What is the best course of action for a 78-year-old female patient with a past medical history (PMH) of insulin-dependent diabetes mellitus (IDDM) on hospice care with a life expectancy of weeks to months, diagnosed with diffuse large B-cell lymphoma (DLBCL) with brain metastases, who is deconditioned and requires assistance with transfers, currently on dexamethasone (0.5 mg twice daily) and glargine (24 units in the morning and 20 units in the evening), with blood sugars ranging from 200-300 mg/dL, and who experienced hypoglycemia (blood sugar 102 mg/dL) after adding a medium dose correction scale at bedtime?

Glucose Management in Hospice Patient with Steroid-Induced Hyperglycemia

Immediate Recommendation

Reduce the bedtime correction scale from medium to low dose immediately, and do NOT hold or reduce the glargine at this time. The morning glucose of 102 mg/dL after medium-dose correction indicates the correction scale was too aggressive, but your basal insulin (glargine 24 AM/20 PM) remains appropriate for a hospice patient on dexamethasone 1.

Understanding the Clinical Context

For terminally ill patients with life expectancy of weeks to months, higher glucose ranges up to 200-250 mg/dL are explicitly acceptable to minimize hypoglycemia risk and maximize quality of life 1. Your patient's blood sugars in the 200-300 range, while elevated, do not warrant aggressive intensification given her prognosis and goals of care.

• The ADA specifically states that glycemic levels >250 mg/dL may be acceptable in terminally ill patients with short life expectancy, with the goal being to minimize glucosuria, dehydration, and electrolyte disturbances rather than achieving tight control 1.
• In hospice settings where frequent glucose monitoring or close nursing supervision is not feasible, higher glucose ranges are appropriate 1.

Specific Management Algorithm

Step 1: Adjust Correction Scale Only

• Change bedtime correction from medium to low dose - this directly addresses the 102 mg/dL morning glucose 1.
• Continue the 1:10 carbohydrate counting with medium-dose correction at meals, as this has not caused hypoglycemia 1.
• The morning glucose of 267 mg/dL before adding bedtime correction was not dangerous for a hospice patient and did not require immediate intervention 1.

Step 2: Maintain Current Basal Insulin

• Do NOT reduce glargine doses - the 44 units total daily (24 AM + 20 PM) is appropriate for a patient on dexamethasone 0.5 mg BID 2.
• Dexamethasone causes insulin resistance requiring 40-60% increases in insulin doses, and your current regimen is already accounting for this 2.
• Reducing basal insulin would worsen daytime hyperglycemia and increase risk of dehydration 1.

Step 3: Monitor for Overtreatment

• If fasting glucose falls below 100 mg/dL on more than 2 occasions per week, then reduce glargine by 2 units 2.
• Blood glucose <70 mg/dL requires immediate dose reduction of 10-20% 1.

Critical Pitfall to Avoid

The single most dangerous error would be holding or significantly reducing basal insulin based on one morning glucose of 102 mg/dL. This value, while lower than recent readings, is not hypoglycemia (defined as <70 mg/dL) and does not indicate excessive basal insulin 1. The 102 mg/dL resulted from the bedtime correction dose, not from the basal insulin.

• Hypoglycemia is defined as glucose <70 mg/dL, with level 2 hypoglycemia at <54 mg/dL requiring immediate intervention 1.
• A glucose of 102 mg/dL is actually within the acceptable target range of 100-180 mg/dL for noncritically ill patients 1.
• Reducing basal insulin would cause rebound hyperglycemia throughout the day, worsening the patient's symptoms and quality of life 1.

Why This Approach Prioritizes Quality of Life

In hospice care, the primary goal is preventing symptomatic hyperglycemia (polyuria, polydipsia, dehydration) while absolutely avoiding hypoglycemia, not achieving tight glycemic control 1. Your patient is asymptomatic despite glucose levels of 200-300 mg/dL, which is acceptable.

• Hypoglycemia causes immediate morbidity with confusion, falls, and distress - completely unacceptable in hospice 3.
• Glucose levels of 200-300 mg/dL in an asymptomatic hospice patient do not require aggressive intervention 1.
• The risk-benefit ratio strongly favors accepting higher glucose levels to prevent any hypoglycemia in this population 1.

Monitoring Plan

• Check fasting glucose daily to ensure it remains >100 mg/dL 1.
• If fasting glucose consistently <100 mg/dL, reduce bedtime correction scale further or eliminate it entirely 1.
• Reassess insulin needs if oral intake declines further, as this would require dose reductions 4.
• If dexamethasone dose changes, adjust insulin accordingly (increases in steroids require proportional insulin increases) 2.

What NOT to Do

• Do not use sliding scale insulin as sole therapy - your current basal-bolus approach with correction is appropriate 1, 5.
• Do not target fasting glucose <100 mg/dL in this hospice patient - this increases hypoglycemia risk without meaningful benefit 1.
• Do not make multiple simultaneous changes - adjust only the bedtime correction scale and observe the response 1.