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1 DOCUMENT CONTROL PAGE Document Number: GUI/CL/WCN/666 Version Number: Version 2 Title: Guidelines for the management of inpatient diabetes, including the management of diabetic emergencies and the management of diabetes during surgery Document Type: Clinical Guideline Application: Trustwide Content: Clinical Author/Originator and Title: Dr C F Whitehead using guidelines produced by the Endocrine and Diabetes Directorate, Aintree Hospitals. Date of Issue: December 2008 Replaces: Version 1 Description of Amendments: changes within document (page 7) summary of Approved By: Approval Information: Clinical Services Committee Name: Dr T.P. Enevoldson Signature: original kept in Clinical Governance Dept Review Date: September 2010 Date: 4 th December 2008 (Approved in September 2008) Responsibility Of: Dr C. Whitehead Training Required: NO Name of Trainer/s: N/A CHECK LIST: Completion of Distribution Information Page Completion of Training Information Page (if required) YES N/A Page 1 of 24

2 This information can be translated on request or if preferred an interpreter can be arranged. For additional information regarding these services please contact the Walton centre on Page 2 of 24

3 Guidelines for the management of in-patient diabetes, including the management of diabetic emergencies and the management of diabetes during surgery Based on: 1. World Health Organisation (1999) Definition, diagnosis and classification of diabetes mellitus and its complications. Geneva: World Health Organisation. Department of non-communicable disease surveillance 2. NICE Guideline: Management of Type 2 Diabetes management of blood glucose. NICE Diabetes UK. Position statement Early identification of people with Type 2 diabetes. Diabetes UK, Gill G. Surgery in patients with diabetes mellitus. In Pickup J, Williams G (Eds) Textbook of Diabetes, 3 rd Edition NICE Guideline: Guidance on the use of long acting insulin analogues for the treatment of diabetes Insulin Glargine. NICE NICE Guidance: Type 1 Diabetes: Diagnosis and management of type 1 diabetes in primary and secondary care. NICE 2004 Page 3 of 24

4 Changes from previous version Page 3 Ref. 6:Nice Guidelines Page 10 Additional to paragraph 1.2: Information about use of gliclazide. Revised advice in paragraph 1.3 about use of glitazones as part of triple therapy. Page 13 Section C, possible regimes updated. Page 14 Use of glucagons Page 16 On call diabetic/medical Specialist Registrar to be informed Page 18 On call diabetic/medical Specialist Registrar to be informed. Page 24 Telephone numbers updated. Page 4 of 24

5 A. Diabetes Guidelines - Hospital In-Patients 1. Diabetes How to Diagnose 2 Symptoms of Diabetes 3 What are the criteria for diagnosis? (WHO) Criteria 1999) 4 What to do if a patient is found to have a raised plasma glucose 5 Screening for diabetes in hospital 6 Whom to screen B. Management of Type 2 Diabetes 1. Guidelines Oral Medication 1.1 Metformin 1.2 Sulphonylureas 1.3 Glitazones 2. Insulin in type 2 diabetes 2.1 Indications 2.2 Insulin Regimens 3. Summary C. Management of Type I Diabetes D. Management of diabetic emergencies & surgery Hypoglycaemia Diabetic ketoacidosis (DKA) Hyperosmolar non-ketotic coma E. Diabetes and surgery 1. Indications for the use of glucose-potassium-insulin (GKI) infusions Page 5 of 24

6 F. Hyperglycaemia in Critical Care G. Who to refer to the diabetes team H. Who are the diabetes team and how can they be contacted? Nursing Medical I. Flowchart: Glycaemic control in type 2 diabetes A. Diabetes Guidelines - Hospital In-Patients 1. Diabetes - Background Diabetes is a serious life-long condition and numbers are reaching epidemic proportions. In the UK at least 2 million people have diagnosed diabetes and at least a million more the missing million" are thought to have diabetes but do not know it yet. Diabetes is a serious life-long condition and complications can severely impair an individual's quality of life. Early diagnosis is important as good blood sugar and blood pressure control can delay the onset of complications. Patients with diabetes are twice as likely to be admitted to hospital and stay twice as long as those without diabetes. 2. Symptoms of Diabetes Thirst Passing lots of urine Fatigue Weight loss Blurred vision Fungal infections Page 6 of 24

7 Some patients with undiagnosed diabetes do not report any symptoms. 3. What are the criteria for diagnosis? (WHO Criteria 1999) Patients with symptoms: a random venous plasma glucose level >11.1 mmol/l or a fasting plasma blood glucose level >7.0mmol/l Patients with no symptoms: A diagnosis should not be made on a single blood glucose result. At least one additional blood glucose result should be recorded on another day. Diagnostic plasma glucose levels are: Fasting >7.0 mmol/i Random > 11.1 mmol/l Page 7 of 24

8 4 What to do if a patient is found to have a raised plasma glucose Ensure the patient does not have previously diagnosed diabetes Ask about symptoms Repeat a random plasma glucose and request a fasting plasma glucose (on 2 separate days) Action Repeated plasma glucose levels normal: do nothing Repeated plasma glucose levels raised: (Random > 11.1 mmol/l or fasting >7.0 mmol/l) Contact the diabetes team If fasting plasma glucose is mmol/l a Glucose Tolerance Test is indicated. If the diagnosis is unsure contact the diabetes team. Cautions in diagnosis Acute illness, surgery and drugs (e.g. steroids) can cause a transient rise in blood glucose Do not diagnose diabetes on a single plasma glucose Do not diagnose diabetes on glycosuria To make a diagnosis a venous sample should be used, not a finger prick test' Do not use HbA1c for diagnosis If in doubt contact the diabetes team 5 Screening for diabetes in hospital Many people with diabetes do not know they have it and may be diagnosed in hospital not previously having symptoms People with Type 2 diabetes may have the condition for up to 10 years before the diagnosis is made Over one third of people with Type 2 diabetes have at least one complication at the time of diagnosis Page 8 of 24

9 6 Whom to screen Diabetes UK, Position statement, November 2002 In the UK screening of the general population is not recommended. However early identification programmes are aimed at those who fall into high risk categories including: White people over 40 years and people from Black, Asian and minority ethnic groups over 25 years with: A first degree family history of diabetes and who are overweight (BMI >25) Ischaemic heart disease, cerebrovascular disease or hypertension Women with a history of gestational diabetes Women with polycystic ovary syndrome Those having impaired glucose tolerance or impaired fasting glycaemia Page 9 of 24

10 B. Management of Type 2 Diabetes NICE Guideline: Management of Type 2 diabetes management of blood glucose, 2002 All patients with newly diagnosed diabetes should be referred to the diabetes nursing team for education and advice. Dietary advice is important in influencing symptoms of hyperglycaemia, improving glycaemic control and lipid profiles. Oral hypoglycaemic agents should normally only be used after an adequate trial of diet alone. However, drug treatment may be considered earlier for patients with marked symptoms and significant hyperglycaemia. Many patients require a combination of oral agents to achieve good glycaemic control. See Appendix 1 for a flow chart for the management of glycaemic control in patients with Type 2 diabetes. 1. Guidelines Oral Medication 1.1 Metformin Metformin is the drug of choice for overweight or obese patients (BMI >25) when dietary intervention has failed to achieve good control. Start at 500mg bd with food and if necessary titrate up to a maximum dose of 1 g tds. Metformin can cause nausea, vomiting and diarrhoea and should, therefore, be taken with food. When used alone it does not cause hypoglycaemia. If poor compliance is suspected Metformin MR should be considered (starting dose 500mg with a main meal, maximum 2g daily. Metformin should not be used in renal insufficiency (creatinine >130), respiratory, hepatic or cardiac failure (risk of lactic acidosis). Metformin should be avoided for 48 hours after the use of intravenous iodinated contrast in patients with normal renal function. In patients with renal insufficiency who have received contrast, metformin should only be reinstituted after 48 hours and renal function has been re-evaluated and found to be normal. 1.2 Sulphonylureas Sulphonylureas are usually first line treatment in non-obese patients when dietary intervention has failed to achieve good glycaemic control. Hypoglycaemia can be a problem and patients should receive advice and education on management of hypoglycaemia. Gliclazide: Commonly used in the elderly or in renal dysfunction. Start with 40 to 80 mg daily, maximum dose 160 mg bd. If poor compliance is suggested consider Gliclazide MR starting dose 30mg daily, maximum dose 120mg daily (Gliclazide MR 30mg is equivalent to Glicazide 80 mg). Page 10 of 24

11 1.3 Glitazones Rosiglitazone and Pioglitazone are new oral hypoglycaemic agents, which decrease insulin resistance. They are licensed for use in patients with Type 2 diabetes as monotherapy (where Metformin is contra-indicated or not tolerated), or in combination with Metformin or a sulphonylurea, or as triple therapy. NB: LFTs (including ALT) should be monitored before treatment is commenced and at 2 monthly intervals for 12 months. Glitazones are contraindicated in heart failure. (Risk of fluid retention) 2. Insulin in type 2 diabetes 2.1 Indications Poor glycaemic control on maximal oral therapy Intercurrent illness Painful neuropathy Diabetic amyotrophy Pre-pregnancy & pregnancy 2.2 Insulin Regimens A combination of insulin and oral hypoglycaemic agents is frequently used in patients with Type 2 diabetes. Once daily isophane insulin e.g. Insulatard, is usually given at bedtime in combination with either Metformin and/or a sulphonylurea during the day. In Type 2 patients who are thin and/or losing weight, twice daily insulin e.g. Mixtard 30 or M3 is more appropriate. Twice daily insulin may also be appropriate in obese patients who are poorly controlled on a combination of once daily insulin and oral hypoglycaemic agents. The long acting analogue Insulin Glargine or Detemir may be useful for patients who are experiencing recurrent hypoglycaemia or who require assistance to administer insulin (NICE Guideline: Guidance on the use of long-acting insulin analogues for the treatment of diabetes insulin glargine. NICE 2002). Patients starting on insulin need intensive education and should be referred to the diabetes nursing team and the Dietician. 3. Summary Oral hypoglycaemic agents should normally only be used after an adequate Trial of diet alone. Page 11 of 24

12 Obese patients The drug treatment of choice for obese patients is Metformin. If the patient is unable to tolerate Metformin or Metformin is contra-indicated then consider a glitazone. If the patient is not adequately controlled on the maximum tolerated dose of Metformin or a glitazone, consider adding a sulphonylurea. Non obese patients The drug treatment of choice for non-obese patients is a Sulphonylurea. If the patient is not adequately controlled then Metformin should be added. If the patient is unable to tolerate Metformin, or Metformin is contraindicated, then a glitazone should be considered in combination with a sulphonylurea. If the patient is not adequately controlled on 2 agents consider triple therapy (Metformin, a sulphonylurea and a Glitazone) If losing weight due to poor diabetic control or non-obese consider insulin. Insulin therapy is sometimes indicated (often on a temporary basis) in Type 2 patients who are acutely ill patients or those with severe infections. NB: Acute illness can lead to a deterioration in glycaemic control warranting a change in medication. However when the acute episode has resolved it is often possible for patients to return to pre-admission medication. For this reason: All patients with diabetes (newly diagnosed or established) should have an HbAc1 on admission to hospital. If in doubt contact the Diabetes Team Page 12 of 24

13 C. Management of Type I Diabetes Insulin regimens in patients with Type 1 diabetes vary from BD mixes (e.g. Mixtard 30, Mixtard 50, Humulin M3) to multiple injection regimens (injections of soluble or analogue insulin with meals and isophane insulin (e.g. Insulatard, Humulin I) at night. Insulin (except analogues, see below) should be injected minutes before meals Insulin analogues (Humalog, Novorapid, Humalog Mix 25 and 50, Novomix 30) are fast acting and can be injected just prior to eating. Most insulins can be given via pen devices. Insulin dose should not be altered as a result of a single raised blood glucose, it is wise to observe for patterns and alter insulin accordingly. Alterations of 10 20% (increases or decreases) are appropriate if blood glucose is persistently high (>10 mmol) or low (<4 mmol). Do not omit insulin in a patient with low blood glucose. If hypoglycaemic then treat and refer to the diabetes team for a review of treatment Page 13 of 24

14 D. Management of diabetic emergencies & surgery Hypoglycaemia Laboratory or bedside blood glucose usually <4.0 mmol/l, typically with symptoms such as hunger, sweating, shaking, paraesthesia, headache, confusion. NB: Bedside blood glucose monitors are not accurate at low readings and hypoglycaemia should be considered in any diabetic patient with the above symptoms. Remember: Diabetes UK advise "Four is the Floor" Oral treatment of hypoglycaemia In patients who are able to tolerate fluids, hypoglycaemia can be treated with: Lucozade approximately 165 mls ( 2 / 3 glass). Available via NHS supplies catalogue code no AAR heaped teaspoons of sugar dissolved in warm tea 3-6 Dextrosol or Lucozade tablets Approximately 165 mls ( 2 / 3) of any sugary drink e.g. coke, fresh orange juice Blood glucose should be recorded again 5-10 minutes after treatment, To prevent further hypoglycaemia this should be followed up by more complex carbohydrate e.g. digestive biscuits, toast, sandwiches or a meal (if due). Parenteral treatment of hypoglycaemia If the patient is unable to take carbohydrate then: 250 ml 10% dextrose can be given IV 1 mg of glucagon may be given IM if hypoglycaemia is prolonged. This may cause headache and vomiting. Page 14 of 24

15 NB: 50% dextrose is hypertonic and carries a high risk of thombophlebitis and serious tissue damage if extra vacation occurs. Therefore it should not be used for the treatment of hypoglycaemia. Sulphonylurea induced hypoglycaemia can produce atypical symptoms (e.g. hemiparesis) and may require prolonged treatment and supervision. Ask for advice if an intravenous infusion of 10% dextrose fails to restore euglycaemia. Give oral carbohydrate once the patient is able to eat safely. Look for a cause. Patients with recurrent hypoglycaemia and/or loss of warning signs should be referred to the diabetes team for a review of treatment. Page 15 of 24

16 Diabetic Ketoacidosis (DKA) Take ketoacidosis (DKA) seriously it can kill Manage DKA in Critical Care within the Walton Centre The on-call Specialist Registrar should supervise treatment Always inform the on-call Diabetologist Treatment 1. Fluids Use 0.9% sodium chloride Give 1 litre quickly (< 1 hour) Then 1 litre 2-hourly Reduce later (after 4 6 hours) as necessary 2. Insulin Use soluble insulin (usually actrapid but Humulin S is acceptable) Set up 50 ml iv infusion pump 50 units in 50 ml 0.9% sodium chloride (1 unit/ml) Start at 4 6 units/hr Aim for slow and steady fall in blood glucose 3. Potassium Await first U & E before starting If plasma K + not high, start KCl Give with saline infusion, mmol/hr Continue according to plasma K + levels 4. Bicarbonate Very rarely needed Consider only if patient very ill and ph <6.90 If used give 50 mmol slowly Never use 8.4% - use dilute solutions 5. Supportive treatment Page 16 of 24

17 Do septic screen, consider antibiotics Nasogastric tube and urinary catheter if comatose If shocked or elderly consider CVP line If hypotension problematic, consider a colloid solution by iv infusion and consider inotropes 6. Monitoring Initial arterial gases, BG and U & Es Hourly bedside BG monitoring Lab BG and U & Es 2 hourly initially Reduce frequency as necessary 7. Later treatment When patient improved and blood glucose <15 mmol/l: Set up "augmented GKI infusion, (500 ml 10% dextrose + 20 units soluble insulin + 20 mmol KCl) Run at 100 ml/hr Adjust insulin and KCl infusion as necessary When patient can eat, revert to s/c insulin Page 17 of 24

18 Hyperosmolar non-ketotic coma Hyperosmolar non-ketotic (HNK) (coma is by no means always present) occur in older Type 2 diabetic patients. Mortality is high and HNK must be taken seriously. Like DKA, manage in Critical Care and utilise Specialist Registrar and on-call Diabetologist for supervision. Treatment Treatment is as for DKA with the following exceptions: Overall fluid deficit is greater, but patients are often old and frail, so fluid replacement needs to be generous but cautious. CVP line often needed. Use 0.9% sodium chloride, but if plasma Na + >150 mmol/i use "half normal" (0.45% sodium chloride) until plasma Na + <145 mmol/l. Bicarbonate is never needed. Give S/C dalteparin 5,000 units daily to help prevent thrombotic complications (stroke and MI are major causes of death). Page 18 of 24

19 E. Diabetes and surgery Always liaise with the anaesthetist Ensure reasonable pre-operative diabetic control Omit breakfast, insulin and/or oral medication on morning of surgery Non-insulin treated patients having minor or moderate surgery need observation only. Do regular bedside BG levels. Restart oral agents with the next meal. Insulin treated patients (Type 1 or insulin requiring Type 2) undergoing surgery need a GKI regime ("glucose-potassium-insulin"). Start at 8 9 am. See "Indications for the use of Glucose-Potassium-Insulin (GKI) Infusions" for full details of GKI infusions (below) 1. Indications for the use of glucose-potassium-insulin (GKI) infusions GKI is a glucose-maintaining regimen, which is useful in the following situations: Insulin treated patients (Type 1 or insulin requiring Type 2) who are undergoing surgery Type 2 patients (on oral hypoglycaemic agents) who are undergoing major surgery Insulin treated patients (Type 1 or insulin requiring Type 2) who are required to fast e.g. scopes, barium studies, interventional radiological procedures (e.g. angiography, MRI) Type 1 patients who cannot tolerate diet and fluids e.g. vomiting Patients with DKA / HNK in the recovery phase A GKI is not usually used to control blood glucose in a patient with hyperglycaemia who is otherwise well. In this situation consider the following options: Type 2 patients with persistently high blood glucose but otherwise well review current treatment and alter or initiate oral hypoglycaemic agents. In some cases e.g. severe infection, insulin may be indicated on a temporary basis. Insulin treated patients with a persistently raised blood glucose who are otherwise well review current treatment Page 19 of 24

20 Efforts must be made to keep starvation time to a minimum. Where at all possible they should be first on a morning list. Nil by mouth from midnight Aim for a blood sugar between 5 and 10. Blood sugar should K+ result from previous day to be available IVI infusion of 10% dextrose (500 ml bag) to start at 100 ml. Per hour via a pump at 0800 hrs. (if IV access established night before and appropriate prescription on drug card, the nursing staff will start regime. If blood sugar <5 no added insulin to bag (if symptomatic doctor to review) If blood sugar , add 5 units of Actrapid to 500ml. bag i.e. to run at one unit per hour. If blood sugar , add 10 units to 500 ml. bag, i.e. to run at two units per hour If K+ <4.5 please add 10 millimoles of potassium to the 500 ml bag of 10% dextrose. K+ should be checked 6 hourly If blood sugar , add 15 units to 500 ml. bag, i.e. to run at three units per hour. Urinalysis 12 hourly for ketones Refer to doctor if positive. If blood sugar >20 - doctor to review - may require bolus of insulin and/or saline infusion. Encourage early oral fluids as appropriate. Blood sugar should be measured hourly preoperatively, hourly in the first four hours, then two Above regime may need increasing if blood sugar continues to rise despite increasing insulin. Management Regular of Inpatient anti-emetics Diabetes may including encourage Emergencies oral intake. & Once Surgery light diet is established, the Approved: patient s September regular 2008 diabetic regime can be recommenced. Page 20 of 24 Review after 24 hours. Watch for hyponatraemia

21 GKI Do s Prescribe a new GKI if there is a trend to falling or rising blood glucose levels Ensure the patient has tolerated normal diet and fluids before prescribing normal diabetic medication and withdrawing GKI regimen Give subcutaneous insulin at least 30 minutes before discontinuing GKI regimen GKI Don ts Administer insulin via a separate syringe pump. It is usually inappropriate and potentially dangerous on the general wards. However, this may be appropriate in Critical Care. Alter the rate of the GKI insulin from 100 mis/hr in response to fluctuating glucose levels. This is ineffective Do not stop insulin unless there is serious hypoglycaemia. From GKI to usual treatment If the patient was previously on bd insulin then restart usual treatment pre-breakfast or pre-tea. If you wish to end GKI at lunchtime (e.g. surgical patient post-op), then give Soluble Insulin (e.g. Actrapid or Humulin S) 8 units with lunch and resume usual insulin at teatime. If the patient was usually on 4 injections daily you can restart usual insulin easily before any of the 3 meals and give isophane insulin at usual times. NB: In insulin-treated patients, when you stop the GKI the patient will have no insulin on board and may rapidly decompensate always continue the GKI for minutes after the patient's meal to allow the subcutaneous insulin time to act. Page 21 of 24

22 If the patient was on tablets for diabetes, stop GKI and give usual medications. If it is lunchtime or teatime and the patient usually only takes tablets pre-breakfast, then give prebreakfast dose before whichever meal it is and then tablets as usual the following day. If the patient was not previously known to have diabetes and now has Type 2 diabetes, then stop GKI and try diet alone, (except post HNK when insulin is usually continued at least in the short term). If not previously diabetic and now thought to have Type 1, then switch to BD regimen. All newly diagnosed patients with either Type 1 or Type 2 diabetes should be referred to the diabetic team. F. Hyperglycaemia in Critical Care Continuous intravenous infusion of Actrapid 1unit/ml may be required in patients in Critical Care in order to achieve tight glycaemic control. Regular blood glucose monitoring is required and the prescription of actrapid should be adjusted as needed to achieve the target blood glucose. The dose prescribed, infusion rate and administration of actrapid should be recorded on the Critical Care blood glucose control chart. G. Who to refer to the diabetes team All patients with diabetic ketoacidosis or hyperosmolar non-ketotic coma All newly diagnosed patients Type 1 or Type 2 Patients whose primary cause of admission is due to diabetes. Patients admitted with other conditions where diabetes is considered to be a contributory factor. Patients with foot ulcers. Recurrent hypoglycaemia. Poorly controlled diabetes. Poor blood sugar control due to steroids. Page 22 of 24

23 H. Who are the diabetes team and how can they be contacted? Nursing: The in-patient diabetes nursing team are available Monday to Friday 9 am 5 pm and can be contacted by bleep; Diabetes Specialist Nurse Bleep 2197 Diabetes Nurse Educator Bleep 2197 Diabetes Nurse Consultant Bleep 5029 In addition, the Diabetes Specialist Nurses are based in the Diabetes Centre (Walton site) and can be contacted for advice on Ext Medical: The Diabetes Specialist Registrars can be contacted on the following bleep numbers 9 am 5 pm: Bleep 4127 Bleep 4128 Bleep 4129 Bleep 5026 Out of hours, the on-call Diabetologist can be contacted via the hospital switchboard. Page 23 of 24

24 FLOWCHART: GLYCAEMIC CONTROL TYPE 2 DIABETES Diet for 6/52 to 3/12 Glycaemic control achieved? No Yes Continue BMI>25 BMI <25 *Metformin 500mg OD (Increase after 2 weeks to BD) Gliclazide40mg OD Adjust dose every 1-3 months to achieve Glycaemic target or maximum dose Glycaemic control achieved? Yes Continue No Combination therapy with Metformin plus Suphonylurea Or Intolerant of Metfomin or sulphonylurea substitute a Glitazone** (Rosiglitazone or Pioglitazone) Into Glycaemic control achieved? Yes Continue No Refer for insulin therapy (DSN) *Metformin should not be used if renal impairment i.e. creatinine > 130 umol/l Glitazones have been licensed for use as monotherapy for patients intolerant of Metfomin or in whom Metformin is contra-indicated. The license was granted after the last NICE guideline was published. ** Glitazonesare contra-indicated in heart failure. Factors affecting drug choice -Contraindication -Compliance Management -Toleranceof Inpatient Diabetes including Emergencies & Surgery Page 24 of 24