Palliative care intervention in the management of diabetes

Steve Jones Consultant Endocrinologist Dean of Clinical Affairs for NUMed Malaysia

Contents
An introduction An overview What are the issues? The evidence Management
Practical issues Psychological issues

Newcastle University Medicine Malaysia

Contents
An introduction An overview What are the issues? The evidence Management
Practical issues Psychological issues

Diabetes and Cancer

346 million people have diabetes
3.4 million die as a result of high glucose

10 million people world wide are diagnosed with cancer each year. Over 7 million people die of cancer each year
WHO 2011

Diabetes and cancer

The incidence of diabetes in people with cancer is six times that found in the general population.
Quinn et al 2006

More than 50% of people with cancer in Malaysia will have diabetes.

Why is diabetes so common in people with cancer?

Shared risk factors
Age Obesity

Cancer and its treatment raises glucose

Treatment with corticosteroids Stress response

Obesity and Cancer

Central Adipose Tissues

Contents
An introduction An overview What are the issues? The evidence Management
Practical issues Psychological issues

Its tricky!
Factors that increase glucose Factors that decrease glucose

Stress response to illness Infection Surgery Steroids

Weight loss Decreased appetite Nausea and vomiting

What are the issues?

Concern about guidelines

Few established guidelines No protocols Trial and error approach with risk of suboptimal care

Stage of illness changes targets

Agreed
Less strict targets needed in last few weeks and days of life.

Concerns that
Symptoms that might be caused or exacerbated by high glucose
Breathlessness, dehydration, confusion, drowsiness

The dilemma
There is that tension between uncomfortable intervention [finger pricking] but avoiding discomfort from something that can be improved [diabetes control]

Specific conditions
Different approaches needed for different types of diabetes
Type 1 Type 2 Steroid induced

INSULIN TREATMENT!!

Communication
Patients with long standing diabetes may find it hard to change eating and testing patterns. it is important that they dont see cessation of insulin as kind of being an abandonment of all care

Contents
An introduction An overview What are the issues? The evidence Management
Practical issues Psychological issues

The evidence
180000 160000 140000 120000 100000 80000 60000 40000 20000 0 23984 38 160461

Diabetes
MEDLINE search May 2011

PC

Both

38 studies on Medline search

Irrelevant 22 Diabetic neuropathy 11 Diabetes management 3 literature reviews 2 original articles

Original articles 1. Audit of case notes 2. Survey and focus groups of palliative care and endocrinology practitioners

Contents
An introduction An overview What are the issues? The evidence Management
Practical issues Psychological issues

Guidelines
Google search diabetes palliative care guidelines
914 000 hits!
www.cancernorth.nhs. uk

Principles 1: Communication
Discuss changing the approach to diabetes management with patient and/or family. If the patient remains on insulin agree monitoring strategy.

Principles 2: Testing
Keep invasive tests to a minimum.
It is necessary to perform some tests to ensure unpleasant symptoms do not occur due to low or high blood sugars.

It is very difficult to identify symptoms due to hypo or hyperglycaemia in a dying patient.

If observed symptoms could be due to blood glucose levels a urine test should be performed, followed by a blood glucose check if necessary.

Tips for patients on insulin

People with T2DM taking > 48 units per day are likely to develop osmotic symptoms if insulin is stopped. Choices for once daily insulin
Glargine Humulin I Insulatard

Reduce total daily dose by 25%

Contents
An introduction An overview of the problem The evidence Management
Practical issues Psychological issues

Thank you for your attention