21st May 2025

Overview of the Medical Management

Patients with lifelong diabetes have often had to stick to stringent clinical targets to mitigate the risks of long-term micro and macrovascular complications. Understandably, if it becomes evident that a patient is approaching EOL, regular monitoring of blood glucose levels can be relaxed. This shift in treatment approach can often cause concern and distress. Therefore, engaging individuals and their families about how they want their care to transition as they approach EOL is essential. This process should be conducted with utmost sensitivity, emphasising that the primary goal of care should transition towards enhancing their quality of life. It necessitates comprehensive discussions on the adjustments required in their medical management. The sections below provide an overview of Non-Insulin Therapies, Insulin Therapies, and Continuous Subcutaneous Insulin Infusion (Insulin Pump Treatment).

Non – Insulin Therapies

During their lifetime, individuals with type 2 diabetes usually transition from diet control to requiring pharmacological treatment. Traditionally, first-line pharmacological management involves metformin; however, this may progress to utilising multiple agents in combination. The patient’s HbA1c levels guide the intensification of therapy. 

When a diagnosis indicates that an individual is reaching the end of their life, it becomes essential to re-evaluate their medication regimen. At this stage, the fundamental principles of drug management remain the same. Particular emphasis should be on optimising medication choices to minimise the side effects and improve quality of life. This includes balancing the risk of both symptomatic hyper- and hypoglycaemia. Additionally, it is crucial to consider factors such as the evolving burden of the disease, the individual’s diminished appetite, and the deterioration of renal and hepatic function.

Table 2: Common medication and risk of hypoglycaemia

Insulin therapies (Type 1 and Type 2 Diabetes)

Individuals diagnosed with type 1 diabetes have an absolute dependence on insulin therapy and should continue to have insulin despite being EOL due to their risk of developing diabetic ketoacidosis.

Conversely, most individuals with type 2 diabetes still maintain some level of endogenous insulin production, protecting them against ketoacidosis. However, they are at risk of developing hyperosmolar hyperglycaemic states, particularly if given corticosteroids.

As an individual’s health deteriorates and they approach EOL, a review of their insulin dosage becomes necessary, often resulting in a reduction. The occurrence of reduced appetite and declining body weight often prompts this adjustment. As food intake diminishes, fast-acting insulin can likely be discontinued, and basal insulin will suffice, even for people with type 1 diabetes.

It is recommended to initiate a conversation about target glucose levels and treatment objectives early to ensure that individuals and their families understand the likelihood of dose reductions.

Continuous subcutaneous insulin infusion (Insulin Pump Treatment)

Insulin pumps have become increasingly common amongst patients with type 1 diabetes because they provide better flexibility. However, as they rely on frequent capillary blood glucose testing and adjusting bolus doses according to the carbohydrate content of their food, they need monitoring and adjustment towards the EOL. Therefore, early involvement of the Diabetes Specialist Pump Team is required.