RESOURCES NHS Lothian In-patient Insulin Use and Supply - - PowerPoint PPT Presentation

Year 4 Prescribing Tutorial 2019 - 2020

PRESCRIBING IN DIABETES

RESOURCES

NHS Lothian In-patient Insulin Use and Supply http://intranet.lothian.scot.nhs.uk/Directory/Diabetes/inpatientdiabetes/Documents/Insulin- inpatient%20insulin%20use%20and%20supply%202017%20- %20Updated%20Sept%2017%20%285%29.docx NHS Lothian In-patient Insulin - Prescribing Guidance Document http://intranet.lothian.scot.nhs.uk/Directory/PolicyHub/Documents/Insulin- %20Inpatient%20Insulin%20Prescribing%20Guidance.pdf NHS Lothian Adult Intravenous Insulin Prescribing Chart http://intranet.lothian.scot.nhs.uk/NHSLothian/Healthcare/A- Z/Diabetes/inpatientdiabetes/Documents/Final%20IV%20Infusion%20Chart%202014.pdf Golden rules of prescription writing http://intranet.lothian.scot.nhs.uk/Directory/MedicinesManagement/Documents/Golden%20rules% 20for%20prescribing%20V%203.1.pdf BNF http://www.bnf.org/ Lothian Joint Formulary http://www.ljf.scot.nhs.uk/Pages/default.aspx

GOLDEN RULES OF PRESCRIBING

 Select correct prescription chart (14 day ± warfarin

chart)

 Write clearly in block CAPITALS using a black

ballpoint pen

 Complete all the required patient details on the front  Use generic names for drugs where possible and

appropriate

 Write drug dose clearly; remember only g, mg and ml

are acceptable abbreviations

 Select route of administration

GOLDEN RULES OF PRESCRIBING

 Enter correct start date (use original start date when

rewriting)

 Remember the once only section  Sign and print your name  Enter supplementary charts in use  Never alter prescriptions (cancel and rewrite)  Discontinue prescriptions correctly

OBJECTIVES

 Describe Type 1 and Type 2 Diabetes Mellitus.  List the different types of insulin.  Describe the principles of an insulin prescription.  Describe factors to consider when prescribing oral

hypoglycaemics.

DIABETES MELLITUS

Chronic Hyperglycaemia Insulin Deficiency Insulin resistance Both

Types of Diabetes:

• Type 1 diabetes mellitus
• Type 2 diabetes mellitus
• Gestational diabetes
• Maturity onset diabetes of young

TYPE 1 AND TYPE 2 DIABETES MELLITUS

Type 1 Type 2 Epidemiology

Can present at any age Peak incidence around puberty Commoner in white Caucasians Usually after age 40 All racial groups, commoner in African/Asian

Inheritance

HLA-DR3 and/or HLA-DR4 in >90% 30-40% concordance in identical twins No HLA links 50% concordance in identical twins Polygenic

Clinical Picture

Insulin deficiency May develop ketoacidosis Usually lean Relative insulin deficiency, and insulin resistance May develop hyperosmolar state Often overweight

PATHOGENESIS

Insulin Glucose Uptake and storage Lipid synthesis Type 1 DM Type 2 DM

INSULIN

 In people without diabetes, there is a basal insulin

secretion, with spikes following meal times.

 Insulin therapy aims to mimic this in patients with

diabetes.

TYPES OF INSULIN

 Classified by how fast they work and how long

their effects last for.

Insulin Onset Peak Duration Role in Blood Sugar Management

Rapid-Acting

Humalog Novorapid

15-30mins 30 – 90 mins 2 – 5 hours

Rapid-acting insulin covers insulin needs for meals eaten at the same time as the injection. This type of insulin is often used in conjunction with longer-acting insulin.

Fiasp 4 mins 60 – 180 mins 3 – 5 hours

Apidra

15 mins 60 mins 2 – 4 hours

Apidra is approved for use within 15 minutes before or within 20 minutes after starting a meal

TYPES OF INSULIN

Insulin Onset Peak Duration Role in Blood Sugar Management

Short-Acting

Actrapid

30 minutes 1 ½ – 3 ½ hours 7 – 8 hours Short-acting insulin covers insulin needs for meals eaten within 30-60 minutes

Humulin S

30 min – 1 hour 2 – 5 hours 5 – 8 hours

Insuman Rapid

30 min 1 – 4 hours 7 – 9 hours

TYPES OF INSULIN

Insulin Onset Peak Duration Role in Blood Sugar Management

Intermediate-Acting

Insulatard

1 ½ hours 4-12 hours 24 hours Intermediate-acting insulin covers insulin needs for about half the day

• r overnight. This type of insulin is
• ften combined with rapid- or short-

acting insulin.

Insuman Basal

1 hour 3-4 hours 11-20 hours

Long-Acting

Lantus

1-2 hours No peak - insulin is delivered at steady rate 20-24hours Long-acting insulin covers insulin needs for about one full day. This type of insulin is often combined, when needed, with rapid- or short- acting insulin.

TYPES OF INSULIN

Insulin Onset Peak Duration Role in Blood Sugar Management

Pre-Mixed

Generally taken twice a day before mealtimes Novomix 30

10 – 20 mins 1 – 4 hours Up to 24 hours

Humalog Mix 25

Approx 15 mins 30 – 70 mins

Dependent on dose, site of injection, blood supply, temperature, and physical activity

Humalog mix 50

Pre-mixed insulins are a combination of intermediate acting and short acting insulins in one pen

INSULIN PRESCRIPTION

 Varies from patient to patient:

• Once daily regimen

 Intermediate or long acting insulin given at bedtime  Only suitable in type 2 diabetes

• Twice daily regimen

 Use biphasic insulin twice daily  Can be complicated by hypoglycaemia between meals

• Basal bolus regimen

 Basal insulin – usually at bedtime  Fast acting insulin at meal times

• Continuous S/C insulin infusion via insulin pump

INSULIN PRESCRIPTION

INSULIN PRESCRIPTION

 Whilst an inpatient, patient’s insulin must be

prescribed on both the drug chart and the insulin chart.

 Prescribe on the main prescription chart…

INSULIN PRESCRIPTION

 Insulin must also be prescribed on the insulin chart.  This is where the nursing staff with record the

patient’s blood sugars.

 These should be reviewed before prescribing insulin.

Before Breakfast Prescribe

Sign

Before Lunch Prescribe Sign Before Dinner Prescribe Sign Bed time Prescribe Sign Units Units Insulin Units Insulin Blood Sugar Insulin Insulin Blood Sugar

Blood Sugar Blood Sugar

CASE SCENARIO 1

50 year old female with T1DM is admitted to hospital with pyrexia, rigors, cough and shortness of breath. CXR shows a right basal consolidation and she is managed with IV antibiotics. You note that she is on a twice daily regimen of Novomix 30, 20 units at breakfast and 10 units in the evening. Prescribe this on the insulin chart.

CASE SCENARIO 1

Before Breakfast Rx Signed Before Lunch Rx Signed Before Dinner Rx Signed Bedtime

6.2

Novomix 30

20 Units

ADoctor DOCTOR

Units

5.8

Novomix 30

10 Units

ADoctor DOCTOR

CASE SCENARIO 1

Two days later, the nurses comment that her blood sugars are high despite her poor oral intake. You look at the chart and notice that her blood sugars are now ranging between 12 – 15 throughout the day.

 Why do you think this is the case?  What would you do?

CASE SCENARIO 1

 During illness and other physiological stresses, insulin

requirements dramatically increase in response to the body’s increased catabolic state.

 Monitor blood glucose more frequently than usual, and

adjust insulin doses appropriately.

 Insulin must be continued at all times, even if oral

intake poor, in type 1 diabetes - this is to avoid ketosis.

 Monitor urine or plasma for ketones if concerns

CASE SCENARIO 1

Date Before Break- fast Prescribe S i g n e d Before Lunch Prescribe S i g n e d Before Dinner Prescribe S i g n e d Bed time Prescribe S i g n e d

02/11

6.2

Novomix 30

20 Units

Units

5.8

Novomix 30

10Units

Units 03/11

10

Novomix 30

20 Units 10.5

Units

16.0

Novomix 30

14Units

Units 04/11

4.0

Units Units Units Units

NOTE slightly low BM of 4. Easy to assume that subsequent insulin dose prescribed should be lowered. This low BM is however consequent of increase insulin dose prescribed the evening before. This insulin dose should have been increased instead Therefore this evening dose should be decrease.

CASE SCENARIO 1

Prescribe the insulin dose on your insulin chart.

Date Before Break- fast Prescribe S i g n e d Before Lunch Prescribe S i g n e d Before Dinner Prescribe S i g n e d Bed time Prescribe S i g n e d

02/11

6.2

Novomix 30

20 Units

Units

5.8

Novomix 30

10Units

Units 03/11

10

Novomix 30

20 Units 10.5

Units

16.0

Novomix 30

14Units

Units 04/11

4.0

Units Units Units Units

CASE SCENARIO 2

40 year old female with T1DM has been admitted a day before into your ward for elective cholecystectomy the next day. Insulin regimen: Novomix 30 40 units morning and 20 units evening

 She is first on the list in the morning and is to be

fasted overnight.

 What would you do with her insulin regimen?

CASE SCENARIO 2

 Give evening insulin as normal  Fast from midnight  Omit morning dose of S/C insulin  Commence insulin sliding scale in the morning  The insulin infusion is prepared by adding 50 Units of

Actrapid insulin to 0.9% Saline in a syringe, to volume

• f 50ml. Thus, 1ml of the solution = 1 unit of insulin.

 Practise prescribing this on the insulin sliding scale

chart and prescription chart.

CASE SCENARIO 2

A A Do Docto tor DO DOCTO TOR

MS PAT ATIEN IENT

40 Years

WGH GH

1

DAY DAY 1 1

FOR TEACHING PURPOSES

TYPE 2 DIABETES MANAGEMENT

 Diet control  Oral agents  Insulin

Type Examples Mechanism Sulphonylureas Gliclazide Promote insulin secretion Avoid in elderly and those with renal failure Taken with meals Biguanides Metformin Reduce glucose production by liver Sensitize target tissues to insulin First choice oral hypoglycaemic drug. It is the only oral antidiabetic drug which has a proven survival

• advantage. Does not need to be limited to
• verweight patients

Risk of lactic acidosis in renal impairment, avoid eGFR less than 30 mL/min α-glucosidase inhibitors Acarbose Impair carbohydrate digestion Slows glucose absorption Thiazolidinediones Pioglitazone Improved insulin action Risk of fluid retention, avoid in heart failure patients. DPP-4 inhibitors Sitagliptin Increase insulin secretion Lower glucagon secretion

TYPE 2 DIABETES MANAGEMENT

 Diet control  Oral agents  Insulin

Type Examples Mechanism Sodium-glucose co- transporter (SGLT2) Empagliflozin Reversibly inhibits SGLT2 in the renal proximal convoluted tubule to reduce glucose reabsorption and increase urinary excretion

CASE SCENARIO 3

 65 year old male  Past Medical History: Type II diabetes, CKD stage 2  Admitted with a change in bowel habit and weight loss  Under investigation for possible malignancy  DHx: Metformin 500mg orally Twice daily with meals  Prescribe this on the prescription chart

CASE SCENARIO 3

 You were informed that as part of his investigations,

he is booked onto a CT scan with contrast.

 What should you do with his medications?

CASE SCENARIO 3

 Diabetic patients on metformin are at higher risk of

lactic acidosis as contrast material from radiological investigations results in poor excretion of meformin.

 Metformin should be omitted before the procedure and

for 48 hours after.

 Careful watch is to be kept on the renal function and it

should be ensured that patients remain well hydrated.

 Make the relevant changes on the prescription chart.

CASE SCENARIO 3

THE END

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