From the Guidelines
Initial management for a 58-year-old patient with steroid-induced diabetes (SID) should focus on insulin therapy, particularly basal insulin, while continuing necessary steroid treatment. The recommended starting dose is typically 0.3-0.5 units/kg/day of intermediate-acting NPH insulin or long-acting insulin like glargine or detemir 1. NPH insulin is often preferred because its peak action can be timed to match the glucose-elevating effects of steroids, especially when morning prednisone is used. Blood glucose monitoring should be performed 2-4 times daily, with target fasting glucose of 80-130 mg/dL and postprandial levels below 180 mg/dL.
Key Considerations
- Oral antidiabetic agents are generally less effective for SID but may be considered in mild cases; metformin can be used if renal function is adequate (eGFR >30 mL/min) at a starting dose of 500 mg once or twice daily, as per the standards of medical care in diabetes-2022 1.
- Lifestyle modifications including consistent carbohydrate intake, moderate exercise as tolerated, and weight management are important adjunctive measures.
- SID requires this insulin-focused approach because steroids primarily cause postprandial hyperglycemia by increasing insulin resistance and hepatic glucose production while suppressing insulin secretion, creating a more severe hyperglycemic pattern than typical type 2 diabetes.
Management Approach
- Insulin therapy should be adjusted based on anticipated changes in glucocorticoid dosing and point-of-care glucose test results, as outlined in the management of diabetes care in the hospital 1.
- For higher doses of glucocorticoids, increasing doses of prandial and correctional insulin, sometimes in extraordinary amounts, are often needed in addition to basal insulin.
- Education on responding to hypoglycemia, anticipating exercise, monitoring for diabetic ketoacidosis, or carbohydrate counting, and transitioning to technologies such as insulin pumps is critical, especially in complex cases or when endocrinology consultation is considered 1.
From the Research
Initial Management of Steroid-Induced Diabetes
The initial management for a 58-year-old patient with steroid-induced diabetes (SID) involves several key considerations:
- Glucose Lowering Strategies: Recommended optimal treatment of SID includes similar glucose lowering strategies as in type 2 diabetes, such as oral hypoglycemic agents or insulin therapy 2.
- Insulin Therapy: Insulin can be started when blood glucose levels are higher than 3.6 g/l (20 mmol/l) with clinical symptoms of diabetes, and can be replaced with oral hypoglycemic compounds when both blood glucose levels and corticosteroid dose have decreased 2.
- Patient Education: Patient education is essential, particularly for the management of hypoglycemia when corticosteroids are withdrawn or their dose tapered 2.
- Treatment Protocols: Challenges in managing steroid-induced diabetes stem from wide fluctuations in post-prandial hyperglycemia and the lack of clearly defined treatment protocols, making insulin therapy coincident with meals the mainstay of treatment 3.
Additional Treatment Options
Other treatment options for SID include:
- GLP-1 Receptor Agonists: GLP-1 receptor agonists (GLP-1 RAs) have been shown to be effective in treating type 2 diabetes, and may also be useful in treating SID, particularly in patients with pre-existing atherosclerotic vascular disease 4.
- Bariatric Surgery: Bariatric surgery, such as Roux-en-Y gastric bypass, has emerged as an effective treatment for type 2 diabetes mellitus, and may also be useful in treating SID, particularly in patients who are obese or have a high body mass index 5.
Diagnosis and Pathophysiology
The diagnosis and pathophysiology of SID involve:
- Insulin Resistance: Corticosteroids induce insulin resistance in the liver, adipocytes, and skeletal muscle, and have direct deleterious effects on insulin secretion 2.
- Post-Prandial Hyperglycemia: The typical post-prandial hyperglycemia linked to the promotion of gluconeogenesis is a key feature of SID 6.
- Early Diagnosis: An early and precise diagnosis of SID is necessary, but current criteria do not seem sensible enough, making dedicated guidelines universally shared mandatory in order to harmonize the treatment of these conditions 6.