Conference over coffee: Oncology, end-of-life care, psychology and insulin dilemmas

Oncology and palliative care

Su Down, Diabetes Nurse Consultant, Somerset

●  20% of people with cancer have diabetes.

●  Diabetes provides the perfect environment for cancer cell growth:

• Insulin is a growth factor.
  
  
• Inflammation.
  
  
• Hyperglycaemia.

Type 3c or pancreatogenic diabetes

●  Results from structural damage to the pancreas (due to e.g. pancreatitis, cystic fibrosis, haemochromatosis). 80% of cases will be related to pancreatitis.

●  Type 3c makes up 8–10% of all diabetes, yet we rarely consider it.

●  We should ask ourselves, “How do I know this is type 2 diabetes – could it be another type?”

●  Check faecal elastase test; CT to assess pancreatic damage; exclude autoantibodies which would suggest type 1 diabetes.

●  Can identify these people by looking at those who needed insulin within 5 years of diagnosis.

Pancreatic carcinoma

●  Difficult diagnosis and often made late.

●  Have high index of suspicion – NICE NG12 recommends urgent 2-week-wait CT scan in all over age 60 years who have weight loss and new type 2 diabetes; also in those whose glycaemic control suddenly deteriorates.

Management of diabetes during chemotherapy

●  Hyperglycaemia can make chemotherapy less effective; increased risk of infections and of hospitalisation.

●  Steroids are often used in large intermittent doses – goals are to limit glucose rises later in the day whilst avoiding overnight hypoglycaemia.

• Prednisolone usually taken as morning dose; hyperglycaemia may develop a few hours after taking and may then wear off.
  
  
• Dexamethasone may result in more prolonged hyperglycaemia through whole 24 hours (see Table 1).

●  Some drugs (e.g. checkpoint inhibitors), can cause rapid-onset new type 1 diabetes.

Deprescribing and end-of-life care

●  Language matters, good communication is important and regular discussion is needed.

●  Manage nausea and vomiting.

●  Cancer cachexia and sarcopenia are common; gradually deprescribe therapies and provide nutritional support. Any type of energy intake, including nutritional supplement drinks, is important – it is the clinician’s role to manage the impact on glycaemia. Prescribe to avoid symptomatic hyperglycaemia and hypoglycaemia.

●  Ideally provide CGM to avoid distressing capillary glucose testing.

●  If prognosis >3 months: deprescribe SGLT2 inhibitors, ACE inhibitors, ARBs, statins.

●  If prognosis <2 months: remove mealtime insulin, retain basal background therapy, decrease sulfonylurea.

●  Prioritise removing drugs if they interfere with appetite (e.g. metformin, DPP-4 inhibitors, GLP-1 receptor agonists) or carry hypoglycaemia risk.

Psychological care in diabetes

Becky Houghton and Shannon McAleese, Psychologists, Northern Health & Social Care Trust

Qualitative research demonstrates that both HCPs and people with type 1 diabetes have similar views about what is important to them. Three interconnected themes were raised by the research shared:

●  The importance of being seen and heard.

●  Management should feel like a collaborative alliance of two experts.

●  Impact of the healthcare system – time, lack of resources impactful. Telehealth may provide a partial solution.

Questions to use for a wellbeing check-in:

●  How can I be of most help to you today?

●  What do we need to make sure we talk about?

●  How are things going with your diabetes at the moment?

• What do you feel isn’t going as well as you would like?
  
  
• What do you feel is going well (can use the PAID [Problem Areas in Diabetes] questionnaire to help identify what is going well or not).

●  Who do you talk to when your diabetes gets rough going? And how do they help?

●  Is there anything getting in the way of you looking after your diabetes at the moment?

Insulin dilemmas

Neil Black, Consultant Physician and Clinical Lead, Endocrinology & Diabetes, Western Health & Social Care Trust

Steroid-induced hyperglycaemia

●  In those without diabetes, 30% develop hyperglycaemia and 18% develop diabetes; may resolve with cessation of steroids. In those with pre-existing diabetes, 100% develop hyperglycaemia.

●  Management: gliclazide 40–80 mg morning; uptitrate to 160–240 mg; add afternoon dose – total 320 mg per 24 hours. Insulin may be required.

●  Glucose lowers within 2–3 days of steroids being reduced – so adjust gliclazide dose.

●  Seek specialist support if insulin required.

●  In end-of-life care, avoid hypoglycaemia and symptomatic hyperglycaemia.

Rescue therapy

●  Consider if HbA_1c is ≥90 mmol/mol, or lower if osmotic symptoms.

●  Add in sulfonylurea to maximum dose, then add insulin if needed.

●  Remember to exclude other types of diabetes – type 1 and LADA.

Downtitration of hypoglycaemic agents

●  Important to understand the modes of action of different therapies and their benefits and potential adverse effects.

●  When adding a new agent: halve the sulfonylurea dose (can consider reducing it to once daily); reduce insulin dose by 20–30%.