medreg+1 tremble diabetes
TRANSCRIPT
Developing people for health and healthcare
A guide to managing hospital diabetes
24th July 2014
Dr Jennifer Tremble
Consultant Diabetologist
Queen Elizabeth Hospital
Outline
Diagnosis of diabetes Type 1 or type 2
Management of newly diagnosed diabetes Insulin sliding scales
Starting patients on insulin
Managing established diabetes
Diabetic emergencies Diabetic ketoacidosis/Hyperosmolar non ketotic coma
Hypoglycemia
Diabetic feet
Diabetes: Diagnosis
Diagnostic criteria
HbA1c 6.5%
HbA1c 6.1-6.4% pre diabetes
Oral glucose tolerance test rarely except in pregnancy
But diabetes can present acutely in which case use
Blood glucose 11.1mmol/L (x2)
Fasting blood glucose 7mmol/L (x2)
Does the patient have type 1 or type 2 diabetes?
Type 1 Type 2
Age <30yrs >40yrs
BMI <27kgm2 >30kgm2
Racial group cauc asian/A-C/cauc
History <1 month >1month
Ketones present absent
Venous bicarb <20 >20
If unsure/patient unwell/pregnant give insulin
Barbie
36 yr old F 2/52 Hx osmotic symptoms and weight loss
BMI 27kgm2
Blood glucose 24mmol/L
Creatinine 72µmol/L
Urine analysis – glucose and ketonuria +++
Blood ketones 0.8mmol/L
New type 1 diabetes - well
If well, not dehydrated blood glucose <30mmol/L and blood ketones< 1.2mmol/L Office hours refer to the diabetes team
Out of office hours can give stat dose of insulin (10 units long acting insulin) - ensure seen by diabetes team the next day
Weekend or bank holiday
Basal bolus insulin regimen e.g. Quick acting 4-8 units pre meal/long acting 12 to 24 units pre bed
Injection technique taught by ward staff
Provide meter and diary for self blood glucose monitoring
Basic education (diet – avoid sugary drinks, 3x meals a day with carbohydrate, effect of exercise, management of hypoglycemia, driving)
New type 2 diabetes - well
Blood glucose <20mmol/L Diet and exercise
Blood glucose 20 – 30mmol/L Diet and exercise Metformin if BMI > 27kgm2 check U&Es Gliclazide – for acute glucose control ? needs to be continued Dipeptidylpeptidase-4 inhibitors (DPP-4s) e.g. Sitagliptin or Glucagon
like peptide -1 mimetics (GLP-1)s e.g. Exenatide or selective inhibitor of the renal sodium-glucose co-transporter 2 (SGLT-2) e.g. Dapagliflozin –long term
Blood glucose >30mmol/L may need admission May need insulin acutely to achieve glycemic control Self blood glucose monitoring
Ensure community follow up
New type 2 diabetes – needs admission
If following features present Rx as for hyperosomolar state Hypovolemia Marked hyperglycemia >30mmol/L Osmolality 320mosmol/kg or more
Otherwise consider need for glycemic control Acute sepsis/acute coronary syndrome/CVA/ not eating or drinking
Insulin sliding scale Convert to subcutaneous insulin
Intercurrent infection/cardiac failure/renal failure/Blood glucose.20mmol/L Subcutaneous insulin
Blood glucose monitoring > 11mmol/L but <20mmol/L Oral hypoglycemic agents – choice depending on clinical
features
Insulins
Quick acting (QA)
duration 2hrs - insulin analogues Humalog kwik pen Novorapid flex pen, Apidra solostar pen
duration 6hrs – human/pork/beef Actrapid, Humulin S (kwik pen), Hypurin porcine or bovine
neutral
Long acting (LA) duration 18hrs – Insulatard, Humulin I (kwik pen), Hypurin Isophane
Insulin analogues – Lantus solostar, Levemir flex pen
Ultra long acting duration 24 to 36hrs – Degludec
Premix NPH/Soluble
Humulin M3 (kwik pen)
Insuman Comb 25 Insuman Comb 50
Humalog mix 25 (kwik pen and vial useful on the wards for multi dose use) or Humalog mix 50 (kwik pen)
Novomix 30 (flex pen)
Insulin regimes
Basal bolus
suitable for type 1, slim/motivated or highly insulin resistant type 2, pregnancy
flexible
multiple injections (4x or 5x a day)
weight gain in T2DM “can eat normally”
Other insulin regimes
QA and LA pre breakfast, QA pre dinner, LA pre bed
4 injections but none at lunchtime
Twice daily LA or a mix
Suitable for type 2 and type 1 in honeymoon
Once daily LA or mix ± oral hypoglycemics give pre bed to avoid weight gain in type 2s
consider when district nurses are going to administer insulin
Insulin sliding scales
Indications Nil by mouth Need immediate good control Severe hyperglycemia to allow calculation of insulin requirement
Requires Hourly BGs Syringe pump Iv dextrose 10% if patient not eating/drinking
Continue usual LA subcutaneous insulin ± usual QA subcutaneous insulin if predictable increase in
insulin requirements e.g with dexamethasone or patient eating/drinking
Trouble shooting – BG not controlled ? reset sliding scale higher or lower ? excess or inadequate or variable calorie intake
QE sliding scale
basal rate = normal total insulin dose
24
If not normally on insulin take basal rate as 2
BG/mmols/L Insulin infusion rate/mls/hr
<3.9 0.5
4-7.9 basal rate
8-9.9 1.5x basal rate
10-14.9 2x basal rate
>15 3x basal rate - adjust scale
Re - starting insulin
Usual doses unless previous poor control
Best done at breakfast but can be done at lunch
If on basal bolus and pre bed LA given give usual s/c insulin dose with the meal,
stop the pump 30 mins after the meal
if LA not given then also give isophane ½ usual dose
If on twice daily As above but given usual morning dose of insulin
NB Can substitute similar insulins if usual insulins not available.
If new on insulin
Give around 2/3rds of predicted 24 hr iv dose
requirement (once BG has come down – ketones cleared)
Basal bolus ½ as LA and ½ divided into 3x meal time doses
E.g. 12-24 units LA and 4-8 units QA with meals
Twice daily 2/3rd pre BF, 1/3
rd pre dinner
E.g. Mix 32 units pre BF 16 units pre dinner
Once daily isophane or lantus
E.g. Humulin I 24 units pre BF
Blood glucose monitoring
Self blood glucose monitoring To titrate medication
To detect hypoglycemia
Not required if on metformin or gliptin
4-6x daily if T1DM or pregnant
Individualised aims pre meal
4-6mmol/L usual, 3.5-5.5mmol/L in pregnancy
11/2 to 2hrs after meals < 10mmol/L (HbA1c 8%)
< 8mmol/L tight (HbA1c 7%)
< 7.5 mmol/L pregnancy (HbA1c 6%)
Sick day rules T1 DM
Food Usual food at regular intervals
If unable to eat
Replace carbohydrate with milk, ice cream, custard, fruit or sugary drinks
If vomiting or unable to take food or drinks go to the emergency dept
Blood testing
Test BG every 4 hours including during the night
Test ideally blood ketones at least twice a day - 4x day if positive
Sick day rules Type 1 diabetes
Use quick acting or mixed insulin Blood ketones <3mmol/L >3mmol/L
Total daily Insulin dose Give extra 10% Give extra 20% every 4 hours every 2 hours Up to 14 units 1 unit 2 units 15 - 24 units 2 units 4 units 25 - 34 units 3 units 6 units 35 - 44 units 4 units 8 units 45 -54 units 5 unit 10 units
Push fluids This algorithm has been adapted from DAFNE guidelines
Sick day rules – T2 DM
Generally do not stop tablets or insulin ? Metformin if anorexia/diarrhoea
Can become hypoglycemic if poor appetite
Increase blood testing 4x a day Safest to see health professional daily
Increase sugar free fluid intake
If unable to eat solid food Ice cream, milk, cola, fruit juice, yoghurt
Sick day rules T2DM on insulin
Blood glucose Insulin to add If total insulin dose to each dose >50 units/day
11-17 mmol/L 2 units 4 units
17- 22 mmol/L 4 units 8 units
> 22 mmol/L 6 units 12units
All adjustments are incremental and should be reduced gradually as the illness subsides.
Diagnosis of diabetic ketoacidosis
All three of the following must be present
Capillary BG >11mmol/L
Capillary ketones >3mmol/L or urine ketones ++ or more
Venous pH <7.3 and/or bicarbonate < 15mmol/L
Management of DKA 0-60mins
0.9% sodium chloride 1 litre over an hour (hypotension, Hx CCF may require more or less).
Fixed rate insulin infusion 0.1units/kg/hour
Assess patient
Further investigations Capillary and laboratory glucose
U&E, FBC, blood cultures, ECG, CXR, MSU
Establishing monitoring regimen Hourly CBG/ketones
Venous bicarbonate/potasium at 1hr then 2 hrly
4hrly plasma U&Es
Cardiac monitoring +/-pulse oximetry
Management of DKA60mins to 6 hrs
Aims of treatment Ketones down by 0.5mmol/L/hr or bicarbonate rise 3mmol/L/hour BG fall by 3mmol/L/hour but avoid hypoglycemia Maintain potasium in normal range
Reassess patient monitor vital signs Continue fluid replacement
0.9% sodium chloride 1litre over 2 hours, 2 hours and 4 hours add 10% dextrose if BG <14mmol/L.
Potassium replacement >5.5mmol/L nil, 3.5-5.540mmol/L, < 3.5mmol/L senior review
Assess response to treatment If response inadequate increase insulin infusion rate 1 unit/hour
increments until target achieved
Additional measures Indications for urinary catheter/nasogastric tube, thromboprophylaxis
Management of DKA6-12 hrs
Aims Ensure clinical and biochemical parameters improving
Continue iv fluids (4-6 hourly, add 10% dextrose 125mls/hour when BG <14mmol/L)
Avoid hypoglycemia
Assess for complications of treatment e.g fluid overload/cerebral oedema.
Rx precipitating factors
Reassess the patient and monitor vital signs.
Review biochemical and metabolic parameters. Target ketones <0.3mmol/L and venous pH >7.3mmol/L
and/or venous bicarbonate >19mmol/L
Management of DKA12-24 hrs
Expectation
ketonemia and acidosis should have resolved.
Ensure clinical and biochemical parameters are continuing to improve or are normal
Ensure long acting insulin is given
if established diabetes usual dose usual time
if new diabetes give LA e.g. Lantus 12-24 units nocte
Management of DKAResolution
Expectation
Patients should be eating and drinking
Ketones and acidosis resolved – ideally BG <17mmol/L
Transfer to subcutaneous insulin
give QA insulin and stop sliding scale 30 mins later.
if new on insulin use dose on sliding scale as a guide e.g. QA 4-8 units tds
if no LA given - intermediate (e.g isophane or levemir) ½ to 2/3rds expected bedtime dose in the morning.
Education whilst inpatient
Follow up with the diabetes specialist team
The hyperosmolar state
Characteristic features
Hypovolemia
Marked hyperglycemia >30mmol/L without signficant ketosis Ketones <3mmol/L or acidosis pH >7.3mmol/L bicarbonate >15mmol/L.
Osmolality 320mosmol/kg or more
Goals of treatment
Normalise osmolality Check frequently
Replace fluid and electrolyte losses Iv 0.9% N saline – only switch to 0.45% saline if the osmolality
is not declining
An initial rise in sodium is expected – thereafter the rate of fall of sodium should not exceed 10mmol/L in 24 hours.
Normalise BG should fall by no more than 5mmol/hr
Low dose o.05 units/kg/hr should be commenced once the BG is no longer falling with iv fluids alone or there is significant ketonemia.
Goals of treatment (cont)
Prevention of arterial or venous thrombosis
Prophylactic low molecular weight heparin or heparin if significant renal impairment
Prevent cerebral oedema/central pontine myelinolysis
Avoid excess fluids and rapid changes in serum osmolality
Prevent foot ulceration
Foot assessment
HHSRecovery
Expectation patients should be
Eating and drinking
Biochemical parameters have normalised
Mobilising
Catheter removed
Subcutaneous insulin
Usually twice daily regime – education + meter to SBGM
Discharge with follow up
Plan to
Start/restart metformin (usually on or soon after discharge)
Convert to/back to oral hypoglycemic agents (usually 6 -12wks)
Ken
36 yr old M 2/52 Hx osmotic symptoms and weight loss
BMI 31kgm2
Blood glucose 44mmol/L
Creatinine 140µmol/L
Urine analysis – glucose and ketonuria +++
Blood ketones 4.2mmol/L
DKA/HHSKetosis prone type 2 diabetes
Acidosis and ketosis with severe hyperglycemia and dehydration.
Usually risk factors for T2DM
Will be managed as per DKA but usually discharged on twice daily mixed insulin
Check GAD and islet cell antibodies
6-12 wks if antibodies negative stop insulin leave on metformin but should probably continue to test BG once a week or more if unwell.
Hypoglycemia on the wards
Definition ?<4 ?<3.5 ? 2.2mmol/L BG 3.5- 3.9mmol/L
60mls lucozade/100mls fruit juice/2 tspns sugar/ 3 dextrosols
BG < 3.5mmol/L if alert as above– may need to repeat
if drowsy or refusing to eat then glucogel
if comatose 100mls iv 20% dextrose or glucagon 1mg im
give snack/meal and insulin if due when BG > 4mmol/L
If on long acting hypoglycemic agent and not eating May need 10% dextrose infusion
Look for the cause
Hypoglycemia in the emergency dept.
Ensure that the hypo Rx
fast then slow CHO
Advice on avoiding
insulin/SU, snack with EtOH or exercise
Advice on managing of future hypos
partner education
Risks of hypoglycemia
implications for driving
hypo unawareness
risk to the fetus
Ensure follow up
Diabetic feet
Always check feet of patients with diabetes Pulses, Other (blisters, abrasions, deformity, callus, ulcers
toenails, swelling) Deformity (varus/valgus, pes cavus/planus, charcot) Infection, Sensation
Admission diabetic foot Neuropathic or vascular or both
Rx sepsis – local guidelines
Imaging – X ray +/- MRI scan
If pulses not palpable – duplex/CT angiogram
Multidisciplinary foot team Podiatrist, diabetologist, vascular surgeon
Final thoughts
Establish whether the patient has T1DM or T2DM
Not just new presentations but also patients with pre existing DM
How well was the diabetes managed before
HbA1c/monitoring diary
Follow the protocols for DKA and HHS
Remember to write up usual insulin
When a patient is not eating and drinking once glucose <14mmol/L will need dextrose – if BG rises increase insulin
Hypoglycemia
BGs 3-3.5mmol/L occur commonly in healthy population
Apple and orange juice are available on every ward
Diabetic feet
Prevention is better than cure – protect the heels
They do grow up!