What is the management of steroid-induced hyperglycemia?

From the Guidelines

Management of steroid-induced hyperglycemia requires a proactive approach tailored to the steroid regimen, with insulin therapy being the preferred treatment for patients on short-term steroids, as evidenced by the most recent guidelines 1.

Key Considerations

• The type and duration of action of glucocorticoids must be considered in determining insulin treatment regimens, with daily-ingested short-acting glucocorticoids such as prednisone requiring intermediate-acting insulin like NPH 1.
• For patients on once- or twice-daily steroids, administering NPH insulin is a standard approach, usually in addition to daily basal-bolus insulin or oral glucose-lowering medications, with NPH action peaking at 4–6 h after administration 1.
• Long-acting glucocorticoids such as dexamethasone and multi-dose or continuous glucocorticoid use may require long-acting basal insulin to manage fasting blood glucose levels, with increasing doses of prandial and correction insulin sometimes needed in addition to basal insulin 1.

Treatment Approach

• Start with NPH insulin at 0.1-0.2 units/kg/day given in the morning for once-daily morning prednisone, matching the insulin's peak action with the steroid's hyperglycemic effect.
• For patients on multiple daily steroid doses, consider basal insulin (glargine or detemir) plus rapid-acting insulin (lispro, aspart, or glulisine) before meals.
• Blood glucose monitoring should occur at least 4 times daily, with insulin doses adjusted every 1-2 days based on patterns.

Additional Considerations

• For long-term steroid use, oral agents may be appropriate, with metformin as first-line therapy unless contraindicated, and DPP-4 inhibitors and GLP-1 receptor agonists as good second-line options due to their low hypoglycemia risk 1.
• SGLT-2 inhibitors should be used cautiously due to potential ketoacidosis risk.
• As steroid doses are tapered, antihyperglycemic medications must be reduced proportionally to avoid hypoglycemia, with daily adjustments based on levels of glycemia and anticipated changes in type, dosages, and duration of glucocorticoids, along with POC blood glucose monitoring, being critical to reducing hypoglycemia and hyperglycemia 1.

From the FDA Drug Label

Corticosteroids, danazol, diuretics, sympathomimetic agents (e.g., epinephrine, albuterol, terbutaline), isoniazid, phenothiazine derivatives, somatropin, thyroid hormones, estrogens, progestogens (e.g., in oral contraceptives) The management of steroid-induced hyperglycemia may involve monitoring of blood glucose levels and adjustment of the treatment regimen, including the use of hypoglycemic agents such as glipizide or pioglitazone, or insulin therapy with detemir.

• Key considerations:
  • Monitoring of blood glucose levels
  • Adjustment of treatment regimen
  • Use of hypoglycemic agents or insulin therapy
  • Caution with certain medications that may affect glucose metabolism, such as corticosteroids 2

From the Research

Diagnosis of Steroid-Induced Hyperglycemia

• The diagnosis of steroid-induced hyperglycemia is often undervalued by professionals, likely due to the lack of quality studies to determine specific strategies of action 3.
• Steroid-induced hyperglycemia can be detected by measuring glucose concentration, with the highest glucose concentrations typically detected on the 3rd day of steroid therapy and 2 hours after meals 4.
• Fasting blood glucose ≥ 7 mmol/L (126 mg/dL) or random blood glucose ≥ 11.1 mmol/L (200 mg/dL) can be considered as overt diabetes, while post-meal blood glucose ≥ 10 mmol/L (180 mg/dL) can be considered as steroid-induced hyperglycemia 4.

Management of Steroid-Induced Hyperglycemia

• The management of steroid-induced hyperglycemia should be proactive, with diagnosis, management, and post-steroid care tailored to the individual patient's needs 5.
• Patients with pre-existing diabetes can continue their current therapy as long as they are clinically stable and eating adequately, but may require modification of doses depending on the degree of hyperglycemia 5.
• Initiating basal bolus with correction regimen is recommended for patients in non-intensive care unit settings, while variable rate intravenous insulin infusion can be used temporarily in intensive care unit settings 5.
• Glycemic variability should be carefully monitored, and interventions should aim to achieve and maintain euglycemia 5.
• Rational use of glucose-lowering drugs is recommended, with treatment regimens ensuring maximum safety for both patient and provider 5.

Treatment Strategies

• Treatment strategies for steroid-induced hyperglycemia should be based on the pathophysiology of the process and the mechanism of action of different corticosteroids, taking into account dosing and administration timing to predict the duration of therapy 3.
• Clinical stratification can help understand patient profiles and determine the treatment course, with patients at home with pre-existing diabetes who are already on oral or injectable therapy able to continue the same as long as they are clinically stable and eating adequately 5.
• Insulin dosage should be reduced subsequently as the steroids taper during transition, with glucovigilance required to monitor for potential hypoglycemia 5.