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Clinical Challenges in Caring for Patients with Diabetes and Cancer

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Clinical Challenges in Caring for Patients with Diabetes and Cancer In Brief to Practice Research From / Diabetes and Coexisting Diseases Diabetes and cancer are two diagnoses that individually overwhelm both patients and clinicians. Approximately 8–18% of people with cancer have diabetes. Together, these two diseases can pose formidable challenges to clini- cians caring for this difficult patient population. Unfortunately, our knowl- edge of this topic is limited by insufficient evidence to determine how best to manage diabetes while simultaneously treating cancer. This article seeks to review some of the most common problems encountered by clinicians caring for these patients. Clinical Challenges in Caring for Patients With Diabetes and Cancer Diabetes and cancer are two diagnoses not be explained by differences in that individually overwhelm both comorbidity, income, age, access to patients and clinicians. Approximately care, or use of estrogen therapy. Helen M. Psarakis, RN, APRN 8–18% of people with cancer have Instead, it was attributed to time con- diabetes.1 Together, these two diseases straints during office visits for com- can pose formidable challenges to clin- plex chronic disease care, perceptions icians caring for this difficult patient of decreased life expectancy by both population. Unfortunately, our knowl- patients and health care providers, edge of this topic is limited by insuffi- and sociocultural barriers to health cient evidence to determine how best education. This should serve as a to manage diabetes while simultane- reminder for clinicians to question ously treating cancer. This article seeks patients about their primary health to review some of the most common care as routinely as they are screened problems encountered by clinicians for diabetes complications. caring for these patients. This trend of decreased prevention services is disturbing given the evi- Cancer Screening and Prevention dence to suggest that insulin resistance Several studies published within the and diabetes are linked to higher inci- past decade demonstrate that patients dences of some cancers. Researchers with a chronic disease are less likely hypothesize that exposure to hyper- to receive preventive services, such as glycemia, elevated insulin concentra- cancer screenings, than their counter- tions, and the growth-promoting parts without diabetes.2–5 A recent effects of IFG-I may stimulate the retrospective study addressed cancer development or progression of cancer. screening in patients with diabetes.6 People with type 2 diabetes are at After examining the mammography higher risk for developing breast, pan- rates of 69,168 Canadian women creatic, liver, kidney, endometrial, and with diabetes and 663,519 Canadian colon cancers. Patients with type 1 women without diabetes, the authors diabetes are more likely to develop concluded that patients with complex cervical and stomach cancers. chronic diseases are 32% less likely to Several studies have also demon- receive this routine cancer screening, strated that patients with diabetes and even though they see primary care cancer have a poorer prognosis com- and specialty physicians more fre- pared with those without diabetes. quently than their counterparts with- Diabetes and hyperglycemia are asso- out diabetes. The discrepancy could ciated with higher infection rates, 157 Diabetes Spectrum Volume 19, Number 3, 2006 shorter remission periods, and shorter the strongest predictors for glucocorti- or hyperosmolar hyperglycemic state median survival times, as well as high- coid-induced diabetes.12 (HHS) if left untreated. er mortality rates.7–10 Treatment of hyperglycemia result- Adding regular insulin to the TPN ing from glucocorticoids depends on solution can help control blood glu- Cancer Treatment the type of diabetes, severity of the cose levels. Initial doses are usually 1 Chemotherapeutic Agents elevated blood glucose levels, and unit per 10 g of carbohydrate. The Patients with diabetes may present dose and duration of the therapy. dose should be titrated daily until unique challenges to clinicians making Giving steroids in multiple doses glycemic control is attained. Using a cancer treatment decisions. Patients throughout the day instead of a single lower carbohydrate formula will help with long-standing diabetes or a histo- bolus dose or administering the total with glycemic control in enterally fed ry of poorly controlled diabetes may daily steroid dose intravenously over patients. present for cancer treatment with pre- 24 hours can assist in controlling These patients may also benefit existing renal, cardiac, or neuropathic hyperglycemia. Patients with pre- from the use of basal insulin. The type complications. Several chemotherapeu- existing diabetes may be kept on their of basal insulin used depends on the tic agents are known to cause or exac- oral hypoglycemic agents and moni- duration of the tube feeding. Some erbate these conditions. For example, tored carefully. However, these clinicians prefer glargine for continu- cisplatin is known to cause renal insuf- agents are usually inadequate for ous tube feeding. However, NPH or ficiency, and the anthracyclines may managing hyperglycemia in this set- detemir given 2–3 times per day may cause cardiotoxicity. Cisplatin, pacli- ting. Patients using insulin before glu- work as well and allow for a quicker taxel, and vincristine may be neuro- cocorticoid therapy will typically titration of the insulin dose. The toxic. Unfortunately, many of these require both basal and preprandial University of Vermont is successfully side effects from chemotherapeutic insulins. These patients may require using a protocol of 70/30 (NPH/regu- agents are permanent. two to three times their usual dose(s) lar) given every 8 hours. The starting Successful cancer treatment usual- of insulin. Insulin is the preferred dose calculation varies based on ly requires at least 85% of the drug for managing steroid-induced or renal/hepatic/cardiac dysfunction, chemo-therapeutic dose be given. exacerbated hyperglycemia in patients obesity, open wounds/infection, or Patients with diabetes must be care- with known diabetes. Many patients steroid therapy. NPH and the fully monitored before initiation of will require basal and prandial bolus NPH/regular 70/30 mix also offer an and during chemotherapy. Treatment insulins to attain adequate glycemic easier transition from continuous to decisions must be based on the control.12–14 timed or bolus tube feeding because a patient’s clinical picture, but always Insulin doses may be estimated dose can be eliminated when the feed- with the knowledge that any alter- based on the patient’s weight and ings are discontinued. Patients receiv- ations in dose, timing of administra- administered subcutaneously. Use of ing tube feeding or TPN should have tion, or substitution of an alternate an intravenous insulin infusion is their blood glucose monitored every chemotherapeutic agent may com- another quick way to lower blood 4–6 hours. Short- or rapid-acting promise outcomes by lowering the glucose as well as estimate the total insulin dosed according to an algo- treatment response rate and shorten- daily insulin requirement in insulin rithm may be given every 6 hours to ing survival.10 naive patients. However, many hospi- correct for any hyperglycemia.18–20 tals are resistant to using intravenous Hypoglycemia is likely to occur if Glucocorticoids insulin drips outside of the intensive TPN is stopped abruptly. Gradually The use of glucocorticoids in patients care setting because of fear of hypo- decreasing the infusion rate at least 1 with pre-existing diabetes typically glycemia. Hourly glucose monitoring hour before discontinuing TPN wreaks havoc on postprandial and insulin drip rate titrations place reduces the risk of hypoglycemia.20 glycemic control. Unfortunately, glu- an added burden on the nursing staff. cocorticoids are routinely used in Regardless of the route or setting, Nausea and Vomiting many cancer treatment protocols. insulin doses should be titrated daily Nausea and vomiting are common Glucocorticoid treatment for cancer as needed and should be tapered as adverse drug reactions in some patients usually consists of short-term glucocorticoid therapy is tapered to chemotherapy regimens. These reac- therapy at a high dose. Lower-dose avoid hypoglycemia.11–17 tions can occur in anticipation of ther- steroids are also used to prevent apy, acutely during or within 24 chemotherapy-induced nausea and Tube Feeding and Total Parenteral hours of the therapy, or may persist vomiting. All patients should be Nutrition over an extended period of time after screened for diabetes before initiating Tube feeding and total parenteral therapy. Breakthrough nausea and glucocorticoid therapy and routinely nutrition (TPN) are frequently used in vomiting may occur, despite prophy- monitored thereafter. These medica- oncology to supplement or replace a lactic treatment. tions raise blood glucose through regular diet for patients who cannot All patients should be screened for increased insulin resistance, gluconeo- sustain their usual intake of nutrition- a history of nausea and vomiting genesis, glycogenolysis, and decreased al requirements. Hyperglycemia is a before initiation of any chemotherapy. insulin production and secretion.11 frequent complication from both of The history should include nausea and It is also common for patients to be these forms of nutrition. It may be vomiting related to motion sickness, diagnosed with diabetes while receiv- exacerbated by coexisting infection, anesthesia,
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