Diabetes Management (Adults and Young People) Ref CLIN-0081.v2.2. Status: Ratified Document type: Guideline

Transcription

1 Diabetes Management (Adults and Young People) Ref CLIN-0081.v2.2 Status: Ratified Document type: Guideline

2 Contents 1 Purpose Related documents Introduction Definition Prevalence in mental health and people with a learning disability Why diabetes is associated with SMI and antipsychotic medications Signs and Symptoms of Diabetes Diagnoses and Screening Tests Random Glucose Test Fasting Glucose Test HbA1c Monitoring for emergence of metabolic syndrome Diabetes Management Diabetes Guidance: essential care required on admission to an inpatient unit Monitoring Treatments for Diabetes Type 1 and Insulin Incretin Mimetics / GLP-1 Agonists Oral Hypoglycaemic Agents (tablets) Education Nutritional Management Exercise Complications of Diabetes Diabetic emergency situations: short term complications Hypoglycaemia Hyperglycaemia Diabetes complications in eating disorder patients Emergency Situations: Red Flags Diabetic Keto Acidosis (DKA) Hyperglycaemic Hyperosmolar State (HHS) Long Term Complications Eye Damage Heart Kidneys Nerves Foot Care Peripheral Artery Disease (PAD) Access to Specialist Advice Pregnancy Gestational Diabetes Pregnancy and Diabetes Ref: CLIN-0081 V2.2 Page 2 of 34 Ratified date: 13 April 2016

3 10 Definitions References Appendices Appendix 1: Treatment of Hypoglycaemia (Adult) flowchart Appendix 2: Treatment of Hypoglycaemia (Young Person) flowchart Document control Ref: CLIN-0081 V2.2 Page 3 of 34 Ratified date: 13 April 2016

4 1 Purpose Following this guideline will help the Trust to:- Define the standards in practice for the management of diabetes to ensure patients receive safe, appropriate care. Support a range of healthcare professionals through the process required to ensure patient safety is maintained in relation to diabetes management. Specific areas of this guideline relevant to young people (12-18 years old) are entitled Diabetes Management Young People (12-18 years old). All staff must read and follow all parts of this guideline. 2 Related documents This guideline describes what you need to do to implement the Management of Long Term Conditions section of the Physical Healthcare Policy. The Physical Healthcare Policy defines the standardised approach to physical healthcare. This guideline also refers to:- Lester Tool Medicines Overarching Framework Physical Healthcare Policy Physiological Assessment Procedure Procedure for Using the Early Warning Score for the Early Detection and Management of the Deteriorating Patient Policy for Consent to Examination or Treatment Patients own drug procedure Royal Marsden Online Ref: CLIN-0081 V2.2 Page 4 of 34 Ratified date: 13 April 2016

5 3 Introduction 3.1 Definition Diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood sugar. Hyperglycaemia, or raised blood sugar, is a common effect of uncontrolled diabetes and over time leads to serious damage to many of the body's systems, especially the nerves and blood vessels (WHO 1999). There are two main types of diabetes: Type 1 diabetes Type 1 diabetes develops when the insulin-producing cells in the body have been destroyed and the body is unable to produce enough or any insulin. Treatment for type 1 diabetes is insulin. Onset is usually sudden, with weight loss and muscle wasting as well as the more usual symptoms of diabetes. Patients with type 1 diabetes are at risk of developing a serious acute metabolic complication called Diabetic Ketoacidosis (DKA). Type 2 diabetes Onset is slower, often undiagnosed for years, as early symptoms may be non-specific or absent. Type 2 diabetes develops when the insulin-producing cells in the body are unable to produce enough insulin, or when the insulin that is produced does not work properly. Treatment for type 2 diabetes maybe a combination of insulin, tablets and diet. (Diabetes UK) 3.2 Prevalence in mental health and people with a learning disability A mental health illness can increase the risk of developing a long term physical health problem (Cormac & Gray 2012). It is estimated that people with a serious mental illness (SMI) such as schizophrenia or bi-polar disorder, are 2-3 times more likely to develop diabetes compared with the general population (Cormac & Gray 2012). People with depression are on average twice as likely to develop diabetes. People with a learning disability have a shorter life expectancy due to barriers they face in accessing timely and appropriate health care including health promotion activity, regular screening programmes and annual health checks (Emerson and Baines 2010). Ref: CLIN-0081 V2.2 Page 5 of 34 Ratified date: 13 April 2016

6 3.3 Why diabetes is associated with SMI and antipsychotic medications A number of common or shared factors are believed to contribute to the higher incidence of type 2 diabetes among patients with severe mental illness. These include obesity, inactive lifestyles and the use of antipsychotic medications (Cormack and Grey 2012). Obesity Reduced dietary fibre, reduced fruit and vegetable intake and increased intake of saturated fat can contribute to the incidence of type 2 diabetes. A weight gain of 7-11kg by someone over 18 years, which may not be uncommon in people with SMI, is associated with a twofold increase in the risk of diabetes. Staff involved in buying and preparing food should be aware of what constitutes a healthy diet. Physical inactivity Inactive lifestyles can contribute to the incidence of type 2 diabetes. Keeping physically active can reduce the risk of type 2 diabetes, stroke or heart attack. Increasing the amount of physical activity, combined with changing an individual s diet can halve the number of people with impaired glucose tolerance that go on to develop type 2 diabetes (NICE 2012). Antipsychotic medication Some antipsychotic medications are known to induce weight gain and may also produce abnormalities in glucose and lipid metabolism. The risk of significant weight gain is highest with clozapine and olanzapine. It is recommended that patients on these medications should be checked regularly to identify any early stages of the development of diabetes. Metabolic Syndrome and Prediabetes Metabolic Syndrome is the medical term for a combination of diabetes, high blood pressure and obesity. All three together increase a person s risk of heart disease, stroke and other conditions affecting blood vessels. Symptoms include obesity, a waist circumference of more than 37 inches, high cholesterol and blood pressure and inherited tendency for insulin resistance. Prediabetes is a metabolic syndrome which is a growing global problem closely linked to obesity. It is characterised by the presence of blood glucose levels that are higher than normal but not yet high enough to be classified as diabetes (fasting blood glucose mmol/L or a HbA1c mmol/l). Prediabetes can develop into type 2 diabetes. NICE guidelines (2012) identify people with mental health conditions or learning disabilities as adults from vulnerable groups whose risk of developing type 2 diabetes may be higher because of their medical condition or that they do not realise they are at risk or are less likely to access healthcare services. These groups are also at a higher risk of developing other physical health conditions such as cardiovascular disease. This is in addition to the risk from taking some antipsychotic drugs. Patients with an SMI should have their risk of prediabetes assessed using the Lester Tool. Patients without an SMI should have their risk of prediabetes assessed using a validated selfassessment questionnaire or validated web-based tool (NICE 2012). Everyone who is identified as at risk should be advised to consider a structured lifestyle education programme. Those at moderate or high risk should discuss this with a healthcare professional. Ref: CLIN-0081 V2.2 Page 6 of 34 Ratified date: 13 April 2016

7 NICE recommends that professionals dealing with vulnerable groups should know how to assess the risk including blood tests and further advice on intensive lifestyle change programmes. It recommends weight management, dietary advice and physical activity. What action should be taken by healthcare professionals? Provide up-to-date information in a variety of formats about local opportunities for risk assessment and the benefits of preventing (or delaying the onset of) type 2 diabetes. This should be tailored for different groups and communities. Provide integrated risk-assessment services and intensive lifestyle-change programmes for prisons and residential homes, as appropriate. Offer longer appointment times or outreach services to discuss the options following a risk assessment and blood test. Ensure intensive lifestyle-change programmes are delivered by sensitive, well trained and dedicated people who are also trained to work with vulnerable groups. There is a recommendation of using Metformin if intensive lifestyle change programmes does not improve the HbA1C (ensure renal function is adequate) as well as the use of Orlistat for those with a BMI of 28kg/m 2 or above. 4 Signs and Symptoms of Diabetes Type 1 diabetes usually develops very quickly, typically over a few weeks. Type 2 diabetes may not be so obvious, as the condition develops slowly over a period of year. The main symptoms of diabetes include: passing urine more often than usual, especially at night increased thirst extreme tiredness unexplained weight loss genital itching or regular episodes of thrush slow healing of cuts and wounds blurred vision (Diabetes UK) Ref: CLIN-0081 V2.2 Page 7 of 34 Ratified date: 13 April 2016

8 5 Diagnoses and Screening Tests 5.1 Random Glucose Test A random glucose test can be taken at any time including after eating and drinking. A random glucose level of greater than 11.1 mmol/l indicates diabetes (Diabetes UK). 5.2 Fasting Glucose Test A fasting plasma glucose test, also known as a fasting glucose test (FGT), is a test that can be used to help diagnose diabetes or pre-diabetes. The test is a simple blood test taken after several hours of fasting. Fasting Glucose Test Results Normal: Fasting Blood Glucose below 5.5 mmol/l (below 110mg/dl) (NICE 2012). Impaired: Between 5.5 and 6.9 mmol/l (between 110mg/dl and 125mg/dl) (NICE 2012). Diabetic: 7.0 mmol/l and above (126mg/dl and above) (NICE 2012). Ensure that when taking fasting or random blood glucose tests it is identified as random or fasting in PARIS and WebIce. 5.3 HbA1c The HbA1c test, also known as the haemoglobin A1c or glycated haemoglobin test, is an important blood test that gives a good indication of how well a patient s diabetes is being controlled. HbA1c can be used as a diagnostic test for diabetes alongside traditional glucose testing but should not be used alone as a routine screening tool. Together with the fasting plasma glucose test, the HbA1c test is one of the main ways in which type 2 diabetes is diagnosed. HbA1c tests are not the primary diagnostic test for type 1 diabetes but may sometimes be used together with other tests. HbA1c Test Results Normal: HbA1c below 42 mmol/mol (6.0%): Non-diabetic (NICE 2012). Impaired: HbA1c between 42 and 47 mmol/mol ( %): Impaired glucose regulation (IGR) or Prediabetes (NICE 2012). Diabetic: HbA1c of 48 mmol/mol (6.5%) or over: Type 2 diabetes (NICE 2012) Ref: CLIN-0081 V2.2 Page 8 of 34 Ratified date: 13 April 2016

9 5.4 Monitoring for emergence of metabolic syndrome Antipsychotic medication, particularly clozapine and olanzapine are known to induce weight gain and the effects of these medications on abnormal glucose tolerance have generated enormous interest in recent years (Cormac & Gray 2012). Before prescribing antipsychotic medication, all risk factors must be taken into account including a clinical and metabolic assessment (clinical history, BP, lipid profile, random blood glucose or HbA1c). This should be repeated at three to four monthly intervals and patients provided with lifestyle advice (see Physical Healthcare Policy); however the risk benefit ratio will always need careful consideration in patients prescribed any antipsychotic medication. Monitoring for the risk is incorporated in the Lester Tool, particularly in patients with a serious mental illness (Physical Healthcare Policy). There is a caution for patients on antipsychotics if the dose has not been stabilised for a few months then HbA1c is not recommended to diagnose diabetes as the medication may cause rapid glucose rise. 6 Diabetes Management 6.1 Diabetes Guidance: essential care required on admission to an inpatient unit All patients with type 1 and type 2 diabetes on admission, even during out of hours admission to an inpatient unit, must have the following completed: Physical examination. A full set of physiological observations and EWS recorded including blood glucose. A urine test for ketones recorded. An assessment for any red flags with immediate transfer to Acute Trust if present. A referral to Acute Trust Diabetologist or Medical Registrar on call if medical advice needed. Review of current diabetes medication. Prescribe and administer appropriate diabetes medication including management of hypoglycaemia, glucogel and glucagon. If a patient brings in their own insulin on admission, consult the on-call pharmacist if unsure of suitability. Record initial assessment and treatment in the Physical Health Casenote on PARIS. Diabetes Management Young People (12-18 years old) On admission, young people with type 1 and type 2 diabetes should be referred to the Trust Dietetic Service for dietary support. The catering department should be informed and liaise with the Dietitian. Ref: CLIN-0081 V2.2 Page 9 of 34 Ratified date: 13 April 2016

10 6.2 Monitoring Blood Glucose Monitoring Restoring blood glucose to as near normal as possible is important to reduce diabetes related complications and for monitoring treatment effects. This can be performed using both blood glucose meters and laboratory tests (refer to Guidelines for Blood Glucose Monitoring 0058.v2 and Royal Marsden Manual Online). Frequency of monitoring will depend on the type of diabetes and the treatment regime. Frequency of monitoring is individual to the patient and needs to be agreed and clearly documented within the intervention plan including a rationale for monitoring. Some patients may use an insulin pump which monitors their blood glucose levels. Staff need to prompt patients to regularly monitor their blood glucose levels in order to reduce risk of hypoglycaemia and hyperglycaemia. The Blood Glucose Monitoring Chart is in development for use in all service areas by the Safe Medication Practice Group. If insulin chart is in use, blood glucose monitoring is recorded on the second page of the insulin chart. Diabetes Management Young People (12-18 years old) Young people with type 1 diabetes will require the following advice in relation to blood glucose and HbA1c blood targets and monitoring: Advise to routinely perform at least 5 capillary blood glucose tests per day. Be aware that some patients may be admitted with continuous glucose monitoring alarms. Explain to young people with type 1 diabetes and their family members or carers that a HbA1c target level of 48mmol/mol or lower is ideal to minimise the risk of long term complications. Target range BM for young people with type 1 diabetes: o On waking 4-7mmol o Before meals and at other times of the day 4-7mmol o After meals 5-9mmol o When driving, at least 5mmol Ref: CLIN-0081 V2.2 Page 10 of 34 Ratified date: 13 April 2016

11 6.3 Treatments for Diabetes Type 1 and 2 (see BNF for complete list of treatments available in the UK for management of diabetes) When initiating a treatment for diabetes, prescribers should refer to the following: Type 1 Diabetes in Adults NICE guidance Diabetes (type 1 & 2) in Children and Young People NICE guidance Type 2 Diabetes in Adults NICE guidance Insulin Insulin is a hormone produced by the pancreas. It helps our bodies utilise glucose for energy by playing a key role in the regulation of carbohydrates, fats and protein. All type 1 diabetics (and some type 2) require the administration of insulin to keep blood glucose levels under control. Insulin is essential for survival and the aim of therapy is to mimic normal physiology. The different types of insulin produce different plasma profiles so dosing and frequency are manipulated to mimic normal physiology. Dosage and insulin regimes Insulin regimens are tailored to individual needs and life style, usually by the specialist diabetes team. Typically short acting insulin is administered with meals whilst long acting insulin is given at bedtime to provide a background level of insulin. This helps to replicate the body s natural process and is called a basal bolus regime. It is essential to establish the patient s insulin regime as part of the initial physical health assessment on admission. Patients must have their insulin prescribed on admission to an inpatient unit. Advice should be sought immediately if staff are unsure of the patient s insulin regime. Diabetes Management Young People (12-18 years old) Staff must be aware that young people with type 1 diabetes may have: Multiple daily injection basal-bolus insulin regimens Use a pump as part of their insulin therapy 1,2,3 insulin injections per day (mixed, short and intermediate acting) Ref: CLIN-0081 V2.2 Page 11 of 34 Ratified date: 13 April 2016

12 There are different types of insulin available according to duration of action. See Table 1 below. Type of insulin When to inject Examples Rapid-acting insulin analogue Short-acting insulin Intermediate or long-acting insulin Long-acting insulin analogue Biphasic insulin During or immediately after a meal 15 to 30 minutes before meals Once (or twice) daily, 15 to 30 minutes before meals Once (or twice) daily at the same time each day (time of day not important) Usually twice daily; just before, with, or immediately after meals NovoRapid (insulin aspart), Apidra (insulin glulisine), Humalog (insulin lispro) Actrapid and Humulin S (both soluble human insulin) Insulatard and Humulin I (both isophane human insulin) Levemir (insulin detemir), Lantus (insulin glargine) Humalog Mix 25, Humalog Mix 50 (insulin lispro with insulin lispro protamine), Novomix 30, Mixtard 30 and Humulin M3 (both human insulin with human isophane insulin) Table 1: Insulin types by duration of action. Prescribing and Administration Care must be taken when prescribing and administering insulin. When prescribing insulin, the term units must always be used. Never use abbreviations. Insulin must be prescribed by brand to help minimise confusion between different types. Insulin is administered subcutaneously by a number of different devices. It must be prescribed as cartridges, disposable pens, vials or insulin pumps. This information should be available on admission from the patient and / or carer / family member. If not available contact the patient s GP. When administrating insulin, staff should follow the Trust Medicines Overarching Framework ensuring they use the principles of the 5 Rights of Medicine Administration. Storing insulin syringes away from other syringes will help avoid mis-selection. If possible check the patient s insulin ID card or Insulin passport for the correct name. Check with the patient what insulin they are using and show them the pen/ container and confirm that the patient is expecting the product. Staff must check the insulin device is in working order. There are over 20 different types of insulin with very different durations of action. Another common error is confusion between similar sounding insulin names or shortening names. Insulins come in more than one strength. For example, Tresiba (Insulin degludec) and Humalog Kwikpen both come as 100units per ml and 200units per ml. These must be kept separate from other insulins and clearly labelled. Ref: CLIN-0081 V2.2 Page 12 of 34 Ratified date: 13 April 2016

13 Insulin has been identified on the list of critical medicines where timeliness of administration is crucial. Staff should be aware of the importance of prescribing and administering insulin and report immediately to medical staff, any omitted or delayed administration issues. It is critical that on admission, during the review of the patient s current insulin regime, medical staff prescribe treatments to manage hypoglycaemia alongside insulin therapy. Refer to the Hypoglycaemia section for the prescribing and administration of dextrose gel and glucagon. Insulin Prescribing and Administration Chart The Trust has a standard Insulin Prescription and Administration Chart that is available from Cardea (LP77766). The Pharmacy Team have developed a set of guidance notes to assist in completing the chart, which are available to staff on InTouch. If a patient has a complex insulin regime, the Drug Prescription and Administration Record Chart may be used. Insulin Injection Technique / choice of needles Refer to Royal Marsden Manual Online for injection techniques and sites recommended for subcutaneous injections. The Trust advocates the use of the BD Auto Shield Duo Safety Pen Needle. Always dispose of needles into a sharps bin. Storage of insulin Care must be taken when storing insulin. Never freeze insulin (frozen insulin should be disposed of appropriately). Never use insulin beyond the manufacturer s expiry date stamped on the vial, pen or cartridge. Never expose insulin to direct heat or light. Avoid direct sunlight and heat e.g. near radiators, fires or window sills. Inspect insulin prior to use: o Solution insulins should be clear; do not use if they have a cloudy appearance. o Suspension insulins should be uniformly cloudy following agitation; do not use if there are clumps of powder or the powder is not uniformly suspended after shaking. Unopened insulin which is not is use should be stored in a refrigerator at a temperature between 2-8 C. Opened in use insulin should be dated with the date of opening or first use and stored below 25 C. Some manufacturers allow below 30 C but you will need to check the individual insulin. When storing pre-filled insulin syringes store them with the needle end pointing upwards. Ref: CLIN-0081 V2.2 Page 13 of 34 Ratified date: 13 April 2016

14 Location of emergency insulin Insulin for use in an emergency is stored on all inpatient sites. The types of insulin available are: Novo Rapid (Insulin Aspart) 3ml Flex Pen. This is short acting Insulin with fast onset of action; this is normally prescribed at meal times. Lantus (Insulin Glargine) 3ml SoloStar Pen. This is long acting Insulin with a prolonged duration of action; this is normally prescribed once a day. Site Cross Lane Hospital Friarage Hospital Harrogate District Hospital Lanchester Road Hospital Roseberry Park Hospital Sandwell Park Hospital West Lane Hospital West Park Hospital Location Danby Ward Emergency Drug Cupboard Fridge Rowan Ward and Cedar Ward Farnham Ward Bransdale Ward Lincoln Ward Evergreen Ward Emergency Drug Fridge Incretin Mimetics / GLP-1 Agonists Incretin mimetics are a group of injectable drugs for treatment of type 2 diabetes. This group of injectable medications are not insulins. The drugs, also commonly known as glucagon-like peptide 1 (GLP-1) receptor agonists or GLP-1 analogues, are normally prescribed for patients who have not been able to control their condition with tablet medication. This type of medication works by increasing the levels of hormones called incretins. These hormones help the body produce more insulin only when needed and reduce the amount of glucose being produced by the liver when it s not needed. They reduce the rate at which the stomach digests food and empties, and can also reduce appetite. Refer to the table below for the currently available incretin mimetics. Generic or proper name Brand or trade name When to inject Exenatide Byetta Twice daily injection Exenatide (long acting) Bydureon Once weekly injection Liraglutide Victoza Once daily injection Lixisenatide Lixumia Once daily injection Dulaglutide Trulicity Once weekly injection Incretin Mimetics / GLP-1 Agonists should only be initiated by specialist diabetologist. Diabetes Management Young People (12-18 years old) The use of Incretin Mimetics/GLP-1 Agonists is not recommended for use in young people with diabetes. Ref: CLIN-0081 V2.2 Page 14 of 34 Ratified date: 13 April 2016

15 6.3.3 Oral Hypoglycaemic Agents (tablets) Oral hypoglycaemic agents are tablets designed to help people with type 2 diabetes manage their condition. When prescribing oral hypoglycaemic agents, refer to British National Formulary (BNF) for dosage, side effects and contraindications. Type of oral hypoglycaemic agents Some Examples Advice Biguanides Metformin Take with or after meals to avoid dyspepsia. Sulfonylureas Thiazolidinediones/ glitazones DPP4 inhibitors (gliptins) Sodium glucose cotransporter 2 (SGLT2) inhibitors Gliclazide, Glipizide, Tolbutamide Pioglitazone Alogliptin Sitagliptin Saxagliptin Linagliptin Canagliflozin Dapagliflozin Empagliflozin Take with or shortly before a meal to avoid hypoglycaemia symptoms. Pioglitazone may be taken with or without food and swallowed with a glass of water. Common side effects include upper respiratory tract infections and headaches. Should be taken daily with water Causes more glucose to be excreted from the urine and so leads to increased risk of infection. Risk of DKA, see section Prandial glucose inhibitors Alpha-glucosidase inhibitor Repaglinide Nateglinide Acarbose Dose must be withheld if meal is missed to prevent hypoglycaemia. Acarbose should always be chewed with the first mouthful of food or swallowed whole with a little liquid immediately before the meal. Diabetes Management Young People (12-18 years old) Treatment with oral antidiabetic drugs in young people should only be initiated under specialist supervision and used when diet alone is insufficient to achieve glycaemic control. Sometimes use of oral antidiabetics are not suitable for use in young people (BNFC 2015/2016). Ref: CLIN-0081 V2.2 Page 15 of 34 Ratified date: 13 April 2016

16 6.4 Education Living with diabetes becomes a lifelong learning process once diagnosed. National Institute of Clinical Excellence (NICE 2014) guidelines recommend that people with diabetes and/or their carers be offered education programmes to help manage their condition. Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND) The DESMOND Programme is a structured, nationally recognised education programme for all patients who are newly diagnosed with type 2 diabetes up to 12 months after diagnosis. DESMOND offers a variety of evidence based modules to support self-management for either people at risk of diabetes or those who are already identified as having diabetes. A referral to the DESMOND programme is via GP. Dose Adjustment for Normal Eating (DAFNE) DAFNE is a training programme to provide the necessary skills to estimate the carbohydrate in each meal and to inject the right dose of insulin. DAFNE is only used in adults with type 1 diabetes. The following should be considered when a patient who is using DAFNE is admitted to an in-patient unit: Establish the range of doses usually administered and evaluate the individual patient s risk of self-harm behaviours. Establish the patient s specific carbohydrate to insulin ratio. All healthcare professionals have a responsibility to ensure that patients receive general information and are signposted to the Diabetes UK website. More specific education programmes described above can be accessed via referral to dietitians or Acute Trusts. Patient Centred Care Management of diabetes typically involves a considerable element of self-care, and advice should, therefore, be aligned with the perceived needs and preferences of people with diabetes and carers. People with type 2 diabetes should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals (NICE 2014). If patients do not have the capacity to make decisions, staff must follow Policy for Consent to Examination or Treatment. Diabetes Management Young People (12-18 years old) Much of the general care for type 2 diabetes is the same as type 1, although initial management is different as are the complications associated with being overweight and obese in type 2. See Nutritional Management Section for further information (NICE 2015). Ref: CLIN-0081 V2.2 Page 16 of 34 Ratified date: 13 April 2016

17 6.5 Nutritional Management All healthcare professionals should offer nutritional information to patients from diagnosis onwards. Dietary topics should include: Hyperglycaemic effects of different foods in the context of the insulin preparations chosen to match the person's food choices. Effects of consuming different food types and the insulin preparations available to match them. Choice of content, timing and amount of snacks taken between meals and at bedtime modify on the basis of self-monitoring tests. Healthy eating to reduce arterial risk (low glycaemic index foods, fruit and vegetables, types and amount of fat). information on: o effects of different alcohol-containing drinks on blood glucose excursions and calorie intake o use of high-calorie and high-sugar 'treats' o use of foods with a high glycaemic index. (NICE 2014) For additional patient education information, follow the links below. For information on Type 1 Diabetes For Information on Type 2 Diabetes For information on Glycaemic Index If further advice is required, refer patient to the Dietetic Service. Diabetes Management Young People (12-18 years old) Staff should support young people with level 3 carbohydrate counting education (Level 3 carbohydrate counting is defined as carbohydrate counting with adjustment of insulin dosage according to an insulin: carbohydrate ratio). Staff should liaise with the Dietitian who will provide support with this. Diabetes Management Young People (12-18 years old) Young people with type 1 diabetes should have their weight and height monitored to ensure their weight is stable within a healthy BMI. Ref: CLIN-0081 V2.2 Page 17 of 34 Ratified date: 13 April 2016

18 Diabetes Management Young People (12-18 years old) Young people with type 2 diabetes should be referred to the Dietitian for advice regarding weight management including calculating BMI and offering advice on healthy eating to reduce hyperglycaemia and CVD risk and where appropriate to promote weight loss. 6.6 Exercise Advise patients that physical activity can reduce complications of diabetes risk in the medium and longer term. Give information (if the person chooses to increase physical activity) on: Appropriate intensity and frequency of physical activity. Self-monitoring of changed insulin and/or nutritional needs. Effect of exercise on blood glucose levels when insulin levels are adequate (risk of hypoglycaemia) or when hypoinsulinaemic (risk of exacerbation of hyperglycaemia). Appropriate adjustments of insulin dosage and/or nutritional intake for exercise and for 24 hours afterwards. Interactions of exercise and alcohol. Where to find more information. Should a patient be on an insulin pump, a temporary basal dose of insulin may be required prior to exercise. This should be explicit in their intervention plan. It is also essential that alcohol is not consumed prior to or during exercise as this could result in hypoglycaemia (both have an effect of lowering blood sugar). If further advice is required, please refer to Dietetics or Fitness /Exercise Practitioner. Should staff arrange for patients with diabetes to attend any physical activity group, they should consider the need to take dextrose tablets and a blood glucose meter. For more information on physical activity, see the NICE pathway on physical activity (NICE 2014). Ref: CLIN-0081 V2.2 Page 18 of 34 Ratified date: 13 April 2016

19 7 Complications of Diabetes 7.1 Diabetic emergency situations: short term complications Hypoglycaemia Hypoglycaemia is a condition which occurs when the blood glucose levels are too low to provide enough energy for the body s activities (Diabetes UK). Hypoglycaemia results from an inbalance between glucose supply, glucose utilisation and current insulin levels. A blood glucose level of less than 4mmol/L should be considered as a hypo. Although some patients may feel hypo above 4.0mmol especially if their diabetes is poorly controlled, it is vital to listen to the patient, if they say they are hypo they usually are. To avoid potential hypoglycaemia Diabetes UK recommends a practical policy of remember four the floor, i.e. 4.0mmol/L the lowest acceptable blood glucose level in people with diabetes. Adult and CAMHS Eating Disorder Services have developed Management of Hypoglycaemia flowcharts in patients with low body weight / starvation which follow MARSIPAN Guidelines. See Eating Disorder Service Operational Policies. A hypo can come on quickly and needs to be treated as urgent needing immediate attention. If untreated there is a risk that a patient can have a seizure (fit) and or loss of consciousness. Hypoglycaemia presentation: The following are signs and symptoms of a patient presenting with a hypo : sweating shaking dizzy hungry tired irritable (moody) anxious confused pallor palpitations headaches Ref: CLIN-0081 V2.2 Page 19 of 34 Ratified date: 13 April 2016

20 Causes of hypoglycaemia: missed or late meals too much insulin not enough carbohydrate in meals unplanned exercise large amount of alcohol especially without food acute illness including vomiting sometimes there is no obvious cause Diagnosis of hypoglycaemia: A diagnosis of hypoglycaemia is made by checking the patient s blood glucose levels using the Trust approved blood glucose meter and following Trust guidelines and Royal Marsden Manual Online. Some patients on an insulin pump may have a glucose meter integrated into the handset which would indicate if the patient is hypoglycaemic. Treatment of hypoglycaemia: Treatment will depend on the severity of symptoms and results of the blood glucose reading. Assess if the patient is conscious and able to swallow. A treatment of hypoglycaemia flow chart has been developed as a quick reference guide and should be followed by all healthcare professionals, displayed in all inpatient clinic settings and available in the pharmacy emergency drug bag (Appendix 1). All inpatient wards should have a supply of edible dextrose tablets to be used in cases of hypoglycaemia. All inpatient wards should have access to emergency drug bags which contain the following: Dextrose gel tubes (One box contains 3x25g) Glucagon injection 1mg for subcutaneous or intramuscular use (Glucagon needs to be reconstituted prior to injecting. The diluent is held alongside the Glucagon) It is critical that on admission, during the review of the patient s current insulin regime, medical staff prescribe treatments to manage hypoglycaemia alongside insulin therapy. It is important to diagnose and treat the patient s hypo and then consider possible causes whilst reviewing their current medication activity level and dietary intake. Diabetes Management Young People (12-18 years old) Refer to flowchart in Appendix 2 for the management of hypoglycaemia in young people. Ref: CLIN-0081 V2.2 Page 20 of 34 Ratified date: 13 April 2016

21 7.1.2 Hyperglycaemia Hyperglycaemia is a condition which occurs when the blood glucose levels are too high. A blood glucose level of more than 7.0mmoll/L before a meal and above 8.5mmol/L two hours after a meal is considered as a hyper (Diabetes UK). Hyperglycaemia presentation: The following are signs and symptoms of a patient presenting with hyperglycaemia Passing more urine than usual (especially at night) Thirsty Headaches Tiredness Causes of Hyperglycaemia: A missed dose of medication Insufficient insulin Eaten more carbohydrate than the body and / or medication can cope with Stressed Unwell from infection Over treating a hypo Diagnosis of hyperglycaemia: A diagnosis of hyperglycaemia is made by checking the patient s blood glucose levels using the Trust approved blood glucose meter and following Trust guideline and Royal Marsden Manual Online. Treatment of hyperglycaemia: If a blood glucose level is high 15mmol/L for two consecutive tests for just a short time such as 2 hours after a meal, the blood glucose should be considered in conjunction with patient presentation and presence of ketones in the urine. If the blood glucose level stays high, take the following action: plenty of sugar-free fluids if the patient is on insulin, take extra insulin if prescribed if the patient is feeling unwell (especially vomiting) contact Doctor, Physical Healthcare Practitioner or specialist advice from an Acute Trust. If a blood glucose level is 15mmol/L or more, urine must be checked for ketones using Siemens 10sg Multistix. If ketones are present, it is likely there is not enough insulin in the body. An increase or extra dose of insulin may be required to prevent the development of ketoacidosis (DKA) as prescribed in the patient s individual intervention plan. If blood glucose levels stay high for extended periods of time - this can lead to the development of long term complications and a medical emergency. If blood glucose levels rise dangerously high - this can lead to short term complications. Ref: CLIN-0081 V2.2 Page 21 of 34 Ratified date: 13 April 2016

22 Diabetes Management Young People (12-18 years old) Staff must be aware that young people with type 1 diabetes should monitor blood ketones if hyperglycaemia is suspected or when they are ill or experiencing high blood glucose levels. Diabetes Management Young People (12-18 years old) Young people with type 1 diabetes should have clear, individualised sick day rules which must be followed during periods of intercurrent illness and episodes of hyperglycaemia. These should include: More frequent monitoring of blood glucose. Monitoring and interpreting blood ketones. Adjusting insulin regime (access to rapid acting insulin analogues). Food and fluid intake. When and where to seek further advice and help Diabetes complications in eating disorder patients Patients with type1 diabetes who have eating disorders may have associated problems of persistent hyperglycaemia, recurrent hypoglycaemia and/or symptoms associated with gastro paresis. Patients should be offered joint management involving their diabetes care team and mental health professionals (NICE 2014). Members of multidisciplinary professional teams should be alert to the possibility of bulimia nervosa, anorexia nervosa and insulin dose manipulation in patients with type 1 diabetes with: over-concern with body shape and weight low body mass index poor overall blood glucose control. (NICE 2014) Ref: CLIN-0081 V2.2 Page 22 of 34 Ratified date: 13 April 2016

23 7.2 Emergency Situations: Red Flags Diabetic Keto Acidosis (DKA) and Hyperglycaemic Hyperosmolar State (HHS) are medical emergencies. Call 9/999 to arrange immediate transfer to A&E Diabetic Keto Acidosis (DKA) Diabetic keto-acidosis (DKA) is a life threatening acute metabolic complication of Type 1 diabetes mellitus, and occasionally type 2 diabetes. It occurs when insulin therapy is omitted or becomes inadequate for the current physiological state, usually as a result of concurrent illness such as chest or urine infections or sickness and diarrhoea. DKA is often precipitated by recurrent vomiting in an unwell patient. It is recommended by the MHRA 2015, patients who are prescribed SGLT2 medication may be at risk of developing DKA. Blood glucose levels may be only moderately elevated e.g. less than 14mmol/L, therefore staff should remain vigilant for the signs and symptoms of DKA. If DKA is suspected, it is essential to test for raised ketones and seek immediate medical advice. DKA Presentation DKA manifests as a state of severe uncontrolled hyperglycaemia and gross dehydration which will inevitably progress unless it is corrected by rehydration with intravenous fluids and adequate insulin. Its characteristics include: Hyperglycaemia (Raised blood sugar) with metabolic acidosis (low serum bicarbonate) Polydipsia / Polyuria / Thirst Nausea or Vomiting Non specific abdominal pain Weakness / Drowsiness / Altered conscious level Hypotension / Tachycardia / Hypothermia / Kussmaul Respirations (Breathlessness due to deep fast respirations) Dehydration Ketones in blood or urine Glycosuria (Glucose in Urine) Acetone Odour on breath (smells like pear drops) Ref: CLIN-0081 V2.2 Page 23 of 34 Ratified date: 13 April 2016

24 Diabetes Management Young People (12-18 years old) All staff must be aware that young people taking insulin for diabetes may develop DKA with normal blood glucose levels, therefore vigilance is essential in the management of a young person with diabetes. It is essential to: Suspect DKA if the blood glucose is normal in a young person with diabetes with any of the following: nausea or vomiting, abdominal pain, hyperventilation, dehydration and reduced levels of consciousness. When DKA is suspected in a young person with known diabetes, measure blood ketones (beta-hydroxybutyrate) using near-patient method if available. If elevated, immediately transfer to acute hospital with acute paediatric facilities. Treat as urgent hospital admission. (NICE 2015) Hyperglycaemic Hyperosmolar State (HHS) (Previously known as HONK) HHS is defined by the presence of marked hyperglycaemia associated with dehydration, raised sodium level in the absence of significant acidosis or ketonuria. It usually occurs as a complication of Type 2 Diabetes in the presence of marked hyperglycaemia without the presence of ketones. Patients can quickly become dehydrated from prolonged hyperglycaemia and eventually if untreated disturbances in osmolality occur and the patient may become hypotensive and collapse. HHS Presentation HHS is characterised by the gradual development of marked hyperglycaemia without the presence of ketones or significant acidosis. Its characteristics include: Osmotic symptoms such as thirst / polydipsia / polyuria Marked Dehydration Altered mental state that can range from a confused state to obtundation (reduced level of alertness) and coma Malaise Signs of infection Glycosuria Blood Glucose usually greater than 30mmols / L Ref: CLIN-0081 V2.2 Page 24 of 34 Ratified date: 13 April 2016

25 7.3 Long Term Complications It is important for patients in our care to be monitored for the following and referred appropriately to an acute hospital Eye Damage People with diabetes are at risk of developing a complication called retinopathy. Retinopathy affects the blood vessels supplying the retina- the seeing part of the eye. Blood vessels in the retina of the eye can become blocked, leaky or grow haphazardly. This damage gets in the way of light passing through to the retina and if left untreated can damage vision. Patients should be supported to attend their annual retinal screening appointment Heart The term cardiovascular disease (CVD) includes heart disease, stroke and all other diseases of the heart and circulation, such as hardening and narrowing of the arteries supplying blood to the legs, which is known as peripheral vascular disease (PVD). People with diabetes have up to a fivefold increased risk of CVD compared with those without diabetes due to prolonged, poorly controlled blood glucose levels, which affect the lining of the arterial walls. This increases the likelihood of furring up of the vessels, causing a narrowing (atherosclerosis). High blood pressure, smoking, obesity and physical inactivity are also risk factors for CVD. Ensure that patients as part of their annual diabetic review have their total cholesterol / HDL ratio blood test in order to detect if they are at high risk of developing CVD using the QRisk2 Tool Kidneys Kidney disease amongst diabetics is commonly called diabetic nephropathy. Diabetes affects the arteries of the body and as the kidneys filter blood from many arteries, kidney problems are a particular risk for people with diabetes. Ensure that patients as part of their annual diabetic review have their urine tested for microalbumin and their blood tested for urea, creatinine and estimated glomerular function (egfr) Nerves Neuropathy is one of the long-term complications of diabetes. High blood glucose levels (hyperglycaemia) are known to harm the nerves ability to transmit signals, and damage the blood vessels that carry oxygen and nutrients to the nerves; therefore good diabetic control is important to reduce the risk of nerve damage. Ensure that patients who complain of numbness, tingling sensation, burning or shooting pain in their legs and feet are referred to the appropriate diabetic specialist team. Ref: CLIN-0081 V2.2 Page 25 of 34 Ratified date: 13 April 2016

26 7.3.5 Foot Care Foot related complications are common for people with diabetes. Foot ulcers can easily develop from blisters and small wounds posing a threat of amputation. Ulcers can develop into serious lower body infections, with the possibility of amputation at an advanced stage. Ensure that patients as part of their annual diabetic review have a foot examination. Good foot hygiene, inspection of the skin and correct fitting footwear are essential for patients with diabetes. Any concerns must be referred to either a podiatrist or the patient s diabetic specialist team. (NICE 2014) Peripheral Artery Disease (PAD) Patients should be assessed for the presence of peripheral arterial disease if they have diabetes, non-healing wounds on the legs or feet, or unexplained leg pain. Do not exclude a diagnosis of PAD in patients with diabetes based on an abnormal or raised ankle brachial pressure index alone. Do not pulse oximetry for diagnosing peripheral arterial disease in patients with diabetes. (NICE 2012) Diabetes Management Young People (12-18 years old) As part of annual monitoring for complications, young people should be screened for coeliac disease. Ref: CLIN-0081 V2.2 Page 26 of 34 Ratified date: 13 April 2016

27 8 Access to Specialist Advice Any patient in whom there are any additional concerns over the management of glycaemic control or other diabetes related complications should be referred to an Acute Hospital specialist diabetic team. Hospital / Service James Cook University Hospital, Middlesbrough Harrogate District Hospital University Hospital of North Tees Scarborough General Hospital Darlington Memorial Hospital University Hospital of North Durham TEWV Dietetics Service Contact details Telephone Telephone Telephone Telephone Telephone Telephone Telephone Instructions Specialist Diabetes Advice can be sought from the Diabetes Care Team at James Cook University Hospital in the following ways: Contact the Diabetes Specialist Nursing Team at JCUH through the Hospital Switchboard on Bleeps 1663 & 4231( hrs) Contact the Consultant Diabetologist on Call through the Hospital Switchboard For Red Flag features or impending Diabetes Emergencies seek early specialist advice from the Diabetes Care Team or the Medical Registrar on Call at JCUH. Specialist Diabetes Advice can be sought from one of the two Diabetology Consultants in the following ways: Dr Hammond can be contacted via hospital switchboard Bleep 5047 Dr Ray can be contacted via hospital switchboard Bleep 3278 Contact Consultant Secretaries on or Diabetologists can also be contacted by sending a fax to Ask for the Medical Registrar on call Ask for the Medical Registrar on call Ask for the Medical Registrar on call Ask for the Medical Registrar on call Ask for Jo Smith, Professional Lead Ref: CLIN-0081 V2.2 Page 27 of 34 Ratified date: 13 April 2016

28 9 Pregnancy 9.1 Gestational Diabetes Gestational diabetes occurs because the body cannot produce enough insulin to meet the extra needs of pregnancy. Treatment includes diet control and medication (tablets or insulin). Blood glucose target levels are 'tighter' and not the same as for women with Type 1 or Type 2. NICE recommends fasting levels of mmol/l and <7.8 one hour after eating. Gestational diabetes usually goes away after the baby is born 9.2 Pregnancy and Diabetes Patients with known diabetes who are pregnant will be offered extra monitoring appointments and scans to help keep good control of blood glucose and check baby s growth and development. Patients should have contact with their diabetes team every one or two weeks. All healthcare professionals should ensure that patients are supported to attend these appointments and any concerns should be raised immediately with the responsible diabetic team. Ref: CLIN-0081 V2.2 Page 28 of 34 Ratified date: 13 April 2016

29 10 Definitions Term Definition Beta-hydroxybutyrate Specific ketone body that s released early in the onset of ketosis. Diabetic Keto Acidosis (DKA) Diabetic keto-acidosis (DKA) is a life threatening acute metabolic complication of Type 1 diabetes mellitus, and occasionally type 2 diabetes. It occurs when insulin therapy is omitted or becomes inadequate for the current physiological state, usually as a result of concurrent illness such as chest or urine infections or sickness and diarrhoea. Gastroparesis Gastroparesis is a chronic (long-term) condition in which the stomach cannot empty itself in the normal way. Hypoglycaemia Hypoglycaemia is a condition which occurs when the blood glucose levels are too low to provide enough energy for the body s activities. A blood glucose level of less than 4mmol/L should be considered as a hypo. Hyperglycaemia Hyperglycaemia is a condition which occurs when the blood glucose levels are too high. A blood glucose level of more than 7.0mmoll/L before a meal and above 8.5mmol/L two hours after a meal is considered as a hyper. Hyperglycaemic Hyperosmolar State (HHS) HHS is defined by the presence of marked hyperglycaemia associated with dehydration, raised sodium level in the absence of significant acidosis or ketonuria. It usually occurs as a complication of Type 2 Diabetes in the presence of marked hyperglycaemia without the presence of ketones. Metabolic Syndrome Metabolic syndrome is the medical term for a combination of diabetes, high blood pressure and obesity. It puts you at greater risk of heart disease, stroke and other conditions affecting blood vessels. Prediabetes Prediabetes, also commonly referred to as borderline diabetes, is a metabolic condition and growing global problem that is closely tied to obesity. If undiagnosed or untreated, prediabetes can develop into type 2 diabetes. Ref: CLIN-0081 V2.2 Page 29 of 34 Ratified date: 13 April 2016

30 11 References Cormac, I and Gray, D. (2012) Essentials of Physical Health in Psychiatry. The Royal College of Psychiatrists. Diabetes UK (Online). Available from (Accessed on 26 th May 2015). Emerson, E and Baines, S. (2010) Health Inequalities & People with Learning Disabilities in the UK: Improving Health and Lives: Learning Disabilities Observatory. Marc De Hert et al. (2011) Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry 10(1): National Institute for Clinical Excellence (2012) Preventing type 2 diabetes: risk identification and interventions for individuals at high risk. London: NICE. National Institute for Clinical Excellence (2014) Type 1 diabetes: Diagnosis and management of type 1 diabetes in children, young people and adults. London: NICE. National Institute for Clinical Excellence (2014) The Management of type 2 diabetes. London: NICE. National Institute for Clinical Excellence (2015) Diabetes (type 1 and type 2) in children and young people: diagnosis and management. London: NICE. National Institute for Clinical Excellence (2015) Type 2 Diabetes in adults: management. London: NICE. National Institute for Clinical Excellence (2012) CG147: Peripheral arterial disease: diagnosis and management updated London. NICE. National Patient Safety Agency (2010) Rapid Response Report: Reducing harm from omitted and delayed medicines in hospital. (Online) Available from: (Accessed on 6th July 2015) Shiers DE, Rafi I, Cooper SJ, Holt RIG update (with acknowledgement to the late Helen Lester for her contribution to the original 2012 version) Positive Cardio metabolic Health Resource: an intervention framework for patients with psychosis and schizophrenia update. Royal College of psychiatrists: London. Stratton et al. (2000) Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): Prospective observational study. BMJ 2000; 321: WHO (1999) Definition, Diagnosis and Classification of Diabetes Mellitus and it s Complications. (Online) Available from: (Accessed on 18 th May 2015) Ref: CLIN-0081 V2.2 Page 30 of 34 Ratified date: 13 April 2016

31 MHRA Drug Safety Update June 2015: SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin): risk of diabetic ketoacidosis _Update_-_June_2015_pdf.pdf Ref: CLIN-0081 V2.2 Page 31 of 34 Ratified date: 13 April 2016

32 12 Appendices 12.1 Appendix 1: Treatment of Hypoglycaemia (Adult) flowchart Ref: CLIN-0081 V2.2 Page 32 of 34 Ratified date: 13 April 2016