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This guideline is only for the use of Kirkwood Hospice KWMD108 Diabetes guideline Created 09/14 JR/SO Reviewed 07/18 AV/SO RV 07/2021 1 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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Page 1: Management of Diabetes in Specialist Palliative Care · Hyperosmolar Hyperglycaemic state (HHS) Page 10 PageDiabetic Ketoacidosis 10 PageHypoglycaemia 11 Diabetes and Enteral Feeding

This guideline is only for the use of Kirkwood Hospice KWMD108 Diabetes guideline Created 09/14 JR/SO Reviewed 07/18 AV/SO RV 07/2021

1

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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2

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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3

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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4

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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5

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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8

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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12

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