Can individuals with diabetes mellitus (DM) receive cortisone injections?

Cortisone Injections for Diabetic Patients

Diabetic patients can receive cortisone injections, but they require close blood glucose monitoring as these injections typically cause temporary hyperglycemia that may last up to 5-7 days, with greater elevations in poorly controlled diabetes. 1, 2, 3

Effects on Blood Glucose Levels

• Cortisone injections can induce hyperglycemia in 56-86% of individuals with and without preexisting diabetes 4
• If left untreated, this hyperglycemia increases mortality and morbidity risk through infections and cardiovascular events 4
• The hyperglycemic response varies based on several factors:
  • Glycemic control: Patients with hemoglobin A1c <7% experience smaller glucose elevations (average rise of 38 mg/dL) compared to poorly controlled patients (average rise of 98 mg/dL) 2
  • Insulin dependence: Insulin-dependent diabetics experience higher glucose elevations (average 99 mg/dL) versus non-insulin-dependent diabetics (50 mg/dL) 2
  • Injection site: Upper extremity injections (shoulder, wrist, hand) cause less significant glucose elevations than knee injections 5

Monitoring Recommendations

• Blood glucose monitoring should be performed every 2-4 hours during initial days after injection, particularly 4-6 hours after administration 1
• Continue monitoring blood glucose 4 times daily (fasting and 2 hours postmeals) for at least 7-10 days post-injection 1, 2
• Target blood glucose range should be 80-180 mg/dL 1

Management Approach

1. Pre-injection assessment:

   • Check most recent HbA1c level - higher levels correlate with greater post-injection glucose elevations 3
   • Document baseline fasting and postprandial glucose levels 2

2. Insulin adjustments:

   • For patients on insulin therapy:
     • Increase basal insulin by 20-30% from baseline during the expected period of steroid effect 1
     • Consider additional prandial insulin coverage with meals 4, 1
     • Use a sliding scale insulin regimen for pre-meal glucose levels above 250 mg/dL 1

3. Oral medications:

   • Continue oral antidiabetic medications
   • Consider alpha-glucosidase inhibitors or rapid-acting insulin secretagogues for postprandial hyperglycemia 1, 6

4. Post-injection vigilance:

   • Monitor for signs of severe hyperglycemia
   • Seek medical attention if capillary blood glucose levels remain persistently above 20 mmol/L despite treatment 1

Important Considerations

• Blood glucose typically returns to baseline within 5-8 days after injection for well-controlled diabetics 2, 3
• Poorly controlled diabetics may have prolonged hyperglycemia 2
• No cases of diabetic ketoacidosis were reported in studies, but it remains a theoretical risk 2, 5, 6
• Cortisol suppression may occur after injection and can last up to 21 days in diabetic patients receiving epidural injections 7

Pitfalls to Avoid

• Failing to adjust insulin doses in anticipation of steroid-induced hyperglycemia
• Overlooking the need for more intensive monitoring in poorly controlled diabetics
• Not considering the injection site when predicting glucose response
• Neglecting to reduce insulin doses as steroid effects wane, which could lead to hypoglycemia 1