Regional G(I)M Specialist Registrar Training Day: Top tips for managing inpatients with diabetes

Wednesday 13th March 2019 Dr Belinda Allan

Inpatient Diabetes Lead Hull University Hospitals Teaching Trust

Case

• 27 year old female • T1 DM – insulin pump (CSII) - A1c 73mmol/mol • Pregnant 5/40; vomiting with PV bleeding • Capillary ketones 2.7mmol/L - CBG 10mmol/L • pH 7.37 - serum bicarbonate 20mmol/L - K+ 3.9mmol/L • Positive pregnancy test - BHCG 11, 500 • No other medication

Considerations

• At risk of DKA • Bolusing from pump – working? • How to manage the patient’s diabetes? • Suffering miscarriage or implantation bleed? • Congenital malformation risk in DM –

unplanned pregnancy

Management

• GKI infusion – glucose supply, insulin to suppress ketogenesis, potassium to prevent hypokalaemia

• Antiemetic • Additional 0.9% saline • Patient changed giving set for pump but then basal

rate resumed (=background insulin equivalent) • Folic acid 5mg • Endocrinologist and obstetrician on-call informed • Repeat USS in 10 days; consider repeat BHCG in 48

hours

Physiology

Placental weight & maternal serum concentrations of human placental lactogen (hPL) during pregnancy. From Selenkow HA, Saxena BN, Dana CL. Measurement and pathophysiologic significance of human placental lactogen. In Pecile A, Finzi C, eds. The Feto-Placental Unit. Amsterdam: Excerpta Medica, 1969:340

T1 diabetes = ABSOLUTE insulin deficiency + Pregnancy = insulin RESISTANT state

T1 diabetes = ABSOLUTE insulin deficiency

Pregnancy predisposition to DKA

Insulin resistance • ▼GLUT 4 and GLUT 5

receptors

• ▲antagonistic hormones

Carbohydrate metabolism • ▼ gut motility • ▲ metabolic rate • ▲eGFR→glycosuria • Fetoplacental transfer of

glucose • Rapid switch from CHO

to fat metabolism

Physiological adaptation to pregnancy • ▲hyperventilation • ▼buffering capacity

Acidosis can be more pronounced at lower glucose levels

Using an insulin pump

• Insulin pumps use rapid-acting insulin only • Pump ?not working

• Insulin cartridge cracked • Cannula site infection • Poor cannula insertion/absorption • Battery failure • Intercurrent illness (illness button) • Carb counting skills? • Forgotten to bolus

Adjusting insulin pumps when ill

• Hyperglycaemia – Check ketones when CBG >=13mmol/L – Correction dose (‘insulin sensitivity factor’ ISF) e.g.

1 unit lowers CBG by 2 or 3 mmol/L – e.g. CBG 18mmol/L – target CBG 6mmol/L =

12mmol/L difference – ISF=1:3mmol/L thus correction dose= 4units (in

addition to insulin taken for any carbs eaten)

Five pieces of information T1 patients need to know before giving insulin with meal

1. Target CBG 2. ISF (correction for raised CBG) 3. Mealtime ratios insulin:carb 4. Amount of carb to be eaten (grams) 5. Insulin on board (duration of action) Then consider…. • Predictable activity e.g. 1 hour at the gym

CBG=capillary blood glucose; ISF= insulin sensitivity factor

Sick day rules

• All patients with T1 diabetes should have access to sick day rules

• TREND-UK leaflet • Trust’s own guidelines • Additional doses of QA insulin administered in

response to rising ketone levels • 100-200ml/hour of clear sugar-free fluids to maintain

hydration

QA=quick-acting insulin e.g. Novorapid, Humalog, Apidra, Fiasp

Top tips for managing T1 patients on insulin pumps

• Never stop an insulin pump • If ketones/glucose failing to respond to single pump bolus –

revert to insulin pen to bolus QA insulin; repeat CBK/CBG in 2 hours following ‘sick day rules’

• If suspicion pump not working – patient should change giving set and re-prime; check battery; contact company

• If pump not working despite above – alternative basal insulin e.g. Levemir 12units BD (or Humulin I or Insulatard or Insuman basal) needs to be administered

• Ensure patient has insulin pens (basal and rapid-acting insulins) on discharge + ketone meter + diabetes team telephone number

Case

• 59 year old male patient with metastatic lung cancer • T2 diabetes • Metformin, dapagliflozin • Commenced on dexamethasone 4mg BD for cerebral

mets • Complained of thirst, weight loss, thrush and

lethargy • A1c 50mmol/mol 86mmol/mol • Ketones 0.2mmol/L

Considerations

• SMBG – usually when on SU and/or insulin only • When commencing steroids consider duration, dose

and effect on diabetes • Consider pre-treatment A1c and increase testing to

QDS in those with pre-existing DM • Warn the patient!

SMBG=self-monitored blood glucose; SU=sulphonylurea e.g. gliclazide

Steroid dose equivalents

N.B. potency relates to anti-inflammatory action, which may not equate to hyperglycaemic effect

Steroid Potency Duration of action (Half-life in hours)

Hydrocortisone 20mg 8

Prednisolone 5mg 16-36

Methylprednisolone 4mg 18-40

Dexamethasone 0.75mg 36-54

Betamethasone 0.75mg 26-54

Management

• CBG : 12 (pre-BF) –18 (pre-L) –24 (pre-EM)-18 (pre-Bed) • Commenced SU 80mg BD with b’fast + evening meal • Adequate hydration; HHS risk • Insulin an option – Actrapid with BF/lunch/EM or twice daily pre-

mixed insulin e.g. Novomix 30 or Humalog Mix 25 or Humulin M3

Steroid-induced hyperglycaemia • Prevalence of steroid use in hospital 10% • In OPD

– 40% in respiratory disease – 60% in cutaneous or MSK disorders or neurological disease

• Most duration of treatment usually <5 days • 22% steroid use > 6 months • Steroid-induced hyperglycaemia = pre-existing diabetes • Steroid-induced diabetes = no known diabetes prior to steroids

Who is at risk of steroid-induced diabetes?

• People at increased risk of diabetes (e.g. obesity, FH diabetes, previous GDM, ethnic minorities, PCOS)

• Impaired fasting glucose or impaired glucose tolerance,

HbA1c 42-47mmol/mol • People previously hyperglycaemic with steroid therapy • Those identified to be at risk utilising the University of

Leicester/Diabetes UK diabetes risk calculator (riskscore.diabetes.org.uk)

Glucose targets for inpatients with diabetes

• National guidance target CBG 6-10mmol/L, accepting a range of 4-12mmol/L BUT avoid tight glycaemic control in the following groups:

Patients with dementia The confused The frail older person People at risk of falling Those with variable appetite and dietary intake EOL care • Aim for CBG 6-15mmol/L in these vulnerable patient groups

JBDS Management of hyperglycaemia and steroid (glucocorticoid) therapy; Oct 2014

Top tips for managing steroid-induced hyperglycaemia/diabetes

• Prescribing steroid? THINK diabetes • Ensure access to CBG meter (from whom and how, ?patient new to testing) • Testing OD pre- or post-lunch (if unknown DM) or QDS (if known DM or

unknown DM but readings >12mmol/L) • Can use gliclazide 240mg AM and 80mg PM in T2/new diabetes (N.B. hypo

risk as steroid withdrawn) • Prepare to move to insulin early • Access to ketone testing in T1 DM • Signpost patient to diabetes team for support (?local diabetes helpline

number) • Test for diabetes 6 weeks (if testing using lab glucose) or 12 weeks (if using

HbA1c test) after steroid cessation in previously undiagnosed DM.

Case

• 80 year old lady from RH with dementia • Progressively unwell over the course of the week • Not eating or drinking • Treated for UTI by GP with nitrofurantoin • Diet + metformin managed T2 DM • A1c 60mmol/mol (6 months prior) • On ACEI/diuretic for hypertension • Unwell, confused, drowsy, clinically very dehydrated

Case

• CBG ‘Hi’; gas glucose >27.8mmol/L; Lab glucose 45mmol/L

• CBK 0.4mmol/L • pH 7.35; lactate 3.5mmol/L; bicarb 19mmol/L • Na+ 142mmol/L • K+ 6.5mmol/L • Urea 28mmol/L • Creatinine 187mcmol/L = AKI stage 2 • Peaked T waves on ECG

Osmolality

• 2 (Na+) + urea + glucose = calculated osmolality • 2x (142) + 28 + 45 = 357mOsmol/kg

Characteristic features of a person with HHS

Hypovolaemia

+ Marked hyperglycaemia (>30 mmol/L)

without significant hyperketonaemia (<3.0 mmol/L) or acidosis (pH>7.3, bicarbonate

>15 mmol/L) +

Osmolality >320 mosmol/kg

Goals of treatment

Gradually and safely: • Normalise the osmolality • Replace fluid and electrolyte losses • Normalise blood glucose Prevention of: • Arterial or venous thrombosis • Other potential complications e.g. cerebral oedema/

central pontine myelinolysis • Foot ulceration (heel protection)

Considerations

• Hyperkalaemia – ?how to manage • Elderly – high CVS risks, fluid resuscitation

appropriate rate • Precipitating cause? • AMU or Level 2 care? Pre-morbid state?

Level 2 care? • Osmolality >350mosmol/kg • Sodium >160mmol/L • Venous/arterial pH <7.1 • Hypokalaemia (<3.5 mmol/L) or hyperkalaemia (>6 mmol/L) on admission • Glasgow Coma Scale (GCS) <12 or abnormal AVPU scale • Oxygen saturation < 92% on air (assuming normal baseline respiratory

function) • Systolic blood pressure <90 mmHg • Pulse >100 or <60 bpm • Urine output less than 0.5 ml/kg/hr • Serum creatinine > 200 μmol/L • Hypothermia • Macrovascular event such as myocardial infarction or stroke • Other serious co-morbidity

JBDS The management of HHS in adults; Aug 2012

Fluid and electrolyte losses in HHS

JBDS The management of HHS in adults; Aug 2012

General principles

• Fluids – 0.9% saline; paradoxical rise in serum sodium due to falling glucose – 0.45% saline once adequately resuscitated and osmolality and glucose

NO LONGER declining – Access to water orally (providing safe swallow)

• Insulin – Only start fixed rate IV insulin infusion (FRIII) when blood glucose is no

longer falling with IV fluids alone – FRIII: 0.5units/kg/hour – Continue s/c basal insulin (if taking pre-admission)

• Anticoagulation – Prophylaxis only

Top tips for managing HHS

• Plot osmolality – progressing as expected? • Serum sodium may rise – not necessarily an indication for hypotonic fluids • Aim for 50% fluid replacement in 12 hours, 50% over next 12 hours BUT

consider degree or renal/cardiac impairment initially which may limit this • Insulin only when CBG no longer falling; use FRIII 0.5units/kg/hr, aim fall 4-

6mmol/L/hour • If the inevitable rise in serum Na+ is much greater than 2.4mmol/L for

each 5.5mmol/L fall in glucose – suggests insufficient fluid replacement • Thereafter, the rate of fall of plasma sodium should not exceed 10 mmol/L

in 24 hours • A target blood glucose of between 10 and 15 mmol/L is a reasonable goal • Complete normalisation of electrolytes and osmolality may take up to 72

hours

Case

• 67 year old male • T2 DM on gliptin/SU/MF • Acute abdomen for bowel obstruction; NBM • On acute theatre list • CBG 23mmol/L and rising • ‘Ring RMO’

Considerations

• ?ketone check • Timing of surgery unknown • ?A1c – issues with compliance • Stress hyperglycaemia • Urgent requirement to stabilise glycaemic

control

Pre-operative glucose levels and perioperative mortality

Peter G Noordzij et al. EJE (2007) 156: 137-142

Frisch A et al Diabetes Care 2010;33(8):1783-1788

Do High Glucose Levels Cause Harm?

Management

• GKI or FRIII?

GKI • 500ml of

– 10% dextrose (10gram glucose/100ml) + – 10mmol KCL + – varying amount of QA insulin e.g. Actrapid 20 units/bag – Infused at 100ml/hour (50ml/hour if fluid restricted)

• ‘Three-in-one’: fixed ratio of substrate to insulin • Good when CBG in target range and maintaining stability required • Avoids problems of unopposed insulin or dextrose if cannula lost • Not helpful when CBG >20mmol/L and rising

• Think about usual insulin dose before considering starting dose of insulin

in GKI bag e.g. TDD 100units insulin – GKI may need to start with 28 units

TDD=total daily dose of insulin

FRIII

• Need to rapidly regain glycaemic control • CBG >20mmol/L and rising • No need for concurrent IV dextrose infusion UNLESS or UNTIL

CBG <14mmol/L then option to convert to GKI OR add separate 5% or 10% dextrose infusion with KCL

• Risk going to theatre if anaesthetist unaware – don’t leave FRIII unattended – hourly CBG and plan for additional dextrose as CBG falls

Top tips for fasting surgical patients with diabetes

• If NBM for no more than 1 missed meal, insulin infusion not necessary • Timing of surgery unknown – start GKI if CBG<20mmol/L but FRIII if CBG

>20mmol/L and rising • Prescribe and administer any s/c basal insulin alongside any insulin

infusion to avoid rebound hyperglycaemia when infusion stops • Liaise with anaesthetist about your plan • Utilise local diabetes guidelines • Up to date A1c - ?control pre-op – may help plan treatment post-op • Refer to inpatient diabetes team if foresee problems with post-op control • Daily U+E whilst on insulin infusion

Case

• 50 year old obese male with T2 DM diet + metformin • Well • Attends ED Friday 7pm with abscess not requiring

admission • CBG 20mmol/L In ED • ?advice

Considerations

• Intercurrent illness; check ketones • Osmotic symptoms, weight loss - CONCERN • Last HbA1c? • SBGM – not routinely with diet/MF/gliptin/SGLT2i/

GLP1/Pioglitazone treatment • ?BMI • Compliance? Carb intake 170g/day recommended • Self-care? • Complications?

Poor control T2

• Step-wise management • NICE confusing • New ADA/EASD guidance on T2 treatment

algorithms • Cardiovascular outcome trials (CVOT) – some

treatments offer more than others

NON-insulin treatments in T2

• Metformin • Gliptins – good for elderly; renal dose adjustment (exc. Linagliptin –

no dose change) • ‘Flozins (SGLT2i’s) – good for obese, CVS high risk or presence of

CVS disease, not in >75’s, care with renal function, euglycaemic DKA (<1%), avoid in acute illness due to infection/D+V

• Pioglitazone – not in heart failure, bladder cancer, osteoporosis, macular oedema

• Sulphonylureas – hypoglycaemia, weight gain, good for rapid control, short-term use, need to be able to SBGM (as per DVLA) as hypo risk

• GLP1 RA – BMI >35kg/m2; initiated in specialist care, s/c injection

Top tips for the well T2 hyperglycaemic patient in ambulatory care

• Is the patient well or ill? • Short duration of osmotic symptoms and weight loss points to

insulin deficiency; could give stat dose intermediate-acting insulin e.g. 6 units Humulin I or Insulatard or Levemir as immediate measure

• Recent A1c (may not be available if POC test used) • SMBG results? Meter with patient if no written diary? • Check ketones • If ketones <0.6mmol/L or <++ – home, plenty of fluids and

refer the patient to the diabetes team next day • Tell patient to avoid drinking sugary fluids

Any questions?

Thank-you