Diabetes background

Definitions

Hypoglycaemia

  • Defined as CBG below 4.0 mmol/L
  • Symptoms include
    • pallor, sweating, tremor, tachycardia, loss of concentration,
    • aggression/confusion, fits, transient neurological deficit, reduced conscious level
  • Causes in palliative care population include
    • Weight loss
    • Anorexia
    • Renal failure (drugs not metabolised)
    • Liver failure (decreased glycogen and gluconeogenesis)
  • Treatment should be instigated when identified, if appropriate to do so. (See Management: Hypoglycaemia)

Hyperglycaemia

  • Defined as CBG above 15.0 for the purpose of this guidance (See references 1,3)
  • Symptoms include
    • Thirst, dry mouth, confusion, drowsiness, polyuria and lethargy
  • Causes in palliative care population include
    • Steroid use
    • Stress response to illness
    • Co-existent infection
    • Pre-existing diabetes
    • Pancreatic cancer
  • Treatment should be instigated if there are symptoms, which generally occur when the CBG is >15 (See reference 4). Which treatment depends on the individual case.

Normoglycaemia – normal blood glucose

Target setting

Target setting has two aims:

  1. To prevent distress from the acute metabolic complications of DKA, HHS and hypoglycaemia
  2.  To provide symptomatic comfort by preventing high blood glucose related symptoms of excessive thirst, polyuria and excessive tiredness.
    Whilst CBG targets can vary between patients and their disease duration, a target range of 6-15mmol/l will be appropriate in most cases (see references 1&2).

A move away from rigid target based CBG control is advised, especially avoiding the use of rapid acting insulins if the CBG is ‘high’ in those T2DM or steroid induced diabetes. There is no evidence to show that the use of rapid acting insulins will offer any symptomatic benefit in this patient group. In these situations, an alteration to the existing diabetes regimen is preferable to ensure CBG readings are within the preferred range. However, in patients with T1DM with a prognosis of longer than weeks, use of rapid acting insulins may avoid ketoacidosis, which would add significant burden of illness. Therefore patient selection, that encompasses type of diabetes and predicted prognosis, is crucial when considering prescription of PRN rapid acting insulin.

Glucose monitoring

Frequency and method of testing is likely to need to change. Ideally, CBG monitoring should be minimised where possible. Urinalysis may be sufficient in some cases, particularly where there is no hypoglycaemia risk, or within the community where access to a CBG machine may be limited. Stopping CBG monitoring altogether may be a reasonable option for some patients. Refer to the Diabetes Management section for specific guidance depending on the type of diabetes and estimated prognosis.

Counselling with Patient and Family

Patients, families and carers will have often spent many years striving for tight glycaemic control in an attempt to reduce the risk of long-term complications. They may find it difficult to understand that when the end of life is approaching, maintenance of strict normoglycaemia, aggressive blood pressure and lipid management, and strict dietary restriction can become detrimental to quality of life. Avoidance of long-term complications becomes an irrelevant goal. They will require sensitive counselling from their clinicians to explain the shift in glycaemic goals.

Vulnerable populations and nutrition

End of Life Guidance for Diabetes Care (1) make note of certain clinical scenarios where special considerations may be necessary.

These include:

Special populations

  • Care Home Residents
  • Frailty
  • Dementia
  • Cancer
  • Renal disease

Nutrition

  • Poor swallow/reduced appetite
  • Enteral feeding

Pumps/flash readers

Please refer to End of Life Guidance for Diabetes Care (1) national document for further exploration of these scenarios.

Optimisation of insulin delivery – move to steroid induced

Insulin delivery pens may need to be reassessed if the physical capabilities of patient alters or carers/family becomes involved in insulin delivery.

Similarly, any change to the insulin regimen should be implemented near the beginning of the week if at all possible.

If there is isolated hyperglycaemia avoid stat doses of short acting insulins such as Novorapid (see Target Setting in Background section). Instead, explore reasons for hyperglycaemia (consider DDDISH)

  • Have the Drugs of diabetes been modified (ie insulin reduced or metformin stopped)
  • Have Drugs causing diabetes been introduced (steroids, immunosuppressives, check point inhibitors)
  • Has the Diet been altered (nutritional supplements)?
  • Infection
  • Stress hyperglycaemia
  • HbA1c

If there is a persistent trend, maintenance therapy should be reviewed. The information above gives further detail on how to up titrate medications depending on the type of diabetes and estimated prognosis of the patient. A DSN can be involved if required.

Disclaimer (SPAGG - Rewrite)

This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.

Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.

While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.