Management of Diabetes during Intercurrent Illness

Management of Diabetes during Intercurrent Illness Aim(s) and objective(s) To ensure that people with Diabetes Mellitus (DM) are provided with appropriate advice about the care of their diabetes during periods of intercurrent illness to help avoid complications such as: Dehydration Ketoacidosis Hypoglycaemia Author June Currie, Diabetes Service Manager User group All Diabetes Specialist staff in NHS Lanarkshire All community health care professionals including Primary Care involved in diabetes care within NHS Lanarkshire Secondary Care acute physicians and nursing staff Those people with DM (including partners, family and carers) living in Lanarkshire This guideline is not intended to serve as a protocol or standard of care. This is best practice based on all clinical data available for an individual case and may be subject to change as scientific knowledge and technology advances and patterns of care evolve. Adherence to guideline recommendations will not ensure a successful outcome in every case, nor should it be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same result. Ultimately a judgement must be made by the appropriate healthcare professional(s) responsible for a particular clinical procedure or treatment plan following discussion with the patient, covering the diagnostic and treatment options available. It is advised that any significant departure from the guideline should be documented in the patient s medical record at the time the decision is taken. 1

Guideline TYPE 1 DM Encourage adequate dietary and fluid intake: Maintain an adequate fluid intake of approximately 1 glass (100-200ml) of sugar-free liquids every hour Maintain a regular intake of carbohydrate if unable to take solid foodstuffs, but tolerating fluids, encourage the person to take carbohydrate in other forms i.e. soup, fruit juice, milk or milky drinks, such as hot chocolate As a last resort, advise the person to replace carbohydrate in liquid form i.e. ordinary, nondiet cola or lemonade If occasional vomiting or nauseated, consider the use of an anti-emetic Consider providing an electrolyte replacement, e.g. Dioralyte, Rehidrat, Electrolade (also appropriate if person is experiencing significant diarrhoea) If, however, the person is unable to swallow or keep fluids down for any length of time (i.e. > 4 hours), hospital admission may be appropriate Increase frequency of blood glucose (BG) monitoring and test for ketones: Increase blood glucose monitoring to at least 4 hourly; if moderate to large ketones (1.5 - > 3 mmol/l) are present, BG testing should be carried out 2 hourly (NB Ensure that glucose and ketone monitoring equipment is accurate (QC (quality control) has been carried out recently), strips are in date and, as far as possible, that the person s self-testing technique is accurate) Ketone testing should also be carried out 2-4 hourly, whether by testing urine or utilising Optium β-ketone test strips with an Xceed meter or LX Ketone sensor with a Glucomen LX meter Specialist and community health care professionals should arrange to review results with the patient on a very regular basis to avoid, where possible, the need for hospital admission Insulin adjustment: INSULIN SHOULD NEVER BE OMITTED, despite a reduction in dietary intake; often both patients and carers have to be convinced that this is the appropriate course of action Increased insulin requirements are often required during periods of illness and ill-health During illness additional rapid-acting insulin can be administered 2-4 hourly to tackle elevated blood glucose levels (in addition to normal insulin doses) see patient information literature (attached to end of guideline). This applies to those on a basal bolus regimen of 4 injections per day and those on twice daily injections of premixed insulins If elevated blood glucose persists, it may be appropriate to consider increasing normal doses of rapid-acting/mixtures of insulin for the duration of the illness/ill-health (NB It is not always appropriate to increase basal insulin in basal/bolus regimes i.e. due to the length of action of analogue insulins) If ketones are present, yet blood glucose levels are low or normal (e.g. in the case of those patients who are vomiting), it may be necessary to consider hospital admission for IV fluid replacement and IV insulin therapy Always recheck blood glucose and ketones within two hours to assess improvement or deterioration 2

In summary Insulin therapy should NEVER be omitted due to the risk of Diabetic Ketoacidosis (DKA). Patients should be encouraged to check for ketones. Additional doses of rapid acting insulin are often required during illness. Appropriate written advice should be provided and is available via the NHSL Diabetes MCN website. Emphasis should be placed on replacement carbohydrate and maintaining adequate fluid intake. TYPE 2 DM For those patients on oral medication only, not including sulphonylurea medication (see below), basic advice would be consistent with routine guidance for any non-diabetic individual who is experiencing a period of illness. Emphasis should, however, be placed on: Continue with medication as normal* Encourage adequate fluid and diet intake, considering dietary alternatives should the patient be unable to manage their normal diet i.e. lighter carbohydrate options Consider providing an electrolyte replacement, e.g. Dioralyte, Rehidrat, Electrolade depending on the severity of vomiting, age of patient etc. (also appropriate if person is experiencing significant diarrhoea) *NB If taking Metformin, the patient should be advised to discontinue this medication if prolonged periods of vomiting/diarrhoea as this can contribute to the risk of developing lactic acidosis. For those patients taking sulphonylurea medication: Patients taking this medication should have access to blood glucose monitoring equipment; frequency of self-monitoring of blood glucose (SMBG) should be increased to a minimum of daily with a range of fasting and pre-meals (especially if dietary intake is affected) Appropriate advice should be provided regarding the increased risk of hypoglycaemia - usually more likely in the early stages of illness, especially if reduced dietary intake is a factor i.e. reinforce the importance of taking some form of regular carbohydrate The patient should be advised to contact their health care professional if blood glucose levels are persistently > 17 mmols/mol For those patients taking insulin therapy: Encourage adequate dietary and fluid intake: Advice is similar to that for Type 2 Diabetes treated with oral sulphonylurea medication, with greater emphasis again on the importance of regular carbohydrate intake and options for lighter carbohydrate foodstuffs (especially at usual mealtimes/when insulin is administered) 3

Increase frequency of blood glucose monitoring/advice re insulin therapy: Frequency of SMBG should be increased to a minimum of twice a day with a range of fasting and pre-meal testing (especially if dietary intake is affected) INSULIN SHOULD NEVER BE OMITTED, despite a reduction in dietary intake; often both patients and carers have to be convinced that this is the appropriate course of action Increased insulin requirements are often required during periods of illness and ill-health; the patient should be advised to contact their healthcare professional if blood glucose levels are persistently > 17 mmols/mol It may be appropriate to consider providing the patient with a simple and individualised plan for adjusting insulin based on blood glucose results support for this can be provided by the diabetes specialist nurse In summary Emphasis should be placed on replacement carbohydrate and maintaining adequate fluid intake. Medication should be continued as normal, with the exception of Metformin where there is an increased risk of dehydration. Insulin therapy should NEVER be omitted, even if dietary intake is reduced. Patients taking sulphonylurea medication should have access to blood glucose monitoring equipment; frequency of testing for those patients already monitoring should be increased during periods of illness. Additional doses of rapid acting insulin can be required during illness. Appropriate written advice should be provided and is available via the NHSL Diabetes MCN website. References NHS Tayside (accessed 1.9.11) Diabetes MCN Handbook. http://www.diabeteshealthnet.ac.uk/default.aspx?pageid=201 Scottish Executive (2006) Scottish Diabetes Framework Action Plan. Edinburgh: Scottish Executive. SIGN (2010) 116: Management of Diabetes. Edinburgh: Scottish Intercollegiate Guidelines Network. Further Reading Diabetes UK (accessed 1.9.11) www.diabetes.org.uk Department of Health (accessed 1.9.11) National Service Framework for Diabetes 2001. http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh_ 4002951 Scottish Government (2010) Diabetes Action Plan 2010. Edinburgh: Scottish Government. Peer Review and Consultation Consultant Diabetologists throughout Lanarkshire Diabetes Specialist Nurse Group A sample of GPs and Practice Nurses who lead diabetes services at practice level Diabetes MCN endorsement May 2014 Review Date May 2017 4

COPING WITH TYPE 1 DIABETES WHEN YOU ARE ILL (SICK DAY RULES) It is very important that you know what to do when you are ill. These are sick day rules. Remember NEVER stop taking your insulin. When you re ill your body becomes much more resistant to the insulin you produce or take by injection. This means your blood glucose levels can rise. You therefore need to monitor your blood glucose and ketone levels and decide if you need more insulin. It is likely that you will need to increase your insulin dose. ALTHOUGH YOU MAY NOT FEEL LIKE IT, IT IS VERY IMPORTANT TO MONITOR YOUR DIABETES CLOSELY TO PREVENT DIABETIC KETOACIDOSIS DEVELOPING. Sick day rules are divided into those for minor illness, where blood glucose may be within normal range or raised but ketones remain negative (e.g. minor viral infection or minor injury); and those for severe illness where blood glucose is raised and ketones are present (e.g. chest infection or high temperature). These are the abbreviations that are used when calculating your insulin requirement: Quick Acting Insulin = Novorapid Insulin Mixture = Humalog Humalog Mix 25 Apidra Humalog Mix 50 Humulin S Novomix 30 Humulin M3 Background Insulin = Lantus Levemir Insulatard Humulin I GENERAL ADVICE IF YOU ARE VOMITING, YOU DO NOT NEED TO EAT UNTIL YOU FEEL WELL ENOUGH TO TRY, BUT DO TRY TO KEEP SIPPING FLUID TO PREVENT DEHYDRATION DURING ILLNESS YOU MAY NOT WISH TO EAT NORMAL MEALS, IF THIS IS THE CASE, TRY TO EAT FOODS THAT ARE EASY TO DIGEST, e.g. SOUP, ICE-CREAM, MILK, PUDDINGS IF YOU RE BLOOD GLUCOSE FALLS BELOW THE NORMAL RANGE, SIP SUGARY DRINKS e.g. FRUIT JUICE, SWEETENED TEA, LUCOZADE OR ICE LOLLIES ADJUSTING YOUR INSULIN DOSES WILL HELP TO CONTROL BLOOD GLUCOSE LEVELS, HOWEVER IF YOU HAVE AN INFECTION YOU WILL ALSO NEED TO CONSIDER MAKING CONTACT WITH YOUR HEALTHCARE PROFESSIONAL FOR ADVICE ON MANAGING THE UNDERLYING INFECTION IF YOU CONTINUE TO VOMIT, ARE UNABLE TO KEEP FLUIDS DOWN, AND / OR CANNOT MANAGE TO REDUCE YOUR BLOOD GLUCOSE OR KETONE LEVELS YOU MUST CONTACT YOUR HEALTHCARE PROFESSIONAL AS AN EMERGENCY 5

SICK DAY RULES - HOW TO WORK OUT YOUR TOTAL DAILY DOSE (TDD) OF INSULIN EXAMPLE : Quick acting insulin (DAILY) Background insulin 10 breakfast 20 bedtime 10 lunch 10 dinner TOTAL 30 TOTAL 20 Total daily dose (TDD) = 30 + 20 = 50 10% OF TDD = 50 10 = 5 20% OF TDD = 50 5 = 10 INJECT AN ADDITIONAL 5 (10% of TDD) quick acting insulin OR 10 (20% of TDD) quick acting insulin IMMEDIATELY AND REPEAT TESTING AND ADMINISTRATION, BASED ON THIS CALCULATION, EVERY 2 HOURS. 10% AND 20% READY RECKONERS Use the table below as a quick guide to 10 or 20% of your total daily dose of insulin Total Daily Dose (TDD) 10% Total Daily Dose (TDD) 15 2 15 3 20 2 20 4 25 3 25 6 30 3 30 6 35 4 35 7 40 4 40 8 45 5 45 9 50 5 50 10 55 6 55 11 60 6 60 12 65 7 65 13 70 7 70 14 20% 6

FEEL UNWELL? TEST YOUR BLOOD GLUCOSE AND KETONE LEVELS NO KETONES (OR TRACE) (LESS THAN 1.5 MMOL/L ON KETONE BLOOD GLUCOSE WITHIN TARGET OR SLIGHTLY ELEVATED MINOR ILLNESS KETONES PRESENT (MORE THAN 1.5 MMOL/L ON KETONE BLOOD GLUCOSE ELEVATED (USUALLY ABOVE 13/14 MMOL/MOL) MODERATE / SEVERE ILLNESS SIP SUGAR FREE FLUIDS (AT LEAST 100ML/ HOUR) TEST BLOOD GLUCOSE AND KETONES EVERY 4-6 HOURS TEST BLOOD GLUCOSE AND KETONES EVERY 2 HOURS If taking multiple injections:- USUAL QUICK ACTING INSULIN DOSES FOR MEALS CALCULATE TOTAL DAILY DOSE (IF CHANGING YOUR DAILY DOSE DEPENDING ON FOOD INTAKE, USE DOSES FROM PREVIOUS DAY MAY ONLY NEED BACKGROUND INSULIN IF NOT EATING USUAL BACKGROUND, BUT YOU MAY CONSIDER INCREASING IT BY 1-2U IF YOU CONTINUE TO BE UNWELL FOR MORE THAN A DAY (DISCUSS WITH YOUR NURSE/DOCTOR IF UNSURE) If taking twice a day injections:- USUAL INSULIN DOSES YOU MAY CONSIDER INCREASING DOSES BY 2-4U IF YOU CONTINUE TO BE UNWELL FOR MORE THAN A DAY (DISCUSS WITH YOUR NURSE/DOCTOR IF UNSURE) KETONES + OR ++ 1.5-3 MMOL/L (ON KETONE GIVE 10% OF YOUR TOTAL DAILY DOSE IN ADDITIONAL QUICK ACTING INSULIN EVERY 2 HOURS PLUS YOUR USUAL INSULIN KETONES +++ OR ++++ ABOVE 3 MMOL/L (ON KETONE GIVE 20% OF TOTAL DAILY DOSE IN ADDITIONAL QUICK ACTING INSULIN EVERY 2 HOURS PLUS YOUR USUAL INSULIN IF YOU CONTINUE TO VOMIT, ARE UNABLE TO KEEP FLUIDS DOWN, OR UNABLE TO CONTROL YOUR BLOOD GLUCOSE OR KETONE LEVELS YOU MUST CONTACT THE HOSPITAL AS AN EMERGENCY. 7 YOU MUST NEVER STOP TAKING YOUR INSULIN