Is it appropriate to discontinue all diabetes medications in a 77-year-old male with a 6-month prognosis due to metastatic cancer?

Diabetes Medication Management in End-of-Life Care

For a 77-year-old male with type 2 diabetes and a 6-month prognosis due to metastatic cancer, discontinuation of all diabetes medications is appropriate and aligns with best practices for end-of-life care. 1

Assessment of Patient Category

The patient falls into the "dying patient" category as defined by multiple diabetes care guidelines, with the following characteristics:

• Limited life expectancy (6 months) due to metastatic cancer
• Likely to have declining oral intake as disease progresses
• Quality of life should be the primary focus

Medication Management Algorithm

For Type 2 Diabetes (this patient):

1. Complete discontinuation of all diabetes medications is recommended 1
   • Rationale: These patients are unlikely to have significant oral intake
   • Focus shifts from glycemic control to comfort and symptom management
   • Risk of hypoglycemia outweighs benefits of tight glucose control

For Type 1 Diabetes (not applicable to this patient, but included for completeness):

1. Do not completely discontinue insulin
2. Consider maintaining a small amount of basal insulin
3. Monitor for hyperglycemic complications that may cause discomfort

Monitoring Recommendations

• Reduce frequency of blood glucose monitoring 1
• Focus monitoring on preventing symptomatic hyperglycemia that could cause:
  • Dehydration
  • Excessive urination
  • Discomfort
• Allow for higher glucose targets (200-300 mg/dL may be acceptable) 1

Rationale for Discontinuation

1. Quality of Life Benefits:

   • Reduces medication burden
   • Eliminates risk of hypoglycemia
   • Decreases need for finger sticks and monitoring
   • Avoids gastrointestinal side effects from medications

2. Evidence Support:

   • The most recent (2025) American Diabetes Association Standards of Care explicitly states that for dying individuals with type 2 diabetes, "discontinuation of all medications may be a reasonable approach" 1
   • This recommendation has been consistent across multiple iterations of guidelines 1

Important Considerations

• Patient and family should be included in the decision-making process 1
• Explain that the goal is shifting from disease management to comfort care
• Monitor for significant hyperglycemia that could cause symptoms (excessive thirst, urination)
• If symptomatic hyperglycemia develops, consider minimal intervention to relieve symptoms only

Pitfalls to Avoid

1. Continuing unnecessary monitoring - frequent blood glucose checks add burden without benefit
2. Concern about quality metrics - HEDIS measures do not apply to hospice patients 1
3. Focusing on A1C levels - no role for A1C monitoring in end-of-life care 1
4. Failing to distinguish between type 1 and type 2 diabetes - approach differs significantly

By discontinuing diabetes medications in this 77-year-old man with metastatic cancer and a limited prognosis, you are following evidence-based guidelines that prioritize quality of life and comfort in end-of-life care.