What is the recommended steroid dose for a patient with type 2 diabetes (DM2) experiencing an upper respiratory infection (URI)?

Steroid Dosing for URI in Patients with Type 2 Diabetes

For patients with type 2 diabetes experiencing an upper respiratory infection requiring corticosteroid therapy, a short course of prednisolone at 0.5 mg/kg daily for 5 days is recommended to manage URI symptoms while minimizing hyperglycemic effects. 1

Steroid Selection and Dosing

• For short-term management of URI symptoms in patients with DM2, prednisolone is preferred over dexamethasone due to its shorter half-life and less pronounced hyperglycemic effects 2
• Initial dosing recommendations:
  • Prednisolone 0.5 mg/kg/day for 5 days 1
  • For most adults, this translates to approximately 30-40 mg daily for 5 days
  • Morning administration is preferred to minimize sleep disturbances and better mimic natural cortisol rhythm 2

Glycemic Management During Steroid Therapy

• Anticipate hyperglycemia primarily between midday and midnight, with glucose levels often normalizing overnight 2

• For patients on oral diabetes medications:

  • Continue baseline diabetes medications 2
  • Monitor blood glucose 4 times daily (fasting and 2 hours after meals) during steroid therapy 2
  • Consider temporary insulin if blood glucose consistently exceeds 15 mmol/L (270 mg/dL) 2

• For patients already on insulin therapy:

  • Increase total daily insulin dose by approximately 30-50% during steroid treatment 2, 3
  • NPH insulin is particularly effective for managing steroid-induced hyperglycemia due to its peak action profile (4-6 hours after administration) aligning with steroid-induced hyperglycemia 2
  • For patients on basal-bolus regimens, increase prandial insulin proportionally more than basal insulin 2

Risk Factors for Steroid-Induced Hyperglycemia

• Older age significantly increases risk of steroid-induced diabetes (odds ratio 1.05,95% CI 1.02-1.09) 4
• Higher steroid doses and longer duration of therapy increase hyperglycemia risk 2, 4
• Patients with pre-existing glucose intolerance or risk factors for diabetes require closer monitoring 2

Monitoring Recommendations

• Check blood glucose levels at least daily while on steroid therapy, preferably 2-4 hours after steroid administration when hyperglycemic effect is maximal 2
• For high-risk patients (elderly, prior history of steroid-induced hyperglycemia), monitor glucose more frequently (2-4 times daily) 2
• Continue monitoring for 1-2 days after steroid discontinuation as hyperglycemic effects may persist 2

Special Considerations

• If the patient requires hospitalization, more intensive insulin regimens may be needed:
  • For severe hyperglycemia, consider basal-bolus insulin at 0.5 units/kg/day, with 50% as basal and 50% as prandial insulin 2, 3
  • Adjust insulin doses daily based on glucose patterns and anticipated changes in steroid dosing 2
• Insulin requirements typically decrease rapidly after steroid discontinuation, requiring prompt dose adjustments to avoid hypoglycemia 2
• Sulfonylureas are not recommended for managing steroid-induced hyperglycemia due to risk of prolonged hypoglycemia 2

Alternative Approaches

• For patients with difficult-to-control diabetes who require frequent steroid courses, consider deflazacort as an alternative to prednisolone, as it may have less impact on glycemic control (30 mg deflazacort is equivalent to 25 mg prednisone) 5
• For patients with recurrent URIs requiring frequent steroid courses, consider prophylactic strategies to reduce URI frequency 1