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
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