06.05 Endo/Metabolic
06.05 Endocrine / Metabolic [PDF link]: Diabetic ketoacidosis (DKA) – Euglycaemic ketoacidosis. Hyperosmotic hyperglycaemic state (HHS). Hypoglycaemia. Diabetes insipidus – Water deprivation test.
More on DKA
No formal NICE guidelines, but a short segment on assessment and diagnosis of DKA and HHS in the CKS page here
The Joint British Diabetes Societies (JBDS) guidelines are quite useful, and there is a single page summary of the guidelines that give a clear list of things to do
More on HHS
Again no specific NICE guidelines, but the JBDS guidelines are useful – p3 specifically has a timeline summary of actions to take to sort out someone with suspected HHS.
Mustafa OG, Haq M, Dashora U, Castro E, Dhatariya KK. Management of Hyperosmolar Hyperglycaemic State (HHS) in Adults: An updated guideline from the Joint British Diabetes Societies (JBDS) for Inpatient Care Group. Diabet Med 2023;40:e15005. https://doi.org/10.1111/dme.15005.
More on hypoglycaemia – practical management
See the JBDS guidelines – PDF guideline is quite detailed and helpful, and there’s also a simple algorithm (no idea why it’s in pptx)
If pt is on IV insulin, pause it. Restart when CBG ≥4mmol/L and monitor regularly (CBG every 1-2h)
After any intervention, recheck glucose in 10-15 min
If CBG ≤2.5-4 mmol/L after 2-3 cycles of treatment (depending on Trust policy) – GET HELP (escalate early / met call if needed)
Parenteral options (prescribing)
Glucagon 1mg IM – licensed only for insulin-induced hypoglycaemia, can take up to 15min to work
IV glucose: 100ml of 20% glucose (at 400ml/hour over 15 minutes) or 200ml of 10% glucose (at 800ml/hour over 15 minutes)
Once CBG ≥4 mmol/L, give longer acting carbohydrate (eg 1-2 slices of bread, biscuits)
If NBM, prescribe 10% IV glucose at 100 mL/h until senior review
If glucagon given, give double the amount of carbs (eg 4 slices of bread) to prevent hypos
Do not omit regular insulin doses. Consider titration of insulin or sulfonylurea doses.
More on diabetes insipidus
Aka arginine vasopressin deficiency (AVP-D; = central diabetes insipidus) or resistance (AVP-R; = nephrogenic diabetes insipidus)
No NICE guidelines. The only UK guideline I could find was from the Society for Endocrinology
Baldeweg SE, Ball S, Brooke A, Gleeson HK, Levy MJ, Prentice M, et al. Society for Endocrinology Clinical Guidance: Inpatient management of cranial diabetes insipidus. Endocrine Connections 2018;7:G8–11. https://doi.org/10.1530/EC-18-0154.
Changing names
Arima H, Cheetham T, Christ-Crain M, Cooper D, Drummond J, Gurnell M, et al. Changing the Name of Diabetes Insipidus: A Position Statement of the Working Group for Renaming Diabetes Insipidus n.d.
Names changed to AVPD and AVPR due to confusion with diabetes mellitus
