Summary We describe two cases of SGLT2i-induced euglycaemic diabetic ketoacidosis, which took longer than we anticipated to treat despite initiation of our DKA protocol. Both patients had an unequivocal diagnosis of type 2 diabetes, had poor glycaemic control with a history of metformin intolerance and presented with relatively vague symptoms post-operatively. Neither patient had stopped their SGLT2i pre-operatively, but ought to have by current treatment guidelines. Learning points: SGLT2i-induced EDKA is a more protracted and prolonged metabolic derangement and takes approximately twice as long to treat as hyperglycaemic ketoacidosis. Surgical patients ought to stop SGLT2i medications routinely pre-operatively and only resume them after they have made a full recovery from the operation. While the mechanistic basis for EDKA remains unclear, our observation of marked ketonuria in both patients suggests that impaired ketone excretion may not be the predominant metabolic lesion in every case. Measurement of insulin, C-Peptide, blood and urine ketones as well as glucagon and renal function at the time of initial presentation with EDKA may help to establish why this problem occurs in specific patients.
Background Diabetes is a prominent health problem with prevalence increasing as the population ages. It is estimated that 11.9% of the Irish population aged 75 years and older are living with type 2 diabetes. This condition puts older people at risk of polypharmacy, incontinence in setting of poor control and neuropathic pain. In addition, they are at risk of premature death and functional impairment arising from associated complications. There is an estimated resource use of 10% of the total healthcare budget including medication costs, hospitalisations and attending non-diabetic specialists for disease associated complications. Methods We reviewed all acute hospital diabetes consultations over a two-month period to identify persons aged 75 years and over who had contact with our clinical nurse specialists and consult service. Results 46 patients aged 75 years and older (median age 79 years) were reviewed on request by the consults service. 6.5% (n=3) had Type 1 Diabetes. 41.3% (n=19) were on insulin and the remainder were on oral medications alone. They had a median HbA1c of 63mmol/mol. 91.3% (n=42) were living at home prior to admission. All patients were reviewed and educated by our clinical nurse specialists. Issues addressed included hypoglycaemic awareness, glucometer use and insulin administration. 17.4% (n=8) had medications discontinued due to hypoglycaemia and/or chronic kidney disease. 32.6% (n=15) had up-titration of insulin and/or addition of new agents. 58.7% (n=27) were subsequently followed up in clinic by telephone. Conclusion The 2018 American Diabetes Association guidelines now recommend treatment goals based on functional status rather than age. Our experience locally is reflective of the spectrum of issues that arise in management of diabetes in the older person. This highlights the positive impact of a multidisciplinary diabetes service in minimising complications and promoting individualised person-centred care.
PurposeInsulin is a high-alert critical medicine used in the treatment of diabetes which bears a heightened risk of causing significant patient harm when used inappropriately and has been identified as a medication safety issue in Galway University Hospitals. The aim of this study was to conduct a local prospective audit on insulin prescribing, administration, and glucose monitoring trends in order to identify and develop quality improvement initiatives. MethodsThis audit was conducted over one day in March 2022, approved by the local Clinical Audit Committee, piloted on two inpatients, and communicated to all data collectors prior to commencement. Generated data were anonymous and securely stored. Independent analysis was conducted by three researchers to confirm reliability of results.Results454 inpatients were reviewed of which 17% [75] had diabetes and 9% [41] were prescribed insulin. The overall insulin error rate with one or more errors comprising prescribing and/or administration per inpatient drug record was 90% [37]. In total, 95% [235] insulin brand names and 89% [220] dose units were clearly prescribed, 84% [208] administration times were clearly specified by a prescriber, 87% [214] orders were signed, 58% [25] prescribers clearly documented their registration number/bleep/name at least once for contact purposes, 35% [30] meal time supplements were documented clearly by a nurse, 70% [202] administrations were double checked by a second person, 53% [142] administration times were documented by a nurse, and 26% [10] of inpatients were administered insulin by a nurse when not prescribed.ConclusionResults will assist in developing quality improvement initiatives to optimise patient care.
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