should be based on their individual experiences during exercise, training, and previous exposure to environmental stressors. This should be discussed in detail with their endocrine provider prior to embarking on a wilderness adventure (Evidence grade: 1B).
  • Although it is insufficient in vivo data on continuous glucose monitoring or novel hybrid closed-loop insulin delivery systems to recommend their use for wilderness athletes with diabetes, the use of such technology may be considered after discussion with an individual’s endocrine provider (Evidence grade: 1C).

  "Clinical practice guidelines are increasingly necessary to help clinicians navigate and synthesize the expanding volume of available medical literature," explained Dr Davis. "Our guidelines are continuously updated to reflect the most current literature and recommendations for wilderness medicine pathology and are uniquely interdisciplinary in their authorship. Our goal is to provide the most up-to-date and relevant clinical information to frontline providers in the wilderness or austere environments."

  For further reference log on to: 
  

  https://doi.org/10.1016/j.wem.2019.10.003