Clinical Guidelines Management of adult patients with diabetes undergoing endoscopic s Document Detail Document type Clinical Guideline Management of adult Patients with diabetes Undergoing Document name Endoscopic Procedures Document location GTi Clinical Guidance Database Version 1.0 Effective from 07 April 2016 Review date 07 April 2019 Owner Gastrointestinal Medicine and Surgery (GMS) Author(s) Dr Sabina De Martino Specialty Doctor in Gastroenterology Dr Gautam Das SPR Diabetes & Endocrinology, Dr Anna Brackenridge, Consultant, Diabetes and Endocrinology. Felicity Andrews Physician associate in diabetes Pam Gilby, Diabetes specialist Nurse Hannan Derez, Diabetes Specialist Nurse Abhiti Gulati, Specialist Clinical Pharmacist Approved by, date Drugs and Therapeutic Committee, April 2016 Superseded documents Related documents GSTT Guidelines: - The Peri-operative management of diabetes mellitus medicines The Management of Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycaemic state (HHS) in Adults- Integrated Care Pathway Hypoglycaemia in Adults with Diabetes within the General Ward Settings: Diagnosis and Treatment Keywords Endoscopic s, endoscopy, diabetes, insulin, glucose, diabetes medications, metformin, anti-diabetic Relevant external law, regulation, standards Change History Date Change details, since approval Approved by DTC Reference: 16045t Review By: April 2019
Management of patients with diabetes undergoing endoscopic s General points:- 1. As patients need to be fasted before endoscopic s, patients with diabetes on diabetes medication will need advice regarding how to adjust it If it is not adjusted they are at high risk of becoming hypoglycaemic 2. All clinical staff working within Endoscopy Services at Guy s and St. Thomas NHS Trust should follow these guidelines to ensure patient safety and support before, during and after endoscopic s. 3. All clinical staff should be able to recognise the signs and symptoms of hypoglycaemia and hyperglycaemia. 4. Nurses must be trained and competent in the operation of the trust approved blood glucose monitor. They must also use their own bar code to operate the machine. 5. Nurses should treat hypoglycaemia, according to the trust guideline for both patients who can take oral fluids and those who are nil by mouth. Hypoglycaemia in Adults with Diabetes within the General Ward Settings: Diagnosis and Treatment 6. Nurses should know where the department s hypoglycaemia treatment box is situated, if you are unsure you must ask the nurse in charge of the endoscopy unit. 7. Nurses should document any hypoglycaemic events and treatment/management in the patients notes. 8. The diabetes registrar can be contacted if required on weekdays on bleep 1801 from 9.00 to 17.00 and via switchboard from 17.00 to 19.00. 9. Dietary advice for patients having bowel preparation: http://gti/resources/patientinfo/gi/colorectal/diet-advice-bowel-prep-colonoscopy.pdf DTC Reference: 16045t Page 1 of 5 Review By: April 2019
Referral for The request form (GP or hospital referral) must state whether the patient has diabetes and the diabetes medication the patient is currently on. Procedure booking. All patients with diabetes should be booked first or second on the morning list wherever possible. Pre-admission advice (telephone or face to face) Medications: For s requiring bowel preparation see table 1 For s not requiring bowel preparation see table 2 Ensure patients have clear sugary drinks available at home and when coming to hospital to treat low blood glucose Ask patients to come to hospital with all their medications including insulin. If patient checks blood glucose advise to check it every 2 hours Patients may have clear sugary drinks up to 2 hours before the Admission to hospital Admission to endoscopy Admission of people with diabetes prior to endoscopy should be avoided unless there is a clear indication Discuss patient with diabetes registrar. Patients on insulin require 2 hourly Capillary Blood Glucose monitoring from admission to discharge Blood glucose levels should be between 4-15 mmol/l prior to the commencement of If blood glucose is below 4 mmol/l, follow hypoglycaemia guideline. If blood glucose level is above 15mmol/l contact diabetes registrar (bleep 1801) for further advice Post As a result of altering their diabetes medication, their diabetes control may not be optimal. Patients need to know that this is only temporary and will be back to usual control within 24-48 hours. DTC Reference: 16045t Page 2 of 5 Review By: April 2019
Table 1) The Management of diabetes medication and insulin for patient having endoscopic s not requiring bowel preparation. Advise patient to alter medication as follows Class Diabetes drug Generic name The day before Morning Afternoon Biguanides Sulphonylurea DPP-IV inhibitor SGLT-2 inhibitor Meglitinide Metformin Metformin M/R Gliclazide Gliclazide M/R Glimepiride Glibenclamide Glipizide Tolbutamide Linagliptin Saxagliptin Sitagliptin Vildagliptin Alogliptin Dapagliflozin Empagliflozin Canagliflozin Repaglinide Nateglinide of. of. of. of. Glitazone Pioglitazone GLP-1 analogue Long or intermediate acting insulin Ultra long acting insulin Exenatide Liragutide Lixisenatide Dulaglutide Lantus (glargine) Levemir (detemir) Insulatard Humulin I Reduce all doses PM doses as normal PM doses as normal Tresiba (degludec) Short or rapid acting insulins (mealtime) Apidra (glulisine) Humalog (lispro) Humulin S Novorapid (aspart) Mixed insulin Humalog Mix 25 Humalog mix 50 Humulin M3 Novomix 30 Take HALF the usual dose at breakfast time even though not Normal insulin with evening meal Take HALF the usual dose with breakfast Normal insulin with evening meal Please note: multiple rows may apply For combination drugs please see table 3 for advice Be aware this list is NOT exhaustive and new drugs may come to market which are not included here. If in doubt check the most recent edition of the BNF or call medicines information on x83855 Inform patients if they have any concerns to contact their local diabetes team for further advice on management DTC Reference: 16045t Page 3 of 5 Review By: April 2019
Table 2) Management of diabetes medication and insulin for patient having endoscopic s requiring bowel preparation. Advise patient to alter medication as follows: Class Biguanides Sulphonylurea DPP-IV inhibitor SGLT-2 inhibitor Meglitinide Diabetes drug Generic name Metformin Metformin M/R Gliclazide Gliclazide M/R Glimepiride Glibenclamide Glipizide Tolbutamide Linagliptin Saxagliptin Sitagliptin Vildagliptin Alogliptin Dapagliflozin Empagliflozin Canagliflozin Repaglinide Nateglinide The day before Morning Afternoon OMIT all doses of. of. of. of. Glitazone Pioglitazone GLP-1 analogue Long or intermediate acting insulin Ultra long acting insulin Exenatide Liragutide Lixisenatide Dulaglutide Lantus (glargine) Levemir (detemir) Insulatard Humulin I Reduce all doses PM doses as normal PM doses as normal Tresiba (degludec) Short or rapid acting insulins (mealtime) Apidra (glulisine) Humalog (lispro) Humulin S Novorapid (aspart) Mixed insulin Humalog Mix 25 Humalog mix 50 Humulin M3 Novomix 30 Take HALF the usual dose with breakfast Take HALF the usual dose in the evening even though not HALF the usual dose at breakfast time even though not Normal insulin dose with evening meal HALF the usual dose at breakfast time even though not Normal insulin dose with evening meal Please note: multiple rows may apply For combination drugs please see table 3 for advice Be aware this list is NOT exhaustive and new drugs may come to market which are not included here. If in doubt check the most recent edition of the BNF or call medicines information on x83855 Inform patients if they have any concerns to contact their local diabetes team for further advice on management DTC Reference: 16045t Page 4 of 5 Review By: April 2019
Table 3) Combination anti-diabetic medications Please use the table below and then refer back to table 1 and table 2 to adjust combination antidiabetic medication. Generic name Brand name(s) Advice Alogliptin AND Metformin Vipdomet Treat as DPP IV inhibitor Linagliptin AND Metformin Jentadueto Treat as DPP IV inhibitor Saxaglptin AND metformin Komboglyze Treat as DPP IV inhibitor Sitagliptin AND metformin Janumet Treat as DPP-IV inhibitor Vildagliptin AND metformin Eucreas Treat as DPP-IV inhibitor Canagliflozin AND Metformin Vokanamet Treat as SGLT2 inhibitors Dapagliflozin AND Metformin Xigduo Treat as SGLT2 inhibitors Empagliflozin and Metformin Synjardy Treat as SGLT2 inhibitors Pioglitazone AND metformin Competact Treat as glitazone Liraglutide AND Insulin Degludec Xultophy Treat as long-acting insulin DTC Reference: 16045t Page 5 of 5 Review By: April 2019