Clinical Solutions in Diabetes Care 2008 Insulin Adjustment

Transcription

1 Clinical Solutions in Diabetes Care 2008 Insulin Adjustment Helen Cressey and Clare MacArthur Helen Gibson and Moira Digby

2 Welcome! First, an introduction with a few facts Some research Some considerations when adjusting insulin Then five case studies, one for each group Nominate a spokesperson Discuss in your groups for five - ten minutes Feedback to others

3 Then lunch!

4 Some facts What are the specific causes of admission to hospital for people with diabetes - excluding long term complications such as myocardial infarction, stroke, etc? according to HES data: Hypoglycaemic emergencies Hyperglycaemic emergencies Other hyperglycaemic disorders Lower limb complications

5 HES data English Hospital Episode Statistics Excludes A&E and paramedic visits query_hrg.jsp Can be viewed easily in terms of SHA area, by PCT area or even by hospital trust Diabetes specific data grouped as K11 K17

6 In 2006/7 in England Finished consultant episodes Hospital admissions Hypoglycaemic emergency 13,442 9,721 Hyperglycaemic emergency 15,074 9,442 Hyperglycaemic disorder 18,701 13,633 Lower limb complication 8,755 5,366

7 In NEYNL* in one year (2005/6) for all ages: Finished consultant episodes Hospital admissions Bed days Hypoglycaemic emergency Hyperglycaemic emergency Hyperglycaemic disorder Lower limb complication *North & East Yorkshire and Northern Lincolnshire SHA, before the changes

8 So, abnormal blood glucose levels glucose levels Are costly to people with diabetes and the health service even before any long-term complications occur There is a preponderance of admissions in older people, as you would expect But also in males (Often more than 2/3 male) While admissions tend to be relatively short, should they be viewed as

9 Some research The 4T study group report one year data, for adding different insulin regimens to oral agents in Type 2 diabetes (study is ongoing) Similar to previous findings using glargine Prandial insulin (3 x mealtime Novorapid) HbA1c more than twice daily bi-phasic insulin (Novomix 30) which HbA1c more than basal insulin (Levemir) alone With a higher rate of hypos and of weight gain Mean no. known hypos per year 12.0, 5.7 and 2.3 Mean weight gain 5.7 kg, 4.7 kg and 1.9 kg Holman et al. (2007) NEJM

10 Self adjustment? Many studies have shown that people taught how to adjust their own insulin dose achieve better control much quicker than when it is adjusted only by health care professionals But people enrolled into trials may not have the problems that we may encounter, such as illiteracy or poor eyesight Phone consultations can be a safe alternative/ support to self adjustment

11 Considerations for insulin adjustment What is the aim of adjusting the insulin? It may not be the dose that is the problem! Are they taking/getting the insulin every time? Are hypos occurring, perhaps that they may be unaware of? QoF doesn t measure these, yet! Consider general safety, and driving etc insulin_initiation_guidelines.pdf

12 Case Studies Nominate a spokesperson (but everybody to contribute!) Discuss in your groups for five to ten minutes maximum What are the problems? Would you need more info? Would you make any suggestions? What would you suggest? Feedback to others No correct answers - just many options! * * * * *

13 Summary Many factors to take into consideration Much of the skill of adjustment is about good communication Eating/drinking patterns (if any), particularly timing of carbohydrate intake Activity and work Injection technique Regimen Both high and low blood glucose levels are important

14 Summary Explain what you think the options are - including changing behaviour - and why To increase your skills take a course, phone a friend, recognise when you shouldn t act as well as when you should and above all listen to the patient.