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  • SICK DAY MANAGEMENT IN

    DIABETES

    -WORKSHOP-

    Dr Anton Harding Paediatric Endocrinologist

    Victoria Stevenson RN, CDE

    Austin Health, Heidelberg & Royal Childrens 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 BGLs 2/wk, HbA1c 6.1%

    Lives with watchful family

    Was still driving!

  • GESTATIONAL DIABETES

    33yo first pregnancy, 1st TM routine test BGL 8s,

    diet management 6s

    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 BGLs 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 BGLs > 12 Panadol and over the counter flu medication Call clinic if other symptoms develop Continue metformin unless dehydration occurs

    BGLs 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

  • BGLS 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 selfcare 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 singleitem 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 comp