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1
Diabetes Management Of Hospice Patients

• Jeff Unger, MD, FAAFP, FACE
• Director, Unger Primary Care Concierge Medical
  Group
• Associate Medical Director,
• Mission Hospice

2
Objectives

• Discuss the American Diabetes Association
  Standards of Care for diabetes management
• Discuss newer technologies and pharmacologic
  interventions used to treat patients with
  diabetes including continuous glucose monitoring
  and integrated insulin pumps and sensors
• Learn about the goals and treatment options for
  end-of life care
• View discussion points with family members of
  diabetes patients who are at lifes end

3
Rule 1

• Please dont refer to your patients as
  Diabetics. Instead suggest that they are
  people with diabetes.
• Nurseplease put the lepper in room 2!

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Why Bother Attending Yet Another Diabetes Lecture?
The World is Changing!

• 30.3 million Americans (9.3 of US population)
  have diabetes
• 92 million Americans have pre-diabetes
• (increased from 79 million in 2010)
• 1 in 3 adults will have T2DM in 2050
• 90 of all diabetes management occurs within the
  primary care setting

• Currently over 257 different drug combinations
  and 18 different classes of medications which can
  be used to manage type 2 diabetes
• How does one customize therapy safely and
  effectively?

• Unger J. Diabetes Management in Primary Care, 2nd
  ed. Philadelphia, PA Lippincott, Williams
  Wilkins 2012.

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T2DM Significantly Reduces Lifespan
Emerging Risk Factors Collaboration. JAMA.
20153145260.
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Diabetes Related Complication

• Microvascular
• Retinopathy
• Neuropathy
• Nephropathy

• Macrovascular
• Stroke
• MI
• Cardiovascular death
• Peripheral arterial disease

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Consequences of Delayed Intervention
Patients with A1C 7 not receiving IT within 1
year
8.5
Patients with A1C lt7 who received IT before 1
year of diagnosis
8.0
A1C,
7.5
7.0
6.5
60
6
12
54
48
Months
CVE, cardiovascular endpoint HF, heart failure
TI, intensification of treatment MI, myocardial
infarction
Paul S et al. Cardiovasc Diabetol 201514100
doi10.1186/s12933-015-0260-x
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Wait a minuteWhat is an A1C?

• 50 of the total A1C is dependent upon plasma
  glucose levels over a previous 30 day period
• Patients without diabetes glycate 5 of their
  hemoglobin
• Prediabetes is defined as having an A1c 5.7-6.4
• Clinical diabetes gt 6.5
• Diabetes complications are more common above 7
• In clinical practice we strive to keep the A1C lt
  7
• A1C gt 5.7 increases the risk of diabetic
  neuropathy and retinopathy

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A1C is NOT for everyone

• Not accurate in patients with diabetic kidney
  disease due to rapid turnover of hemoglobin
• Not accurate in patients with sickle cell
  disease, anemia, hemoglobinopathies, sepsis, high
  dose vitamin C as the glucose cannot bind to C
  terminus of the hemoglobin
• Not accurate in pregnancy

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Glucose variability is not apparent from A1C
Which patient would fare best if initiated on
basal insulin at bedtime Oral agents?
Mean BG ( HbA1c)
Patient A (A1C 7.8)
Patient B (A1C 7.8)
400
Hyperglycemia
360
320
280
240
Glucose mg/dL
200
160
120
80
Hypoglycemia
40
0
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
23
24
22
Time (hrs)
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Image adapted from Penckofer et al. Diab Tech
Ther 20121430310
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42 year old construction worker T2DM x 5
yearsHow would you interpret this glucose log?

• A1C 7.6
• How would you safely and effectively adjust his
  medical regimen?
• Meds
• Metformin 500 mg BID
• Insulin degludec Liraglutide)  22 u/d

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• Self-monitoring of blood glucose (SMBG)
  limitations

• Even with multiple daily fingersticks, SMBG can
  leave highs lows undetected1 

• Patients using SMBG could be spending significant
  time outside of range

SMBG only provides readings for a single point in
time 
Not actual patient data for illustrative
purposes only.

• 1. Janapala Rajesh Naidu, et al. Continuous
  Glucose Monitoring Versus Self-monitoring of
  Blood Glucose in Type 2 Diabetes Mellitus A
  Systematic Review with Meta-analysis. Cureus 11,
  no. 9 (September 2019)e5634. DOI
  https//doi.org/10.7759/cureus.5634.
• 2021 Abbott. ADC-31277 v2.0 2/21

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HOW CGM CAN HELP REDUCE DIABETES MANAGEMENT
CHALLENGES

• Self-monitoring of blood glucose (SMBG)
  limitations

• Even with multiple daily fingersticks, SMBG can
  leave highs lows undetected1 

• Patients using SMBG could be spending significant
  time outside of range

SMBG only provides readings for a single point in
time 
Not actual patient data for illustrative
purposes only.

• 1. Janapala Rajesh Naidu, et al. Continuous
  Glucose Monitoring Versus Self-monitoring of
  Blood Glucose in Type 2 Diabetes Mellitus A
  Systematic Review with Meta-analysis. Cureus 11,
  no. 9 (September 2019)e5634. DOI
  https//doi.org/10.7759/cureus.5634.
• 2021 Abbott. ADC-31277 v2.0 2/21

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HOW CGM CAN HELP REDUCE DIABETES MANAGEMENT
CHALLENGES

• A1c results alone have limitations

• The same A1c result can have a different meaning
  for different patients1

• Day-to-day information on glucose control is not
  provided 
• Only average blood glucose over a 3-month period
  is captured

Time in Range (TIR) provides more actionable
information than A1c alone and should complement
A1c2

• 1. Hirsch, Irl B., and Eugene E. Wright. "Using
  flash continuous glucose monitoring in primary
  practice." Clinical Diabetes 37, no. 2 (April
  2019) 150-161. https//doi.org/10.2337/cd18-0054.
  2. Battelino, Thomas, et al. Clinical Targets
  for Continuous Glucose Monitoring Data
  Interpretation Recommendations From the
  International Consensus on Time in Range.
  Diabetes Care 42, no. 8 (August 2019) 1593-1603.
  DOI https//doi.org/10.2337/dci19-0028.
• 2021 Abbott. ADC-31277 v2.0 2/21

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HOW CGM CAN HELP REDUCE DIABETES MANAGEMENT
CHALLENGES

• Moving beyond A1c

• Using a combination of metrics allows for a more
  complete picture of glucose profile1

• A1c AGP (Ambulatory Glucose Profile)Combining
  each patient's A1c with their ambulatory glucose
  profile (AGP) uncovers critical daily patterns
• TIR (Time in Range) TBR (Time below
  range)Monitoring TIR and TBR glucose variability
  helps show how closely readings of an individual
  patient fall within target range, or below, in
  hypoglycemia
• Glucose dataAdditional access to acute, daily,
  and long-term (90 days) data allows for more
  informed treatment decisions

AGP provides a standardized visualization that
condenses glucose data generated from GGM over
several days or weeks into a single, 24-hour
window.
LibreView is developed, distributed, and
supported by Newyu, Inc. LibreView data
management software is intended for use by both
patients and healthcare professionals to assist
people with diabetes management. LibreView
software is not intended to provide treatment
decisions or to be used as a substitute for
professional healthcare advice. 1. Battelino,
Thomas, et al. Clinical Targets for Continuous
Glucose Monitoring Data Interpretation
Recommendations From the International Consensus
on Time in Range. Diabetes Care 42, no. 8
(August 2019) 1593-1603. DOI https//doi.org/10.
2337/dci19-0028.

• 2021 Abbott. ADC-31277 v2.0 2/21

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AGP Clinical Analysis

• ARE THE READINGS IN TARGET?    
• When is the interquartile range in, below, or
  above the target range? What can be causing the
  patient to be out of range?
•             
• WHAT ARE THE PATTERNS OF HYPOGLYCEMIA? 
• Is any part of the graph below the target range? 
• WHAT IS THE SHAPE OF THE MEDIAN CURVE?    
• When is it steep up and down? When is it moderate
  up and down? When is it flat? What could be
  causing these variations?  
• WHAT IS THE WIDTH OF THE IQR OR DARK BLUE BAND?
• When is it wide? When is it narrow? Narrow is
  good. Wide suggests glycemic variability.

Not based on real patient data. Illustrative only.
IQR inter quartile range (dark blue band)
16 of 107
16 of 49
2020 Abbott. ADC-28007 v1.0 10/20
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Who Benefits from routine use of continuous CGM?

• ALL patients treated with intensive insulin
  therapy (MDI or insulin pumps)
• ALL patients with problematic hypoglycemia.
  (Frequent, nocturnal, hypoglycemia unawareness)
• Children and adolescents with T1DM
• Pregnant women with either T1DM or T2DM (treated
  with insulin)
• Patients with gestational diabetes treated with
  insulin
• Consider CGM for patients with T2DM who are
  treated with less intensive therapy

AACE Guideline The use of advanced technology in
the management of persons with diabetes mellitus.
Endocrine Practice. 2021. 505-537.
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Chuck Before and After Using CGM
May 15, 2021 0 in targeted range of 70-180
June 15, 2015 61 in range, with no hypos on MDI
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How Often Is Interstitial Glucose Being Monitored
Dexcom
Notifications will only be received when alarms
are turned on and the sensor is within 20 feet of
the reading device. 1. Data on File, Abbott
Diabetes Care. 2. Dexcom G6 CGM system User
Guide. 3. FreeStyle Libre 2 system Users Manual 
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Continuous Glucose Monitors

• Interstitial glucose sensor (size of an eyelash)
  is inserted manually
• Data from the interstitial sensor is transmitted
  to a "reader," insulin pump or app and displayed
  to the user
• CGM Available Data
• Current glucose level
• Glucose trends related to meals, exercise,
  medication, sleep, travel
• Glucose directional trends
• Alarms for glucose levels lt 70 or gt 240 mg/dL

Dexcom 6 Sensor
Dexcom 6 Transmitter (battery)
Guardian Medtronic pump and sensor
Abbott Freestyle Libre Sensor
Unger J, Kushner P, Anderson JE. Practical
guidance for using the Freestyle Libre Flash
continuous glucose monitoring in primary care.
Postgraduate Medicine. https//doi.org/10.1080/003
25481.2020.1744393 . March 30, 2020.
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Optional, Customizable Real-Time Glucose Alarms
Every minute, the Sensor transmits data to the
Reader that may result in a potential alarm no
scanning required
Sensor has BOTH Bluetooth low energy (BLE) and
NFC transmitters. Notifications will only be
received when alarms are turned on and the sensor
is within 20 feet of the reading device. 
2020 Abbott. ADC-25847 v3.0 10/20
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CGM Devices
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Smart Pens

• Medtronic InPen
• Smart pens automatically track insulin doses and
  calculate active insulin
• Improve TIR without increasing hypoglycemia risk
• Real world study of 1736 patients before and
  after using InPen increased TIR by 2.3 in
  patients with a GMI gt 8 and 5 for patients
  with a GMI gt 9.5
• Improved glycemic control with less injections
  given (less stacking)

81st annual American Diabetes Association
Scientific Sessions, June 28, 2021
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Connected CGM and Insulin Pumps. Why Consider
Such An Option?

• Note that glucose values change every 5 minutes.
• Using automated insulin delivery connected to
  CGM, insulin dosing can be adjusted every 5
  minutes as well
• Higher glucose results in insulin correction
• Lower glucose reduces or stops insulin delivery

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AACE Guidelines For Insulin Delivery Technologies

• Connected Pens
• Consider for all persons with DM who are treated
  with intensive insulin management with 3 or more
  injections per day and who are not using insulin
  pumps
• Assess if device may help patient and clinician
  optimize insulin regimen and avoid stacking of
  rapid-acting insulin which could lead to
  hypoglcyemia

• Insulin Pump With CGM
• Low glucose suspend is strongly recommended for
  all patients with T1DM to reduce the severity and
  duration of hypoglycemia
• Anyone with frequent hypoglycemia, impaired
  hypoglycemia awareness and fear of hypoglycemia
  should use low glucose suspend (LGS) or
  predictive low-glucose suspend (PLGS) technology

AACE Guideline The use of advanced technology in
the management of persons with diabetes mellitus.
Endocrine Practice. 2021. 505-537
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Automated Insulin Delivery Devices (AID)

• Strongly recommended for all persons with T1DM
• Devices have been shown to increase TIR without
  causing an increased risk of hypoglycemia

• Preferred method of insulin deliver for people
  with diabetes and suboptimal glycemia, glycemic
  variability, impaired hypoglycemia awareness or
  who allow for permissive hyperglycemia due to
  their fear of hypoglycemia

AACE Guideline The use of advanced technology in
the management of persons with diabetes mellitus.
Endocrine Practice. 2021. 505-537
27
In What Settings or Special Situations Is The Use
of Diabetes Technology Useful?

• Continuation of CGM and or CSII should be
  considered in hospitalized patients without
  cognitive impairment
• rtCGM is recommended for people gt age 65 with
  insulin requiring diabetes to achieve improved
  glycemic control, reduce episodes of severe
  hypoglycemia and improve QOL.
• Individualize glycemic targets in this
  population due to increased risk of comorbidities
  and long term diabetes related complications
• Use CGM to track glucose before during and after
  exercise, help direct insulin and carbohydrate
  consumption and mitigate glycemic variability

AACE Guideline The use of advanced technology in
the management of persons with diabetes mellitus.
Endocrine Practice. 2021. 505-537
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Unger History Lesson 1

• In 2006 Diabetes management was real easy
• Target A1C of 7
• Start with metformin
• Sulfonylurea (glipizide, glucotrol)
• TZD (rosiglitazone, pioglitazone)
• Insulin

• In 2021 clinicians have lots to consider
• Duration of diabetes
• Presence or absence of diabetes related
  complications
• ?Diabetic kidney disease
• ? Coronary artery disease
• Hypoglycemia risk
• Age and physical condition of patient?
• Cost of therapy
• Presence of obesity

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Glucose-lowering Medication in Type 2 Diabetes
2021 ADA Professional Practice Committee (PPC)
adaptation of Davies et al. and Buse et al.

• Pharmacologic Approaches to Glycemic Treatment

Pharmacologic Approaches to Glycemic Management
Standards of Medical Care in Diabetes - 2021.
Diabetes Care 202144(Suppl. 1)S111-S124
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• Pharmacologic Approaches to Glycemic Treatment

Pharmacologic Approaches to Glycemic Management
Standards of Medical Care in Diabetes - 2021.
Diabetes Care 202144(Suppl. 1)S111-S124
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What about hypoglycemia?

• Defined by FDA as glucose level lt 59 mg/dL
• Severe hypoglycemia implies that the patient
  was unable to reverse the effects of hypo without
  assistance from a 3rd party
• Symptoms of hypoglycemia may not be evident in
  patients with gt 5 year history of treating
  diabetes with insulin
• Autonomic hypoglycemia occurs in patients whos
  diabetes is poorly controlled, yet their glucose
  levels are still elevated

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Symptoms of Hypoglycemia Are Like Falling In Love
For The Very First Time

• You feel off balance
• You drool
• You lack for intelligent words
• You get sweaty
• You say stupid stuff

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Frequency of Adverse Outcomes in Patients With
T2D Experiencing Severe Hypoglycemia
Zoungas S, et al. N Engl J Med.
20103631410-1418.
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Effects of Hypoglycemia on Thrombosis in T2D

• P lt.05 vs euglycemia
• P lt.01 vs euglycemia apart (data are mean
  standard error of the mean)
• N10 patients with T2DM underwent paired
  hyperinsulinemic clamp studies at least 4 weeks
  apart.

Chow EYK, et al. Diabetologia. 201356S243.
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Abnormal QT Prolongation and T-Wave Morphology
During Hypoglycemia in a Single Patient

• Normal QT interval 0.36 to 0.44 sec (varies
  slightly with age, gender, pulse)
• Baseline QTc 456ms
• Glucose nadir 2.5 mmol QTc 550 ms
• Progressive flattening of T wave is noted with
  fall in glucose over time

Chow E, et al. Diabetes. 2014631738-1747.
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Emergent Management of DiabetesRule of 15

• 15 grams of carbs
• Raisins
• 4 oz OJ
• Honey
• After 15 minutes recheck BG
• If lt 60 mg/dL give 15 additional grams of carbs

Gvoke HypoPen for Severe Hypoglycemia
Glucose Shot
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Hospice And Palliative Care Management Of Diabetes

• All diabetes meds have the potential to cause
  hypoglycemia
• The treatment of diabetes in hospice patients
  should focus on comfort care, minimization of
  hypoglycemic events without concern about the
  patient developing long-term complications

• Glycemic targets in non-hospice patients 80-140
  mg/dL, A1C lt 7
• Glycemic goals for hospice patients 200-300
  mg/dL without concern for A1C
• Remember, higher glycemic goals reduce risk of
  hypoglycemia!
• Patients using insulin pumps should make certain
  pump is functioning and minimize their risk of
  developing diabetic ketoacidosis

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Diabetic Ketoacidosis

• Due to insulin deficiency, insulin pump
  malfunction, failure to administer insulin
  injections in patients with T1DM
• Symptoms
• Nausea, vomiting, rapid breathing, abdominal
  pain, anorexia, lethargy, dry mouth, frequent
  urination, altered consciousness, joint pain and
  stiffness due to accumulation of AGEs (advanced
  glycated end-products)

• Treatment
• Fluids
• Monitor BG level every hour
• Restart insulin (rapid acting- novolog, Humalog)
• Correction factor 1 unit insulin lowers BG level
  20 points. Target is 150 mg/dL If BG is 500,
  inject 17 units insulin. Do not repeat any
  injections for 4 hours as patient may develop
  hypoglycemia
• Allow patient to eat when BG lt 200 mg/dL
• Pt may not feel well for 24 hours as blood levels
  of acids take time to clear

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Managing Hospice Patients With Diabetes

• Counsel families about reducing need for
  intensive diabetes management
• Consider stopping meds if patient refuses to eat
  as this could increase risk of hypoglycemia
• Maintain basal insulin (glargine) at 10 units/d
  for patients with T1DM who are not eating. Give
  meal time insulin 4 units AFTER meals.
• Patients on insulin pumps may continue use of
  pumps and sensors as long as family members have
  the expertise in team management
• Minimize SBGM.

• Howeversuggestions to DC meds could be seen by
  family members as a lack of concern or Hospice
  showing indifference to their loved one.
• Clarify that stopping or adjusting meds is done
  to prevent harm and promote well-being

Angelo M, et al. An approach to diabetes mellitus
in hospice and palliative medicine. J Palliat
Med. 2011 14 (1) 83-7
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Diabetes Medication Use in Palliative Care
Medication Concerns
Metformin Reduce dose if eGFR lt 30 (lactic acidosis and death) Take with food- can cause GI side effects
Sulfonylureas Hypoglycemia risk, especially when used with insulin Increased risk of sudden death in patients with CAD
Pioglitazone Contraindicated in patients at risk for or with bladder cancer
DPP-4 inhibitors Dose must be adjusted in patients with DKD and a eGFR lt 45
GLP-1 RAs Excellent drugs, but very expensive. Cannot use in patients with medullary thyroid cancer or pancreatitis
SGLT2s Can cause orthostatic hypotension in older patients
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The 2 Rules of medicine

• 1) Do no harm!
• 2) Never kill anyone!

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SBGM

• Frequency of SBGM should be individualized. If on
  oral meds, monitor fasting only 1st 7 days of
  each month
• Pts on insulin pumps prefer CGM over Finger
  sticks
• Alcohol should not be used to clean the finger
  tips prior to testing unless the patient eats
  with their hands
• Have family or nursing staff maintain records of
  SBGM for review
• Can DC finger sticks if patient is no longer
  eating or taking meds

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Advanced Care Planning For Hospice Patients With
Diabetes

• Discuss diabetes care responsibilities with
  family members, hopefully while patient can
  participate in these sessions
• Reassure family members that comfort is the most
  important aspect of care. Dont worry about
  dietary concerns. If the patient wants ice cream,
  give him/her the treat.
• Patients want some control over the way they will
  die. Most want time to complete important
  business plans, say goodbye to family members or
  attend a wedding. Thus, support the patients
  request to achieve these important goals
• Longevity is not always the patients goal.
  Comfort and family participation is often the
  target.
• Research has shown that patients and family
  members DO want to discuss end of life care,
  while clinicians are afraid to broach the topic

Dunning TL. Palliative and end-of-life care
Vital aspects of holistic diabetes care of older
people with diabetes. Diabetes Spectrum 2020. 33
(3) 246-254
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Meet Judy

• 81 year old diagnosed with T1DM in 1995
• Admitted to Hospice in 2019 with advanced
  Parkinsons disease
• On a Tandem Insulin pump and Dexcom 6 CGM without
  integration since 7/18. Multiple basal rates
• Pts husband, George, does all the pump care
  including infusion site changes every 3 days,
  meal time bolusing, correction boluses for post
  meal elevations and management of hypoglycemia
• Last recorded A1C was 7.7 in July 2019
• On my last visit, 7/9/21, George forgot to give a
  lunch bolus and Judys BG was 365.
• Kudos to George for helping keep his wife alive!
  He knows more about diabetes management than ANY
  doctor in So. CAexcept ME!

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Summary

• Diabetes is a chronic progressive disease which
  can increase ones risk of long and short term
  diabetes-related complications
• Intensification of hyperglycemia and glycemic
  variability is essential early after the
  diagnosis is made
• Patients with diabetes on hospice or palliative
  care should avoid hypoglycemia and DKA risk.
• Patients and family members should work together
  with Hospice to individualize their own
  management plans
• Newer technological advances are exciting tools
  to use in all patients with diabetes, including
  children

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Questions