1. Western Sussex Hospitals NHS Foundation Trust SICK DAY GUIDANCE SARA DA COSTA NURSE CONSULTANT, DIABETES

2. Type 2 Sick day rules

3. KEY POINTS: Why and when do we need “Sick day guidance”? What is the general and specific advice, according to type of diabetes? What are the risks of “Sick day guidance”?

4. Why do we need Sick day guidance? When we are ill, our bodies will respond to fight infection, and we need to manage other symptoms eg dehydration, +/- medical care People with long term conditions, are particularly vulnerable to acute illness, which can also destabilise their co-morbidities Knowing this, one of our aims as clinicians is to reduce the risk of avoidable harm to our patients, so sick day guidance is important We know that people with CKD, heart failure or those taking certain medications, are at increased risk of AKI When ill, people with diabetes will often experience hyperglycaemia, which can cause and be compounded by dehydration, and can lead to keto-acidosis

5. When do we need Sick day guidance? When we are sick! For the duration of the illness,(may be acute or chronic episode) but not when well. How sick do we have to be? NHS Highland (2015) definition of acute illness is Pyrexia, fevers, sweats & shaking & D &V (not minor) Infection or sepsis Clinically ill – require admission Post surgery or post procedure

6. What risks does illness bring to patients with renal disease and diabetes? Better control of both conditions improves resilience to illness and outcomes. RENAL: People with mild and moderately low kidney function are at greater risk of developing kidney damage during periods of acute illness such as infection eg flu or gastroenteritis( leading to AKI) ; also associated with ESRF DIABETES: During illness, insulin resistance increases, increasing insulin requirements Additionally, stress hormones cause glucose levels to rise, leading to hyperglycaemia, and if untreated, HONK & DKA Illness in both of these conditions can lead to unplanned admissions, as well as greater risk of death in short and long term, and are largely PREVENTABLE if guidance is known (And used by clinicians)

7. General Guidance during illness RENAL During acute inter-current illness, particularly with disturbed fluid balance, certain drugs are advised to be temporarily discontinued, e.g NSAID’s -may increase risk of AKI by impairing renal auto- regulation Hypotensive agents (ACE,ARB’s)- reduce systemic BP Diuretics – exacerbate hypovolaemia DIABETES Drugs may also accumulate as a result of reduced kidney function in AKI, increasing risk of side effects Metformin- increased risk of lactic acidosis in high risk patients Sulphonylurea-increased risk of hypoglycaemia; care with insulin SGTLT2- exacerbate hypovolaemia Education is key- patients need to be advised as to how to manage their own medication should they become unwell ( this doesn’t relate to clinical management of known or suspected AKI by clinicians)

8. General guidance during illness Avoid dehydration as can exacerbate hypotension, hyperglycaemia. Drink plenty of water and sugar-free fluids (n.b specific advice required if fluid restrictions in place) If you are unwell, your blood glucose may rise higher than usual Continue your insulin, even if you are not eating- replace the carbohydrate in meals with milky drinks, soup, yoghurt or fruit juices Check BS more frequently, and if Type 1 diabetes, or ketosis –prone Type 2’s, check ketones If symptoms are worsening eg BS rising, ketones rising, or vomiting, seek prompt medical advice e.g GP or A&E. Do not sleep it off!

9. Type 1 Sick Day guidance Continue insulin even if not eating; check blood for glucose every 1-2 hrly and ketones every 2-4 hrly Use the advice on your regimen advice sheet to increase insulin according to your BS (and ketone) levels e.g. basal bolus below NB Insulin resistance in illness means more insulin is needed, and in the absence of sufficient insulin, body fat is broken down to supply energy, and ketones are formed which accumulate to cause DKA Blood glucose levelInsulin dose 13-17 mmols/LAdd 2 extra units to each dose rapid insulin 17-22 mmols/LAdd 4 extra units to each dose rapid insulin More than 22 mmols/LAdd 6 extra units to each dose rapid insullin

10. Type 1 on Insulin pump sick day guidance Follow advice in pump booklet re fluids, food, BS and ketone testing- tables are included with specific dosing advice If BS are rising, check pump to ensure it is working e.g Check no air in tubing Change the cannula and check the site is not inflamed Temporarily increase basal rate Try to identify cause of high BS and seek treatment If you suspect pump is not working or if this advice is not successful, give correction boluses by your insulin pens Contact GP or A&E if vomiting occurs Contact pump company for technical support, and DSN helpline in hours for advice

11. Type 2 Sick day rules If on Metformin, sulphonylurea, SGLT2, or GLP1 discontinue temporarily or permanently (renal function will determine latter) Review insulin doses and increase if hyperglycaemic, but decrease if hypoglycaemia occurs, which can happen with low egfr (<30mmols/L) Ensure Metformin remains withheld in cases of sepsis, cardiac problems or pre scan preparation. Advise fluids, food and increased blood glucose testing. Nb Some Type 2 patients are ketosis –prone and are often on insulin; ensure they can ketone test and know to do so if hyperglycaemic ie BS remaining >13-15 mmols/L ( individual targets apply, consider other co-morbidities, capability, quality of life) If insulin-treated, may need to increase doses, or may need to start insulin, temporarily or permanently Will need agreed next steps and plan to review

12. Risks of Sick day guidance Education is key- when to use guidance, and when to stop! Risk is that patients and clinicians do not restart treatments, causing poor glucose or blood pressure control, with increased health risks Reduced adherence to drug treatment, which may have been incorrectly described as “nephrotoxic” Drugs may not be titrated back to previous levels when AKI has been treated or excluded from diagnosis Issues related to removing medication from dossette boxes causing confusion

13. Summary Diabetes and renal disease require complex management during illness Patient and clinician education is key, alongside useful and relevant information being provided in a timely manner Knowing what to do when ill, and what to change, and when and where to gain advice is important in keeping people well and safe Planning for return to health or previous level of health is an important and often overlooked part of sick day guidance

14. Recommendations Make time for adequate patient and carer education before patients are ill if at all possible. Provide useful information, which shows what do and when. (specific handouts) Ensure clear collaborative planning with clinicians- when to restart treatments, when stop completely, and what alternatives to use Communicate these strategies and information to other clinicians- changes are often made in acute care but advice regarding next steps is often late, or absent.

15. References Sick day guidance in patients at risk of Acute Kidney Injury: an interim position statement from the Think Kidneys Board Griffith K et al Version 8:13 November, 2015. NHS Managing diabetes during inter-current illness in the community February 2013 WSHT Diabetes team guidelines for Illness for Type 1 and Type 2 diabetes Websites- Think Kidneys, DUK.

21. Western Sussex Hospitals NHS Foundation Trust End slide Thank you, etc.