Admission avoidance, troubleshooting & what's new?
Contents
1. held record from CCG website includes insulin passport Consider SU if e Not overweight MET not tolerated e Rapid response needed because of hypoglycaemic symptoms HbA1c 26 5 after lifestyle intervention Consider substituting Consider adding DPP 4 or TZD for SU if DPP 4 or TZD if e Risk of hypoglycaemia MET not tolerated or SU is MET or contraindicated contraindicated or not DPP 4 or TZD tolerated Consider adding sitagliptin or TZD Instead of insulin if insulin is unacceptable MET SU sitagliptin or Consider adding exenatide MET SU TZD or to MET and SU if MET SU exenatide e BMI 235kg m2 or BMI lt 35 l kg m and insulin Insulin MET SU unacceptable Increase insulin dose and intensify regimen Consider adding pioglitazone if e A TZD has previously had marked effect or blood glucose control is inadequate with high dose insulin MET metformin SU sulphonylureas TZD thiazolidinedione DPP 4 dipeptidyl peptidase 4 inhibitor 1 Adapted from National Institute for Health and Clinical Excellence Clinical Guideline 87 Type 2 diabetes newer agents a partial update of CG66 quick reference guide 14 DPP 4 dipeptidyl peptidase 4inhibitors NICE CG87 e The use of Sitagliptin or Vildagliptin is recommended instead of an SU as second line therapy if BG control remains or becomes inadequate if the person is at significant risk of hypoglycaemia or its co2. L start 10 glucose at 125mls hour alongside the 0 9 saline Action 3 identify and treat precipitating factors Key messages Differential diagnosis T1 v T2 Basic education for patients new to diabetes in all practices Refer early not late Don t hang on to patients if you are not sure Test your knowledge Try to undertake a self assessment e www diabetes nhs uk sate use _of_insuli n elearning course e Any questions
3. Admission avoidance amp troubleshooting JAY EQUIP12 Points for discussion What brings people into hospital What care should they receive to avoid admission When is admission necessary What should happen when a patient is diagnosed with Type 1 and Type 2 diabetes Troubleshooting HbA1c option appraisal Updates on DKA ACS What support is available Key messages Reasons for admission Non diabetes related HONK New Type 1 in DKA Known Typel in DKA drug alcohol abuse Hypoglycaemia Hyperglycaemia Who is admitted National diabetes in patient audit 2011 Reason for admission 5 1 of patients admitted for diabetes 69 2 for medical reasons 25 6 non medical 80 70 60 50 40 30 20 10 0 Management of Diabetes H Other Medical Broomfield Hospital England Broomfield Hospital England Me Other key findings 2010 and 2011 Appropriate BG monitoring 6 7 7 compared to 6 2 7 in 2010 good days 4 4 7 compared to 3 9 7 Diabetes team visit 53 8 compared to 28 3 in 2010 Medication errors 16 7 this year compared to 36 1 in 2010 Prescription errors reduced from 31 1 to 16 7 includes not signed for Taking control 83 3 from 74 3 Diabetes awareness 92 3 but only 50 enough staff knowledge Satisfaction with care of their diabetes 78 6 from 75 6 Admission avoidance What care should patient s receive to avoid admission New Type 1 suspected urgent same day referra
4. ast acting sugar e g another 3 dextrose tablets Step 3 Slow acting sugar is required to ensure the blood glucose levels does not drop again This should be taken once the blood glucose level has risen above 4mmol l Aim for 10 15g carbohydrate of slow sugar e g e 1 slice of bread e 1 piece of fruit e g banana apple orange e 1 2 digestive or rich tea biscuits e Yoghurt e 200ml milk e Note If hypo is just before a meal ensure use of fast acting sugar but replace snack with meal must have CHO Hypoglycaemia driving update Insulin treated patients must e Carry monitoring kit and test 2 hourly e BG gt 5 mmols to drive e If hypo whilst driving treat and do not resume for 45mins e Read a number plate at 20metres e lfone or more hypo requiring assistance of another person in previous 12months DVLA notifiable driving License will be re voked group 1 amp 2 Nocturnal included e 3 months of BG readings for a downloaded meter not log book When is admission necessary DKA new or existing T1 HONK usually undiagnosed T2 Pregnancy related emergency Infected diabetic foot ulcer Troubleshooting HbA1c Option appraisal What should happen when a patient is diagnosed with Tor T2 e Type 1 HBGM education basal bolus regime refer for CHO counting insulin adjustment and general support e Type 2 follow NICE guidance refer for structured education e T1 amp T2 Give or ask patient to download hand
5. choosing insulin regimens in Type 2 Not achieving goals of therapy Was failure of previous medication due to non compliance adherence Mismatched goals Weight gain Variable depending upon regimen and pre therapy state Availability or lack of dietary support Hypoglycaemia Risk is lower in type 2 diabetes 18 Onset and Duration of Insulin 20 24 Rapid acting analogue e g Humalog insulin lispro NovoRapid Apidra Short acting soluble regular e g Humulin S Human insulin Actrapid Insuman Rapid Intermediate acting Isophane e g Insulatard Humulin Isophane human Insuman Basal Long acting analogue e g Lantus or Levemir Rapid acting analogue intermediate mixture e g Humalog Mix25 Mix50 or NovoMix30 Short acting intermediate mixture e g Humulin M3 Insuman Comb 15 25 50 4 T study 3 year efficacy of complex insulin regimens in Type 2 diabetes e Sponsored by Novo Nordisk independently designed run and reported by an academic group Oxford e 1 year results published in 2007 e First phase 1 yr head to head comparison of the efficacy of 3 different types on insulin Prandial Insulin Aspart Novorapid three times daily biphasic insulin aspart NovoMix 30 twice daily basal insulin detimir Levemir once daily twice if required e 3 yr study in 708 Type 2s in 58 UK Irish centres e Second phase Evaluation over 2 further years for the need
6. d with ACS e 65 of patients with AMI not Know to have diabetes had positive impaired glucose regulation on OGTT e It is a powerful predictor of poorer survival and Tt risk of complications whether the patient has diabetes or not e Persistently elevated BG during AMI is associated with thospital mortality better predictor than admission glucose e Not always treated e Post DIGAMI 1 amp 2 we still need to take this seriously Nice Clinical Guideline 130 October 2011 Recommendations Hyperglycaemia in the first 48hours of ACS Keep BG levels below 11mmol litre but avoid DTA consider Do not routinely offer intensive insulin therapy ie insulin glucose infusion K to manage BG gt 11mmol litre unless clinically indicated Identifying patients with Hyperglycaemia after ACS who have arisk of developing diabetes HbA1c before discharge Fasting BG levels no earlier than 4 days after onset of ACS Do not routinely offer OGTT to patients with pst cae a after ACS without known diabetes if HbA1c and FBG are normal Recommendations not know diabetes Advice and ongoing monitoring e Lifestyle advice on healthy eating exercise weight management smoking cessation and alcohol consumption e Increased risk of T2DM e Patient to Consult GP if they experience osmotic symptoms e GP should be offer annual test for diabetes annual HbA1c and FBG Summary Implications for practice Within first 48 hou
7. e biochemical triad of ketonaemia hyperglycaemia and acidaemia ketonaemia 2 3 mmol L or significant ketonuria gt 2 on standard urine sticks blood glucose gt 11 mmol L or known diabetes HCO3 lt 15 mmol L and or venous pH lt 7 3 0 to 60 minutes Action 1 IV access and initial investigations Action 2 restoration of circulating volume systolic BP lt 90 500 1000mlI 0 9 saline stat systolic BP gt 90 see chart Action 3 potassium replacement see chart Action 4 commence a fixed rate intravenous insulin infusion IVII start continuous fixed rate IVII via an infusion pump 50units human soluble insulin Actrapid Humulin S made up to 50m with 0 9 sodium chloride solution infuse at a fixed rate of 0 1unit kg hr i e 7ml hr if weight is 70kg 60 minutes to 6 hours Action 2 review metabolic parameters Measure blood ketones and capillary glucose hourly Measure venous blood gas for pH bicarbonate and potassium at 60 minutes and 2 hours and 2 hourly thereafter if blood ketone not falling by at least 0 5 mmol L hr check the insulin infusion pump is working and connected increase insulin infusion rate by 1 unit hr increments hourly until ketones falling at target rates Continue fixed rate IVII until Ketones lt 0 3 mmol L venous pH gt 7 3 and or venous bicarbonate gt 18 mmol L Action 1 re assess patient monitor vital signs If glucose falls lt 14 mmol
8. for more complex insulin regimens and overall efficacy of insulin strategies above Holman RR et al New England Journal of Medicine 2007 357 1716 30 4 T study 3 year efficacy of complex insulin regimens in Type 2 diabetes e Demographics e No difference between 3 groups Age Duration of diabetes BMI HbA c Concomitant OHA s Results e No statistically difference in median HbAi c between groups Differences in proportions reaching target level e Hypos lowest in basal group e Weight gain highest in prandial group of patients who required intensification using a second insulin 67 7 for biphasic 73 6 for prandial 81 6 for basal Determinants of success Appropriate insulin regimen e A need for more evidence in Type 2 diabetes e Therefore the choice of insulin should be based on presumed likelihood of success Appropriate dose titration e Empowerment for self titration with appropriate instruction e Pt confidence in self adjustment Compliance concordance with treatment Updates Acute coronary syndromes ACS e Defined as a spectrum of unstable coronary artery disease ranging from unstable angina to transmural myocardial infarction The underlying cause of all categories of ACS is an inflammatory process within the blood vessels the formation of fatty deposits atheromatous plaques which blood clots then adhere to Hyperglycaemia e Common in patients admitte
9. l to diabetes team at Diabetes centre by phone backed up with a faxed letter bleep a DSN 01245 362000 Individualised care with appropriate goals that may not be QoF friendly avoid hypos A small amount of basal may keep a non ketotic patient safe whilst you seek specialist help holding measure only Access to support phone Blood Ketone testing in Type 1 supported by appropriate education Early Podiatry intervention Hypoglycaemia Management must be included in education package for patient Our recommendation on CCG website The message requires to be re enforced Scope for further work with the ambulance service Treating hypos what should tell my patient Step 1 e Fast acting sugar Gives a quick rise in blood glucose within 5 10mins This should contain 10 20g of fast acting carbohydrate eg 10g CHO 20g CHO 3 Dextrose tablets 6 Dextrose tablets Lucozade original 60ml Lucozade original 120ml Coke Lemonade 150ml non diet Coke Lemonade 300ml non diet 3 jelly babies or wine gums 6 jelly babies or wine gums 1 tubes Hypostop Glucogel 2 tubes Hypostop Glucogel 200ml Orange juice 400ml Orange juice NB If blood sugar lt 3mmol may need to take a larger dose of fast acting sugar initially e g 20g CHO such as 6 Dextrose tablets Step 2 e After 10 minutes wash hands again before testing as a sugary snack has been consumed test blood glucose D or it has risen above 4mmoll If it has not take some more f
10. nsequences Barnett A Brice R hall G Holt R Kanumilli N Mulnier H 2010 Nice technology Appraisal on liraglutide Interpretation and practical implications Supplement to Diabetes amp primary care Vol 12 No6 Glucagon like peptide 1 receptor angonist or GLP 1 Modes of action class effect Acts by binding to and activating the GLP 1 receptor Increases glucose dependent insulin secretion from the pancreatic beta cells as glucose concentrations decrease insulin secretion subsides Suppresses inappropriately elevated glucagon levels Slows gastric emptying thus reducing the rate of which meal derived glucose appears in the circulation Patient should reach satiety sooner and thus eat less Caution if eGFR 30 50mL min avoid if eGFR lt 30mL min 1 73m2 BYDUREON a to other GLP 1 agonists in a weekly preparation same ay BYDUREON is exenatide incorporated into polymer based microspheres Following s c injection the microspheres slowly biodegrade and release the exenatide gradually at a controlled rate over an extended period of time Therapeutic levels are achieved in 2 weeks and steady state is achieved at 6 7weeks Target patient Cost for 28 days 73 36 Lower incidence of nausea then BD exenatide or 1 8mgs liraglutide Some problems with skin pruritus nodules erthema at injection sites Compare and Contrast GLP 1 conc in plasma Effects on insulin amp glucagon GI side effects Tolerabili
11. rs of ACS keep BG lt 11mmol litre with standard S S Do not routinely use previous insulin glucose infusion digami with K supplements unless a clear indication HbA1c before discharge FBG after 4days General lifestyle education and ongoing surveillance on an annual basis by GP PN Mid Essex Integrated Diabetes Service Consultant led Diabetes Centre e Pregnancy pre conceptual e Renal Acute foot care e Young Type 1 and adolescent transition e Insulin pumps CGMS e Award winning Structured education in Type 1 BERTIE e Complex T2 2 complications e Education e Telephone admission avoidance Tier 2 Community wide GPwSI supported e One stop shop for glycaemic intensification e Insulin conversions group and one to one e Newer therapies e Straightforward Type 1 e Structured education for T2 CREDIT Maldon monthly B W amp C Ford alternate e Primary care support e Education telephone support The Management of Diabet Ketoacidosis in Adults March 2010 DKA e incidence 4 6 to 8 episodes per 1 000 patients with diabetes e cerebral oedema remains the most common cause of mortality particularly in young children and adolescents e the main causes of mortality in the adult population include severe hypokalaemia adult respiratory distress syndrome co morbid states such as pneumonia acute myocardial infarction and sepsis Definition e DKA consists of th
12. ty Supraphysiological levels of GLP 1 Not limited by endogenous secretion of GLP 1 insulin release when glucose elevated Glucagon release when glucose elevated Food intake gastric emptying Mild amp transient nausea in 10 30 Low rates of hypo unless with SU Increased levels of GLP 1 in physiological range Limited by endogenous secretion of GLP 1 insulin release when glucose elevated Glucagon release when glucose elevated No significant effect Low rates of hypos unless with SU or insulin sitagliptin only Compare and contrast Method of administration Approximate reduction in HbA1c in phase III clinical trails Typical effect on body weight s c injection 0 1 5 11 16mmols mol Weight loss Oral 0 5 1 0 5 11mmol mol Weight neutral What currently guides choice of insulin Aim of treatment What are the goals of therapy from HCP amp patient perspective Individual capabilities Knowledge skills and competence Lifestyle social aspects Dietary patterns employment etc Patient choice What does this actually look like Are patients given a choice re number of injections pen devices regimens Patients want to know the full information to be able to make an informed choice Unless a treatment is asked for it may not ever be offered It was felt this amounted to gate keeping of information Further points to consider when
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