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Managing Diabetes in the Last Days of Life Dr Jayne McAuley Consultant Palliative MedicineAims of the Guidance • Ensure effective symptom control at end of life • Individualise treatment to the patient’s need • Avoid metabolic de-compensation and diabetic emergencies • Hypoglycaemia • Diabetic ketoacidosis • Hyperosmolar hyperglycaemic state • Persistent symptomatic hyperglycaemia • Avoid symptomatic clinical dehydration • Support the patient and their familyCommunication • Patient • Family • Diabetic Specialist Nurse (DSN) Ward Team or GP/District Nurse • Key points • Aim capillary blood glucose 6-15mmol/L in end of life care • Be clear if Type 1 or Type 2 diabetes mellitus • Seek DSN advice early • Keep blood glucose tests to a minimum, but do check if symptomaticSymptomatic? • Hypoglycaemia • Shaking • Dizzy or faint • Palpitations/feeling anxious or jittery • Sweating • Pallor • Confusion • Drowsiness Coma •Symptomatic? • Hyperglycaemia • Increased thirst • Dry mouth • Blurred vision • Increased urinary output • Nausea • Fruity smell to breathType 2 Diabetes Diet Controlled or on Metformin • Stop Metformin • Stop monitoring blood glucose • Discuss changes with patient/ familyType 2 Diabetes On other tablets/Insulin/GLP-1 RAs If Insulin Stopped • If patient appears symptomatic can check blood glucose (not routine) • If blood glucose over 20mmol/L give 6 units of rapid acting Insulin and re-check blood glucose after 2 hours • If requires rapid acting Insulin more than twice in 24 hours, consider daily long acting Insulin eg: Lantus • Refer DSN if neededType 2 Diabetes On other tablets/Insulin/GLP-1 RAs If Insulin Continues • Prescribe once daily morning long- acting Insulin eg: Lantus based on 25% less than total previous daily Insulin dose • Check blood glucose at teatime • by 10-20%8mmol/L reduce Insulin dose • dose by 10-20% to reduce risk ofin symptoms or ketosis • Refer DSN if needed Type 1 Diabetes Insulin continues: ➢ Change to a once daily long acting Insulin, such as Lantus, with reduction in dose (seek advice from DSN) ➢ Check blood glucose at teatime daily ➢ If below 8mmol/L reduce insulin by 10-20% ➢ If above 20mmol/L increase insulin dose by 10-20% (reduces risk of symptoms/ ketosis)Case 1 Mr . L • 84 year old man with advanced dementia • Now at EOLC stage (aspiration pneumonia) • Not eating last 3 days, managing occ. sips of water • On Metformin for Type 2 Diabetes, but not managed tablets this am • On QID CBG monitoring on wardManagement • Stopped Metformin (and other oral medications) • Stopped CBG monitoring and observations • Anticipatory medications prescribed (pain, N&V, agitation, secretions) • Full supportive discussion with family • Patient died comfortably 3 days later (no evidence hyperglycaemia)Case 2 Mrs. C. • 63 year old woman • History of metastatic bowel cancer and Type I diabetes since 15 years old • Now EOLC • Not eating or drinking • CBG being checked QID and between 6 and 16mmol/L • Still prescribed Lantus 10 units in evening and Novomix 30 BD 20 units • DSN involved• Novomix was stopped and Lantus moved to morning and dose reduction of daily insulin by about 25% (30 units) CBG monitored at teatime only and observations stopped • • Anticipatory medications were prescribed (pain, N&V, agitation, secretions) Full supportive discussion with family • • CBG were between 12-16mmol/L • Mrs. C. died comfortably 2 days later with her family presentCase 3 Mr . M. • 54 year old man • Pancreatic CA and Type 2 diabetes • EOLC (not eating or drinking) • CBG being checked QID on ward and normally between 6-15mmol/L • Still written up for Metformin and Dapagliflozin but not taken yesterday or today • On twice daily Novomix 30 Flexipen 10 units BD • DSN support ongoingManagement • Oral medication including diabetic drugs stopped • CBG monitoring changed to once daily at teatime • Insulin was changed to Lantus in morning with 25% dose reduction (15 units) • His CBG reading was 5mmol/L the following teatime so Lantus was reduced by 20% to reduce risk of hypoglycaemia (12 units) • CBG reading remained over 8mmol/L with no evidence of symptoms of hypo/hyperglycaemia • He died comfortably 3 days laterKey points to remember • Know whether type 1 or 2 Diabetes Mellitus • Good communication • Involve DSN • Goal blood glucose 6-15mmol/L with minimal testingManaging the Effects of Steroid therapy on glucose control in a Palliative Setting Dr Jayne McAuley Consultant Palliative MedicineSteroid therapy in Palliative Care • Frequently prescribed for symptom control • Remember steroid card • Can cause problems with hyperglycaemic symptoms in diabetic patients and patients not previously diagnosed with diabetes mellitus • Once daily steroid therapy tends to cause rise in glucose levels late afternoon/early eveningAims of the Guidance • Ensure effective symptom control at end of life • Individualise treatment to the patient’s need • Avoid metabolic de-compensation and diabetic emergencies • Hypoglycaemia • Diabetic ketoacidosis • Hyperosmolar hyperglycaemic state • Persistent symptomatic hyperglycaemia • Avoid symptomatic clinical dehydration • Support the patient and their familyCommunication • Patient • Family • Diabetic Nurse Specialist (DSN) Ward Team or GP/District Nurse • Key points • Aim capillary blood glucose 6-15mmol/L in end of life care • Do not use this guidance if patient on steroids for Covid19 infection • Seek DSN adviceSymptomatic? • Hypoglycaemia • Shaking • Dizzy or faint • Palpitations/feeling anxious or jittery • Sweating • Pallor • Confusion • Drowsiness Coma •Symptomatic? • Hyperglycaemia • Increased thirst • Dry mouth • Blurred vision • Increased urinary output • Nausea • Fruity smell to breath Type 1 Diabetes If on Basal Bolus Insulin Consider transferring evening basal • dose insulin to the morning and titrate the short/fast acting Insulin by 10-20% daily until blood sugars OK • Seek DSN advice early especially if blood sugars still high or if at risk of hypoglycaemic symptoms despite snacksType 1 or 2 Diabetes If on twice daily Insulin Titrate morning dose by 10-20% • according to pre-evening meal CBG readings • Seek DSN advice early especially if blood sugars still high or if at risk of hypoglycaemic symptoms despite snacks Type 2 Diabetes If on once daily nightly Insulin Change time of injection to • morning • Titrate by 10-20% according to pre- evening meal CBG readings • Seek DSN advice early especially if blood sugars still high as may need BD or basal bolus regimen Type 2 Diabetes • If no “hypo” syms and NOT on a sulphonylurea or insulin •Start Gliclazide 40mg mane and titrate daily until blood sugars OK (maximum dose of 240mg mane) •Seek DSN advice early especially if 160mg or higher) • May be appropriate to move to BD gliclazide or Insulin after specialist advice if blood sugars still too high Not previously diabetic but high sugars on steroids Start Gliclazide 40mg mane and • titrate daily until blood sugars OK (maximum dose of 240mg mane) • Seek DSN advice early especially if 160mg or higher) When steroids reduced or stopped • continue glucose testing if CBG >12mmol/L as patient may be a new diagnosis of diabetes and require referral for investigation and ongoing managementCase • Mrs S, 48 year old woman • 4 year history breast carcinoma with bone metastases • Admitted with 1 week history of increasing back pain radiating down both legs and now felt legs were weaker • Suspected Malignant Spinal Cord Compression (SCC) •Commenced on high dose Dexamethasone 16mg daily •Urgent MRI whole spine confirmed SCC •Treated with one fraction XRT• CBG checked daily 5pm • Consistently >18mmol/L • New onset steroid induced diabetes • Discussed with DSN • Commenced on Gliclazide 40mg daily • Gliclazide titrated up to 80mg daily • CBG well-controlled (<15mmol/L and no hypos) • Plans to reduce Dexamethasone and Gliclazide were made and supported with advice from DSN (regular CBG monitoring)Key points to remember • Know whether type 1 or 2 Diabetes Mellitus • Good communication • Involve DSN early • Goal blood glucose 6-15mmol/L in end of life care