Refractory Hypoglycemia at the End of Life Treated with Continuous Dextrose Infusion through Ambulatory Infusion Pump

Dear Editor:

A 55-year-old woman originally from Trinidad and Tobago was admitted to the medicine service with abdominal pain, weakness, hematuria, and severe hypoglycemia: her presenting capillary blood glucose was 30 mg/dL. She had a six-year history of metastatic KRAS-mutant colon cancer, which had been treated with multiple chemotherapy regimens. She had recently experienced progression of pulmonary, hepatic, and retroperitoneal disease while considering trial enrollment. A previously placed percutaneous nephrostomy tube was exchanged, and symptomatic anemia was treated with red blood cell transfusion. Her pain was managed successfully with standing methadone and breakthrough hydromorphone. Hypoglycemia, which was likely due to anorexia, cachexia, impaired gluconeogenesis, and tumor metabolism, initially responded to intravenous D50W and oral glucose tablets.

In discussion with palliative care, the patient decided that treating cancer was no longer her priority and the consulting oncology team agreed with supportive care and symptom management, especially given decline in ECOG performance status from 3 to 4. The patient's primary goal became returning to Trinidad from New York City to be with her extended family and continue comfort care there. The main barrier to her achieving this goal was the development of severe, recurrent hypoglycemia. Her blood glucose dropped as low as 19 mg/dL on the morning of hospital day 9. Although she was not consistently symptomatic at glucose levels below 40 mg/dL, repeat D50W boluses and eventually continuous infusion of dextrose-containing fluids through preexisting portacath were necessary. Despite increased doses of oral glucose tablets, liberalization of diet, and even the addition of oral dexamethasone, the patient could not be weaned off of intravenous D10W at a rate of 50 mL/hour (5 g/hour).

Given her heroic goal of returning to Trinidad before she died, the decision was made to pursue continuous home dextrose infusion. Airline travel and necessity of high dextrose would require an ambulatory infusion pump as opposed to gravity infusion. Candidacy for this palliative intervention required several key factors. A home infusion company compassionately loaned a CADD-prizm^® ambulatory infusion pump while the family arranged the funds to purchase this device (approximate cost of $2,500). The family was also able to pay for a supply of D10W bags and intravenous tubing. The patient's sister, a pharmacist by training, was taught how to replace completed D10W bags. The family arranged for medical follow-up in Trinidad to provide glucose monitoring as well as portacath access and dressing changes. The infusion pump was programmed before discharge and the patient took a commercial airline flight with accompaniment to Trinidad. She was comfortable and successfully maintaining home D10W infusion as of one-week post-hospital discharge.

Hypoglycemia is not an uncommon issue for terminally ill patients. Treatment options include “corrective” strategies as well as supportive care focused on relieving the symptoms of hypoglycemia. ¹ Although artificial nutrition and hydration typically have a limited role for symptom management, quality of life, or survival at the end of life, personal values and individual goals are paramount. ² The decision to pursue continuous ambulatory infusion of dextrose solutions at the end of life should include careful consideration of the risks and feasibility of this heroic intervention if it is necessary to achieve a dying patient's goals.