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Diabetes - Special Circumstances

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Introduction

Special Circumstances covering

Steroid treatment

Investigations

Enteral feeding 
Terminal Palliative Care

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Steroids & Impact on Glucose
Glucocorticoids are commonly used as part of therapy in the management of COPD or asthma or as an adjunct to chemotherapy for various cancers as well as in inflammatory bowel disease, neurological and musculoskeletal disorders.
Prednisolone or dexamethasone are the most commonly used steroids. Both can cause mild to moderate hyperglycaemia as both promote gluconeogenesis and insulin resistance even in people without diabetes but glycaemic impact in people with diabetes is far greater and can be serious depending on pre-steroid glucose control.
Duration and dose of steroid treatment vary considerably. Glycaemic effects of prednisolone and dexamethasone are highly dependent on dose and timings of medication.
A once daily regime in the morning increases blood glucose level progressively from mid morning to early evening then generally decline progressively particularly after midnight. Adjustment of hypoglycaemic therapy is often required in the morning or at lunchtime but rarely required in the evening.
If once daily steroids are taken in the afternoon or in the evening then hyperglycaemia may be predominantly at bedtime or overnight and treatment will need to be adjusted correspondingly.
In twice or thrice daily regimes, the glycaemic burden is similar throughout 24 hours with notable postprandial peaks. Therefore adjustment would be required throughout the day accordingly.
Steroid courses with a gradual dose reduction will have a reducing hyperglycaemic effect with each reduction therefore hypoglycaemic therapy may need to be adjusted down at each step. Otherwise the patient will be at risk of hypoglycaemia.
All people with diabetes being started on steroid therapy should be informed on the potential adverse effects on their glucose control and arrangements should be made for close monitoring throughout the day (not just fasting level as this is often unaffected) and adjustment of treatment made as necessary.
  See - patient leaflets on steroid treatment
Prompt referral to specialist team is often required
Suggested management
  The following are intended as guidance only and management of individual patients should be tailored to their particular circumstance and glycaemic response. If there is any doubt seek specialist advice or admission if warranted.
 

 
PDF File Steroid Management Pathway

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Investigations

Investigations in people with diabetes may need particular preparation / arrangements especially if they involve fasting, dietary modification or use of intravenous contrast materials.

Endoscopy

It is essential to inform endoscopy departments of the diagnosis and treatment of diabetes at the time of requesting the endoscopy

The exact advice will vary according to the procedure and specific instructions should be given by the endoscopy department.

 

For instructions for Colonoscopy & Gastroscopy see - Useful Resources & External Links

 

Radiology

It is essential to inform radiology departments of the diagnosis and treatment of diabetes at the time of requesting the procedure.  IV contrast agents may affect renal function and there are specific precautions for patients on metformin.

The exact advice will vary according to the procedure and specific instructions should be given by the radiology department.
  See - Royal College of Radiologists Guidance

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Enteral Feeding and Diabetes

Enteral feeding is the provision of food in a liquid form into the gastrointestinal tract via a tube. It is used to maintain or supplement nutrition in patients whose co-existing conditions preclude or limit adequate oral food intake.

Any enteral feed regimen is a significant departure from the usual oral dietary pattern of a healthy diabetic diet, in terms of timing, frequency, duration as well as content.

The usual diabetic treatment is designed to suit an oral diet is invariably unsuitable for an enteral feeding regimen.

Patients on enteral feed often cannot swallow tablets by mouth either: insulin treatment is therefore often necessary.

Primary or secondary care teams should always review medication and seek expert advice before commencing any patient on enteral feeding

Treatment should be carefully adjusted to suit the enteral feeding regimen to avoid hyperglycaemia and hypoglycaemia.

 

Feeding Regimens

Continuous fixed rate infusion this is the commonest form of enteral feed and is provided via pump over a number of hours each day

Bolus feed this is sometimes used instead of or in addition to continuous feed, and given by manual syringing

 

Initiation of Enteral Feeding

Enteral feeding is initiated under the guidance of the dietetic / nutrition team while the patient receives treatment or assessment of the underlying condition.  Close liaison between dietetic / nutrition / diabetes specialist team should ensure appropriate modification or initiation of diabetes treatment to suit the feeding regimen.  

Occasionally enteral feed is initiated in the community with the support from the community dietetic team. This is most common in patients undergoing radiotherapy treatment for head and neck or oesophageal cancer, or in patients with chronic neurological conditions that cause progressive decline in swallowing mechanism. It is vital that the diabetes regimen is adjusted to account for this to prevent major metabolic upset following the initiation of enteral feeding.  Blood glucose monitoring is essential to facilitate optimisation of medication as the feeding regime and or oral feeding are introduced/ reintroduced.

 

Blood Glucose Management in Enteral Feeding

Due to the high caloric content of enteral feed preparations, most diabetic patients, even if previously well controlled on diet and or hypoglycaemic therapy, develop significant hyperglycaemia on starting enteral feed.

Some patients who are previously not known to be diabetic, develop hyperglycaemia requiring treatment, when they start enteral feeding.

All patients on enteral feed and/or their carers should have access to regular blood glucose monitoring and advice from specialist diabetes team to guide glycaemia management.

Oral hypoglycaemic agents are generally not suitable for control of hyperglycaemia in enteral feeding as:

 

Most patients cannot swallow tablets

 

Crushing of tablets for administration through feeding tubes is not recommended due to the risk of tube blockage

Insulin therapy is therefore commonly used to control hyperglycaemia in enteral feeding.

Choice of subcutaneous insulin regimen depends on mostly on frequency, duration and timing of enteral feed.

Intermediate/ long acting subcutaneous insulin preparations are commonly used for continuous fixed rate infusion enteral feeding: isophane (NPH) insulin preparations (eg insulatard, Humulin I), detemir (Levemir), or glargine (Lantus). Insulin injection is given at start of feed, and is commonly used once daily, occasionally twice daily.

Short/ fast acting insulin preparations such as soluble insulin (eg Actrapid, Humulin S), NovoRapid, Humalog Lispro, are used if patient is on bolus feeds.

For patients on continuous enteral feed infusion and intermediate/long acting subcutaneous insulin preparations, it is crucial to keep to the agreed feed break hours every day. Disruption of feed or changes in feed break hours after injection of insulin, can led to hypoglycaemia.  Any changes in feed break or disruption in feeding must be planned so that concomitant adjustment in insulin can be made.

If hypoglycaemia develops, patient should be managed by giving additional glucose in liquid form via the feeding tube as per usual hypoglycaemic treatment guideline. Fizzy drinks should not be used as they will damage the tube.

The diabetes specialist team should be consulted if hypoglycaemia or hyperglycaemia develops, if the regimen is changed or if oral feeding is reintroduced. 

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End of Life

When a diabetic patient becomes terminally ill, blood glucose management should focus on comfort, symptom control and minimising pain and discomfort rather than good glycaemic control.

Food intake is likely to reduce drastically so adjustment in glycaemic therapy is necessary to avoid symptomatic hypoglycaemia. In insulin treated patient, stopping insulin treatment completely and abruptly may cause symptomatic hyperglycaemia (thirst, polyuria and dehydration) which may cause further discomfort for the patient. Patients with Type 1 Diabetes will need to continue some insulin to prevent the development of ketoacidosis.

The following algorithms offer some guidance for healthcare professionals, when a diabetic patient has entered the terminal / palliative phase and proceeds to the agonal stage (previously covered by the Liverpool Care Pathway for Care of the Dying). Individual management should be tailored to suit the needs and circumstances of each patient. Wishes of the patient and their family on the monitoring and management of glycaemia should always be respected.

 

End of Life Guidelines for the Management of Diabetes - whilst continuing to take food and fluids

End of Life Guidelines for the Management of Diabetes NBM no longer taking food or fluids

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Useful External Links & Resources

View

National Patient Safety Suite - Safe management of diabetes during end of life care - e-learning module

PDF File

Steroid Management Pathway

PDF File

Patient leaflets on Steroid Treatment

PDF File

Bedford | Endoscopy Guidelines

PDF File

Upper and lower GI guidelines

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Royal College of Radiologists | Metformin: Updated Guidance for use in diabetes with Renal Impairment - 2010

PDF File

End of Life Guidelines for the Management of Diabetes NBM no longer taking food or fluids

PDF File

End of Life Guidelines for the Management of Diabetes - whilst continuing to take food and fluids

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