May 08, 2020 Enhanced Sick Day Management - Keeping Clients Safe During the COVID Pandemic

Grace Leeder: Okay so it’s 12:01, so we will get started. Thanks for joining us today in another one of our COVID-19 and diabetes webinars in our Diabetes Canada webinar series. We’re really glad that you could join us today for a presentation called “enhanced sick day self-management: keeping clients safe during the COVID-19 pandemic," presented by Susie Jin and Catherine Yu. So we’re really excited, and what we typically do first is just do some polling questions to get a sense of who our audience is today. So our first question is, what is your profession? So if you could go ahead and participate in the poll, we’ll give it about 30 seconds and then we’ll see who’s joining us today.

Okay great, so 50 percent of our audience today are registered nurses. We also have a couple of nurse practitioners, 20 percent registered dietitian, some pharmacists. We have a family physician or a general practitioner, and about 14 percent are “other”, so a good diverse group of folks joining us today. And we will do our second polling question, which we just would like to know where you’re viewing from today. So, which province do you live in.

Okay, so, as has been the case in our series, the majority of folks are calling in from Ontario, probably because we're watching at lunchtime noon Eastern time, but really nice to see we have someone from every province joining us today. So, 8 percent British Columbia, 16 percent Alberta. Yeah, so thank you so much. So without further ado, I'll pass it over to Catherine and Susie for today's presentation.

Catherine Yu: Thanks Grace. And thank you to Joanne, Alice, and other members of Diabetes Canada for inviting Susie and I to present on a topic that's near and dear to our hearts, particularly Susie.

So my name is Catherine Yu. I'm an endocrinologist at St. Michael's Hospital, and I'm pleased to present with Susie Jin, who is a pharmacist extraordinaire, a close friend and colleague who is very passionate about diabetes care and would never leave us for asthma, as we discussed yesterday.

So, by the end of this webinar, you should be able to counsel adults clients effectively on sick day management, describe a step-wise approach for individualizing ambulatory management of severe hypoglycemia, and list three reasons for which adult clients *must* go to the hospital. This session will be interactive. So we're going to keep about 15 to 20 minutes at the end to answer any questions that you might have. So if you have a question, feel free to jot it down and we'll get to those at the end, just for smoothness of presentation because I'm not quite as the expert.

And in order to go through these objectives, we'll walk through some perspectives. So just to step back and think about COVID and diabetes. And we'll talk about sort of standard safety management, step up to *really* safety management and then finish with *really, really* sick day management. So starting with some perspective, this article recently came up last month,  looking at the rates of hospital admissions and hospital occupancy during the COVID pandemic. And so, many of you I'm sure are also aware of this. So, in many Canadian hospitals, admissions are down 25 to 50 percent and our ward beds have been empty. We know that not all 25 percent to 50 percent of these admissions are unnecessary, and so the corollary is that people who need to come into hospital aren't coming in, because they're afraid and when they do present, they present with worse disease that can be reversible. And so, in fact, while you know, while the push has always been, you know, let's get patients out of hospital. It's a mixed blessing. And I think this cartoon depicts this really nicely. I'll give you a moment to read that, about how a good thing, too much of a good thing, can actually be quite bad. And to give you a bit of perspective.

So I think what we need is balance. Just as we're finding balance in our new lives during this pandemic, we need to help our patients find a balance between appropriate stay-at-home management, and appropriate acute care assessments. And then, happy to share some stories.

Susie Jin: Yes, so it's my turn to be able to say some awesome words on behalf of everybody on the webinar so far. So I see that we have about 99, almost 100 participants. And I really wanted to take this opportunity to, unfortunately you guys are muted and I  know you'd say it better than me, but to thank Catherine for being our hero. And I know that we all say that all the people on the frontline are heroes, but I think that almost diminishes what Catherine actually means to all of us. As you know, she has is the one who really led us all to bring the guidelines to life. She has changed positively the care of people with diabetes, not only across our nation but internationally as well. So I know if you guys could, you'd all be like with your zooms clapping and all that stuff. But I just, Katherine, I wanted to thank you from the bottom of our hearts. And speaking of hearts.

When Catherine and I thought about putting this together, you know, there's always those theories and there's the concepts that we want to try to get across with respect to prevention, helping people know how to stay safe or manage their sick day, or prevent and then manage, and so forth. But what I think we didn't realize is that Catherine actually was redeployed and in her role of endocrinologist, she actually had to be on the front lines of the COVID unit and actually cutting people into the hospital, that she works at - St. Mike's - and servicing those people with COVID. So I thought, wow, not only is she a hero in what she's done for diabetes care, but even more so now. So we thought, by way of keeping it personal, we thought it'd be pretty interesting to find out what did she see, some of the interesting stories that she saw and then finding out if there's a way that we could have helped keep them at home, safe, and responsibly before it actually got to the really, really sick.

Catherine Yu: Thanks Susie. I had skipped over the introductions, and said that I would just introduce myself. Susie didn't say anything, so I thought I'd gotten away with it, but knowing Susie, I should have known that I would not have gotten away with it. And it's all while I, you know, cut people off in person, I feel like it's ruder to cut them off on Zoom. So, anyways. And so I'm pleased to share. So as Susie mentioned, I was attending on the COVID ward as part of redeployment at my hospital. And she pushed me to think of a couple of cases that would be relevant, and it actually was very hard. So I'm going to go through two cases with a COVID twist. And the first is “just another gastro?” And the second one is “just another diabetic foot infection?” And so the first case is a 58-year-old man, Mr O. His past medical history is significant for type two diabetes, ischemic heart disease for which he had a recent CABG and then stent, nephrolithiasis and BPH. And he presented with a history of nausea, vomiting, profuse diarrhea, and a maculopapular rash. So a very viral looking critic against them. So he, um, so, you know, sounds typical. You know, bad timing. But the kicker is that four days later he then presented to the emergency department via EMS with syncope, and given his relatively recent bad heart history, he was code treated as a CODE-STEMI. And when he was resuscitated, he was found to have a creatinine of 587 from his baseline of 100 to 120. And he ended up not being CODE-STEMI. What it was, was that he probably had a viral gastro, as evidenced by his symptomatology the viral example, resulting in severe ECF volume depletion, resulting in AKI, as well as his sympathy. And because of his fever and rash, he was treated as a COVID PUI. But he ended up being COVID-negative with his creatinine going back down to his baseline of 127. So when I was telling Susie this story I told her, I said, I have something embarrassing. So Mr. O, is actually one of my outpatients who I see for diabetes. And I thought, wow, you know, I've gone through sick day management, I've gone through said man's, I've given him the handouts. And yet, this still happened. Mind you, his blood glucose was pristine before his admission and during his admission, but you ,he did not go to EMERG, the, sort of, I think, the fear of coming into hospital had superseded, sort of what he knew he was supposed to do. And I think we need to recognize that and really take the opportunity to stress that in each of our encounters with patients. So now when I have telephone appointments with my patients, I say, “if you need to come to hospital, it's okay. We have precautions.” Just as further reassurance to know that we're still there for them.

So that was the first case and the second case was a 72-year-old man, not my patient but now he is, who had a past medical history of type two diabetes and Klinefelter’s syndrome. And was basically, was followed by primary care kind of lost to care. He presented with a two-week history of increasing redness of his right foot and shin and an ulcer on the tip of his big toe. He was, he's somewhat underhoused, so he was febrile and brought in as a COVID PUI. An X-ray of his big toe showed osteomyelitis and blood cultures on day one, were positive for gram positive cocci in chains. So the twist here, the backstory, is that four weeks ago, he was prescribed pressure stockings for venous stasis. However CCAC was held, so he was self-applying them himself and maybe not taking them off appropriately, and he had no RN assessments. And I think because of reduced care, reduced monitoring, and it was able to get to this point of osteomyelitis and a later assessment for care which actually wasn't driven by his ulcer but rather by his fever and concern for being COVID PUI.

But as with the other case, there's a happy ending. He defervesced and is being maintained on a six-week course of oral antibiotics with close follow-up. With infectious diseases, as well as myself, both for the type two diabetes, I'm fine filter. So the other positive thing is he's just linked back with care, which he hadn't received for either of those in the last 50 years. I'm going to flip back to Susie now, who's going to again step back and just give us some thoughts about diabetes and COVID-19 preparedness.

Susie Jin: Thanks, Catherine. So Catherine has shared some of her stories that she's seen when she's caring for people with COVID. I am a community pharmacist and so I will see the opposite, well the other extreme, right. The more prevention or the early, “What can we do when they're still at home?” and I'll share. So one of my stories I had is early in the times of COVID, we did have people coming in. Of course, there was a lot of fear, a lot of unknowns, and I had people coming in and asking, “Should they take vitamin C to help prevent against COVID?” and, you know, obviously, you could try to answer those kinds of questions on the spot.

But I think the other more important thing that we could actually do is just take a minute to go back to, we really don't know what vitamin C does for COVID at that time and, possibly, you know, recognize that they're in a really good more preparedness state of change, more actionable state of change, and try to go over the evidence-based things that we can do to help prepare our bodies to fight off COVID if we were to have, if we were to come down unfortunately with COVID. So having said that, that's my way of telling Catherine because I'm on video so she’ll know, the first thing I would do would be to really get I think at the forefront has always got to be for my thing is mental health.

Susie Jin: As we all know, when we have a decreased capacity or are affected by mental health, that does affect our self-care capacity often, and as well as having other sequelae. And so, Dr. Michael Vallis had done an excellent presentation on mental health, which is also available on the same Diabetes Canada Timed Right webinar series. So if you haven't had a chance to look at that, I will refer you to that just as a nice lead-in to how we can help them support people with mental health during the times of COVID.

Okay, the other thing is, is also very much at the forefront. If we're starting to think that they might be in a more stage of change or a further actionable state of change, would be to possibly have another conversation or reopen the conversation about smoking cessation, smoking of any sort. If that's on board for that person. So again, just bring that into, into light, and then the vaccinations story. And I feel like with the, *hopefully*, the coming of a COVID vaccination, that is another idea of just putting it out there as an idea of, “hey, when it comes out, make sure you get it.”

Unfortunately, sometimes I still will hear people, the same people who unfortunately don't, also don't want to get flu shots, will also be talking about “Yeah, I don't know if I'm going to get that COVID vaccine when it comes out.” So I think that every opportunity we have to remind them of the fear that they actually had about coming down with COVID would be another opportunity just to speak to the value of getting that vaccination when it does come out.

Then with respect to the flu shot, simple questions I would say to them when they, if they were asking me about something possibly, that doesn't have as much evidence, I would actually be asking them if they did happen to get the flu shot or if they do get their annual flu shot. So not just the one, but their annual flu shot. I think that now is what may, sorry I will go back, but now is what may. So I think that obviously it's sort of, “how beneficial are you going to be by having it now?” I think that's not so much, you know, we're definitely going to be talking about it for, “make sure you get it next year.” But there is one time when I will actually encourage it. If, if I have had somebody, because now don't forget they're in that stage of change and, or hopefully they're positive state of change. If they're that one person who I often have where they've had the flu shot before and they had such a bad experience. They were sick and they'll never have a flu shot ever again in their life. It was the most worst experience ever. I always try to remind them that the flu shot does take two weeks to work. So, of course, if they got sick shortly after getting the flu shot, it was really probably because they didn't get it early enough.

But I'll also try to explain to them that, you know, we have to get over that fear, because many times they might be at the stage where they're young and healthy and maybe they're doing it, the flu shot they’re doing is more benefit they're getting is for the herd immunity, and they're actually doing it to possibly hopefully protect the rest of our community from coming down with influenza. But later on in life if they live with this fear of the flu shot, they will get to the point, possibly, if they're so lucky to live very long,

where they might have complications and comorbid conditions, where they personally would benefit from the flu shot. And so getting over that flu shot fear by just having one just for the sake of having one, there would, I think, still be benefit.

Okay. So, with respect to pneumonia vaccinations. There are two vaccinations on the market. And so the questions I would ask, pose to them are, have they had both pneumonia vaccinations.

And if not, then refer them. Well, certainly if you know which ones they should be, then, you know, go ahead, have that conversation, and if not refer them to somebody who actually does give the new pneumococcal vaccinations. So, whether it be their primary care provider. I think most provinces across Canada,  community pharmacists can give the pneumococcal vaccinations, but so having them speak to somebody about whether it's appropriate for them, whether they can have access to it, because in some provinces, depending on which one, it’s not covered the on the government plan. And is the timing right for them? So again, depending on comorbid conditions and which vaccinations, they may already have on board, the timing might be yes, I should get it now, or no, they should wait eight weeks or a year depending, to go ahead and get that shot. So, just making sure that they're aware of it and that they need to double check whether, when what timing is best for them.

And then with respect to the shingles vaccination. There are two single vaccinations on the market. But unlike the pneumonia vaccinations where both are recommended in people with diabetes - I have to specify because that's different than the general population. But with respect to the shingles shot, there are two available and in the shingles vaccination, quite honestly, it would be recommended pretty much for everybody over the age of 50. But the difference is, is that there is an older generation Zostavax – Zostavax II vaccinations shingles shot - and then there's the newer generation, Shingrix. And unlike the pneumonia vaccinations where both are indicated, in the shingles vaccinations, if you've had the older vaccination, then the newer generation vaccination is, should be considered. But if you have not had the older generation, then don't worry about it because we just go with the newer Shingrix vaccination. The Shingrix vaccination is a two shot to series. So the question would be, “have you had your shingle shot which one and if it was the Shingrix, did you get both shots?” which would be zero and then two or six months later. 

Okay. And then we get to the majority, the main crux of what we were going, what our presentation today is on, which is to become glycemia-specific preparedness, which is awesome that Catherine's first person had sugars. But which of course I would expect, but so while we have glycemia-specific preparedness, we have the possibility of hypoglycemia and hyperglycemia. So the hypoglycemia is actually going to be covered in part two of this webinar series, which is next week, this same time, which will be hosted or the guest speaker would be our other awesome hero, Dr. Alice Cheng, so stay tuned for that next week. And today's presentation is really going to concentrate on the hyperglycemia that we get in sick day.

Okay. So speaking about the hyperglycemia. The first part, we're going to talk about with respect to sick day management is possibly the early, right, the prevention of how do we prevent that hyperglycemia from happening. And then we'll get into really sick day when it actually, how do we manage that hyperglycemia in sick day. And then, of course, we're getting going to get into the really, really sick day. Okay. So speaking of sick day then, when it comes to the priorities of care, I think we have to, we can't just treat everybody the same, right, as that person sitting in front of us. We want to individualize the care to them. And so a lot of that is involved, thinking about what can happen in sick day and what are they specifically at risk for. So, well, the first thing we can think about is hyperglycemia, we've already identified that there is hyperglycemia, but, but actually, we haven't actually said why, right, why. Why is hypoglycemia naturally part of sick day? So just as a review, this is a reminder for everybody, when we are sick, we have the counter-regulatory stress hormone release, right. So what I'm doing is, I'm kind of trying to show that normally, in the perfect world, we live in a balance of insulin and counter-regulatory hormones that are quite honestly moving together, being released in and together, right. And when we're sick, unfortunately, we will have a count arrived in the counter-regulatory hormone release. So that would be the cortisol, the glucagon, the adrenaline growth hormone, right. So all of those are going to increase. And those are going to cause the hyperglycemia. So of course later on we're going to talk about it. But if we don't increase our insulin accordingly, even if we make no changes, but we are sick and we're just still giving our same normal dose, we will have that hyperglycemic reaction. Okay. What else are we concerned about? Well, if we have fever, which Catherine's patient had right, if we have fever. If we have vomiting and diarrhea, we are at risk of dehydration. And what does that, what is our real concern with that will, certainly, yes, there's the dehydration and the electrolyte abnormalities that are possible which have other heart problems. But specifically, or what's the other thing we're really concerned about, is the acute kidney injury that is exacerbated in the sick day state, or sick state, plus exacerbated with dehydration, that if we can't manage it, we are increased risk of acute kidney injury.

 Okay. And then what's the other thing we are concerned about is possibly diabetic ketoacidosis, right, and I think I explain that a little bit. Why do we get diabetic ketoacidosis? Diabetic ketoacidosis is that gap, and the bigger the gap is between the counter-regulatory hormones and endogenous or existing insulin, so I should say existing insulin onboard, the larger that gap, the higher the risk of diabetic ketoacidosis. So, if we can bring that up, we're minimizing, we're reducing our risk of DKA. Okay, so who are at risk, who is at risk for hyperglycemia. And yes, it's all people, all people with diabetes, sorry, but let's be clear - all people with diabetes are at risk of hyperglycemia. How is the best way to prepare or mitigate the risk of hyperglycemia, ss to have them check their glucose, right? Now I wrote increase in brackets because some people, possibly, especially people with type one are maybe already taking quite a bit. So, whether increasing or not, certainly glucose monitoring. But let's just take a look at that statement, just as it is. Does that mean if I want to prepare everybody, all my patients with diabetes for sick day, everybody, I should be giving them a blood glucose meter. And truthfully, you and I both know we have people who are on Metformin alone, metformin and a DPP four, for example, they're not checking their sugars and that's responsible enough because if they are maintaining good A1C, do they need to have a blood glucose meter at home, do they need to be checking, right? We also have people who are on insulin, basal insulin, let’s say in the cell phone or urea and they're also not checking. Should they be checking? And I think we would all love that if they had access to it. Yes. But truthfully, I think when we go back to just thinking about who should be checking their sugars, who would benefit from blood glucose monitoring? I think that we have to look at the three criteria, they have to meet all three criteria. The first criteria is that either the person themselves or a caregiver can demonstrate proficiency with actually using the meter, because if not, it's a waste of actually giving them. And sometimes it's just stressing them out with asking them what their sugars are. The other thing is either the patient or their caregiver has to recognize, has to be able to know what their targets are, so I actually say it, not just knowing your targets, but interpreting the values, right, they have to know what their targets are and they have to know when they're outside of the targets. And then the third thing is, is they have to be willing and motivated to take action on the results, right, because checking your sugars without taking the action on the results is actually still quite useless, right. So an action could easily be picking up the phone and phoning their health care provider when they are in a sick day and saying, you know, “what should I do?” but at least they are actioning on those results. So having said that, when I'm thinking about who should be checking their sugars, I want to make sure that everybody I place a blood glucose meters in their hands, that they meet those three criteria they know how to action on the results they know how to use the meter.

Okay, so with respect to the dehydration, who is at risk of dehydration? Technically, Catherine, all people, right, all people are at risk. And so that's actually interesting. That's actually expanding this out. So a lot of people on this call. Many of us care for, specifically, people with diabetes, and others of us are actually caring for just everybody. So, how can I help prepare everybody for possibly sick day or COVID, or how can I prevent acute kidney injury in everybody? We could make sure that they have oral rehydration solutions at home, and although because that does cost them money, so access could be an issue. At least have raw fruits in their house available at all times, possibly. So that's just another, you know, another thing. Having said that, if, if they're able to rehydrate appropriately, are they at risk of dehydration? Technically, we've managed their dehydration by appropriately rehydrating and I want to say *appropriately*. A lot of times I'll tell people, “oh, you should have rehydration solutions,” but they don't, you know, they might vomit two to three cups of fluids, but they're only taking one cup of oral rehydration solution. So it has to be, you know, volume out comes volume back in. But once you've been able to mitigate the risk of dehydration, then technically we've actually reduced that risk, right.

So when we read, who is at risk of dehydration and acute kidney injury, it's those who have, who are at risk with fever, vomiting, diarrhea, and who are unable to replace the appropriate fluid, and it's in those people that we hold SADMANS medications. So I know that the little bit of nuances, because why am I careful not to just jump and hold SADMANS meds is because, for example, if I hold a cell phone while you're real too early, possibly, we're just contributing to the hyperglycemia. On the other hand, the other last S is an SGLT2, so I might actually consider holding that earlier than the stuff on the radio. Those are just, um, I guess you know we all, we all, the SADMANS is an excellent algorithm, but how we interpret it, how we actually manage it can sometimes help people without holding too early, but not holding too late.

Okay. So, with respect to diabetic ketoacidosis, who is at risk? So basically, number is those people who have that bigger gap. So we have this hyperglycemic happening, effect happening due to the counter-regulatory hormones. It's pretty much the people who are at risk are the ones who actually have less endogenous insulin, because technically, remember how I was saying everything's in balance. And if we were without diabetes, then we would be able to, the hormone release the counter-regulatory hormone release goes up, but so does our natural endogenous release. So the people who are at higher risk of DKA, there's those literally that have a compromised endogenous release of insulin release. So that would be type one diabetes, type two who have, their diabetes has progressed to the point where they actually need basal/bolus insulin implies that they have less endogenous insulin available, and then anybody who's on an SGLT2-I, right. So I know you can use it off-label in type one, so literally anybody even if you're just, you know, metformin on an SGLT2-i, are you at risk of DKA because the SGLT2-i which is causing, hopefully lowering the sugar levels, will have less of, of the insulin being released, possibly. And how do we how do we mitigate for the DKA would be to make sure they're doing all the first three, the first two buckets *and* checking ketones. And you'll see the ketones, I also have that red little star there too, because a ketone meter, just like a blood glucose meter shouldn't necessarily be placed in anybody's hands. It has to be placed with the appropriate three criteria: does a person know how to use it, have we shown them how to use it, have they demonstrated proficiency in how to use it - or the caregiver. Do they know what the numbers mean and do they know how to take action on those numbers. So again it's, I definitely would put it in people's hands with that meeting those three criteria.

So as a quick overview, how do I manage all people with diabetes? I want to make sure everybody has oral rehydration solutions or broth soup. I need to make sure everybody knows what the SADMANS meds are for them. And the glucose monitoring should happen with education with appropriate, purposeful glucose monitoring. And then more specifically ,the people with type one diabetes, type two on basal/bolus insulin, or anyone on SGLT2-i, same things. Plus, add a ketone meter with the same education.

Okay. So we talked about SADMANS and I did allude to it. I just think, I think most people on the call probably know how to, know what the different categories are. The other thing is just to make sure people know where to find that, which would be on guidelines, the Diabetes Canada website, and it's Appendix 8. But you can find that on the website. Okay, so this tool is also available on the website under the “Keeping people safe” bucket, and I will use this tool in my pharmacy, especially when people are at that stage of change and they want to know how to care for themselves. And I find that this one tends to help because it does, so Catherine if you advance, it does show you because some people don't know the different drugs which are in which classes. And so this helps me help them, especially because sometimes things are, you know, they'll change from Jardiance, they'll combine the Jardiance with the Metformin that will become SinJarD. So, you know, we have to make sure that we're staying on top of all the different names that the person might be on, and making sure that they know what's available or what, what exactly they're taking. You'll see here's the list of the different fluids, but I still kind of try to emphasize, what's the gold standard, which is those electrolyte replacement therapies, because that to me is the step that literally you're, you're trying to rehydrate, you're trying to rehydrate and if you can't get that in, if you can't keep that down, that's when you unfortunately will need to be going back to step before an IV, right. So, and the difference between the commercially available electrolyte replacement solutions versus possibly watered-down apple juice, for example, is just the way the concentration of electrolyte to glucose is, is available in the product and how in the commercially available products, they are physiologically balanced and that's how it's absorbed across the dashboard, a membrane. And then the last thing in on this, well sorry, all their things on it of importance I want to touch on is the fact that this tool couldn't be a be all and end all for everybody, but it did point out that if you're on insulin, you need to check your blood sugar more often and you might need to adjust your dose. So the idea is just to give them an idea of, that they, they should be aware of that they have to do it. And if they don't know how to adjust their insulin, we need to spend more time and explain that to them.

Okay. This one is a little overview of quite honestly, everything that we've talked about and we are going to talk about. But the one thing I wanted to point out is the very, the fourth bullet, the last bullet, which says, “develop the sick-day plan with your diabetes health-care team.” And what I thought I would share with you is one of the things I tried to do in my practice, is when somebody comes in and if I actually have spent the time to work with this person and develop this sick-day plan, which would possibly include insulin adjustments, including possibly insulin adjustments with ketone measurements. I'll ask the patient who's on their diabetes health-care team. And if they have an endocrinologist on board or if they have a, like, in addition to the primary care provider and if they are also seeing a diabetes educator, I'll ask them for permission, that I may fax this over to their entire members of their team, so that we're all saying the same messaging and I share that with you because if you guys are in diabetes education centers, I'm hoping you might do that similarly with us as community pharmacists. Ask the patient if it's okay that you share it with our team, with their entire team. As a community pharmacist, I would definitely and I shouldn't say, just give me a family health team, right, we would all scan it in attach it to the file. There’d be a date on it and if I was called and the person was sick and they couldn't reach anybody else but they reach to me, I would at least be able to help them just double-check their calculations, possibly. Okay. I think, Catherine.

Catherine Yu: Alright, so thank you, Susie for that. So that was the preventive bit as Susie mentioned. Now we're going to move on to really, so, really sick day management where okay, you have, you know, maybe milder, early DKA, what do you do now? And so the disclosure now is that we are following up away from the guidelines and that we don't have specific guidelines or guideline materials regarding treating mild DKA at home. And so really what, what's coming now is just practical tips as, as healthcare professional that we are sharing with you for really sick-day management. So, um, what to do if there's early, mild DKA or HHS, and here we've defined that as blood glucose greater than 14, with an asterisk, and blood ketones more than 0.6. So the asterisk, many of you guys are probably already know is for the incidence of euglycemic DKA with SGLT2-inhibitor use, and so you wouldn't necessarily need to have this criteria.

If you were, if you were worried about someone with DKA on SGLT2-inhibitor. As Susie mentioned, does that mean that all my patients with an SGLT2-inhibitor know how to test for ketones. And, Susie mentioned, I worry more in people who are more insulinopenic. So we're again that gap of where they're, where I worry that they have low insulin. So like, the skinny type two. Or the,  the type two who is on max dose for example, or agents, where I know that they have a low insulin endogenous reserve. In those situations, and oftentimes when I'm prescribing it of course I’m counseling about DKA and then their question will be, “well, how do I know if that happens?” I'll say, well, you can check with the ketone meter and then the prescription will also include a ketone meter and if they don't want to check for ketone meters, then I just tell them to go seek urgent care. Mention that they are on this medication and to check for ketones.

OK, so moving on, we're going to go through a few cases of different regimens for type two diabetes. So if you're not on insulin, usually we recommend to our patients checking blood glucose every four hours, not necessarily checking ketones, unless your on SGLT2-inhibitors, and then in some would not be applicable. If you're on an SGLT2-inhibitor if initially positive, I would continue checking ketones every four hours. If on basal insulin, then I would again, check blood glucose every four hours, check ketones every four hours if initially positive. And again, because they're on basal insulin, they won't have any rapid acting and so I wouldn't suggest corrective insulin unless they happen to have a prescription or rapid-acting insulin at home. Similarly,  for mixed insulin, the same algorithm. If you're on basal/bolus insulin, I would check every two hours. Not because I think the disease is worse, but more because we can act on it. There's sort of no point in, in checking more frequently if you can’t act upon it. And so with basal/bolus insulin, I would check every two hours, both blood glucose and ketones. And then in terms of insulin, Susie's going to walk us through different algorithms for corrective insulin in a few minutes. But I think the most important column is coming up here, which is when to go to the emergency department, and we’ll reiterate this again. If blood glucose continues to rise after eight hours and ketones more than 1.5 hours. So note that, a lot of sources and references will say six hours. I've indicated eight here because it's hard to do every six hours when you're checking every four hours. And then the other thing is if ketones are more than 1.5. So I'm going to hand this over to Susie now.

Susie Jin: Actually Catherine, keep it on the other one. So, Catherine was telling her stories and how she was embarrassed because one of her patients actually ended up in, which I love that she so honest because it just makes it like, oh, thank goodness that it happens to other people too, right. So I did also have another story where I had somebody who was on an SGLT2i and basal insulin and they were started on a GLP1. And of course, you can imagine that, that time they're starting a new agent, they get all this different state of change and they're kind of thinking, okay, what else can I do. So we started also looking at their healthy behavior interventions, including reducing some, like, they went to low carb, they did go keto but they went low carb. So of course, later on, later later on, they start telling me they get stomach upset. So, you know, I'm a community pharmacist, I don't want to be having one of my patients in emerg. But you know they're on an SGLT2i, they're on a low carb foods, I really, you know, unless you really spend the time to actually look at exactly, you know, but now they have stomach upset, but they're on the GLP1. So you sort of say, but don't forget, I also, as they're going down on a low-carb carb foods, you're gonna cut back your basal insulin. So, are they with their stomach upset just the DLC1 or could they possibly be, maybe you know, if you cut back the insulin too much. That's also sometimes what happens when you get that different risk. So it's an interesting story of trying to make sure that we're positioning ketone meters in the right people. And I think that's an example where I actually had my delivery guy rush a meter, a ketone meter over to them. They checked and they were able to manage at home. I've also had awesome experiences where my diabetes education center has phoned me and asked me how quick I can get a ketone meter ready for a patient's family member to come pick up. And just to give you an example of how collaboration seems to work really well. And it was awesome just to be part of the team when they phoned me and said, “I need to get a ketone meter to the person immediately and, you know, that we are helping patients together and keeping them safe.” Okay, so, Catherine, actually go back one second. Catherine has gone over what to do to in early or mild DKA or hypersomolar hyperglycemic syndrome in people with type two diabetes. So I always like this. So the next slide is going to be on type one, but I always like to say to myself, actually go back. It's like, what would be the difference, what would be the difference in the slides between the type two and a type one, because sometimes you're just like, “oh, I got it,” right. So, let's look at the title, what to do in early, mild DKA/hypersomolar hyperglycemic syndrome. So you can imagine type one, they don't have the endogenous insulin. So they're not going to have HHS, right, so they're going to go straight to DKA, and then if you look on the very bottom line there. Type one would be on basal/bolus insulin, do you think will still check every two hours, do you think will still check ketones every two hours? And so I like to sort of say to myself, where would I be different? And if we go to the next slide, you'll see it actually is all the same, except for the fact that there's no HHS, and the only difference is, is because the risk of DKA and progressing is so much faster, the “go to emergency department” is to blood glucose, if the blood glucose has continued right after six hours instead of the eight hours.

All right, next slide them. So when it comes to, yeahif you go to the next slide, if sorry, Catherine okay, thanks. So when you go, when you look at this one is the algorithm for people with type one or type two diabetes on basal/bolus insulin and I just wanted to point out a couple things. So if you forward slide. You can see that, of course, if we're less than, if we’re having a low, then of course you're going to treat the low. But if you're vomiting, that's when you it's not, because we're now sick, right. So it's not just treat the low, but if you're vomiting, contact your diabetes team because we are worried that that is a symptom of DKA. Okay, next. Say you have a four to 16 as a blood sugar norm, but you can see if there's no ketones, then it's just take your usual dose, unlike when you do have moderate ketones or blood ketones above 0.6, that's when we have that hyperglycemia kind of sick day more counter-regulatory hormones, which is why we need to add the 10 percent, and I know so many people will have, in their sick day, of course they're vomiting, they, they're not eating as well. And they always were, “why am I still taking my insulin?” And I think that hopefully that by explaining that you, you have more confidence as to why it's important to not stop your insulin and to definitely even increase depending on the ketone level. Okay, I'm going to skip over the rest, only because it's kind of there. And these are available through you saw St Mike's, St Mike's website. And then the other one that Catherine has, is the Alberta health services, my little point is, is that sometimes, see how this is done by weight, sometimes you'll still see people who are insulin sensitive. So I think it's take it with a grain of salt. You can see that as the weight goes up, you'll need more insulin because possibly you have more insulin resistance. But sometimes I'll really just do it based on ketones and blood sugars. Catherine, did you have anything else to add about those?

Catherine Yu: No, I mean it's just an example of resources that are available across the country. That so you don't need to reinvent the wheel. And oftentimes, I've seen people share it on the, on the Diabetes Canada platform, so I think the important part is individualizing it to your patient and making sure that you do the education.

Susie Jin: Perfect.

Catherine Yu: So we're gonna move on to really, really sick day management, and then I see there's some questions coming up. And so we'll finish up quickly to answer those questions. So for really really sick day management, as you can probably guess from sort of the tone and flow of this presentation, our clients need to get themselves to the hospital. And what situations would be the absolute, you have to go, would be can’t keep down fluids, changing level of consciousness, persistent hyperglycemia despite treatment for more than six hours, persistent hyperketonemia despite treatment for six hours. And lastly, to lead into Dr Cheng's presentation, if you have hypoglycemia, because obviously, the management that we went through will result in hypoglycemia. And if you can't balance that off treating ketones, with the glycemia, than they need to come into hospital. But again, it's very individualized if someone if, if you are not confident in someone’s self-management, then they need, you should have a lower threshold for sending them to hospital. So someone who is, is not savvy about how their medications work, who you're not certain will hold the correct medications will just be, “go to emerg. That's the safest thing for you right now.” And so I hope that you're now able to counsel clients effectively on sick day management, describe a stepwise approach for individualizing ambulatory management, and list three reasons for which adult clients *must* go to the hospital. And just to finish off with and to lead into Dr. Cheng’s session for next week, I did have two more stories from the front lines of two of my patients that ended up in hospital due to, ue to other reasons other than COVID-19. And so in this case I'll start with the twist, the twist is home baked bread resulted in the other. It resulted in my patient, going to the hospital. So as you know, baking is a comfort activity and yeast and flour are, are, are now extinct in the grocery store aisles. And so one of my patients - type one on an insulin pump, very well managed. His wife was making home-baked bread. Earlier that week he had to, he had, he had some. He had underestimated dose and was hyper. Later in the week, it was a different loaf, a different flour. And so, and because he had underestimated previously, he then overestimated. He went for a walk, and unfortunately did not have any of the supplies with him. Was passed out, was found by a bystander who called 911 and brought him to the hospital. And I think after he was given glucagon, his blood glucose was found to be 2.9. And so another thing to counsel our patients about as a preventable way of entering into hospital, and then my other case was another woman who had gone to emerg and I was emailed urgently from the emerg R4, saying that your patient is having recurrent hypos 1.4, 1.9, you have to see her urgently. And then further history from my nurse revealed that it was the, the Freestyle Libre that she was getting 1.4's to 1.9’s but feeling fine and so she was one of those rare, maybe not so rare, patients where there's poor correlation between the Libre and capillary blood glucose. So I'm just going to finish off there. We were all in this together, we can do it, especially by staying home and staying safe.

Catherine Yu: So I'm happy to answer any questions. I see that there's one question here already, and Susie, do you want to take it? The question is, “what role do DPP-4 inhibitors play in DKA?”

Susie Jin: Yes. Quite honestly, they don't, they don't increase your risk. So they would be, if we go back to the slide. They would be the same as all people with diabetes. So there. So unless that person on a DPP-4 is also on basal/bolus insulin, for example, with it. We're really just thinking about the endogenous ability to make insulin. If they're, they would literally be just at the very top with, they're just all people with diabetes. So what would I do, I would make sure that they have a glucose meter if they know how to use it and have oral rehydration solutions and of course not part of SADMANS, so you wouldn't have to hold it.

Catherine Yu: So, great, thanks Susie.

Grace Leeder: I saw that someone raised their hand. We don't have a way of letting people's mic go live and ask a question. So if you have a question, you just have to type it in the Q&A box.

Susie Jin: Excellent. So I'll read out the next one. “Blood ketone strips are expensive and expire. How realistic is it to give to all our type one patients with diabetes?” Good question. So I think let's just make sure, so it's true that they are expensive and they do expire, let's make sure that we are not just jumping to that conclusion. Let's double check that they have a drug plan and if they have a drug plan, let's make sure that we, let's make sure that we still make it accessible to them. Other than that, it although we do prefer blood ketone, there are urine ketones, which also expire. The other option is depending on how far they live from the pharmacy, you might be able to do it the way I did it, which was or which you know, when they're sick then you rush out and get it. Not the best, there's, I wish there was a better answer.

Catherine Yu: Susie, there's another question, “looking at urine ketones, are they good enough?”

Susie Jin: I think they're better than nothing, but they won't be as accurate or won't pick it up as early, but certainly better than nothing. So that's, I think, why we do the guidelines even say we prefer blood, but there still is in the all those charts, moderate to trace markings for urine ketones.

Catherine Yu: There's another question here. “I noticed ASA is not in the sick day sheet. Any reason why?”

Susie Jin: Because a sick day medication sheet was created to help prevent, quite honestly, acute kidney injury, which has to do more with the flow of the dynamic. So unless, maybe Catherine, maybe they're referring to the fact that ASA is a form of an NSAID, so we can just stop it. So actually, it is technically, just we didn't really fully specify ASA.

Catherine Yu: I would say if you're using ASA at sort of NSAID inflammatory doses, that it should be held. But oftentimes it's used in quote primary prevention at 81 milligrams per day, which I would think has minimal effects on renal blood flow. But if it's easier to counsel your patient to stop an NSAID, then go ahead because the few days, if you're not,

Susie Jin: Yeah, it’s probably not going to count.

Catherine Yu: Will likely be fine.

Susie Jin: There's another question, “is outpatient foot care still being provided?”

Susie Jin: And actually, I think Wounds Canada just released a whole article about foot care, outpatient foot care in the time of COVID, so I'll make sure I get that and load it up on Timed Right.

Catherine Yu: Thanks Susie. In my experience, I have, we do have additional resources out in the community, that foot care is still being performed.

Catherine Yu: And there's another question. “Do we need to worry if blood ketones are above zero but less than 0.6? Should we start extra hydration?”

Catherine Yu: I can take that. So, blood ketones between zero and 0.6. So, if I was to check my ketones now, they would probably be 0.6 because, because I haven't eaten yet. So, but I'm not concerned because I'm not ill. If, if someone hasn't been eating, that's probably why their ketones are between zero and 0.6. But if they're ill, that could be another reason, if they're ill, I would, I wouldn't get them to start extra rehydration at that point. So it was, it's more of the illness, rather than the ketone level that would trigger the extra hydration. Does that answer the question?

Susie Jin: Yeah, although extra hydration, of course, as always. Well, except for unless you’ve been told to restrict your fluids, but generally it’s always a good thing anyway.

Catherine Yu: Yeah. And then another question, "have I seen marked hyperglycemia, acute insulin deficiency in COVID patients who do not previously have diabetes?”

Catherine Yu: So, it's hard to say. I haven't seen that. And the literature suggests that, the literature has not been suggestive of that. What we do know recently in a cell metabolism paper is that marked rises in hyperglycemia portend, not surprisingly, a poor prognosis. Whether that's because of an effect, a direct effect in the pancreas, has not been demonstrated, but more likely as a quote side effects slash consequence of the severity of illness.

Susie Jin: Thanks Stephanie. I’m thinking, could COVID in itself, you know, sometimes you're, you could be seeing undiagnosed or unrecognized diabetes. So maybe we're seeing things that are happening. That it's not maybe COVID that brought it on, but you're, it's the infection that caused the unmasking of the diabetes, possibly.

Catherine Yu: Potentially, for sure. So, when I was attending on COVID, and not because I'm an endocrinologist. But actually, everyone's blood glucose were very well controlled, like it wasn't one of the things where, oh, I need to consult endo because the blood sugar's up and down. In fact, they were, the blood sugars were pristine during, during COVID. And then in weird cases, I mean, like one guy came in on insulin, like 26 units of Lantus. And then, and this is not to say that there's like a protective effect because there's like a million other things going on in this guy's life. But then I discharged him on Metformin and Linagliptin only. So, so I haven't seen that there has been an impact on, in terms of hyperglycemia.

Grace Leeder: Yes. So it's, um, it's, it's one o'clock, so I think we'll wrap up, I really want to thank Catherine and Susie for today’s presentation. It was really great, really informative and I think very useful resources that the recording will be available on Timed Right. Should be available today or by tomorrow and we'll get a recording up on diabetes.ca as well for future reference. So again, thanks. Catherine and Susie and thanks for everyone who joined in today.

Susie Jin: Thanks Grace.

Catherine Yu: Thanks Grace. Stay safe everyone.