Managing sick and stress days Rebecca Thompson RSCN, BSc, MSc Nurse Consultant – Diabetes, UCLH

Aims: Review the effect of sick days on diabetes Review the effect of stress on diabetes To identify potential strategies To review the effectiveness of strategies

Sick Days

Your turn: Vomiting + diarrhoea Flu Exam time Infection Having surgery Chicken pox Recovering from an illness Start of a new school term In groups, discuss the scenarios Would you anticipate: BG levels to go up? BG levels to go down? No impact on BG levels?

Relationship between illness & hyperglycaemia Infection Increased secretion of cortisol and glucagon High blood glucose levels Increased insulin resistance Decreased immune function Decreased wound healing Increase in inflammatory factors

Illness Fever/ Infection Nausea/ Vomiting Increases the need for insulin - 25-50% ↑ over 24 hours Decreased appetite may ↓ amount of insulin needed Risk of DKA from insulin deficiency Difficulty in retaining nutrients due to nausea / vomiting / diarrhoea Decreased appetite may decrease amount of insulin needed Risk of low blood glucose levels In gastroenteritis, slower emptying of stomach may contribute to hypos

Management - Blood glucose testing Frequent monitoring facilitates optimal management BG should be monitored at least every 3-4 hours, including overnight Sometimes, frequency might need increasing to every 1-2 hours

Ketones ‘Starvation’ v. ‘insulin deficiency’ Ketones produced by the liver from fatty acids that are used as an alternative energy source As ketone levels become more seriously elevated, then ketoacidosis (or DKA) may occur Symptoms acetone (or pear-drop) smelling breath abdominal pain Nausea / vomiting

Urine strips measure acetoacetate (AcAc) Blood strips measure beta-hydroxybutyrate Enables earlier identification & treatment Normalises sooner than AcAc preventing hypoglycaemia from over insulin treatment

Your turn – when to get help? BG high x2, no ketones Temp 36.7°, sore throat Ketones increasing/ persistent despite ↑ insulin BG <4mmols but tolerating fluids BG high x2, + ketones Temp 40°, rash, high BG Vomiting and unable to tolerate fluids for 2 hours BG <4mmols & drowsy BG high, child confused, abdo pain In groups, discuss the scenarios Decide: When would you feel it safe to manage at home? When do you feel you would need advice? When would you head straight to A&E?

When to get help Repeated vomiting / unable to tolerate fluids Increasing level of ketones Increasing BG levels despite additional insulin Inability to reverse hypoglycaemia Laboured breathing Severe or unusual abdo pain Confusion or deterioration of well being Parental concern ? Possibility of underlying infection requiring AB

Managing at home Treat current illness ?GP Symptom treatment Test & document every couple of hours Blood glucose levels Ketone levels Maintain hydration High BG’s, fever, ketones and glucose in urine will ↑ fluid loss Small amounts frequently Juice/ oral rehydration solutions Drinks containing glucose if BG low

Insulin adjustment May have increased insulin requirements during the incubation period of an infection (few days before the physical symptoms) Increased need for insulin may continue several days after the illness has passed, due to insulin resistance NEVER STOP THE INSULIN Insulin may need to be increased or decreased

Changes in insulin sensitivity over 24 hours

Insulin adjustment Easiest to adjust short acting insulin according to BG Humalog, NovoRapid or Apidra Change the correction/ sensitivity ratio? Low BG levels will ↑ sensitivity to insulin High BG levels will ↓ sensitivity to insulin Correction dose can be calculated using: 0.05 - 0.1 unit / Kg body weight every 2-3 hours 5 - 10% of the total daily insulin dose every 3-4 hours 100 rule (1 unit of insulin will reduce BG by X mmols/L)

Additional insulin Calculate a current correction ratio for your child using one of the methods

Blood ketones Urine ketones <5.5 5.5-10 10-14 14-22 >22 <0.6 Negative - trace No insulin ↑ insulin for next meal if BG high Give extra 5% of TDD or 0.05 U/kg Give extra 10% of TDD or 0.1 U/kg 0.6-0.9 Trace-small Check again in 2 hours Starvation ketones Extra CHO Give extra 5-10% of TDD or 0.05-0.1 U/kg 1.0-1.4 Small-moderate Starvation ketones Give 5-10% of TDD or 0.5-1.0 U/kg Repeat if needed 1.5-2.9 Moderate-large Starvation Extra CHO. May need IV glucose Extra CHO Give extra 5% of TDD or 0.05 U/kg Give extra 10-20% of TDD or 0.1 U/kg. Repeat dose after 2 hours if ketones do not decrease >3.0 Large As above Risk of ketoacidosis

Beware of “Insulin Stacking”

ABCC CSII & increase in DKA Assess Bolus via pump Check Change + Injection (Blood glucose – 10) ÷ correction ratio = dose of insulin

Additional strategies using insulin pump therapy Use temporary basal rates Percentages easier Increase by 150-200% for feverish illness Decrease to 50-75% for vomiting/ diarrhoea

Temporary Basal in action Duration of Temporary Basal Rate

Stress Days

Stress & Diabetes Impact very individual Mild stress can lower BG’s However, stress often raises BG’s Hard to evaluate as different from day-today When body is exposed to stress Release of Adrenaline Stone age “fight or flight” response Increased blood glucose Liver releases more glucose Decrease movement of glucose into cells

Causes of stress in every day life Mental stress: New school Exams Conflict at home Death of loved ones Diabetes as a stressor Feeling alone Worrying about the future Physical stress: Illness infection

Relationship between stress and glycaemic control Relationship between stress and glycemic control. From Ref. 21. Lloyd C et al. Diabetes Spectr 2005;18:121-127 Copyright © 2011 American Diabetes Association, Inc.

Helpful strategies Impact of stress might not be obvious until change in BG Adjust insulin Bolus - Remember to evaluate active insulin Temp basal rates on CSII Evaluate relationship between emotions & blood glucose levels Use the comments section on BG charts to record Look for patterns Use of CGM Plan ahead to minimise impact E.g. School exams

Helpful strategies – who else can help? Share feelings, worry and guilt Coping skills Grey et al.demonstrated that preventive strategies such as teaching coping skills(1999,2000) to adolescents with type 1 diabetes in order to better prepare them for stressful life events led to improvements in glycemic control Improvements in quality of life the improvement was maintained over time Role of Psychology

Questions? rebecca.thompson@uclh.nhs.uk