St Luke’s
Hospice Diabetic Guidelines
Contents
1. Guidance for testing of patient blood glucose during inpatient stay
2. Management of elevated blood glucose results in known diabetic patients
3. Management of elevated blood glucose results in non diabetic patients
4. Sick day guidance for the known diabetic patient
5. Management of the unwell & hyperglycaemic diabetic patient
6. Tailoring the use of glucose lowering therapy in the end of life setting
7. Management of diabetes in the last few days of life
8. Management of hypoglycaemia
Contact Details for Diabetic Team at Derriford Hospital
Diabetic Specialist Nurse:
Diabetes Registrar: Bleep 89535
Diabetes Smart Phone: Currently manned Mon-Fri 9-5: 07851 910096
Out of hours emergency advice: Medical registrar on Call via DGH
switchboard
First drafted 2012. Last reviewed February 2017 by Dr Jeff Stephenson
Guidance for testing of patient blood glucose during inpatient stay
The overall aim of monitoring during admission is to provide an appropriate level of monitoring and intervention according to the patients’ stage of illness and to avoid and detect metabolic
de-compensation and diabetic related emergencies.
1.
Management of elevated blood glucose results in known diabetic patients
Is the patient taking
steroids?
If symptomatic, fasting blood
glucose >15mmol/l or out with their own pre-set targets liaise
with the diabetes team to optimise management
Yes
No
Management of elevated blood glucose results in non diabetic patients
Random blood glucose on
admission found to >15mmol/l
3.
Sick day guidance for the known diabetic patient
Type 2 Diabetes that are
diet controlled or taking metformin
Sip sugar free fluids
regularly ~ 100ml per hour
Offer frequent small
portions of easily digested food and or fluids e.g. soups, milky
drinks
Observe for signs and
symptoms of hyperglycaemia
Aim for blood glucose
≤15mmol/l
Consider stopping metformin
if the patient has vomiting and or diarrhoea
Type 2 Diabetes that are
on a sulphonylurea and/or insulin or GLP1 agonist
Sip sugar free fluids
regularly ~ 100ml per hour
Offer frequent small
portions of easily digested carbohydrate food to replace meals if
not eating normally
Consider an increase in the
sulphonylurea or insulin if blood sugar >15mmol/l
Consider a decrease in the
sulphonylurea or insulin if the blood sugar <6mmol/l
Type 1 Diabetes on Insulin
Do not discontinue long
acting insulin
Sip sugar free fluids
regularly ~ 100ml per hour
If unable to eat usual meals
offer frequent small portions of easily digested food or fluids
If the patient has symptoms
of hyperglycaemia or dehydration check urine for ketones
If ≥2+ ketones and not
appropriate to transfer the patient for IV fluids and IV insulin
contact diabetes team for advice of managing within the hospice
setting.
4.
Management of the unwell & hyperglycaemic diabetic patient
5.
Tailoring glucose lowering medication in the end of life setting
Recently diagnosed as in
the end of life phase, expected prognosis of one year
Cardio-protective therapies
should be reconsidered in light of the diagnosis (ACE inhibitors,
aspirin, and statins), caution in those managing cardiac failure or
hypertension.
Cholesterol management may
no longer be a priority and risk of side effects will rise as renal
and liver function is affected by disease progress.
Glucose lowering therapies
should be reviewed and targets for control may need adjustment
Weight loss may mean a
reduced need for pharmacological management of glucose control.
Unstable or advanced
disease, expected prognosis of one to two months
Aim to keep drug
interventions to the minimum that will control symptoms
Complex regimens should be
reviewed and in general it is easier for patients to switch to
insulin alone.
Insulin regimens should be
simplified if possible and once daily insulin is often simplest in
light of changing appetite and increased carer involvement.
Patient rapidly
deteriorating and prognosis one to two weeks
Implement changes as above
Dose adjustments may need
intensive support due to daily changes in well being and appetite
Aim to implement simplest
regimen to control symptoms, i.e. once daily insulin
U
6.
Metformin
|
Sulphonylureas
|
Pioglitazone
|
Gliptins
|
GLP-1 Analogues
|
Insulin
|
Review dose according to changing renal function
Withdraw if egfr <30ml/l
Review if gastrointestinal disease is present
|
Review if dietary intake is reduced or significant weight loss Review dose with deteriorating renal function Review dose with deteriorating liver function, at risk of hypoglycaemia
|
Should only be prescribed if clear benefits can be identified
|
Review doses as renal function deteriorates
Some gliptins can be used in all stages of renal disease
Higher risk of hypoglycaemia if combined with sulphonylurea
|
Withdraw if abdominal pain or pancreatits develops
Review if significant weight loss |
Accumulates in renal failure so dose reduction likely to be needed
Risk of hypoglycaemia to be reassessed as eating patterns change
Simplest regimen is once daily
|
Management of diabetes in the last few days of life
NB: Own background insulin or medicated insulin accumulates in renal failure so be aware of lower doses or needed or to stop insulin altogether
Management of hypoglycaemia
Overall aim is to prevent hypoglycaemia as symptoms are more unpleasant than hyperglycaemia
Glucose targets are a guidance and may need to be individualised based on patients lower limit for symptoms
Rationalise glucose lowering therapy in the end of life setting
Assess the influence of opiates, pain and other symptoms are having on appetite
8.
Tags: contents 1., diabetic, luke’s, guidance, hospice, contents, guidelines