Summary:  Claudia Hurwitz

Editor:  Glynis Ross

 

With Associate Professor Glynis Ross, Endocrinologist at Royal Prince Alfred Hospital, Sydney, Australia

James talks to Glynis Ross about blood glucose monitoring on the wards in patients with diabetes.

 

Associate Professor Glynis Ross is a Visiting Endocrinologist at Royal Prince Alfred Hospital and part-time Senior Staff Specialist at Bankstown-Lidcombe Hospital, Sydney. She has been in charge of the Diabetes in Pregnancy Service at Royal Prince Alfred Women’s and Babies’ Hospital for over 25 years.

Glynis was a member of the Australasian Diabetes in Pregnancy Society (ADIPS) Council from 1991-1998 and 2002-2012, and President from 2008-2010. She has been on the Australian Diabetes Society Council since 2012 and is currently Vice-President and President-Elect. Her major clinical and research interests are Diabetes in Pregnancy, Type 1 Diabetes, Insulin Pump Therapy and In-patient Diabetes Management. Dr Ross serves on State and National Working Parties in these areas. She is involved in the teaching programs of trainees of the Australasian Colleges of Anaesthetics, Obstetrics & Gynaecology, and Physicians, as well as education programmes for Midwives, General Practitioners and Medical Undergraduates.

 

Introduction

Diabetes is a common condition, with about 30% of inpatients having diabetes. The majority of patients have type 2 diabetes, about 10% having type 1 diabetes and a smaller subset having an alternate cause such as pancreatic or monogenic. There are also temporary forms of diabetes such as steroid induced or gestational diabetes in people at higher risk of diabetes. Additionally, a large number of people have insulin resistance, a prediabetes state.

1. Concerns with hyperglycaemia

  • Increased risk of infection, including post-operative wound infection
  • Slower wound healing post-operatively
  • Increased length of stay in hospital
  • If blood glucose levels (BGLs) are very high, hyperosmolar hyperglycaemic non-ketotic syndrome or diabetic
    ketoacidosi

2. How do you diagnose diabetes?

  • As an inpatient, it is difficult to confirm because being acutely unwell compromises results
  • As an outpatient, two of the following tests or one test and unequivocal symptoms of hyperglycaemia
    • Fasting plasma glucose (FPG) values ≥7.0 mmol/L
    • Two-hour plasma glucose values of ≥11.1 mmol/L
    • HbA1c values ≥6.5 %
      • However, HbA1c can be falsely negative
      • It is also possible to have an HbA1c below this but still have diabetes

3. Classification of diabetes

  • Type 2 diabetes: 80-90% of patients
    • Typical age of onset >30 years old, but increasingly seeing cases in younger patients, including teens and subteens
    • Pathophysiology: Insulin resistance with loss of beta cell insulin production, the disease progresses over time
  • Type 1 diabetes: ~10%
    • Typical age of onset <30 years old, but can present at any age
    • Pathophysiology: Autoimmune
    • Diagnosis strongly suggested with anti-GAD antibodies, anti-Ia2, anti-ZnT8 transporter antibodies
    • Additionally, C-peptide levels, which reflect a patient’s own production of insulin will be low

 

Case 1 – You are a junior doctor on the ward and you have been asked to see a patient with a BGL of 14 mmol/L.

 

1. What should you ask the nurse over the phone?

  • Is the patient well or unwell?
    • If the patient is unwell you need to see the patient sooner
  • Have there been any other blood glucose levels? Were they normal? What is the trend?
    • If it is a one off, you may not need to do anything, the BGL should be rechecked because confounders can exist such as glucose on hands from food

2. Should you give a phone order for a short acting insulin?

  • No, 14mmol/L is not a very high blood glucose level and there should not be knee-jerk reaction to order short acting insulin
  • The patient should have ongoing blood glucose monitoring and be reviewed to identify the cause of the elevated BGL

3. Should you give a phone order for a short acting insulin?

  • Assess for symptoms of hyperglycaemia
  • Detailed food history
  • Check HbA1c if not already done; urgent electrolytes, bicarbonate and blood ketones – to exclude possible type 1 diabetes and evolving ketoacidosis
    • If you suspect type 1 diabetes or there are positive blood ketones (>0.6), you should consult the endocrinology team
  • When starting medication in hospital, insulin is generally the first choice
    • Insulin should be charted as the “three B’s”
      • Basal insulin, long acting insulin, calculation is weight based
      • Bolus insulin, cover for meal requirement
      • Booster insulin, correction of blood glucose level

4. What are some cases to watch out for?

  • Patients on SGLT2 inhibitors are at risk of euglycaemic ketoacidosis, especially when oral intake is very low such as in perioperative situations
    • SGLT2 inhibitors: Forxiga (Dapagliflozin), Jardiance (Empagliflozin)

If you enjoyed listening to this week’s podcast feel free to let us know what you think by posting your comments or suggestions in the comments box below.

 

Podcast

Part 1: Blood glucose monitoring – Hyperglycaemia