SICK DAY MANAGEMENT IN IABETES -WORKSHOP …2014.ads-adea.org.au/.../Sick-Day-Management.pdf · international sick day management guidelines. ... 24 hour phone support ... People

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

Courtesy-

Maria Craig

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

AN ADULT WITH DIABETES CALLS FOR ADVICE AND

REPORTS A BGL OF 17.5 MMOL/L

…WHAT WOULD YOU ASK?

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?

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

SICK DAY MANAGEMENT GUIDELINES

Similar in all groups

Levels of evidence

Expert opinion

Experience

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

ADEA SICK DAY GUIDELINES 2006

ADEA Guidelines 2014

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.

Presentation endorsed by ADEA for 1 CPD Point.