What are the considerations for using steroid injections in individuals with diabetes?

From the Guidelines

Steroid injections in diabetic patients require careful monitoring and adjustment of diabetes medications to mitigate the risk of hyperglycemia, and the most recent guidelines recommend administering NPH insulin concomitantly with intermediate-acting steroids 1. When considering steroid injections in individuals with diabetes, several factors must be taken into account to minimize the risk of adverse outcomes, particularly hyperglycemia.

• The type and duration of action of the glucocorticoid must be considered in determining insulin treatment regimens, as different steroids have varying effects on blood glucose levels 1.
• For individuals on once- or twice-daily steroids, administering intermediate-acting (NPH) insulin is a standard approach, and it should be given concomitantly with the steroid to maximize its effectiveness 1.
• For long-acting glucocorticoids such as dexamethasone, long-acting basal insulin may be required to manage fasting blood glucose levels, and higher doses of glucocorticoids may necessitate increasing doses of prandial and correctional insulin 1.
• Blood glucose monitoring should be increased for 1-3 days after injection, with testing recommended 4-6 times daily, particularly after meals when spikes are most likely, and patients should be educated about the potential hyperglycemic effects of steroids and provided with a clear plan for glucose monitoring and medication adjustments 1.
• Temporary insulin adjustments may be necessary, and the ratio of insulin to steroids should be carefully managed to minimize the risk of hypoglycemia and hyperglycemia, with some studies suggesting that increasing the ratio of insulin to steroids can be positively associated with improved time in range 1.

From the FDA Drug Label

Because corticosteroids may increase blood glucose concentrations, dosage adjustments of antidiabetic agents may be required.

• Key Considerations: When using steroid injections in individuals with diabetes, it is essential to consider the potential impact on blood glucose levels.
• Main Idea: Corticosteroids, such as those used in steroid injections, can increase blood glucose concentrations, which may require adjustments to antidiabetic agents.
• Clinical Decision: Patients with diabetes should be closely monitored for changes in blood glucose levels when receiving steroid injections, and their antidiabetic medication may need to be adjusted accordingly 2.

From the Research

Considerations for Using Steroid Injections in Individuals with Diabetes

• Steroid injections can cause hyperglycemia in patients with diabetes mellitus, with peak values reaching as high as 500 mg/dL 3.
• The peak increase in blood glucose does not occur immediately after injection and may take several days to occur, with post-injection hyperglycemia often occurring within 24 to 72 hours 3.
• Diabetic patients should be advised to regularly monitor their blood glucose levels for up to a week after injection and seek medical advice if safe thresholds are breached 3.
• Glucocorticoids can exacerbate hyperglycemia in patients with diabetes mellitus or facilitate the development of metabolic disease in apparently healthy subjects, known as steroid-induced diabetes mellitus 4.
• Screening or more stringent monitoring must always be suggested before starting corticosteroids, and hypoglycemic therapy should be personalized based on the severity of hyperglycemia, type of steroid used, and patients' comorbidities 4.

Management of Steroid-Induced Hyperglycemia

• Insulin is the most studied drug and the medication recommended for severe hyperglycemia, for patients with pre-existing diabetes, or for those who have to undergo prolonged therapy over time 4.
• Pharmacological management of diabetes is needed in patients with blood glucose levels exceeding 2.16 g/l (12 mmol/l), and insulin therapy can be started when blood glucose levels are higher than 3.6 g/l (20 mmol/l) with clinical symptoms of diabetes 5.
• Patient education is essential, particularly for the management of hypoglycemia when corticosteroids are withdrawn or their dose tapered 5.
• Higher HbA1c levels before injection are associated with greater elevation in blood glucose after steroid injection, and careful monitoring of blood glucose is required on the first day after injection in patients with poorly controlled diabetes 6.

Clinical Importance and Recommendations

• The clinical importance of intra-articular steroid injections on glycemic control in patients with diabetes is minimal, but patients with good glucose control may experience acute hyperglycemia for 2 or 3 days after injection 7.
• Steroid injections into the shoulder may briefly raise postprandial glucose levels with larger and repeated doses, but the mean glucose levels may not be affected 7.