DIABETES SURGICAL BOLT-ON

1. DIABETES SURGICAL BOLT-ONPresented by: Phil Mannall Inpatient DSN

2. DIABETES SURGICAL BOLT-ON SUBJECTS TO DISCUSS: T1 & T2 DM DIABETES & NUTRICIAN THERAPEUTIC BL. GL. LEVELS HbA1c HYPOGLYCAEMIA DIABETES ORAL MEDS & INSULIN SAFE ADMINISTRATION OF INSULIN SLIDING SCALES AGENDA

3. What Is Diabetes? • Diabetes mellitus is a disorder in which the blood sugar level is persistently raised above the normal range. • Normal blood glucose range: • 4 – 7 mmol/l • The abnormality is caused by an absolute or relative lack of insulin, secreted from the pancreatic β-cells.

4. Diabetes mellitus = ‘flowing over with sweet urine’ • Diabetes (Greek) means ‘siphon’ or ‘fountain’ • Mellitus (Latin) means ‘sweet like honey’ • The most obvious sign of diabetes is passing a lot of urine. Early physicians in Egypt and India tasted the urine and noted it was very sweet (1500 BC and 400 BC). • In many languages, like Finnish and German, the condition is actually called ‘sugar disease’

5. How Is Diabetes Diagnosed? The person may experience some or none of the following symptoms: Frequent urination, even at night (polyuria) Excessive thirst (polydipsia) Tiredness and weakness (fatigue) Constant hunger (polyphagia) Blurred vision Weight loss Dry, itchy skin (pruritis), boils Genital irritation/thrush/urinary infections

6. DIABETES SURGICAL BOLT-ON Diagnostic Criteria for Diabetes • Patient showing symptoms of diabetes: • Random venous plasma glucose ≥ 11.1 mmol/lOR • Fasting venous plasma glucose ≥ 7.0 mmol/l • Asymptomatic patient: • Two samples, either random or fasting, taken on different days, are needed to confirm diagnosis • These blood values refer to blood taken from a vein and tested in the laboratory. Capillary blood values by a finger prick test on the ward are about 1.0 mmol/l lower. A meter reading is not sufficient to diagnose diabetes. (WHO Diagnosis and Classification of Diabetes Mellitus 1999)

7. Diagnostic Criteria for Diabetes Patient showing symptoms of diabetes: Random venous plasma glucose ≥ 11.1 mmol/lOR Fasting venous plasma glucose ≥ 7.0 mmol/l Asymptomatic patient: Two samples, either random or fasting, taken on different days, are needed to confirm diagnosis These blood values refer to blood taken from a vein and tested in the laboratory. Capillary blood values by a finger prick test on the ward are about 1.0 mmol/l lower. A meter reading is not sufficient to diagnose diabetes. (WHO Diagnosis and Classification of Diabetes Mellitus 1999)

8. What Is Type 1 Diabetes? • Type 1 Diabetes happens when the β-cells in the pancreas are destroyed by the body’s own immune system. They stop making insulin and blood glucose levels rise. • Type 1 Diabetes usually comes on suddenly, within a few months or weeks. The person is typically young (<30 years) and thin. • The missing insulin must be given every day for lifetime in order to survive.

9. DIABETES SURGICAL BOLT-ON What Is Type 2 Diabetes? • Type 2 Diabetes happens when the pancreas is not making enough insulin, or the body is not able to use insulin properly (insulin resistance). • Type 2 Diabetes appears most often in middle-aged and older adults. Often not diagnosed until 10-15 years after the onset. • These people should aim to lose weight, be more active. • They may require tablets, and because Diabetes is a slow onset disorder may require insulin in the future.

10. What Causes Diabetes? DIABETES SURGICAL BOLT-ON TYPE 1: • Inherited genetic susceptibility:HLA genes which initiate the immune attack against β-cells • Environmental factors: viruses, early use of cow’s milk in infancy, toxins in smoked fish/potatoes, low exposure to sunlight and low Vitamin D level • Autoimmune response: pancreatic cells destroyed by own lymphocytes (circulating islet cell antibodies, insulin antibodies, and GAD antibodies) • Highest incidence in Finland, rare in Africa

11. DIABETES SURGICAL BOLT-ON What Causes Diabetes? • TYPE 2: Genetic factors: possibly several genes, leading to inherited apple-shape body with abdominal (visceral) fat layer; genes in certain ethnic groups (South-East Asians, Afro-Caribbeans, American Indians, Mexicans) Environmental factors: small birth weight, rapid weight gain in babyhood, sedentary lifestyle, large calorie intake, obesity Highest incidence in India, Hispanic people in USA, and Black Americans

13. How Is Diabetes Treated? • Type 1: need insulin for life; some doctors also prescribe Metformin tablets, especially to people who have raised fasting glucose levels, or who need large amounts of insulin. • Type 2: all patients benefit from dietary advice and increase in physical activity; need to start on oral tablet (OHA) or a combination of two/three, if glucose levels still high; most Type 2 patients need insulin, if they live long enough.

14. Eating, Drinking and Diabetes(1) There are no ‘forbidden’ foods for diabetics There is no ‘diabetic diet’! No ‘diabetic yoghurts, ice-cream, marmalade, or jam’! People with diabetes follow same healthy eating principles as everyone should do: Avoid sugary puddings, cakes, biscuits Reduce saturated/animal fats – trim off fat, use low-fat alternatives, avoid pastries and pies Avoid sweetened drinks and fruit juices – use ‘No added sugar’ drinks or diet drinks Do not add salt in cooking, use herbs and spices Do not buy ‘diabetic foods’ – sorbitol is high in calories – they are expensive, cause diarrhoea, taste foul

15. Eating, Drinking and Diabetes (2) Brown bread or wholemeal bread is no better than white bread – whole-grain bread is preferable Eat at least 5 portions of fresh fruit and vegetables a day (frozen or tinned are OK) Cut down your portion sizes – keep a diary of what you eat for a week or two! Eat foods with low GI index – such as , pulses, lentils, brown pasta, and nuts Drink plenty of fresh water – 2-3 litres a day In Type 2 diabetes, eat 3 small meals a day – to avoid large increases in post-meal blood glucose

16. Eating, Drinking and Diabetes (3) Avoid ready meals and take-aways Use olive oil in cooking, have at least two meals of oily fish (salmon, herring, mackerel, sardines) per week Alcohol (any wine or beer) in moderation is protective to your blood vessels. Do not go for ‘low-alcohol’ beers – they are high in sugar. Do not choose ‘low-sugar’ beers – they are high in alcohol. Use the ordinary varieties 1-2 units a day for women 2-3 units a day for men REMEMBER: alcohol can lead to weight gain! REMEMBER: if you take insulin or tablets, alcohol causes hypos within 6-12 hours – always have food with alcohol

17. Tablets In Type 2 Diabetes Also called oral hypoglycaemic agents -(OHAs) or antihyperglycaemic agents Insulin secretagogues increase insulin secretion from β-cells Insulin sensitizers decrease insulin resistance Inhibitors of glucose absorption slow down glucose absorption from the gut

18. ORAL HYPOGLYCAEMIC AGENTS

19. OHAs In Type 2 Diabetes (1) INSULIN SECRETAGOGUES: Sulphonylureas (Gliclazide, Glimepiride, Glipizide) increase ‘second-phase’ insulin release (10-120 minutes) after a meal. They are taken with a meal. Can cause hypoglycaemia, which can be severe. I

20. OHAs In Type 2 Diabetes (2) INSULIN SENSITIZERS: Metformin reduces hepatic glucose production, increases glucose uptake by muscles, and reduces appetite. Helps to lose weight, no hypos. Thiazolidinediones/ Glitazones ( Pioglitazone) increase insulin sensitivity especially in fat tissue; improve lipid problems; lower blood pressure; redistribute abdominal fat to peripheral subcutaneous fat layers. Can cause weight gain and oedema. Take 4-6 months to show full effect.

21. Which OHA(s) to choose? SULPHONYLUREAS: Glipizide up to 20mg od Glimepiride up to 6mg od  2nd phase insulin secretion hypos, weight gain, NOT in renal failure Gliclazide up to 160mg bd Gliclazide MR 30mg –up to 120mg od METFORMIN/ METFORMIN SR up to 1G bd First-line in all Type 2 diabetes patients; hepatic glucose out-put; fasting and post-prandial BG; glucotoxicity; FFAs; insulin requirement; appetite; weight gain; allows β-cell recovery; endothelial function; no hypos on its own  Abdominal discomfort, diarrhoea; slow release formula better tolerated NOT in renal impairment (if creatinine > 130), NOT in cardiac or respiratory failure; NOT 48 hours before or after IV contrast medium for radiological investigations

22. Combination Therapy With Insulin And OHAs Until recently, insulin was introduced in Type 2 Diabetes as a last resort after serious deterioration in glucose levels Insulin is now discussed with the patient on diagnosis, and the progressive loss of β-cells and hence insulin secretion is explained NICE guidelines now recommend HbA1c target of ≤ 7%, except in the elderly and very frail Insulin is now introduced when HbA1c is around 8% and there is still some residual insulin secretion

23. Insulin Therapy With Tablets In Type 2 Diabetes Start with OD basal insulin, e.g. glargine, detemir, or insulatard, together with metformin; this will suppress glucose production from the liver at night-time and control fasting BG level; metformin will keep the required insulin dose lower and help control weight and improve blood cholesterol. Continue sulphonylurea also to keep insulin dose low When post-meal glucose ‘spikes’ start to appear, BD pre-mix insulin, e.g. NovoMix 30, or Humalog Mix 25, can be introduced, together with Metformin Later basal bolus regimen with three rapid-acting pre-meal injections and OD glargine/detemir is preferred for younger patients with less predictable daily routines To keep insulin dosages lower, some diabetologists now add thiazolidinedione, such as pioglitazone, which sensitizes tissue cells to insulin. It enhances the utilisation of both endogenous and exogenous insulin. (Not yet licensed in the UK.)

25. INSULINS Human insulin is manufactured using genetic DNA methods in E.Coli bacteria or yeast Animal insulins are extracted from the pancreas of pigs (porcine) or cows (bovine) and purified. Some people still prefer to use them, as they feel human insulins made them lose their hypo-awareness Analogue insulins are made using DNA recombinant technology in bacteria to make a few changes in the human insulin structure

26. National Patient Safety AgencyRapid Response ReportSafer Adminstration of Insulin For IMMEDIATE ACTION by all organisations in the NHS and independent sector. 1. All regular and single insulin (bolus) doses are measured and administered using an insulin syringe or commercial insulin pen device. Intravenous syringes must never be used for insulin administration. 2. The term ‘units’ is used in all contexts. Abbreviations, such as ‘U’ or ‘IU’, are never used. 3. All clinical areas and community staff treating patients with insulin have adequate supplies of insulin syringes with subcutaneous needles, which staff can obtain at all times. 4. An insulin syringe must always be used to measure and prepare insulin for an intravenous infusion. Insulin infusions are administered in 50ml intravenous syringes 5. A training programme should be put in place for all healthcare staff (including medical staff) expected to prescribe, prepare and administer insulin. An e-learning programme is available from: www.diabetes.nhs.uk/safe_use_of_insulin 6. Policies and procedures for the preparation and administration of insulin and insulin infusions in clinical areas are reviewed to ensure compliance with the above.

27. Types Of Insulins By Their Action

28. Where Should Insulin Be Injected? Insulin should be injected into subcutaneous fat tissue, not in the muscle Suitable sites: Abdomen below navel and both sides of the navel Upper outer thighs below trochanter Lower outer aspect of upper arms below deltoid Buttocks Short- and rapid-acting insulins are best injected in the abdomen, long-acting in the thighs or buttocks. Glargine can be injected in any of the sites The actual injection spot in each site must be rotated for every injection to avoid lipos from forming

29. Insulin injection sites

30. Timing Of Insulin Injections Rapid-acting analogues – NovoRapid and Humalog - can be given just at the start of a meal, or if BG is very low, even after the meal Short-acting Actrapid or older pre-mixes, Mixtard 30 (Disc. Dec. 2010 and Humulin M3, should be given 20-30 minutes before eating Analogue mixes, NovoMix 30, Humalog Mix 25/50, can be given at the start of the meal

31. Where Should Insulin Be Kept? Do not keep live insulin pens in the fridge! Do not leave the pen near heat (radiator, cooker, car glovebox) or in sunlight. Only spare cartridges need to be in the fridge. Vials must be marked with date of starting – discard in a month. Always remove pen needle after injecting, fit a new needle on the pen just before the next injection.

32. What Is Hypoglycaemia ?

33. What Is Hypoglycaemia ? Hypoglycaemia means blood glucose <4.0mmol/l although in many people with diabetes hypos can occur >4.0 mmol/l. Please check with patient/carers Hypo is caused by insulin or sulphonylureas Poor renal function can lead to hypos in Type 2 diabetic patients, as some SU tablets and insulin are not secreted by the kidneys and build up When BG falls below 3.5 mmol, glucagon, epinephrine and nor-epinephrine – counterregulatory hormones – are released to make the liver release glucose This causes the ‘autonomic’ signs of a hypo: sweating, trembling, pounding heart, and hunger

34. Hypoglycaemia And Hypoglycaemia Unawareness(2) If BG continues to fall to 3.2 – 2.8 mml/l, cognitive brain function starts to deteriorate. Symptoms of this ‘neuroglycopenia’ include: confusion, visual disturbances, drowsiness, odd or aggressive behaviour, speech difficulty, tingling in the lips and tongue. If BG falls still below 1.5 mmol, coma develops. Children and elderly may have convulsions or transient hemiplegia. Unfortunately, people who have had diabetes for years or who suffer from frequent hypos, lose their hypo awareness: the autonomic symptoms do not develop until the brain dysfunction has started, and the person can no longer take any action to correct the low blood sugar. A training programme of avoiding hypoglycaemia with regular blood glucose testing and regular snacks can often restore hypoglycaemia warning symptoms.

35. What Causes Hypoglycaemia ? (3)

36. What Causes Hypoglycaemia? (3) Too much insulin or sulphonylurea, especially if renal or liver function is impaired and/or appetite poor Too little food or a missed meal Vigorous, prolonged exercise hours earlier Inappropriate giving time of insulin, e.g. rapid-acting NovoRapid given too early and meal delayed Gastroparesis, which causes delayed digestion and absorption of food Inappropriate type of insulin, e.g. Insulatard given at bedtime, reaching peak action around 3 am, when no food taken! Pre-mixed Mixtard 30 given am, hypo likely if lunch delayed Sudden increase in skin temperature after injection, e.g. hot bath, sauna, sunbathing Alcohol intake without food – alcohol will stop the liver from releasing glucose for hours afterwards Drugs, such as betablocker (propranolol and sotalol), can reduce hypo awareness and delay recovery from hypo

37. HYPO GLYCAEMIA FLOWCHART

38. How To Treat A Hypo? (1) 3-4 Dextrosol (1 tablet = 3g glucose) tablets plus a drink of water 100 ml Lucozade 100 ml Orange juice 1 tube Glucogel ALL THESE WILL RAISE BG ABOUT 2-3 mmol IN 10-20 MINUTES. RETEST BLOOD SUGAR IN 10 MINUTES. HAVE A SANDWICH, 2 BISCUITS, A BANANA OR YOUR NEXT MEAL, IF IT IS DUE Do NOT overtreat a hypo. Use this guide as a prescription! Otherwise, severe hyperglycaemia will follow leading to a vicious cycle.

39. How To Treat A Moderate to Severe Hypo (2) If not able to swallow safely or too confused, DO NOTPUT ANYTHING IN THE MOUTH! RISK OF ASPIRATION INTO LUNGS! Glucagon 1 mg IM or SC – will raise BG by 2-3 mmol in 10-15 min. Easy to give even to an agitated person; does not need IV access; does not damage veins; does not overtreat hypoglycaemia. After 30 min, give 2-3 biscuits, a sandwich, a yoghurt, or a meal. IV Dextrose 20% 75-80ml - will raise BG by 8-10 mmol in 5 min. Needs a cannula; difficult to manage in a patient who is restless or fitting; overtreats the hypo DO NOT USE DEXTROSE 50% - VERY VISCOUS, DIFFICULT TO PUSH INTO CANNULA; DAMAGES PATIENT’S VEIN; CAUSES SEVERE NECROSIS IF EXTRAVASATES!

40. What Is ‘Rebound Hyperglycaemia’ ?

41. What Is ‘Rebound Hyperglycaemia’ ? Answer Rebound hyperglycaemia: high blood sugar following a severe hypo and with little insulin left in the body, esp. in the morning. Glucagon and epinephrine release glucose from the liver too effectively, the person over treats the hypo, and even lowers the next insulin dose! Result: rebound hyperglycaemia.

42. Question.Where would you find the guideline for Perio-operative management of patients with Diabetes?

43. Where would you find the guideline for Perio-operative management of patients with Diabetes? Answer On the intranet. Type in ‘Diabetes’ in the search window and scroll down to find all the guidelines for Diabetes in hospital management.

50. Sliding Scale Insulin And After NOTE: Intravenous sliding scale insulin is given to treat Diabetic ketoacidosis (DKA) and Hyperosmolar non-ketotic state (HONK), but also to give insulin replacement peri-operatively or during serious intercurrent illness (MI, stroke, or pancreatitis). The insulin sliding scale may be the same, but the IV fluid regimen will differ. In DKA, after the initial fall in BG to 15 mmol/l, N.Saline should be replaced with 5% Dextrose infusion to keep BG around 10-15 mmol/l. It is important to provide the body with insulin and glucose for fuel, in order to clear the ketones. Once ketones have cleared from the urine (trace or negative) and the patient is able to eat and drink, transfer to sc insulin. IV SOLUBLE INSULIN HAS A HALF- LIFE OF 4-6 MINUTES ONLY – AFTER THAT THE PATIENT WILL HAVE VIRTUALLY NO INSULIN AND BLOOD SUGAR WILL RISE DRAMATICALLY IF S/C INSULIN HAS NOT BEEN GIVEN AT THE RIGHT TIME BEFORE STOPPING THE IV SLIDING SCALE INSULIN!