Sick day rules
Hypoglycaemia overview
• Hypoglycaemia:
– Is the main potential side effect of insulin
• Hypoglycaemic symptoms occur when blood glucose concentration falls below normal levels:
– Technically defined as blood glucose <4 mmol/l
Hypoglycaemia does occur in patients with type 2 diabetes 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 Sulphonylureas
(n=103) Insulin <2 years(n=85) Insulin >5 years(n=75)
Mild hypoglycaemia Severe hypoglycaemia Pr op or ti on o f p at ie n ts r ep or ti n g at l ea st o n e h yp o g ly ca em ic ep is od e (9 5 % C I)
Many patients fear hypoglycaemia
• Many patients with type 2 diabetes are
worried about hypoglycaemia
• Fear of hypoglycaemia may lead to:
– Increased snacking – Missed insulin doses
Hypoglycaemia can be mild or major
Ability to
self-treat hypoglycaemiaMild
Late, more severe symptoms
Usually blood glucose
<2.8 mmol/l
External assistance
required
Major
hypoglycaemia
+
=
=
+
and/or Early symptoms
Who does hypoglycemia affect ?
Type 1 and type 2 patients on insulin
therapy
Type 2 people on insulin secretagogues: -sulphonylurea
-nateglinide & repaglinide
NICE recommends adding a gliptin or glitazone to metformin instead of a
Facts about Hypoglycemia
• In a cohort of patients with diabetes, more than 50% had asymptomatic (unrecognized) hypoglycemia*
• Only 15% of type 2 diabetes patients who experienced a hypoglycaemic event reported the incident to their doctor1,2
• In a prospective study3 of well-controlled elderly T2D patients, 25%
of hospital admissions for diabetes were for severe hypoglycemia
• Increased mortality of 9% in a study4 of severe SU-associated
hypoglycaemia
• 45 serious road accidents caused by hypos per month5
*Chico A, et al. Diabetes Care 2003;26(4):1153-1157
Risk factors for Hypoglycaemia
• Use of insulin and sulfonylureas1
• Older people2,3
• Long duration diabetes2
• Irregular eating habits (food-insulin mismatch)3
• Exercise3
• Have lower HbA1c4
• Periods of fasting e.g. Ramadan
• Prior hypoglycemia5,6,7
• Hypoglycemia unawareness8
• Alcohol9
• Hot weather
• Renal failure
Causes of hypoglycaemia:
some examples
Many things can contribute to hypoglycaemia, e.g
• Taking insulin at the wrong time
• Missing insulin doses and overcompensating later • Inaccurate doses
• Missing meals
• Dietary changes without dose adjustments
• Problems with injection technique or injection site
• Failure to fully re-suspend premixed or intermediate insulin • Alcohol
• Exercise
• Other illnesses
Treating hypoglycaemia
Early signs
(mild hypoglycaemia)
Late signs
(moderate/major hypoglycaemia)
• First: 15–20 g fast-acting carbohydrate, e.g.,:
– 5–7 dextrose tablets
– 150-200 ml fizzy drink (not diet) – 200ml orange juice
– 100-120 ml energy drink (e.g., Lucozade®)
– Repeat if no improvement in symptoms after 10min
• Then:
– If next meal is due, possibly add extra carbohydrate
– If next meal is not due for more than 1 hour , eat longer-acting carbohydrate(10-20g), such as biscuits, fruit, x1 toast.
• Patient requires assistance with treatment
• If conscious:
– Carer should help the patient to consume 15–20 g fast-acting carbohydrate
– Dextrose gel may be useful
• If unconscious:
– Don’t put anything in patient’s mouth – Intramuscular glucagon or intravenous
glucose should be administered
– Not effective if alcholol induced – Ensure relative has training
– Pt still need rapid acting and longer acting carbohydrate
Discussing hypoglycaemia with
your patients
• Most hypoglycaemic episodes are readily treated; however, if untreated they can be very dangerous
• Patients must be aware of hypoglycaemia and how to treat it • Discuss in detail and often with your patients:
– Hypoglycaemic symptoms and awareness change over time • Repeat information
• Check learning by asking the patient what they know – What is hypoglycaemia?
– What are the symptoms of hypoglycaemia?
– What should you do if you experience symptoms? – What concerns do you have?
• Provide information in writing too
Tackling fear of hypoglycaemia
• Emphasise negative consequences of hyperglycaemia
• Discuss strategies to reduce hypoglycaemic risk:
– More frequent blood glucose monitoring
– Different insulin regimens may reduce risk – Tailor dosing
Hypoglycaemia can occur at night
• Patient is normally asleep so unable to respond to symptoms
• Nocturnal hypoglycaemia can result in:
– Disturbed sleep
– Diminished well-being the next day – Next-day fatigue
– Early morning headache – Feeling of being ‘hung over’ – Hypoglycaemia unawareness – Rebound hyperglycaemia
• Fear of nocturnal hypoglycaemia may compromise self-management
ILLness
• Illness can affect insulin requirements for
several reasons:
– In general, blood glucose increases during illness
– Blood glucose may rise even if patients are unable to eat
Sick Days
Illness, infection, injury, pain and stress
↓
Stress Hormones
(counter Regulatory Hormones)
Adrenaline, Glucagon, Cortisol and Growth Hormone
↓
Sick day rules
• Continue to take insulin
• Test blood for glucose at least four-times daily:
– Insulin dose may need to be increased
• Test urine for ketones if blood glucose >13 mmol/l:
• Try to eat normal meals; if unable to, replace meals with carbohydrate-containing drinks
e.g. 100ml orange juice, 200ml milk, 200ml tomato soup, 80g ice cream
• Drink plenty of liquid 100-200ml/hour
• Contact named healthcare professional if at all uncertain about what to do.
Insulin Dose Adjustment During Illness
Ketones large and/or vomiting Blood sugars 15+
• Give quick acting (20% of total daily dose as a SC bolus)
• Admit to hospital for assessment and treatment
Unwell with ketones (moderate/large) present and/or blood sugars 15+
• Drink ++ (non sugary) to avoid dehydration, but if poor appetite give sugary drinks
• Give usual insulin PLUS 20% of total daily requirements as fast acting insulin every 2-4 hours
Small, trace or negative ketones Blood sugars 15+
• Drink ++ (non sugary) to avoid dehydration, but if poor appetite give sugary drinks
• Give usual insulin PLUS 10% of total daily requirements as fast acting insulin every 4 hours No ketones
Unwell and/or Blood sugar 8-15
• Drink ++ (non sugary) to avoid dehydration • Increase usual insulin by 10%
If vomiting on insulin with ketones in urine • Admit to hospital
WHAT TO DO WHEN UNWELL?
• Increase blood glucose monitoring every 4 hourly
• Treat underlying cause of the illness
• Maintain carbohydrate intake using sugary drinks or snack foods if difficulty in eating
• Fluid intake is important - glass of water every hour, aiming for 3 litres in 24 hours
• Test for ketonuria (urine or blood) once or twice a day, more frequently if hyperglycemia is persistent
• People taking Metformin should stop Metformin during periods of dehydration or acute illness – increases the risk of lactic acidosis
• Should take insulin as normal, provided carbohydrate intake continues at least every 4 hours
Alcohol
• Moderate alcohol intake will not affect blood glucose
• Recommended alcohol limits are the same for people with diabetes.
• Alcohol calorific, impact on weight gain
• Heavy alcohol consumption may lower blood glucose
– Usually has a delayed effect i.e. during the night – BM may be higher initially if alcohol contains
carbohydrate giving a false sense of security for the patient.
Alcohol Precautions
• Never drink on an empty stomach
• Do not choose drinks with high sugar content or larger that is sugar free (has higher alcohol
content)
• Have a snack containing carbohydrate before bed if drunk significant amounts.
• Do not correct a high bg pre bed • Carry ID when out drinking
• Be aware of an impact on bg lowering with alcohol and exercise e.g dancing/sex.
Negative interactions of insulin with illegal drugs
• You should discuss the effects of recreational drug use with patients if appropriate:
– It’s their choice – allow them to make an informed decision
• Recreational drug use can lead to hypoglycaemia unawareness and poor glycaemic control:
– Uppers (amphetamine, cocaine) can increase heart rate and activity, which could affect glucose level
– Marijuana can increase appetite, which may lead to hyperglycaemia or weight gain
• Drugs can impair judgement and influence ability to manage diabetes. Patients:
– May not eat regular meals
– May fail to take appropriate and timely insulin doses
Effect of physical activity on insulin
• Insulin requirements may be lower during and after physical activity:
– Activity increases insulin sensitivity and glucose uptake by muscles
• Patients should be encouraged to monitor blood
glucose before and after activity
• Insulin dose or food intake may need to be altered depending on if activity planned or unplanned.
• Patients should not inject into subcutaneous fat above muscles that they are about to use:
– E.g., thigh before walking, arm before swimming
Insulin regimen (or food intake) may need altering when physical activity is planned
Medium term – gentle e.g bike ride 30min
If undertaking intense – prolonged activity:
e.g. aerobic class 1 hour, cycling 2-4 hours
• Additional carbohydrate 10-20g
• Monitor glucose before and after You may need to:
• Increase portions of carbohydrate foods OR • Decrease insulin dose prior to activity (30-50%)
• Top up glucose during activity (sports drink, fruit juice)
Prolonged exercise: e.g. a day hiking
You may need to:
• Monitor blood glucose during activity
• Consume fast-acting carbohydrate, drink fluids, and snack regularly
• Reduce background and quick acting insulin by up to 50%
Diabetes UK. http://www.diabetes.org.uk/Guide-to-diabetes/Treatment__your_health/Keeping_active/Strenuous_sports/
Exercise precautions
• Hyperglycaemia
– people should not exercise if blood glucose is >13 mmol/l or have ketones
– Postpone exercise until blood glucose has decreased (may give correction with quick acting insulin)
• Reactive hyperglycaemia may occur if:
– Patient has consumed more carbohydrates than were utilised during activity
– Insulin dose before exercise was reduced by too much
• Delayed hypoglycaemia
– (prolonged activity may need reduction in background insulin)
– If exercise managed well could prevent