Managing Diabetes Through COVID-19 - Sick Day Rules
Managing diabetes throughCOVID-19 - Sick day rulesFacilitator Name & TitleThis meeting has been developed, organised and funded byEli Lilly and Company.Lilly is a registered trademarks of Eli Lilly and Company.The content of these slides is Lilly property. You are permitted to download and use these slides for your own personal use only. Under nocircumstances should these slides be distributed to third parties.Adverse events and product complaints should be reported. Reporting forms andinformation can be found at UK: www.mhra.gov.uk/yellowcard or search for MHRAYellow Card in the Google Play or Apple App Store, or Ireland: www.hpra.ie. Adverseevents and product complaints should also be reported to Lilly: please call Lilly UK on01256 315 000, or Lilly Ireland on 01 664 0446.PP-LD-GB-0905 July 2020 2020 Eli Lilly and Company. All rights reserved.1
Disclosures Names has/have received consultation and / or lecture fees from: Companies LillyPP-LD-GB-0905 July 2020 2020 Eli Lilly and Company. All rights reserved.2
Objectives To appreciate the effect that illness has on glucose metabolism. To identify those at risk from hyperglycaemia in a timely manner. To be aware of the treatment management and considerations forprescribing/deprescribing to prevent risk of acute complications. To be aware of the resources available to support people withdiabetes.PP-LD-GB-0905 July 2020 2020 Eli Lilly and Company. All rights reserved.3
NHS GuidanceGeneral guidance for the management of people with diabetes duringthe coronavirus pandemic:“Diabetes services should look to maintain andoptimise the health of individuals within their servicesover the course of the pandemic, and should notunderestimate the importance of these contributionsto the overall health service response1.”1. NHS. Clinical guide for the management of people with diabetes during the coronavirus pandemic. Available tes-19-march-v2-updated.pdf [Accessed: July2020]PP-LD-GB-0905 July 2020 2020 Eli Lilly and Company. All rights reserved.4
Non-acute considerations If diabetes control is not managed during illness, it can rapidlyescalate into further acute complications that require hospitaladmission.– It is important to avoid hospital admission at this time. For those with sub-optimal control, treatment intensification andlifestyle measures are key to staying well and recovering faster. Help the person with diabetes “be the best they can be” duringany illness.PP-LD-GB-0905 July 2020 2020 Eli Lilly and Company. All rights reserved.5
Ways to help people with diabetes “be thebest they can be” to face illnessImproving ability to adhere to therapy and maintain a suitable lifestyle & dietIntensifying therapies to improve controlConsidering additional BGM in people with type 2 diabetesHaving sick day rules: Advising on medications and illnessReviewing ketone monitoring and access to specialist care in type 1 patientsBGM, blood glucose monitoringPP-LD-GB-0905 July 2020 2020 Eli Lilly and Company. All rights reserved.6
Effect of illness on glucose metabolism Illness causes a stress response leading to the release of hormonessuch as cortisol and adrenaline1. These hormones oppose the action of insulin and as a result, thebody produces additional glucose1. The ability to produce and secrete additional insulin to counter theseeffects is either non-existent (Type 1) or impaired (Type 2) in peoplewho have diabetes leading to persistent hyperglycaemia1. On the contrary, during a gastric-type illness, blood glucose may bemore likely to be lower due to lack of carbohydrate intake leading tohypoglycaemia2.1. Avery L et al. Chapter 8: Acute complications of diabetes. Intercurrent illness and infections. Oxford Handbook of Diabetes Nursing. Oxford:Oxford University Press; 2009. p170-171; 2. Diabetes UK. Diabetes and being ill. Available at: with-diabetes/illness#Illness [Accessed: July 2020]PP-LD-GB-0905 July 2020 2020 Eli Lilly and Company. All rights reserved.7
Assessing hyperglycaemia without bloodglucose testingWhen people with type 2 diabetesdo not monitor their blood glucoselevels,whatwouldindicatehyperglycaemia? Increased thirst1 Increased urination1How do these symptomsdiffer to COVID-19?How does the patientdifferentiate thesesymptoms from those ofCOVID-19? Lethargy11. NHS. Hyperglycaemia. Available at: erglycaemia/ [Accessed: July 2020]PP-LD-GB-0905 July 2020 2020 Eli Lilly and Company. All rights reserved.8
Assessing hypoglycaemia without bloodglucose testingWhen people with type 2 diabetes do notmonitor their blood glucose levels, whatwould indicate hypoglycaemia?– Initially:Sweating, paleness, tremblingtremor, tingling lips, palpitations,anxiety1– Progressing to:Blurred sight, aggression,tearfulness, poor concentration,tiredness1How do these symptomsdiffer to COVID-19?How does the patientdifferentiate thesesymptoms from those ofCOVID-19?In the elderly, symptoms of hypoglycaemia are often blunted and medication mayneed to be reduced2.1. Diabetes UK. What is a hypo? Available at: lications/Hypos [Accessed: July 2020] ; 2. DiabetesUK. Older people and diabetes. Available at: r-people-and-diabetes [Accessed: July 2020]PP-LD-GB-0905 July 2020 2020 Eli Lilly and Company. All rights reserved.9
Sick day rulesSADMANS3First aid advice Rest1Prevent dehydration1If able, increase BG monitoring1Review of current medication1–– Never stop insulinSee SADMANSReview carbohydrate intake1Check for ketones in type 12S sulphonylureasA ACE inhibitorsD diuretics, direct renin inhibitorsM metforminA angiotensin receptor blockersN non-steroidal anti-inflammatoryS SGLT-2 inhibitorsBG, blood glucose1. TREND. Type 2 diabetes: What to do when you are ill. Available at: https://trend-uk.org/wpcontent/uploads/2020/03/A5 T2Illness TREND FINAL.pdf. [Accessed: July 2020]; 2. TREND. Type 1 diabetes: What to do when you are ill.Available at: https://trend-uk.org/wp-content/uploads/2020/03/A5 T1Illness TREND FINAL.pdf [Accessed: July 2020]. 3. Canadian Journal ofDiabetes. Appendix 8 – Sick day medication list. Available at: df?ext .pdf [Accessed: July 2020]PP-LD-GB-0905 July 2020 2020 Eli Lilly and Company. All rights reserved.10
Diabetic Ketoacidosis (DKA)1 If blood glucose is 11 mmol/L or over, test ketones– Blood glucose may be lower in pregnancy and type 2 patients on SGLT-2iBelow 0.6 mmol/LThis is a normal readingBetween 0.6-1.5 mmol/LSlightly increased risk of DKA, testagain in 2 hours Remember that ketones are thebest surrogate marker for risk How to advise people on /resources/Between 1.6-2.9 mmol/LIncreased risk of DKA, contact diabetesteam/GP as soon as possible3 mmol/L or overVery high risk of DKA, seek medicalhelp immediatelyClicking on the link above will take you to a site maintained by a third party, which issolely responsible for its content. Eli Lilly Company and its affiliates do not control,influence, or endorse this site, and the opinions, claims, or comments expressed onthis site should not be attributed to Eli Lilly Company and its affiliates. Eli LillyCompany and its affiliates are not responsible for the privacy policy of any third-partywebsites. We encourage you to read the privacy policy of every website you visit.1. NHS. Diabetic ketoacidosis. Available at: s/. [Accessed: July 2020]PP-LD-GB-0905 July 2020 2020 Eli Lilly and Company. All rights reserved.11
Titration of insulin during illness With less access to specialist/secondary care advice, you maybecome more involved with simple titration of insulin This advice is found in the following TREND patient leaflets via:https://trend-uk.org/resources/– Type 1 diabetes: What to do when you are ill (March 2020): https://trend-uk.org/wp-content/uploads/2020/03/A5 T1Illness TREND FINAL.pdf– Type 2 diabetes: What to do when you are ill (March 2020) https://trend-uk.org/wp-content/uploads/2020/03/A5 T2Illness TREND FINAL.pdf Encourage people with diabetes to self-titrate where possible Insulin regimes may need to be intensifiedClicking on the link above will take you to a site maintained by a third party, which is solely responsible for its content. Eli Lilly Companyand its affiliates do not control, influence, or endorse this site, and the opinions, claims, or comments expressed on this site should notbe attributed to Eli Lilly Company and its affiliates. Eli Lilly Company and its affiliates are not responsible for the privacy policy of anythird-party websites. We encourage you to read the privacy policy of every website you visit.PP-LD-GB-0905 July 2020 2020 Eli Lilly and Company. All rights reserved.12
Initiation of insulin If medications are withdrawn following the SADMANS rules andblood glucose rise, or if illness causes hyperglycaemia beyond theiroptimised oral medications Guidance can be found via:– TREND: https://trend-uk.org/resources Basal insulin initiation in adults with type 2 diabetes (March 2020)– RCN: pdf?la en Starting injectable treatments in adults with type 2 diabetes (March 2020)Clicking on the link above will take you to a site maintained by a third party, which is solely responsible for its content. Eli Lilly Companyand its affiliates do not control, influence, or endorse this site, and the opinions, claims, or comments expressed on this site should notbe attributed to Eli Lilly Company and its affiliates. Eli Lilly Company and its affiliates are not responsible for the privacy policy of anythird-party websites. We encourage you to read the privacy policy of every website you visit.PP-LD-GB-0905 July 2020 2020 Eli Lilly and Company. All rights reserved.13
COVID-19 Covid-19: a remote assessment in primary care, available via:https://www.bmj.com/content/368/bmj.m1182 (March 2020) Consider impact of isolation on mental healthClicking on the link above will take you to a site maintained by a third party, which is solely responsible for its content. Eli Lilly Companyand its affiliates do not control, influence, or endorse this site, and the opinions, claims, or comments expressed on this site should notbe attributed to Eli Lilly Company and its affiliates. Eli Lilly Company and its affiliates are not responsible for the privacy policy of anythird-party websites. We encourage you to read the privacy policy of every website you visit.PP-LD-GB-0905 July 2020 2020 Eli Lilly and Company. All rights reserved.14
Patient leafletsTREND: https://trend-uk.org/resources/– Type 2 diabetes and diabetic ketoacidosis (March 2020)– Type 1 & 2 diabetes: What to do when you are ill (March 2020)– Diabetes: Why do I sometimes feel shaky, dizzy and sweaty?Hypoglycaemia explained (March 2020)Diabetes UK: https://www.diabetes.org.uk/– Multiple online resourcesClicking on the link above will take you to a site maintained by a third party, which is solely responsible for its content. Eli Lilly Companyand its affiliates do not control, influence, or endorse this site, and the opinions, claims, or comments expressed on this site should notbe attributed to Eli Lilly Company and its affiliates. Eli Lilly Company and its affiliates are not responsible for the privacy policy of anythird-party websites. We encourage you to read the privacy policy of every website you visit.PP-LD-GB-0905 July 2020 2020 Eli Lilly and Company. All rights reserved.15
How do we identify those at risk of acute crisis?Diabetic Ketoacidosis (DKA)Hyperosmolar hyperglycaemic syndrome (HHS)Hypoglycaemia(especially if sulphonylurea or insulin has been increased/added)PP-LD-GB-0905 July 2020 2020 Eli Lilly and Company. All rights reserved.16
Diabetic Ketoacidosis (DKA)Diabetic Ketoacidosis is a condition that results when the body breaks down fat asa source of energy. This can lead to a diabetic coma1.Symptoms––––––DiagnosisThirst (polydipsia)1Increased urination (polyuria)1Fatigue1Weight loss2Nausea/vomiting1Fruity-smelling breath1 (notdetectable by all people)– Abdominal pain1– Deep or rapid breathing(Kussmaul)1– Collapse/unconsciousness1– Ketonaemia 3.0 mmol/L or 2 onstandard urine sticks3– Blood glucose 11.0 mmol/L or knowndiabetes3– Bicarbonate (HC03- 15.0 mmol/Land/or venous pH 7.33– Consider euglycaemic DKA31. NHS. Diabetic ketoacidosis. Available at: s/ [Accessed: July 2020]; 2. NHS. Hyperglycaemia. Availableat: erglycaemia/ [Accessed: July 2020] ; 3. JBDS. The Management of diabetic ketoacidosis in Adults.Available at: hat%20we%20say/Management-of-DKA-241013.pdf [Accessed: July 2020]PP-LD-GB-0905 July 2020 2020 Eli Lilly and Company. All rights reserved.17
Hyperglycaemic Hyperosmolar State (HHS)Hyperglycaemic Hyperosmolar State is severe dehydration caused bythe body trying to get rid of excess w onsetUrinationThirstNauseaDry skinDisorientationIn later stages, drowsiness andgradual loss of consciousness– A mixed picture of HHS and DKA mayoccur– Hypovolaemia– Marked hyperglycaemia 30 mmol/Lor more– Osmolality usually 320 mosmol/kg ormore– No significant ketones or acidosis– Severe dehydration1. Diabetes UK. Hyperosmolar Hyperglycaemic State (HHS). Available at: ications/Hyperosmolar Hyperglycaemic State HHS [Accessed: July 2020]; 2. JBDS. The management of the hyperglycaemichyperosmolar state (HHS) in adults with diabetes. Available at: tatements/JBDS-IP-HHSAdults.pdf. [Accessed: July 2020]PP-LD-GB-0905 July 2020 2020 Eli Lilly and Company. All rights reserved.18
Quick wins: Type 1 diabetes Re-cap sick day rules with the patient Contact people with diabetes to ensure they still have a functioning,quality-controlled meter People with type 1 diabetes need access to ketone meters– Some older ketone meters are no longer produced Check repeat prescriptions to ensure people with type 1 diabetes havecollected their glucose/ketone strips and have adequate supplies ofinsulin As illness resolves, ensure insulin doses are reviewed to avoidhypoglycaemia Be aware:– Type 1 diabetes may develop during periods of illness; don’t overlooksymptoms of newly diagnosed diabetesPP-LD-GB-0905 July 2020 2020 Eli Lilly and Company. All rights reserved.19
Quick wins: Type 2 diabetes Follow sick day rules Discontinue SGLT-2i in illness if concerned about risk of dehydrationuntil person is well People with type 2 diabetes on SGLT-2i need to be aware of the risk ofDKA while taking this medication1– Be aware that symptoms of euglycaemic DKA could be confused with thoseof Covid-19 When medications are withheld during illness, alternative treatmentsmay need to be prescribed and adequate supplies provided Assess the risk of hypoglycaemia with sulphonylurea when not eating Ensure sulphonylurea or insulin doses are re-evaluated, as illnessresolves, to avoid hypoglycaemia1. Association of British Clinical Diabetologists (ABCD). SGLT-2 inhibitors in people with type 2 diabetes: An educational resource for healthprofessionals. Available at: https://abcd.care/sites/abcd.care/files/site -ABCD.pdf [Accessed:July 2020]PP-LD-GB-0905 July 2020 2020 Eli Lilly and Company. All rights reserved.20
Useful weblinksUK-Specific: https://trend-uk.org/resources/ https://www.diabetes.org.uk/ /specialty-guides/Ireland-Specific: https://irishpracticenurses.ie https://www.icgp.ie https://diabetes.ie/covid-19-questions-answers/ -groups.html on-for-people-living-with-type-1-diabetes/General: df?ext .pdfClicking on the link above will take you to a site maintained by a third party, which is solely responsible for its content. Eli Lilly Companyand its affiliates do not control, influence, or endorse this site, and the opinions, claims, or comments expressed on this site should notbe attributed to Eli Lilly Company and its affiliates. Eli Lilly Company and its affiliates are not responsible for the privacy policy of anythird-party websites. We encourage you to read the privacy policy of every website you visit.PP-LD-GB-0905 July 2020 2020 Eli Lilly and Company. All rights reserved.21
Certificate of AttendanceThis is to certify thatHas attendedManaging diabetes through COVID-19 - Sick day rulesLearning hours40 minutesSignatureDatePP-LD-GB-0905July 2020PP-LD-GB-0905July 2020This meeting is developed,and fundedEli Lillyand Company. 2020 Eli organisedLilly and Company.Allbyrightsreserved.Lilly is a registered trademark of Eli Lilly and Company. 2020 Eli Lilly and22Company.All rights reserved.
Yellow Card in the Google Play or Apple App Store, or Ireland: www.hpra.ie. Adverse events and product complaints should also be reported to Lilly: please call Lilly UK on 01256 315 000, or Lilly Ireland on 01 664 0446. Managing diabetes throu
Bruce W. Bode, MD, FACE Atlanta Diabetes Associates Atlanta, Georgia American Diabetes Association. Facts and Figures. Available at: http://www.diabetes.org/ada/facts.asp. Accessed January 18, 2000. Diagnosed Type 1 Diabetes 0.5 - 1.0 Million Diagnosed Type 2 Diabetes 10.3 Million Undiagnosed Diabetes 5.4 Million Prevalence of Diabetes in the US 3
Diabetes in the United States More than 29 million people in the U.S. have diabetes 8.1 million people with diabetes are undiagnosed 9.3% of the U.S. population 1.7 million Americans aged 20 years or older were newly diagnosed with diabetes in 2010 Every 19 seconds, someone is diagnosed with diabetes
Clinical Diabetes. 2017 Jan; 35(1)51-54. Speight J, Conn J, Dunning T, Skinner TC, Diabetes Australia. Diabetes Australia position statement. A new language for diabetes: improving communications with and about people with diabetes. Diabetes Res Clin Pract 2012 Sep; 97(3): 425- 31.
Type 2 Diabetes Type 2 diabetes, which used to be called adult-onset diabetes, can affect people at any age, even children. However, type 2 diabetes develops most often in middle-aged and older people. People who are overweight and inactive are also more likely to develop type 2 diabetes. Type 2 diabetes usually begins with insulin resistance—a
TABLE 57-3. Proposed Classification System for Diabetes in Pregnancy Gestational diabetes: diabetes diagnosed during pregnancy that is not clearly overt (type 1 or type 2) diabetes Type 1 Diabetes: Diabetes resulting from β-cell destruction, usually leading to absolute insulin deficiency a. Without vascular complications b.
TODAY ON WEBMD Getting Past the Guilt of Type 2 . Managing Your Diabetes Are your 'good' habits doing harm? 3 Types of Exercise How they help diabetes. Type 2 Diabetes Are you at risk? RECOMMENDED FOR YOU ARTICLE Insulin Shots and Your Daily Life SLIDESHOW Essential Tips to Manage Your Diabetes SLIDESHOW Best Exercises If You Have Diabetes
Managing Diabetes Mellitus: Guide for Health Workers 2 Definition, Diagnosis and Classification of Diabetes Mellitus Dr. B.R. Giri MD. Diabetes mellitus is a metabolic disorder that result in hyperglycemia due to defects in insulin secretion, insulin action, or both. Chronic hyperglycemia of diabetes is associated with long term damage,
The North Carolina Diabetes Advisory Council supports efforts to find a cure for type 1 diabetes. A major focus of this guide and the Diabetes Advisory Council is on type 2 because it is more common and is preventable. For the remainder of this document, references to “diabetes” will be referring to type 2 diabetes unless indicated otherwise.
