Diabetes

Diabetes is an increasingly common pre-existing condition as well as associated with many terminal diseases, and their treatment, making it a consideration for many patients receiving palliative care. It may or may not cause symptoms itself and can be a worry to patients and those that care for them as oral intake decreases and insulin requirement potentially drops. Whilst the aim when in good health is strict blood sugar control and lowering of HbA1c as patients enter the final months and weeks of life a more pragmatic, symptom driven approach is preferable.

Any change in goals and to medication regimes will need to be openly explained and explored.

Type 1 diabetes or type 2 diabetes on insulin (stable control)

Continue current regime and monitoring
Discuss relaxation of blood sugar targets to 6-15mmol/L
Reiterate hypo awareness and reporting
Adjust long-acting insulin as oral intake reduces

Type 2 diabetes (tablet controlled)

Stop oral hypoglycaemics and check blood sugars twice a day
If blood sugars 6-15mmol/L no further treatment required
If blood sugar raised >15mmol/L start small dose of Lantus insulin once a day
Monitor blood sugars once a day and increase by 4 units a day until blood sugar 6-15mmol/L
If blood sugars drop below 6mmol/L then halve insulin dose

Steroid induced diabetes (and steroids plan to continue)

Once daily long-acting insulin and once daily blood sugar measurement
If blood sugars come down to 6-15mmol/L (and oral intake stable) no further monitoring is needed until steroid dose reducing
If blood sugars remain raised considering increasing dose by 4 units a day until blood sugars in range 6-15mmol/L
Remember to continue monitoring and adjust insulin as need when dose reduced/discontinued

Avoid

Mixed formulations of insulin as this makes hypoglycaemia harder to predict
Four times daily regimes due to the burden of injecting and monitoring
Twice daily steroids as this prolongs hyperglycaemia
Metformin due to the side effects