Principles of rationalising antihyperglycaemic drugs in palliative care

Ideally start discussing rationalisation of antihyperglycaemic therapy when patients have a prognosis of less than a year. This discussion should prompt review of the aims of and approach to diabetes management with respect to prognosis and goals of care. Gradually change the focus of care to avoiding hypoglycaemia and drug adverse effects (both of which become more likely as oral intake, level of activity and physical condition declines), while also minimising burdens of treatment and the risk of symptomatic hyperglycaemia. This will involve revisiting glycaemic targets and potentially relaxing glycaemic monitoring and dietary restrictions; the emphasis of care should be monitoring for symptoms. Although blood glucose concentration and HbA1c targets may no longer be relevant, if practical, a less strict blood glucose concentration target between 6 and 15 mmol/L is suggested to minimise symptomsDunning, 2020Trend Diabetes Limited, 2021.

In addition to the principles of medication rationalisation, the approach to rationalising antihyperglycaemic drugs depends on the type of drug (see advice on oral antihyperglycaemic drugs and insulin) and the patient’s:

• type of diabetes (type 1 or type 2)
• stability of glycaemic control
• history of acute complications (eg ketoacidosis)
• comorbidities
• concurrent drugs (eg corticosteroids)
• physical condition
• diet
• level of activity
• goals of management.

Antihyperglycaemic drugs can be stopped without a gradual withdrawal. Blood glucose monitoring may be useful to guide rationalisation.