How to manage steroid-induced diabetic hypoglycemia?

From the Guidelines

Managing steroid-induced diabetic hypoglycemia requires immediate consumption of 15-20 grams of fast-acting carbohydrates, such as 4 ounces of fruit juice or 4-5 glucose tablets, and rechecking blood glucose after 15 minutes to repeat treatment if necessary, as recommended by the American Diabetes Association standards of medical care in diabetes 1. The treatment approach should prioritize prompt recognition and a multi-faceted strategy to prevent and manage hypoglycemia.

• Key considerations include:
  • Consuming fast-acting carbohydrates to rapidly increase blood glucose levels
  • Rechecking blood glucose after 15 minutes to determine if additional treatment is needed
  • Eating a small meal or snack containing complex carbohydrates and protein to maintain stable levels once blood glucose normalizes
  • Monitoring blood glucose more frequently when on steroid therapy, particularly during peak steroid activity times
  • Adjusting diabetes medications in consultation with a healthcare provider, which may involve reducing insulin doses or temporarily discontinuing or modifying oral medications like sulfonylureas, as suggested by the 2016 American Diabetes Association standards of medical care in diabetes 1
  • Maintaining consistent meal timing and carbohydrate intake to minimize the risk of hypoglycemia
  • Always carrying hypoglycemia treatment supplies to ensure prompt response to hypoglycemic episodes The risk of steroid-induced hypoglycemia is highest during steroid tapering or in the hours when steroid effects are waning, as glucocorticoids typically raise blood glucose, and adjusting diabetes medications to counteract this effect can lead to hypoglycemia if steroid doses are reduced or discontinued without corresponding adjustments to diabetes medications.

From the FDA Drug Label

Medication Insulin requirements may be increased if you are taking other drugs with blood-glucose-raising activity, such as oral contraceptives, corticosteroids, or thyroid replacement therapy Drugs that may reduce the blood-glucose-lowering effect: Corticosteroids, isoniazid, certain lipid-lowering drugs (e.g., niacin), estrogens, oral contraceptives, phenothiazines, danazol, diuretics, sympathomimetic agents, somatropin, atypical antipsychotics, glucagon, protease inhibitors and thyroid replacement therapy.

Treatment of Steroid-Induced Diabetic Hypoglycemia: To manage steroid-induced diabetic hypoglycemia, the following steps can be taken:

• Monitor blood glucose levels frequently: This is crucial in detecting hypoglycemia early and taking corrective action.
• Adjust insulin regimen: The patient's insulin regimen may need to be adjusted to accommodate the increased blood-glucose-raising effect of corticosteroids.
• Eat foods or drinks that contain sugar: Mild to moderate hypoglycemia can be treated by consuming foods or drinks that contain sugar.
• Carry a quick source of sugar: Patients should always carry a quick source of sugar, such as hard candy or glucose tablets, to treat hypoglycemia.
• Seek medical assistance: If the patient experiences severe hypoglycemia or is unable to take sugar orally, they should seek medical assistance immediately 2, 2.

From the Research

Treatment of Steroid-Induced Diabetic Hypoglycemia

• The treatment of steroid-induced diabetic hypoglycemia should be reasoned and tailored according to proposed glycemic thresholds and patient comorbidities, choosing between antidiabetic oral drugs and insulin 3.
• Insulin neutral protamine Hagedorn (NPH) is a safe and efficacious option for acute care hospitalized patients experiencing steroid-induced hyperglycemia, and more aggressive dosing initiation of NPH based on steroid dose may allow for earlier achievement of euglycemia without a difference in hypoglycemia 4.
• Continuous glucose monitoring (CGM) can reduce episodes of severe hypoglycemia in patients with type 1 diabetes and reduce the proportion of patients with hypoglycemia (blood glucose levels <54 mg/dL) 5.
• Structured diabetes education programs can reduce episodes of severe hypoglycemia and time below 54 mg/dL in outpatients taking insulin 5.
• Glucagon formulations not requiring reconstitution can be used to treat severe hypoglycemia, but may be associated with longer times to recovery from hypoglycemia 6.

Management of Hypoglycemia

• Education and regular review are essential between people with diabetes and their caregivers and healthcare professionals about symptoms, prevention, and treatment of hypoglycemia 6.
• Awareness of the potential dangers of hypoglycemia is fundamental to the optimal management of diabetes 6.
• The use of an inpatient computerized glycemic management program utilizing electronic health record data can be associated with fewer patients with and episodes of hypoglycemia with blood glucose levels lower than 70 mg/dL and fewer patients with severe hypoglycemia compared with standard care 5.
• Long-acting basal insulin analogs and rapid-acting insulin analogs can be associated with less hypoglycemia and reduced severe hypoglycemia, respectively 5.