Caring for Diabetics in a Palliative Care setting; The challenges. Dr Simon Pennell. GPwSI Palliative Care.

Transcription

1 Caring for Diabetics in a Palliative Care setting; The challenges. Dr Simon Pennell. GPwSI Palliative Care.

2 Diabetes in Palliative Care. What is worth knowing? Likely to seeing more patients with DM + use of steroids in Palliative Care creating more. No good evidence-base at present-using consensus view and expert opinion The AIMS of control and challenges Management of DM should reflect the disease stage and include explanation to patient/carer Use Algorithm. No LCP for patients with DM

3 Clinical Case 1 Male 78. DM many years. Using BD Mixtard 30u. Known poor renal function Ca Bowel, metastatic disease, poor prognosis. Weight loss, poor appetite for weeks. Now bed bound nearing last days of life.

4 Clinical Case 2 Male 79. Ref to CGPCT Sept 08. PMH End stage COPD, Renal failure, cardiac failure, type II DM, inc peripheral oedema. Now inc SOB, poor mobility, functional status On gliclazide 160mg/80mg, pred 20mg/day. Nov 08 BM 28.5 Died in hospital

5 Diabetes in Palliative Care. Hyperglycaemia...Symptoms include: Dry mouth Polyuria Polydipsia Lethargy Recurrent infections Blurred vision

6 Diabetes in Palliative Care. Hypoglycaemia...Symptoms may include Sweating and pallor Confusion and disorientation Unconsciousness/Coma Hunger and trembling Drowsiness Blurred vision Headache Non specific

7 Pitfalls of Insulin use BD mixtures; risk of hypos at lunchtime and overnight. QDS regimens; Involve multiple tests and injections. Avoid giving bolus or PRN insulin doses such as Actrapid - (Rarely achieves control and may cause hypoglycaemia). Steroids; Given AM cause late afternoon and evening hyperglycaemia. Given BD cause marked Hyperglycaemia. Lantus rarely effective with steroids. Risk of fasting hypoglycaemia

8 Patients with diabetes undergoing palliative care Diabetes Test blood sugars daily. Diet Controlled Oral therapy Stop Metformin and Glitazone therapy Insulin If starting steroids Blood sugar <17 commence daily blood No steroids Testing between Do not test any further Eating Not eating Blood sugar >17mmols +/- symptoms, start Long acting OD (SU) (eg) Glimepiride at hrs Eating No symptoms test daily At 18.00hrs Not Eating Symptoms Continue regimen Stop short acting insulin. Continue or swap long acting insulin to Lantus OD Give at Test at Blood sugars <17mmols Continue. Less than 4mmols Halve dose Blood sugars >17mmols Increase or start SU If blood sugars >17mmols commence Lantus10u O/D Liase with diabetes team to optimise Treatment (01202) Start Long acting SU (Glimepiride at 2mg) increase every 48 hrs by 2mg to a max of 6mg if blood glucose remains >17mmols Lantus start at 10u at 08.00hrs and increase by 2 u every 48 hrs if blood sugar >17mmols ST/TR0306

9 Treating patients who develop diabetes with steroids during palliative care Starting oral therapy for patients developing DM 1/ Glimepiride has been chosen for this patient group as this tablet is more convenient to take as a once daily preparation, and is easy to swallow and has simple increments 2/ The tablet should not be taken by the patient if the patient has failed to take their steroids for whatever reason or is NBM 3/ If the patient has forgotten to take their Glimepiride and <8hrs have elapsed since taking their steroids omit for that day due to risk of hypoglycaemia

10 Treating patients who develop diabetes with steroids during palliative care Starting Insulin 1/ An Insulin conversion takes approx 45mins by the Community Diabetes Specialist Nurse at the McMillan Unit Xchurch (Home visits by request will be discussed) 2/ Patients with established type 1 or 2 diabetes who already take Insulin and are not on Lantus should be discussed with the Diabetes Specialist Nurse EXT 4888 ( ) 3/ When using steroids be aware that a patients physical and cognitive suitability for insulin should be considered. Not everyone will manage ongoing insulin management 4/ After starting insulin if blood sugars remain above 17mmols after 3 days of testing increase by 2u every 3 rd day until goal achieved. If symptoms of hypos re experienced discuss with diabetes team

11 DM triggered by steroid use Start with OHA - Single Dose taken in the morning Use SU (e.g.) Glimepiride 2 mg Increasing every 48hrs until max dose of 6mg Blood sugars raised above 17mmols convert to Insulin. Test blood sugars at as corresponds to giving treatment.

12 Treating patients with steroids in palliative care No previous History or documented Diabetes Type 2 diabetes Commencing steroids *Stop Metformin & Glitazones Commence long acting once daily SU(eg) Glimepiride 2mg at Discuss with Diabetes Specialist Nurse (01202) Test blood sugars for 5 Consecutive days hrs. 1/In some cases test at day 1 and day 5 only based On patient coping mechanisms 2/Arrange phone contact with diabetes team to discuss results.(01202) Blood sugar <17mmols Stop testing Blood sugar 17 mmols On 2 readings Patient needs to test blood sugars at 18.00hrs daily whilst on SU Week 2 (phone patient) 17mmols commence Glimepiride 4mg Week 3 (phone patient) 17mmols increase Glimepiride to 6mg Patient may require an Insulin conversion to relieve any hyperglycaemic symptoms. Start Lantus 10u OD Insulin at or (Coincides with blood test to minimise intervention) *Increase dose by 2u every 72hrs until blood sugars less than 17mmols at If Steroid dose Increases restart Testing as above Week 4 (phone patient) 17mmols (Book patient for insulin conversion) ST/TR March 2008 *If patient is already on insulin prior To starting steroids liaise with diabetes team

13 Clinical Case 1 Male 78. DM many years. Using BD Mixtard 30u. Known poor renal function Ca Bowel, metastatic disease, poor prognosis. Weight loss, poor appetite for weeks. Now bed bound nearing last days of life.

14 Clinical Case 2 Male 79. Ref to CGPCT Sept 08. PMH End stage COPD, Renal failure, cardiac failure, type II DM, inc peripheral oedema. Now inc SOB, poor mobility, functional status On gliclazide 160mg/80mg, pred 20mg/day. Nov 08 BM 28.5 Died in hospital