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!