Guidelines for people with insulin treated diabetes undergoing outpatient colonoscopy / flexible sigmoidoscopy

i) Guidelines for people with insulin treated diabetes undergoing outpatient colonoscopy / flexible sigmoidoscopy (morning and afternoon)
a) Morning appointment
1. General Advice

This leaflet deals with your diabetes management during fasting and you should also read colonoscopy / flexible sigmoidoscopy leaflet for preparing your bowels. The dietary restrictions placed on you can affect your blood sugar levels, especially on the day before (when you can drink fluids only) and the day of the colonoscopy itself.

Do not worry if your blood sugars are less well controlled than usual, but it is important to avoid low blood sugars (less than 4 mmol/l) and high blood sugars (more than 15 mmol/l). Some people with Type 1 diabetes and problematic hypo’s may require overnight admission prior to the procedure.
Your appointment should ideally be scheduled for early morning, if not please contact the number given in your appointment letter.

If you need advice please contact the Diabetes Specialist Nurses at least two weeks prior to your appointment.

2. How to manage your medications

Monitor your blood sugars at least 4 times a day three days prior to your colonoscopy appointment. Continue to take your daily insulin injections, but the amount may need to be varied according to your blood sugars and the amount of carbohydrate you are taking. In general your doses may need to be reduced by one quarter to half.

A) If you take an injection of long acting insulin in the morning

(Glargine (Lantus), Detemir, (Levemir), Isophane (Insulatard, Humulin I))

Day before procedure- Take usual dose.

Day of procedure- Take ½ of your usual dose in the morning of the test. (For e.g. if you take 24 units of insulin take 12 units in the morning). Take the other ½ as soon as you reasonably can after the test. Be sure to eat a regular sized meal at that time.

Please see section C if you take short acting insulin as well.

B) If you take an injection of long acting insulin in the evening

(Glargine (Lantus), Detemir, (Levemir), Isophane (Insulatard, Humulin I))

Day before procedure- Take ½ usual dose.

Day of procedure (after procedure) - Take usual dose.

Please see section C if you take short acting insulin as well.

C ) If you take several injections of short acting insulin (Novorapid, Humalog, Humulin S) and one or two injections of long acting insulin (Glargine (Lantus), Detemir, (Levemir), Isophane (Insulatard, Humulin I))

Day before procedure- As you are on clear fluids only, ideally if you can take your usual amount of carbohydrate (see section 3), then take your usual dose of short acting insulin. If not, you may need to reduce your dose by one quarter to half. (For e.g. if you take 12 units of insulin you may need to take 6- 9 units)

Day of procedure- Take no short acting insulin on the morning of the test.

Take your short acting insulin as soon as you are able to have a meal after the test.

Please see section 2A and/or 2B for advice regarding your long acting insulin.
D) If you take two injections of insulin i.e. morning and evening with mixed insulin

(Humalog Mix 25, Humulin M3, Novomix 30 or Human Mixtard 30)
Day before procedure - Take usual dose in the morning and ½ the dose in the evening.
Day of procedure- Take 1/3^rd of your usual dose before the test. (For e.g. if you take 24 units of insulin, take 8 units in the morning). Take another 1/3rd of the dose as soon as you are able to have a meal after the test.

Take your usual evening dose with your tea.

E) If you take tablets in addition to your insulin – Metformin (Glucophage), Pioglitazone (Actos, Competact), Rosiglitazone (Avandia, Avandiamet), Gliclazide (Diamicron), Glipizide (Glibenese) Glimepiride (Amaryl), Glibenclamide (Daonil), Tolbutamide.
Day before procedure - Take your morning dose and omit all other doses

Day of the procedure - Omit all tablets until after the procedure. Restart your usual dose once able to eat a regular meal.

3. Dietary guidance

1. 
   On the day before your procedure
   

You are allowed to drink clear fluids only. To include some carbohydrate in your diet you will need to drink some fluids containing sugar. These are digested more rapidly and you will be more likely to have a low blood sugar reaction. Therefore it is recommended that you take your clear fluids in seven portions i.e. breakfast time, mid-morning, lunch time, mid-afternoon, dinner, 2-3 hours after dinner and at midnight. You are required to have around 45 g carbohydrates per portion if you intend to take full dose of short acting insulin.

The following have similar amount of carbohydrate to 1 medium slice of bread

(15g carbohydrate):

150mls clear apple juice

150mls grape juice

60mls sweetened squash

80mls lucozade

250mls lemonade

150mls carbonated beverages

100g clear jelly

5 dextrose tablets (to be sucked)

2. 
   On the day of the procedure
   

Do not have anything to eat, but you may continue to drink up to 2 hours prior to the colonoscopy.

Have a suitable drink equivalent to 15-20g of carbohydrate (see previous section) to avoid the risk of hypo between 6 and 7 am.
If you have a hypo i.e. blood glucose less than 4 mmol/L, then suck 3 dextrose sweets initially followed by another 3 if you do not feel any better. You can also drink 80 -150 mls of lucozade, sweetened squash or fruit juices. Make sure you tell the medical staff if you have a hypo.
4. Take your insulin, blood glucose monitor and insulin injecting equipment with you. You can carry a packed meal so as to avoid delay in administering your insulin dose after the procedure.
Be sure to tell the medical personnel if you are having a hypo. Bring lucozade, glucose tablets or glucogel should it be needed. If you have Type 1 diabetes, you should also check your urine for ketones if blood sugars are higher than 17mmol/L. In the unlikely event of urine ketones being moderate or large, please contact your general practitioner if you feel ill.
5. What to do after your procedure?
The nursing staff will inform you when it is safe to eat and drink. Take your insulin as advised above when you are able to have a regular meal.

When you get home, your sugar levels may be upset for a short time, so continue to monitor your blood sugar levels more closely than normal for a few days and adjust your insulin doses accordingly.

If you need any advice regarding your diabetes please contact the Diabetes Specialist Nurses at ARI (01224 559364) or Woolmanhill (01224 555491) from 9am to 5pm.

For advice out of hours please contact diabetes ward at ARI (01224 551042) or your general practitioner.


b) Afternoon Appointment

1. General Advice

This leaflet deals with your diabetes management during fasting and you should also read colonoscopy / flexible sigmoidoscopy leaflet for preparing your bowels.

The dietary restrictions placed on you can affect your blood sugar levels, especially on the day before (when you can drink fluids only) and the day of the colonoscopy itself.
Do not worry if your blood sugars are less well controlled than usual, but it is important to avoid low blood sugars (less than 4 mmol/L) and high blood sugars (more than 15 mmol/l). Some people with Type 1 diabetes and problematic hypos may require overnight admission prior to the procedure.
If you need advice please contact the Diabetes Specialist Nurses at least two weeks prior to your appointment.
2. How to manage your medications
Monitor your blood sugars at least 4 times a day three days prior to your colonoscopy appointment. Continue to take your daily insulin injections, but the amount may need to be varied according to your blood sugars and the amount of carbohydrate you are taking. In general your doses may need to be reduced by one quarter to half.

A) If you take an injection of long acting insulin in the morning (Glargine (Lantus), Detemir, (Levemir), Isophane (Insulatard, Humulin I))

Day before your procedure- Take your usual dose.

Day of your procedure- Take ½ your usual dose on the morning of your test. For e.g. if you take 24 units of insulin take 12 units.

Please see Section C if you take short acting insulin as well.

B) If you take an injection of long acting insulin in the evening (Glargine (Lantus), Detemir, (Levemir), Isophane (Insulatard, Humulin I))

Day before your procedure- Take ½ your usual dose in the evening. For e.g. if you take 24 units of insulin take 12 units.

Day of your procedure (i.e. after procedure) Take your usual evening dose.

Please see Section C if you take short acting insulin as well.

C) If you are on several injections of short acting insulin (Novorapid, Humalog, Humulin S, and one or two injections of long acting insulin (Glargine (Lantus), Detemir, (Levemir), Isophane (Insulatard, Humulin I))
Day before, and the morning of your procedure- As you are on clear fluids only, ideally if you can take your usual amount of carbohydrate (see section 3) then take your usual dose of short acting insulin .If not you may have to reduce your dose by one quarter or half. For example, if you take 12 units of insulin you may need to take 6 to 9 units.

Day of the procedure- Omit your lunchtime dose of short acting insulin. Take your short acting insulin once you are able to have a regular meal after your procedure.

Please see section 2A and /or 2B for advice about your long acting insulin.
D) If you take two injections of insulin (for example morning and evening with mixed insulin (Humalog Mix 25, Humulin M3, Novomix 30 or Human Mixtard 30)
Day before procedure- Take usual dose in the morning and half the dose in the evening. For e.g. if you take 24 units of insulin take 12 units.
Day of procedure- Take 1/3 rd of your usual dose on the morning of the test. For example if you take 24 units of insulin, take 8 units of insulin in the morning. Take your usual evening dose with your tea.
E) If you take tablets in addition to your insulin – Metformin (Glucophage), Pioglitazone (Actos, Competact), Rosiglitazone (Avandia, Avandiamet), Gliclazide (Diamicron), Glipizide (Glibenese) Glimepiride (Amaryl), Glibenclamide (Daonil), Tolbutamide.
Day before procedure - Take your morning dose and omit all other doses
Day of the procedure - Omit all tablets until after the procedure. Restart your usual dose once able to eat a regular meal.
3. Dietary guidance

1. 
   On the day before your procedure
   

You are allowed to drink clear fluids only. To include some carbohydrate in your diet you will need to drink some fluids containing sugar. These are digested more rapidly and you will be more likely to have a low blood sugar reaction. Therefore it is recommended that you take your clear fluids in seven portions i.e. breakfast time, mid-morning, lunch time, mid-afternoon, dinner, 2-3 hours after dinner and at midnight. You are required to have around 45 g carbohydrates per portion if you intend to take full dose of short acting insulin.

The following have similar amount of carbohydrate to 1 medium slice of bread

(15g carbohydrate):

150mls clear apple juice

150mls grape juice

60mls sweetened squash

80mls lucozade

250mls lemonade

150mls carbonated beverages

100g clear jelly

5 dextrose tablets (to be sucked)

B) On the day of the procedure

Do not have anything to eat, but you may continue to drink up to 2 hours prior to the colonoscopy.

Please have clear fluids as advised above at breakfast time (7 to 8 am). In addition have a suitable drink equivalent to 15-20g of carbohydrate (see previous section) to avoid the risk of hypo between 10 and 11 am.
If you have a hypo i.e. blood glucose less than 4 mmol/L, then suck 3 dextrose sweets initially followed by another 3 if you do not feel any better. You can also drink 80- 150 mls of lucozade, sweetened squash or fruit juices. Make sure you tell the medical staff if you have a hypo.
4. Take your insulin, blood glucose monitor and insulin injecting equipment with you. You can carry a packed meal so as to avoid delay in administering your insulin dose after the procedure.

Be sure to tell the medical personnel if you are having a hypo. Bring lucozade, glucose tablets or glucogel should it be needed. If you have Type 1 diabetes, you should also check your urine for ketones if blood sugars are higher than 17mmol/L. In the unlikely event of urine ketones being moderate or large, please contact your general practitioner if you feel ill.

5. What to do after your procedure?
The nursing staff will inform you when it is safe to eat and drink. Take your insulin as advised above when you are able to have a regular meal.

When you get home, your sugar levels may be upset for a short time, so continue to monitor your blood sugar levels more closely than normal for a few days and adjust your insulin doses accordingly.

If you need any advice regarding your diabetes please contact the Diabetes Specialist Nurses at ARI (01224 559364) or Woolmanhill (01224 555491) from 9am to 5pm.

For advice out of hours please contact diabetes ward at ARI (01224 551042) or your general practitioner.