diabetes_audacity_p1

Hey all, my name is Iman Ali. I'm one of the new behind the knife education fellows at Duke, and today we're going to continue our quick hits med search series with diabetes. I'm joined by Dr. Catherine Neal, an assistant professor of medicine at Duke Hospital, who does a lot of incredible work leading our Threatened Living team.

And thank you Dr. Neal for joining. I guess we'll just start with a vignette. A 56 year old gentleman comes to the emergency department in the middle of the night with complaints of malodorous discharge from his left first toe. His past medical history is significant for afib on eloquence, C. A. D. with a P.

C. I. in 2021, peripheral arterial disease with a recent left sided fempaw bypass with ipsy vein in 2022 after some acute limb ischemia. chronic kidney disease, not on dialysis right now, and type 2 diabetes with the last A1c of 10 percent on metformin, glargine 20 units at night, and regular insulin 4 units before meals.

He's evaluated by vascular surgery in the emergency department who recommended a debridement next morning with a diagnostic and possibly therapeutic angio. The patient was then admitted to the threatened limb

team under medicine for multidisciplinary So this is a really common scenario. At this institution, we're very lucky to have such a good team.

And the first question is just. Where do you start with an admission with respect to diabetes, and what are common pitfalls and errors that we can avoid? Thank you so much, first of all, for having me. I really enjoy the collegiality we have working with our surgical partners here at Duke, and I find I'm always learning from you as well.

So one of the most important aspects I think about when caring for folks with diabetes, but really any patient who's being admitted to the hospital with or without diabetes, is to confirm and reconcile their home medications. This is a really simplistic view of it, but it's really important to specify if the patient is insulin deficient, as in they have type 1 diabetes.

and they are prone to ketoacidosis versus being insulin resistant as in type 2 diabetes. And this will affect how insulin is dosed and if it's essential to continue insulin, despite an upcoming surgery or being

MPO. I usually talk to the patient about how Often they're checking blood sugars at home.

And if it's feasible or if we have it in the record, I'd like to look at their most recent hemoglobin A1c result. So the patients I care for and being a hospitalist, not an endocrinologist, but somebody who takes care of many patients with with diabetes, They usually come in needing an urgent or emergent debridement, amputation, or revascularization like the patient you've described.

I think that having the A1C data gives us more evidence to how the patient's handling their diabetes at home and how we can support them through the hospital stay and after discharge. On the other hand, I think it's important to know that we sometimes find the opposite, that we have somebody who's quite elderly coming in and on multiple medicines for their diabetes with an A1c that's, you know, below 7%.

And I think the thing to note there is with their age and comorbidities, is it appropriate to actually scale back a little bit on their diabetes regimen to

avoid hypoglycemia? Yeah, thank you for the overview. And usually If I'm on consults or something in the middle of night, I'm admitting this patient.

I usually just make them NPO and I might place an order for Q6 checks with a sliding scale and hold everything else. But in whom is that not the right decision? And what pitfalls can I sort of fall into? I think how best to control the patient's blood sugars when they're admitted is complicated, right?

There's many competing factors. Patients are MPO for periods of time due to testing or procedures. Patients blood sugars are elevated because they're coming in with an infection. They're nauseated and vomiting after anesthesia or maybe due to the infection itself. And then we also use some medications which can affect the blood sugar, you know, people need.

stressed steroids or receive steroids as part of their anesthesia. So I think establishing a few goals is a good place to start. So while the patient's admitted to the hospital, primarily we want to avoid hypoglycemia, right? This is the most dangerous to the

patient in the short term. So while we want blood sugars controlled, we should, we certainly don't want folks to have blood sugars that are too low.

And generally we count that as less than 70. On the other hand, we want to avoid extreme hyperglycemia, but in general, we want to avoid ketoacidosis and hyperosmolar states, of course. Hyperglycemia is also linked to increased infectious complications and impaired wound healing, so we want to set people up for success by controlling their blood sugars perioperatively.

I think in the context of this, we also want to keep electrolytes generally within a normal range and have the patient maintain some bubolemia. And of course, if your blood sugars are very elevated or sometimes too low, this can lead to electrolyte disturbances and issues with volume that can be dangerous.

So for the question you posed regarding correction insulin only, it's imperative to continue basal insulin in patients who are insulin deficient and prone to ketoacidosis. So for patients with type 1 diabetes, basal insulin is mandatory. However, insulin doses

may need to be reduced to avoid hypoglycemia while in the hospital for the reasons noted above.

Now, if you're quite concerned about the patient becoming hypoglycemic, an alternative to ordering the finger sticks Q6 is you can order them at least at Duke five times per day, which will include a middle of the night. Check it through in the morning. This really is not a level that, or a value that you want to be chasing with insulin doses, but is instead really to make sure the patient is not hypoglycemic in the middle of the day.

Or middle of the night, sorry. Especially in the ozempic days today, there are a lot of new classes of medications that we may not all be familiar with. And they all have some side effects, which are, some of them pertinent to surgery. Like a new policy here anyway is that for elective cases, patients on ozempic need to hold it for about a week due to the gastric dysmotility.

But what are some other classes and general side effects and things that we should be aware of? Sure. I think that's a great question. I think that we'll see this more and more. And I will be honest

with you that I don't know all the up and coming diabetes meds either. And I have to look them up almost every time because I think it's important, like which class is this in?

What do we need to do with it? I think from a simplistic point of view, you know, the oldest or one of the most common medications we see people on for type two diabetes metformin. Generally I'll hold that on anybody who's coming into the hospital. And that's for a couple of reasons. The sulfonylurea class, which would include medications such as glipizide or glomepiride, those put the patient at risk of hyperglycemia.

So again, I generally hold these through the hospital stay, or at least until the patient has been stabilized, had their procedure, their oral intake is back to baseline. But I think it's been my general practice to hold those until time of discharge. I think the newer classes, so the Sodium Glucose Pro Transporter two inhibitors which are SGLT two.

And those include medications such as Jardiance, Farxiga with the generic names of

Nagly, Fain, or Dalyin. Those should be stopped several days before planned surgeries. If we can you know, obviously people coming in with Emerge procedures, we just do what we need to do, but. These medications have been linked to you glycemic diabetic ketoacidosis and I've definitely seen that more often within the last year or two with more people taking those types of medications.

I don't see these medicines as much anymore. It doesn't seem that the diazolidine, dione, such as pioglitazone or rosiglitagrone should be held in the hospital. They can cause fluid retention and can cause issues with congestive heart failure. They do come in combination pills sometimes. And so again, just looking up what your patient's taking, if you're not familiar with the brand name or the name on them.

bottle that they show you. Another group that we're seeing probably a bit more the DPP 4 or dipeptidyl peptidase 4 inhibitors. And this would be medications such as citigliptin or Genuvia. They don't have the same risk of

hypoglycemia. So I think that there are some folks who will say that they can be given preoperatively, but they do have a risk of altering gastric motility.

So again, I think we're generally holding those, but I have seen our endocrinologists resume them in the hospital because again, they don't put people at risk of hypoglycemia, like something like glipizide. So last, the big one, and probably the one that more and more people seem to be taking in some form.

So there are a lot of different names, but the glucagon like peptide 1 receptor agonist, such as semaglutide or azempic, or there's now a dual GLP 1 and glucose dependent insulinotropic polypeptide GIP receptor agonist, such as terzepatide. These are a hot topic, right? More people are taking them. I think we'll see, come to find more kind of benefits, but also more risk would take amaranth just like anything when folks are using medications more.

The idea here is that they do slow gut motility, and they can put the patient at risk of aspirating with anesthesia. I think that there's

not really consensus or accurate data yet on how long they affect the gastric motility or how best to deal with it. So I think that there'll be more data coming out in the, in years, you know, months to years.

I think that there are some that are allowing a liquid diet the day prior to surgery for folks on these medications, just with the idea that that would be kind of more easily absorbed and won't be. sitting in the stomach when they go to electively intubate you. I think some folks are advocating holding the medicine.

So again, I think it depends on your circumstances. I mean, I think when folks come in urgently, we do the best we can and we try to hold these meds. I think otherwise, if you want to be on the safe side and you're not sure if the patient took it, talk with your anesthesia colleagues and maybe think about doing a liquid diet the day prior to surgery.

Awesome. Thank you for that overview. The last thing for you is just what are some pearls you have about diabetes for a surgical care team. Simple, but bears repeating. For patients that are in

diabetic ketoacidosis, you have to wait until the patient's anion gap is closed before stopping the insulin drip.

Sometimes we'll also repeat the beta hydroxybutyrate if we're unsure, but if the anion gap is persisting but the sugars have normalized, the fluids need to contain glucose. or dextrose, and you need to add that to the patient's regimen. So if you're already hydrating the patient, but they're on an insulin infusion for diabetic ketoacidosis, and the blood sugar is getting down to 200, switch their fluids to something containing dextrose.

And again, that requires a lot of attention to the labs, but also really close communication with nursing staff. I think the second thing, which is related, is, Transitioning off of an insulin drip in the middle of the night is difficult. It's not impossible, but it's really hard to time doses of subcutaneous insulin when the patient is naturally not eating and in fact, there should be sleeping and, you know, going into the night again, it's not convenient to have finger sticks checked every hour.

But again, the timing of the subcutaneous insulin dictates when you're able to turn the

drip off. So to doing this in the middle of the night is just not ideal. Kind of on a piggyback of that, insulin drips don't cover meals. So patients who are eating the drip does not cover what they're eating.

It's really just their basal. I think that this is what I see frequently. So folks come in with an acute kidney injury. This is common for patients with diabetes, and then they require less insulin or less meds just depending on the degree of their renal impairment. So, kind of, as you think about.

reviewing the chart of a patient with kidney injury, right? We all think about, Oh, am I looking at, are they still on their ACE inhibitor? Are they taking, are they using morphine, et cetera, but think about the diabetes regimen as well for dose adjustments that may need to be made because the insulin will stick around more if patients do have an acute kidney injury.

And kind of a, an aside to that, you may see as patients progress towards needing dialysis, that they either come off much or a lot of their diabetes medications.

The last thing I was thinking about were things to consider at the time of discharge. So, be mindful of the discharge regimen and review doses of both the old and the new meds when it's time for a patient to leave the hospital.

I think it's important to mention hypoglycemia, whether that is talking about symptoms, how to treat it, how to avoid it, you know. People who are new to insulin need to be told if you use your mealtime insulin, you need to eat. It is, you know, it's not optional at that point. Because that again is a far more dangerous situation, at least in the short term.

And that is what I worry about when I send folks home with new insulin. I think the last thing is that you shouldn't be afraid to ask for help. I think that as patients get more complicated with many more comorbidities and they're living longer it seems with many more problems, I think that we really need to work as a team.

So using your colleagues in internal medicine or endocrinology or pharmacy to help optimize the care of these folks is really important. But I really appreciate the chance to talk with you all about this.

Well, thank you so much. I mean, diabetes and good control that really helps everyone including our surgical outcomes, which really care about.

And it definitely affects a lot of our patients. And so thank you again for taking the time. Thank you so much.