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SICK DAY MANAGEMENT IN
DIABETES
-WORKSHOP-
Dr Anton Harding – Paediatric Endocrinologist
Victoria Stevenson – RN, CDE
Austin Health, Heidelberg & Royal Children’s Hospital, Victoria
Tuesday 26 August 2014
DISCLOSURES Dr Anton Harding
Roche Diagnostics
Victoria Stevenson
Astra Zeneca
Novo Nordisk
Roche Diagnostics
Deakin University
Mayfield Education
6 YEAR OLD BOY
6yo boy t1DM, basal bolus insulin– short acting tds
and intermediate acting nocte
Fever, cough, sore throat with anorexia – refusing
to eat
Paracetamol, 2hourly BGLs 10-16
Fluids, increased insulin - BGLs 6-8
Started to eat next day, fever continued, required a
further increase in insulin doses
25 YEAR OLD MALE ADMITTED IN
HYPOGLYCAEMIC COMA
Type 1 diabetes admitted with BGL of 2.4 post hot
weather, eating less, taking usual insulin.
Has hypoglycaemic unawareness, hypo BGL’s 2/wk,
HbA1c 6.1%
Lives with “watchful” family
Was still driving!
GESTATIONAL DIABETES
33yo first pregnancy, 1st TM routine test BGL 8’s,
diet management 6’s
2nd TM BGL 9-11, started basal bolus insulin
with good response
Gastro illness at 34w – vomiting, diarrhoea
Hydralyte, monitoring BGL 2hourly and
increased insulin
Improved in 24 hours
45 YEAR OLD MUM, T1DM ON
PUMP
2030 Changed line & reservoir
2200 BG of 16.7mmol/L, ate ice cream and bolused
Wanted to void overnight but slept on
0630 BG18mmol/L, ketone strips OOD, vomited x3
0900 Called ambulance (& was lectured!), went to GP
BG “19.4” with large urine ketones
Admitted with evolving DKA (pH 7.35, HCO3 22,
BKL 3.7) HbA1c 8.7%
The culprit……..
68 YEAR OLD UNWELL MAN
T2DM for 6years on 1g metformin bd with good BGL’s of 7-9 Developed flu symptoms (fever, cough, sneezing, nasal
congestion) Saw usual GP and advised:
to increase fluids increase AC/PC testing, report if BGL’s > 12 Panadol and over the counter flu medication Call clinic if other symptoms develop Continue metformin unless dehydration occurs
BGL’s 8-13 which returned to normal in 3 days.
88 YEAR OLD CHINESE MATRIACH ADMITTED IN
A HYPERGLYCAEMIC HYPEROSMOLAR STATE
(HHS)
Type 2 diet treated
Non English speaking, lives with daughter
suffered an unwitnessed fall
10/7 Hx of increasing confusion, extreme fatigue,
polyuria (every 2 hours), unsteady, recurrent falls
Fiercely independent, significant sugar/soft drink
intake, refused GP visit
BGL 30.2mmol/L, urine ketones +, BKL
0.7mmol/L Osmolality 356 mosmol/kg
AIMS OF WORKSHOP Understand the clinical evidence supporting the local and
international sick day management guidelines.
Learn more about an Australian review on the effectiveness of ambulatory ketone monitoring to prevent DKA. The findings will guarantee to challenge your current thinking.
This workshop will keep you abreast of the current consensus and guidelines on creating and implementing a sick day management plan.
OBJECTIVES
The place of sick day management plans in self-management of diabetes
Current guidelines and evidence
Myths and misconceptions – a review of the evidence base for ambulatory monitoring of ketones
Realities – proactive management of blood glucose levels is key to good control on sick days
THE AIMS OF SICK DAY MANAGEMENT • To avoid
– diabetic ketoacidosis (DKA) – hypoglycaemia hyperglycaemic hyperosmolar state (HHS) – reduce hospitalisations – reduce absenteeism from school and work – reduce cost of illness to the community – reduce anxiety in family/friends – improve early contact with the diabetes team – demonstrate effective action when unwell – recover as soon as possible – prevent the re-occurrence of an illness
EVIDENCE FOR EARLIER INTERVENTION Better outcomes when timely interaction with HPC
(Laffel, 2000)
Prevention of DKA & HHS – with better communication, education & medication
(Kitabchi, 2009)
24 hour phone support – significant reduction in presentations with DKA, 31 patients (83 contacts), 2 with DKA
(Farrell & Holmes-Walker, 2011)
ADMISSIONS OVER A DECADE (WRIGHT, 2009) Factors contributing to
DKA
Number of Admissions Percentage of
admission (%)
Poor control and
compliance
160 57.6
Infective illness
65 23.4
Psychological problems
57 20.5
Missed insulin dose
52 18.7
New diagnosis
28 10.1
Alcohol abuse 25 9.0
Vomiting or diarrhoea
19 6.8
Family problems 11 4.0
Cough/cold/flu-like
symptoms
5 1.8
Other 3 1.1
BGL’S ON THE RISE…
Hyperglycaemia occurs in 1 hour
Ketone production begins in 3 hours
DKA may occur in 4 Hours
Patient education is critical
Walsh, J & Roberts 2000, Pein, P. Hinselmann, C, Pfitzner et al 1996
HYPERGLYCAEMIC HYPEROSMOLAR STATE (HHS)
1% of all primary diabetes-related admissions
Usually affects middle aged or older people
Infection most common precipitating factor
Symptoms evolved over days to weeks
2/3 of episodes of HHS occur in people not known to have diabetes
MANAGEMENT OF HYPOGLYCAEMIA DURING ILLNESS Illness associated with nausea, vomiting or diarrhoea
Pregnant women with type 1 and type 2 diabetes are at increased risk
Routine hypoglycaemic management is recommended
ie 15-30 grams of glucose is recommended for the
conscious individual experiencing hypoglycaemia
(ADA, 2014)
People with type 1 diabetes should have a glucagon kit (in date) for severe hypoglycaemia. Support team need how when and how to use it.
LOCAL AND INTERNATIONAL GROUPS
ADEA – www.adea.com.au APEG/ADS/NHMRC – www.apeg.org.au NZ – www.diabetes.org.nz ADA – www.diabetes.org IDF – www.idf.org ISPAD – www.ispad.org Canadian DA- www.diabetes.ca UK – NICE guidelines – www.diabetes.org.uk LWPES/ESPE
THE EFFECTIVENESS OF AMBULATORY BLOOD
KETONE MONITORING IN THE PREVENTION AND
MANAGEMENT OF KETOACIDOSIS IN TYPE 1
DIABETES:
A SYSTEMATIC REVIEW
JANUARY 1993- SEPTEMBER 2012
Victoria Stevenson, Seham Girgis, Armita
Adily, Anton Harding, Jane Speight, Jeanette
Ward, Maarten Kamp
Thanks to Roche Australia for an unrestricted education
grant
INTRODUCTION
Diabetes ketoacidosis is life threatening Two thirds of patients hospitalised have type 1 diabetes International organisations support ambulatory capillary
blood and urine ketone monitoring as components of clinical practice and self management
Using a systematc review, we wanted to determine the quantity and quality of existing evidence of ketone monitoring in people with t1DM
1. IN PEOPLE WITH TYPE 1 DIABETES, HOW EFFECTIVE IS AMBULATORY KETONES MONITORING?
The retrieved evidence is by no means definitive. We do not know whether ambulatory ketones monitoring is effective in preventing DKA or reducing the likelihood of serious clinical incidents such as DKA‐ related hospitalisation.
It remains unclear whether ketones monitoring is at all necessary in ambulatory settings with the availability of precise glucose monitoring.
Urinary ketone monitoring during sick days is embedded in clinical practice recommendations and patient self‐care regimens, but the evidence of beneficial impact is uncertain.
Addition or substitution of urinary ketone monitoring by blood ketone monitoring is unjustified with the extant evidence.
In summary, this question has not yet been sufficiently researched to provide definite conclusions.
2. IS AMBULATORY KETONE MONITORING ASSOCIATED WITH AN IMPROVEMENT IN PSYCHOSOCIAL OUTCOMES IN PEOPLE WITH TYPE 1 DIABETES OR THEIR CAREGIVERS? (E.G. CONFIDENCE IN DIABETES MANAGEMENT, DIABETES RELATED DISTRESS, IMPACT ON SCHOOL OR UNIVERSITY OR OTHER EDUCATIONAL OBLIGATION, WORK ATTENDANCE AND ABSENTEEISM)
Unknown The available evidence comprises only one study which did not measure any of these required psychosocial outcomes (Laffel et al., 2006) A single‐item question about satisfaction with blood ketone monitoring was asked only of those randomised to receive it and the wording of the item is not available The sample size of patients of whom this item was asked was small (possibly only 40 participants but not reported exactly by the authors)
3. IN PEOPLE WITH TYPE 1 DIABETES, WHAT IS THE EVIDENCE OF A DIFFERENTIAL EFFECT BETWEEN AMBULATORY BLOOD KETONE AND URINE KETONE MONITORING FOR THE PREVENTION AND MANAGEMENT OF DKA?
Findings: Evidence to date is not yet compelling.
4. IN PEOPLE WITH TYPE 1 DIABETES OR THEIR CAREGIVERS, WHAT IS THE EVIDENCE OF A DIFFERENTIAL EFFECT BETWEEN AMBULATORY BLOOD KETONE AND URINE KETONE MONITORING IN PSYCHOSOCIAL OUTCOMES?
Findings:
Evidence to date is not yet compelling.
CONCLUSION
The evidence about the effectiveness of ambulatory urine and blood ketone monitoring in prevention and management of DKA is not yet compelling
Definitive research is needed to address this important clinical question
BLOOD Β-HYDROXYBUTYRATE VS. URINE ACETOACETATE TESTING FOR THE PREVENTION AND MANAGEMENT OF KETOACIDOSIS IN TYPE 1 DIABETES: A SYSTEMATIC REVIEW
KLOCKER, PHELAN, TWIGG & CRAIG – JULY 2013
Literature search to 2012 – 4 studies
299 participants across 11 centers
Blood compared with urine ketone testing Reduced frequency of hospitalisation ( 1 study)
Reduced time to recovery from DKA (3 studies)
Cost benefits ( 1 study)
Greater satisfaction ( 1 study)
Blood more effective than urine testing Reducing ED assessment
Hospitalisation and time to recovery from DKA
‘Potentially lowering healthcare expenditure’
AUGUST 2014
Urine ketone strips available on the NDSS
Blood Ketone strips are still NOT available on the NDSS
Why?
KETONE MONITORING FOR TYPE 1 DIABETES
Two methods available
Does not diagnose DKA
Differences between urine and blood ketone capabilities
Ensure correct meter for blood ketone monitoring
Expiry date
Storage
Costs
OVERVIEW OF INTERNATIONAL PATIENT MATERIALS (2014) Key messages Key messages
•Never stop insulin •Extra insulin •Fluids •Importance of carbohydrate in some form •BGLs that don’t come down •BGL’s that don’t go up •Ketones •A fever higher than 100 degrees F (37.8 C) •Drowsy or confused (make sure carers are aware of this) •The individual and their supports •Sick Day kits •Over the counter medication
•Trouble moving arms or legs? •Vision, speech or balance problems? •Anti-emetics •Symptoms to watch out for •No vigorous exercise •Contacts •Educate really well! •Rest •Treat underlying inter-current illness sufficiently •Complementary therapies •Impact on school/ work/ family •School plans
WHAT TO ASK?
How long have you felt unwell / how do you feel now?
Have you been vomiting? If yes, must come to hospital!
Can you tolerate any food & or fluids?
Have you had your insulin
Have you had your other diabetes medicines?
Is your insulin device working correctly?
Is the insulin in use older than one month
What are your most recent BGL’s
Are your glucose meter strips in date
? clean fingers
What are your urine/blood ketone levels? (t1DM)
What may have caused the high sugars?
Do you have any foot problems?
Have you contacted your usual doctor/diabetes team?
Who is with you?
Other
CAUSES OF HYPERGLYCAEMIA INCLUDE
Infection / acute illness / surgery
Gastroparesis
Decreased activity
Too much carbohydrate
Missing / wrong dose insulin / OHAs
Over treating hypos
Some medications e.g. steroids
Weight gain
Depression/anxiety
Premenstrual hormonal changes
Menopause
Pregnancy
KEY POINTS Fluids
Blood glucose monitoring
Ketones (if required)
Medication adjustment
Additional medications
Engaging with the diabetes care team including after hours contacts
Which hospital
Precipating causes
Other assistance to consider
WHEN UNWELL, EARLY INCREASE IN BGM IN THOSE “AT RISK” INDIVIDUALS WHO…
Have recurrent DKA
Have poor glycaemic control
Have an eating disorder
Are known to frequently/inappropriately omit insulin
Are pregnant
Have multiple co=morbidities which my include end stage organ failure
Are elderly
Live in remote/isolated areas
Are travelling
IN RESIDENTIAL/CORRECTIONAL ORGANISATIONS
Have an agreed care plan in place
Identify a designated doctor who accepts responsibility
Identify who to contact when initial professional advice is quickly
Identify when hospitalisation is indicated
SUPPLEMENTAL DOSES OF INSULIN ARE DEFINED AS: • Rapid-acting insulin doses to be given in addition to usual insulin dose(s)
• Currently available rapid-acting insulins are aspart, lispro, glulisine
• Insulin to be given straight away (but not closer than 2 hours to the previous dose of rapid-acting insulin) and not just delayed until the time that the next prescribed usual insulin dose is due.
• Being calculated as a percentage of the total daily dose ie. % of the total of short and intermediate/long acting in a day.
Example of how to calculate extra insulin
ADEA CLINICAL GUIDING PRINCIPLES FOR SICK DAY MANAGEMENT OF ADULTS WITH TYPE 1 AND TYPE 2 DIABETES
Table 4 - Management of glucose lowering medicines during illness
Medication Specific concerns or
considerations Action
Metformin Rapid dehydration resulting from acute illness may impact on renal function, further reducing creatinine clearance in people with known renal impairment and in the frail elderly. Is contraindicated in severe liver, cardiac and respiratory disease. Requires awareness of the clinical signs and symptoms of lactic acidosis*.
Prompt medical direction should be sought to confirm continuation of metformin in people at high risk of acute renal failure in the presence of rapid dehydration. Metformin should never be commenced during an episode of acute illness.Presentation to hospital required if lactic acidosis is suspected and metformin is ceased.
GLP -1 mimetics Illness that results in sudden nausea, vomiting or anorexia (not as an adverse drug effect) may be exacerbated by continued short term use of exenatide, liraglutide Sudden abdominal pain.
Medical direction should be sought to confirm continuation of GLP-1 mimetics. Cease GLP-1 mimetics with full medical and pathology assessment to look for possible development of pancreatitis.
Sulfonylureas Illness that results in sudden nausea, vomiting or anorexia may increase risk of hypoglycaemia, especially with long-acting preparations.
Frequent self-monitoring blood glucose levels to identify falls in blood glucose. Medical direction should be sought to confirm continuation of sulfonylureas.
Thiazolidinediones Can contribute to fluid retention. Should be reviewed if marked fluid retention is occurring or if symptoms are suggestive of cardiac failure develop.
Dipeptidyl peptidase-4 inhibitors
Sudden abdominal pain. Cease DPP4 inhibitors with full medical and pathology assessment to look for possible development of pancreatitis.
Alpha-glucosidase enzyme inhibitor
Development of an ileus. Medical direction should be sought to confirm continuation.
Page 30 of 53
Non insulin
Diabetes
medications
exenatide
glibenclamide
acarbose
sitagliptin
pioglitazone
SPECIFIC MANAGEMENT ISSUES FOR PEOPLE USING INSULIN PUMPS
Additional sick day education is required pre, commencement of pumps and at regular intervals
Pumpers can be at greater risk for developing ketosis and DKA
More frequent BG monitoring when unwell
Pumpers need manage pump malfunctions and must have an emergency plan
The emergency plan should include a subcutaneous insulin regimen/education on calculation of insulin doses, should there be an urgent need to switch back to MDI
Basal rate and/or correction boluses may need to be increased with illness
Replace line, cannula, reservoir, insulin
If ketones positive or hyperglycaemia, suspect a problem with the pump
Pump
Pregnant Women with Pre-Gestational Diabetes
• DKA occurs more often with type 1 diabetes • Pregnancy increases risk of DKA • More prone to ketosis • DKA more likely in 2nd and 3rd trimester (Increase in
insulin resistance, relative insulin deficiency & accelerated starvation)
• Usual sick day plan will require modifications • More frequent BG monitoring • Nausea and vomiting may worsen ketones • Prompt medical intervention and hospitalisation
when there is hyperglycaemia and/or ketosis
CARBOHYDRATE ALTERNATIVES
1 cup of milk
Fruit juice
Sports drink
Toast
Arrowroot/ morning coffee biscuits
Cheese and biscuits
Mashed potato
Rice
Custard
Jelly
Ice creams
Icy poles
IN THE SCHOOL Collectively develop an understanding of diabetes
and the diabetes related needs of the individual
student. The following areas may need to be
addressed:
•Recognizing the signs and symptoms
of low blood sugar (insulin reaction)
•When it is most likely to occur
•How to prevent it
•How to treat it
IN THE SCHOOL 2 Recognizing the signs and symptoms of high
blood sugar
Identifying food and snack requirements and routines
Identifying blood sugar monitoring needs
Routine
Privacy
Developing an action plan for emergencies
SCHOOL PLAN EXAMPLE
Student – Diabetes Management Plan for School
If in doubt, treat as Hypoglycaemia and give sugar. Never delay. Never leave unattended
HYPO [Hypoglycaemia] Blood Glucose Levels (BGL) Below 4 mmol/L
Insert picture of Student
Hyper [Hyperglycaemia] Blood Glucose Levels Above 15 mmol/L
Possible causes: delayed eating, insufficient food, too much insulin or exercise
Possible causes: forgotten insulin, too much food, illness and stress
MILD SEVERE Transient BGL > 15 Persistent BGL > 15
POSSIBLE SYMPTOMS
POSSIBLE SYMPTOMS
USUALLY NO SYMPTOMS POSSIBLE SYMPTOMS
pale
hungry
sweating
trembling or shaky
reporting feeling “hypo”
TREATMENT
give sugar serve then follow with carbohydrate serve
If around morning tea or lunch give sugar serve then snack or meal
HYPO BOXES Class Room Sick Bay
Student should have access to hypo food at all times
Serve Amount =
5 jelly beans (sugar) 4 to 6 dry biscuits or sandwich (CHO) PE and Sport = 1 serve of CHO for every hour of activity 1 serve of sugar before every 30mins of swimming.
unable to stand
disorientated or confused
unable to swallow
unconsciousness or seizure
If unable to swallow or unconscious:
call an ambulance 000
Never leave unattended.
TREATMENT
ensure insulin has not been forgotten
do not withhold normal meal or snack
encourage water
Student may need extra toilet privileges
Retest BGL in 2 hours Student can participate in sports if his BGL is >15, but DO NOT make Student perform physical exercise to reduce the blood glucose level. It may not help and may elevate the level.
frequent urination
thirst
lethargy
nausea
irritability
vomiting TREATMENT
ensure insulin has not been forgotten
if unwell (eg vomiting) Student to go home
parents to check for ketones at home
Blood Glucose Level Testing
Pre Lunch
Anytime Hypo is suspected
EMERGENCY CONTACT NUMBERS
Home: Mobile:
Ambulance 000 Austin Health 9496 5000
Ask for the Paediatric Registrar or Diabetes Nurse Educator
.
Exams or NAPLAN Ensure student is > 5.0 before taking the test, and allow CHO to be consumed for every 1 hour of test.
INDICATIONS FOR HOSPITAL ADMISSION
(REGARDLESS OF TREATMENTS)
A suspicion of underlying diagnosis that requires hospital
admission ( eg MI, intestinal obstruction) – admit immediately
Inability to swallow or keep fluids down (if persists more than a
few hours)
Significant ketosis in a person with type 1 diabetes despite
optimal mx and supplementary insulin
BG persistently >20mmol/L despite best therapy
Any signs of ketosis or worsening conditions (eg Kussmaul’s
respiration, severe dehydration, abdominal pain), symptoms of
chest pain, fruity breath, dry mouth
Unable to manage adjustment of normal diabetes care
The patient lives alone, has no support and may be at risk of
slipping into unconsciousness
SO FINALLY…WHEN DO YOU TALK SICK DAYS?
Give sick day discussion a higher priority
Review knowledge regularly
Review guidelines after all episodes of illness
Document
How available are you or your team when someone is ill?
Gain as much experience in sick day management as possible
IN CONCLUSION
Make Sick Day Management a high
priority for all people with diabetes
Recognise issues that face individuals,
families and health professionals
Current resources
Staff education
Ensure 24 hour contact within your
organization
REFERENCES INCLUDE:
Australian Diabetes Educators Association. Clinical Guiding Principles for Sick Day Management of Adults with Type 1 and Type 2 Diabetes (2014) Canberra.
ADEA Guidelines for Sick Day Management for People with Diabetes (2006), Canberra.
Australian Paediatric Group and the Australian Diabetes Society National evidence-based clinical care guidelines for type 1 diabetes in children, adolescents and adults (2011) Canberra.
General practice management of type 2 diabetes – 2014-2015. Melbourne: (2014) The Royal Australasian College of General Practitioners and Diabetes Australia.
Katsilambros. N et al Diabetic Emergencies, Diagnosis and Clinical Management (2011) , Wiley-Blackwell, West Sussex.