1. Developing people for health and healthcare
A guide to managing
hospital diabetes
24th July 2014
Dr Jennifer Tremble
Consultant Diabetologist
Queen Elizabeth Hospital

2. Outline
 Diagnosis of diabetes
 Type 1 or type 2
 Management of newly diagnosed diabetes
 Insulin sliding scales
 Starting patients on insulin
 Managing established diabetes
 Diabetic emergencies
 Diabetic ketoacidosis/Hyperosmolar non ketotic coma
 Hypoglycemia
 Diabetic feet

3. Diabetes: Diagnosis
 Diagnostic criteria
 HbA1c  6.5%
 HbA1c 6.1-6.4% pre diabetes
 Oral glucose tolerance test rarely except in pregnancy
 But diabetes can present acutely in which case use
 Blood glucose  11.1mmol/L (x2)
 Fasting blood glucose  7mmol/L (x2)

4. Does the patient have type 1 or type 2 diabetes?
 Type 1 Type 2
 Age <30yrs >40yrs
 BMI <27kgm2 >30kgm2
 Racial group cauc asian/A-C/cauc
 History <1 month >1month
 Ketones present absent
 Venous bicarb <20 >20
 If unsure/patient unwell/pregnant give insulin

5. Barbie
 36 yr old F 2/52 Hx
osmotic symptoms and
weight loss
 BMI 27kgm2
 Blood glucose 24mmol/L
 Creatinine 72µmol/L
 Urine analysis – glucose
and ketonuria +++
 Blood ketones
0.8mmol/L

6. New type 1 diabetes - well
 If well, not dehydrated blood glucose <30mmol/L
and blood ketones< 1.2mmol/L
 Office hours refer to the diabetes team
 Out of office hours can give stat dose of insulin (10 units long
acting insulin) - ensure seen by diabetes team the next day
 Weekend or bank holiday
 Basal bolus insulin regimen e.g. Quick acting 4-8 units pre
meal/long acting 12 to 24 units pre bed
 Injection technique taught by ward staff
 Provide meter and diary for self blood glucose monitoring
 Basic education (diet – avoid sugary drinks, 3x meals a day with
carbohydrate, effect of exercise, management of hypoglycemia,
driving)

7. New type 2 diabetes - well
 Blood glucose <20mmol/L
 Diet and exercise
 Blood glucose 20 – 30mmol/L
 Diet and exercise
 Metformin if BMI > 27kgm2 check U&Es
 Gliclazide – for acute glucose control ? needs to be continued
 Dipeptidylpeptidase-4 inhibitors (DPP-4s) e.g. Sitagliptin or Glucagon
like peptide -1 mimetics (GLP-1)s e.g. Exenatide or selective inhibitor of
the renal sodium-glucose co-transporter 2 (SGLT-2) e.g. Dapagliflozin –
long term
 Blood glucose >30mmol/L may need admission
 May need insulin acutely to achieve glycemic control
 Self blood glucose monitoring
 Ensure community follow up

8. New type 2 diabetes – needs admission
 If following features present Rx as for hyperosomolar
state
 Hypovolemia
 Marked hyperglycemia >30mmol/L
 Osmolality 320mosmol/kg or more
 Otherwise consider need for glycemic control
 Acute sepsis/acute coronary syndrome/CVA/ not eating or drinking
 Insulin sliding scale
 Convert to subcutaneous insulin
 Intercurrent infection/cardiac failure/renal failure/Blood
glucose.20mmol/L
 Subcutaneous insulin
 Blood glucose monitoring > 11mmol/L but <20mmol/L
 Oral hypoglycemic agents – choice depending on clinical
features

9. Insulins
 Quick acting (QA)
 duration 2hrs - insulin analogues
 Humalog kwik pen Novorapid flex pen, Apidra solostar pen
 duration 6hrs – human/pork/beef
 Actrapid, Humulin S (kwik pen), Hypurin porcine or bovine
neutral
 Long acting (LA) duration 18hrs –
 Insulatard, Humulin I (kwik pen), Hypurin Isophane
 Insulin analogues – Lantus solostar, Levemir flex pen
 Ultra long acting duration 24 to 36hrs –
 Degludec

10. Premix NPH/Soluble
 Humulin M3 (kwik pen)
 Insuman Comb 25
Insuman Comb 50
 Humalog mix 25 (kwik
pen and vial useful on
the wards for multi dose
use) or Humalog mix 50
(kwik pen)
 Novomix 30 (flex pen)

11. Insulin regimes
 Basal bolus
 suitable for type 1, slim/motivated or highly insulin resistant
type 2, pregnancy
 flexible
 multiple injections (4x or 5x a day)
 weight gain in T2DM “can eat normally”

12. Other insulin regimes
 QA and LA pre breakfast, QA pre dinner, LA pre bed
 4 injections but none at lunchtime
 Twice daily LA or a mix
 Suitable for type 2 and type 1 in honeymoon
 Once daily LA or mix ± oral hypoglycemics
 give pre bed to avoid weight gain in type 2s
 consider when district nurses are going to administer insulin

13. Insulin sliding scales
 Indications
 Nil by mouth
 Need immediate good control
 Severe hyperglycemia to allow calculation of insulin requirement
 Requires
 Hourly BGs
 Syringe pump
 Iv dextrose 10% if patient not eating/drinking
 Continue usual
 LA subcutaneous insulin
 ± usual QA subcutaneous insulin if predictable increase in
insulin requirements e.g with dexamethasone or patient
eating/drinking
 Trouble shooting – BG not controlled
 ? reset sliding scale higher or lower
 ? excess or inadequate or variable calorie intake

14. QE sliding scale
 basal rate = normal total insulin dose
24
If not normally on insulin take basal rate as 2
BG/mmols/L Insulin infusion rate/mls/hr
<3.9 0.5
4-7.9 basal rate
8-9.9 1.5x basal rate
10-14.9 2x basal rate
>15 3x basal rate - adjust scale

15. Re - starting insulin
 Usual doses
 unless previous poor control
 Best done at breakfast but can be done at lunch
 If on basal bolus and pre bed LA given
 give usual s/c insulin dose with the meal,
 stop the pump 30 mins after the meal
 if LA not given then also give isophane ½ usual dose
 If on twice daily
 As above but given usual morning dose of insulin
 NB Can substitute similar insulins if usual insulins
not available.

16. If new on insulin
 Give around 2/3
rds of predicted 24 hr iv dose
requirement (once BG has come down – ketones
cleared)
 Basal bolus ½ as LA and ½ divided into 3x meal time doses
 E.g. 12-24 units LA and 4-8 units QA with meals
 Twice daily 2/3
rd pre BF, 1/3
rd pre dinner
 E.g. Mix 32 units pre BF 16 units pre dinner
 Once daily isophane or lantus
 E.g. Humulin I 24 units pre BF

17. Blood glucose monitoring
 Self blood glucose monitoring
 To titrate medication
 To detect hypoglycemia
 Not required if on metformin or gliptin
 4-6x daily if T1DM or pregnant
 Individualised aims
 pre meal
 4-6mmol/L usual, 3.5-5.5mmol/L in pregnancy
 11/2 to 2hrs after meals
 < 10mmol/L (HbA1c 8%)
 < 8mmol/L tight (HbA1c 7%)
 < 7.5 mmol/L pregnancy (HbA1c  6%)

18. Sick day rules T1 DM
 Food
 Usual food at regular intervals
 If unable to eat
 Replace carbohydrate with milk, ice cream, custard, fruit or sugary
drinks
 If vomiting or unable to take food or drinks go to the
emergency dept
 Blood testing
 Test BG every 4 hours including during the night
 Test ideally blood ketones at least twice a day - 4x day if
positive

19. Sick day rules Type 1 diabetes
 Use quick acting or mixed insulin
 Blood ketones
 <3mmol/L >3mmol/L
 Total daily Insulin dose Give extra 10% Give extra 20%
 every 4 hours every 2 hours
 Up to 14 units 1 unit 2 units
 15 - 24 units 2 units 4 units
 25 - 34 units 3 units 6 units
 35 - 44 units 4 units 8 units
 45 -54 units 5 unit 10 units
 Push fluids
 This algorithm has been adapted from DAFNE guidelines

20. Sick day rules – T2 DM
 Generally do not stop tablets or insulin
 ? Metformin if anorexia/diarrhoea
 Can become hypoglycemic if poor appetite
 Increase blood testing 4x a day
 Safest to see health professional daily
 Increase sugar free fluid intake
 If unable to eat solid food
 Ice cream, milk, cola, fruit juice, yoghurt

21. Sick day rules T2DM on insulin
 Blood glucose Insulin to add If total insulin dose
to each dose >50 units/day
 11-17 mmol/L 2 units 4 units
 17- 22 mmol/L 4 units 8 units
 > 22 mmol/L 6 units 12units
 All adjustments are incremental and should be reduced
gradually as the illness subsides.

22. Diagnosis of diabetic ketoacidosis
 All three of the following
must be present
 Capillary BG >11mmol/L
 Capillary ketones
>3mmol/L or urine
ketones ++ or more
 Venous pH <7.3 and/or
bicarbonate < 15mmol/L

23. Management of DKA
0-60mins
 0.9% sodium chloride 1 litre over an hour (hypotension,
Hx CCF may require more or less).
 Fixed rate insulin infusion 0.1units/kg/hour
 Assess patient
 Further investigations
 Capillary and laboratory glucose
 U&E, FBC, blood cultures, ECG, CXR, MSU
 Establishing monitoring regimen
 Hourly CBG/ketones
 Venous bicarbonate/potasium at 1hr then 2 hrly
 4hrly plasma U&Es
 Cardiac monitoring +/-pulse oximetry

24. Management of DKA
60mins to 6 hrs
 Aims of treatment
 Ketones down by 0.5mmol/L/hr or bicarbonate rise 3mmol/L/hour
 BG fall by 3mmol/L/hour but avoid hypoglycemia
 Maintain potasium in normal range
 Reassess patient monitor vital signs
 Continue fluid replacement
 0.9% sodium chloride 1litre over 2 hours, 2 hours and 4 hours add 10%
dextrose if BG <14mmol/L.
 Potassium replacement >5.5mmol/L nil, 3.5-5.540mmol/L, <
3.5mmol/L senior review
 Assess response to treatment
 If response inadequate increase insulin infusion rate 1 unit/hour
increments until target achieved
 Additional measures
 Indications for urinary catheter/nasogastric tube, thromboprophylaxis

25. Management of DKA
6-12 hrs
 Aims
 Ensure clinical and biochemical parameters improving
 Continue iv fluids (4-6 hourly, add 10% dextrose 125mls/hour
when BG <14mmol/L)
 Avoid hypoglycemia
 Assess for complications of treatment e.g fluid
overload/cerebral oedema.
 Rx precipitating factors
 Reassess the patient and monitor vital signs.
 Review biochemical and metabolic parameters.
 Target ketones <0.3mmol/L and venous pH >7.3mmol/L
and/or venous bicarbonate >19mmol/L

26. Management of DKA
12-24 hrs
 Expectation
 ketonemia and acidosis should have resolved.
 Ensure clinical and biochemical parameters are
continuing to improve or are normal
 Ensure long acting insulin is given
 if established diabetes usual dose usual time
 if new diabetes give LA e.g. Lantus 12-24 units nocte

27. Management of DKA
Resolution
 Expectation
 Patients should be eating and drinking
 Ketones and acidosis resolved – ideally BG <17mmol/L
 Transfer to subcutaneous insulin
 give QA insulin and stop sliding scale 30 mins later.
 if new on insulin use dose on sliding scale as a guide e.g. QA 4-8
units tds
 if no LA given - intermediate (e.g isophane or levemir) ½ to
2/3rds expected bedtime dose in the morning.
 Education whilst inpatient
 Follow up with the diabetes specialist team

28. The hyperosmolar state
 Characteristic features
 Hypovolemia
 Marked hyperglycemia >30mmol/L without signficant ketosis
Ketones <3mmol/L or acidosis pH >7.3mmol/L bicarbonate
>15mmol/L.
 Osmolality 320mosmol/kg or more

29. Goals of treatment
 Normalise osmolality
 Check frequently
 Replace fluid and electrolyte losses
 Iv 0.9% N saline – only switch to 0.45% saline if the osmolality
is not declining
 An initial rise in sodium is expected – thereafter the rate of fall
of sodium should not exceed 10mmol/L in 24 hours.
 Normalise BG
 should fall by no more than 5mmol/hr
 Low dose o.05 units/kg/hr should be commenced once the BG
is no longer falling with iv fluids alone or there is significant
ketonemia.

30. Goals of treatment (cont)
 Prevention of arterial or venous thrombosis
 Prophylactic low molecular weight heparin or heparin if
significant renal impairment
 Prevent cerebral oedema/central pontine
myelinolysis
 Avoid excess fluids and rapid changes in serum osmolality
 Prevent foot ulceration
 Foot assessment

31. HHS
Recovery
 Expectation patients should be
 Eating and drinking
 Biochemical parameters have normalised
 Mobilising
 Catheter removed
 Subcutaneous insulin
 Usually twice daily regime – education + meter to SBGM
 Discharge with follow up
 Plan to
 Start/restart metformin (usually on or soon after discharge)
 Convert to/back to oral hypoglycemic agents (usually 6 -12wks)

32. Ken
 36 yr old M 2/52 Hx
osmotic symptoms and
weight loss
 BMI 31kgm2
 Blood glucose 44mmol/L
 Creatinine 140µmol/L
 Urine analysis – glucose
and ketonuria +++
 Blood ketones
4.2mmol/L

33. DKA/HHS
Ketosis prone type 2 diabetes
 Acidosis and ketosis with severe hyperglycemia and
dehydration.
 Usually risk factors for T2DM
 Will be managed as per DKA but usually discharged
on twice daily mixed insulin
 Check GAD and islet cell antibodies
 6-12 wks if antibodies negative stop insulin leave on
metformin but should probably continue to test BG
once a week or more if unwell.

34. Hypoglycemia on the wards
 Definition ?<4 ?<3.5 ? 2.2mmol/L
 BG 3.5- 3.9mmol/L
 60mls lucozade/100mls fruit juice/2 tspns sugar/ 3 dextrosols
 BG < 3.5mmol/L
 if alert as above– may need to repeat
 if drowsy or refusing to eat then glucogel
 if comatose 100mls iv 20% dextrose or glucagon 1mg im
 give snack/meal and insulin if due when BG > 4mmol/L
 If on long acting hypoglycemic agent and not eating
 May need 10% dextrose infusion
 Look for the cause

35. Hypoglycemia in the emergency dept.
 Ensure that the hypo Rx
 fast then slow CHO
 Advice on avoiding
  insulin/SU, snack with
EtOH or exercise
 Advice on managing of
future hypos
 partner education
 Risks of hypoglycemia
 implications for driving
 hypo unawareness
  risk to the fetus
 Ensure follow up

36. Diabetic feet
 Always check feet of patients with diabetes
 Pulses, Other (blisters, abrasions, deformity, callus, ulcers
toenails, swelling) Deformity (varus/valgus, pes
cavus/planus, charcot) Infection, Sensation
 Admission diabetic foot
 Neuropathic or vascular or both
 Rx sepsis – local guidelines
 Imaging – X ray +/- MRI scan
 If pulses not palpable – duplex/CT angiogram
 Multidisciplinary foot team
 Podiatrist, diabetologist, vascular surgeon

37. Final thoughts
 Establish whether the patient has T1DM or T2DM
 Not just new presentations but also patients with pre existing DM
 How well was the diabetes managed before
 HbA1c/monitoring diary
 Follow the protocols for DKA and HHS
 Remember to write up usual insulin
 When a patient is not eating and drinking once glucose <14mmol/L
will need dextrose – if BG rises increase insulin
 Hypoglycemia
 BGs 3-3.5mmol/L occur commonly in healthy population
 Apple and orange juice are available on every ward
 Diabetic feet
 Prevention is better than cure – protect the heels

38. They do grow up!