glycaemic control - bordersdiabetesnetwork.scot.nhs.uk · • bm < 4mmol/l considered...
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Glycaemic Control
Complexity of CareComplexity of Care
Aims
• Treatment of Diabetes and practical aspects of management.
• Diabetic Emergencies– Hypoglycaemia– Impaired Awareness of Hypoglycaemia– Recognising DKA– Recognising HONK
Treatment of Type 1 Diabetes
Short acting insulins
• Relatively rapid onset of action
• Short duration– Soluble insulin
(Humulin S, Actrapid)– Hypurin S– Human insulin
analogues (Novorapid, Humalog and Apidra)
Biphasic) Insulins (intermediate-acting
• Anologue mixtures– Novomix 30– Humalog Mix 25
• Biphasic isophane insulins– Mixtard 30– Humulin M3– Others
Long Acting Insulins
• Analogue insulin– Glargine– Levemir
• Isophane Insulin– Insulatard– Humulin I
• Animal Insulin– Hypurin
Aim of Treatment
• To prevent death from Ketoacidosis• To relieve symptoms• To maintain glucose as near normal as
possible to reduce complications• Insulin regimens are designed to mimic
basal and post prandial insulin secretion
Normal Insulin secretion vs Insulin Treatment
Insulin Regimens
• Basal Bolus regimens– Long acting insulin analogues-levemir/glargine
provide a basal rate insulin– Rapid acting analogue premeals to mimic
insulin secretion in relation to ingestion of foods
• Biphasic insulin regimens– Twice daily injections of soluble and isophane
insulins premeals.
Twice Daily Premix
Breakfast Lunch Evening Meal
Basal Bolus Regimen
Treatment in type 2 diabetes
• Diet and Metformin• Sulphonlyureas• Sitagliptin• Thiazolidinediones• GLP-1• Insulin
Case One
• 45yr old window cleaner type 1 diabetes
• BD Novomix 30• High BMs at 3pm (12-
14mmol/l) HbA1c 9.8%
• What are you going to advice?
• Would you check for Ketones
• Look at profiles• Look for trends in
BMs• Dietary intake• Adjust insulin
Case Two
• 20 yr old student nurse type 1 diabetes on basal bolus novorapid and lantus
• Low BMs all day with High BMs at night and weekends
• What would you advise??
• Check Ketones• Diet• Profiles• Activity• Look for patterns• Adjust insulin, by how
much/• Which insulin first?
Case Three
• 65 yr old music teacher type 2 diabetes 3yrs
• 1g metformin tds• 80mg gliclazide bd• Persistent diarrhoea• BM between 6-12
• HbA1c• Review medication• Check renal function• Diet• Activity levels
Case Four
• 38yr old HGV driver• Type 2 diabetes• BMI 32• Treated with
pioglitazone and metformin
• BMs climbing• Hba1C 8.9%
• Profiles
• Lifestyle changes
• Treatment options
• Employment implications
Recognition And Treatment Of Hypoglycaemia
Prevalence
• Each year, 25-30% of all insulin treated diabetic patients suffer one or more ‘severe’ hypoglycaemic episode
(severe= requiring assistance) • Each year 10% of type 1 experience coma • Remember sulphonlyureas may induce
hypoglycaemia
Definition of Hypoglycaemia
• BM < 4mmol/l considered hypoglycaemia• Side effect insulin or sulphonlyurea
treatment• 25% insulin treated diabetes one or more
‘severe hypoglycaemic’ episode• 10% type 1 experience coma• predisposing factors:
tight control, alcohol, sleep, high insulin doses, impaired awareness of hypoglycaemia
Recognition of Hypoglycaemia
• Autonomic (↑ PNS/SNS)– sweating, tremor, palpitations, hunger (3 mmol/l)
• Neuroglycopenic– confusion, behavioural changes
• Non-specific symptoms– malaise, headache
• Non-specific Signs– pale, sweaty, tachycardia, dilated pupils, ↑ WBC,
seizures, hemiplegia
Treatment of Hypoglycaemia• Confirm hypoglycaemia by BM • Conscious patient
fast acting carbohydrate e.g.oral glucose/lucozade followed by long acting carbohydrate e.g. toast, sandwich
• Unconscious patientGlucagon 1mg or 50mls of 50%Dextrose
Hypoglycaemia due to sulphonlyureas may be prolonged (no glucagon)
Impaired Awareness of Hypoglycaemia
• Affects 25% of all insulin treated diabetics, more common with ↑ duration of diabetes
• Acute hypo unawarenessassociated with strict control
• Chronic hypo unawarenesslong duration of diabetes (15 yrs)
Sequelae of Hypoglycaemia
• Mortality 2-4% of all deaths in type 1 diabetes
• Effects on brain depend blood glucose nadir duration, frequency hypoglycaemiapresence of brain insults e.g. Head injury,
alcohol
Hypoglycaemia Induced Neurological Syndromes
• Transient hemiplegia• Convulsions (2/100 patients/yr. In up to 10% pts
insulin)• Cerebral oedema• Permanent neurological effects
pvs, hemiparesis, epilepsy, focal (motor, sensory), ataxia
Summary
• 2-4% All deaths in type 1 diabetes• Common side effect insulin or
sulphonlyureas• Risk increased as glycaemic control is
improved• Recurrent hypoglycaemia can lead to
cognitive impairment• Immediate treatment with glucose/glucagon
Case One
• 72 yr old female• Type 1 diabetes x 30yrs• BD Novomix 30• Sweaty, PR 100/min• What do you do?• What treatment do you
administer?• What change do you make
to her insulin if any??
• Check BM• Quick acting
carbohydrate (egLucozade)
• Long acting CHO
Case Two
• 25 yr old type 1 diabetes at age 10
• Basal bolus humalog and levemir
• HbA1c 6.5%• Episode of collapse• Denies Hypoglycaemia• What would you do
next???
• Review diary– What are you looking for?
• Diet and exercise• Impaired awareness?• What advice would
you give?
Case Three
• 55 yr old type 2 diabetic
• Gliclizide, Metformin, GLP-1
• Weight loss• HbA1c 6%• Feels light headed
most of the day • What next?
• Review Diary– No hypos recorded
• Dietary intake• Which medication
would you alter???
Management Of Diabetic Ketoacidosis
Introduction
• High mortality 2% in young patients, 20 % in patients over
65yrs• Most episodes avoidable and due to
electrolyte abnormalitiesaspiration pneumoniafailure to recognise ppts (eg MI)
Clinical Features
• Dehydration• Tachycardia, ↑RR• Vomiting/abdominal pain (children)• Ketosis (acetone on breath)/ketonuria• Acidosis (Kussmaul breathing)• Severe metabolic derangement
HypotensionImpaired level of consciousness
Management• Rehydration
– need approx 4-6l in first 24hrs • Potassium replacement• Insulin, average 6units/hr (4-10u/hr) • Individual response to insulin is variable
Summary
• DKA is a medical emergency• Delay in treatment may have disastrous
consequences• Rapid examination with blood and urine
tests gives initial diagnosis• Treatment should be commenced without
delay
Case One
• 45 yr old type 1 diabetes
• BM high in morning 26mml/l
• Feels unwell, not eating
• Omits insulin• What advice would
you give??
• Continue to omit insulin?
• Check urine Ketones• Precipitants• Sick day rules
Hyperosmolar Non-Ketotic Coma
• Usually older people (over 40 yr).• Known NIDDM or first presentation
(50%undiagnosed)– .Diuretics,steroids may be ppt factors.
• Infection may be present.• Marked hyperglycemia , BG may be > 50
mmols/l • Dehydration, no Ketosis• Glycosuria and Coma• Mortality 30-50%
Management of HONK
• Rehydration• Insulin (smaller doses then required for
DKA)• Heparin
Diabetic Patients With Non Diabetic Problems
Management of Surgical Diabetic
• Mr DB 60yr male• Type 2 diabetes
insulin treated with Mixtard 30
• Admitted for laparoscopic hernia repair
• Management?
• First on list• May need to reduce
insulin night before• Start GKI morning of
surgery• Resume normal
regimen at tea time if eating
Radiological Procedures
• Mrs BM 55yrs type 2 DM on Metformin and Gliclizide
• Planned out patient CT Thorax with contrast ± biopsy
• Stop oral agents• Will not need insulin
infusion• Restart Gliclizide after
procedure• Do not restart
metformin for 48 hours
Emergency Procedures
• Type 1 diabetes 15 yrs • Admitted with
haematemesis• Needs Endoscopy• What do you do?
• Need insulin and glucose
• Gki or infusion and pump
• Continue until normal diet is resumed
Myocardial Infarction
• Acute ST elevation anterior myocardial infarction
• Thrombolysis• Glycosuria • Bm 13.2 mmol/l• Management?
• DIGAMI• Insulin for 3 months
and review opd
Summary
• 2 million people in the UK with Type 2 diabetes estimated to increase to 3 million by 2010
• Multiple complications which are preventable
• Need to be aware of how to manage common problems/ presentation of patients with diabetes