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Cast from most appointments when they start because it's really something quite foreign to us, not something we used to, even though we understand like the principles maybe a little bit before we start. When we actually do it, it can get very confusing and there's a lot of errors when it comes to insulin prescription. So the first thing I'm going to talk about is the junior doctor, um, like diabetes handbook. So in the queen list, but I, I don't know, depending on where you're going to work, it might be different, different places, but it's quite comprehensive and um the skylines on a lot of things in that. So in my sides here, I've included all the different topics that they have in the handbook. And if you go through them, it's really, really good because it's different flow charts and different like diagrams and stuff you can look at and like step by step what to do for a lot of diabetic complications slash issues slash, you know, it's kind of like troubleshooting, basically anything that you might want to ask your inpatient diabetes team. Um, but I think this hand looks quite helpful. Um Most people can access it. So if you just search up NHS GDC clinical guidelines and you could just look true and you'll find it under endocrine if I'm not mistaken. Um, and you know, if there's something on that that's not really that you still haven't answered your question or you still need more information on, then you can refer to inpatient diabetic team. So, um, the things I'm going to go through on the talk today are hypoglycemia, hypoglycemia slash hypoglycemic control and when or how to withhold insulin or how to restart as well. And some V R I um examples and things like that as well. So first thing I'm going to start with is blood grupos aims that we should aim for in most patient's. So the majority of people um you're gonna aim between a six and 10 range. So for people who are frail or elderly are quite unwell, you can give them a bit more leeway as you can aim between eight and 12 or also if people um have reduced on know hyper awareness. So they're at high risk of hypos and not being aware that it's happening. You aim for like a higher end. So eight rather than six. And as a rule of thumb, in general, one unit of insulin will drop some of the blood glucose by approximately 2 to 3 millimoles. But obviously, in patient's who are insulin resistance, this dose can be increased and you might need to give them a higher dose of it. So it could be like, you know, two or three depending on patient's. And when you're prescribing insulin is really important to check the dose in time of day, that patient's get it. So when you look online again, depending where you work, but where I work on ecus, it just says the type of insulin that on and then usually just says as directed. So you need to go and ask the patient. Um Another good, good practice would also then be to um double check of a different source. So call the G P, call it um pharmacy, ask a family member or something like that. But usually patient's are quite, especially if they're not confused or not unconscious or something like that, they will be able to tell you what insulin it on because it's something that patient manage every day at home. Um And usually if it's sometimes it does say that it's twice daily, but be careful because most insulin would be twice daily, meaning morning and five pm rather than morning and 10 pm. So always clarify with the patient when they take it, but it should usually be morning and five pm on this slide, which is quickly look through the different insulin types. So the injectable therapies that we have include long acting, intermediate acting, short acting, rapid acting and also mix. So long acting includes the ones here as you can see on the list there. Um So that's usually once daily except Levemir because it has a shorter half life. So it tends to be be d intermediate acting, short acting is quite fast. Um And then mix like I put here as well. So the number next to it. So for example, never mix 30 or HumuLIN N three is 30% short acting and 70% intermediate acting. So that's the one that you, you should give twice daily. So sometimes if the patient's not, well and things like that, you might have to split it into a long acting and separate um short acting ones. And so again, depending on where you work, but over at the Kiwi or in Glasgow in general, um you prescribe it on happen as well. So make sure that you prescribe it for the appropriate times and not just PRN so that nurses are a where they need to give it at these certain times, especially gets more complicated locations are on long acting as well as short acting with meals. So it's very important that you prescribe it for the correct times. So again, this is, I guess quite focused on Glasgow, but it's the sheets that we use. So um that's how we prescribe our insulin in Glasgow, you would write the prescription to the type of insulin under the prescription box and a number of units and then sign it and it's important to fill in this box. Um because most patient's won't know, like sometimes they don't know what, but the type one attack too, especially in emergency, it's not great to go look like having to look and figure out whether the type one or type two. So if you feel this chart in, well, you should take whether the type one or type two and put on the usual medications because obviously when patients in hospital, the insulin requirements might change. So the insulin regime might change the hospital, but at some point, they will likely revert back to the original regime. So moving on, um, now I'm going to talk about hypoglycemias. So this is a very, very common emergency that everyone's have to deal with. And it's, and it also happens very, very, very often and most of the time you have to, you're the first one there and you have to deal with it before you get any help. And it can be quite scary because sometimes patient's can be unconscious. So, um, it's also very, very commonly happens because it's very easy for patient's to get hypos due to reduced intake because they're unwell or they don't like the hospital food or they're fasting or something like that, but nobody's really adjusted their insulin regime. So, so they're getting the normal dose of insulin that but not really meeting the needs for that. So they're more likely to hypo and it's important to treat even if it's a symptomatic because a lot of patients have reduced hyper awareness. So even if Vanessa's call you and are like, oh the BMS read this but they're not really symptomatic. They're find eating, drinking, whatever, like consider treating them. Even with some, at least some oral, like fast acting just cause they might just have reduced hyper awareness. And these um this is what I used to like categorize the severity of the hypoglycemia. So if it's mild, it's just autonomic symptoms. So a bit sweating, maybe a bit of like, but they're still awake, they're so conscious, they're able to communicate with you. So you can just give them some fast acting um carbohydrates and then moderate. So modern depends, they can be a bit more unconscious, a bit more confused. So that's when you might consider giving them I am or IV and severe is when it's really bad and they're basically unconscious at that point and they might even be having a seizure. So, treatment summary. So when it's my only give 15 to 20 mg of fast acting carbohydrate. Moderate. If cooperative, you give them fast acting carbohydrate. If uncooperative but still able to swallow, you can give two tubes of glucose gel. Um And if non responsive, you can give I Am Glucagon or if they have access, you can also give them IV glucose and then if severe you have to give them I be um and then if it's not responsive after that, you can consider giving I am. Um And then as soon as possible try to give a long acting carb. So in the handbook, there's loads of different options for different patient's. For example, if they are nil by mouth or if they have uh G tube down, there's different options of feed that you can give them as a long acting carb to make sure that the hyper doesn't recur. So the main causes of recurrent hypos obviously as multifactorial. So parents could be fasting for scans, they could be reduced intake because they're not able to eat as much. Um Maybe that I'm able to keep food down because they're vomiting, patient's unwell. So they're spending most of the day, you know, asleep or just resting, not really have much of an appetite near by mouth for various reasons. Um Nurses might also push you to prescribe over the weekend, which is not exactly the safest thing to do even though obviously, you tend to do it most times because it just, it's really hard for them to get them. Get an F I want to come around to prescribe the insulins when everybody's pressed over the weekend or nights. So usually no issue, the BS have been stable over the last week or there's not been much, you know, titrating with the insulin doses, then it's all right. But if they have been label and um there has been quite a lot of change in the last few days, then don't do it because then you're very likely to push them into a hypo and it could be a very bad hypo where they have a seizure and then stick their rules. So for Metformin, people are well aware that it's one of drugs you suspend on admission and people unwell because it increases your risk of lactic acidosis. But this doesn't really cause hypos. So yes, it's good to stop it. But you need to think about glucosides when your, when somebody's having recurrent hybrid, because glycosides will drop your blood glucose levels. And um so another cause of it would be just insufficient reduction of insulin and glipiZIDE in unwell patient's or when there's not much need for it and also an A K I S because insulin is really secret it. So if you're finding that somebody is recurrently having hypos, but you can't really figure out why have a look and see if they have an A K I and that's probably what's causing them to hold on to more of the insulin in the body because the, you know, like your kidneys are not able to clear it as quickly. Therefore, meaning you're getting a higher dose of it actually, which is more likely to cause the hypo. So how to adjust the hypo. So the main information you need is what regime are they on? So are they on a basal bolus? Are they on uh just once daily? Are they on all the different other types of regimes people could be on, are they on a pump? You know, for example, are they eating less? What else is a pattern of the BG readings? So look at the insulin prescription sheets. Look, sometimes people also documented on the news charged at the bottom. There's, there's, there's a column for blood glucose. So you can have a look at that as well. And again, don't forget to stop leukocytes. So this is a rule which I'm sure most of you would have learned when you're studying for your P S A slash, maybe over the course of your uni. So if a hyper was happening between breakfast and before dinner, consider reducing the breakfast dose by 10 to 20%. And if it's happening um after dinner overnight, before you wake up again in the morning, reduced evening dose for 2020% or have a snack before going to bed. I have some examples over on over later on which will help, you know, solidify this concept. So this is a type of different regimes. I'm talking about the basal bolus, for example. So that's when you give a long acting in the morning. Um for example, Levemir or Lantus to Tresiba. And then when, so then you need to think about when is the hypo. So if with meals, consider reducing the fast acting, if there's so the bolus, for example, so you can maybe keep the Levemir but then reducing over rapids that patient's are getting um that's just a repeat. So basically that if the blood glucose levels are consistently running closer to the low end, you can consider a reduction in the basal insulin rather than just the insulin. So if it's running, you know, closer to the answers of them, dropping into hypo is more like more likely, obviously. So then therefore, you would reduce the basal insulin as well. And another thing to note is that most patient's especially type one diabetics have been dealing with this condition for their whole life. So patient's know how to carb count, they know how to manage the diabetes if they're not in, you know, not eating that much or a bit more unwell. They, they have dealt with this before and it's always a good idea to have, go, go have a chat with them because they might be able to give you, um, exactly what they need without you having to figure out on your own. Um, but obviously, you know, take it with a pinch of salt because you need to figure out for yourself as well, whether that's actually okay to do or if it's the correct thing to do, it's so and then went to withhold insulin. So never ever stop basal insulins. For type one diabetics, you might need a reduction but never ever stop it because if you stop it, you're just increasing the chances of them, um going to D K because you know, by the nature of it, like they're not producing their own insulin. Therefore, you're just going to push them into DKA. If the B M's are low, like just to reiterate from just now, if the B M's are low with the meal and they're not going to eat, then you can maybe consider stopping the bolus. Um Just, you know, depending case by case, obviously. And if they're type one diabetic and very, very poor oral intake, consider B R I I, this is slightly turn on more about B R I I s and when maybe to consider them in patient's. So then moving on to hyperglycemia. So, so this is just a flow chart for type one diabetics with CBD is more than 14. So a lot of places should have keto meters which will be able to tell you what the patient's ketones are. And if not, you can use uh urine dip as well. So different, um I don't know if I included this in my slides. Actually, I'll go find a picture of you of this, but different urine dips equivalent to different um ketone readings. But usually if it's positive it's all and you, you don't have access to a keto meter. It's good practice to just do A V B G just to make sure that they're not indicate. So they're not acidotic basically. Um So this is a good flow chart to follow. So if they're, but ketones are less than 1.5 and there are hydrogen ions less than 45 you could consider correction, those they don't necessarily have to give it. So, realistically, if ketones are above 0.6, you can already consider giving them a correction. Those just because you don't want them because this is kind of impending um DK basically. And then just follow the flow chart as this to give, deciding whether you want to give uh number apoptosis or not. So, um as much as possible avoid corruption doses because you want to utilize and fix there are normal regime rather than giving them correction doses because the more correction doses you give, the more it's going to mess up their normal regime and it will be very hard to then go back to the normal regime once they're well and stuff like that. Um So make sure you also give nova rapid not act wrap it and then recheck after two hours. So if the blood glucose is still more than 18, you can consider um giving another a repeat of the PRN of rapid dose because patient might be quite high risk for DKA S. Um Or if for example, if you're type one and you think they are very high risk of cape and just give another dose like, you know, nobody's going to ever reprimand you for giving a dose when you think it's appropriate, it's just better to stay away from it if you want it like, you know, to prevent messing up the normal regime. And then, so another thing that is quite important is that a lot of patients get as well, is there induced hypoglecemia? So if you go through the handbook, this whole section about this, I didn't include it much in my crock because obviously it's a very, it's quite a niche area kind of. So it's better to have a look at it when you have a patient that has this rather than, you know, knowing generally have to deal with it. But most of the time, what you would do was would be start them on glucoside because glycosides work better than insulin for stirring, induce hypoglycemia. And then there's different doses depending on the number of doses of steroid to get and then the number of doses of liquid sides you can get. So keto meters. So as I was saying, just now, if someone's type one or pancreatic diabetes, diabetes, then and they have a blood glucose level of more than 14, it's important to check ketones. Unwell, patient's patient's on D K protocol. Obviously, unwell patient's on SGLT two inhibitors. So this is very, very important, especially when you currently explain why this patient's unwell. Um And there are blood glucose is actually normal. So patient's on SGLT two inhibitors can get euglycemic DKA A. Um So it's quite important that, you know, you think about this in the case, but obviously, you know, most of time when you're dealing with somebody and, well, it's more likely to be a senior there so they will hopefully figure this out. But, you know, if they don't then, and if you notice, if you're going through the drugs and you're thinking, oh, what could have caused this patient being unwell, have to think about whether it's the SGLT two inhibitor and check their ketones because they might be indicating. So V I, I, so you would consider, er I, I usually, and type one diabetics um rather than type tools mainly because they're at high risk of D A S. Um So if the nil by mouth prolonged nausea, vomiting that for they are unable to keep any food down, reduce consciousness. Another reason to use VIIS uncontrolled hyperglycemia. So I've seen it been used a lot in um type new type two patient's when they've just come in. So um they come in, they lose a kind of all over the way. So you put them on A B R I and then you can, you can use that to then calculate the total number of like the total dose of the insulin that they need over the 24 hours. And then you can prescribe a 70% dose of that as um they're like usual insulin resume. So have a bit more about that in the next side as well preoperatively. So, um as you know, different patient's have different requirements when you preoperative. So depending on the patient, depending on the surgery, depending how long they're going to be fasting for, depending on the blood glucose, depending on how tight they control of their deputies is. So there's different things to look at and there's guidelines for all of this and it changes from place to place. Um And whenever you put somebody on the V I I, it's good practice to always continue the long acting alongside the V R I just so it means it's easy to stop the B R I um when you want to stop it, rather than having tweet for meal time that you have to do quite a lot. And that's annoying because obviously, like it usually means you're waiting till dinnertime and then it means it's out of hours and then if it needs to go back to the er I it's more work for the out of our scheme and things like that. And that's just a video on how to fill in the form when, if you're working in, in G C. So how to stop the I I. So if the patient's eating and drinking normally, and it's clinically indicated that, you know, the blood glucose are stabilizing, they're eating and drinking, they're moving around and fine, then that's when you can stop there. I consider stopping the ri so, like I said before, if the long acting is already on board, you can stop whenever appropriate. So whenever the patient's like whenever the blood glucose have stabilized and all that you can just stop then already if long acting is not on board, give the usual on acting dose and then stop the B R I after two hours. So it's just to give the long acting some time to work before you're taking away the B R I. And then um and then yeah, of course, I'll send off the slides. Um I put my email at the end as well. So if not just send me an email and I'll send them to you and then if you're switching back to a mixed regime. So that's depending on human entry or Nova mix or one of those other mixed ones. It needs to be on a mealtime because obviously you're reintroducing the fast acting as well as the long acting one as well. So it needs to be done at a mealtime. And then, so you give them a dose of the mixed. Do you can then um stop the beer? I two hours post meal and then continue checking blood the ghost four times daily after that just to make sure that everything's all right. And then like I was talking about just now if you're newly starting somebody on insulin. So it's the best presentation, etcetera, etcetera. You can give 75% 70 to 75% of the total um insulin dose that day um in an appropriate sub cut regime. So you can put that either you can split it into two. So obviously, depending on how much they need it because there's only so much you can give somebody in one dose. Um You can split it into two or you can consider they maybe need Nova Rapids if they need different things with that. So if you're unsure about that, to be honest, I, I would still discuss it with seniors as well because it's more senior decision, then it would be an F Y one decision to, you know, start somebody on new. And so and no, so another thing that we're having to deal with more and more in the hospital is patient's with insulin pumps. So um patient's are usually very, very well educated about them. Um They have gone through vigorous training, multiple learning sessions, multiple learning sessions, multiple, you know, education sessions, multiple meetings with consultants with, you know, diabetic nurse, specialist pump specialist, all these type of things before once even decided whether they can get a pump or not. And so they should be able to manage your own pump. But obviously there are exceptions to this when patient's are unconscious, if they're confused and incapacitated, if they're, you know, just really, really out of it, they're not gonna be able to tell you how to deal with the pump. So in hours, you can obviously call a diabetes reg or call a senior who maybe might know more about this and deal with it like that. But if it's out of hours and there's nobody really around that knows about it. The best thing to do would be take out the pump and start of, er, I, I, and then discuss the diabetes team as soon as possible, which usually will probably be the next morning. So then, now I'm just going to go through some examples with you. So, a very, quite simple one to start off with. So, as you can see in this, this patient is a type one diabetic and they're getting Levemir 20 B D um the political coast as you can see the readings there. And then, so you're done essays called you to prescribe the Levemir for the next morning and you're looking at the sheet and you're wondering what, you know, how much instants should you give? So if anybody wants to see the answer. Yeah. So yes. So you would increase the morning dose of the oh, sorry, I put an over mix that I met Levemir by 10%. So as you can see here, the blood glucose is high in the evening. So meaning that the one you should then increase would be the one prior to that. So the Levemir 20 was not enough to cover the whole day until evening. So you would then increase that 20. So you can increase it by 2 22 or even 24 if you want, depending on what you think the patient might need So then next question. So what would you do in this scenario? So this patient's also type one diabetic on logo mix 30 20 minutes BD. Um He's hyper in the morning once and then overnight he's hyper it again. So I think I didn't complete this picture. I think there's more to this picture. But yes, you would decrease the evening dose to Oh no, no, that's fine. So I put too many pictures in this light show that I've forgotten which pictures go where. But yeah, so you would decrease the evening um dose by 20% because they're hypoing overnight. So therefore you need to again decrease the dose just before the event. So correct. And the last question that I have here is this patient. So again, type one diabetic per oral intake, but this is the first hypothesis admission. So what would you do with the Levemir? And what would you do with the nerve a wrap it? I know there's no options here. So I can also just speak through it with you guys. So um so because it's a type one diabetic, you should never stop the long acting insulin. So therefore the level may will need to be continued. Um but you can give it at a reduced dose. So you can see from the day before he also like blood sugars are not running too high. They were quite okay. So you can give it at a reduced dose of about maybe 10 to 15 units, depending on, you know, have a chat with the patient, see how much actually eating and things. And depending on that, you can decide how much you wanna actually reduced level nearby. And then because the patient's still hyper weighing at 3.3 in the morning and they're still pull or Atlantic, you need to stop the nova rapid for that meal at least. So you need to withhold another rapid for that meal. This is a very common scenario that you get in the hospital because lots of patient's hypo overnight and you come in in the morning and the messes are like, oh, what should we do? Like should be withholding blah. And the main mistake a lot of people make is especially the type one diabetic is to stop the, you know, long acting one as well, which is very, very dangerous and you might then push them into DKA and type two diabetic. You, it needs to be a more case by case um situation. But as a general rule of thumb, you can reduce it by even half an attack two diabetic because if they're not eating, they really don't need the insulin because the body is still, you know, still producing it. It's just more of an insulin resistance. So sometimes reducing it by half doesn't even actually have much of effect because like the receptors are not working to its insulin anyway. And then so doesn't make two main tips to be honest, like not much as a summary from the from the whole presentation. Um never ever stop basal insulin and type one diabetics because very, very quickly they will deteriorate and they will go into DKA and the neces will hate you because the D K protocol is a lot of hard work for the masses. Um and then stop, look aside and hypos because pigeons always think doctors said to always think about the insulin prescription and thinking about stopping that and like, you know, looking at the prescription sheets and realizing that that needs to be stopped, but not really looking at what um oral tablets are on. And besides one of the very important ones that very, very high risk of um giving you hypos. So that's mostly my presentation there. Um I hope you enjoyed it. We can also go through the diabetic handbook if that's useful for you guys. Sorry, I was a bit late. So I kind of cut down my presentation a little bit as well just to make sure, you know, we're still finished on time and things. I hope that was helpful and yeah, just drop me an email if you want my slides and let me just be able to let me just put on my feedback as well. So, yeah, if you guys don't mind filling in that feedback, it'll be really great. I really appreciate it. Um And again, just email me if you have any questions?