Download The Clinician - Outcome Resources

The Clinician
The Outcome Resources Drug Information
Diabetes Management Decisions in Hospice
Jim Joyner, PharmD, CGP
Diabetes management in hospice patients may often lead to important clinical and
practical decisions about continuing insulin, routine blood glucose & hemoglobin A1c
monitoring, and oral-hypoglycemic drug therapy. Initial challenges may become
apparent when insulin dependent patients who are on intensive blood glucose monitoring (tight glycemic control) are considering admission to hospice. The hospice
philosophy of care is generally characterized by least invasive methods, low-tech approaches, and palliative medicine. The prevention of longer-term complications
(diabetic retinopathy and diabetic nephropathy) is not consistent with the concept of
hospice care. Additional challenges emerge when diabetic patients nearing end of
life exhibit significant changes in dietary intake which will require decreases in dosage of insulin or oral-hypoglycemic medication in order to avoid hypoglycemia. At
the final stages of terminal disease, most patients will have significantly decreased
levels of consciousness and often no oral intake necessitating discontinuation of all
insulin and oral agents.
Tight glycemic control is beneficial in reducing risks for long-term complications
to diabetes which may develop after many years of inadequately controlled blood glucose levels. This type of diabetes management is not appropriate for a hospice patient and may pose a danger to the patient because of increased risks for hypoglycemia. The primary goal for a diabetic hospice patient should be focused upon minimizing the symptoms of sustained hyperglycemia and avoiding the two major negative outcomes of prolonged severe hyperglycemia: diabetic ketoacidosis (DKA) and
hyperosmolar hyperglycemic state (HHS). This goal can be accomplished without
tight glycemic control. Preventing long-term diabetic complications is not relevant to
hospice care. Diabetic patients are sometimes admitted to hospice with sliding scale
insulin orders, where the blood glucose finger-sticks are performed multiple times per
day with multiple daily doses of short-acting insulin administered in response to the
results. These orders are not appropriate for a hospice patient for reasons stated earlier regarding the fact that the potential benefits of reducing long-term complications
are trumped by the risk for hypoglycemia. In addition, the excessive invasive nature
of this order is not warranted nor is it consistent with the hospice philosophy of palliative care with the least invasive measures.
In this issue
Diabetes
Management
Decisions in
Hospice
1
Constipation:
pitfalls in
management
for
hospice patients
3
January 2013
Vol. 8
Issue: 1
Hypoglycemia
 Symptoms: diaphoresis, anxiety, tremors, weakness, palpitations, coma
 Both insulin and oral hypoglycemic drugs may cause hypoglycemia
 Blood glucose: < 60mg/dL
Hyperglycemia
 Symptoms: thirst, polyuria, dehydration
 Blood glucose: > 180mg/dL
Hyperosmolar Hyperglycemic State (HHS)
 Symptoms: thirst, polyuria, dehydration, lethargy, coma
 Sustained severe hyperglycemia. Occurs in insulin dependent Type 2’s
 Blood glucose: > 750mg/dL
Diabetic Ketoacidosis (DKA)
 Symptoms: hyperventilation, nausea-vomiting, abd pain, coma
 Due to insulin lack, characterized by acidosis. More common in Type 1’s
 Blood glucose: > 300mg/dL
Appropriate target ranges for blood glucose in the diabetic hospice patient will vary depending upon severity of diabetes along with the patient’s current condition and prognosis. For example, it may be appropriate to continue insulin and oral hypoglycemic drugs in patients that are prone to DKA or HHS, have a Palliative Performance Scale (PPS) rating of at least 40%, and anticipated survival-time measured in months.
On the other hand, the decision to stop all diabetic therapy may be appropriate in Type 2 diabetics with a poor
quality of life and a survival time estimated to be a few weeks.
The frequency for blood glucose checks should be as minimal as possible, but needs to be individualized.
In the patient that is deemed to be at low risk for hyperglycemia or hypoglycemia that does not have a history
of symptomatic hyperglycemia, the glucose checks can be done only when the patient is symptomatic.
Measuring hemoglobin A1c to assess overall level of glycemic control is not relevant in hospice patients.
These tests should be D/C’d.
For those patients where the decision is made to continue insulin and/or hypoglycemic drug therapy, the
goal should be one of keeping the blood glucose levels low enough to minimize the symptoms associated
with osmotic diuresis due to hyperglycemia, but high enough to avoid hypoglycemia. Osmotic diuresis is
most often precipitated when the blood glucose levels persist in a range of 180mg/dL to 200mg/dL. Based
on this threshold for hyperglycemia related diuresis, a rational approach would be to aim for target ranges of
180 – 200mg/dL as a goal for the diabetic hospice patient. Some experts have raised the target to 250 or
even 300mg/dL, however, individual patient history should temper these decisions.(1, 2) For example, if a
Type 1 diabetic has a history of developing DKA with a blood glucose as low as 300mg/dL, the target
should be lower than that since DKA may develop very rapidly ( within a day). The long-acting basal
“peakless” insulins (insulin glargine - Lantus) may be quite beneficial for maintaining blood glucose levels
in the 180 - 200mg/dL range, especially when the patient exhibits inconsistent caloric intake.
Page 2
The Clinician
General Guidance Based on Survival Time Estimates: (1, 2, 3, 4)
Prognosis of a couple months or more:


Type 1 diabetic should continue insulin to maintain blood glucose target of 180-250mg/dL
Type 2 diabetic on insulin and oral hypoglycemic drugs may stop insulin and just use the oral agents unless prone
to HHS
Prognosis of weeks:


Type 1 diabetic prone to DKA should continue insulin, preferably long-acting basal insulin
Type 2 diabetic on oral hypoglycemic drugs may stop taking all of them unless prone to HHS
Prognosis of less than one week (final days):


All insulin and oral hypoglycemic drugs can be discontinued in the final days of life when patients may have significantly decreased oral intake and major alteration of consciousness
Type 1 diabetics prone to DKA may develop this condition within days of insulin being stopped & some may
need to continue on low-dose daily doses of long-acting basal insulin through the final days.
One needs to be very cautious about using short-acting, rapid-onset insulins in these patients due to the risk
for hypoglycemia. These types of insulins should be used cautiously in patients who are in the late stages of
terminal illness and only be administered when the patient is actually eating meals.
The balance between undesirable side effects and therapeutic benefits of many of the oral hypoglycemic
drugs may change for patients during end of life care. Many of these drugs, including the sulfonylureas
(Diabeta, Glucotrol) and metformin (Gluophage), can cause troublesome g.i. side effects such as abdominal
pain, nausea-vomiting, diarrhea, cramping, and gas. Others, such as the thiazolidinediones (Actos, Avandia)
may cause significant problems with headache and edema. During end of life care the troublesome nature of
these side effects may begin to outweigh the potential therapeutic benefits, leading to decisions to discontinue
use. In addition to the common side effects mentioned above, significant declines in renal and hepatic function
seen in hospice patients may render a commonly used drug like Metformin to be contraindicated, requiring
discontinuation in order to avoid more serious problems such as lactic acidosis.
The guidance provided here is intended to serve as a starting point for discussion among the hospice team,
patient, and family. Decisions regarding dosage and continuation of diabetic therapy should be individualized.
Many factors need to be taken into account such as the goals of care, quality of life, level of consciousness,
history of DKA, HHS, and hypoglycemic episodes, possible anxiety over stopping therapy, as well as possible
empowerment of patient/family that may be associated with continuing therapy. (references on request)
Pitfalls in the Management of Constipation in Hospice Patients
Julia Harder, PharmD, CGP
The management of constipation in hospice patients is notoriously challenging. Constipation is the one side effect
of opioids to which patients do not develop tolerance – which means it is nearly ubiquitous among patients taking
opioids routinely. In addition to opioids, hospice patients take many other medications that cause constipation,
including the many different medications with anti-cholinergic properties. Furthermore, hospice patients often
have fluctuating dietary and fluid intake and gradually decreasing levels of physical activity and movement,
which contribute to constipation. There are 4 common pitfalls that we should be aware of in the management
of constipation in the hospice population. These are:
Docusate alone
For the treatment of constipation, docusate is generally ineffective when used alone. The role for mono-therapy
with docusate is mainly for patients who are having regular bowel movements, but are producing dry, hard stool
that is causing discomfort or straining. In hospice, we normally encounter patients who are NOT producing
Page 3
President & CEO: Martin McDonough, PharmD, CGP, DAAPM
Director of Operations: Ann McLaughlin
Director of Clinical Operations: Jim Joyner, PharmD, CGP
2210 Plaza Dr. Suite 300
Rocklin, Ca. 95765
Phone: 866-877-2053
Director of Client Services: Mary Davies
Editor: Jim Joyner, PharmD, CGP
www.outcomeresources.com
regular bowel movements, especially in the setting of opioid-induced constipation, where the source of the constipation is
slowed gastrointestinal motility. When patients are not producing regular bowel movements (regardless of the consistency
of the stool), a stool softener alone is insufficient. The popular phrase is that with a stool softener alone you have “all mush
and no push”. Docusate can be used, and should be used if the consistency of the stool is hard and dry, but it should be
combined with a stimulant laxative (such as senna or bisacodyl) or an osmotic laxative (such as Miralax or milk of magnesia) in order to help the GI contents move along.
Magnesium-based laxatives in renal impairment
Many of our patients have impaired renal function, and for these patients, magnesium-based laxatives (such as milk of
magnesia) should be avoided as they can lead to electrolyte imbalances. The problem stems from the fact that up to 20% of
the magnesium in magnesium salts may be absorbed systemically. Impaired kidneys do not eliminate all that extra magnesium effectively, and hyper-magnesemia can result. As an alternative, use polyethylene glycol (Miralax) in patients with
renal impairment, which has the same mechanism of action (osmotic laxative) but does not carry the same risk of electrolyte imbalance.
Bulk-forming laxatives in patients taking opioids
Bulk-forming laxatives, such as psyllium (Metamucil) and methylcellulose (Citrucel) can actually WORSEN constipation
when patients are taking opioids. This is because in the setting of impaired G.I. motility that is induced by opioids, bulkforming laxatives are not adequately propelled through the G.I. tract. The colon stretches to accommodate the bulk, but
does not respond with adequate propulsive action due to the opioid effects. The result is painful, colicky G.I. symptoms,
and potentially complete G.I. obstruction. For this reason, bulk-forming laxatives should be avoided in patients taking
opioids.
Overlapping mechanisms of action
Because constipation is so common, and so difficult to treat, we often end up trying to attack it by adding on one laxative
after another, using everything in our armamentarium in an attempt to resolve the issue. This often results in therapeutic
duplication, which is not only ineffective, but is also costly and increases the risk of side effects. When managing
constipation, it is important to keep in mind the underlying mechanism of action of each laxative, and to choose just one
medication from each group when combining multiple therapies. Use this chart to help:
Bulk-Formers
(hold water in stool to increase bulk-stimulating
peristalsis)
Stool softeners
(facilitate admixture of fat and water to soften
stool)
Stimulant/irritant laxatives
(direct stimulant action on intestinal mucosa or
nerve plexus)
Osmotic laxatives
(attract/retain water in intestinal lumen, increasing
intraluminal pressure)
Lubricant/emollient laxatives
(impairs colonic absorption of fecal water; softens
stool)
Psyllium (Metamucil)
Methylcellulose (Citrucel)
Calcium polycarbophil (FiberCon)
Docusate (Colace)
Senna
Bisacodyl (Dulcolax)
Cascara sagrada
Magnesium hydroxide (milk of magnesia), magnesium citrate)
Sodium phosphate (Fleet)
Polyethylene glycol (Miralax)
Lactulose
Sorbitol
Glycerin (Fleet)
Page 4