On oral hypoglycaemic agents

• Of the diabetes tablet therapies only metformin comes in a liquid, the others cannot be used with a NG/J tube. Stop all other agents and contact the diabetes team.

On GLP-1 agonist sub-cut injections

• If there is no other contra-indication (acute GI disturbance, pancreatitis) this can be continued.

On insulin

• In an emergency please continue long acting insulin (if the patient is on this) and start a variable rate insulin infusion to run alongside the feed. Please contact the diabetes team as soon as practicable.
• Never withhold all insulin.
• In daytime hours please contact diabetes team for advice.

• Patients should have CBGs checked at the start of feed, end of feed and 4 hourly when on a feed.
• Target CBGs are 6-12, although a higher range may be more suitable for those who are frail.

• If a patient has had their insulin and the feed stops (e.g. displacement of tube) they will need an alternative source of glucose until the feed is restarted as they are at risk of hypoglycaemia.
• The glucose should be run IV at the same rate as the carbohydrate content of the feed (this information can be found on the label on the feed bag or by searching the feed manufacturer and name online). Note 5% glucose contains 5g glucose per 100ml and 10% glucose contains 10g per 100ml.
• CBGs should be checked hourly in these patients until the feed is re-established.
• If patient has Type 1 diabetes or is hyperglycaemic please start VRII.

• The doses of insulin should be increased by 10-20% if the CBGs are over target. Some patients may be very hyperglycaemic on enteral or parenteral feeding and may need much higher increases in their insulin doses to maintain their CBG in target.
• If the patient has CBG >14 and has Type 1 diabetes check ketones and follow ketones guideline if >0.6.
• Contact diabetes team in daytime hours for further review, and overnight if concerns.

1. ABCDE assessment

• If patient unconscious or any significant clinical concern - 2222

2. How to treat the hypo

• If the feeding tube can be used give 60ml Glucojuice or 150-200ml orange juice or 50-70ml Fortijuice (NOT Fortisip) or bolus feed to give 15-20g carbohydrate.
• If the feeding tube cannot be used give 1mg IM glucagon or 150-200ml 10% glucose IV as a bolus or give 2 tubes glucogel buccally.
• DO NOT use glucogel down a fine bore NGT as this will block the tube.
• Recheck the CBG after 15minutes to ensure the hypo has resolved.

3. Prevent a recurrent hypo

• If the hypo occurred when the feed was running, reduce the preceding dose of insulin by 20% for the next day.
• If the hypo occurred when the feed was not running unexpectedly, commence 10% glucose at the carbohydrate rate of the usual feed until the feed is re-established.
• If the hypo occurred when the feed was not running in the rest period after a 12-20hour feed, reduce the preceding insulin dose for the next day by 20%.

Please contact diabetes team if you have any concerns or initial management is not successful

Further information can be found in the full Joint British Diabetes Societies enteral feeding guideline.