Diabetes Management in Palliative Care. Ryan Liebscher and Carolyn Wilkinson

Transcription

1 Diabetes Management in Palliative Care Ryan Liebscher and Carolyn Wilkinson

2 What are your learning needs?

3 Objectives Review types and prevalence of diabetes Review what is unique to management in the palliative patient Review symptoms of hyper and hypoglycemia Review blood sugar targets and monitoring Review Tension points Review unique features of steroid induced Diabetes Review insulin preparations and regimens Review approach to management in the palliative patient Work through 2 scenarios

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5 Type 1 Diabetes (T1D) Type 2 Diabetes (T2D) Steroid induced Diabetes Diabetes Prevalence 7-10% of general population; increasing Incidence of diabetes in pts with cancer 6X that of general population Increases with age and certain cancer types 8-18% of those with newly diagnosed cancer Obesity increasing, more comorbidities, people living longer The numbers will continue to grow

6 Diabetes Management Usual Goals Usual goals of treatment (non-palliative setting): Reduce micro and macrovascular complications (long term) Reduce unpleasant osmotic symptoms related to hyperglycemia Avoid hypoglycemia Regular testing/monitoring Lots of literature and evidence

7 Management of Diabetes in the Palliative Patient Little evidence and guidance for the Management of diabetes in palliative population One touch monitoring Target sugar levels Disagreement on best practice between Palliative Care Physicians, Endocrinologists and Diabetic Nurses

8 Key principals of care Provision of a painless and symptom-free death Tailor glucose-lowering therapy & minimize diabetes-related side effects Avoid metabolic de-compensation and diabetesrelated emergencies: frequent and unnecessary hypoglycemia diabetic ketoacidosis hyperosmolar hyperglycemic state persistent symptomatic hyperglycemia End of Life Diabetes Care: Clinical Care Recommendations 2nd Edition. Oct Diabetes UK.

9 Key principals of care Avoidance of foot complications in frail, bed-bound patients with diabetes Avoidance of symptomatic clinical dehydration Provision of an appropriate level of intervention according to stage of illness, symptom profile, and respect for dignity Supporting and maintaining the empowerment of the individual patient and carers to the last possible stage End of Life Diabetes Care: Clinical Care Recommendations 2nd Edition. Oct Diabetes UK.

10 Unique management challenges in the diabetic palliative patient Patients may wish for less monitoring and less focus on chronic medical conditions More pills/therapies/monitoring can be burdensome We must consider the place of care and patient and or caregiver abilities Before all other things, establish what is important, the goals of care

11 Physiologic challenges in the diabetic palliative patient Palliative patients are at higher risks of hypo & hyperglycemia Anorexia-cachexia syndrome Increases risk of hypoglycemia Diabetic therapies are affected by kidney & liver impairment Increases risk of hypoglycemia Bowel obstruction or vomiting Increases risk of hypo or hyperglycemia Pancreatic cancer can induce diabetes Increases risk of hyperglycemia

12 Medications in Palliative Medicine Steroids such as Dexamethasone are commonly used Steroids cause the liver to breakdown glycogen to glucose and is released into the blood. Hyperglycemia has been noted in up to 20% of those on high doses Other medications that can increase sugars: Octreotide, thiazide diuretics

13 Why do we care? Symptoms of hyperglycemia (>20mmol/l.or less) Thirst, lethargy, fatigue, polyuria and dehydration Neurologic symptoms, blurry vision Increased risk of candida, vaginal & other infections Impaired wound healing Threshold for symptoms individually determined But hyperglycemia is not the only problem Hyperosmolar hyperglycemic non-ketotic syndrome Diabetic keto-acidosis Hypoglycemia

14 Symptoms of Hypoglycemia Noradrenergic Tremor, palpitations, anxiety, sweating, hunger, parasthesias Diaphoresis, pallor, tachycardia Neuroglycopenic Cognitive impairment, psychomotor changes, behavior changes, seizures, decreased level of consciousness, blurred vision, speech problems Threshold for signs and symptoms usually <3mmol/l But may be much higher than this if poorly controlled We don t want our patients with sugars < 5mmol/l

15 Blood sugar targets in our palliative patients So we want to avoid hyper and hypoglycemia but... No guidelines nor evidence to guide us Literature suggests. Palliative care docs tend to favor BG levels no higher than 15-20mmol/l Diabetic docs favor BG no higher than 10-15mmol/l Some suggest no higher than 10-20mmol/l Maybe aim between 6-15mmol/l (Diabetes UK. 2013)

16 Blood sugar monitoring in our palliative patients No evidence nor guidelines Tailor to patient/family wishes/goals and to clinical scenario Consider burden of pinprick vs reassurance of pinprick Needs discussion with patient/family Check if suspect hyper or hypoglycemic symptoms If not on insulin and sugars stable stop monitoring When prognosis days short weeks, only do PRN

17 Tension points with monitoring How often to monitor glucose levels (one touches)? Is the finger prick invasive? Yes No Sometimes Many patients very accustomed to this, others hate it We see patients with days, weeks, months and sometimes years to live. Palliative care continues to move upstream. We see patients with different goals Some patients may be reluctant to decrease or stop testing Confusion Abandonment

18 Treatment Approach Depends on Type of Diabetes, place of care, caregiver ability, oral intake, prognosis, symptom burden and comorbid disease such as renal and liver impairment Consider Goals: Help patients and families have improved QOL Manageable care plan Avoid symptoms of hyper or hypoglycemia Education consider diabetic nurse educator; Diet - liberalize Oral agents Insulin (handout) Balance risks of hypo and hyperglycemcia

19 Treatment Approach - Monitoring In both T1D and T2D monitoring should be reduced to acceptable minimum 2-3x/week if on insulin 0-2x/week if on oral hypoglycemics Unless suspect/develops symptoms (hyper or hypo) Significant decrease in intake/vomiting New corticosteroids Target sugar 6-15mmol/l in early terminal illness Target 6-20mmol/l in later stages (unless symptoms)

20 Insulin Regimens Sliding scale Ultra rapid pre, during or right after meal Basal Mixed Medium or Long acting Basal and sliding scale Basal prandial Basal is usually about 40% of total daily insulin dose

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22 Type 1 Diabetes Continue insulin regime with least burdensome monitoring but if reduced intake, a dose reduction may be appropriate. Until last days patients will require basal insulin and while eating likely some preprandial short acting insulin Dose reductions will be necessary when intake decreases Monitoring will continue Goal is regimen and monitoring that is least burdensome to patient, family and avoids symptoms of hyper and hypoglycemia

23 Type 2 Diabetes If Oral hypoglycemic agent (OHA) can cause hypoglycemia (sulfonylureas eg. Glyburide) then stop/decrease as intake (or kidney fn decreases) If OHA -> side effects eg. Metformin->diarrhea->stop If OHA but sugars >15mmol/l consider switch to insulin Ideally we just use basal insulin OD-BID but for some this will not work We increase basal insulin according to use of sliding scale while considering risks of hypoglycemia

24 Type 2 Diabetes With insulin, need to see when sugars are high If AM fasting high Night NPH If post prandial high AM NPH or Lantus +/- preprandial or sliding scale (ultra short acting) If always high BID NPH or OD Lantus + preprandial or sliding scale Monitoring depends on goals, stability, symptoms and risk of hypoglycemia, burden and what is manageable (location)

25 The challenge of steroid-induced diabetes. Case #1

26 35 A Case of Steroid-Induced Diabetes mg Dexamethasone Blood Glucose Insulin NPH Metformin started 6 DAYS

27 Steroid induced diabetes If diabetic or prediabetic need to monitor sugars with steroid initiation or increases Be on the lookout for symptoms! Hyperglycemia usually worse post prandial and later in day (rather than fasting sugar in am) Often NPH or Lantus in the AM with sliding scale and titrate up is good approach. (could consider OHA gliclazide) We may or may not decrease steroid Sugars may take a while to normalize with decreases/ discontinuation

28 Algorithm for patients on oral hypoglycemics in T2DM Routine Care Establish goals Patient education Palliative and diabetic join care and planning Dietician review Symptom evaluation and treatment Consider stopping oral hypoglycemics (OHA) Life-expectancy Hours/days Weeks/months Stop monitoring\stop oral hypoglycemics *Poor intake or vomiting Renal or hepatic failure Modified from King et al Low hypoglycemia risk Monitor sugars (0-1x/wk) Target sugar 6-15ish Cont. Current treatment *High hypoglycemia risk Monitor sugars (1-2x/wk) Target sugar 6-15ish Reduce/stop Glyburide Consider D/C other OHA

29 The challenge of long-term diabetes at end of life. Case #2

30 Algorithm for patients on insulin therapy in T2DM Routine Care Establish goals Patient education Palliative and diabetic join care and planning Dietician review Symptom evaluation and treatment Life-expectancy Hours/ short days Stop monitoring Stop insulin *Poor intake or vomiting Renal or hepatic failure Some Days Monitor minimally Consider short acting insulin PRN Or stop both Low hypoglycemia risk Monitor sugars Target sugar 6-15ish Current treatment Consider med/long acting insulin Weeks/months *High hypoglycemia risk Monitor sugars Target sugar 6-15ish Reduce Insulin Consider short acting insulin Modified from King et al. 2012

31 Summary Goals of care shape the care plan Consider always Prognosis Education and good communication Place of care What are burdens of monitoring, treatment or no treatment How will the care plan be managed by/affect caregivers Don t forget your friendly diabetic nurse and dietician Remember that good diabetic care is good palliative care

32 References King EJ et al The management of diabetes in terminal illness related to cancer. Q J Med. 105:3-9. Oyer DS et al How to manage steroid diabetes in the patient with cancer. J Support Oncol. 4 (9) Quinn K et al Diabetes Management in Patients receiving palliative care. J Pain symptom Manage. 32: End of Life Diabetes Care: Clinical Care Recommendations 2nd Edition. Oct Diabetes UK.