Diabetes Update guidelines/recommendations: a) Driving ability b) Insulin treatment in dependent patients

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1 Diabetes Update guidelines/recommendations: a) Driving ability b) Insulin treatment in dependent patients Annual Meeting SGED-SSED 2016 Christoph Henzen Schweizerische Gesellschaft für Endokrinologie und Diabetologie - SGED

2 Working group SGED/SDG/SGRM Schweizerische Gesellschaft für Endokrinologie und Diabetologie - SGED

3 Diabetes and Risk of motor vehicle accident: On insulin treament (SIR) On sulfonylurea (SIR) (ADHS: 4.4, OSAS: 2.4) Cox D et al, Am J Med Sci 2013;345:263- Symptomatic hypoglycemia while driving: events per year driven per km driven Harsch IA et al, J Int Med 2002;252:352- Schweizerische Gesellschaft für Endokrinologie und Diabetologie - SGED

4 Conclusions: 1. Diabetes can contribute to higher risk of driving impairments but not everyone with diabetes is at increased risk. 2. Moderate hypoglycemia impairs driving safety (and hyperglycemia > 14 mmol/l). 3. Some individuals with T1DM are more vulnerable to driving mishaps, and this is associated with a recent history of hypoglycemia-related driving mishaps, mismanagement of hypoglycemia, lower limb neuropathy and greater exposure, i.e. high volume driving. 4. Clinicians have legal and ethical responsibilities to evaluate and educate individuals with diabetes and to educate and counsel them in risk reduction. Schweizerische Gesellschaft für Endokrinologie und Diabetologie - SGED

5 Assessment of the hypoglycemia risk Working group SGED/SDG/SGRM High-risk hypoglycemia? - severe hypoglycemia during last 2 years?* - Impaired hypoglycemia awareness (Clark Score > 4)? yes no 1x daily basal insulin or gliclazide or glinides? no yes High risk of hypoglycemia Increased risk of hypoglycemia Low risk of hypoglycemia Schweizerische Gesellschaft für Endokrinologie und Diabetologie - SGED

6 Checklist hypoglycemia 1. Kennen Sie Ihre typischen Hypo-Symptome? 2. Wie häufig haben Sie Hypos, die Sie korrigieren müssen pro Woche? 3. Wieviele schwere Hypos (Fremdhilfe/Bewusstlosigkeit) haben Sie bisher gehabt? 4. WARUM haben Sie Hypo? 5. Ab welchem Blutzucker denken Sie, dass Sie etwas machen müssen? 6. Tragen Sie Traubenzucker bei sich? 7. Wieviele KH nehmen Sie zu sich bei BZ unter 2.5? unter 3.9? 8. Messen Sie immer den Blutzucker vor dem Autofahren? 9. Wie hoch soll der Blutzucker sein, bevor Sie losfahren? 10. Haben Sie ein GlucaGen Notfallset? 11. Weiss Ihr Partner was bei einem schweren Hypo zu machen ist? Diabetes Care, April 2013

7 Driving ability/license «3. Medizinische Gruppe»

8 Regulations depending on hypoglycemia risk No risk No hypoglycemic treatment No measures (no SMBG) needed Low risk 1x daily analogue basal insulin or No SMBG before driving gliclazide or glinides Carbohydrates and blood glucose meter in car Increased Insulin treatment (MDI) or combined SMBG before and during long driving risk with sulfonylureas No driving when BG < 5mmol/L Carbohydrates and blood glucose meter in car High risk Severe Hypo grade II or III (last 2 years) Assessement by diabetologist Impaired hypoglycemia awareness After severe hypoglycemia: In particular if age >70years, impaired CGMS or 6-8x SMBG daily for 2 years renal function (GFR <45ml/min), or required diabetes duration >20years

9 Driving ability/license «1./2. Medizinische Gruppe»

10 Regulations depending on hypoglycemia risk No risk No hypoglycemic treatment No measures (no SMBG) needed Low risk 1x daily analogue basal insulin or No driving ability for D and D1 gliclazide or glinides Regular SMBG (3-4x daily) HbA1c % Not necessary before driving Carbohydrates and BGM in car Assessment by diabetologist AND traffic medicine Increased Insulin treatment (MDI) or combined Waiting period 3 months risk with sulfonylureas No secondary complications SMBG before and during long driving No driving when BG < 5mmol/L Carbohydrates and blood glucose meter in car High risk Severe Hypo grade II or III (last 2 years) Close follow-up by diabetologist Impaired hypoglycemia awareness Waiting period > 3 months MDI or combination of Insulin and CGMS or 6-8x SMBG daily necessary sulfonylureas

11 Schweizerische Gesellschaft für Endokrinologie und Diabetologie - SGED

12 Working group SGED Schweizerische Gesellschaft für Endokrinologie und Diabetologie - SGED

13 Hypoglycemia: cardiovascular and all-cause mortality Diabetes Care 2015;38: Clin Epidemiol 2014;6:287-

14 Hospital admissions because of hypoglycemia JAMA Intern Med. 2014;174:

15 HbA1c target in the aging patient JAMA 2016;315:1034- Standards for the odiabetes education of nurses omeasures in hypoglycemia onutrition ogeneral practitioners odiabetologist ointerprofessional team Education: Basic knowledge of diabetes Treatment targets Prevention of Hypo/Hyperglycemia Proper technique Characteristics of the nutrition Application of Glucagen Hypokit

16 Hypoglycemia algorithm Emergency Urgent Tx needed Measure to be taken Coma or unable to swallow BG<3.9 and symptoms BG<3.9 and no symptoms Inform senior g Carbohydrates Repeat BG test <3.5 >3.5 1mg Glucagon sc/im or 20g Glucose iv Repeat BG test after 15 min. If coma persists: 117 Inform senior >4.5 mmol/l Repeat BG test after 30 min. Meal with >15 g carbohydrates Reasons for hypoglycemia? Record and report incident

17 HbA1c target in the aging patient JAMA 2016;315:1034- Standards for the odiabetes education of nurses omeasures in hypoglycemia onutrition ogeneral practitioners odiabetologist ointerprofessional team

18 Working group SGED/SDG/SGRM R. Lehmann, M. Egli, D. Fischer, H.U. Iselin, V. Pavlicek, R. Schinz, T. Weng, R. Seeger Working group SGED B. Felix, D. Fischer, U. Keller (Vorsitz), U. Ledermann Bulti, B. Meichtry, C. Willi Thank you! Schweizerische Gesellschaft für Endokrinologie und Diabetologie - SGED