Diabetes review winter 2011 - diabetes - people/team awards

Diabetes Centre
Queen Alexandra Hospital
Diabetes Review
Winter 2011
Focus On: Oral Hypoglycaemics
Learning From Recurrent Clinical Incidents
Clinical Incident:
Continuation of Pioglitazone following
Drug and clinical management incidents
patient admission with heart failure
repeatedly occur within the day to day
Learning Point:
management of diabetes. The diabetes team
hope that by highlighting these errors to the
resistance, leading to a reduction in glucose wards with correct management learning
level. However, it can cause fluid retention points, diabetes care will be enhanced,
which may exacerbate or precipitate heart reducing adverse incidents and optimising
failure and so should not be administered in the patient journey.
patients with a history of, or active heart failure. This risk is increased further if Pioglitazone is Clinical Incident:
Sulphonylureas (e.g. Gliclazide)prescribed
twice daily at 0800 and 2200hrs
Clinical Incident:
Continuation of Metformin during acute
Learning Point:
This group of oral antidiabetic agents predominantly augment insulin secretion. Learning Point:
They are only effective when some residual The use of Metformin during acute sepsis may pancreatic beta-cell function is present. lead to the development of Lactic Acidosis. During sepsis the patient is at high risk of and to minimise this must be administered deterioration in renal function. Impaired renal function in combination with Metformin may hypoglycaemia may persist for several hours cause lactic acid to build up causing acidosis. and in all cases care of the patient must As a guide, if a person requires IV antibiotics, the sepsis is severe enough to cause renal deterioration so avoid use of Metformin during this stage.
Clinical Incident:
Clincial Incident:
Metformin prescribed at 0800 and 2200hrs
Continuing Gliclazide and Metformin in
Learning Point:
patients who have impaired renal function
Learning Point:
increases peripheral utilisation of glucose. It Largely, oral anti-diabetic agents are not appropriate for use in patients who have an insulin and so is effective only if there is some residual functioning pancreatic islet cells. severe hypoglycaemia or lactic acidosis. Recently an oral agent called Saxagliptin was launched in which is licensed at its smallest associated with gastric side effects and so dose for use in patients who have an eGFR should be administered prior to a meal to of 15. In these circumstances s/c insulin is For further information on the rationale for any of the management statements
above please contact the Diabetes Centre on ext 6260:
Inpatient leads are Anita Thynne DSN and Dr Iain Cranston
Practice Points
This quarterly feature aims to highlight one
real-life case scenario and discuss the practical
issues surrounding patient management
Learning From Real Case Scenarios
decisions that may lead to improved clinical care
The Presenting Case
Mary is an 82 year old lady who has had Type 2 diabetes for 12 years. She has managed to maintain optimal glycaemic control through dietary changes and oral anti-diabetic agents. Prior to admission Mary was administering Gliclazide 160mg BD and Metformin 500mg BD. Capillary glucose levels ranged between 59 mmols/l prior to becoming unwell. Mary was admitted following a collapse and was diagnosed with a UTI and acute confusion. On admission Mary’s usual anti-diabetic agents were continued. Intravenous antibiotics were commenced. Mary then suffered from a hypoglycaemic episode with a capillary glucose of 1.2mmols/l with altered level of consciousness. Glucose was not checked on admission but laboratory blood tests showed elevated creatinine levels and an eGFR of 18.
Why did Mary suffer from a
Learning Points
hypoglycaemic episode?
A. Mary was hypo on admission but is was
[ The Trust standard is for glucose levels to be checked on admission for ALL people with B. The infection has led to acute renal
[ In times of acute or chronic renal failure people will be more likely to have lower C. Impaired renal function combined with
D. All of the above
pharmacodynamics of Gliclazide may be altered in people with severe renal failure. [ A hypoglycaemic episode occurring in these people may be prolonged. The half life in Mary’s glucose level was not checked on admission and so her reducing glucose was [ On admission try to predict potential problems - if a person is septic they may be at risk of not identified. Sepsis can lead to acute renal acute renal failure and therefore are changes failure of which can affect the excretion of Gliclazide and subsequent hypoglycaemia.
In addition, Metformin should be withheld during times of acute sepsis /renal failure to prevent lactic acidosis Diabetes Resources
$ IT Web Tools found on: Intranet home page / departments / diabetes
$ DIPPIE - Diabetes InPatient Pathways for Increased Effectiveness
$ Peri-Operative Pathways
$ Insulin Safety
$ List of available direct link guidelines
$ Credited e-learning insulin course
For further information on the rationale for any of the management statements
above please contact the Diabetes Centre on ext 6260:
Inpatient leads are Anita Thynne DSN and Dr Iain Cranston

Source: http://connect.qualityincare.org/__data/assets/pdf_file/0006/390282/Diabetes_review_Winter_2011_QiC.pdf