What monitoring and management should be done for a patient with sarcoidosis on long-term steroid therapy, who is at risk of developing steroid-induced diabetes and has a history of taking calcium supplements, Hormone Replacement Therapy (HRT), and alendronic acid (bisphosphonate)?

Monitoring and Management of Long-Term Steroid Therapy in Sarcoidosis

For a patient with sarcoidosis on long-term steroid therapy, regular monitoring of blood glucose, bone health, and blood pressure is essential, with immediate initiation of diabetes screening through post-meal glucose testing and implementation of bone protection measures including calcium, vitamin D, and bisphosphonate therapy.

Steroid-Induced Diabetes Monitoring

Screening and Detection

• Request immediate blood glucose monitoring with emphasis on post-meal readings, particularly:
  • 2-hour post-lunch and post-dinner glucose measurements on the 3rd day of steroid therapy 1
  • HbA1c testing to assess longer-term glycemic control 2
  • Fasting blood glucose (though less sensitive for steroid-induced hyperglycemia)

When to Suspect Steroid-Induced Diabetes

• Post-meal blood glucose ≥10 mmol/L (180 mg/dL) indicates steroid-induced hyperglycemia 1
• Fasting blood glucose ≥7 mmol/L (126 mg/dL) or random glucose ≥11.1 mmol/L (200 mg/dL) indicates overt diabetes 1

Management Recommendations

• If hyperglycemia is detected:
  • Dietary modifications to reduce carbohydrate intake, particularly at lunch and dinner
  • Consider antidiabetic medication based on severity of hyperglycemia
  • More frequent monitoring during periods of steroid dose changes

Bone Health Management

Immediate Assessment

• Request bone mineral density (DEXA scan) if not done within the past year 2
• Assess calcium and vitamin D levels
• Review the reason for discontinuation of alendronic acid and consider restarting

Bone Protection Strategy

• Resume bisphosphonate therapy (alendronate) immediately as this is critical for preventing steroid-induced osteoporosis 2, 3
• Continue calcium supplementation (800-1000mg daily) 2
• Ensure adequate vitamin D supplementation (800 IU daily) 2
  • If vitamin D deficient, request higher dose supplementation (50,000 IU weekly for 6 weeks) 2
• Reassess bone density annually if declining, or every 2-3 years if stable 2

Special Considerations

• Calcium and vitamin D supplementation is safe in sarcoidosis patients despite theoretical concerns about hypercalcemia 4
• Patients without calcium/vitamin D supplementation are actually at higher risk for developing hypercalcemia 4

Blood Pressure Monitoring

• Request regular blood pressure measurements at each visit
• Target blood pressure should be <140/90 mmHg
• If hypertension develops, consider antihypertensive therapy that doesn't worsen glucose control

Additional Monitoring Recommendations

Regular Laboratory Tests

• Complete blood count (CBC) every 3-6 months
• Electrolytes including potassium
• Renal function tests
• Lipid profile annually

Ophthalmologic Assessment

• Annual eye examination to screen for cataracts and glaucoma 2

Adrenal Function

• Be aware of potential adrenal suppression with long-term steroid use
• Ensure any steroid dose reductions are gradual to prevent withdrawal syndrome 2
• Symptoms of withdrawal include weakness, fatigue, nausea, vomiting, and abdominal pain 2

Steroid-Sparing Strategies

• Consider discussing addition of steroid-sparing agents like methotrexate (10-15mg once weekly) 2, 5
• Methotrexate requires monitoring of CBC, liver and renal function 2, 5
• This approach may allow reduction in steroid dose while maintaining disease control

Key Points to Discuss with GP

1. Implement immediate post-meal glucose monitoring (particularly 2 hours after lunch and dinner)
2. Restart bisphosphonate therapy if no contraindications exist
3. Continue calcium and vitamin D supplementation
4. Consider steroid-sparing agents to reduce cumulative steroid exposure
5. Schedule regular monitoring of blood pressure, electrolytes, and bone density
6. Ensure gradual tapering of steroids when appropriate to prevent adrenal crisis

Remember that early detection and management of steroid-related complications can significantly improve long-term outcomes and quality of life for patients with sarcoidosis requiring prolonged corticosteroid therapy.