Post on 25-Jul-2020
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Management of Diabetes in Specialist Palliative Care
Contents
Principles of Management Page 1 Sources of Information Page 2 Diagnosis of Diabetes Page 2 Glucose Control Targets Page 2 Common Treatments for Diabetes Pages 2-3 Insulin Regimens, types of insulin, and hypoglycaemia risk Page 3 Initiating and titrating treatments (1) Oral Glucose lowering therapy Page 4 Initiating and titrating treatments (2) Managing Diabetes on Steroids Page 5 Initiating and titrating treatments (3) Insulin Page 6
Initiating insulin Page 6
Switching between insulins Page 7
Titrating insulin Page 7
Managing diabetes as things change Page 8
Type 1 Diabetes Page 8
Type 2 Diabetes Page 9
Diabetic Emergencies Page 10
Hyperosmolar Hyperglycaemic state (HHS) Page 10
Diabetic Ketoacidosis Page 10
Hypoglycaemia Page 11
Diabetes and Enteral Feeding Page 12 References Page 12
Principles of Diabetes Management in Palliative Care At end of life it is important to provide effective symptom control whilst remaining attentive to the possibility of
diabetes related emergencies, dehydration or loss of symptomatic control whilst considering impact, burden and
potential effects of ongoing treatment & monitoring.
Sources of information CHFT Diabetic Specialist Nursing Team can be contacted on 01484 347297 (inpatients) or 01484 344270
(community)
Online resources include the Diabetes UK End of Life Diabetes Care Clinical Recommendations (March 2018)
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Diagnosis of Diabetes (in non-pregnant adults)
OR OR OR
Symptomatic patients need a single positive result for diagnosis. Asymptomatic patients need two positive results
Glucose Control Targets Based on accepted practice, and the Diabetes UK guidelines, the following should be achieved where possible:
These ranges should help avoid symptoms of hyperglycaemia and reduce the risk of hypoglycaemia, Hyperosmolar
Hyperglycaemic State (HHS) or Diabetic Ketoacidosis (DKA).
Common Treatments for Diabetes Mellitus
Oral Medications
Action: Enhance insulin response
Action: Promote insulin secretion
Action: Enhance the action of gut
hormones (incretin mimetics) Indications:
First line treatment for patients with type 2 diabetes as monotherapy or
combination therapy
Indications: Type 2 diabetes as monotherapy or
combination therapy
Indications: Type 2 diabetes as monotherapy or
combination therapy
Contraindications : Ketoacidosis, use of general anaesthesia
Contraindications : Ketoacidosis
Contraindications : Ketoacidosis
Cautions: Can provoke lactic acidosis
Cautions: Elderly, G6PD deficiency
Cautions: History of pancreatitis
Renal Impairment:
Review dose if eGFR < 45 Stop if eGFR< 30
Impairment: Avoid or reduce dose in severe hepatic
impairment Increased hypoglycaemia risk in renal
impairment, increase monitoring
Impairment: Reduce to 50mg OD if eGFR 30-50 Reduce to 25mg OD if eGFR < 30
Common side effects: GI upset (consider switch to M/R)
Common side effects: Hypoglycaemia
Common side effects: GI upset, nasopharyngitis, pain(NOS), oedema, URTI
Prognosis: Days
Aim for BMs 6-20
Prognosis: Weeks to months
Aim BMs 6-15
Prognosis: > 1 year
Aim BMs 6-15
Random blood
glucose
≥ 11.1mmol/L
Fasting plasma
glucose
≥ 7.0mmol/L
HbA1c
≥ 48mmol/mol
Positive OGTT
Metformin Sulfonylureas (e.g.
Gliclazide)
DPP-4 inhibitors
(e.g. Sitagliptin)
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Insulin regimens
Type of insulin: Short acting + long or
intermediate acting (given separately)
Type of insulin: Short + intermediate acting
(given together as a mix)
Type of insulin: Long acting or
intermediate acting
Type of insulin Variable, usually rapid
acting
Frequency:
Short acting given TDS with or just before meals
Long/intermediate acting given OD
Frequency:
BD, usually before breakfast and evening
meal
Frequency:
Once daily, usually AM
Frequency:
Continuous with bolus doses if necessary
Indication:
Usually in Type 1 Diabetes. Replicates natural insulin
release with meals Allows flexibility with
meals and doses
Indications:
Patients with Diabetes with high post-prandial
BMs with a stable diet and regular daily routine
Indications:
Patients with hyperglycaemia day and night, those unable to administer their own
insulin, and patients at end of life
Indications:
Patients with Type 1 Diabetes whose blood
sugars are uncontrolled with optimum basal-bolus
regimen
Cautions:
Hypoglycaemia risk with meal calculations and dose
variation
Cautions:
Hypoglycaemia risk if sudden lifestyle or diet
change
Cautions:
Does not allow for variation in BMs with
meals/diurnal variation
Cautions:
Involves insertion, monitoring and high level
of patient knowledge
Types of insulin If a person’s blood glucose control is adequate on their existing insulin regimen, this should be continued and
ordered from pharmacy. If initiating or switching insulin types, the table below lists the preparations recommended
as Kirkwood stock (NB none of the stock insulin is porcine/bovine in source and are therefore not restricted on
dietary/religious grounds).
Name Action Source Instructions Peak onset/Duration of action
Novorapid Rapid-acting Analogue Just before/with food Peak: 0-3 hours Duration: 4-5 hours
Humulin M3 Mixed short & intermediate acting
Human 20-45 mins before food Peak: 30 mins – 8 hrs Duration: 18 hours
Humulin I Intermediate Acting Human 30 mins before food or bed Peak: 1-8 hours Duration: 18 hrs
Lantus Long acting Analogue Once a day, at same time No specific peak Duration: over 24hrs
Hypoglycaemia risk with medications
Metformin Gliptins (e.g. Sitagliptin) Sulphonylureas (e.g. Gliclazide) Pioglitazone SGLT2 agents ‘flozins’ Insulin
GLP-1 analogues (e.g. Exenatide)
Basal-Bolus Biphasic (BD) Once daily Insulin Pump
No risk High risk Low risk
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Initiating and titrating treatments (1) Oral Glucose-Lowering Therapies
These medications are predominantly prescribed for patients with Type 2 Diabetes in whom dietary measures have
failed.
In patients who are newly diagnosed, or those with poor diabetic control, the following is a guide to treatment.
Please note table on page 5 detailing common side effects and cautions. Please consult BNF for an exhaustive list.
For the purposes of this guideline, other oral agents have been excluded – namely pioglitazone, GLP1 agonists (e.g.
Liraglutide), and Sodium-Glucose Co-transporter 2 Inhibitors (e.g Dapagliflozin). This is based on side effect and risk
profiles, stock availability and familiarity with use. For advice regarding these drugs, speak to the Diabetes CNS team
at CHFT.
Prescribe a sulfonylurea:
Gliclazide 40mg OD, and titrate
accordingly
Monitor BMs BD (am and eve)
If glucose control remains
suboptimal despite Metformin
titration– add in a sulfonylurea:
Gliclazide 40-80mg OD, and titrate
accordingly
Monitor BMs BD (am and eve)
New diagnosis of diabetes or inadequately
controlled diabetes on diet alone
eGFR 30-45ml/l/1.73m2
Check renal function
eGFR > 45ml/l/1.73m2
Prescribe Metformin S/R
Initial dose 500mg OD (unless
contraindicated). Use M/R if not
tolerated
Monitor BMs OD
If glucose control remains suboptimal – add in a DPP4
inhibitor (‘gliptin’):
Sitagliptin 50-100mg OD (dependant on eGFR)
Monitor BMs BD (am and eve)
If glucose control remains
suboptimal – add in a DPP4
inhibitor (‘gliptin’) e.g. Sitagliptin
50mg OD
Monitor BMs BD (am and eve)
If glucose control remains suboptimal:
Consider starting insulin (see p4)
Liaise with Diabetes CNS (if
complex)
eGFR <30ml/l/1.73m2
Prescribe a DPP4 inhibitor
(‘gliptin’):
Sitagliptin 25mg OD
Monitor BMs BD (am and
eve)
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Initiating and titrating treatments (2) Patients on Steroid Therapy
In patients with existing diabetes, blood sugar levels will typically rise within a few hours of taking steroids and peak
in the afternoon or evening. Blood glucose will typically return to more acceptable levels by the following morning.
Note should therefore be taken of the need to titrate morning doses of diabetic medication according to the
morning steroid dose and the evening blood glucose level.
Reduction or cessation of steroid doses should also prompt a review of whether diabetic medication is still required.
Hyperglycaemia on once daily steroids
Diet controlled, or treated
with Metformin or gliptin On sulphonylurea On Insulin
If evening BM consistently
high (3 or more days), add
Gliclazide 40mg OD (am)
Check BMs am and eve
initially
If evening BMs remain high,
increased Gliclazide am dose
in 40mg increments every 1-
2 days (max 240mg)
If evening BMs remain high,
(with no hypoglycaemia
symptoms) add 40-80mg
Gliclazide evening dose or
consider insulin
If evening BM consistently
high (3 or more days),
increase Gliclazide am dose
to maximum 240mg (in
40mg increments)
Check BMs am and eve
initially
If evening BMs remain high,
(with no hypoglycaemia
symptoms) add 40-80mg
Gliclazide evening dose
If evening BMs remain high,
(with no hypoglycaemia
symptoms) add Humulin I
AM dose – 10 units and
titrate according to BMs
If evening BM consistently
high:
On OD/BD insulin,
increase am dose in
10-20% increments
On basal-bolus insulin,
increase breakfast and
lunchtime fast acting
insulin by 10-20%
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Initiating and titrating treatments (3) Insulin
Insulin should be considered if:
Blood glucose levels are inadequately controlled despite dual oral anti-diabetic drugs
Oral anti-diabetic drugs are not tolerated or are contraindicated
This decision should be considered in the context of the overall health of the patient and the possible implications
for lifestyle. If discharge home is planned, for a patient newly started on insulin, the Diabetes CNS team should be
involved to ensure self-management and education is optimal.
Initiating insulin
* Diabetes UK recommend it is generally simpler to switch from combinations to long acting insulin only, particularly
when hypoglycaemia risk is high and carers are involved in administration
Blood glucose inadequately controlled
on oral anti-diabetic drugs
Speak to Diabetes CNS at CHFT. If not possible (e.g. OOH):
Switch to (long acting) insulin - Lantus 8-10 units OD (am)*
Monitor BMs BD
Prognosis: Weeks to months
Aim BMs 6-15
Prognosis: Days
Aim for BMs 6-20
Blood glucose inadequately controlled
on oral anti-diabetic drugs
Switch to (long acting) insulin - Lantus 8-10 units OD (am)
Monitor BM OD
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Switching biphasic or basal-bolus insulin to once daily
Titrating insulin Insulin dose should be titrated according to target blood glucose ranges based on sustained patterns (not sole
readings).
As a general rule:
Increase insulin in increments of 10-20%
Reduce insulin for hypoglycaemia by 20-30%
Patient already on insulin
As a general rule: Calculate total daily insulin
dose, reduce by 25%, and switch to OD
Lantus (am)
If the patient has been having
hypoglycaemic episodes or there is an
acute change in oral intake, consider a 30-
40% reduction in total insulin dose
Monitor BMs BD initially, then once stable
reduce to OD (eve)
BMs are stable and no side
effects or complications
BMs are unstable +/- patient is at risk of
side effects or complications of existing
regimen
If the patient has been having
hyperglycaemic episodes consider a direct
switch or a smaller reduction in total daily
insulin dose
Continue current regimen
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Managing Diabetes as things change: Type 1 Diabetes
Individuals with Type 1 Diabetes have an absolute requirement for insulin treatment, without which they will rapidly
become hyperglycaemic and develop diabetic ketoacidosis.
Insulin dose requirements will change at end of life. As appetite reduces and weight falls the amount of insulin
needed to control blood glucose will correspondingly fall. As food intake drops it is likely that fast-acting insulin can
be discontinued, and basal insulin will suffice.
The following is a guide to general management of those patients with Type 1 Diabetes approaching end of life:
*see ‘Switching Insulin’ guidance on Page 7
Insulin pumps Continuous subcutaneous insulin pumps are increasingly used to manage Type 1 Diabetes. For patients admitted to
the hospice with an insulin pump – please speak to the trust Diabetes CNS team for advice on ongoing management.
Consider rationalising medicines (e.g. ACEi)
If stable on established regimen, continue and
monitor.
If stable on established regimen, continue and
monitor.
Consider change to OD
Lantus (am) insulin regimen if appropriate *
Agree targets for glucose control
Consider simplifying insulin regimen to BD or OD insulin
if appropriate *
Consider simplifying insulin
regimen to OD Lantus (am) if appropriate *
Check BM once daily
(evening)
Assess hypoglycaemia
risk with changes in eating patterns
Check BMs before insulin
doses and in evening (unless symptomatic)
Check BMs before insulin
doses and in evening (unless symptomatic)
DO NOT STOP INSULIN
Prognosis > 1 year Prognosis days Prognosis weeks
to months All patients
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Managing Diabetes as things change: Type 2 Diabetes
The following is a guide to general management of those patients with Type 2 Diabetes approaching end of life:
*see ‘Switching Insulin’ guidance on Page 7
**see ‘Initiating Insulin’ guidance on Page 6
Consider
rationalising medicines (e.g.
ACEi)
Continue current
diabetes management unless complications
or side effects
Continue current
diabetes management unless complications
or side effects
Continue current
diabetes management unless complications
or side effects
Continue current
diabetes management unless complications
or side effects
Review target glucose levels (especially if weight loss)
Simplify regimens where possible (if
appropriate)
For those on insulin
(+/-oral agents) consider simplifying
insulin regimen to BD or OD insulin if appropriate *
If diet controlled or on
metformin – stop monitoring BMs and
stop metformin
Consider change to OD
Lantus (am) insulin regimen if
appropriate*
Assess
hypoglycaemia risk with changes in eating patterns
Check BMs before
giving hypoglycaemic agents (not
metformin) and in evening
Check BMs before
giving hypoglycaemic agents (not
metformin) and in evening
If on other oral
agents/gliptins and unable to take oral
meds – stop these, but monitor BMs BD
initially
Check BM once daily
(evening)
If unable to take oral
meds and hyperglycaemic:
If BM > 20 and symptomatic
administer Novorapid 6 units SC
If BM > 20 on 2 or more occasions in
24hrs, start Lantus insulin OD
(am)** and check BM OD (eve)
Avoid rapid acting
insulins where possible, but:
If BM > 20 and symptomatic ,
administer Novorapid 6 units SC
Titrate background insulin according to
BMs
Prognosis:
Weeks to
months
Prognosis:
Days – On oral
agents alone
Prognosis: Days
– On insulin (+/-
oral)
All
patients
Prognosis > 1
year
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DIABETIC EMERGENCIES (1) Hyperosmolar Hyperglycaemic State (HHS) and Diabetic Ketoacidosis (DKA)
If DKA or HSS not diagnosed, continue rehydration and review ongoing glycaemic control
Urgent exclusion of HHS
IV access
Send urgent bloods for U&E,
serum osmolality, glucose and FBC
Start IV infusion 0.9% saline 1L
2hourly until blood results known.
Urgent exclusion of DKA
IV access
Send urgent bloods for U&E,
glucose, bicarbonate and FBC
Start IV infusion 0.9% saline at
500ml/hour until blood results
known
Patient who presents with any of the following (including those not known to be
diabetic):
Dehydration
Lethargy and/or confusion
Generally unwell
Abdominal pain
Vomiting or diarrhoea
Initial Assessment
Airway, Breathing, Circulation
Full set of physical observations
Check urine for ketones
Random BM
Hyperglycaemic AND 2+ ketones in urine
Hyperglycaemic with 0-1 ketones in urine
(with features described above)
If serum bicarbonate < 15mmol/L in
presence of 2+ ketonuria and BM >11
= Diabetic ketoacidosis
This is a medical emergency. Contact on
call Consultant and transfer to hospital if
treatment is appropriate.
If serum osmolality >320mOsm/kg and
serum Na+ >150mmol
= Hyperosmolar Hyperglycaemic State
Contact on call Consultant and transfer to
hospital if treatment is appropriate.
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DIABETIC EMERGENCIES (2) Hypoglycaemia
*NB Glucagon may be less effective in liver disease
Patient with random BM or < 4mmol/L
Conscious
Semi responsive or unresponsive
If able to eat and drink
Give 15-20g of rapid
acting glucose:
1-2 tubes of Glucogel
4-5 Glucotabs®
100ml Lucozade
150-200ml fruit juice
Support airway
Give 1mg glucagon SC*
Contact Doctor
Recheck BM after 10
mins. Repeat above if
BM<4 (can be repeated
up to 3 times)
Follow with a starchy
snack once BM >4
1-2 slices of toast
2 biscuits
200-300ml milk
A banana
If has an enteral feeding
tube
Give 15-20g of rapid
acting glucose:
1-2 tubes of Glucogel
150-200ml fruit juice
110-140ml Fortijuice
(not Fortisip)
Follow all treatments
with a 50ml water flush
If BM remains < 4 contact Doctor
If BM remains < 4: Give 150-200ml
10% glucose IV over 15 minutes
If BM >4 and patient regains
consciousness: Give a starchy
snack:
2-3 slices of toast
4 biscuits
500-600ml milk
Recheck BM after 10 mins.
Repeat above if BM<4
(can be repeated up to 3
times)
Restart feed once BM >4
Give 1mg IM glucagon*
If BM remains <4 after 10 mins
Repeat BM after 10 mins
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Enteral feeding and diabetes
Patients with enteral feeding regimens tend to have high carbohydrate loads which can make diabetes management
more difficult. Collaborative care with a dietician is important as the types and timings of feed can vary significantly.
Oral hypoglycaemic agents (with the exception of metformin) are not available in liquid form and should not be
crushed, therefore the mainstay of treatment is insulin.
As a general rule:
Prolonged feed (e.g. overnight Give an intermediate acting (e.g. Humulin I) at the start of the feed
Bolus feeds Give a short acting insulin (e.g Novorapid) at the start of each feed. Type 1 diabetics may also need a long acting insulin (e.g. Lantus)
Continuous feed with regular supplements or meals in addition
Give a long acting or intermediate acting insulin at the start of the feed, and a short acting insulin with bolus supplements or meals
Liaising with the Diabetic CNS team is strongly recommended.
References
(1) End Of Life Diabetes Care Clinical Care Recommendations, Diabetes UK, March 2018
(2) Type 2 Diabetes in adults: management, NICE (NG28) May 2017
(3) The Hospital Management of Hypoglycaemia in Adults with Diabetes Mellitus 3rd edition, Joint British
Diabetes Societies for Inpatient Care, April 2018
(4) The management of the Hyperosmolar Hyperglycaemic State (HHS) in adults with diabetes, Joint British
Diabetes Societies Inpatient Care Group, Aug 2012
(5) The management of Diabetic Ketoacidosis in adults with diabetes, Joint British Diabetes Societies Inpatient
Care Group, Sept 2013
(6) BNF 2018