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
  • 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 If steroids are withdrawn patients are potentially at risk of hypoglycaemia if insulin is not altered quickly, or marked hyperglycaemia if all treatment including insulin is stopped and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
Editorial Information

Last reviewed: 31 August 2017

Next review: 31 August 2019

Author(s): Palliative and Community Care Pharmacist

Version: 3

Approved By: Policies, Procedures and Guidelines Subgroup of ADTC

Reviewer Name(s): Alison MacRobbie