What is the best approach for managing hyperglycemia (high blood sugar) in patients at the end of life?

From the Guidelines

The best approach for managing hyperglycemia in end-of-life patients focuses on comfort and symptom control rather than strict glycemic targets, as stated in the most recent guidelines 1.

Key Considerations

• Blood glucose goals should be relaxed to prevent symptomatic hyperglycemia while avoiding hypoglycemia, with a target range of 180-270 mg/dL (10-15 mmol/L) 1.
• Simplify medication regimens by discontinuing complex insulin protocols and oral agents with long half-lives or those requiring frequent monitoring, to minimize the burden of care and risk of hypoglycemia.
• For patients with type 2 diabetes who are still eating, consider once-daily basal insulin like glargine (10-20 units) or NPH (10-20 units), supplemented with short-acting insulin (Novolog, Humalog, or regular insulin 2-6 units) only for readings above 270 mg/dL, as recommended in recent guidelines 1.
• For type 1 diabetes, maintain basal insulin at reduced doses (typically 50-80% of previous dose) to prevent ketoacidosis, even when oral intake decreases, as suggested by recent studies 1.

Monitoring and Treatment Adjustments

• Blood glucose monitoring can be reduced to once daily or discontinued if the patient is comfortable, to minimize the burden of care and focus on comfort and symptom control.
• Treatment plan simplification and deintensification/deprescribing should be considered to decrease the complexity of the medication plan and minimize the risk of hypoglycemia, as outlined in recent guidelines 1.

Goals of Care

• The primary goal is to enhance quality of life rather than achieve tight glycemic control that no longer benefits the patient's overall prognosis or comfort, as emphasized in recent studies 1.
• Focus on promoting comfort, controlling distressing symptoms, avoiding dehydration, and preserving dignity and quality of life, as recommended in recent guidelines 1.

From the Research

Managing Hyperglycemia at End of Life

• The management of hyperglycemia in patients at the end of life is a complex issue, with no clear consensus on the best approach 2.
• A study published in 2006 found that consultants in diabetes and palliative care in the UK generally agreed that treatment and monitoring should be stopped in patients with type 2 diabetes once they enter the terminal phase, but there was less consensus regarding the management of type 1 diabetes 2.
• Another study published in 2020 emphasized the importance of incorporating palliative and end-of-life care into holistic diabetes management, particularly for older people with diabetes and comorbidities 3.
• This study suggested that the focus of care should shift from tight blood glucose control to safety and comfort as patients approach the end of life 3.

Blood Glucose Measurement and Control

• Accurate blood glucose measurement is crucial in managing hyperglycemia, particularly in critically ill patients 4.
• A review published in 2009 highlighted the importance of point-of-care testing methods for blood glucose measurement in intensive care units, but also noted the potential for errors and interferences in these measurements 4.
• The benefits of tight glycemic control in critical illness have been debated, with some studies suggesting a mortality benefit, while others have found it to be harmful 5.
• Current international recommendations advise clinicians to aim for a blood glucose level of <10 mmol/L in critically ill patients, rather than tight glycemic control 5.

Identifying and Managing Hyperglycemia in Inpatients

• Identifying patients with hyperglycemia or undiagnosed diabetes mellitus is important for improving care and reducing costs in the inpatient setting 6.
• Patients with diabetes mellitus are known to require longer hospital stays, regardless of the admission diagnosis, making efficient and effective management of hyperglycemia a key objective 6.
• National groups have provided recommendations for blood glucose assessment and glycated hemoglobin testing, and institutions should strive to implement these recommendations to improve patient care and cost-effectiveness 6.