What are the guidelines for steroid use in COVID-19 patients with diabetes?

Steroid Use in COVID-19 Patients with Diabetes

For COVID-19 patients with diabetes, corticosteroids should only be used in severe or critical disease requiring oxygen therapy or mechanical ventilation, with strict glycemic monitoring and control to prevent complications such as hyperglycemia and mucormycosis.

Indications for Corticosteroid Use

Recommended Use:

• Corticosteroids are strongly recommended only for patients with severe or critical COVID-19 requiring oxygen therapy or mechanical ventilation 1
• The WHO guidelines show a 28-day mortality reduction of 3.4% in severe or critical COVID-19 with systemic corticosteroids 1
• Corticosteroids should not be used in patients with mild COVID-19 not requiring oxygen, as they may increase mortality in this group (RR = 1.23, NNH = 29) 2

Contraindications and Cautions:

• Unnecessary use of corticosteroids for early mild symptoms of COVID-19 in diabetic patients can lead to rhino-orbital-cerebral mucormycosis (ROCM) 3
• Diabetes mellitus is the most common risk factor (60-92%) for developing COVID-19-associated mucormycosis, with steroid use being another significant risk factor 1

Glycemic Management During Steroid Therapy

Monitoring Protocol:

• Regular blood glucose monitoring every 2-4 hours during steroid therapy 1
• Monitor blood glucose 4-6 hours after steroid administration when steroid effect peaks 4
• Target blood glucose range: 80-180 mg/dL 4

Insulin Management:

1. Initial Dosing:

   • For patients already on insulin: Calculate total daily NPH dose as 80% of current dose, distribute as 2/3 in morning and 1/3 at bedtime 4
   • For insulin-naïve patients: Start NPH insulin at 0.1-0.2 units/kg/day, given with morning steroid dose 4
   • Prandial insulin may need to be increased by 40-60% for higher doses of glucocorticoids 4

2. Dose Adjustment:

   • Increase morning NPH by 2 units every 3 days if afternoon/evening glucose >180 mg/dL 4
   • Increase evening NPH by 2 units every 3 days if fasting glucose >130 mg/dL 4
   • Reduce insulin by 10-20% if hypoglycemia occurs 4

3. During Steroid Taper:

   • Calculate 3-day average glucose and adjust NPH dose proportionally to the prednisone taper 4
   • Consider a ratio of approximately 0.4-0.5 units of NPH per mg of prednisone 4

Prevention of Complications

Mucormycosis Prevention:

• Strict glycemic control and optimization of corticosteroid use is strongly recommended (Strong recommendation, low quality of evidence) 1
• Avoid unnecessary or prolonged steroid use in diabetic patients 3
• For patients who develop mucormycosis, both antifungal therapy and immediate surgical debridement are recommended 1

Hyperglycemia Management:

• Lower blood glucose on admission and lower peak blood glucose on corticosteroids are associated with lower odds of mortality and successful extubation 5
• Hyperglycemia may negate potential benefits of corticosteroid therapy 5
• Patients with COVID-19 and diabetes treated with corticosteroids need vigilant monitoring for early diagnosis and treatment of invasive fungal infections 3

Common Pitfalls to Avoid

1. Inappropriate Steroid Use:

   • Using steroids in mild COVID-19 cases not requiring oxygen therapy 1, 2
   • Self-medication with steroids without physician advice 3, 6
   • Prolonged steroid use beyond recommended duration 3

2. Inadequate Glycemic Control:

   • Overbasalization (excessive basal insulin without adequate prandial coverage) 4
   • Delayed insulin adjustments 4
   • Failure to anticipate hyperglycemia 4
   • Not aligning insulin peak with steroid peak effect 4
   • Inadequate monitoring during steroid taper 4

By following these guidelines, clinicians can optimize the benefits of corticosteroid therapy in severe COVID-19 while minimizing the risks in patients with diabetes, particularly the risk of mucormycosis which has emerged as a serious complication in this population.