Diabetes In-Patient Pathways for Increased Effectiveness Credits MENU (Click anywhere to continue) Instructions For Use To use the most appropriate pathway click the coloured circle most closely describing your patient’s problem on the menu screen, and continue to follow the advice on screen (all coloured circles are hyperlinks) QUIT This tool has been developed by the diabetes team to try and provide diabetes-related information and management advice to improve the care of patients with Diabetes whilst they are in hospital and to assist with planning their longer-term care. A diabetes specialist nurse will be available to provide help and advice for problems not covered by the pathway, the referral process for accessing the DSN is embedded within this tool Credits Design and Editorial – Iain Cranston & Anita Thynne Policies and Clinical Content – The Diabetes Clinical Team Portsmouth Hospitals NHS Trust Web Maintenance – Mark Harvey Ward Support Team – MENU Sharon Allard, Anita Thynne & Jo Newell BACK QUIT Type 2 Patient requiring insulin Admission Unrelated to Diabetes New Diagnosis In Hospital Diabetes and Pregnancy Menu (click the most appropriate button) (eg surgery) General Diabetes Management Or… Acute Diabetic Emergency Contents List Device-related Problems Complications Of Diabetes QUIT This is how to use it!!!! • This is a power-point presentation that links many clinical documents relating to the in-patient management of diabetes • Circular shapes will, if clicked, link you to the information described. • Use the mouse to click (with the left mouse button) on the most appropriate clinical problem to follow a pathway, or if you need a specific piece of information click a topic from the contents page • You can navigate the presentation either using the menu/back and quit buttons or via the forward / back arrows on the toolbar (top left of screen) • You can view or print as much as you need MENU BACK QUIT Contents How to use this tool Diagnosis • • • • Diagnosis of Diabetes Type 1 or Type 2 Diabetes Letter to GP for new diagnosis Management of New Type 2 Diabetes Acute management • • • • • • • • • • DKA (Ketoacidosis) Management DKA (Ketoacidosis) Monitoring Standards HONK Pathway Hyperglycaemia Flowchart How to prescribe insulin When To Start a Sliding Scale When to stop a sliding scale How to write a sliding scale Sliding Scale Prescription Grid Sliding Scale PHT Policy • • Hypoglycaemia flowchart Hypoglycaemia PHT Policy • • MI therapy Rationale Hyperglycaemia after an MI • • Acute Foot Pathway Assessment of the diabetic foot • Referral Criteria for specialist input MENU Surgical Info • • • • • • • • • Guidelines for medical/surgical procedures Pre-operative Diabetes Assessment proforma Emergency Surgery Pre-Operative Glucose Management Peri-Operative Glucose Management Post Operative Glucose Management Incidental New Diagnosis pre-operatively Suitability Criteria for day-case procedures Wound care management (general) Insulin Therapies • • • • • • • • • • • Indications for Acute Insulin Use Insulin Action Profiles Insulin Regimens Insulin Dosing Advice in type 2 diabetes Insulin Adjustment Insulin Storage Teaching Self Injection Insulin Injection Sites Insulin Injection Devices Problem solving for injection devices Insulin Injections PHT Policy BACK Routine Care • • • • • Glycaemic Management of Diabetes Glucose Monitoring Standards Interpreting Blood Glucose Results Blood Glucose Meter Problems Medications for Type 2 Diabetes • • • • • • CV Risk assessment in diabetes Treatment of Lipids in Diabetes Treatment of BP in Diabetes Management of renal disease in diabetes Eye Screening Pathway Diabetes and Pregnancy • • • Dietary Information for In-patients Dietary Information to take home Hospital Meal Menus and Diabetes • Discharge from Hospital Checklist Patient Literature • • • • • • • Diabetes Centre Support for In Patients External Links / Support Groups Foot Care Information Information for New Type 2 Diabetes Information for New Type 1 Diabetes Starting with Insulin Manual (SWIM) Newly Diagnosed Type 2 Diabetes Manual QUIT Type 1 Diabetes Not Sure! Type 2 Diabetes MENU BACK QUIT Type 1 or Type 2 Diabetes? Type 1 • Autoimmune destruction of the beta cells causing sudden cessation of insulin secretion leading to hyperglycaemia • Characteristics at diagnosis: – – – – – – – – – MENU Dramatic weight loss Ketonuria (ketones present on urinalysis) Lethargy (extreme tiredness) Polydipsia (excessive thirst) Polyuria (excessive urine production) Blurred vision Genital / oral thrush Vasculitis of legs causing burning/pins & needles Most likely to be slim in appearance Type 2 • Metabolic disease characterised by relative insulin deficiency and insulin resistance leading to hypoglycaemia • Characteristics at diagnosis: – – – – – – – • People most at risk – – – BACK Lethargy (slow progression of over time) Polydipsia (slow progression of over time) Polyuria (slow progression of over time) Blurred vision Genital / oral thrush Vasculitis of legs causing burning/pins & needles Most likely to be obese in appearance Family history People who are overweight Of Asian/Afro Caribbean origin QUIT Ensure accurate diagnosis, as per WHO guidelines Teach patients To self-inject Insulin MENU Insulin Sliding Scale Information Starting Insulin - Which one? BACK Give initial information and education Refer to diabetes specialist nurse A Thynne QUIT Sorry! – this link is still under construction MENU BACK QUIT TEACHING SELF INJECTION Step 1 Identify insulin type and appropriate pen device Which Insulin? Step 2 Educate on use of pen How to use a pen Injection sites Principle: Which Pen? MENU Step 3 Educate and choose appropriate injection site Injection sites must be varied to prevent a build up of fatty lumps Hosp Policy Document BACK Step 4 Roll pen between hands to mix insulin. Dial insulin dose and uncap needle Hold pen at a 90o angle to the skin Step 5 ‘Lift up’ fold of skin between thumb and forefinger. Insert needle firmly into skin Step 6 Steadily depress plunger When insulin administered Count to 10; remove needle QUIT Which insulin regimen ? • • • • MENU There are various insulin regimens and insulin types which may be Insulin adopted to suit all patient lifestyles. Products Generally, the more injections a person administers the more flexible the regime. Insulin Profiles BD insulin regimen Twice daily injections before breakfast and evening meal using an insulin such as Mixtard 30/70 or Humulin M3 will provide 30% quick acting and 70% long acting insulin. Usually divided 60% am and 40% evening injection Regimes encompass a combination of long acting insulin; providing a constant background maintenance dose of insulin, and quick acting QDS insulin regimen insulin to provide a boost matching Injection Quick acting insulin such as Actrapid the rise in glucose following a meal. Times or Humulin S may be injected prior Opposite are two common to each meal with a long acting regimens, the top one being insulin such as Insulatard or appropriate for a more routine Insulin Humulin I injected at bed time to lifestyle, the bottom one is more Doses provide background coverage. suitable for an active, unpredictable Usually divided 30% at night and lifestyle. 20% with each meal BACK QUIT Which Pen Device? Device Images Insulin pen devices vary. Certain insulin cartridges will only fit certain pens. PEN DEVICE INSULIN TYPE Novopen 3 or Innovo All Mixtard insulins (pen fill 3ml cartridges) Insulatard (pen fill 3ml cartridges) Actrapid (pen fill 3ml cartridges) Novorapid (pen fill 3ml cartridges) (Pre-filled disposable pens also available on request if patient cannot manage Novopen 3) Humapen or Autopen (Pre-filled disposable pens also available on request if patient cannot manage Humapen) Optipen or Autopen24 (Pre-filled disposable pens also available on request if patient cannot manage Optipen) MENU All Humulin M insulins (3ml cartridges) Humulin I (3ml cartridges) Humulin S (3ml cartridges) Humalog / Humalog Mix 25 (3ml cartridges) All Insuman Comb insulins (3ml cartridges) Insuman Basal (3ml cartridges) Insuman Rapid (3ml cartridges) Insulin Glargine (Lantus) BACK QUIT Available Devices Novo Disposable Pen Novo Innolet Optiset Device Novo Flexpen (disposable) Innovo Device Optipen Pro MENU BACK QUIT HOW TO USE PEN DEVICES • Please refer to instruction leaflets within the pen device box for step by step guide • USEFUL HINTS – All brand of needles fit all of the pen devices. The diabetes centre will supply the patient with needles while they are an inpatient but the GP must be made aware that they need to be prescribed after discharge. Needles must be changed at least daily – To ensure the pen device is working prior to administration an ‘air shot’ but must be completed to prime the needle and show that insulin is being delivered – The numbers shown on the barrel of the pen device indicate approximately how much insulin is left in the cartridge. If there is uncertainty on whether there is enough insulin to give a full dose, change the cartridge MENU BACK QUIT How to prescribe Insulin Previously on Insulin New to Insulin MENU BACK QUIT Previously on Insulin • Check that previous insulin regimen was adequate (home BM control, recent HbA1c) • If adequate and not requiring >1.5X usual TDD whilst on IV insulin then restart usual regimen as soon as eating & drinking Stopping IV Insulin Insulin Adjustment • If previous control inadequate, use TDD whilst on IV insulin as a guide to dose adjustment (consult DSN or Diabetes Registrar if unsure) • The insulin doses should be reviewed (increased) daily to reduce the need for ‘prn’ doses MENU BACK QUIT New to Insulin • Anyone starting insulin in hospital (ie an ill patient) is likely to need at least bd insulin • Recommend Mixtard 30 Insulin pre breakfast and evening meal and usually 10units at each injection unless information from a recently used sliding scale is available (total dose in 24hrs split for bd dosing) • Additional ‘prn’ actrapid 4-6units may be used for BGL > 18 • The mixtard doses should be reviewed (increased) daily to reduce the need for ‘prn’ doses Stopping IV Insulin Insulin Adjustment • Prior to discharge the DSN’s and Dietitian should have been given the opportunity to review and GP informed MENU BACK QUIT Blood Glucose Meter Problems Replacement meter procedure Replacement test solution • For replacement QID or PCX meters please call: • Please obtain replacement control test solution from either Technical Helpline 0500 467466 Biochemistry Laboratory or Diabetes Or Claire or Carrie 01628 678827/8 Centre • Please have the following available when calling: – – – – MENU Meter error or problem Meter Serial No. Account number 34893 Hospital post code PO6 3LY Replacement control record books • Please obtain from Diabetes Centre BACK QUIT INJECTIONS SITES AND ‘LIFT UP’ • Recommended sites for injection are as follows: – – – – • Abdomen. Lateral to the umbilicus but avoiding above or below it and the extreme flanks Thigh. Upper anterior and lateral parts of the thigh Buttocks. Upper external parts of the buttocks Arms. Upper lateral and external parts of the arms avoiding the muscle areas Absorption rates vary as follows: – Abdomen – FAST – Arms – MEDIUM – Thighs and Buttocks - SLOW MENU BACK QUIT Diagnosis suspected? Undertake blood test Link to WHO Diagnostic Criteria Reference Random plasma glucose (RPG) 11.1 mmol/l or Fasting plasma glucose (FPG) 7. 0 mmol/l yes no Hyperosmolar symptoms eg polydipsia or polyuria Is RPG or FPG < 6mmol/l no no yes Repeat fasting plasma glucose Repeat blood test no yes RPG 11.1 mmol/l or FPG 7.0 mmol/l FPG > 6.0 - <7.0mmol/l yes yes Diagnosis of Diabetes Mellitus confirmed MENU Impaired FPG* BACK no Diabetes Unlikely QUIT Link to full WHO Diagnostic Criteria Reference Link to local ‘short’ version MENU BACK QUIT SORRY Electronic Referrals are not yet implemented in DIPPIE to refer to the DSN please go into the “OCM” system and refer as previously MENU BACK QUIT Expect Insulin To be Required only as an in-patient Why is Insulin Required? (patient leaflet) Insulin Sliding Scale Information MENU Expect Insulin to be Continued after Discharge Starting Insulin - Which one? BACK QUIT Indications for Acute insulin Use Insulin Dosing Policies in T2DM What to do At/before discharge MENU BACK QUIT Device-Related Problem Diabetes Complication MENU BACK QUIT Device-Related Problem Diabetes Complication Patient Request To talk with a DSN MENU BACK QUIT Patient Glucose Monitoring Device Ward Glucose Monitoring Device Ward Meter Policy Insulin Injection Device MENU BACK QUIT MENU Foot Problems Renal Problems Eye Problems Cardiovascular Problems BACK QUIT Eye screening pathway Is your patient registered with the diabetes Eye screening programme? YES NO Consult with Jane Cansfield (X6655) diabetes centre for details of their most Recent retinal photography (on Diabeta 3 database) Does the patient Require screening While an inpatient YES NO MENU BACK Refer to Eye Department Give details of local District program (press for details) QUIT Portsmouth District Diabetes Retinal Screening • Contact centre at SJH coordinates appointments – 02392 815051 • Pt will need to know their NHS number as well as demographic details when ringing • Pt will need to sign consent to data being held on computer when attending for screening • Cameras are based at: • • • • St Mary’s Hospital (ISTC) Gosport War Memorial Hospital Emsworth Hospital Coldeast Centre (late 2008) • Results of screening are accessible via Diabeta 3 Database in Diabetes & ophthalmology Departments MENU BACK QUIT Acute Foot Pathway Infection Management Guideline Wound Care Guidelines Community Podiatry Clinics Principles of Foot Care (leaflet) How to assess The foot in Patients with Diabetes In-Patient Podiatry Referral MENU BACK QUIT MENU Hypertension Management Cardiovascular Risk Assessment Lipid Management Acute MI Protocol BACK QUIT Print a patient MI Pathway (including glucose recording charts) View clinical Guideline and Rationale MENU BACK QUIT “Peri-MI” Diabetes Therapy • Acute IV insulin therapy (with glucose and potassium) for 48hrs followed by s/c insulin in those presenting with an MI and hyperglycaemia (>10mmol/L) has a dramatic effect on morbidity and mortality from MI (NNT to save a life = 9!!) • Therapy needs to be started EARLY (ie on first measurement of hyperglycaemia) for this effect – we should develop a thrombolysis-like approach to this therapy • For safety (and following the evidence-base), IV insulin should be prescribed with iv glucose & K+ infusion (if volume is a concern use higher strength glucose at lower infusion rates) • Common Sense needs to be applied to those who will continue to require insulin after the initial 48 hrs, to avoid unnecessary intervention MENU BACK MI Pathway QUIT Diabetic & Pregnant Pregnancy Patient Leaflets Gestational Diabetes MENU Diabetes & Labour Management BACK Diabetic & Planning Pregnancy Post Partum Gestational Diabetes QUIT Pregnancy Patient Leaflets Type 1 Mother MENU Type 2 Mother BACK QUIT Diabetic Keto-Acidosis (DKA) Hypoglycaemia Widely Swinging Sugars MENU Hyper-Osmolar Non-Ketotic (HONK) BACK QUIT H.O.N.K. Immediate Management MENU Ongoing Management BACK QUIT Immediate Management of HONK Similar to DKA in most respects but higher risks: 1) Involve specialist input early 2) Beware of development of hypernatraemia 1) 2) 3) 4) 5) MENU Consider use of ½ normal saline if Na > 160 Switch earlier to 5% dextrose infusion Use DKA proforma Patient Monitoring Guidelines Patients are usually older and frailer – consider early HDU/ITU placement Hyperosmolarity increases thrombotic risk – in most cases consider therapeutic heparinisation Over-rapid osmotic and electrolyte shifts can result in neurological deficit – aim for 10% reduction per hour – no more BACK QUIT Flowchart for Hyperosmolar Non Ketotic Coma Patients – Post Initial Emergency Treatment Is patient known to have Type 2 diabetes? NO YES Consider cause such as illness, omission of treatment and address as appropriate If patient usually administering oral hypoglycaemic agents, consider need for long term insulin therapy MENU WHO Diagnostic Criteria Diagnose as per WHO criteria Insulin in T2DM BACK Consider treatment options: Oral hypoglycaemic agents may be suitable longterm but insulin therapy may be required temporarily for a few months to gain adequate glucose control QUIT Patient Monitoring Guidelines DKA Print a Clerking Proforma Clinical Management Guidelines MENU Insulin Sliding Scale Information (with recording charts and guideline info) BACK QUIT Glucose Monitoring Standards in Hospital Variable Control Insulin Sliding Scale Information ‘Routine’ Glucose Management Hypoglycaemia MENU Hyperglycaemia BACK QUIT Glucose Monitoring Standards In Patients Out Patients MENU BACK QUIT In-Patient Glucose Monitoring Standards Remember, a patient who is in hospital is either acutely ill or about to be subjected to a stressful procedure – both of these situations can be expected to affect glucose control •On IV insulin – Measure capillary blood glucose (CBG) levels hourly for adjustment of IV insulin therapy (half-life of IV insulin <5mins, changes can occur rapidly). •On S/C insulin – Measure CBG at least 4 times daily – routinely pre-meals and at 22.00 (more frequently if the clinical situation demands it) •On Oral Therapy as an IP – Initially measure CBG as for patients on S/C insulin (as therapy changes may be required) – once glucose levels are stable and acceptable for 48hrs the frequency can be adjusted downwards – eventually to a pre-meal daily test •Peri-operatively – Once starved measure CBG at least 2 hourly (hourly if on sliding scale) MENU BACK QUIT Hypoglycaemia View a flow chart Insulin Adjustment Information View the full policy statement MENU BACK QUIT Hypoglycaemia Flow Chart Acknowledgement of occurring hypoglycaemic event via evident symptoms or patient Is patient Conscious ? No Give 25-50ml of 50% glucose IV information Yes Give 10-20g of glucose orally. Granulated sugar in clear fluid is recommended (10g = 2 tsp). Alternatively give non-diet fizzy drinks, full sugar squash, etc. Repeat at 10-15min intervals as necessary MENU If oral or IV glucose would be difficult to administer, Glucagon can be given as an alternative via S/C Glucagen Kit 1mg BACK Maintenance carbohydrates such as bread, potato, pasta, rice must be given following glucose. (a) If hypo has occurred prior to a meal ensure satisfactory amounts of food are consumed. (b) If hypo has occurred between meals give 2-3 biscuits, crackers, toast, etc QUIT Variable Control Interpreting Glucose Monitoring Results (how to analyse the problem) Insulin Adjustment Information MENU BACK QUIT Interpreting Blood Glucose Results • A capillary blood glucose level taken at a given time is a reflection of the hours preceding the recording • A capillary blood glucose level taken at a given time has little bearing on control for the forthcoming hours • Capillary blood glucose level results should be used to reflect on the past in order to make decisions for the future • Know your patients target glucose levels. If the glucose trend is consistently out of target refer to… Insulin Adjustment Information MENU BACK QUIT Hyperglycaemia View a management flow chart Insulin Adjustment Information View the full policy statement MENU BACK QUIT How long has the patient been hyperglycaemic ? One off / Unusual for patient YES YES Is the patient unusually suffering from hyperosmolar symptoms (i.e. polyuria, polydipsia, lethargy or headache) Consider administering 4 - 8units of short-acting insulin and monitor effect. Repeat 4 hourly as required Review possible causes. If > 1dose used in a 24 hour period adjust usual medications NO Persistently Since admission but normally good glycaemic control YES Consider possible causes (i.e. stress, pain, steroid treatment, infection) and treat where possible No immediate action to be taken. Monitor glucose levels to ensure a ‘one off’ and review possible causes Review current anti-hyperglycaemic medication and adjust as necessary. If controlled with dietary management only, consider introduction of oral anti-hyperglycaemic agents or insulin therapy as appropriate. REMEMBER additional treatment may only need to be temporary YES Long-term poor glycaemic control prior to admission YES Does the patient have a healing wound or are they peri-operative? NO MENU Insulin Adjustment Information BACK Consider referral to diabetes team if adjustments do not give improved effect and telephone advice required Please refer to diabetes team for advice re: medication initiation or adjustment Refer patient to their usual diabetes management team (i.e. GP, Practice Nurse or Diabetes specialist team for an outpatient review QUIT Elective Surgical Admission Procedure / Investigation Insulin Sliding Scale Information Emergency Surgical Admission MENU Other (eg Routine in-patient glucose monitoring & management) BACK QUIT Elective Surgical Pathway Planner Click Here to link To the Surgical Pre-Admission Planning Pathway, which will produce an Individualised plan depending on the Characteristics of the patient You are advising MENU BACK QUIT Referral Criteria In-patient Specialist Input Out-patient Specialist Input Out-patient Primary Care Input MENU BACK QUIT Spec In-pt Spec Out-pt REFER TO DIABETES CENTRE FOR SPECIALIST INPUT: Person with newly diagnosed Type 1 diabetes GP T1DM? Person admitted with recurrent hypoglycaemic events Person at high risk: Poor glycaemic control (HbA1c >7.5)and another complication eg MI, amputation Person commencing insulin therapy MENU BACK Hypo Start Insulin QUIT Spec In-pt Spec Out-pt GP REFER TO DIABETES CENTRE FOR AN OUTPATIENT APPOINTMENT: Person who is known to have recurrent admissions of similar nature,or complications associated with their diabetes that need input Person with long-term poor glycaemic control who requires further, on-going glycaemic support and does not have regular follow-up elsewhere MENU BACK QUIT Spec Out-pt GP Spec In-pt REFER TO PRIMARY CARE (GP AND PRACTICE NURSE): Person newly diagnosed with Type 2 diabetes Person with uncomplicated type 2 diabetes GP Referral Letter MENU Patient Info BACK QUIT When to start a Sliding scale PHT Sliding Scale Policy When to stop a Sliding scale Print PHT Sliding Scale Prescription Chart How to prescribe An individualised sliding scale MENU Prescribing S/C Insulin BACK How to stop a Sliding scale QUIT When to stop a sliding scale In principle – as soon as possible! How to stop a Sliding scale • Post operatively – once eating and drinking • Post DKA – once eating and ketone-free • Post sepsis – as soon as a regular subcutaneous dose can be reliably predicted • Special Circumstances (eg MI, pregnancy) – as per individual guideline MENU BACK QUIT Start a sliding scale in the following circumstances: Print A scale • Diabetic Emergencies (DKA/HONK) • Type 1 diabetic being starved • Person with Diabetes vomiting (>12 hrs or with abnormal U&E’s or with significant ketones) • Unwell with hyperglycaemia (>20, especially if abnormal U&E’s) • Special circumstances (MI/labour/sepsis and hyperglycaemia/post op hyperglycaemia) MENU BACK QUIT How to stop sliding scale insulin STEP ONE STEP TWO (a) Inject soluble insulin 30 minutes prior to the meal DO NOT STOP A SLIDING SCALE INFUSION UNTIL THE PATIENT OR CAN TOLERATE DIETARY (b) If using analogue insulin inject INTAKE AND ADEQUATE immediately prior to the meal FLUIDS Insulin Products STEP THREE STEP FOUR (a) Stop infusion 30 minutes after If normal insulin injection not due the soluble insulin is to be given at time of wishing to administered discontinue infusion – Administer OR 6u of soluble insulin subcutaneously (b) Stop infusion immediately after 30mins prior to the meal and follow administering analogue insulin Step 2 (a) and 3 (a) MENU BACK QUIT ADJUSTMENT OF INSULIN Principle: Nocte Insulin Regimen MENU Insulin should be adjusted according to trends in glucose, not one-off levels QDS Basal Bolus Regimen Using Soluble Insulin BACK BD Insulin Regimen QDS Basal Bolus Regimen Using Analogue Insulin QUIT NOCTE INSULIN REGIMEN ADJUSTMENT • Nocte insulin regimens usually comprise a slow long acting insulin. Therefore the insulin will peak in the small hours and start to wane during the morning Insulin Profiles Insulin Products • If glucose levels are above target before breakfast, increase nocte insulin by 2-4 units. Repeat until optimum levels achieved. Usually target fasting glucose of ~8mmol/L MENU BACK QUIT BD MIXED INSULIN REGIMEN ADJUSTMENT • If glucose levels are elevated before bed and before breakfast – increase EVENING dose of insulin by 2 – 4 units. Repeat until optimum levels achieved. Ideally 60% am, 40% pm. • If glucose levels are elevated before lunch and before evening meal – increase MORNING dose of insulin by 2 – 4units. Repeat until optimum levels achieved MENU Insulin Profiles BACK Insulin Products QUIT QDS BASAL BOLUS REGIMEN ADJUSTMENT - USING SOLUBLE INSULIN AND ISOPHANE • If glucose levels are elevated before breakfast - increase NOCTE insulin dose by 2-4 units • If glucose levels are elevated before lunch – increase MORNING MEAL insulin dose by 2 units • If glucose levels are elevated before evening meal – increase LUNCH MEAL insulin dose by 2 units • If glucose levels are elevated before bed – increase EVENING MEAL insulin dose by 2 units MENU Insulin Profiles BACK Insulin Products QUIT QDS BASAL BOLUS REGIMEN ADJUSTMENT – USING ANALOGUE INSULIN AND ISOPHANE • If glucose levels before meals or before bed are elevated – increase the Isophane background insulin by 2-4 units • If glucose levels are elevated two hours post a meal – increase the Analogue insulin prior to that particular meal by 2 units MENU Insulin Profiles BACK Insulin Products QUIT Insulin Action Profiles Insulin Products Rapid-acting (analogue) Insulin Short-acting (soluble) insulin 0 3-4 hrs Intermediate insulin 0 MENU 4 0 2 4 6- 8 hrs Mixture Insulin 12-18 hrs BACK QUIT Insulin Profiles Insulin Products Injection Times Rapid-Acting (Analogue) Insulin Short-Acting (soluble) Insulin • • • • • Humalog (Lispro) Novorapid (Asparte) Mixed Insulin (Ratio of Short: Intermediate Insulin) • • • • • MENU Humulin M (2 / 3 / 5) Mixtard (10 / 20 / 30 / 40 / 50) Insuman Comb (15 / 25 / 50) Humalog Mix 25 (analogue mix) Novomix 30 (analogue mix) Humulin S Actrapid Insuman Rapid Intermediate/Long Acting Insulin • • • • • BACK Humulin I Insulatard Insuman Basal Lente / Ultra Lente Monotard QUIT STORAGE OF INSULIN If the manufacturers expiry date printed on the vial has not passed, insulin expires: At room temperature: 4 weeks after first use In the fridge: 3 months after first use DO DON’T • Store spare insulin in the • Use insulin if date of first fridge use is not known – discard • Store current insulin used • Freeze or heat insulin. If in pen devices at room this happens – discard temperature • Store patients’ own insulin • Use insulin that is lumpy, a strange colour or will not separately from ward stock mix – discard and use only for the named patient MENU BACK QUIT Insulin Injection Times Rapid-Acting (Analogue) Insulin Short-Acting (soluble) Insulin • • • • Immediately prior to all meals or During all meals - or Up to 15mins post all meals 20 – 30 mins prior to all meals Mixed Insulin Intermediate/Long Acting Insulin • • • • • MENU 20 – 30 mins prior to breakfast and evening meal Humalog Mix 25 or Novomix 30 – as analogue timing prior to breakfast and evening meal Insulin Profiles BACK Prior to bed - or Prior to breakfast – or Split dose prior to bed and breakfast Insulin Products QUIT Example 1. 2. Writing a Sliding Scale Print a Grid Print a grid to prescribe the scale How much insulin does the patient normally inject each 24 hours? (= Total Daily Dose or TDD) (if unknown, assume a 70kg man with type 1 DM requires 48units/day) 3. What Blood Glucose Level would you like to run them at? (‘ideal’) (for example if aiming for sugars to run 6.1-10mmol/L) 4. The starting point for writing the scale is to put steps 1&2 together eg to maintain BG @ 6-10mmol/L, they will require 2 units per hour (TDD/24). 5. Next write glucose ranges either side of the ideal which will include a full range of glucose levels (mmol/L) eg 0-3; 5. MENU 6.1-10; 10.1-15; 15.1-24; >24 Prescribe insulin doses (units per hour) corresponding to the glucose ranges as increments: low doses for low glucose ranges! eg 0.5; 6. 3.1-6; 1; 2; 3; 4; 6 Prescribe appropriate fluids to cover the insulin infusion (generally dextrose WILL be required to counteract the effects of insulin!) BACK QUIT Example Grid Step 1 Print the Grid Step 2 Weight 70kg Step 5 MENU Step 3 TDD 48units BM Units/hr 0-3 0.5 3.1-6 1 6.1-10 2 10.1-15 3 15.1-24 4 >24 6 BACK Step 4 Step 6 QUIT Pre-Operative Assessment Peri-operative Management Post-operative Management MENU BACK QUIT ? Suitable for day-case surgery ? Needs specialist input Print an assessment proforma New Diagnosis of diabetes at assessment MENU Pre-operative Management BACK QUIT Colonoscopy Gastroscopy Metformin and Radiological Procedures Other (& barium studies) MENU (general principles) BACK QUIT Screening for Renal Disease In Diabetes Renal Guidelines In-Patient Management Guidelines (Renal) Renal/Diabetes Out-patient Joint Policies MENU BACK QUIT In-Patient Renal Guidelines (under construction) • • • • • • MENU Safe Use of Metformin Oral Diabetes Therapies in Renal Failure Insulin use in Renal Failure Insulin and CAPD Insulin and Haemodialysis Interpreting results in renal Failure BACK QUIT Ensure accurate diagnosis, as per WHO guidelines Print Short Patient Information Leaflet View full ‘starting out With Diabetes’ Document Dietetic Information & Referral (over 40 pages) Type 2 Diabetes Management Statement MENU Therapies & strategies for glucose Management Insulin Sliding Scale Information Print Referral Letter To Primary Care Other Diabetic Problem BACK QUIT MENU Step-Wise Management of Type 2 Diabetes Principles of Glucose Control “rules of thumb” Medications for Type 2 Diabetes Strategies for glucose Management BACK QUIT MEDICATIONS FOR PEOPLE WITH TYPE 2 DIABETES Sulphonylureas Metformin e.g. Gliclazide 40 – 160mg bd, Glimepiride 1 – 6mg daily Increases insulin secretion Associated with weight gain. Not recommended as first line with overweight patients Associated with hypoglycaemia due to long duration of action Caution with renal and hepatic impairment To be taken 20mins before food A – Glucosidase Inhibitors e.g. Acarbose 50mg – 100mg tds Slows absorption of starchy foods reducing post meal glucose levels Neutral weight gain. Low incidence of hypoglycaemia GI side effects, doses should start low and be titrated up weekly MENU e.g. Metformin 500mg – 1g bd/tds Improves insulin sensitivity Neutral weight gain. Drug of choice for overweight patients Low incidence of hypoglycaemia GI side effects, doses should start low and be titrated up weekly Taken after food Post Prandial Regulators e.g. Repaglinide 0.5 – 4mg tds, Nateglinide 60mg – 180mg tds Stimulate insulin secretion post meals reducing mealtime spikes Some association to weight gain Caution with hepatic impairment or those of over 75yrs To be taken just before meals Low incidence of hypoglycaemia BACK Thiazolidinediones e.g. Pioglitazone 15 – 45mg once daily, Rosiglitazone 4 – 8mg once daily Improves insulin sensitivity Not licensed in monotherapy or with insulin Small association with weight gain Require regular liver enzyme tests QUIT MANAGEMENT STATEMENT: PERSON WITH NEWLY DIAGNOSED TYPE 2 DIABETES WHILST IN HOSPITAL Most of the management decisions in type 2 diabetes will be undertaken in primary care (who therefore need to be adequately informed of the patients diagnostic status – see “referral letter to primary care”) however during acute illness some patients with type 2 diabetes will need acute management decisions to be made including some in whom short-term insulin therapy will be required. For these patients there are management guidelines (shown within this tool) and liaison with the diabetes team may be required. MENU Management Guidelines BACK Criteria for Diabetes referral QUIT Stepwise Management of Newly Diagnosed Type 2 Diabetes in Hospital • Diagnose as per WHO guidelines and exclude ketonuria • Refer to dietitian. Attempt dietary modifications alone for up to three months • If patient has marked hyperosmolar symptoms and their level of glycaemia is detrimental to patient status in hospital therapies may be required, otherwise no specific in-patient medical intervention is necessary. • Refer to Primary care team for ongoing diabetes management, education and support (see “referral letter to primary care”) • After three months: if dietary modifications are not sufficient to maintain glycaemic control commence Metformin 500mg OD initially and titrate if the person is obese (BMI >27). Commence Gliclazide 40 – 80mg OD / BD initially and titrate if the person is of normal weight. • Only refer to Secondary care if the person has, or is at increased risk of major complications (see drive guidelines for referral criteria to secondary care) MENU BACK QUIT Give initial information and education Insulin Dosing Policy for type 2 Diabetes Teach Patients To self-inject Insulin MENU Refer to diabetes specialist nurse BACK QUIT “Starting with Insulin Manual” SWIM – over 50 pages Short Information Leaflet MENU BACK QUIT Insulin Starting Insulin in Type 2 DM Products Options: • Add once daily night-time intermediate insulin to all usual daily tablets (usually start at 10units) • Give twice daily mixed insulin (usually 10units bd) instead of sulphonylurea - maintain metformin use • Stop all oral agents and use a basal bolus regimen TDD 20-30 units (seek DSN/specialist advice) Remember: “I SMILE” “Starting with Insulin & pen Insulin Manual” SWIM – over 50 pages Strips/Meter/Information/Letter/Education MENU BACK QUIT Dietary Information In hospital ‘Diabetic’ Menu Stickers Dietary Information To take home MENU Dietetic Referral BACK QUIT Red Diabetic Stickers and Menus Kitchen ‘police’ What is the purpose ? MENU Diabetic stickers alert the kitchen to the patient status A low sugar version of the chosen pudding will be provided rather than a full sugar one Plainer biscuits will be provided than chocolate or crème filled varieties Reduced fat milk will be used in the meals/puddings BACK If a patient who has diabetes chooses a food not marked with a ‘D’ even with a red sticker present, the kitchen will no longer change it. It will be the responsibility of the ward nurse to ensure the patient is aware of appropriate choices to make an informed decision. Cakes and snack foods are available throughout the day so assess patient need to avoid hypos and encourage people to bring in their own hypo management foods that can be preserved in the lockers QUIT MENU Diabetes UK Web Site QAH Diabetes Centre Web Site Local Podiatrists List Local Optometrists List BACK QUIT Thank you for using the Diabetes Pathway Document If you have comments regarding its content please contact Dr Iain Cranston or DSN Anita Thynne MENU www. Further Information END