diabetes during intercurrent illness in the 糖尿病并发的疾病管理中的课件

End of life Diabetes Care Clinical Care Recommendations .uk/end-of-life- care Background: Each year around 500,000 people die in the UK Of these tens of thousands have diabetes Despite this there has been little published evidence to demonstrate a preferred or effective approach to diabetes care at the end of life End of Life Care is Care that: “Helps all those with advanced, progressive, incurable illness to live as well as possible until they die. It includes management of pain and other symptoms and provision of psychological, social, spiritual and practical support.” (Source: National Council for Palliative Care 2006) Clinical Care Recommendations For end of life Diabetes Care Commissioned by Diabetes UK in 2010 Endorsed by Multiple Professional Groups including NHS Diabetes, ABCD, TREND- UK Acknowledgement that given lack of studies this document is currently a “consensus of opinion” to be used to assist in development of own guidance. What diabetes specific issues might present with the individual with diabetes at the end of life? Principles of high quality diabetes care at the end of life Provision of painless and symptom free death Tailor glucose lowering therapy and minimise diabetes related adverse treatment effects Avoid metabolic decompensation and diabetes related emergencies DKA/HHS Avoidance of foot complications in frail, bed bound patients Avoidance of symptomatic clinical dehydration Provision of appropriate level of intervention Supporting empowerment of individuals and carers to the last possibe stage Clinical recommendations: Aim 1 No glucose levels lower than 6mmol/l Aim 2 No glucose levels higher than 15mmol/l Targets for those on su/insulin lower should not be problem for those not at risk of hypoglycaemia End of life stages: A. BLUE individuals with life expectancy of 12 months B. GREEN individuals with advanced disease and life expectancy of months C. YELLOW individuals whose condition is deteriorating and may have an expectancy of weeks D. RED individuals in the last few days of life Guidance gives recommendations on how to tailor oral/injectable therapy when: Appetite is reduced Patient experiences hypoglycaemia Intercurrent illness needs to be managed Steroids are used Middle arm - insulin stopped in Type 2 DM (consider if low dose) Urinalysis for daily glucose check. If over 2+glucose - then capillary glucose. If above 20mmol/l then give 6units rapid acting insulin + recheck glucose in 2hrs If individual requires rapid acting insulin more than twice then consider daily Isophane/Lantus May be simpler to resume smaller dose of usual insulin N.B Basal insulin at least to continue in Type 1 Managing the effects of steroid therapy Steroid therapy is frequently used in palliative care for symptom control, usually as dexamethasone or prednisolone. The impact of steroids on glucose control can cause additional hyperglycaemic symptoms. Once daily steroid therapy taken in the morning tends to cause a late afternoon or early evening rise in glucose levels which can be managed by a morning sulphonylurea (e.g. Gliclazide) or morning Isophane insulin (e.g. Insulatard, Humulin I or InsumanBasal). Typical uncontrolled glucose profile (in estabilshed DM) with steroids dosed in morning Break2 hrslunch2hrsEve meal 2 hrsbed 5.41420.5 13.418 6.223.6 12.432.120 5.928.9 Slide no 20 UK/DB/0309/0079 Date of Preparation: March 2009 Intermediate-acting insulin (NPH or Isophane) Cloudy insulin - crystals in suspension (need to re- suspend prior to injection) Onset 1 1/2 hours Peak 6-10 hours Duration of action generally up to 16-18hrs Note: The graphical representation above is for educational and illustrative purposes only Time Action Slide no 21 UK/DB/0309/0079 Date of Preparation: March 2009 Premixed combinations: Premixed combinations of fast/rapid and intermediate- acting insulin Cloudy (needs re-suspending) Onset 10-30 minutes Novomix 30, Humalog Mix 25/Mix 50/Humulin M3 Time Action Steroids contd If steroids are to be given twice daily, for example splitting higher doses of dexamethasone, it will be necessary to recommend an alternative approach to setting times for testing glucose levels and for managing the impact on blood glucose. Twice daily Gliclazide or isophane insulin can be effective but there is a risk of early morning hypoglycaemia and care must be taken in adjusting doses with that risk in mind. First arm (diet or Met or Met + DPP4) Test before evening mealtime If develops repeated high readings (urine glucose 2+ or blood glucose 15mmol/l) add Gliclazide 40mg with breakfast Increase morning dose by 40mgs increments Aim for blood gucose 6-15mmols/l or 1+ t