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

P RESCRIBING IN D IABETES Year 4 Prescribing Tutorial 2019 - 2020

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

O BJECTIVES  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.

D IABETES M ELLITUS Insulin Deficiency Insulin resistance Both Chronic Hyperglycaemia Types of Diabetes: • Type 1 diabetes mellitus • Type 2 diabetes mellitus • Gestational diabetes • Maturity onset diabetes of young

T YPE 1 AND T YPE 2 D IABETES M ELLITUS Type 1 Type 2 Can present at any age Usually after age 40 Peak incidence around All racial groups, commoner in Epidemiology puberty African/Asian Commoner in white Caucasians HLA-DR3 and/or HLA-DR4 in No HLA links >90% 50% concordance in identical twins Inheritance 30-40% concordance in Polygenic identical twins Insulin deficiency Relative insulin deficiency, and May develop ketoacidosis insulin resistance Clinical Picture Usually lean May develop hyperosmolar state Often overweight

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

I NSULIN  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.

T YPES OF I NSULIN  Classified by how fast they work and how long their effects last for. Role in Blood Sugar Insulin Onset Peak Duration Management Rapid-Acting Rapid-acting insulin covers Humalog insulin needs for meals eaten at Novorapid 15-30mins 30 – 90 mins 2 – 5 hours 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 is approved for use within 15 minutes before or Apidra 15 mins 60 mins 2 – 4 hours within 20 minutes after starting a meal

T YPES OF I NSULIN Role in Blood Insulin Onset Peak Duration Sugar Management Short-Acting Actrapid 30 minutes 1 ½ – 3 ½ hours 7 – 8 hours Short-acting insulin covers Humulin S 30 min – 1 hour 2 – 5 hours 5 – 8 hours insulin needs for meals eaten within 30-60 Insuman Rapid 30 min 1 – 4 hours 7 – 9 hours minutes

T YPES OF I NSULIN Insulin Onset Peak Duration Role in Blood Sugar Management Intermediate-Acting Intermediate-acting insulin covers Insulatard 1 ½ hours 4-12 hours 24 hours insulin needs for about half the day or overnight. This type of insulin is Insuman often combined with rapid- or short- 1 hour 3-4 hours 11-20 hours acting insulin. Basal Long-Acting Long-acting insulin covers insulin No peak - needs for about one full day. This insulin is Lantus type of insulin is often combined, delivered 20-24hours 1-2 hours when needed, with rapid- or short- at steady acting insulin. rate

T YPES OF I NSULIN Role in Blood Sugar Insulin Onset Peak Duration Management Pre-Mixed Novomix 30 10 – 20 mins 1 – 4 hours Up to 24 hours Generally taken Humalog Mix Dependent on dose, site of twice a day before 25 injection, blood mealtimes Approx 15 30 – 70 mins supply, mins Humalog mix temperature, 50 and physical activity Pre-mixed insulins are a combination of intermediate acting and short acting insulins in one pen

I NSULIN P RESCRIPTION  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

I NSULIN P RESCRIPTION

I NSULIN P RESCRIPTION  Whilst an inpatient, patient’s insulin must be prescribed on both the drug chart and the insulin chart.  Prescribe on the main prescription chart…

I NSULIN P RESCRIPTION  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 Prescribe Before Prescribe Before Prescribe Bed Prescribe Sign Sign Sign Sign Breakfast Lunch Dinner time Insulin Insulin Blood Insulin Insulin Blood Blood Blood Sugar Sugar Sugar Sugar Units Units Units

C ASE S CENARIO 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.

C ASE S CENARIO 1 Before Breakfast Rx Signed Before Rx Signed Before Dinner Rx Signed Bedtime Lunch Novomix Novomix ADoctor ADoctor 6.2 30 30 DOCTOR DOCTOR 5.8 Units 20 Units 10 Units

C ASE S CENARIO 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?

C ASE S CENARIO 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

C ASE S CENARIO 1 Before Prescribe S Before Prescribe S Before Prescribe S Bed Prescribe S Break- i Lunch i Dinner i time i fast g g g g n n n n e e e e Date d d d d 02/11 Novomix Novomix 30 6.2 5.8 30 10 Units 20 Units Units Units 03/11 Novomix Novomix 30 10 10.5 16.0 30 Units Units 14 Units 20 Units 04/11 4.0 Units Units Units Units This insulin dose This low BM is however NOTE slightly low BM of 4. Easy to should have been Therefore this consequent of increase assume that subsequent insulin increased instead evening dose should insulin dose prescribed the dose prescribed should be lowered. be decrease. evening before.

C ASE S CENARIO 1 Before Prescribe S Before Prescribe S Before Prescribe S Bed Prescribe S Break- i Lunch i Dinner i time i fast g g g g n n n n e e e e Date d d d d 02/11 Novomix Novomix 30 6.2 5.8 30 10 Units 20 Units Units Units 03/11 Novomix Novomix 30 10 10.5 16.0 30 Units Units 14 Units 20 Units 04/11 4.0 Units Units Units Units Prescribe the insulin dose on your insulin chart.

C ASE S CENARIO 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?

C ASE S CENARIO 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 of 50ml. Thus, 1ml of the solution = 1 unit of insulin.  Practise prescribing this on the insulin sliding scale chart and prescription chart.

C ASE S CENARIO 2

FOR TEACHING PURPOSES MS PAT ATIEN IENT 1 WGH GH DAY DAY 1 1 40 Years A Do A Docto tor DO DOCTO TOR