Can budesonide (corticosteroid) via nebulizer cause hyperglycemia in patients with poorly controlled diabetes?

Budesonide Nebulizer and Hyperglycemia in Poorly Controlled Diabetics

Yes, budesonide via nebulizer can cause hyperglycemia in patients with poorly controlled diabetes, though the risk is lower compared to systemic corticosteroids. 1, 2

Mechanism of Hyperglycemia

• Corticosteroids, including budesonide, can induce hyperglycemia through multiple mechanisms:

  • Impaired beta cell insulin secretion 1, 2
  • Increased total body insulin resistance 1, 2
  • Enhanced hepatic gluconeogenesis 1, 2

• The hyperglycemic effect typically peaks 7-9 hours after administration 1

• The degree of hyperglycemia correlates directly with the steroid dose 1, 2

Risk Factors for Budesonide-Induced Hyperglycemia

• Pre-existing diabetes, especially poorly controlled diabetes, significantly increases the risk of steroid-induced hyperglycemia 2, 3

• The incidence of hyperglycemia doubles with each severity grade of dysglycemia:

  • 20% in normoglycemic patients
  • 40% in prediabetic patients
  • 90% in diabetic patients 3

• Patients with poorly controlled diabetes are particularly vulnerable to significant glucose elevations 2, 3

Monitoring Recommendations

• For patients with poorly controlled diabetes using budesonide nebulizer:

  • Monitor blood glucose levels, particularly 6-9 hours after administration when hyperglycemic effects peak 1, 2

• The American Association of Clinical Endocrinologists recommends blood glucose monitoring four times daily (fasting and 2 hours after each meal) for patients at high risk 2, 4

• Target blood glucose range should be 5-10 mmol/L (90-180 mg/dL) 2, 4

Management Strategies

• For mild hyperglycemia with budesonide nebulizer:

  • Consider temporary adjustments to existing diabetes medications 1

• For significant hyperglycemia:

  • Intensify diabetes treatment regimen, potentially including insulin therapy 2, 4
  • The preferred regimen for steroid-induced hyperglycemia is intermediate-acting insulin (NPH) given in the morning to match the pharmacokinetics of steroids 2, 4

• As treatment continues, adjust insulin doses based on blood glucose patterns, with particular attention to afternoon and evening readings 2, 4

Special Considerations

• For elderly patients with poorly controlled diabetes, budesonide may be a better choice than other corticosteroids when treatment is necessary 5

• For patients without cirrhosis who are at high risk for severe steroid-related side effects (including poorly controlled diabetes), budesonide 9 mg/day plus azathioprine 1-2 mg/kg/day may be an appropriate choice for certain conditions requiring steroid therapy 5

• Patients should be educated about symptoms of hyperglycemia to monitor for and when to seek medical attention 1, 2

Important Caveats

• While inhaled corticosteroids generally have fewer systemic effects than oral or parenteral steroids, they can still cause hyperglycemia, particularly in susceptible individuals like those with poorly controlled diabetes 6, 7

• The risk of hyperglycemia with inhaled budesonide is lower than with systemic corticosteroids, but it is not zero, especially in vulnerable populations 7

• A retrospective analysis of controlled trials did not show an increased risk of new-onset diabetes with inhaled corticosteroids, but this does not rule out exacerbation of existing diabetes 7