GOLD Pathway Cuts Diabetes Emergencies in Older Cancer Patients on Steroid Therapy
核心洞察
A UK quality improvement project enrolled 126 older adults with cancer (搜索) in a structured, age-adapted diabetes (搜索) monitoring pathway during steroid-based systemic anti-cancer therapy.
The GOLD pathway produced no episodes of diabetic ketoacidosis (搜索) or hyperosmolar hyperglycaemic syndrome (搜索) and only three asymptomatic hypoglycaemic events across the programme.
Steroid regimens were modified for 24% of patients, and secondary referrals to specialist diabetes (搜索) services fell from 36% in 2022 to 5% in 2025.
A structured, age-adapted diabetes (搜索) monitoring pathway developed at Guy's and St Thomas' NHS Foundation Trust in London kept older adults with cancer (搜索) safe during steroid-based systemic anti-cancer therapy, with no episodes of diabetic ketoacidosis (搜索) (DKA) or hyperosmolar hyperglycaemic syndrome (搜索) and only three asymptomatic hypoglycaemic events, according to a quality improvement project published in European Geriatric Medicine.
The GOLD diabetes (搜索) enhanced monitoring pathway, developed within the Geriatric Oncology Liaison Development clinic, was conducted between February 2022 and June 2025 and enrolled 126 patients with a median age of 74 years. Fifty-eight percent were male and 77% were living with pre-existing diabetes. The most common tumour sites were the oesophagus, colon and breast, and 94% received chemotherapy as their primary systemic anti-cancer (搜索) therapy, most commonly supported by dexamethasone at a median daily dose of 8 mg for the first four days of each cycle, chiefly for its anti-emetic and anti-allergic properties.
Risk Stratification and Patient Selection
The pathway began with risk stratification. Patients with an HbA1c below 48 mmol/mol and no history of diabetes (搜索) were classified as low risk and followed by their oncology team and general practitioner. High-risk patients — including those on insulin, those with HbA1c of 64 mmol/mol or above, glucose readings of 15 mmol/L or higher, pancreatic cancer (搜索), or a previous episode of steroid-induced hyperglycaemia (搜索) — were referred directly to specialist diabetes services.
The intermediate group became the focus of the GOLD pathway. These were typically patients with HbA1c between 48 and 63 mmol/mol or capillary glucose between 11 and 14.9 mmol/L, or patients with diabetes (搜索) managed on oral agents who did not meet high-risk criteria.
Comprehensive geriatric assessment data, available for 81% of participants, revealed a largely pre-frail population with a median Clinical Frailty Scale score of 3, and identified malnutrition in 46% of the cohort, alongside social isolation, functional impairment and recent falls in smaller proportions. Personalised geriatric interventions spanning physiotherapy, occupational therapy, dietary support and medication management were implemented for the vast majority of those with identified impairments.
Monitoring Schedule and Intervention Thresholds
Each enrolled patient received a capillary blood glucose meter and personalised education from a geriatric clinical nurse specialist, delivered face to face or by telephone within days of referral, because the interval between referral and the start of systemic anti-cancer (搜索) therapy is often extremely short. Education covered the symptoms of high and low blood sugar, recognition of diabetes (搜索) emergencies, glucose targets, and practical demonstrations of the meter, all calibrated to each patient's health literacy, cognition and physical abilities, with caregivers involved where necessary.
During every treatment cycle, patients checked their glucose on the day of steroid administration and the following two days, before breakfast and before the evening meal — a schedule designed to capture the late-afternoon and evening peaks characteristic of steroid-induced hyperglycaemia (搜索). Telephone follow-up by nurse specialists after each cycle formed the backbone of the monitoring system, with the team reviewing all glucose readings, assessing food intake and treatment side effects, and applying decision-making algorithms for intervention.
Hyperglycaemia was defined as at least two readings above 15 mmol/L, and hypoglycaemia as any reading below 4 mmol/L. When medication was required, the protocol favoured gliclazide, a sulphonylurea that directly stimulates insulin secretion and thereby counteracts the steroid-driven suppression of pancreatic beta-cell function. The team deliberately adopted a higher intervention threshold of 15 mmol/L, compared with the 12 mmol/L in national guidance, reflecting broader glycaemic targets for older people and a conscious effort to avoid hypoglycaemia and its consequences, particularly in patients with poor oral intake or renal impairment.
Iterative Refinement Through Seven PDSA Cycles
The pathway was refined through seven Plan-Do-Study-Act cycles between 2022 and 2023, each incorporating feedback from healthcare professionals and addressing specific local barriers such as the feasibility of glucose measurement, intervention thresholds and the medication titration process. Risk criteria were sharpened over successive cycles, with the glucose range adjusted from 12–20 to 11–15 mmol/L and the HbA1c range expanded from 48–59 to 48–64 mmol/mol.
Fortnightly multidisciplinary meetings were introduced from January 2023 to review complex cases, and the geriatric nursing team grew increasingly autonomous in managing intermediate-risk patients, reducing the burden on specialist diabetes (搜索) services while retaining rapid access to expert advice. The multidisciplinary group comprised geriatricians, oncologists, diabetologists and clinical nurse specialists, who translated national guidance from the UK Chemotherapy Board and the Joint British Diabetes Societies for Inpatient Care into a practical, locally tailored system.
Safety and Treatment Continuity Outcomes
Clinical advice on diabetes (搜索) management was provided to 89% of patients, and diabetes medication intervention was required in 32%, with gliclazide initiated or escalated in 92% of those cases. Women and patients with pre-existing diabetes were significantly more likely to need medication.
Critically, only three hypoglycaemic events occurred, all asymptomatic and all managed without clinical consequences. Among 35 unplanned hospital admissions within a year, only two were related to hyperglycaemia, and there were no episodes of DKA or hyperosmolar hyperglycaemic syndrome (搜索), and no admissions for hypoglycaemia. During a median follow-up of 300 days, 41 patients died, but mortality was associated with metastatic disease, malnutrition and social isolation rather than with glycaemic control or diabetes (搜索) intervention, suggesting that proactive metabolic monitoring did not add risk in this fragile population.
The pathway also influenced cancer (搜索) treatment itself. Steroid regimens were modified for 24% of patients, almost always involving dose reductions driven by hyperglycaemia, and in 80% of those cases the adjustment was linked to the need for diabetes (搜索) medication. While steroid reduction triggered treatment toxicity symptoms in four patients, leading to early discontinuation or dose reduction of the anti-cancer protocol in two, the overall signal was one of balance: oncologists could taper steroids with confidence knowing that a safety net existed for the metabolic consequences.
Secondary referrals to the diabetes (搜索) team fell dramatically over the project period, from 36% of patients enrolled in 2022 to just 5% in 2025, evidence that the geriatric team's growing expertise was absorbing demand that would otherwise have overwhelmed specialist services.
Limitations and Next Steps
The authors are candid about limitations. The single-centre design, the predominance of pre-frail patients, the absence of a comparator group and the use of clinical rather than validated tools for some geriatric domains all constrain generalisability, and under-ascertainment of nocturnal or asymptomatic glycaemic excursions cannot be excluded with intermittent fingerstick testing.
Even so, the team argues that the GOLD pathway offers a robust, patient-centred model for integrating geriatric, oncology and diabetes (搜索) care, aligned with national and international recommendations for multidisciplinary management of older adults with complex needs. Future priorities include multi-centre validation, comparative and randomised designs to confirm effectiveness, integration of continuous glucose monitoring and digital health tools to reduce nursing workload, evaluation of patient-reported outcomes and cost-effectiveness, and incorporation of patient feedback to improve usability for those who struggle with glucometer technology.
Broader Guidance on Cancer Therapy–Induced Hyperglycaemia
The GOLD initiative addresses one facet of a widening metabolic challenge in oncology. Cancer (搜索) therapy–induced hyperglycaemia has emerged as an important concern with the expanding use of immunotherapies and targeted therapies, and the American Diabetes Association (搜索) (ADA) expanded its recommendations in the 2026 Standards of Care to provide more detailed guidance on glucose monitoring in patients receiving cancer therapies associated with hyperglycaemia.
The updated guidance emphasizes that the optimal monitoring strategy depends on the mechanism of the anticancer agent. Immune checkpoint inhibitors, including PD-1 (搜索), PD-L1 (搜索) and CTLA-4 (搜索) inhibitors, can trigger autoimmune destruction of pancreatic beta cells; although relatively uncommon, this complication can lead to abrupt insulin deficiency and life-threatening DKA, and onset may be sudden between clinic visits. The ADA therefore supports routine random plasma glucose monitoring in these patients, which can be incorporated into routine laboratory assessments during treatment visits and can identify unexpected glucose elevations regardless of meal timing.
In contrast, targeted therapies such as phosphatidylinositol 3-kinase alpha (PI3Kα) inhibitors and mammalian target of rapamycin (mTOR (搜索)) inhibitors cause hyperglycemia through insulin resistance and impaired glucose signalling pathways. Hyperglycemia is considerably more common with these agents and often follows a predictable timeline after treatment initiation, making fasting plasma glucose monitoring generally preferred. Clinical trials have demonstrated high rates of hyperglycemia with PI3Kα inhibitors, particularly alpelisib, with hyperglycemia emerging within days to weeks after treatment initiation in some studies.
The ADA recommends structured monitoring schedules during these vulnerable treatment windows, with baseline metabolic risk factors — obesity, prediabetes, type 2 diabetes (搜索), metabolic syndrome or elevated haemoglobin A1C — informing more intensive protocols. Both sets of guidance converge on the same operational conclusion: early detection allows for timely intervention, improved treatment continuity and better patient outcomes, and proactive glucose monitoring should become a standard component of comprehensive cancer (搜索) care.