Avoiding

Hypoglycaemia

Toolkit

Pilot version - February 2016

Y&H AHSN Avoiding Hypoglycaemia Toolkit

CONTENTS

Page

Avoiding Hypoglycaemia Toolkit – Introduction 1

Avoiding Hypoglycaemia Pathway 2

Hypoglycaemia Risk – Assessment Tool 3-6

Approach to Restore Hypoglycaemic Recognition 7-9

Professional Avoiding Hypoglycaemia Assessment 10-11

Hypoglycaemia Emergency Plan 12-15

Avoiding Hypoglycaemia Action Plan & 16

15 Ways to Avoid Hypoglycaemia 17-20

Avoiding Hypoglycaemia Assessment - Checklist 21

Supplementary Information (Improvement Method Pilot; Project Stage Plan; PDSA Cycle Example; PDSA Cycle Document)

Symbols: = Patient = Diabetes team

Y&H AHSN – Avoiding Hypoglycaemia Toolkit Contents List

AVOIDING HYPOGLYCAEMIA TOOLKIT - INTRODUCTION

This toolkit has been developed by a working group of diabetes experts in Yorkshire & Humber who have reviewed the hypoglycaemia evidence-base and incidence in our region. During 2014-15 there were over 2000 recorded episodes of hospital admissions relating to hypoglycaemia, costing over £6 million pounds. The majority of these episodes are preventable. The aim of this toolkit is to help patients and professionals to both recognise hypoglycaemia risk and avoid of future episodes in adult patients using a sulphonylurea or insulin. The toolkit supports the agreement of an individualised action plan in people who are at risk of hypoglycaemia or starting to have problems with the early recognition of hypoglycaemia. USING THE AVOIDING HYPOGLYCAEMIA TOOLKIT The toolkit is aimed at people with diabetes managed in primary care at risk of hypoglycaemia (using a sulphonylurea and / or insulin).

The patient ‘Hypoglycaemia Assessment Tool’ can be given out opportunistically by pharmacies, community staff, the ambulance service following a hypoglycaemic call and general practice. Patients can also be identified following a hypoglycaemic episode or via use of a risk stratification tool. This assessment can be completed by the patient alone, or with assistance from a health care professional.

On completion of the assessment the patient will be directed to discuss hypoglycaemia with their diabetes

team either urgently, non-urgently or routinely. The toolkit also includes documents to support the diabetes team in the discussion:

Approach to restore hypoglycaemia recognition

Professional avoiding hypoglycaemia assessment

Hypoglycaemia check list

The discussion with the diabetes team is supported by the following patient documents:

Hypoglycaemia Emergency Plan

Avoiding Hypoglycaemia Action Plan

15 ways to avoid hypoglycaemia

The discussion will be recorded on the GP clinical system and a review appointment date agreed with the patient.

WHEN NOT TO USE THIS TOOLKIT:

This toolkit is not intended for use with patients who are experiencing severe episodes of hypoglycaemia (unable to

self treat) or those with hypoglycaemia unawareness (the inability to recognise deep drops in blood glucose levels

into the hypoglycaemia range). This group of patients should be referred urgently to the local Diabetes Specialist

team for review.

Y&H AHSN – Avoiding Hypoglycaemia Toolkit (1/1) Page 1

AVOIDING HYPOGLYCAEMIA PATHWAY

HYPOGLCYAEMIA RISK – ASSESSMENT TOOL

AT RISK OF HYPOGLCYAEMIA?

NO YES

APPROACH TO RESTORING HYPOGLCYAEMIA RECOGNITION

PROFESSIONAL AVOIDING HYPOGLYCAEMIC ASSESSMENT

AVOIDING HYPOGLYCAEMIA ASSESSMENT - CHECKLIST

EMERGENCY HYPOGLCYAEMIA PLAN

15 WAYS TO AVOID HYPOGLYCAEMIA

AVOIDING HYPOGLCYAEMIA ACTION PLAN

= Patient = Diabetes team = Appointment = Clinical system

Y&H AHSN – Avoiding Hypoglycaemia Toolkit – Pathway (2/2) Page 2

HYPOGLYCAEMIA RISK – ASSESSMENT TOOL

Hypoglycaemia is an abnormally low level of glucose in the blood (less than 4 mmol/L).

People living with diabetes and treated with a sulphonylurea tablet (e.g. Glibenclamide; Gliclazide; Glipizide; Glimepiride) or insulin may experience occasional episodes of hypoglycaemia.

Most people will have some early warning signs that their blood glucose levels are falling under 4 mmol/L, which gives them time to correct the level. However, experiencing frequent episodes of hypoglycaemia carries a risk that in time, the early warning signs can be reduced. People who are starting to lose their recognition of hypoglycaemia early warning signs are able to tolerate blood glucose levels below 4 mmol/L without any symptoms. This can lead to more the more serious problem of ‘Hypoglycaemia Unawareness’ where warning signs are completely lost.

However, people who are developing reduced levels of hypoglycaemia warning can be helped by their diabetes team to regain recognition of hypoglycaemia early warning signs.

This tool has been developed to help people taking a sulphonylurea tablet or insulin understand their individual ‘level of risk’ relating to hypoglycaemia.

Completing the assessment will help you to understand your level of risk and advise you what to do next in order to avoid future hypoglycaemic episodes.

There are separate assessments overleaf, for those people who regularly test their blood glucose levels and those who do not test. Please complete the appropriate assessment.

If your score advises you to make an appointment with your diabetes team, please take this assessment with you. Y&H AHSN - Avoiding Hypoglycaemia Toolkit – Assessment Tool (1/4)

HYPOGLYCAEMIA RISK – ASSESSMENT (FOR PEOPLE WHO DO TEST THEIR BLOOD GLUCOSE LEVELS)

Please complete the assessment below, if you DO test your blood glucose levels. (If you do not currently test please complete the assessment overleaf). Circle the appropriate answer, add-up the numbers in the brackets ( ) for your total score and then read the related ACTION plan (on last page). Take your completed assessment to your next diabetes review.

1. IN A TYPICAL WEEK , HOW OFTEN DOES YOUR BLOOD GLUCOSE FALL BELOW 4 MMOL/L?

SCORE: NEVER ( 1 ) ONCE OR MORE ( 3 ) DAILY ( 5 )

2. IN A TYPICAL WEEK , HOW OFTEN DOES THE WORRY OF YOUR BLOOD GLUCOSE LEVEL FALLING BELOW 4 MMOL/L AFFECT YOU?

SCORE: NEVER ( 1 ) ONCE OR MORE ( 3 ) DAILY ( 5 )

3. IN A TYPICAL WEEK , HOW OFTEN DO YOU TEST YOUR BLOOD GLUCOSE LEVEL?

SCORE: ONCE OR LESS ( 5 ) TWICE OR MORE ( 3 ) DAILY ( 1 )

4. CAN YOU TELL BY YOUR SYMPTOMS THAT YOUR BLOOD GLUCOSE IS FALLING BELOW 4 MMOL/L?

SCORE: RARELY ( 5 ) SOMETIMES ( 3 ) ALWAYS ( 1 )

5. WHAT LEVEL DOES YOUR BLOOD GLUCOSE FALL TO, FOR YOU TO TAKE GLUCOSE / TREAT YOUR HYPO?

LESS THAN 2.9 MMOL/L 3.0 – 3.5 MMOL/L 3.6 – 4 MMOL/L

SCORE: ( 5 ) ( 3 ) ( 1 )

TOTAL SCORE = (SEE LAST PAGE FOR YOUR ‘ACTION PLAN’)

Y&H AHSN - Avoiding Hypoglycaemia Toolkit – Assessment Tool (2/4)

HYPOGLYCAEMIA RISK – ASSESSMENT (FOR PEOPLE WHO DO NOT TEST THEIR BLOOD GLUCOSE LEVELS)

Please complete this if you DO NOT test your blood glucose levels. (If you do currently test your blood glucose levels, please complete the assessment overleaf). Circle the appropriate answer, add-up the numbers in the brackets ( ) for your total score and then read the related ACTION plan (on last page). Take your completed assessment to your next diabetes review.

1. CAN YOU TELL BY YOUR SYMPTOMS THAT YOUR BLOOD GLUCOSE MAY BE FALLING TOO LOW?

SCORE: RARELY ( 5 ) SOMETIMES ( 3 ) ALWAYS ( 1 )

2. IN A TYPICAL WEEK, HOW OFTEN DO YOU EXPERICENCE ‘FUNNY DO’S’: SHAKING/SWEATING/DIZZY/CLUMSY/CONFUSED/SLEEPY/HEADACHE?

SCORE: NEVER ( 1 ) ONCE OR MORE ( 3 ) DAILY ( 5 )

4. IN A TYPICAL WEEK , HOW OFTEN DO YOU ‘FEEL’ YOUR BLOOD GLUCOSE LEVEL FALLS TOO LOW?

SCORE: NEVER ( 1 ) ONCE OR MORE ( 3 ) DAILY ( 5 )

3. IN A TYPICAL WEEK , HOW OFTEN DOES THE WORRY OF YOUR BLOOD GLUCOSE LEVEL FALLING LOW, AFFECT YOU?

SCORE: NEVER ( 1 ) ONCE OR MORE ( 3 ) DAILY ( 5 )

5. IN A TYPICAL WEEK , HOW OFTEN DO YOU TAKE GLUCOSE OR EAT OR DRINK SOMETHING, BECAUSE YOU FEEL YOUR BLOOD GLUCOSE LEVEL HAS FALLEN TOO LOW?

SCORE: RARELY ( 1 ) ONCE OR MORE ( 3 ) DAILY ( 5 )

TOTAL SCORE = (SEE LAST PAGE FOR YOUR ‘ACTION PLAN’)

Y&H AHSN - Avoiding Hypoglycaemia Toolkit – Assessment Tool (3/4)

DATE ASSESSMENT COMPLETED: ____________ MY TOTAL SCORE = _____

TAKE YOUR TOTAL SCORE AND LOOK AT THE RELATED ACTION PLAN BELOW:

TOTAL

SCORE:

12 and Over 9-11 6-8 5

You may have developed significant problems relating

to hypoglycaemia recognition.

You may have developed

some problems relating to hypoglycaemia recognition.

You may experience

occasional problems relating to hypoglycaemia.

Your answers show that you are able to manage your risk

of hypoglycaemia well.

ACTION

PLAN:

Contact your diabetes team

to make an URGENT appointment.

Contact your diabetes team to

make an appointment.

Contact your diabetes team

to make an appointment.

Discuss ways to maintain this at your next diabetes

appointment.

The following related hypoglycaemia advice leaflets are available at your local pharmacy and GP practice:

HYPOGLYCAEMIA EMERGENCY ACTION PLAN – includes signs, symptoms and treatment of hypoglycaemia and your personal details. Can be shared with friends, family and colleagues to help them better understand hypoglycaemia.

15 WAYS TO AVOID HYPOGLYCAEMIA - ‘tips’ to help reduce you avoid hypoglycaemic episodes Y&H AHSN - Avoiding Hypoglycaemia Toolkit – Assessment Tool (4/4)

APPROACH TO RESTORE HYPOGLYCAEMIC RECOGNITION

The document is aimed at primary care clinicians. It describes the various considerations and actions

required to help people with diabetes begin to restore their recognition of hypoglycaemia.

MONITORING AND GOAL SETTING

Support and enable home blood glucose monitoring

Encourage BG testing before meals, at bedtime and when feeling hypoglycaemic symptoms

Encourage BG testing at 2am and 5am, at least three times weekly

Set targets for pre-meal blood glucose from 7.0-8.0 mmol/L

Try to prevent all hypoglycaemic episodes for at least 3 weeks without running blood glucose levels consistently in double figures

Agree individualised HbA1c target

PATIENT EDUCATION

Educate patients on hypoglycaemic symptoms and the role of recurrent hypoglycaemia in the development of diminishing hypoglycaemic recognition

Explain to patients that hypoglycaemia recognition can be improved through avoidance of hypoglycaemia

Train patients to recognise and respond to subtle symptoms, such as tiredness; weakness; poor concentration; blurred vision

Ensure regular and adequate carbohydrate intake

Advise carrying glucose tablets/jelly babies etc. and ensure access to carbohydrates at all times

Consider use of glucagon / glucose gel and teaching others in the use of

EXERCISE / ALCOHOL / DIETING OR FASTING

Advise to avoid:

- Intensive exercise

- Excessive amounts of alcohol (> recommended amounts)

- Dieting or fasting

during the period working on the restoration of hypoglycaemia recognition.

Drinking excessive amounts of alcohol can be dangerous for people who have diminished

recognition of hypoglycaemia

Y&H AHSN – Avoiding Hypoglycaemia Toolkit – Approach to restoring hypoglycaemic recognition (1/3) Page 7

INJECTION SITES

Examine injection sites for build-up of ‘lipohypertrophy’ (lump/thickened area under the skin caused by accumulation of extra fat at insulin injection site)

Injecting insulin into lipohypertrophy usually causes impaired absorption of insulin resulting in erratic and unexplained fluctuations in blood glucose

Ensure new injection needles are used for every injection, reusing needles contributes to lipohypertrophy

Be aware that insulin injected into a fresh site will be absorbed more efficiently, therefore doses should be decreased and extra testing performed.

MEDICATION ADJUSTMENT

SULPHONYLUREA

Consider reducing the dose or switching to a different agent such as a Thiazolinedione, DPP4 inhibitor, SGLT2 inhibitor, or GLP-1 analogues (follow NICE guidelines)

Monitor renal function INSULIN Insulin types can be substituted to reduce hypoglycaemia risk. Refer to your local diabetes specialist team.

OTHER MEDICATIONS

In patients with reduced hypoglycaemia recognition, it is important to review other medication therapies which may interact and increase the risk of hypoglycaemia.

DRIVING

Advise to avoid driving on long journeys whilst working on the restoration of hypoglycaemia recognition

Ensure that ‘safe driving advice’ is followed before and during journey’s

Driving should be stopped completely following two episodes of severe hypoglycaemia in the last twelve months. A severe episode of hypoglycaemia is a big risk factor for further episodes. The driving licence should be revoked until awareness has been restored. Advise voluntary surrender of driving licence (see https://www.gov.uk/hypoglycaemia-and-driving)

Refer patient urgently to local specialist diabetes service. Y&H AHSN – Avoiding Hypoglycaemia Toolkit – Approach to restoring hypoglycaemic recognition (2/3) Page 8

OTHER CONTRIBUTORY FACTORS

RENAL

Insulin and sulphonylurea clearance is decreased with impaired hepatic or renal function. Reducing the dose of some anti-hyperglycaemic medications and avoiding others may be necessary.

OTHER CONTRIBUTORY FACTORS

AUTONOMIC NEUROPATHY People with autonomic neuropathy can also develop ‘gastroparesis’ (slow gastric emptying). The delayed food absorption increases the risk of hypoglycaemia. Refer patient to local specialist diabetes service.

HYPOTHYROIDISM

Hypothyroidism slows the absorption of glucose through the gastrointestinal tract, reduces peripheral tissue glucose uptake, and decreases gluconeogenesis. Measure the level of

thyroid-stimulating hormone to assess for hypothyroidism.

AGEING Slowed counter-regulatory hormones, erratic food intake, and slowed intestinal absorption place older adults at higher risk of hypoglycaemia as they are more sensitive to cognitive dysfunction. Pay close attention to renal function, weight, and nutrition status in older people.

PREGNANCY

Hypoglycaemia in early pregnancy is common. If unexplained or frequent hypoglycaemia is occurring

in a female of child-bearing age, consider pregnancy as a possible cause.

REFERRAL ONTO SPECIALIST DIABETES SERVICES

Refer urgently for:

Episode of severe hypoglycaemia

Hypoglycaemic episode when driving

Pregnancy

Gastroparesis suspected

Frail elderly patients

Refer non-urgently for:

Change of regime

Dietetic review to explore carbohydrate awareness/intake

Assessment for use of continuous blood glucose monitoring device

Assessment for use of insulin pump

Structured diabetes education

Consider referral onto specialist diabetes services should no improvement in recognition be seen within 3 weeks.

Y&H AHSN – Avoiding Hypoglycaemia Toolkit – Approach to restoring hypoglycaemic recognition (3/3) Page 9

PROFESSIONAL AVOIDING HYPOGLYCAEMIA ASSESSMENT

This document is aimed at primary care clinicians. The assessment questions support the clinician to

explore the patient’s experience of hypoglycaemia; help to identify any gaps in patient knowledge

and any actions/behaviours which may contribute in the avoidance of future hypoglycaemic episodes

and to an improvement in hypoglycaemia recognition. The questions are supplementary to the

patient reported questions on the ‘Hypoglycaemia Risk Assessment’ form.

1. When your blood glucose falls below 4 mmol/L, what is usually the reason for this?

______________________________________________________________________________________________________________________________________________________________

_______________________________________________________________________________

2. What precautions do you take to try and avoid a possible fall in blood glucose levels below 4 mmol/L?

_______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________

3. Do you ever suspect that you have had a hypoglycaemic episode during the night?

______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________

4. How many times have you had a hypoglycaemic episode where you have been unable to treat yourself and needed someone else’s help?

Since the last clinic visit ______________________ times

In the last year _____________________________ times

5. How many times have you had a hypoglycaemic episode where you could not think clearly/ properly control your body/ had to stop what you were doing, but you were still able to treat yourself?

Since the last clinic visit ______________________ times In the last year _____________________________ times

Y&H AHSN - Avoiding Hypoglycaemia Toolkit – Professional Avoiding Hypoglycaemia Assessment (1/2) Page 10

6. How often do you carry a snack or glucose tablets (or gel) with you to treat a fall in blood

glucose below 4 mmol/L?

Never Rarely Sometimes Almost Always

7. What and how much food and drink do you usually treat a blood glucose level fall below 4 mmol/L with?

_______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________

8. Do you check your blood glucose before driving?

Yes, always Yes, sometimes No

9. What level does your blood glucose fall to before you think you should not drive?

Less than ________________ mmol/L 10. How often have you felt your blood glucose level falling below 4 mmol/L whilst driving?

Since the last clinic visit ______________________ times In the last year _____________________________ times

11. How often do you rotate your injection sites and change your needles? [Review/examine injection sites/consider appropriateness of needle size for site]

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

12. Does a spouse, relative or other person close to you notice that you are having a hypoglycaemic

episode before you are aware of it? Yes No 13. Does a spouse, relative or other person close to you know how to manage a hypoglycaemic

episode? Yes No

Y&H AHSN - Avoiding Hypoglycaemia Toolkit – Professional Avoiding Hypoglycaemia Assessment (2/2) Page 11

HYPOGLYCAEMIA EMERGENCY PLAN

ABOUT ME:

NAME: NHS NUMBER:

ADDRESS:

MOBILE TELEPHONE: HOME TELEPHONE:

NEXT OF KIN: TELEPHONE:

MY DIABETES TEAM:

DIABETES NURSE:

ADDRESS:

TELEPHONE:

The purpose of this hypoglycaemia emergency plan is to help you recognise your usual causes, signs and symptoms of

hypoglycaemia.

Hypoglycaemia is an abnormally low level of glucose in your blood (less than 4 mmol/L). When your glucose level is too low, your

body doesn't have enough energy to carry out its normal activities. Being aware of the early signs of hypoglycaemia will allow you

to treat your low blood glucose levels quickly - in order to bring them back into the normal range. Understanding the reasons for

your hypoglycaemia will help you avoid future episodes.

This plan should be shared with relatives; friends and colleagues. You should make them aware that have diabetes and are at risk

of hypoglycaemic episodes, explain the signs, symptoms and treatments.

You should inform your diabetes team if you experience frequent episodes of hypoglycaemia and make an urgent appointment if

you have an episode that you are unable to treat yourself.

CAUSES OF HYPOGLYCAEMIA

TOO MUCH INSULIN OR WRONG TYPE OF INSULIN MISSING OR DELAYING MEALS OR SNACKS

NOT EATING ENOUGH FOOD (CARBOHYDRATES) HOT WEATHER GETTING EXTRA, INTENSE OR UNPLANNED ACTIVITY

BEING ILL (VIRUS OR UPSET STOMACH) DRINKING ALCOHOL

* Circle usual cause above

SIGNS & SYMPTOMS OF HYPOGLYCAEMIA

> >> >>> >>>> >>>>> >>>>> >>>>>>>>>

SHAKY JITTERY SWEATY CONFUSED DISORIENTATED

HUNGRY HEADACHE BLURRY VISION UNCOORDINATED IRRITABLE OR NERVOUS

PALE TINGLY LIPS WEAK LETHARGIC ARGUMENTATIVE COMBATIVE

DIZZY SLEEPY POOR CONCENTRATION CHANGED PERSONALITY OR BEHAVIOUR

INABILITY TO EAT OR DRINK

UNCONSCIOUS

UNRESPONSIVE

SEIZURE OR CONVULSIONS

* Circle usual symptoms above

Y&H AHSN - Avoiding Hypoglycaemia Toolkit - Hypoglycaemia Emergency Plan (2/4) Page 13

TREATING HYPOGLYCAEMIA

If possible, check blood glucose level. Treat for hypoglycaemia if blood glucose level is less than 4mmol/L

Able to ‘self treat’ Unable to ‘self treat’

(requiring help from someone else) Treat immediately with fast-acting carbohydrate:

glass of fruit juice or non-diet soft drink between three and five dextrose tablets a handful of sweets

Retest your blood glucose levels after 10-15 minutes and re-treat if blood glucose level is still less than 4mmol/l.

Follow with a snack of slower-acting carbohydrate:

Sandwich

Plain biscuits/Cereal Bar

Fruit Next meal

Unable to ‘self treat’ but conscious:

Give glucose gel

Slowly squeeze 1 tube into the mouth

Massage into cheeks if not willing to swallow

Repeat with second tube

Monitor until recovery

Unable to ‘self treat’ and unconscious:

Put you into the recovery position (on your side with your head tilted

back and knees bent) Give you a glucagon injection – if available Call an ambulance immediately if :

- no glucagon available - no recovery within 10 minutes of receiving glucagon injection - no-one is trained to give a glucagon injection

ARRANGE AN URGENT FOLLOW-UP WITH YOUR DIABETES TEAM

HYPOGLYCAEMIA RECOGNITION

Reduced hypoglycaemic recognition can occur if blood glucose levels frequently fall below 4 mmol/L. People who are starting to lose their hypoglycaemia recognition may not notice the early warning signs and symptoms of hypoglycaemia and are able to tolerate blood glucose levels below 4 mmol/L without any symptoms. Should this occur frequently, recognition can diminish further leading to the more serious condition, Reduced Hypoglycaemic Awareness. Your diabetes team are able to help you regain recognition of early signs and symptoms.

Reduced Hypoglycaemic Awareness occurs when people with diabetes do not experience the usual early warning symptoms of hypoglycaemia (blood glucose level below 4 mmol/L) and without warning, lapse into severe hypoglycaemia, becoming confused or disoriented or falling unconscious. People with reduced hypoglycaemia awareness are also less likely to be awakened from sleep when hypoglycaemia occurs at night.

Reduced hypoglycaemia awareness occurs more frequently in those who:

frequently have blood glucose levels below 4 mmol/L (which can cause you to stop recognising the early warning signs of hypoglycaemia)

have had diabetes for a long time

very tight blood glucose control (which increases your chances of having frequent hypoglycaemic episodes)

drink excessive amounts of alcohol

Because the person doesn’t realise that they have a blood glucose level below 4 mmol/L, they may not appreciate the potential risks associated with activities such as: driving, operating machinery, working at heights, etc.

If a blood glucose level below 4 mmol/L is left untreated, it may continue to fall and the person can lose consciousness.

If you are frequently unable to tell when your blood glucose level drops below 3 mmol/l you are likely to have a degree of reduced hypoglycaemic awareness. Speak with your diabetes team urgently, they can help you identify ways to improve your hypoglycaemic awareness.

Y&H AHSN - Avoiding Hypoglycaemia Toolkit - Hypoglycaemia Emergency Plan (4/4)

AVOIDING HYPOGLYCAEMIA ACTION PLAN

THE AIM OF THIS PLAN IS TO SUPPORT YOU WITH YOUR DIABETES HEALTH CARE PROFESSIONAL TO AGREE A ‘GOAL’ AND ‘ACTION PLAN’ WHICH WILL

HELP YOU TO AVOID FUTURE EPISODES OF HYPOGLYCAEMIA

GOAL (Describe what you are trying to achieve and when by?)

IMPORTANCE SCORE (How important is it to achieve the goal? If you score under 7 – revise the details of your ‘goal’)

0 1 2 3 4 5 6 7 8 9 10

ACTION PLAN (How are you going to get there? What are the things you need to do, to achieve the goal?)

1.

2.

3.

(What might get in the way? What can you do about this? Any support needed?)

CONFIDENCE SCORE (How confident are you that you can achieve the goal? If you score under 7 – revise the details of your ‘action plan’)

0 1 2 3 4 5 6 7 8 9 10

ACTION PLAN REVIEW DATE:

Y&H AHSN – Avoiding Hypoglycaemia Toolkit – Avoiding Hypoglycaemia Action Plan (1/1)

15 WAYS TO AVOID HYPOGLYCAEMIA

This aim of this leaflet is to give ‘tips’ to people with diabetes (treated with a sulphonylurea tablet (e.g. Glibenclamide; Gliclazide; Glipizide; Glimepiride) or insulin to help them avoid hypoglycaemia. Hypoglycaemia is an abnormally low level of glucose in your blood (less than 4 mmol/L). When your glucose level is too low, your body doesn't have enough energy to carry out its normal activities. Being aware of the early signs of hypoglycaemia will allow you to treat your low blood glucose levels quickly - in order to bring them back into the normal range. Understanding the reasons for your hypoglycaemia will help you avoid future episodes.

1. UNDERSTAND YOUR MEDICATIONS

Understanding how your diabetes medication works and when it needs to be taken is critical for avoiding hypoglycaemia (a blood glucose level of 4.0 mmol/L or below).

2. CHECK YOUR BLOOD GLUCOSE LEVEL REGULARLY

Testing your blood glucose level at different times of the day can help you to understand how the levels fluctuate. If you don’t currently test your blood glucose, discuss this with your diabetes team.

3. AVOID INSULIN MIX-UPS

If you use more than one type of insulin, store vials or pens in different locations (away from sunlight and at room temperature). Make sure you can tell which insulin is quick or slow acting (try using different coloured pens/cases).

4. EAT WHEN YOU PLAN TO EAT

Ensure insulin is given at the correct time in relation to meals. A common reason for people to require treatment for severe hypoglycaemia is taking diabetes medication and then waiting too long before eating carbohydrate. If you have taken your treatment and your meal is delayed, make sure you have a carbohydrate snack whilst waiting.

5. KNOW THE SYMPTOMS

Having a good understanding of HYPOGLYCAEMIA SYMPTOMS, including those you haven’t personally felt, will help you decide to treat rather than ignore the symptom.

6. TREATING HYPOGLYCAEMIA

Treating an episode of hypoglycaemia http://www.nhs.uk/Conditions/Hypoglycaemia/Pages/Treatment

The immediate treatment for hypoglycaemia is to have some sugary food or drink (about 15 to 20g of

rapidly acting carbohydrate) to end the attack. For example, this could be:

a glass of fruit juice or non-diet soft drink between three and five dextrose tablets a handful of sweets

Avoid fatty foods and drinks, such as chocolate and milk, because they don't usually contain as much sugar

and the sugar they do contain may be absorbed more slowly.

Y&H AHSN – Avoiding Hypoglycaemia Toolkit – 15 Ways to Avoid Hypoglycaemia (1/4)

After having something sugary, you should have a longer-acting carbohydrate food, such as a few biscuits,

a cereal bar, a piece of fruit or a sandwich.

It will usually take around 15 minutes to recover from a mild episode of hypoglycaemia. If you have a blood

glucose meter, measure your blood sugar again after 15 to 20 minutes. If it's still too low (below 4mmol),

you should have some more sugary food or a drink before testing your levels again in another 15 to

20 minutes.

7. CARRY FAST-ACTING CARBOHYDRATE (GLUCOSE)

Always carry glucose tablets or glucose gel, and some identification.

8. CARRY SLOWER-ACTING CARBOHYDRATE (SNACK)

Follow your glucose treatment with slower-acting carbohydrate (sandwich, biscuits, fruit, or next meal), this will prevent your blood glucose falling low again before your next meal.

9. ENSURE PEOPLE AROUND YOU KNOW ABOUT DIABETES

Tell your friends, family and work colleagues that you have diabetes and are at risk of hypoglycaemia. Make sure that they know what to look out for and what to do. Wear a bracelet or carry identification that lets people know that you have diabetes.

10. TAKE CARE WITH ALCOHOL

Drinking too much alcohol, or drinking without food can cause hypoglycaemia. Never drink alcohol on an empty stomach. If you have been drinking alcohol, always have a carbohydrate-based supper or a snack before bed.

11. PAY ATTENTION TO PHYSICAL ACTIVITY

Whether you are working out in the gym or going shopping, physical activity can lower blood glucose—for hours or even a full day afterwards. Make sure to eat some extra carbohydrate or reduce your diabetes medication doses to accommodate your activity.

12. DIETING AND FASTING

Reducing the amount of carbohydrate taken with a meal can cause hypoglycaemia. Talk to your diabetes team about altering your diabetes medication if you want to change your diet to lose weight or for fasting.

13. TAKE CARE OF YOUR INJECTION SITES

Your injection sites can become damaged through over-use and re-using needles. Damage to your injection sites can cause delays in absorption of insulin and erratic blood glucose levels. Make sure that you use a new needle for each injection and rotate within your injection site and from right to left sides. Ask your diabetes team to check your injection sites at each visit.

14. THINK ABOUT ‘HEAT’

The effect of heat speeds up the action of insulin and can cause a fall in blood glucose levels, e.g. hot weather, hot baths, sitting too close to a radiator or fire, sitting under a hair dryer. Consider taking additional carbohydrate or adjusting medication doses during hot summer months or holidays abroad. Y&H AHSN – Avoiding Hypoglycaemia Toolkit – 15 Ways to Avoid Hypoglycaemia (2/4)

15. TAKE CARE DRIVING

Many of the accidents caused by hypoglycaemia are because drivers have continued to drive, ignoring their hypoglycaemia warning signs (e.g. hunger, sweating, feeling faint).

Check your blood glucose before getting behind the wheel and every two hours whilst driving. If blood glucose is 5mmol/L or less you should take carbohydrate before driving. If it is less than 4mmol/L you must not drive – you need to treat the hypo and retest. Wait 45 minutes after your blood glucose has risen to 4mmol/L before driving.

Avoid delaying or missing your meals (in particular carbohydrate) Take breaks on long journeys Always keep glucose treatments to hand in the car

If you have a hypo whilst driving:

Stop the vehicle as soon as possible Switch off the engine, remove the keys from the ignition and move into the passenger seat (to

demonstrate that you are not in charge of the car)

Treat the hypoglycaemia

Do not start driving until 45 minutes after your blood glucose has risen to 4mmol/L because your response rates will be slower

The DVLA has guidance in place for reporting episodes of hypoglycaemia. It is important you notify them in line with this guidance. The latest Medical Standards of Fitness to Drive can be found on the DVLA website:

https://www.gov.uk/hypoglycaemia-and-driving

If you have poor warning signs, or have frequent hypos, discuss this urgently with your diabetes team.

Y&H AHSN – Avoiding Hypoglycaemia Toolkit – 15 Ways to Avoid Hypoglycaemia (3/4)

HYPOGLYCAEMIA RECOGNITION

Diminished hypoglycaemic recognition can occur if blood glucose levels frequently fall below 4 mmol/L. People who are starting to lose their hypoglycaemia recognition may not notice the early warning signs and symptoms of hypoglycaemia and are able to tolerate blood glucose levels below 4 mmol/L without any symptoms. Should this occur frequently, recognition can diminish further leading to the more serious condition, Reduced Hypoglycaemic Awareness. Your diabetes team are able to help you regain recognition of early signs and symptoms.

Reduced Hypoglycaemic Awareness occurs when people with diabetes do not experience the usual early warning symptoms of hypoglycaemia (blood glucose level below 4 mmol/L) and without warning, lapse into severe hypoglycaemia, becoming confused or disoriented or falling unconscious. People with reduced hypoglycaemia awareness are also less likely to be awakened from sleep when hypoglycaemia occurs at night.

Reduced hypoglycaemia awareness occurs more frequently in those who:

frequently have blood glucose levels below 4 mmol/L (which can cause you to stop recognising the early warning signs of hypoglycaemia)

have had diabetes for a long time

very tight blood glucose control (which increases your chances of having frequent hypoglycaemic episodes)

drink excessive amounts of alcohol

Because the person doesn’t realise that they have a blood glucose level below 4 mmol/L, they may not appreciate the potential risks associated with activities such as: driving, operating machinery, working at heights, etc.

If a blood glucose level below 4 mmol/L is left untreated, it may continue to fall and the person can lose consciousness.

If you are frequently unable to tell when your blood glucose level drops below 3 mmol/L you are likely to have a degree of reduced hypoglycaemic awareness. Speak with your diabetes team urgently, they can help you identify ways to improve your hypoglycaemic awareness.

Y&H AHSN – Avoiding Hypoglycaemia Toolkit – 15 Ways to Avoid Hypoglycaemia (4/4)

AVOIDING HYPOGLYCAEMIA ASSESSMENT - CHECKLIST

This document is intended as an ‘aide memoire’ aimed at diabetes health professionals who are undertaking a diabetes review with a patient at risk of or experiencing hypoglycaemic episodes.

1. Review the patient’s completed hypoglycaemia assessment Ask the patient to share their experience of hypoglycaemia Assess level of hypoglycaemia knowledge/management

2. Review patient recent blood glucose monitoring record

Identify any readings in the hypoglycaemic range

Identify any patterns in readings

3. After hypo THINK lipo! Examine injection sites for signs of lipohypertrophy Ensure new needles used for each injection Consider if length of needle is appropriate for injection site used Encourage patients to regularly examine their injection sites

4. Identify potential hypoglycaemic triggers Assist the patient to identify strategies to avoid hypoglycaemia Agree medication changes where clinically appropriate Prescribe glucose gel / glucagon as appropriate and teach others

5. Discuss hypo risk and driving

Discuss hypo management when driving Explain DVLA requirements

6. Complete Hypoglycaemia Emergency Plan with the patient

Give patient a copy of the plan 7. Agree an Avoiding Hypoglycaemia Action Plan with the patient

Agree a review date Give patient a copy of the plan

Consider requesting ‘support’ from specialist diabetes team or refer

Y&H AHSN – Avoiding Hypoglycaemia Toolkit – Avoiding Hypoglycaemia Assessment - Checklist (1/1) Page 21