• This guidance is for use in Adult and Paediatric Diabetes Services across Frimley Health

• Advice on Insulin titration must be adjusted using the guidelines within.

• Advice on adjustment of oral medication and injectables.

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition. Print copies must be destroyed after use.

Abbreviations

To authorise appropriately qualified and trained Diabetes Specialist Nurses/ Diabetes Specialist Dietitians to advise alterations to insulin doses to individuals without the requirement for a patient specific prescription written by a medical practitioner or non-medical prescriber.

This guideline is intended for use by Diabetes Specialist Nurses and Diabetes Specialist Dietitians at Frimley Health NHS Foundation Trust.

Medication titration is recognised as an integral part of diabetes care and self-management.

For clarification, this indicates an increase or decrease in dose of medication already prescribed to the patient.

Non-medical prescribing has perhaps highlighted some concerns around dose titration in diabetes. This document will clarify the need for expert nurses and dietitians within diabetes, to dose titrate according to agreed guidelines.

A key role of the Diabetes Specialist Nurse (DSN) and Diabetes Specialist Dietitian (DSD) is to initiate, review and evaluate diabetes treatment regimens and advise patients, their carers and other care providers on adjusting therapy safely and effectively.

The recommendation is that the DSN and DSD job description reflects all competencies required to fulfil the role that meets service requirements, and achievement of such through Personal Development Plans.

The expectation would be that the employing Trust will assume vicarious liability for practice and competence within service need and this would be explicitly stated on their job description.

1. agree to be professionally accountable for their work.

2. be competent to assess the capacity of the patient/carer/parent/person with parental responsibility to understand the nature and purpose of the alteration in dose for them to give or refuse consent.

3. be aware of current treatment recommendations and be competent to discuss issues concerning insulin with the patient/ carer/parent/person with parental responsibility.

(iv) have been trained and assessed as being competent in the adjustment of insulin doses and oral hypoglycaemic agents.

4. maintain their skills, knowledge, and their own professional level of competence in this area according to their individual Code of Professional Conduct.

Clinical managers will be responsible for:

1. ensuring that the current guideline is available to staff providing care under this guideline.

2. ensuring that staff have received adequate training and are deemed competent in the adjustment of insulin doses and other aspects relevant to this guideline and meet the requirements above. This includes any updates to training that may be required.

3. maintaining a current record of all staff authorised to alter insulin doses.

Initiation of Insulin (adult services only):

Initiation of insulin for full insulin replacement should be based on a guidance of

0.4 - 0.5 units X weight in kg = total daily dose of insulin

For adding on long-acting insulin only it should be based on a guidance of

0.1-0.2 units X weight in kg

The type of insulin regimen should be decided according to the best treatment regimen to suit the individual.

Titration of insulin can be given in the form of subcutaneous injections. This should be increased by no more than 10-20% increments of individual’s total daily dose. If this is to differ it should be documented by a prescriber.

Patients that carbohydrate count or receive insulin via subcutaneous insulin pumps may be the exception to this, as due to their ratios this may exceed a 20% increase.

When blood glucose levels indicate a need to exceed the recommended maximum dose, advice from a registered prescriber should be sought, and a new maximum dose limit or new medication agreed.

Hospital guidance should be agreed and followed for the management of illness particularly in patients with type 1 diabetes, see Diabetes Ketoacidosis (DKA) or Hyperosmolar Hyperglycaemic State (HHS) Guidelines.

Local guidance should be agreed for insulin initiation and dose adjustment in high dose steroid therapy and chemotherapy.

Initiation of oral hypoglycaemic agents should be suggested by the DSN/DSD but prescribed by the reviewing medical team. Titrate in recognised dose adjustments to a maximum daily dose according to the BNF recommendation. In the event of patients experiencing hypoglycaemia on OHA dose reductions should be followed according to guidance within the BNF. Advice from a registered prescriber should be sought if further advice needed.

In the event of patients experiencing hypoglycaemia, blood glucose readings below the agreed target range or other contributing factors which may result in hypoglycaemia, the insulin dose should be based on a guidance reduction of a 10-30% of the current total daily dose.

When a Larger Insulin Dose Reduction May Be Needed.

Certain conditions increase hypoglycaemia risk and may require greater insulin dose reductions:

• Acute renal impairment: Reduced renal gluconeogenesis, insulin clearance, and caloric intake.

• Acute hepatic impairment: Impaired gluconeogenesis and depleted glycogen stores.

• Severe cardiac failure: Hepatic congestion and poor nutrition reduce gluconeogenesis and glycogen stores.

• Alcohol-induced hypoglycaemia: Raised β-hydroxybutyrate, low C-peptide, blunted growth hormone response, and increased postprandial insulin effect.

• Malnutrition or poor intake: Limited substrates for gluconeogenesis and glycogenolysis.

Advice:
Seek input from a registered prescriber to agree on a new, reduced insulin dose or regimen, as a larger adjustment may be required.

When dose adjustment has been recommended the staff/patient/carer will be provided with DSN, PDSN, DSD or PDSD or team to follow up contact details and/or advised who to contact should any problems arise. Details of all changes to an insulin dose or oral medication must be documented within the medical notes or electronic records. If deemed necessary, a letter should be sent to the patient’s GP with details on medication changes or insulin dose recommendations.

Competency is assured through clinical supervision by the Lead Diabetes Specialist Nurse for DSNs and DSDs with support by the diabetes consultants. Regular pharmaceutical updates on new and existing treatments should be undertaken, and where possible, treatment pathways should be used. PDSNs and PDSDs will undertake clinical supervision formally with a paediatrics consultant/diabetologist 4 times per year, specifically with regard to insulin dose titration. This will include a retrospective review of patient notes. The responsibility to arrange and access supervision is with the PDSN and PDSD. Competency review should be an integral component of the DSN, PDSN, DSD and PDSD annual appraisal and evidence should be shown of regular updates on new medication.