Diabetes in adults in palliative care

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Pre-terminal disease will influence glycaemic control

  • goal of treatment is to avoid hypoglycaemia and manage symptoms of hyperglycaemia (balance against burdens of additional treatment and monitoring)
  • Type 1 diabetes has an absolute insulin requirement (wish to avoid diabetic ketoacidosis)
  • little evidence to guide best practice
  • individualised treatments, particularly in Type 2 diabetes.

Additional symptom burden to patients may include:

  • Hyperglycaemia: dry mouth, thirst, lethargy, blurred vision, polyuria, recurrent infections
  • Hypoglycaemia: sweating, hunger, trembling, blurred vision, headache, confusion and disorientation, drowsiness, unconsciousness/coma, seizures.

Potentially reversible issues: infection 

  • stop or limit drugs which adversely influence blood glucose
  • avoid hyperosmotic hyperglycaemic states.
Pathway

 

Palliative care considerations for glycaemic control
  • Anorexia and cachexia
    • inability to take food or medicines
    • increased hypoglycaemia risk
  • Infection
  • Metastatic disease
    • increased risk of hypoglycaemia (liver, adrenals)
    • increased risk of lactic acidosis
  • Cirrhosis
    • hypoglycaemia risk
  • Tumour products
    • most promote insulin resistance
    • may induce hypoglycaemia
  • Cardiac failure
    • catecholamine excess leads to insulin resistance
  • Renal failure
    • Increased risk of hypoglycaemia, and need for reduction in insulin doses
  • Pancreatic cancer
    • pancreatic destruction may lead to Type 1 diabetes-like insulin deficiency
  • Nutritional status
    • supplements or nasogastric feeding cause hyperglycaemia
Drugs which may adversely affect blood glucose
  • octreotide:
    • inhibits insulin secretion, causing hyperglycaemia
  • steroids (given in the morning can cause late afternoon and evening hyperglycaemia)
    • orexigenic (stimulates appetite), may contribute to hyperglycaemia
    • induce insulin resistance, causing hyperglycaemia.

(Insulin doses are often increased to accompany steroid therapy. If steroids are withdrawn patients are at risk of hypoglycaemia if insulin is not altered quickly or marked hyperglycaemia if all treatment including insulin is stopped and there are still steroids in the system)

  • Some diuretics
  • Some atypical antipsychotics may increase insulin resistance and cause hyperglycaemia
Communications with patients and families

Patients/families who have lived with diabetes over a long period of time may find a more relaxed attitude to diet and monitoring difficult to come to terms with. It is important that the addition of insulin therapy is not seen as adding to anxiety or withdrawal perceived as abandonment of care.

Individualise monitoring based on patient factors, therapy and goals of care.

Glossary
Abbreviation Meaning
BM Blood glucose
GLP-1 Glucagon-like peptide-1
PCAS Palliative Care Advisory Service
SGLT2i Sodium Glucose Transporter 2 inhibitor
References

Warren, R.E.,Deary, I. J. and Frier, B.M. The Symptoms of  Hyperglycaemia in   people with Insulin-treated Diabetes:classification Using Principle Components Analysis. Diab Metab Res  2003;19:408-14

Quinn K, Hudson P and Dunning T. Diabetes Management in Patients Receiving Palliative Care.  Journal of Pain and Symptom Management. 2006;32(3): 275 -286

Ford-Dunn S, Smith A & Quin J. management of Diabetes During the Last Days of Life: Attitudes of Consultant Diabetologists and Consultant Palliative Physicians in the UK. Palliative Medicine 2006;. 20(:3):197-203

Steven Miller, Clinical Lecturer in Medicine, University of Glasgow, Consultant Endocrinology & Diabetes, and General (Internal) Medicine, Hairmyres Hospital  - personal communication to Scottish Palliative Care Pharmacist’s Association Conference 3/9/10.

For Health Care Professionals: End of Life Guidance for Diabetes Care. 2021. https://diabetes-resources-production.s3.eu-west-1.amazonaws.com/resources-s3/public/2021-11/EoL_TREND_FINAL2_0.pdf

Editorial Information

Last reviewed: 22 March 2022

Next review: 31 March 2025

Author(s): Palliative and Community Care Pharmacist

Version: 4

Approved By: TAM Subgroup of ADTC

Reviewer Name(s): Consultant in Palliative Care and Consultant Physician in Diabetes

Document Id: TAM340