When it comes to hospice patients with type 2 diabetes, avoiding hypoglycemia may be more important than strict glycemic control, researchers argued.
In a researcher letter appearing in JAMA Internal Medicine, about 12% of hospice patients with type 2 diabetes residing in nursing home experienced hypoglycemia within 180 days of admission — a glucose reading under 70 mg/dL.
As for severe hypoglycemia — a glucose reading under 50 mg/dL — this was experienced by approximately 5% of hospice patients in nursing homes within 180 days of admission, reported Laura A. Petrillo, MD, of Massachusetts General Hospital in Boston, and colleagues.
The risk was even greater for those receiving insulin: cumulative incidence of 38% for all hypoglycemia and 18% for severe episodes within 180 days of admission, with the peak risk occurring during the initial 20 days. Hyperglycemia incidence was 9% overall; 35% among those on insulin.
“[H]ypoglycemia is not consistent with a goal of comfort, and these data demonstrate suboptimal avoidance of dysglycemia among patients with type 2 diabetes on hospice in nursing homes,” wrote Petrillo and colleagues.
According to the 2016 guidelines from the American Diabetes Association, people with diabetes receiving end-of-life care should relax glycemic control targets and eventually discontinue diabetes medication in order to avoid hypoglycemia, which Petrillo’s group calls a “potentially preventable cause of suffering among hospice patients.”
The retrospective cohort study included 20,329 hospice patients with type 2 diabetes admitted to Veterans Affairs nursing homes between 2006 to 2015. All patients either had an HbA1c over 6.5% or were identified with type 2 diabetes through an ICD-9 code. Patients with type 1 diabetes were excluded from the analysis.
The majority of hospice patients — nearly all of whom were male (98%) — were not being treated with insulin (91.7% no insulin vs. 8.3% on insulin). The most common comorbidities included hypertension (38%), cancer (35%), chronic kidney disease (24%), and chronic pulmonary disease (24%).
Use of an oral glucose lowering medication was relatively low among the total cohort (12%), while oral medication use was more common among patients on insulin (11% no insulin vs. 21% on insulin; P<0.001). Patients on insulin also had higher HbA1c levels at baseline (6.8% no insulin vs. 7.4% on insulin; P<0.001) and experienced more frequent glucose tests while in hospice (0.6 tests per day for vs. 1.7 tests per day on insulin; P<0.001). Only one-fifth of all patients had no HbA1c testing recorded — the majority of whom were not on insulin (21% no insulin vs. 12% on insulin; P<0.001).
The 100-day mortality rate among all patients was 83%, although death within 100 days of admission was significantly lower among patients treated with insulin (85% no insulin vs. 61% on insulin; P<0.001). Patients on insulin also had a longer median length of stay (10 days no insulin vs. 25 days on insulin; P<0.001).
“Patients treated with insulin lived longer and experienced more hyperglycemia than patients not treated with insulin, which suggests that clinicians may be choosing to continue insulin for those hospice patients with a longer life expectancy and more severe diabetes at hospice admission,” the research group noted.
In regards to future research, the group recommended additional studies are required to “establish optimal timing of diabetes medication titration and cessation,” as well as to “characterize the effect of hypoglycemia and hyperglycemia on the symptom burden of patients with diabetes on hospice.”