Pre-Dialysis Insulin Information for Patients with Type 2 Diabetes receiving haemodialysis

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1 Pre-Dialysis Insulin Information for Patients with Type 2 Diabetes receiving haemodialysis Exceptional healthcare, personally delivered

2 2 This leaflet is for patients with Type 2 diabetes who require insulin and who are treated with haemodialysis for renal failure. At this dialysis unit, we offer a treatment option known as Pre- Dialysis Insulin. This leaflet aims to explain what this involves. If you have any further questions after reading the leaflet, please ask your dialysis nurse. What is Pre-Dialysis Insulin? Pre-Dialysis Insulin is an insulin regime for people with Type 2 diabetes who have haemodialysis three times a week. The insulin is injected into subcutaneous fat just before haemodialysis starts and is designed to improve your blood glucose control. The long-term aim is that your diabetes will be totally controlled by these three insulin injections each week. There are a number of reasons that this regime is effective: n The insulins used are very long-acting and have a flat or peakless action. n Patients on haemodialysis have reduced renal function, which means that insulin stays in the system much longer than in patients with normally functioning kidneys. In other words, the insulin is not excreted from the body as quickly. This means it continues to do its work for the whole period between dialysis sessions. n Insulin is not removed by the dialysis machine, so it begins working on your blood glucose levels while dialysis is in progress. This is particularly useful for patients who experience a rise in blood glucose level (hyperglycaemia) as a result of dialysis. Which patients are suitable for Pre-Dialysis Insulin? Only patients with Type 2 diabetes can be treated with Pre- Dialysis Insulin. Insulin-requiring patients who may benefit from this nurse-led regimen include: Information For Patients Using Pre-Dialysis Insulin

3 n Those who have poor diabetes control that has not responded to conventional treatments. n Those who are unable to manage their own insulin injections, for a variety of reasons (eg vision problems, difficulty using an insulin pen due to pain or numbness in the hands). n Those who do not have carers who can support them with insulin injections at home. n Those who suffer needle phobia. Which insulin is used for Pre-Dialysis Insulin? The insulin used is one of two long-acting analogues (synthetic, chemically produced insulins): either Glargine (also known as Lantus) or Levemir (Detemir). Who gives the insulin? You can give your insulin injection yourself, or the nurses will be happy to do this for you if you prefer. If you would like to do your own injections, the nurses will show you how to use either an insulin syringe or an insulin pen, both using a small 6-8mm needle; this should be painless. If the nurses are doing your injections for you, they will use an insulin syringe with an 8mm needle, which again should be painless. Does Pre-Dialysis Insulin replace all my diabetes medications? Pre-Dialysis Insulin may be used in a variety of ways: n On its own, as the sole diabetes medication; n Alongside oral diabetes medication; n As a top-up insulin for patients already on subcutaneous insulin but who require large doses, which make subcutaneous injections difficult. Information For Patients Using Pre-Dialysis Insulin 3

4 If you are already taking medication for diabetes, it is unlikely that this will be stopped immediately when Pre-Dialysis Insulin is started. Instead, we will run the two regimes alongside each other, and gradually reduce your tablet or mixed-insulin doses as the dose of Pre-Dialysis Insulin is increased. The long-term aim is that your diabetes will be totally controlled by Pre-Dialysis Insulin, but this may take some time to achieve. What dose do I need to take? The dose of Pre-Dialysis Insulin required varies between individual patients, and may also vary for an individual, depending on factors such as illness and infection. Everyone begins on a starting dose of 10 units, which is given for at least three haemodialysis sessions before it is reviewed and increased. The dose is ideally increased each week until your blood glucose levels are correct for you. This may take many weeks to achieve, and may require very high doses of insulin (much higher than you would give under other conditions). This is because the insulin is only given three times a week and has to control the blood glucose for hours instead of the usual hours. Some people are worried that such high doses of insulin will mean that they put on weight. In fact, we have found that the weight of patients on Pre-Dialysis Insulin remains very stable, no matter how high the dose of insulin they are given. Does my insulin need to be altered if I am admitted to hospital? If you have to stay in hospital for more than 24 hours, you are likely to have dialysis at different and varying times compared to your usual outpatient routine. This makes giving Pre-Dialysis Insulin more difficult. For this reason, the doctors will instead prescribe a daily dose of your usual Pre-Dialysis Insulin; this dose will be calculated by totalling up your total weekly insulin intake and dividing it by seven, so that you continue to receive the same amount of insulin over the week. When you are discharged, you will return to having your Pre-Dialysis Insulin as before. 4 Information For Patients Using Pre-Dialysis Insulin

5 What happens if I go away on holiday? Pre-Dialysis Insulin continues in the normal way when you go on holiday and you should take your usual dose. Warmer weather, holiday food and different levels of activity may all affect your blood glucose levels. It is a good idea to check your blood glucose levels at least once a day to see how your diabetes is being affected. When away, ask your holiday dialysis nurses to check your blood glucose level before and after dialysis. If you don t usually do blood glucose testing yourself and you would like to learn how to do this whilst on holiday, your named nurse will provide you with a meter and show you how to use it ready for when you go away. You will need to take your insulin and insulin syringes with you and take enough supplies to last while you are away. You should already carry an identification card stating that you have diabetes and take insulin. These cards are available from Diabetes UK in different languages. If you are planning on driving a hire-car whilst away, you will need to declare you are on insulin. Insulin needs to be kept cool during your journey. Keeping it in a cool box or bag is a good idea. If going abroad, you need to take your insulin in your hand luggage as it would freeze in the hold of the plane and be destroyed. Please check local guidelines from your tour operator. If going abroad, you will need a letter to present at customs explaining that you will be flying with insulin and syringes. This can be obtained via your named nurse. What if I have a hypoglycaemic attack while taking Pre-Dialysis Insulin? If your blood glucose levels drop below 4mmol/l at any time of the day or night, this indicates that your diabetes-management regime needs reviewing. Always tell your dialysis nurse and/or diabetes nurse about any hypos that you experience, and treat hypos with fast-acting dextrose in tablet or liquid form (eg Lucozade). Information For Patients Using Pre-Dialysis Insulin 5

6 If you are still taking oral diabetic medication or self-administered subcutaneous insulin, the doses of these will need to be reduced or stopped altogether. If you are only on Pre-Dialysis Insulin, this dose may need to be altered, though there may be another reason for the hypoglycaemia that we need to discover and correct. Hypoglycaemia has many different causes, including: n Insufficient food intake, especially at bedtime, as there is such a long gap between meals over night. n Alcohol may also cause hypoglycaemia. n If you undertake more exercise or activity than usual, your blood glucose level may drop. n Poor insulin injection technique if the insulin is not injected into fat but goes into the skin or muscle instead, the insulin will not be absorbed correctly at the correct time and could cause hypoglycaemia many hours later. These are all things to consider when exploring the causes of hypoglycaemia. Do I need to monitor my own blood glucose levels? The nurses will record your blood glucose levels before and after every dialysis session ( pre- and post-dialysis monitoring), to help us assess how effective the Pre-Dialysis Insulin is for you. You are also encouraged to record your blood glucose levels occasionally at home, and your named nurse will give you advice about this. When we are all satisfied with the results, and your blood glucose levels have stabilised, regular blood glucose testing will then be stopped. Instead we will record your HbA1c (glycosylated haemoglobin) levels every three months to ensure your diabetes remains well-controlled. HbA1c gives a very accurate review of blood glucose control over a three-month period, as it measures the amount of sugar attached to red blood cells. The result is given as a percentage and is different to home-testing and fingerprick 6 Information For Patients Using Pre-Dialysis Insulin

7 results. The ideal result is an HbA1c of between 48-63mmol/mol ( %). We have found that the Pre-Dialysis Insulin regime has helped many patients achieve a significantly lower HbA1c which, evidence shows, means better long-term health outcomes and a reduced risk of developing serious complications caused by diabetes. NHS Constitution. Information on your rights and responsibilities. Available at Information For Patients Using Pre-Dialysis Insulin 7

8 If you or the individual you are caring for need support reading this leaflet please ask a member of staff for advice. North Bristol NHS Trust. This edition published May Review due May NBT002100

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