NHS GGC INPATIENT DIABETES

EDUCATIONAL SLIDE SET

Version 1, February 2020

14 TOPICS 1. Inpatient Capillary Blood Glucose (CBG) targets

2. Types of injectable and oral therapies in Diabetes

3. Admission checklist

4. What to do with usual Diabetes therapy in an acutely unwell patient

5. How to avoid / manage hypoglycaemia

6. When to measure blood ketones in T1D and how to act on the result

7. How to avoid / manage hyperglycaemia

8. How to manage a fasting or vomiting patient with Diabetes

9. When and how to start or stop a VRIII

10. How to manage hyperglycaemia during NG feeding

11. How to manage steroid-induced hyperglycaemia

12. Ensuring insulin safety

13. When and how to refer to the IP Diabetes Team

14. Discharge checklist

1) Capillary Blood Glucose (CBG) targets for inpatients – use clinical judgment

• Default target (pre meal) CBG: 6-10 mmol/L

• Consider target CBG: 8-12mmol/L • for elderly and frail patients • for patients with reduced/no hypoglycaemia awareness

• Consider target CBG: 8-15mmol/L • for patients on an end-of-life pathway

• Consider more liberal targets if clinical circumstances indicate • e.g. if significant or severe cognitive/behavioural/psychiatric issues • liaise with inpatient diabetes team if necessary

INJECTABLE THERAPIES ORAL THERAPIES

DPP-4 inhibitors

GLP-1 mimetics

Insulin

long acting rapid acting

intermediate acting

Humulin I Insulatard

Lantus Abasaglar Levemir Toujeo Tresiba

Fiasp Novorapid Humalog Apidra

short acting

Actrapid Humulin S

(2) Types of injectable and oral therapies in Diabetes

(Liraglutide + Tresiba)

SGLT-2 inhibitors

Dapagliflozin Empagliflozin Canagliflozin Ertugliflozin

Sitagliptin Linagliptin Alogliptin

Metformin Gliclazide

Pioglitazone

Xultophy

Liraglutide Dulaglutide Semaglutide Exenatide

mix

Humulin M3 Novomix 30 Humalog Mix25 Humalog Mix50

Combinations of oral drugs

(always check which generic drugs are included in branded combinations, and clarify doses)

‘BASAL’ ‘BOLUS’

(2) What are the most commonly used insulin regimes?

• BASAL BOLUS Long/intermediate-acting insulin given once or twice daily to provide background (basal) insulin with short/rapid-acting (bolus) insulin to cover meals

• ‘BD MIX’ Combination of intermediate- and short/rapid-acting insulin, usually given before breakfast and evening meal . The number refers to the percentage (eg 25, 50) or proportion (eg 3/10) of short/rapid-acting insulin (e.g. Humulin M3 = 30% short-acting + 70% intermediate-acting insulin)

• BASAL ONLY Long/intermediate-acting insulin, usually given once daily to provide background (basal) insulin

(2)

(3) Admission checklist for patients with Diabetes

• Clarify type of Diabetes

• Check HbA1c (if no result within last 3/12)

• Consider checking blood ketones / VBG if patient hyperglycaemic (see [6] [7])

• Check at least 2 sources (e.g. ECS., patient, relative) for Diabetes drugs, especially Insulin – clarify type, frequency, doses

• Prescribe Insulin by brand name (e.g. Novorapid), not generic name (eg Insulin Aspart)

• Prescribe/document insulin delivery method on insulin chart (if ordinarily self-administers) – i.e. penfill cartridges or type of disposable pen (e.g. Novomix 30 flexpen)

• Be aware of concentrated insulin and combination pens (see [12])

• Always prescribe on both Kardex and Insulin Prescription Charts with ’units’ pretyped. Never write U or IU after the number

• Consider holding non-insulin therapy depending on acute presentation (see [4])

• Consider proactively altering Insulin doses depending on acute presentation and initial CBG measurements (see [4] [8] [11])

• Never stop intermediate/long-acting Insulin in Type 1 / pancreatic Diabetes

• If patient on ‘Insulin Pump’, seek early senior / specialist advice, especially if patient drowsy or confused (see [12])

(4) What to do with usual non-insulin therapy in an acutely unwell patient with T2D

• Metformin • Stop if eGFR <30; reduce dose to 500mg bd if eGFR 30-44

• Hold if severe sepsis, especially if lactate >5

• Hold if D&V

• ‘Gliptins’ (DPP-4i) & ‘Glutides’ (GLP-1 mimetics) • Hold if D&V

• Dose-adjust if AKI (as per BNF)

• ‘Gliflozins’ (SGLT-2i) • Hold if septic (especially urosepsis), dehydrated or AKI

• Low threshold to check ketones and VBG to rule out euglycaemic (CBG>6) ketoacidosis

• Pioglitazone • Hold if acute fluid overload (eg heart failure)

• Gliclazide • Hold or reduce dose if AKI, HbA1c <53, reduced oral CHO intake

• Consider increasing dose if hyperglycaemic (e.g. steroids –] see [11] ), review dose prior to discharge

(4) What to do with usual insulin therapy in an acutely unwell patient with diabetes

• Check HbA1c (mmol/mol) to provide a context for CBG patterns during acute illness: 40-55 = mean CBG 7.0-8.5 (over previous 6-8 weeks)

56-70 = mean CBG 8.5-11 (over previous 6-8 weeks)

71-90 = mean CBG 11-14 (over previous 6-8 weeks)

91-120 = mean CBG 14-18 (over previous 6-8 weeks)

• Target (pre meal) CBG 6-10 mmol/l (see [1] for exceptions) (if HbA1c >70, insulin will need to increase)

• Sepsis, trauma, major surgery, steroid therapy

• CBG usually rises – insulin doses may need to be increased (see [5] )

• Consider checking ketones if CBG>14 (Type 1, pancreatic, Type 2 with DKA history) or >20 (Type 2)

• Fasting, recent weight loss, end-of-life, severe AKI

• CBG usually falls – insulin doses may need to be decreased (especially short/rapid-acting insulin) (see [8] )

• In a Type 1 patient, never completely stop long-acting insulin

(5) How to avoid / manage hypoglycaemia

Type 1 Diabetes with CBG > 14 mmol/l (> 10 mmol/l if pregnant) :

consider correction dose

of insulin

(6) When to measure blood ketones in T1D and how to act on the result

Blood ketones 3.0**

H+ >45 bic <18

check blood ketones & VBG (VBG 1st cycle only)

DKA PROTOCOL

Blood ketones 3.0**

H+ < 45

Blood ketones 1.5- <3.0*

H+ <45

Blood ketones < 1.5 H+ <45

recheck CBG and blood ketones in 2 hours

#TDD = total daily dose, sum of all long and fast acting insulin taken in 24 hours

give 10% of TDD#

as fast acting insulin give 20% of TDD#

as fast acting insulin

*Blood ketones 1.5- <3.0 = urine ketones ++ ** Blood ketones 3.0 = urine ketones +++ or ++++

(7) How to approach acute hyperglycaemia

Type 1 Diabetes / Diabetes secondary to pancreatic disease If CBG > 14 mmol/l (>10 if pregnant), check ketones:

1. If patient is well, and urine ketones 0 or +, or blood ketones <1.5 mmol/l, give correction dose of Novorapid according to patient’s insulin sensitivity index (ISI). If ISI not known, give 1 unit for every 3mmol/l required reduction (eg 4 units to reduce by 12mmol/l)

2. If patient is well, and urine ketones ++, or blood ketones 1.5-3.0 mmol/l, give 10% of total daily insulin dose as Novorapid

3. If patient is well, and urine ketones +++ or ++++, or blood ketones >3.0 mmol/l, give 20% of total daily insulin dose as Novorapid

4. Repeat after 2 hours

5. If CBG and ketones not improving, check VBGs, commence on VRIII (H+<45, bic >18) or DKA protocol (H+>45, bic<18) and seek senior / specialist input

(7) How to approach acute hyperglycaemia

Type 2 Diabetes If CBG > 14 mmol/l:

1. If recent HbA1c is <75 ask why CBG is high (e.g. sepsis, steroids,

nutritional supplements)

2. Usually no need for acute correction dose

3. Increase usual doses of insulin by 20% or consider starting once or twice daily long/intermediate-acting (basal) insulin

4. If CBG >20 mmol/l on 2 or more measurements, check VBG (and blood ketones if acidotic), consider VRIII / DKA / HHS protocol (whichever appropriate) and seek senior / specialist input

(7) How to titrate insulin doses

1. Patients on BD Mix insulin regime (e.g. Humulin M3, Novomix 30, Humalog Mix25, Humalog Mix50) 1. Set appropriate CBG target (see [1] )

2. If pre-breakfast CBG off-target (on 2 or more days), adjust evening meal dose by

10% (‘minor change’: <6 or >10) or 20% (‘major change’: <4 or >14)

3. If pre-evening-meal CBG off-target (on 2 or more days), adjust pre-breakfast dose by 10% (‘minor change’: <6 or >10) or 20% (‘major change’:<4 or >14)

2. Patients on Basal/Bolus or Basal only regimes (e.g. Humulin I, Insulatard, Lantus,

Levemir, Toujeo, Tresiba) 1. Set appropriate CBG target (see [1] )

2. If pre-breakfast CBG off-target (on 2 or more occasions), adjust long/intermediate-

acting (basal) Insulin dose by 10% (‘minor change’:<6 or >10) or 20% (‘major change’: <4 or >14)

(8) How to manage a fasting or vomiting patient with Diabetes

Type 1

- increase frequency of CBG monitoring

- give usual intermediate/long-acting insulin doses, and hold short/rapid acting insulin (if on mix insulin (e.g. Humulin M3), temporarily convert to intermediate-acting insulin (e.g. Humulin I) at 50-70% lower total dose). If CBG trending downwards, proactively reduce doses.

- if unwell and/or erratic CBG profile and/or blood ketones >3.0, consider VRIII / DKA protocol

- while on VRIII / DKA protocol, continue to give intermediate/long-acting insulin at usual time (i.e. Humulin I, Insulatard, Lantus, Levemir, Toujeo, Abasaglar, Tresiba)

Type 2

- increase frequency of CBG monitoring

- hold all oral Diabetes drugs and GLP-1 mimetic injectable drugs

- if on insulin give usual intermediate/long-acting insulin doses and hold short/rapid-acting insulin (if on mix insulin (e.g. Humulin M3), temporarily convert to intermediate acting insulin (e.g. Humulin I) at 50-70% lower total dose). If CBG trending downwards, proactively reduce doses.

- if very unwell and/or erratic CBG profile, consider VRIII

(9) When and how to start or stop a VRIII

Before starting VRIII:

• Check if the patient is already on a long- or intermediate-acting insulin (i.e. Humulin I, Insulatard, Lantus, Levemir, Abasaglar, Toujeo or Tresiba). If so, administer at the usual time whilst using VRIII (unless advised otherwise).

• Pre-mixed insulin (e.g. Humulin M3, Novomix 30, HumalogMix 25, HumalogMix 50) should not be administered

whilst on VRIII. When stopping VRIII:

• If long-acting insulin already on board, can stop VRIII any time

• If no long-acting insulin already on board, give usual dose and stop VRIII after 2 hours

• If switching back to mix insulin, must be done either at breakfast or dinner, and stop VRIII after 2 hours

• If new insulin start, calculate total dose over past 24 hours and give 70% in appropriate subcutaneous regime (and refer on Trakcare for DSN education)

Training video on VRIII at https://www.youtube.com/watch?v=7OWRkZmb6D4 (takes approx 9mins)

(10) How to manage hyperglycaemia during NG feeding

• Hyperglycaemia induced by enteral or parenteral feeds should be treated with insulin

• To assess insulin dose requirement, start VRIII while on maintenance feed

• Continue VRIII for 24-48 hours

• Retrospectively calculate ‘total daily insulin dose’ and subtract 25%

• Split this dose according to feed duration with tailored insulin regime (eg for 16 hour feed, give 2/3 at start as Humulin M3 then 1/3 after 10 hours as Humulin I)

(11) How to manage steroid-induced hyperglycaemia

(a) CBG monitoring of patients who don’t have Diabetes but are at high risk of steroid-induced hyperglycaemia

If one or more risk factors for steroid-

induced hyperglycaemia present 1 check HbA1c

If HbA1c 42-47

mmol/mol, move to STEP 1

STEP 1

Measure CBG once daily at 4pm

If CBG>10mmol/l,

move to STEP 2

STEP 2

Measure CBG 4 times daily

If CBG>10mmol/l on 2 or more occasions in

24 hrs, move to TREATMENT ALGORITHM

1 Risk factors for steroid-induced hyperglycaemia are: obesity, strong FH T2D, previous gestational diabetes, PCOS and South Asian & Middle Eastern ethnicity

Target CBG 6-10mmol/l

(11) How to manage steroid-induced hyperglycaemia

(c) Treatment of steroid induced hyperglycaemia in patients without Diabetes and patients with Diabetes who are not on Gliclazide or Insulin

If CBG>10 on 2 or more occasions in 24 hrs

If CBG>20, consider moving straight to Insulin, and refer for specialist input

Patient on single morning dose of steroid

Patient on > 2 daily doses of steroid

Start Gliclazide 40mg once daily in the morning

Start Gliclazide 40mg twice daily with breakfast and evening meal

Increase morning Gliclazide daily by 40mg increments until target achieved (max dose 240mg)

Increase Gliclazide daily by 40mg increments until target achieved

(max dose 160mg twice daily)

If still not to target, add morning Humulin I at a dose of 10 units and

titrate daily thereafter

If still not to target, add morning Lantus at a dose of 10 units and

titrate daily thereafter

Target CBG 6-10mmol/l

(11) How to manage steroid-induced hyperglycaemia

(b) CBG monitoring of patients on high dose steroids who are known to have Diabetes

Check baseline HbA1c in all patients with Diabetes prior to starting high dose

steroids

STEP 1

Measure CBG 4 times daily

If CBG>10mmol/l on 2 or more occasions in

24 hrs, move to TREATMENT ALGORITHM

Target CBG 6-10mmol/l

(11) How to manage steroid-induced hyperglycaemia

(c) Treatment of steroid induced hyperglycaemia in patients with Diabetes who are on Insulin

If CBG>10 on 2 or more occasions in 24 hrs

Once daily bedtime Insulin

Basal bolus Insulin

Move Insulin to morning and increase by 10-20%

Move long acting Insulin to morning and increase by 10-20%

Single morning dose of steroid

Twice daily dose of steroid

Increase dose of morning Mix Insulin by 10-20%

Increase dose of both morning and evening Insulin by 10-20%

Target CBG 6-10mmol/l

Twice daily Mix Insulin

1. Always check type of insulin, dose and frequency of administration with at least 2 sources (eg ECS and patient) . If importing medicines from ECS into hospital electronic systems, add the brand and check the dose as some systems convert to generic names.

2. If patient uses pen insulin, prescribe the type of pen (if disposable, otherwise the appropriate insulin penfill cartridge insulin, and administer pen insulin

3. Use pen safety needles (ensure appropriate training)

4. Always prescribe on Insulin Prescription Charts with ’units’ pretyped. Never write U or IU after the number!

5. Be aware that changes in patient’s condition may affect insulin requirement (nutrition, steroids, sepsis, renal function) and adjust doses as necessary (target pre-breakfast and pre-evening-meal CBG 6-10 mmol/l)

6. Continue basal / long-acting background insulin in a Type 1 patient, even if fasting or NBM (dose may need adjusted)

7. Ensure that basal insulin has been given before discontinuing intravenous insulin

8. If a patient on an insulin pump is admitted and unable to self manage, remove pump and start variable-rate intravenous insulin infusion (VRIII)

9. Be aware of concentrated pen insulins (Tresiba 200units/ml, Toujeo 300units/ml, Humalog200units/ml). Never draw insulin from a pen with a syringe!

10. Be aware of Xultophy (Tresiba100units/ml + Liraglutide, fixed combination). Advise temporary switch to Tresiba100units/ml as inpatient (‘dose steps’ = units)

(12) Ensuring insulin safety

(13) When and how to refer to the IP Diabetes Team

Indications for referral to diabetes inpatient team:

New diagnosis of Type 1 Diabetes Diabetic Ketoacidosis (DKA) Recurrent or severe hypoglycaemia, where attempts at Insulin or Gliclazide titration are unsuccessful Hyperglycaemia (when recent HbA1c <70mmol/mol), where attempts at Insulin or Gliclazide titration are unsuccessful Hyperglycaemic Hyperosmolar State (HHS) Patients who require insulin initiation Intravenous insulin (VRIII) > 48 hours Patients using continuous subcutaneous insulin infusion (CSII) pumps Active foot ulceration (refer also to Podiatrist via Trakcare) Diabetes in pregnancy NBM or parenteral or enteral feeding, with problematic glycaemic control Problematic glycaemic control in the context of changing renal function Patient education – sick day rules, hypoglycaemia, driving advice, insulin administration, glucose testing

Refer via Trakcare – select patient, new request – other – diabetes inpatient referral

(14) Discharge checklist for patients with Diabetes

• Review any ‘held’ Diabetes drugs and consider restarting if appropriate

• Review any inpatient dose titrations (especially Insulin and Gliclazide) and communicate with patient and GP about any ongoing titration advice (eg proactive down-titration in context of reducing-dose steroids) - include insulin doses on IDL (use brand names, not generic)

• If patient has been started on Insulin during admission, ensure patient / carers have had appropriate Diabetes Specialist Nurse (DSN) education

• Ensure patient / carers know doses on discharge and any short-term titrations expected • Disposable pens v penfill cartridges? – ensure the IDL has the correct type

• If patient unable to self-manage new Insulin regime, ensure that Community Nursing Team and Community DSN Team are aware (ward nurses can refer)

• If Community Nurse to be involved, vials and syringes must be prescribed on the IDL

• Ensure that IDL includes reasons for any changes to diabetes drugs

• Ensure patient has follow-up with local Diabetes OP Team (if appropriate) and copy IDL to relevant Consultant

• If DSN follow-up arranged prior to discharge, check that patient knows when and where

14 TOPICS 1. Inpatient Capillary Blood Glucose (CBG) targets

2. Types of injectable and oral therapies in Diabetes

3. Admission checklist

4. What to do with usual Diabetes therapy in an acutely unwell patient

5. How to avoid / manage hypoglycaemia

6. When to measure blood ketones in T1D and how to act on the result

7. How to avoid / manage hyperglycaemia

8. How to manage a fasting or vomiting patient with Diabetes

9. When and how to start or stop a VRIII

10. How to manage hyperglycaemia during NG feeding

11. How to manage steroid-induced hyperglycaemia

12. Ensuring insulin safety

13. When and how to refer to the IP Diabetes Team

14. Discharge checklist