Glycaemic Control

Complexity of CareComplexity of Care

Aims

• Treatment of Diabetes and practical aspects of management.

• Diabetic Emergencies– Hypoglycaemia– Impaired Awareness of Hypoglycaemia– Recognising DKA– Recognising HONK

Treatment of Type 1 Diabetes

Short acting insulins

• Relatively rapid onset of action

• Short duration– Soluble insulin

(Humulin S, Actrapid)– Hypurin S– Human insulin

analogues (Novorapid, Humalog and Apidra)

Biphasic) Insulins (intermediate-acting

• Anologue mixtures– Novomix 30– Humalog Mix 25

• Biphasic isophane insulins– Mixtard 30– Humulin M3– Others

Long Acting Insulins

• Analogue insulin– Glargine– Levemir

• Isophane Insulin– Insulatard– Humulin I

• Animal Insulin– Hypurin

Aim of Treatment

• To prevent death from Ketoacidosis• To relieve symptoms• To maintain glucose as near normal as

possible to reduce complications• Insulin regimens are designed to mimic

basal and post prandial insulin secretion

Normal Insulin secretion vs Insulin Treatment

Insulin Regimens

• Basal Bolus regimens– Long acting insulin analogues-levemir/glargine

provide a basal rate insulin– Rapid acting analogue premeals to mimic

insulin secretion in relation to ingestion of foods

• Biphasic insulin regimens– Twice daily injections of soluble and isophane

insulins premeals.

Twice Daily Premix

Breakfast Lunch Evening Meal

Basal Bolus Regimen

Treatment in type 2 diabetes

• Diet and Metformin• Sulphonlyureas• Sitagliptin• Thiazolidinediones• GLP-1• Insulin

Case One

• 45yr old window cleaner type 1 diabetes

• BD Novomix 30• High BMs at 3pm (12-

14mmol/l) HbA1c 9.8%

• What are you going to advice?

• Would you check for Ketones

• Look at profiles• Look for trends in

BMs• Dietary intake• Adjust insulin

Case Two

• 20 yr old student nurse type 1 diabetes on basal bolus novorapid and lantus

• Low BMs all day with High BMs at night and weekends

• What would you advise??

• Check Ketones• Diet• Profiles• Activity• Look for patterns• Adjust insulin, by how

much/• Which insulin first?

Case Three

• 65 yr old music teacher type 2 diabetes 3yrs

• 1g metformin tds• 80mg gliclazide bd• Persistent diarrhoea• BM between 6-12

• HbA1c• Review medication• Check renal function• Diet• Activity levels

Case Four

• 38yr old HGV driver• Type 2 diabetes• BMI 32• Treated with

pioglitazone and metformin

• BMs climbing• Hba1C 8.9%

• Profiles

• Lifestyle changes

• Treatment options

• Employment implications

Recognition And Treatment Of Hypoglycaemia

Prevalence

• Each year, 25-30% of all insulin treated diabetic patients suffer one or more ‘severe’ hypoglycaemic episode

(severe= requiring assistance) • Each year 10% of type 1 experience coma • Remember sulphonlyureas may induce

hypoglycaemia

Definition of Hypoglycaemia

• BM < 4mmol/l considered hypoglycaemia• Side effect insulin or sulphonlyurea

treatment• 25% insulin treated diabetes one or more

‘severe hypoglycaemic’ episode• 10% type 1 experience coma• predisposing factors:

tight control, alcohol, sleep, high insulin doses, impaired awareness of hypoglycaemia

Recognition of Hypoglycaemia

• Autonomic (↑ PNS/SNS)– sweating, tremor, palpitations, hunger (3 mmol/l)

• Neuroglycopenic– confusion, behavioural changes

• Non-specific symptoms– malaise, headache

• Non-specific Signs– pale, sweaty, tachycardia, dilated pupils, ↑ WBC,

seizures, hemiplegia

Treatment of Hypoglycaemia• Confirm hypoglycaemia by BM • Conscious patient

fast acting carbohydrate e.g.oral glucose/lucozade followed by long acting carbohydrate e.g. toast, sandwich

• Unconscious patientGlucagon 1mg or 50mls of 50%Dextrose

Hypoglycaemia due to sulphonlyureas may be prolonged (no glucagon)

Impaired Awareness of Hypoglycaemia

• Affects 25% of all insulin treated diabetics, more common with ↑ duration of diabetes

• Acute hypo unawarenessassociated with strict control

• Chronic hypo unawarenesslong duration of diabetes (15 yrs)

Sequelae of Hypoglycaemia

• Mortality 2-4% of all deaths in type 1 diabetes

• Effects on brain depend blood glucose nadir duration, frequency hypoglycaemiapresence of brain insults e.g. Head injury,

alcohol

Hypoglycaemia Induced Neurological Syndromes

• Transient hemiplegia• Convulsions (2/100 patients/yr. In up to 10% pts

insulin)• Cerebral oedema• Permanent neurological effects

pvs, hemiparesis, epilepsy, focal (motor, sensory), ataxia

Summary

• 2-4% All deaths in type 1 diabetes• Common side effect insulin or

sulphonlyureas• Risk increased as glycaemic control is

improved• Recurrent hypoglycaemia can lead to

cognitive impairment• Immediate treatment with glucose/glucagon

Case One

• 72 yr old female• Type 1 diabetes x 30yrs• BD Novomix 30• Sweaty, PR 100/min• What do you do?• What treatment do you

administer?• What change do you make

to her insulin if any??

• Check BM• Quick acting

carbohydrate (egLucozade)

• Long acting CHO

Case Two

• 25 yr old type 1 diabetes at age 10

• Basal bolus humalog and levemir

• HbA1c 6.5%• Episode of collapse• Denies Hypoglycaemia• What would you do

next???

• Review diary– What are you looking for?

• Diet and exercise• Impaired awareness?• What advice would

you give?

Case Three

• 55 yr old type 2 diabetic

• Gliclizide, Metformin, GLP-1

• Weight loss• HbA1c 6%• Feels light headed

most of the day • What next?

• Review Diary– No hypos recorded

• Dietary intake• Which medication

would you alter???

Management Of Diabetic Ketoacidosis

Introduction

• High mortality 2% in young patients, 20 % in patients over

65yrs• Most episodes avoidable and due to

electrolyte abnormalitiesaspiration pneumoniafailure to recognise ppts (eg MI)

Clinical Features

• Dehydration• Tachycardia, ↑RR• Vomiting/abdominal pain (children)• Ketosis (acetone on breath)/ketonuria• Acidosis (Kussmaul breathing)• Severe metabolic derangement

HypotensionImpaired level of consciousness

Management• Rehydration

– need approx 4-6l in first 24hrs • Potassium replacement• Insulin, average 6units/hr (4-10u/hr) • Individual response to insulin is variable

Summary

• DKA is a medical emergency• Delay in treatment may have disastrous

consequences• Rapid examination with blood and urine

tests gives initial diagnosis• Treatment should be commenced without

delay

Case One

• 45 yr old type 1 diabetes

• BM high in morning 26mml/l

• Feels unwell, not eating

• Omits insulin• What advice would

you give??

• Continue to omit insulin?

• Check urine Ketones• Precipitants• Sick day rules

Hyperosmolar Non-Ketotic Coma

• Usually older people (over 40 yr).• Known NIDDM or first presentation

(50%undiagnosed)– .Diuretics,steroids may be ppt factors.

• Infection may be present.• Marked hyperglycemia , BG may be > 50

mmols/l • Dehydration, no Ketosis• Glycosuria and Coma• Mortality 30-50%

Management of HONK

• Rehydration• Insulin (smaller doses then required for

DKA)• Heparin

Diabetic Patients With Non Diabetic Problems

Management of Surgical Diabetic

• Mr DB 60yr male• Type 2 diabetes

insulin treated with Mixtard 30

• Admitted for laparoscopic hernia repair

• Management?

• First on list• May need to reduce

insulin night before• Start GKI morning of

surgery• Resume normal

regimen at tea time if eating

Radiological Procedures

• Mrs BM 55yrs type 2 DM on Metformin and Gliclizide

• Planned out patient CT Thorax with contrast ± biopsy

• Stop oral agents• Will not need insulin

infusion• Restart Gliclizide after

procedure• Do not restart

metformin for 48 hours

Emergency Procedures

• Type 1 diabetes 15 yrs • Admitted with

haematemesis• Needs Endoscopy• What do you do?

• Need insulin and glucose

• Gki or infusion and pump

• Continue until normal diet is resumed

Myocardial Infarction

• Acute ST elevation anterior myocardial infarction

• Thrombolysis• Glycosuria • Bm 13.2 mmol/l• Management?

• DIGAMI• Insulin for 3 months

and review opd

Summary

• 2 million people in the UK with Type 2 diabetes estimated to increase to 3 million by 2010

• Multiple complications which are preventable

• Need to be aware of how to manage common problems/ presentation of patients with diabetes