SGLT2 Inhibitors in Steroid-Induced Hyperglycemia
SGLT2 inhibitors should be avoided in steroid-induced hyperglycemia due to increased risk of euglycemic diabetic ketoacidosis and other safety concerns in the acute setting. 1
Rationale for Avoiding SGLT2i in Steroid-Induced Hyperglycemia
Safety Concerns
- SGLT2 inhibitors increase the risk of euglycemic diabetic ketoacidosis, particularly in acute illness or stress states like those requiring steroid therapy 1
- Steroids induce a state of insulin resistance and hyperglycemia that can be unpredictable and rapidly fluctuating, making the glucose-lowering effects of SGLT2i potentially dangerous 2
- SGLT2i should be withheld during times of critical medical illness when patients may be at greater risk for ketosis 3
Hemodynamic Considerations
- SGLT2 inhibitors have diuretic effects that may compound volume depletion in acutely ill patients 4
- The combination of steroid-induced fluid retention and SGLT2i-induced volume contraction creates unpredictable hemodynamic effects 3
- Patients on steroids may already experience fluid and electrolyte disturbances that could be exacerbated by SGLT2i 1
Metabolic Complications
- Steroids primarily cause postprandial hyperglycemia with relatively normal fasting glucose, while SGLT2i have a more consistent effect throughout the day, creating a mismatch in glycemic management 2
- The risk of hypovolemia increases when SGLT2i are used in patients who may be dehydrated or on other medications affecting volume status (common in patients requiring steroids) 3
- SGLT2i can alter lipid metabolism, which may interact unpredictably with steroid-induced dyslipidemia 5
Preferred Approaches for Steroid-Induced Hyperglycemia
Inpatient Management
- Basal-bolus insulin regimens with correction doses are recommended for managing steroid-induced hyperglycemia in hospitalized patients 2
- Variable rate intravenous insulin infusion may be temporarily used in intensive care settings under close supervision 2
- Insulin therapy allows for dose adjustments that can match the pharmacokinetic profile of the specific steroid being used 1
Outpatient Management
- For patients with pre-existing diabetes on oral or injectable therapy, modification of existing regimens is preferred over adding SGLT2i 2
- Patients should be monitored for glycemic variability, especially as steroid doses are tapered 2
- Insulin dosage should be reduced as steroids are tapered to prevent hypoglycemia 2
Special Considerations
Chronic Kidney Disease Patients
- While SGLT2i are beneficial in CKD patients (eGFR ≥20 ml/min per 1.73 m²) for cardiovascular and renal protection 3, this benefit must be balanced against the acute risks during steroid therapy
- For CKD patients requiring steroids, the cardiovascular benefits of SGLT2i should be reconsidered after the acute phase of steroid therapy 3
Cardiovascular Disease Patients
- Despite SGLT2i being recommended for patients with type 2 diabetes and cardiovascular disease 3, the acute risks during steroid therapy outweigh the chronic benefits
- Consider resuming SGLT2i after steroid therapy is completed in patients with established cardiovascular disease 3
Practical Approach
- Hold SGLT2i during steroid therapy and for 2-3 days after steroid discontinuation 3
- Monitor for signs of diabetic ketoacidosis including nausea, vomiting, abdominal pain, and dyspnea, even in the absence of significant hyperglycemia 3
- Implement "sick day rules" if SGLT2i must be continued, including temporary discontinuation during acute illness 3
By avoiding SGLT2 inhibitors in steroid-induced hyperglycemia, clinicians can reduce the risk of serious complications while effectively managing glucose levels with more appropriate therapeutic options.