1. Managing Patients with Diabetes on the Haemodialysis Unit Jo Reed Diabetes Specialist Nurse (Renal) November 2015

2. Managing patients with diabetes on the dialysis Unit. What we are going to cover: Guidelines: Glycaemic targets Insulin regimen Facts to consider Case history

3. What do the guidelines tell us re. insulin on the dialysis unit: With regard to: glycaemic targets insulin regimens There are no agreed guidelines regarding Insulin management on the dialysis unit

4. But they are coming……….

5. Recommended HbA1c targets in CKD UK Renal Association 2010: 48-57 mmol/mol (6.5-7.5%) NKF-KDOQI 2012: < 53 mmol/mol (7%) BUT………….

6. ADA-EASD Position Statement: Management of Hyperglycemia in T2DM Glycemic targets- Individualization is key:  Tighter targets (6.0 - 6.5% / 42 – 48 mmol/mol), younger, healthier  Looser targets (7.5 - 8.0% +/ 53-60 + mmol/mol) - older, comorbidities, hypoglycemia prone, etc. - Avoidance of hypoglycemia Diabetes Care, Diabetologia. 19 April 2012

7. HbA1c and Reliability HbA1c is a reflection of ambient glycaemia and red cell half life ESRF & Dialysis Shortened Red cell half life, recent transfusion, erythropoietin cause falsely low HbA1c Joy.MS, et al. Am J Kidney Dis 2002; 39:297–307. Other options?

8. Diabetes Care, Diabetologia. 19 April 2012 (Adapted with permission from: Ismail-Beigi F, et al. Ann Intern Med 2011;154:554)

9. What should we consider? Avoidance of macro & micro-vascular disease The risk of hypoglycaemia Consequences of severe hypoglycaemia

10. Why should we be cautious? Risk of hypoglycaemia  Decreased gluconeogenesis Malnutrition/eating patterns Impaired hormonal response to hypoglycaemia Increased half life of insulin in ESRD

11. CKD changes the pharmacokinetics of all Insulin Novomix 30 eGFR > 90 ml/min/1.73m2 Novomix 30 eGFR < 15 ml/min/1.73m2

12. Oral Diabetic Therapies: HYPOGLYCAEMIA All sulphonylurea drugs however are associated with significant hypoglycaemia Diabetes - MIMS Clinical Update

13. Case History : Mr C.K Dee 62 yr old Asian man, MHD 8 yrs (AM slot) Presumed T2DM – 33 yrs. Insulin treated 2yrs after diagnosis CVA 2006 Registered blind Hypertension Dyslipidaemia

14. Case continued: Admitted due to hypoglycaemia Poor appetite for some months Lives alone Sister lives nearby but has limited contact

15. Current Medication Diabetes Medication Novomix 30 insulin 30 units in the morning 18 units in the evening The Rest Rosuvastatin 10mg nocte Irbesartan 75mgs bd Amlodipine 10mg mane Doxazosin 4mg Bisoprolol 10mg bd Nicorandil 30mg bd Renagel 2 every meal Omeprazole 40mg od Asprin 75mg Clopidogrel 75mg Alphacalcidol 1mcg

16. Case continued: Has a talking meter at home Prefers to use needle and syringe for insulin delivery Reports having frequent hypos but also frequent episodes of hyperglycaemia Unclear how often the insulin is actually being taken Mentions rather a lot of insulins Says he prefers his sisters insulin!

17. Range of insulin's used in the past…… Mix 30 M3 Glargine Insulatard Levemir Novomix 30 (Hba1c Range 45-145)

19. What are the issues that have contributed to this admission

20. Case continued: Confusion about insulin Administration of insulin Insulin timing Injections very close together on dialysis days In relation to oral intake Goes to bed at 9pm Insulin duration No pattern to hypoglycaemia

21. Case continued: Safety Realistic targets Eliminate hypoglycaemia Help with regaining his appetite (Impact of gastroparesis, malnutrition) Encourage independence Use an insulin he has confidence in One dose of insulin daily May need a 2nd dose if eats more Mindful of the impact of shifts/transport Follow up/support

22. Take Home Messages : Patients often frail & elderly with >10 yrs DM with multiple co-morbidities Pharmacokinetics of insulin and oral agents affected Less insulin is required in deteriorating renal function Eliminate hypos first Keep it simple and involve the patient

23. Take Home Messages : Avoiding both acute and chronic extremes of hypoglycaemia and hyperglycaemia matters in these patients Measures of glycaemia have different roles predicting outcomes and for day to day use in ongoing patient care Despite certain limitations, HbA1c should continue to be used to ensure integrated glycaemic control is maintained within a safe range Consider an HbA1c target 7.5-8.5% (58- 69 mmol/mol)

24. Finally - A different perspective? Different doses on different days Using a BD insulin just once a day Using a long acting insulin on just the dialysis days

25. Thank you for listening