SICKDAY MANAGEMENT Children With Diabetes Friends for Life

SICK-DAY MANAGEMENT Children With Diabetes Friends for Life Conference Orlando, FL July 23 – 27, 2008 H. Peter Chase, MD Professor of Pediatrics University of Colorado Denver Barbara Davis Center for Childhood Diabetes 1

DIABETES EDUCATION: The cornerstone for optimal care and outcome. “Apple pie and Motherhood” § New-onset (1 -3 days) § Daily phone contact, one week, one month – every three months § Understanding Diabetes: 15, 000 copies/year “ The Pink Panther Book” § “The First Book” (Synopsis of “big book”) 53, 000 copies last year (available: 1 -800 -695 -2873 or free on the internet at: www. barbaradaviscenter. org) 2

SICK-DAY MANAGEMENT 1) People with diabetes get sick just like anyone else. 2) Average = 6 known infections per year in children. 3) Four main concerns: 4) I. Dehydration 5) II. Hyperglycemia (high BG) 6) III. Ketones (DKA) 7) IV. Hypoglycemia 3

I. DEHYDRATION (loss of body fluids) 1) Can occur in anyone if fluid intake is not adequate. 2) More likely with diabetes because the glucose pulls water out of the body for excretion in the urine (can’t excrete sugar cubes). 3) Diabetes is the only disease in which someone can be dehydrated and still pass much urine. 4) The higher the BG, the more water that is “pulled” out of the body. 5) Vomiting and not drinking adequate fluids add to the problem. 6) A good physical sign to look at is often the dryness of the tongue. 4

DEHYDRATION/VOMITING* 1) May need a medicine to stop vomiting: Phenergan: children over age 2 years Zofran: oral 2) Fluids – Start slowly: Pedialyte, juice, water BG <100: Fluids with sugar; popsicles, jello, etc. - Gradually increase to requirement of 1 oz/yr of age/hour for up to age 16 yrs. 3) The fluids help to “wash-out” sugar and ketones, to restore circulation, BP and other parameters. 4) Solid foods: When no further vomiting (e. g. crackers, banana, soup, what child wants) * Understanding Diabetes – page 178 5

II) HYPERGLYCEMIA (High blood sugar) 1) Many infections cause release of cortisone which raises BG (e. g. Mumps). 2) Make sure ketones are not present. 3) Give usual insulin plus extra injections or boluses every 2 hours. Use usual correction factor (most common is 1 unit/50 mg/dl over 150). 4) Frequent blood sugars is a key. 6

III. KETONES (DKA) 1) MUST CHECK KETONES WITH ANY ILLNESS (even vomiting one time) OR IF HIGH BG (e. g. >300 mg/dl). 2) Education about ketone testing is the most common deficiency in families referred to our Center. 3) If ketones build up = DKA. * 4) DKA is the number one cause of death in children with diabetes. 5) DKA is almost completely preventable in a properly trained family. 6) *(Understanding Diabetes, Chapter 15, page 163) 7

WHAT CAUSES KETONES? * 1) INFECTIONS – number 1. Due to fat breakdown to supply extra energy and secondary to increased cortisol. 2) MISSED INSULIN → fat breakdown. 3) PUMP INSERTION DISLODGING. 4) NOT ENOUGH INSULIN. 5) TRAUMATICE STRESS ON BODY. 6) *Understanding Diabetes – page 164 8

WHERE DO KETONES COME FROM? Fatty Acids and Glycerol Fat Liver Acetyl-Co. A + Oxaloacetate Hydroxybutyric acid ( -OHB) TCA Cycle for energy Acetoacetic acid (Ac. Ac) Acetone 9

HOW TO CHECK FOR KETONES 1. MUST ALWAYS HAVE A METHOD IN THE HOME and ALONG ON TRIPS. 2. Urine test: cheapest; not as accurate as urine may not reflect current status. Ketostix – good for 6 months once bottle opened (get foil-wrapped!). 3. Blood meter: Precision. Xtra • More expensive; most accurate – gives the exact level at time of testing. • Many families do only if can’t get urine or if urine test high. • More apt to do (93%) than urine (53%) when ill. 10

COMPARISON OF BLOOD and URINE KETONES: * Blood (mmol/L) Urine < 0. 6 negative 0. 6 to 1. 5 small to moderate 1. 6 to 3. 0 usually large ≥ 3. 0 go directly to the E. R. Very large *Understanding Diabetes – page 30 11

The Annual ADA Standards of Care states: “Blood Ketone testing methods that quantify ß-HBA, the predominant ketone body, are available and are preferred over urine ketone testing for diagnosing and monitoring ketoacidosis. ” ADA Clinical Practice Recommendations: Jan, 2003 Position Statement: Diabetes Care, S 107, 2003 12

-hydroxybutyrate is a better indicator of metabolic status when detecting and treating DKA* * Schade DS, Eaton RP Special Topics in Endo and Metab 1982; 4: 1 -27 13

Old Paradigm: Check urine ketones New Paradigm: Check blood -OHB Ø Blood -OHB tells you how you are doing at the time of the test (Urine may have been in bladder for hrs) Ø Urine ketone levels may not accurately reflect the severity of the problem Ø A person may not be able to void Ø Some (teens) give false urine test results 14

New Paradigm: Check blood -OHB (cont. ) Ø Some people are too ill/exhausted to do the urine test Ø Urine ketone strips spoil after opened x >6 months Ø Urine strips check for Ac. Ac, whereas the more important ketone is -OHB Ø Use of blood -OHB test may save an ED visit or a life! 15

If Money/Insurance Is a Problem: 1. Can test urine ketones 2. (If a sample can be obtained) 2. Skip the blood ketone test if the urine test is negative, trace or small 3. Use the blood strips anytime the urine test is moderate or large 16

Why are ketones dangerous? § Acidosis ensues as ketones build up § - Hydroxybutyric acid ( -OHB) is the main ketone § Glucose is high: dehydration § Potassium is lost GI motility vomiting § The “acid” state of the body interferes with body metabolism 17

Diabetic Keto. Acidosis (DKA) § 160, 000 Admissions to private hospitals/year § Cost = over 1 billion $ annually § 65% = <19 years old § Main cause of death in children with diabetes (approximately 85%) § Cerebral edema in 69% of deaths 18

Signs of DKA: i) Increased urination ii) Stomachache, vomiting iii) Fruity odor to breath iv) Dry mouth and tongue v) Drowsiness vi) Deep breathing vii) Coma viii) Death (very rare if treated early) 19

Denver DKA Data (ED or Hospitalization) (Rewers, Chase, et al: JAMA 287: 2511, 2002) § Definition: an episode of DKA leading to an ED and/or hospital admission § 1243 children living in metro Denver with known type 1 diabetes (not new onsets) § 3994 person years of f/u (1/1/1996 -12/31/2002) § Infancy to age 19 yrs § Incidence: 8 per 100 patient-years 20

TREATMENT: (Directions from Understanding Diabetes* page 167) -OHB level (mmol/L) 1) 0. 6 – 1. 5 = Take 10% of total daily insulin dose every 2 hrs; fluids; Call HCP. 2) > 1. 5 – 3. 0 = Take 20% of total daily insulin dose every 2 hrs; fluids. Must call HCP. 3) >3. 0 = Go to ED. *available: www. barbaradaviscenter. org or call: 1 --800 -695 -2873 21

TREATMENT: “Mild” Ketones* • A much more common problem than severe DKA. • Almost every child with diabetes has 1 -4 times annually after the “honeymoon” period is over. • By definition: Able to be handled in the home setting – usually with telephone help from the HCP. Always take phone numbers on trips! *Small - moderate urine ketones or blood ketone level <3. 0 mmol/L. 22

“Mild” Ketones: Denver Data on Phone – Management: Chase et al: i) Ped in Review 11: 297, 1990 ii) Arch Pedriatr Adolesc Med 152: 672, 1998 iii) 57 children, ages 1 – 18 yrs. iv) Small ketones = 4 pts v) Moderate ketones = 22 pts vi) Large ketones = 31 pts. vii) Time to resolution: Mod = 4. 1 Hrs viii) Lge = 4. 5 Hrs ix) Four children = ED and/or Hospital (6%) 23

Sick Day Management Study* Goal: To evaluate the impact on hospitalizations of a blood ß-hydroxybutyrate (ßOHB) test vs. urine ketone tests Design: • 123 participants, ranging in age from 3– 23 years • 61 participants randomized to use blood ßOHB measurements using the Precision Xtra™ Advanced Diabetes Management System • 62 participants randomized to use traditional urine acetoacetate measurement using Ketostix® • All participants were trained on their sick-day guidelines • Data collected included episodes of illness, ER visits, hospitalizations, blood glucose testing frequency, ketone testing frequency and A 1 c (glycohemoglobin) *From Laffel et al, Poster 426 -P, presented at ADA Scientific Sessions, San Francisco June 2002 24

Testing for Ketones When ill 123 Adolescents randomized: ü 62 to blood OHB ü 61 to urine ketone testing Sick Days Checked for Ketones OHB = 304 91% Urine K = 279 56% (Laffel L et al, Diabetes 51, 426 P, 2002) 25

Summary: Study Findings • Participants managed with blood ßOHB ketone test during sick days were 46% less likely to require an ER visit • Participants managed with blood ßOHB ketone tests during sick days were 64% less likely to be admitted to the hospital • 70% of those participants testing blood ßOHB reported they would check blood ketones more often than urine ketones (Laffel L et al, Diabetes 51, 426 P, 2002) 26

Directions in Understanding Diabetes regarding blood -OHB (page 166) -OHB level (mmol/L) < 0. 6 = Normal 0. 6 to 1. 0 = Take extra insulin + fluids 1. 0 to 1. 5 = Same; call HCP 1. 5 to 3. 0 = Call HCP STAT > 3. 0 = Go to ED 27

CASE EXAMPLES 11 yo ♀; Mom calls (10: 00 am) • Home from school with fever • Rapid-strep test positive yesterday • Treatment with penicillin • BG 380 mg/d. L; -OHB = 1. 3 mmol/L • Usual AM insulin: 4 H/12 NPH – 7: 00 pm: 4 H/20 Lantus (40 units total per day) • Plan: 4 units H every 2 hrs until -OHB <0. 6 Encourage fluids (juice if BG <150) 28

CASE EXAMPLES: 4 yo ♂; GI flu 7: 00 am: Mother phoned: emesis x 5 thru night 1 st void since 9 pm BG = 180 mg/d. L; Urine ketones = Large ? Take extra insulin ? Advice: Do blood -OHB level 7: 15 am: Blood -OHB = 0. 3 mmol/L (normal) Advice: No extra insulin; Usual dose + fluids 9: 00 am: Urine ketones neg; feeling fine 29

CASE EXAMPLE: 14 yo♂; Pump failure Time -OHB Art. p. H BG (mg/d. L) 11 am > 6. 0 7. 02 1042 2: 30 pm 5. 7 7. 2 409 5 pm 3. 0 7. 23 267 7: 30 pm 1. 7 7. 34 162 8: 30 pm 0. 2 7. 45 119 30

CASE EXAMPLES: Diabetes Camp 7: 00 am: infirmary? 4 children with moderate urine ketones, which one(s) need to go to the -OHB level (mmol/L) #1: 10 yo ♂; BG = 276/mod 0. 3 #2: 13 yo ♀; BG = 303/mod 0. 5 started menses #3: 9 yo ♀; BG = 240/mod 1. 7 upset stomach #4: 9 yo ♂; BG = 320/mod 0. 4 31

III) KETONES SUMMARY § DKA is a serious illness and complication of diabetes. § Checking serum -OHB early (and often when elevated) and implementing proper treatment can lead to early resolution and MAY BE LIFE-SAVING! § Use of blood -OHB testing likely saves money in the prevention and treatment of severe DKA. 32

SICK DAY MANAGEMENT: IV. HYPOGLYCEMIA 1) When treating Dehydration (I above) or Ketones (III above), must add fluids with sugar when the BG is <150 mg/dl (<8. 3 mmol/L) (Ketones may still be present and need to continue giving insulin every 2 hours to turn ketone production off – so must keep BG up in safe range). 2) Pedialyte, Gatorade, Jello, Popsicles are examples of early liquids in Table 4, page 179. 3) Solids (when ready) might include: soup, crackers, bananas, apple sauce (page 179). 4) Frequent checks of BG (and/or CGM) are essential. 33

IV: HYPOGLYCEMIA: A Low Dose of Glucagon: (page 178 – Understanding Diabetes) 1) NOT the larger (0. 3, 0. 5, 1. 0 cc) dose used for a severe low. 2) Use if BG is low (e. g. <60 mg/dl [<3. 3 mmol. L]) and food cannot be kept down. 3) Dose: 1 unit/year of age up to 15 units. 4) Can repeat every 20 minutes if needed. 5) Has done more to save ER visits than anything else in my career. 34

INSULIN DOSAGE WITH ILLNESS: (page 176 – Understanding Diabetes) 1) Some insulin MUST ALWAYS be taken (to keep ketones turned off). 2) If BGs are low – may only need basal insulin (Lantus, Levemir) or basal insulin in pump. 3) If trace/small ketones with low or normal BG, may just need to eat (to provide calories and stop fat breakdown). 4) If high BG or ketones, extra rapid-acting insulin every 2 hours (as above). 35

EXERCISE WITH ILLNESS 1) Don’t exercise with moderate or large urine ketones or with blood ketones above 0. 6 mmol/L. Exercise results in increased adrenalin (epinephrine) output which can further increase ketones. 2) It is an “old wives tale” that one can’t exercise with high BG when ketones are negative (the increased utilization of glucose overrides any adrenalin effect). 3) Use common sense. 36

SUMMARY: SICK DAY 1) Sick days require a bit more work for people/families with diabetes – but can be managed. 2) Illness – related factors (e. g. sore throat) should be handled by the primary care MD and diabetes – related factors (ketones, insulin dose, etc. ) by the diabetes team. 3) Good education, as with all of diabetes management, is the key to handling sick-day management. 4) QUESTIONS? 37