Palliative care and heart failure in diabetes

Heart failure is a major cause of morbidity and mortality in diabetes and once established the mortality is very high. There is evidence for a U‐shaped association between HbA1c and risk of mortality with the lowest risk associated with an HbA1c of 6.5–7.5% (48–58 mmol/mol). Guidelines for management of chronic heart failure recommend palliative care for end‐stage disease, but because of the unpredictable trajectory of heart failure it can be difficult to decide exactly when palliative care should be introduced. Despite the frequent combination of diabetes and heart failure, end of life guidelines for each condition fail to provide recommendations for management when they coexist. While no class of cardiac failure medication is contraindicated in diabetes, some blood glucose lowering agents may have an adverse effect on heart failure. Cardiovascular outcome studies have linked pioglitazone, saxagliptin and possibly alogliptin with increased risk of heart failure and these drugs should be avoided once the condition is diagnosed. Blood glucose targets should aim for avoidance of hypoglycaemia (increased risk of arrhythmias) and hyperglycaemia (increased risk of dehydration and renal impairment when combined with diuretics). Despite the usual advice to reduce blood testing to a minimum in palliative care, monitoring of both the blood glucose and renal function may be needed to ensure optimal symptom control. Multidisciplinary heart failure and diabetes teams should be trained to provide palliative care and should use their combined skills to optimise care. They should aim to alleviate symptoms and to address the anxiety and depression often associated with heart failure. Both family and patient should be supported to deal with the uncertainty associated with the unpredictable trajectory towards death. Authors of guidelines should collaborate to produce recommendations for management of the combination of end‐stage heart failure and diabetes.