Webinar # 4: Diabetes management

Thursday, August 20th, 2020 | Rory | No Comments

Diabetes management with Dr. Alex McCleod and Sharon Sandilansd, hosted by Dr. Matilda Hamilton. The link is below and is available on YouTube. The audio is also available via podcast on the Leaning on Fenceposts podcast via iTunes or wherever you listen to your podcasts (may take a few hours to become available).

Show notes:

Type I Diabetes & HHS

  • Type I diabetes
    • More common onset in the young
    • However, can occur any stage in life & second peak later in life
    • Will often present with higher sugars than a Type II diabetic
    • High glucose directly toxic to pancreas
      • Explains ‘honey-moon’ phase when Type I treatment starts, pancreatic function temporarily improves
    • Glucose spikes around meals, as opposed to Type II with higher basal BSL (although can develop post-prandial highs too)
  • HHS = Hyperglycaemic Hyperosmolar State (previously called HONK)
    • Profound metabolic derangement
    • Profound dehydration
    • Require large volumes & treatment underlying illness
    • Higher glucose levels than DKA/not acidotic/not ketosis
  • Continuous glucose monitoring
    • Available in NZ, not funded

Insulin in acute illness

  • Use novorapid for correction (NOT actrapid, it is actSLOW and lasts around 8 hours)
  • Novorapid – quick acting, 3 hours action
  • No insulin is as good as our native insulin – rapid onset/offset
  • Consider stopping metformin during acute illness and starting insulin
  • Don’t forget to restart metformin before discharge!
  • BSL monitoring during admission: pre-meal, pre-bed, 0200 (monitor for hypos) +/- post-meal (?post-prandial highs)
  • Suggested regime for basal/bolus regime during admission
    • Australian Subcutaneous Insulin Chart
    • Total daily insulin requirement = 0.5 units/kg
      • Split this 50:50 basal & bolus
    • Basal Wt(kg/4) = basal insulin requirement
    • Pre-meal blous = remaining daily insulin requirement/3
    • Example: 100kg woman
      • Estimated total daily dose = 0.5*100 = 50 units
      • Basal requirement = 100/4 = 25 units (note this is half daily dose)
      • Bolus doses = 25/3 = 8 units (8 units pre meal)
      • 25 units (basal) + 8 units + 8 units + 8 units = 50 units (daily dose)
    • Correction factors
      • These are doses of insulin given pre-meal (based on the BSL) that are added onto the usual pre-prandial (bolus) dose
      • Correction factor calculated 100/total daily dose (eg. Case above 100/50 = 2). The correction factor is the expected reduction in BSL for every unit of inulin. (For cases expect BSL to drop by 2 for every unit of insulin).
      • For example this patient may have BSL target of ~ 10.Pre meal BSL 20.  Want to drop BSL by 10, therefore add correction factor of 5 units onto usual pre-meal insulin.
    • Reviewing insulin dosing during acute admission
      • Add up previous 24 hours insulin requirement, then split this 50:50, adjusting the basal and bolus doses accordingly.

Insulin for long-term treatment:

  • When to start?
    • Not reaching target HbA1c despite ma oral therapy
    • Targets
      • Younger patients HbA1c ~50
      • Slightly older ~ 64
      • Elderly more lenient – must avoid hypos!
    • Continue metformin once on insulin
      • Improves insulin sensitivity
    • Options: long-acting vs mixed vs basal bolus
      • Need BSL profile to guide prescribing eg. Post-prandial highs may be indication for mixed insulin
      • Patient factors – eg. May opt for most simple option = safest
    • Mixed insulin – a note
      • Mixture or short-acting & intermediate acting
      • Last ~ 8 hours, therefore often BD dosing

Diabetic Medications – the old & the new

  • Metformin
    • Reduce oral absorption of glucose
    • Increase glucose uptake by cells, by increasing insulin sensitivity
    • Reduce liver production of glucose
    • Main side effect – GI upset
  • Sulfonylureas
    • Being phased out
    • Augment insulin secretion
    • Risk hypoglycaemia
  • GLP-1 receptor agonists (glucagon-like- peptide)/incretin mimetics
    • Increase insulin production when BSL elevated
    • Slow gastric emptying (can cause nausea)
    • Increase weight loss
    • Injection only
    • Not really available in Aotearoa
  • DPP – 4i, enzyme blocker
    • Reduce glucagon & increase insulin
    • Reduce weight
    • Vildaglitpin = Galvus (available in NZ)
    • Galvumet = vildagliptin + metformin
  • SGLT2 – inhibitors (Flozins)
    • NZ dapagliflozin (Forxiga) (not funded)
    • CKD/CVD benefits
    • Probably add on therapy for heart failure
    • Enhances renal excretion of glucose
    • Increase risk of UTIs and thrush
    • Risk DKA with relatively normal BSL

Non-pharmaceutical management = the important stuff

  • Remember the importance of advice around:
    • Diet to reduce glucose intake
    • Exercise to improve insulin sensitivity
  • Engage patients with appropriate services (eg. Free annual diabetic review, Kaupapa Māori services)
  • Walk beside your patients and be gentle on them – diabetes is a long, hard road.

Podcast:

Available on iTunes or any other podcast apps


 

Rural CME Webinar #2: Focus on mental health

Tuesday, March 17th, 2020 | Rory | 1 Comment

Recording from the latest Rural CME webinar in case you missed it or want to watch it again. Below are some additional resources including Dan’s Pneumonic device for delirium (I CLAP in time).

There are some really good printable self help guides here; https://web.ntw.nhs.uk/selfhelp/

I often recommend people have a look at https://www.headspace.com/ which is a smart phone app that teaches / guides people through relaxation exercises.

http://www.mhaids.health.nz/your-health/help-for-mild-to-moderate-mental-health-issues/ is a page with a lot of links to other support resources and there are a whole load of other information and support agencies out there.

 

I CLAP (in time)

 

I   Inattention (most sensitive sign)

C  Cognitive Impairment (Think of the domains on the MoCA)

L  Level of Consciousness (usually decreased but can be increased arousal)

A  Affective changes (usually depression)

P  Perceptual disturbance (visual hallucinations)

These are the classic symptoms of delirium.

They occur ACUTELY and TEND TO FLUCTUATE (that’s the ‘time’ bit).