Hospitalization as an Opportunity to Optimize Glycemic Control in Oncology Patients

Hypoglycemia in Terminally Ill Patients with Cancer with a History of Diabetes Mellitus Admitted to a General Ward: A Retrospective Observational Study

Background

Poor glycemic control may be a risk factor for hypoglycemia in terminally ill patients with cancer with a history of diabetes mellitus (DM). However, no guidelines have been established for achieving glycemic control in this patient population, and epidemiological information remains lacking.

Objectives

We aimed to investigate the prevalence of hypoglycemic episodes and provide epidemiological information on hypoglycemia in terminally ill patients with cancer with a history of DM admitted to a general ward.

Design

This was a single-center, retrospective, observational study.

Setting/Subjects

This study enrolled terminally ill patients with cancer with a history of DM, receiving palliative care at a hospital in Japan between January 2017 and July 2022.

Measurements

Data extracted from the patients' medical records were age, sex, body mass index, primary cancer, liver metastases, dialysis status, Eastern Cooperative Oncology Group performance status score, type and duration of DM, HbA1c level, and use of diabetes medications (antihyperglycemic agents and types and insulin) at the time of initial visit within 180 days of death.

Results

Among the 104 patients included in the analysis, hypoglycemic episodes occurred in 36 patients (34.6%). The total number of hypoglycemic episodes was 132, and the median number of hypoglycemic episodes for each patient during hospitalization was 2.5 (interquartile range, 1-6).

Conclusions

The prevalence of hypoglycemia in terminally ill patients with cancer with a history of DM who were admitted to a Japanese general ward was 34.6%. Further studies are needed to determine the frequency of hypoglycemia because of overtreatment in this patient population.

The real-life management of glucose homeostasis abnormalities in pediatric onco-hematological diseases: data from a national survey

Glycemic abnormalities are a frequent finding in pediatric oncological patients, both during treatment and after its discontinuation. Moreover, impaired glucose tolerance (IGT), impaired fasting glycemia (IFG) and diabetes mellitus (DM) are not rarely diagnosed in non-oncological hematological diseases. To explore the current pediatric Italian approach to the diagnosis and the management of the glycemic alterations in this clinical setting and, thus, to identify and enforce current clinical needs, we submitted an online 23-items survey to all the Italian Associazione Italiana Ematologia Oncologia Pediatrica (AIEOP) centers, and surveys were descriptively analyzed. Thirty-nine AIEOP centers were involved in the study. In 2021, among 75278 children and adolescents affected by an oncological or a hematological disease, 1.2 and 0.65% developed DM, while IGT or IFG were widespread in 2.3 and 2.8%, respectively. The main causes of DM were the use of corticosteroids in patients with cancer and the iron overload in patients with thalassemia. Venous fasting plasma glycemia was the most used tool to detect glycemic abnormalities. The performance of oral glucose tolerance test (OGTT) was extremely limited, except when IFG occurred. Despite the diagnosis of DM, ∼45% of patients with cancer and 30% of patients with one hematological disease did not receive an appropriate treatment. In the other cases, insulin was the drug of first choice. Emerging technologies for diabetes care (glucose sensors and insulin pumps) are not largely used yet. The results of our study support the standardization of the care of the glycemic abnormalities during or after onco-hematologic diseases in the pediatric age. Despite the scarce data in pediatric literature, proper guidelines are needed.

Glucocorticoid-Induced Hyperglycemia in Oncologic Outpatients: A Narrative Review Using the Quadruple Aim Framework

Glucocorticoids are a central part of cancer treatment protocols. Their use in patients receiving chemotherapy increases patient risk of hyperglycemia and associated adverse outcomes. Despite this, there have been few published protocols that guide the management of this patient group. In this narrative review, we use the quadruple aim as a framework to evaluate the current literature, including interventions, on glucocorticoid-induced hyperglycemia in patients receiving oncologic treatment, with a focus on the outpatient setting. Findings were drawn from published review articles, observational studies, qualitative reports and costing data. Results were synthesized using the framework's 4 dimensions of care: population health, provider experience, patient experience and cost. Prospective studies proposing an intervention on oncologic patients receiving glucocorticoids were identified as intervention studies. Management of glucocorticoid-induced hyperglycemia in oncologic patients is a complex problem with no published interventions addressing all components of the quadruple aim. Most evidence on this population is based on retrospective studies. Six prospective intervention studies were identified and highlighted in this review, and only 2 were exclusively in the outpatient context. Challenges included lack of standardization in screening strategies and a paucity of interventions that have examined impact on patient and provider experience. There is limited evaluation of the impact of interventions targeting glycemic management on clinical outcomes and cost of care delivery, especially in the outpatient context. We propose a conceptual framework for evaluation of quality improvement programs. Management of glucocorticoid-induced hyperglycemia in the outpatient setting is complex and requires well-designed intervention studies evaluated across the quadruple aim.

Effects of glucocorticoids on interstitial glucose concentrations in individuals with hematologic cancer and without known diagnosis of diabetes: a pilot study

Objective

To analyze interstitial glucose behavior during glucocorticoid use in non-diabetic patients receiving chemotherapy for hematologic malignancies.

Methods

Prospective pilot study carried out to assess interstitial glucose levels in 15 non-diabetic individuals with hematologic malignancies who received glucocorticoids in combination with chemotherapy. The FreeStyle Libre flash monitoring system (Abbott Diabetes Care) was used for up to 14 days to measure interstitial glucose.

Results

Median age and body mass index were 53 (42-61) years and 25 (23-28) kg/m² respectively. Interstitial glucose levels >180mg/dL lasting at least one hour were detected in 60% of participants. Interstitial glucose profile parameters (median and peak interstitial glucose levels and percentage of time during which interstitial glucose levels were >180mg/dL) were significantly (p<0.01) higher during glucocorticoid use (115mg/dL, 218mg/dL and 10% respectively) than after glucocorticoid discontinuation (97mg/dL, 137mg/dL and 0% respectively). Mean interstitial glucose levels increased in the afternoon and at night during glucocorticoid use.

Conclusion

This pilot study was the first to evaluate interstitial glucose levels in non-diabetic individuals using glucocorticoids in treatment of hematologic cancer. Glucocorticoid use during chemotherapy significantly increases interstitial glucose levels in these patients.

Evaluation of the Efficacy of the Hospital Glycemic Management System for Patients with Malignant Tumors and Hyperglycemia

OBJECTIVE

To explore the efficacy of the hospital glycemic management system with information integration in patients with malignant tumors and hyperglycemia.

METHODS

Three hundred ninety-three patients diagnosed with malignant tumors with hyperglycemia and hospitalized in the non-endocrinology department of a specialized cancer hospital from March 2019 to November 2020 were recruited. All the patients were diagnosed and treated according to the clinical department and disease course. In total, 196 patients were divided into the control group, who received the conventional blood glucose management mode, and 197 patients were divided into the intervention group, who received the hospital glycemic management system with information integration. The average daily glucose levels were recorded before and after breakfast, lunch, and dinner, at bedtime and at night. The average glucose level, glucose compliance rate, hypoglycemia rate, hyperglycemia rate, glucose measurements per day, average number of hospitalization days and patient satisfaction were compared between the groups.

RESULTS

In the intervention group, the average glucose level was significantly lower than that in the control group (P<0.05). The hyperglycemia and hypoglycemia rates in the intervention group were lower than those in the control group (P<0.05). The glucose compliance rate in the intervention group was higher than that in the control group (P<0.05). The highest blood glucose level in the intervention group was lower than that in the control group (P<0.05), and the lowest blood glucose level was higher than that in the control group (P<0.05). The glucose measurements per day in the intervention group were higher than those in the control group, and the average number of hospitalization days in the intervention group was lower than that in the control group (P<0.05). Patient satisfaction in the intervention group was higher than that in the control group (P<0.05).

CONCLUSION

The hospital glycemic management system with information integration significantly improved the glycemic management of patients with malignant non-endocrine tumors and hyperglycemia, including their glucose level and glucose compliance rate, as well as patient satisfaction, and reduced the average number of hospitalization days and risk of hyperglycemia/hypoglycemia.